COLUMBIA LIBRARIES OFFSITE .HEALTH SCIENCES STANDARD HX00048208 RECAP a;.;i;t{|S]:;;.: >V' f4'''-ti|l'/.-t'';'":*:- 2i76 Pathology Z77 Prognosis 378 Treatment 378 Chronic 379 Symptoms 379 General Tuberculous Adenitis . . 380 Local Tuberculous Adenitis . . . 380 Diagnosis 381 Etiology- 382 Pathology 383 Prognosis 384 Treatment 384 Adenoid A'egetations 389 Definition 389 Symptoms and Diagnosis 389 Etiolog}- 395 Pathology 397 Prognosis 397 Treatment 403 Preparation of the Patient 401 Position of the Patient 402 Anesthesia 402 Instruments and ^^lethods 405 Accidents and Complications 408 After-treatment 411 Adiposis. See Obesity. Adiposis Dolorosa ; Dercum's Disease . . 412 Definition 412 Symptoms and Course 413 Xodular Form 413 Localized Diffuse Form 416 Generalized Diffuse Form 417 Etiology' 421 Patholog}' 423 Diagnosis 428 Prognosis 429 Treatment 429 Adipositas Cerebralis. See Obesity, Frohlich's Disease. Adnephrin. See Animal Extracts. Adonis Vernalis 431 Dose 431 Physiological Action 431 Incompatibilities 432 Contraindications 432 Therapeutics 432 Adrenalin. See Animal Extracts : Ad- renals. Adrenals, Diseases of 434 The Adrenal Secretion in Pulmonary and Tissue Oxidation 434 The Adrenal Secretion in Immunity' . . 435 Classification 436 Terminal Hypoadrenia 436 Definition 436 PAGE Adrenals, Diseases of. Classification {continued). Pathogenesis and Symptomatol- og}' 436 Patholog}' 440 Treatment 441 Acute Hyperadrenia and Adrenal Hemorrhage 444 Definition 444 SymptomatologN' and Pathogen- esis 444 Etiologj' 447 Pathology- 449 Treatment 452 Hemorrhagic Pseudocysts of the Adrenals 453 Symptoms 453 Diagnosis 454 Etiolog}' 455 Pathology 455 Prognosis 455 Treatment 456 Functional Hypoadrenia 456 Definition 456 Symptomatology and Pathogen- esis 456 Infancy 456 Childhood 457 Adult Age 458 Old Age 459 Prophylaxis and Treatment 461 In the Infant 461 In the Child 463 In the Adult 464 In Old Age 465 Progressive Hypoadrenia 466 Cancer of the Adrenals 466 Varieties 466 Symptoms 467 Diagnosis 469 Treatment 470 H3^pernephroma 471 S3-mptomatolog}- 472 ]\Ialignant Hj-pernephroma of the Adrenals 472 H3-pernephroma of the Kidnej^ 475 Symptomatology 475 Diagnosis 477 Patholog}- 478 Prognosis 479 Treatment 480 Adrin. See Animal Extracts : Adrenals. Agalactia. See Mammary Gland. Agar-agar 481 Agaricin 481 Dose 481 Physiological Action 481 Therapeutics 482 XII CONTEXTS. PAGE Agglutination Test 482 Agoraphobia. See Index-Supplement. Agurin 483 Modes of Administration 483 Therapeutics 483 Ainhum 483 Definition 483 Symptoms 484 Etiology 484 Pathology 484 Treatment 485 'Airol ' 485 Modes of Administration 485 Physiological Action 485 Therapeutics 485 Albargin 486 Therapeutics 486 Albuminuria 486 Definition 486 Physiological Albuminuria 487 Physiological Cj'clical, Orthostatic, and Orthotic Albuminuria 492 Pathological Albuminuria 497 Tests 500 Test by Boiling 500 Heller's Test 502 Test by Acetic Acid and Potassic Ferrocyanide 502 Heynsius's Test 502 The Magnesium-nitric Test (Rob- erts's) 502 Metaphosphoric Acid (Hindenlang's) 502 Picric Acid Test (Johnson's) 502 Perchloride-of-mercury or Spiegler Test 502 Millon's Test 503 Tanret's Test 503 Xanthoprotein Test 503 Transportable Reagents for Albu- min 504 Quantitative Tests 505 Miscellaneous 506 Alcohol 507 Preparations and Dose 507 Modes of Administration 508 Contraindications 510 Physiological Action 511 Digestive Tract 511 Nervous System 512 Circulation 514 Blood 515 Respiration 516 Secretions 517 Temperature 517 Metabolism 517 Immunity 517 Absorption and Elimination 519 Role of Alcohol in Nutrition 520 PAGE Alcohol, Phj^siological Action (coii- tiniied). External Action 524 Therapeutics 525 As a "Stimulant" 525 As a Vasodilator 527 As a Narcotic and Hypnotic 530 As a Stomachic, Antemetic, etc. . . . 530 As a Diuretic 532 In Phenol Poisoning 532 External Uses 532 Alcohol Injections 536 Neuralgia and Neuritis 536 Laryngeal Tuberculosis 537 Tumors 538 Alcoholic Neuritis. See Neuritis. Alcoholism, or Alcohol Inebriety 538 Definition 538 Toxicity of the Alcohols 540 Varieties 541 Acute Alcoholism 541 Definition 541 Svmptoms 541 Differential Diagnosis 543 Pathology 544 Treatment 545 Chronic Alcoholism 547 Definition 547 Symptoms 547 Diagnosis 550 Pathology 552 Prognosis 552 Treatment 553 Home Treatment 553 Office Treatment 554 Hospital Treatment 555 General Treatment 556 Acute Alcoholic Delirium, or De- lirium Tremens 560 Symptoms 560 Diagnosis 561 Pathology 561 Prognosis 562 Treatment 562 Acute Alcoholic Mania (Mania a Potu) 565 Symptoms 565 Differential Diagnosis 566 Etiology and Pathology 566 Prognosis 566 Treatment 566 Aleppo Boil. See Oriental Sore. Aloes 566 Properties and Constituents 566 Dose and Preparations 567 Modes of Administration 568 Incompatibles 568 Contraindications 568 CONTENTS. xin PAGE Aloes (continued). Physiological Action 568 Untoward Effects 569 Therapeutic Uses 569 As a Laxative 569 As a Stomachic 570 As an Emmenagogue 570 In Hemorrhoids 570 Alopecia 570 Definition 570 Congenital Alopecia 571 Senile Alopecia 572 Premature Alopecia 572 Alopecia Seborrhoeica 573 Etiology and Pathology 573 Prognosis 575 Treatment 575 Alopecia Areata 577 Definition 577 Symptoms 577 Etiology 578 Pathology 580 Prognosis 580 Treatment 580 Phototherapy 582 Alsol. See Aluminum : Aluminum Ace- totartrate. Alum 582 Dose 582 Modes of Administration 582 Incompatibles 583 Contraindications 583 Physiological Action 583 Untoward Effects and Poisoning 583 Therapeutic Uses 584 As an Astringent 584 As a Caustic 585 As an Emictic 585 As a Stimulant to Peristalsis 585 Aluminum 586 Aluminum Hydroxide 587 Aluminum Sulphate 587 Aluminum Acetate 587 Aluminum Acetotartrate (Alsol) 588 Aluminum Borof ormate 589 Aluminum Borotannate (Cutal) 589 Aluminum Borotartrate (Boral) 589 Aluminum Carbonate 589 Aluminum Chloride 590 Aluminum Phenolsulphonate 590 Aluminum Salicylate 590 Aluminum Silicate 590 Alumnol 590 Mode of Employment '. 590 Therapeutic Uses 590 Amaurosis 592 Definition 592 Amaurosis in Brain Disease 592 PAGE Amaurosis, Definition (continued). Amaurosis in Nephritis 592 Amaurosis in Hysteria 593 Amaurosis in Spinal Disease 593 Amaurosis Following Hemorrhage . 594 Amaurosis in Pregnancy 594 Amaurosis from Fracture of the Skull 595 Congenital and Hereditary Amau- rosis 595 Amblyopia 596 Definition 596 Amblyopia from Intracranial Causes. 597 Hysterical Amblyopia 598 Simulated Amblyopia 598 Amblyopia Exanopsia 599 Amblyopia from Exhaustion 600 Amenorrhea 600 Definition 600 Varieties 600 Symptoms 600 Etiology 601 Nervous Disorders 601 General Affections 602 Blood Disorders and Wasting Dis- eases 602 Lesion of Genitourinary Organs . . . 603 Pathology 604 Diagnosis 604 Prognosis 604 Treatment 604 Aminoform. See Hexamethylenamine. Amidoacetphenetidin Hydrochloride. See Phenocoll Hydrochloride. Ammonia 606 Properties 606 Preparations and Dose 607 Modes of Administration 607 Incompatibles 608 Contraindications 608 Physiological Action 608 Local Effects 608 Eft'ects on Internal Use 608 Toxicology 609 Treatment of Ammonia Poisoning . 610 Therapeutic Uses 610 As a Stimulant 610 As an Antacid 611 As a Counterirritant, Rubefacient, or Cauterant 611 Ammonium 612 Physiological Action 613 Ammonium Acetate 614 Mode of Administration 614 . Incompatibles 614 Physiological Action 614 Therapeutics 615 As a Diaphoretic and Diuretic . . . 615 XIV CONTENTS. PAGE Ammonium (continued). Ammonium Carbonate 615 Modes of Administration 616 Incompatibles 616 Physiological Action 616 Toxicology • • 617 Therapeutics 617 As an Expectorant 617 As a Stimulant 617 As a Gastric Stimulant or Emetic . 617 As a Rubefacient and Discutient . 617 Ammonium Chloride 617 Mode of Administration 618 Incompatibles 618 Physiological Action 618 Therapeutics 619 As a Stimulant to Mucous Mem- branes 619 In Aural Disorders 620 In Gastric Catarrh 620 In Cystitis 620 As a Stimulant to the Liver 620 In Alcoholism 620 In Neuralgia and Migraine 620 External Uses 621 Ammonium Ichthyol Group. See Ich- thyol. Amputations and Resections. See Re- sections, Amputations, etc. Amyl Nitrite. See Nitrites. Amylene Chloral. See Dormiol. Amylene Hydrate 621 Dose and Modes of Administration . . 621 Physiological Action 621 Untoward Effects ; Poisoning 622 Therapeutic Uses 622 Amyloform 623 Physiological Action 623 Therapeutic Uses 623 Amyl Valerate 624 Physiological Action 624 Therapeutic Uses 624 Analgen 624 Physiological Action 624 Therapeutic Uses ■. . 625 Anemia. See Anemia, Secondary. Anemia, Pernicious Progressive 625 Definition 625 Symptomatology 625 Blood Examination 627 Pathology 630 Diagnosis 636 Etiology 638 Prognosis 639 Treatment 641 Anemia, Secondary, or Symptomatic . . . 646 Definition 646 Types of Secondary Anemia 646 PAGE Anemia, Types of Secondary (con- tinued). Posthemorrhagic Anemias 646 Infectious and Toxic Anemias 647 Trophic Anemias 648 Pathology 649 Symptomatology 653 Diagnosis 657 Prognosis 659 Treatment 659 Anemia, Splenic. ' See Spleen, Diseases of. Anesin. See Chloretone. Anesthesia. See Various Anesthetics : Ether, Chloroform, etc. Anesthesin 664 Physiological Action 664 Therapeutic Uses 664 Aneurism 665 Definition 665 Varieties 665 Congenital 665 Idiopathic 665 Traumatic 665 Hernial 665 True 665 False 665 Difl-use 665 Dissecting 665 Embolic 665 Miliary 666 Fusiform or Ectatic 666 Sacculated 666 Etiology 666 Pathology 668 Symptoms 670 Course 674 Differential Diagnosis 674 Treatment 675 Arterial Compression 677 Forced Flexion 677 Arterial Ligature 677 Dix's Operation 678 Excision of the Sac and Implanta- tion 679 Reinoval or Obliteration of the Sac . 679 Obliterative Method of Matas ... 679 Matas's Conservative Endoaneu- rismorrhaphy 680 Macewen's Acupuncture 681 Electrolysis 681 Moore's Method 681 Moore-Corrady's Method 681 Arteriovenous Aneurism 683 Aneurismal Varix 683 Varicose Aneurism 683 Symptoms 683 Treatment 683 Conditions Related to Aneurisms 684 CONTENTS. XV PAGE Angina Ludovici. See Pharynx. Angina Pectoris 684 Defmition 684 Symptoms 684 Diagnosis 686 Etiology 689 Pathology 690 Prognosis 694 Treatment 695 Angiomata. See Blood-vessels, Tumors of 698 Angioneurotic Edema. See Ascites and Edema 698 Anhalonium Lewinii 698 Preparations and Dose 699 Physiological Action , . 699 Therapeutic Uses 699 Anhidrosis. See Sweat Glands. Diseases of 700 Anidrosis. See Sweat Glands, Diseases of. Animal Extracts, or Organotherapy .... 700 Thyroid Gland Organotherapy 700 Physiological Action 701 Action on Metabolism 701 The Thyroparathyroid Secretion as Opsonin 704 The Active Principle of Thyroid . . . 707 Preparations and Dose 708 Untoward Effects and Their Preven- tion 709 Treatment of Thyroid Poisoning . . 709 Therapeutics 710 Hypothyroidia, or Hypothyroid- ism 711 Hyperthyroidia, or Hyperthyroid- ism 715 Cretinism 717 Danger Signals 721 Myxedema 723 Contraindications 725 Obesity 1TJ Contraindications 728 Miscellaneous Disorders 729 Acromegaly 729 Arteriosclerosis 730 Arthritis, Chronic Rheumatoid . 730 Cancer 732 Cutaneous Disorders 734 Exophthalmic Goiter 735 Goiter Til Hemophilia 738 Incontinence of Urine 738 Infectious Diseases 739 Insanity 741 Lactation 744 PAGE Animal Extracts, Therapeutics, Mis- cellaneous Disorders (continued). Middle-ear Disorders 744 Nervous Disorders 744 Epilepsy 744 Eclampsia 746 Migraine 747 Asthma 748 Tetanus 748 Osseous Disorders 748 Rheumatism, Chronic Progress- ive 749 Uterine Disorders 750 Summary 751 Parathyroid Organotherapy 752 Therapeutics 753 Adrenal, or Suprarenal, Organother- apy 755 Physiological Action 756 Physiology of Local Action 757 Preparations and Dose 758 Untoward Effects 759 Therapeutics 763 Addison's Disease 763 Shock, Collapse, and Surgical Dis- eases 764 Toxemias and Bacterial Infec- tions 766 Postoperative Intestinal Atony . . . 768 Miscellaneous Disorders 769 Hemorrhage 769 Sthenic Cardiac Disorders 770 Asthma 770 Effusions 770 Disorders of Pregnancy and Parturition 770 Cancer 771 Osteomalacia 772 Local Use 773 Hemorrhage 773 Hemorrhoids 773 Neuralgia, Sciatica, and Neu- ritis 774 Cutaneous Disorders 774 Pituitary Organotherapy 774 Preparations and Dose 776 Therapeutics 777 Acromegaly 777 Cardiac Disorders 777 Obstetrics 778 Infectious Diseases 780 Exophthalmic Goiter 781 Nervous and Mental Diseases and Myopathies 781 Stunted Growth and Imbecility . . . 782 XVi CONTENTS. Pituitary Organotherapy, Therapeutics (continued). Intestinal Paresis 782 Orchitic, or Testicular, Organother- apy ; Spermin 783 Therapeutics 785 Ovarian Organotherapy 786 Preparations and Dose 787 Therapeutics 787 Natural and Artificial Menopause. 787 Corpus Luteum Organotherapy 788 Preparations and Dose 789 Therapeutics 789 Natural and Postoperative Meno- pause and Disorders of Pregnancy 789 Pituitary Organotherapy (continued) . Kidney Organotherapy 790 Therapeutics and Dose 791 Thymus Organotherapy 792 Therapeutics 792 Diseases of the Thyroid 792 Rachitis, or Rickets 792 Bone-marrowr Organotherapy 793 Brain and Nerve Substance Organo- therapy 794 Mammary Gland Organotherapy 794 Spleen Organotherapy 795 Hepatic Organotherapy 795 Bile, Bile-salts, and Biliary Extracts . 797 Hormones 799 SAJOUS'S ANALYTIC CYCLOPEDIA of PRACTICAL MEDICINE ABDOMEN, SURGERY OF — Abdominal surgery in its wide sense includes a great variety of operative procedures which are based upon the same general principles as the ones which are included in this article, but which have been left to contributors in the other departments: all of the external hernias, a good part of renal surgery, the surgery of the abdominal walls, and all of the pelvic surgery of the female. This article takes account of that part of abdominal surgery which in- cludes hollow and solid viscera, the former comprising the various parts of the alimentary tube between the diaphragm and the brim of the pelvis, all biliary and pancreatic ducts and the gall-bladder. The solid viscera belonging to this series of articles comprise the liver, spleen and pan- creas only. There is a general sameness of the alimentary canal in these various parts which leads to more or less correspondence between operations done at the different levels of this tract. Operations of the biliary ducts and gall-bladder also have many points in common, and they resemble in a way the operative resources that are employed for the genitourinary passages. We propose to consider the spe- cial features of abdominal surgery in two ways : first, as a series of typical operations which are intended to cor- rect certain diseased states, and then from the other direction as a series of diseased states to be relieved by operative procedures of various kinds. It seems therefore of advantage to consider the typical operations for the stomach, small and large intestines and biliary passages as operations which are in a way applicable to all surgical conditions of these organs. Surgical diseases of the peritoneum, appendix, liver, spleen and pancreas require separate consideration in detail, be- cause of the relative absence of typi- cal operations, making the treatment more or less individualized for each case. THE FOURTH ERA IN SUR- GERY. — In abdominal surgery we have perhaps the best field for object lessons relative to the new fourth or physiologic era in surgery. The first era in surgery was the heroic, under which practically no abdominal sur- gery was done. In the second or anatomic era of surgery, abdominal ABDOMEN, SURGERY OF (MORRIS). operations were in general so danger- ous that few were attempted, except- ing in cases of great emergency, and usually with a fatal ending. The third or pathologic era of surgery was based upon the studies of Pasteur and of Lister. Aside from its technique of preventing the development of bac- teria in wounds, it included the idea of removing all products of infection with painstaking care. Notwithstanding the injury that was done to patients by surgeons carrying out the principles of this era, abdominal surgery made its first great advances. Detailed attention was given to the deliberate disposal of products of infection found within the peritoneal cavity, and little or no at- tention was paid to the natural re- sistance forces contained within the patient himself. There was an enor- mous waste of such forces, in fact, in our abdominal surgery of the patho- logic era. The entirely modern or physiologic era is based upon the studies of Metchnikofif and Wright, and includes the principal idea of allowing the patient to retain his natural forces in such a way as to gain control of infections. Metchnikofif and his fol- lowers taught us that certain cells of the blood and lymph circulatory sys- tems not only disposed of bacteria daily under normal conditions, but that these cells were increased in number rapidly to meet emergen- cies of infection. These investigators showed also that bacteria were de- stroyed by certain fixed body cells. Wright and his followers showed fur- ther that, in the presence of an infec- tion, several kinds of antibodies were elaborated in the animal economy, and these antibodies lent their aid in removing infections and in destroy- ing certain toxins that were produced by bacteria. The principles of this fourth or physiologic era of surgery brought us face to face with the problem of operating in such a way as to leave the patient in the very best condition for managing infec- tions himself with his own phagocytes and antibodies, and led to a revolu- tion in methods, forcing us to drop out of our technique such parts of the system of the third or pathologic era as interfered with the ability of the patient to produce phagocytes and antibodies. For instance, a prolonged and painstaking operation for removing all of the pus from the peritoneal cavity so shocked the great vaso- motor centers of the patient that they were palsied, and unable promptly to take up the work of conducting the manufacture of phagocytes and anti- bodies, with which the patient him- self could dispose of the products of infection much better than the sur- geon could do it in his crude mechani- cal way. Unnecessarily prolonged operations acted in precisely the same way; and where we had thought best to expend a half-hour in carrying out the theories of the pathologic era in surgery, we may now expend five minutes under the principles of the physiologic era. Shock is producea more readily by manipulation of the abdominal viscera than by gross injuries, when animals are fully anesthetized, especially when the anesthetic used is chloroform. The parietal peritoneum and the peritoneal mesenteries are especially sensitive to shock under manipulation. Mam- mery and Symes (Brit. Med. Jour., vol. ii, p. 790, 1908). ABDOMEN, SURGERY OF (MORRIS). A long period of anesthesia was commonly required for tlioroui;li work under the prineiples of the third era, but we now know, from our experi- ments upon animals, that individuals profoundly under the influence of alcohol, or of ether or of chloroform, temporarily lose resistance to infec- tions, and some acute infections which would not gain headway under a few- minutes of anesthesia may seize the opportunity to gain ascendancy if the anesthesia is prolonged for an hour or two. Bulky or complicated drainage apparatus, acting as a foreign body, further produce derangement of func- tion of the vasomotors in such a way as to prevent the patient from manu- facturing his phagoc3^tes and anti- bodies. We are just entering, then, the era in which the greatest degree of success is to follow our opera- tive procedures within the abdominal cavity. ANTEOPERATIVE MANAGE- MENT. — Aside from the general prin- ciples which govern the preparation of a patient for any major operation, certain special requirements are indi- cated which lessen the operative risk, and the tendency to postoperative complications in abdominal surger}^ Postoperative pneumonia, for in- stance, will occur less often if we make careful choice of the anesthetic for any given case, and if we make this period of anesthesia as short as possible, on account of the known tendency of some acute infections to shoot ahead when the patient is under the influence of ether or chloroform. Some operators will choose nitrous oxide and oxygen in cases in which this phenomenon is anticipated. In some feeble patients, or patients with complications of disease of vital organs, spinal anesthesia according to the Jonncsco method is dcsiraljle. Preoperative intestinal asepsis can only be approximated, but for most practical purposes a good purgative given within twenty-four hours of operation will suffice. If the stomach itself is to be operated upon, further steps in the direction of asepsis are required, and we wash the stomach out very thoroughly with saturated boric acid solution just in advance of operation. This is done most comfort- ably, as a rule, after the patient is under the influence of the anesthetic, and by means of the common siphon tube. After the alimentary tract has been cleansed by purgatives, it is im- portant to give only the simplest arti- cles of food and drink in advance of the operation, but we must avoid hav- ing a patient abstain in such a way as to become unduly weakened. Pa- tients who are accustomed to dieting may sometimes be placed on special diet to advantage for a few days in advance of operation, but the physical effect of placing a patient on diet for any length of time is apt to be such as to counteract any good effect. In general a short period of rest in bed before an operation is of advan- tage, but if this time extends beyond twenty-four hours, excepting for patients who are already in bed with some severe abdominal complication, the apprehension and introspection of the patient with a negative imagina- tion, in advance of operative proced- ures may be disastrous, and has even gone to the point of allowing the patient to develop suicidal impulse. For patients who are not already in bed from necessity, the author pre- fers to have as short a period of prep- aration as expediency would suggest, ABDOMEN, SURGERY OF (MORRIS). not more than twenty-four hours as a rule. There are many instances in which the patient needs special medical treatment in advance of opera- tion, because of some defect of the heart, lungs, or kidneys, but under such circumstances with most patients it is best not to tell them of the date set for operation far in advance, up to which they are to be led. Anteoperative narcosis is undesir- able for one chief reason shown by Cantacuzene in his experiments with animals subjected to the influence of opium after infection. This author showed that narcotized animals rapidly succumbed at the time when another series subjected to the same infection, but not narcotized, were meeting the infection. Arrangements Ishould be made in advance of opera- tion for maintaining the animal warmth of the patient with woolen garments or blankets, and it is best to have a good circulation of air in the operating room. In an OA^er- heated operating room with closed windows and doors the surgeon him- self may be extremely uncomfortable, and feeling the need for oxygen, and we assume that the patient at the same time suffers the same depressing influence in addition to the shock of the operation. Experiments with animals have shown that the perito- neum is not injured by exposure to air currents and to Ioav temperature as much as it is injured by contact with .gauze antiseptic solutions, or by rough handling. The author believes that the temperature and air circulation of the room most agreeable to the sur- geon is at the same time most benefi- cial to the patient. x\sepsis is to be begun where possible before the operation with a general bath, and particular attention given to the prep- aration of the umbilical region. The skin in the field of operation may be well prepared in the common way by shaving, then scrubbing with green soap, which is washed off with a weak bichloride of mercury solution, and a pad of gauze wet with this solu- tion is placed in contact with the wound for a few hours. A recently introduced and A^ery effective way of sterilizing the skin consists in simply painting it over with a 2 per cent, solu- tion of iodine in benzin after shaving. The need of aseptic surroundings relating to the preparation of the operating room need not be discussed in this article. Asepsis on the part of the operator is met by the wearing of a sterile gown and cap and a mouth guard of gauze, because with every breath, and particularly in the course of conversation during an operation, bacteria are projected from the mouth of the operator OA^er the field of the Avound. The hands and forearms may be prepared simply by scrubbing with green soap, and then in a Aveak solu- tion of bichloride of mercury. This destroys practically all of the bacteria AA'hich are likely to cause trouble. Latent colonies of bacteria AAdiich work out of the • epithelium of the hands in the course of an operation are generally dormant colonies Avhich are managed by the blood-serum or tissues of the patient safely. The use of rubber gloves in abdominal sur- gery is particularly undesirable ; first because they interfere Avith the nice sense of touch required for separating adhesions, or for doing rapid sutur- ing. The operator wearing rubber gloves is apt to require longer inci- sions Avhich alloAV him to Avork by ABDOMEN, SURGERY OF (MORRIS). 5 sight, and this is not in harmony with the principles of the ph}siokigic era in surgery. The peritoneum protects itself so well if given fair opportunity that we do not need to apply the extreme degree of asepsis that would he needed in opening the knee-joint or the meninges of the brain, but it is well for assistants Avho are not engaged in separating adhesions, or in applying- sutures, or in hunting for structures within the abdomen, to wear rubber gloves. One can do a much higher class of operative work Avithin the peritoneal cavity where nice sense of touch is not interfered with ; and the greater length of time required in operating where rubber gloves are used and the longer inci- sions counterbalance the benefit of such asepsis as would be gained through the use of the gloves. In more than half of the cases of chronic suppuration in the pelvis the pus is sterile at the time of operation, showing that sterilization of the in- fected focus takes place automatically within a reasonable time in the major- ity of cases. H. S. Crossen (Surg., Gynec, and Obstet., Oct., 1909). It has been shown experimentally with Petri plates in the operating room that large numbers of bacteria are constantly falling into every open wound, no matter what precautions have been observed in advance. These bacteria are for the most part disposed of in the patient's tissues and blood- and lymph-vessels ; but the longer the incision and the greater the length of time during which any given wound remains open, the more bacteria fall into the w^ound from the air. If one can work more quickly and through shorter incisions with bare hands, he naturally makes better asepsis of the wound, provided that his hands have been well prepared in advance. The recent reawakening of iodine disinfection of the surface in abdominal surgery is fraught with danger. In animal experiments (rabbits), very small amounts of iodine injected intra- peritoneally will produce in a short time abundant layers of fibrin and firm membranes and bands between the in- testines. The effect is to a certain degree specific, in contrast to that of turpentine. The writer injected intra- peritoneally in a dog 20 drops of the tincture of iodine, dissolved in 80 c.c. sterile saline solution, and found after forty-eight hours, in the region of the liver and stomach, abundant fibrous ad- hesions. There were no adhesions iii the region of the small intestine. The abdominal cavity in the human subject, on the other hand, inclines especially to adhesions, particularly from a moder- ately specific irritation, as from gonor- rheal infection. The writer has, siirce the introduction of iodine disinfection, in about 70 cases of appendicitis, simple or complicated with abscess or peri- tonitis, 6 times found ileus from kink- ing or adhesions. This was unusual before the use of iodine for this pur- pose. Of about 300 cases of appen- dicitis in 1910 and 1911, before the in- troduction of iodine disinfection, there were only 5 cases of mechanical intes- tinal obstruction. He concludes that eventration of the intestines directly upon the browned skin should be ab- solutely avoided. They should be laid on interposed layers of gauze moist with saline solution. Whether this will be sufficient to prevent harmful effects from the iodine must be determined by further observations. Propping (Zen- tralbl. f. Chir., Bd. xxxviii, S. 661, 1911). Instruments may be sterilized by dry heat in the oven, by immersion in 95 per cent, carbolic acid, or in the more common wa)^ by boiling in water for fifteen minutes, In the ABDOMEN, SURGERY OF (MORRIS). later case bicarbonate of soda in the proportion of a teaspoonful to a quart of water is added to prevent the rust- ing of instruments. The carbolic acid preparation is particularly suitable for small, sharp, delicate instruments, and does not interfere in any way with their edges. The carbolic acid ^^'hich clings to them on removal is instantly neutralized by immersion in alcohol. INSTRUMENTS AND APPA- RATUS. — Scissors. — There are very few intra-abdominal operations which cannot be performed from first to last with a pair of scissors and a couple of needles and no other instruments whatsoever. In adding other instru- ments which give special facility in certain operations it is well to remem- ber this statement, and it will avoid the multiplicity of instruments which are frequently used to the patient's disadvantage or injury, as may be observed often enough. The form of scissors which the author prefers is the ordinaiy French locked type, five or six inches long, with one sharp point and one blunt point, and kept very sharp. The preference for scis- sors over scalpel is based upon the fact that small blood-vessels seem to ooze much less after division with the scissors than with the scalpel. This is possibly due to contraction stimu- lated by the character of the cut made by the scissors, but there is no inter- ference with primary union of the tissues subsequently, according to ob- servations extended over a series of years. Needles of the Hagedorn t3^pe will suffice for practically all abdominal work, and needles threaded with cat- gut slipDed under bleeding vessels readily take the place of the artery forceps without loss of time, with a rather greater degree of accuracy, and with less crushing of tissues. For intestinal or gastric suturing the author prefers a needle that is con- siderably larger than the one that is commonly used, for the reason that it carries a suture of greater diameter, and a suture of fairly large diameter does not cut out of the tissues so readily as an extremely fine suture when subjected to tension. The custom of using a very fine needle and silk is based upon the idea of causing the least degree of operative damage and avoidance of leaking of contents of the hollow viscera, but it is not based upon our observations of the extent to which the mucous mem- brane will plug fairly large punctures, or our knowledge of the greater secu- rity of tissues sutured with a strand large enough to bind without cutting. Retaining Apparatus. — The author is in favor of depending upon his fingers, and those of assistants, rather than upon clamps and other retaining apparatus in abdominal work; but this is because his methods were ac- quired while many of the proficient clamps which facilitate these proced- ures were in the course of develop- ment, and which gave mechanical advantages which seemed attractive, but which were sometimes observed to be injurious. Rubber-covered clamps of various forms, if carefully used, allow one to work speedily. One may not make such accurate ad- justments or such regular insertion of sutures if he disposes of mechanical adjuncts, and yet in cases where he can work quite as quickly without them the balance of advantage is in favor of the gentler method. Tem- porary steadying sutures may some- ABDOMEN, SURGERY OF (MORRIS). 7 times be employed in addition to the lingers in order to maintain a viscus in a certain position while operation is being- performed, and these are liable to do less harm than steel instruments in the peritoneal cavity. The author has employed most of the mechanical devices described for facil- itating operative work upon the stomach and bovv^el, but has dropped most of them, excepting the Murphy button, in favor of simple methods of suturing-, and the button is not used nearly as often now as it was a few years ago. Drainage tubes for the most part should be small, as otherwise they pla}^ the part of a foreign body in the abdominal cavity, and this is resented by the peritoneum. In 1895 the author described, in his book on the subject of appendicitis, a drainage wick which would take the place of drainage tubes in most places in the peritoneal cavity, and which would cause very little offense to the perito- neum. It consisted of gauze rolled loosely in a covering of gutta-percha or of rubber dam, very much as one rolls a cigarette, but leaving one end of gauze protruding. This soft, flexi- ble drainage wick acts by capillarity, adapts itself to bends and angles, and suffices for most purposes of abdom- inal drainage, provided that one understands the principles of capillary drainage, and keeps a good mass of fresh gauze upon the abdominal wall in such a way as to maintain the capillary power df the wick. Gauze drains not protected with an inoffensive covering are quickly filled with lymph-coagula poured out from the peritoneum in response to their irritating presence, and they become fastened to tissues in such a way that on removal they may draw loops of bowel into angulation. Where a very long drain is required, as from the cystic duct or from the bottom of the pelvis, the same principle may be ap- plied by using an ordinary flexible- rubber drainage tube or catheter split throughout its entire length on one side, and the wick of absorbent gauze carried loosely through the lumen of the tube. It is very seldom at the present time that one will need to use any gauze packing in the peritoneum cavity; but if such a calamity does arise, less harm is done if the gauze is covered with an apron of gutta- percha tissue or rubber dam to keep the bowel from becoming adherent, thus carrying out in a way the prin- ciple of the protected drainage wick. For patients with very heavy abdom- inal walls where pressure might nearly close the wick drain with its cover of rubber dam, or of rubber tubing, sheet lead is a useful part of our apparatus. Sheet lead can be cut with the scis- sors into strips of any desired width or length, and this strip doubled upon itself carries between the two arms a drain of absorbent gauze. The end of lead projecting upon the external abdominal wall can be bent over to avoid the danger of the drain slipping within. Lead seems to be quite as benign as rubber or gutta-percha tissue, and is accepted kindly by the tissues, excepting where it projects to some distance within the abdom- inal cavity, in which latter case it presents a more rigid and objection- able foreign body. Suture Materials. — The choice of suture materials in abdominal surgery is extremely important. For ordinary ligating of vessels, and for suturing of the peritoneum ABDOMEN, SURGERY OF (MORRIS). where adhesions are to be avoided, very simply prepared catgut is pref- erable, and excepting for large vessels a catgut which would be absorbed in forty-eight hours possesses advan- tages, because any suture material for the peritoneum which remains for two or three days is prone to cause, by its irritating presence, a line of peritoneal lymph-exudate followed by annoying adhesions. This is in ac- cordance with the well-known action of the peritoneum in walling in any object which is a source of irrita- tion. While such adhesions may be absorbed later, and may not be in a position to cause much annoyance, nevertheless there are many thou- sands of patients today suffering to some degree from adhesions of the omentum or bowel to the anterior abdominal wall, in cases where this complication could have been entirely avoided by the use of very fine, quickly absorbed suture material, which would not have caused the pouring out of much lymph by the peritoneum. Peritoneal margins united with the finest of sutures become adherent so quickly that there is no real need for any suturing which will last for more than twenty-four hours in the parietal peritoneum of the abdominal wall, or in other places where strong permanent adhesions are not purposely induced. For suturing the cut margins of bowel or stomach for the purpose of preventing hemorrhage, and of closing of tissues against infection, small chromic catgut in the place of simply prepared catgut is desirable, for it resists digestion when in con- tact with the secreting glands of these organs longer than simply pre- pared catgut. Simply prepared cat- gut, when in the secreting glands of the stomach or bowel, may be lique- fied in a very few hours, and chromic catgut in this position will do no harm, because it is at a point where adhesions are purposely secured. Linen thread and silk are used in the positions where we wish snug apposition of tissues until firm adhe- sions have been formed, or cut struc- tures of the stomach or bowel have united. For closing all parts of the abdominal wall we may dispose of any suture material, excepting the very fine, simply prepared catgut for the peritoneal layer and skin, and chromic catgut for the anterior and posterior sheaths of muscles; but, in place of chromic catgut where a last- ing, yet absorbable material is desired, the author is very fond of kangaroo tendon. It is remarkably benign in the tissues, which receive it with such a degree of toleration that large strands are carried readily, and the kangaroo tendon lasts in the tissues for a longer time than chromic catgut, unless the latter is prepared in a way which makes it so hard as to be irritating. POSTOPERATIVE TREAT- MENT. — The patient on being re- turned to bed should have wool next the skin and hot bottles at the ex- tremities, even though not much shock be present, for shock is present to some degree after almost any abdominal operation, due to stimula- tion of the afferent nerves of the brain and cord centers, with more or less lack of vasomotor power. There is apt to be more or less perspiration from leaking sweat-glands when the patient is placed in bed, and any undue exposure at this time may lead to a chilling which would be inducive ABDOMEN, SURGERY OF (MORRIS). to postoperative pneumonia. For the first twenty-four hours approximately the disturbance of the intimate gang- lia of the bowel will usually result in derangement of function of the bowel so that any food material is apt to undergo fermentation instead of diges- tion, and the toxemia from such fer- mentation may be very injurious, and might give rise to serious complica- tions. Thirst is inseparable from the post- operative period, and hot water given in teaspoonful doses frequently will partially allay the thirst, and supply all the real needs of the stomach for some hours after the operation. Patients are very urgent at times in their demands for cold water or ice after an operation, but cold water has a distinct tendency to increase vomit- ing, and ice in the mouth produces the same reaction that cold does upon the skin, as one observes after making snowballs : the hands become red and irritated, and in the same way the mucous membrane of the mouth and pharynx becomes irritated, if the patient is allowed ice or ice-water, excepting in the most minute quanti- ties. It has been the practice with surgeons . after abdominal operations to with- hold water by the mouth for twenty- four hours, or until the patient is free from nausea and vomiting. During this time the thirst is distressing. Some surgeons have for several years administered water by the rectum in small quantities to allay thirst ; but the routine method of injecting a large quantity of saline solution (0.6 per cent.) for the prevention of thirst after abdominal operations was first resorted to in the Johns Hopkins Hospital. The procedure consists in the injection of a quart of normal saline solution into the lower bowel immediately at the close of the operation and while the patient is still under the influence of the anesthetic. The patient is elevated to the moderately high Trendelenburg posture, a stiff rectal tube is inserted well up into the sigmoid flexure, and the fluid slowly poured into a glass fun- nel, which is held 3 or 4 feet above the level of the patient's buttocks. John G. Clarke reviewed the charts of 100 abdominal section cases which had not and 100 cases which had re- ceived the saline enemata; he was able to report the most gratifying results not only in the alleviation of thirst, but also in the reduction to a minimum of vesical irritability, which is so common in operative cases. W. M. Taylor (Memphis Med. Monthly, Feb., 1897). Saline rectal infusion is a most valuable means of relieving thirst so frequently complained of after ab- dominal operations. A. S. Morrow (Diagnostic and Therapeutic Technic, p. 509, 1911). Diet. — The first food to be borne after the hot-water period is passed is liquid diet and predigested milk, or fermented milk of several kinds, and broths are usually well borne. In two or three days, if the temperature and other vital signs are fairly normal, a more liberal diet will allow the patient to regain strength more rapidly. Meteorism, which is usually present to some extent, with or with- out colic, because of the disturbance of the sympathetic ganglia of the abdomen, may be relieved ordinarily if stimulating enemata are given ; but for the most part it is well to leave the patients pretty much alone, without attempting to do too much for them during the first twenty-four hours after an abdominal operation. Many times the author has asked patients what they most desired during the first day after an abdominal opera- tion, and the common answer has been that their greatest desire was to be left alone. 10 ABDOMEN, SURGERY OF (MORRIS). Opiates. — There is a general ten- dency to give opium in some form after abdominal operations, if the patient is in pain, but we must remember the specific action of opium in lessening the resistance to the spread of infection immediately after an operation, and not apply mistaken efforts at kindness in wishing to quiet the patient's pain. There are some patients of nervous temperament who suffer so much and who are so rest- less that they tire themselves out with fretting, if we do not give opium in some form. Consequently the resource is one that we may be obliged to use, but it should not be used excepting with full knowledge of its danger. It is the author's habit to tell patients in advance of operation that they are going to suffer a great deal afterward from colic, nausea and pain, but that they will arrive at a comfortable stage soon afterward. The effect of this statement to the patient has never, so far as the author knows, deterred anyone from having an op- eration done, as there is the natural feeling of pride in being able to meet such conditions, and the patient, ex- pecting a good deal of trouble imme- diately after operation, and prepared for it, is frequently enough surprised to find it so much less in degree than had been anticipated. Insomnia is so dependent on stom- ach and bowel disturbances that the two belong closely in association. Insomnia which is dependent upon the disturbance following an opera- tion is not so distressing if the patient has a good nurse who suggests quiet in all of her movements, and who does not allow avoidable disturbances to keep the patient awake. Sleep will be established frequently in a natural way b}^ the third night. Part of this insomnia at night is due to the fact that patients doze off at various times during the day, and really get during the twenty-four hours about all of the sleep that is necessary. A number of ordinary hypnotics, avoiding the opium preparations, will give some relief, and this is a matter which must be left to the judgment in individual cases rather than stated in the way of a general rule. Should the patient be allowed to leave his bed early? The suitable cases after abdominal section are those in which traumatism within the peritonevim is slight. Great care is necessary in the selection of these cases, because union of the abdominal wound may not be strong- enough to withstand the intra-abdominal pres- sure of sneezing or coughing even so late as the twelfth day. Vance (New York Med. Jour., Feb. 16, 1907). The writer allowed 100 patients to rise in the course of the first week after laparotomy, 13 on the first day, 16 on the second da3% 21 on the third, 30 on the fourth, 10 on the fifth, 8 on the sixth, and 2 on the seventh day, and has been much pleased with the results. Thrombosis occurred in 3 cases, but soon subsided; the condition was evidently responsible for it. It is advisable to be cautious in allowing pa- tients to get up very early when they had unduly high temperature or dis- turbances in circulation in the legs or pelvis, but under other conditions it is an important advance in the treatment. F. Cohn (Zentralbl. fiir Gynak., Sept. 19, 1908). No matter what the lesion or how weak the patients, the writer has them recover from ether in the sitting pos- ture by means of a bedrest. He keeps them in this posture for about twelve hours, and then allows them to lie down and turn in any position that is com- fortable. They sit up again with a bed- rest practically all the next twenty-four Abdomen, surgery of (morris). 11 hours. On the third day, if strong, but anyway on the fourth day, he has them in a chair. On the fourth or fifth day they walk around. From that time on they walk or sit up with their clothes on during the day, leaving the hospital usually from the tenth to the fourteenth dav. Chandler (Albany Med. Annals, Feb., 1908). Report based on results in 164 cases of laparotomy which were allowed to leave the bed between one and three days after laparotomy. Of these, SO were for hernia ; 56 for interval appen- dicitis ; 20 for acute appendicitis ; 7 for cyst of the ovaries; 4 for uterine myoma ; 8 for Alexander Adams's op- eration ; 3 for cholecystectomy ; 3 for gastroenterostomy, and 4 for entero- anastomosis. The rest were instances of exploratory laparotomy. Of all these cases, 1 only suffered from throm- bosis, and that to a mild extent. The formation of a firm cicatrix occurred promptly in all. Perfect narcosis with- out vomiting or other untoward effects, rapid operating and but little loss of blood, firm and close fascial suture, and aseptic healing of the wound are essen- tial to success. Kummell (Zentralbl. fiir Chir., Bd. xxxv, S. 4, 1908). The writer does not believe in keep- ing patients upon whom laparotomy has been performed several weeks in bed. If there are no indications of fever he is inclined to let them get up after a few days, dependent greatly on the pa- tient's own desire. When there is fever, however, the patients are kept in bed, as early rising may then do harm. The objections usually urged, dangers of secondary hemorrhage, breaking open of the wound, and embolism, are theoretical rather than practical. Har- tog (Berl. klin. Woch., March IS, 1909) . We are still too much tied down in this respect by the traditions of the old, bad S3^steni of septic surgery with its suppurating wounds. When a Avound is full of pus no relaxation can be al- lowed, but aseptic wounds are a new development and must be judged by totally different standards. So far as these are concerned, it is time that we discard ancient authority and think out the matter for ourselves. In the first place, a clear distinction must be drawn between allowing a patient to be lifted quietly out of bed and placed in a com- fortable chair with abundance of cush- ions and pillows for a few hours each day, for the sake of having his meals in comfort or for other reasons, and letting him get up and get about by himself, doing whatever he thinks fit. The latter is opposed, if for no other reason than that it is impossible to guarantee the patient against accidents. Moullin (Clin. Jour., March 16, 1910). POSTOPERATIVE COMPLICA- TIONS. — Shock when severe in de- gree requires special treatment in addition to the customary methods for retaining the body heat and keep- ing hot bottles at the extremities. Elevation of the foot of the bed temporarily allows the heart to work with less effort, but we have to be guarded about suddenly lowering the foot of the bed at any time while the patient is still in a condition of shock. The patient at this time may be suffer- ing from one of two kinds of anemia : anemia due to lack of vasomotor power and perhaps also anemia due to direct loss of blood.- For the anemia due to loss of vasomotor power secondary to derangement of function caused by disturbance of the sympa- thetic ganglia of the abdomen strych- nine is indicated, and should be given hypodermically in doses of from a thirtieth to a twentieth at intervals of about four hours. For the anemia due to actual loss of blood the indications are for sup- plying the loss of blood temporarily, and this is done either by direct trans- fusion of blood or more commonly by intravenous infusion of normal saline solution. In cases in which we have 12 ABDOMEN, SURGERY OF (MORRIS). both kinds of anemia present at the same time the use of the strychnine rnay be quickly transitory and injuri- ous, unless we have first by transfu- sion or infusion given the heart and blood circulatory system the mechan- ical advantage of possessing a full com- plement of fluid. Adrenalin or digitalis are powerful stimulants, but they stimulate the heart out of proportion, and are very transitory in effect, and unless given with great caution may lead to over- stimulation, especially if given in con- junction with strychnine. Overstimu- lation will be followed by secondary shock coming on a few hours after apparent recuperation from the first evidences of shock. Bandaging the legs firmly in order to driA^e out the blood in part and give the heart less work is, like elevation of the foot of the bed, a resource of temporary value, but we need to be guarded about removing the bandages before recuperation from the condition of shock is well established. The best method of administering the adrenal principle is by continuous rectal injection in saline solution, 1 dram of solution of adrenalin to a pint of the saline solution — that is to say, 1 in 160,000; the temperature of the liquid should be between 108° and 112° F., and it should be allowed to flow in not faster than at the rate of 1 pint an hour. A. J. Walton (Lan- cet, July 11, 1908). Adrenalin will raise the blood-pres- sure in normal animals in every degree of shock, with the medulla cocainized, or in the decapitated animal. It is rapidly oxidized by the solid tissue and by the blood. Its effect is fleeting; it must, therefore, be given continuously. By this means the circulation of a de- capitated animal was maintained ten and a half hours. G. W. Crile (Med. News, Nov. 29, 1902). Hypodermic injections are absorbed very slowly in the blood-stream during severe shock, but intravenous injec- tions of the adrenal principles, adre- nin, etc., or of pituitary extracts, raise the blood-pressure to a greater extent than in the normal state, a single injection of an extract of the poste- rior lobe of the pituitary influencing arterial tone for upward of an hour, i.e., long enough to produce recovery in some cases. Mummery and Symes (Brit. Med. Jour., vol. ii, p. 790, 1908). In 3 cases of postoperative shock, the writer injected 1 c.c. of a 20 per cent, solution of the posterior lobe of the pituitary body intramuscularly into the patient's arm before the pa- tient had fully recovered from the anesthetic. The effect was almost immediate, and the almost imper- ceptible pulse soon became large and bounding. This effect lasted from twelve to sixteen hours, and grad- ually passed off. Not only did the pulse become larger in expansion, but it was also slowed, and whereas it had been irregular it became regular. This effect seems due not only to the action of the drug on the blood-ves- sels, but also on the heart. The in- jection was given in conjunction with normal saline by rectum. G. G. Wray (Brit. Med. Jour., Dec. 18, 1909). Meteorisrn of extreme degree also appears to depend upon two chief factors : partial paralysis of the mus- cularis of the alimentary tube due to disturbance of the sympathetic cen- ters, and to fermentation of contents of the alimentary tract caused by saprophytes, which gain ascendancy when the normal control occurring in the. course of undisturbed digestion is taken away. The meteorisrn second- ary to mechanical obstruction or of spreading peritonitis includes these same prime factors, but the different forms of this condition require treat- ment based upon causation in the indi- A'idual case. The meteorism which is due to simple shock calls for mechani- ABDOMEN, SURGERY OF (MORRIS). 13 cal treatment chiefly, although the fermentation of intestinal contents is relieved to some extent by the use of subgallate of bismuth as an intestinal antiseptic, and by the use of the lactic acid ferment, consisting of prepared cultures of the Bacillus Biilgaricns, which now may be obtained in tablet form, or which may be used indirectly in milk prepared by the action of this bacillus. Mechanical resources consist, in ordinary cases, of introducing a rectal tube to allow the earh^ escape of gas, and by abdominal massage applied gently but persistently, beginning at the right side over the cecum and car- r3'ing the massage along the entire course of the colon. This order of massage movements seems to relieve distention of the small bowel quite as well as the colon, probably because of the natural tendency toward emptying of the small bowel into the colon. In the presence of severe colic in meteor- ism, massage would seem to be contra- indicated, but it is not, because colic is due to a spasm of the muscularis of the bowel, in its effort to contract to the normal caliber, and massage move- ments seem to give to the bowel the same sense of security that is obtained by a splint in cases of fracture with muscular spasm of the extremities. The author is impressed by the fact that treatment of meteorism of the bowel in this way by massage and by the rectal tube is not commonly appre- ciated as it should be, and he has very many times afforded decided and last- ing relief by these resources. A hj'podermic injection of y^o grain of salicylate of eserine gives excellent results in cases of tympanites after colotomy. Within fifteen minutes of its injection the patient begins to pass flatus. An enema of sulphate of mag- nesium should then be given. The re- sult is often marvelous. If necessary, the injection may be repeated in six hours without danger. F. E. Taylor (Treatment, Feb., 1906). Acute dilatation of the stomach belongs to the same category, is prob- ably dependent upon the same causes as meteorism of the bowel, and has practically the same order of compli- cations. In many cases there seems to be selective impression made upon the innervation of the stomach by shock, perhaps because of its proxim- ity to the solar plexus, and dilatation of the stomach occurs out of propor- tion to dilatation of the bowel. When we recognize acute dilatation of the stomach by the persistent vomiting, distress, and visible distention of the upper left quadrant of the abdomen in excess of distention of other parts of the abdomen, we have the charac- teristic features of this form of meteorism. In this condition the mechanical features of treatment are all important, and are obtained by placing the patient prone upon the abdomen, with the result of causing constant compression of the distended stomach. With the patient in this position, the stomach tube introduced at frequent intervals, washing of the stomach with warm saline solution results in causing the escape of very large quantities of gas. Patients suf- fering from this condition are not so sensitive to the introduction of the stomach tube as many others, and the immediate relief which is given temporarily often makes them eager for the next introduction of the tube. The important matter is to applv the stomach tube often enough, and this is a point commonly neglected. AVe must keep the stomach empty of gas and fermenting contents. 14 ABDOMEN, SURGERY OF (MORRIS). In cases in which the patient hap- pens to rebel against introduction of the stomach tube because of highly sensitive fauces we may spray the fauces in advance with cocaine solu- tion, and, if the tube is lubricated with a nice quality of sweet oil to which is added a few drops of wintergreen, the patient, relishing this, will chew the tube for a few moments, and then begin swallowing it. Further advance of the tube is made by the surgeon. Meteorism due to mechanical ob- struction of the bowel is also met with. At the present time we see very much less of dynamic and adynamic ileus than we did a few years ago, when it was common practice to use gauze packing in abdominal surgery. This gauze packing lowered the patient's general resistance, as a foreign body in the peritoneal cavity. It caused excessive exudation of plastic lymph from peritoneal sur- faces, and adhesion angulation was a frequent feature in consequence, or if not angulation, the arrest of peristalsis from the involvement of the long segments of the bowel among adhe- sions. That form of ileus in which per- istalsis progresses violently up to the point of arrest with a rapid produc- tion of graA^e symptoms can often- times be relieved by posture. If the patient's hips and legs are elevated upon the back of a chair which has been placed upside down in bed, and gentle massage applied, gravitation will sometimes stop the angulation or kinking of bowel in a few minutes, and it is gratifying to see the whole picture of a desperate case change so rapidly as it sometimes will when this posture resource is being applied, together with gentle massage. Re- opening of the abdomen and a search for the point of mechanical obstruc- tion are such very fatal procedures that they must not be employed with much hope of obtaining relief, but some authors hope, which the author does not share freely, to secure an occasional good result by opening the distended bowel by incising it after reopening the abdominal cavity to allow the escape of gas, or by inject- ing sulphate of magnesia solution through trocar punctures in the bowel. Clinically I think that we may usually observe that when the bowel is opened at any point for the escape of gas it allows the escape of gas only in the immediate vicinit}^ the paralysis of the bowel preventing the contraction necessary for empty- ing the lumen at more distant points. Rapid opening of the distended bowel at a point above the obstruction, inser- tion of a drain to carry off the poison- ous contents, and subsequent operation for the relief of the obstruction, after the patient has made some gain, is oc- casionally successful. Our resources must be applied promptly in cases of ileus with meteorism, because toxins generated in any part of the bowel which is not emptying itself rapidly lead to a dangerous toxemia, and the colon bacillus particularly increasing in virulent culture in an obstructed or paralyzed part of the bowel may not only cause general toxemia, but may be carried to the kidneys and liver, and there give origin to a train of serious complications discussed under the next heading. Colon Bacillus Nephritis. — If this continues after relief from the ileus has • been obtained, it will require special treatment internally. Five ABDOMEN, SURGERY OF (MORRIS). 15 grains of benzoate of soda coml)incd with five grains of hexamethylenamine administered at rather frc(|uent inter- vals, accordino- to the judgment of the physician, will exert a specific influeiice upon the complication of colon bacil- lus nephritis which so commonly follows various causes of loss of confrol over this bacterium. When the benzoate of soda and hexamethylena- min internally do not control colon bacillus nephritis in a satisfactory way, the pelvis of the kidneys may be flushed through a ureteral catheter. In many cases one may state inci- dentally that colon bacillus nephritis is often enough present in advance of operation in many abdominal condi- tions, passing for ordinary nephritis, unless one devises means for de- termining if the colon bacillus is present, and the author has known of instances in which excellent consult- ants wished to postpone operation because of the presence of albumin- uria, when, as a matter of fact, this albuminuria was due to the presence of the colon bacillus, and to be cured only after removal of the focus of original infection by the abdominal operation. The colon bacillus nephri- tis which occurs with appendicitis may often clear up rapidly after the operation without any special treat- ment directed to the nephritis, and the same result may be anticipated in a certain proportion of the cases of colon bacillus nephritis occurring with ileus. Meteorism due to extension of peritonitis after operation is some- times treated by the old Clark opium method, which consists in placing the patient profoundly under the influ- ence of morphine. It acts by limiting the spread of peritonitis due to peris- taltic movements of the l)o\vel, and tlie loss of resistance on the part of the patient from the shock which goes with peritoneal ])ain. On the other hand, we have the objection that bacteria increase more rapidly in a patient under the influence of opium. In addition to the beneficial influence of opium in selected cases, the ice-coil placed on the abdomen has the tend- ency to lessen the spread of peritonitis besides limiting the pain. The author has preferred the prin- ciple of turning the blood-current toward emunctories of the bowel, and securing elimination of toxins along with a free watery discharge from the mucosa of the bowel. This is accom- plished fairly well by the high rectal injection of an ounce of alum in a quart of water. The alum in the bowel produces the same effect that it does in the mouth, causes rapid watery secretion from neighboring glands, and incidentally stimulates contrac- tion of the paralyzed bowel, with emptying of its contents. We might anticipate that alum would have in the bowel an astringent effect, with the tendency to cause constipation, but it has precisely the reverse action, and the great amount of watery exudate which is drawn out in the presence of alum seems to overcome any irritating effect which it might have. Sulphate of magnesia by high injec- tion has an effect like alum, of causing watery evacuation which presumably carries off toxins, and the influence of sulphate of magnesia is probably due to its hygroscopic nature, drawing fluids from the peritoneal cavity toward the bowel lumen by osmosis. The sulphate of magnesia injection, either alone or combined with glyc- 16 ABDOMEN, SURGERY OF (MORRIS). erin, which is also hygroscopic, is perhaps the favored method of obtain- ing movement when there is any decree of paralysis of the bowel, but the alum injection is much more effective, and willact in cases where paralysis is established to such a degree that sulphate of magnesia would exert no apparent influence. In addition to these rectal injections, a very gentle massage is effective in some cases in overcoming the par- alysis of the bowel, although it seem- ingly would be counterindicated. In cases where septic peritonitis is present at the time of operation, and there is danger of such peritonitis remaining as a postoperative compli- cation, the Murphy proctoclysis is invaluable. This consists of the very slow instillation of warm saline solu- tion into the rectum continuously for a long period of time, and many forms of special apparatus for the purpose have been devised. The apparatus of Dr. Robert C. Kemp maintains an even temperature of the saline solution by the use of the vacuum principle in the container of the fluid, similar to that obtained by the thermos bottle. The methods here described for treating cases with spreading peritonitis assume that we have made provision for suffi- cient drainage and have applied other resources in an operative way. Poisoning by bichloride of mercury and by iodoform have in the past been com.mon postoperative compli- cations, although at the present time they do not occur so frequently, but still require attention. Poisoning by bichloride of mercury through absorp- tion from large wound surfaces gives rise to the characteristic irritation of the mucosa of the alimentary tract, but seldom appears in abdominal work, because there is almost no situation in which an expert operator would think of using bichloride of mercury. Iodoform, however, is very frequently used in abdominal sur- gery, but chiefly with iodoform gauze, and this gives rise to iodoform poison- ing so frequently that the author on one occasion, when being asked to look for it in a hospital ward, found several cases unsuspected in one ward. Iodoform is taken up very rapidly by the peritoneum, and its symptoms are commonly mistaken for the symptoms of septicemia, with rapid pulse, wet skin, and peculiar mental wandering. Where we have occasion to sus- pect that iodoform poisoning is a postoperative complication in abdom- inal work, we may determine the point by adding a pinch of calomel to some of the patient's urine in a saucer, and stirring with a wooden spatula. If free iodine is present in the urine it makes the customary re- action to iodide of mercury, distin- guished at once by the cloud of color. Removal of iodoform gauze from the wound in such a case, and taking up iodoform which is adherent to the tis- sues by pouring sterilized oil into the cavity from which the gauze was re- moved, and leaving the oil there for some minutes before abstracting it with absorbent apparatus, will com- monly allow the patient to recover from a severe case of iodoform poisoning. Patients vary greatly in their sus- ceptibility to iodoform, and the author observed one death from iodoform poisoning with characteristic signs in a young girl, sixteen years of age, in a case in which he arrived too late in consultation. And the young ABDOMEN, SURGERY OF (MORRIS). 17 girl had been poisoned by a roll of iodoform gauze, not much larger than two fingers in size, after an appendix operation. The surgeon in charge had been absolutely at a loss to account for the symptoms. While there are positions in which iodoform gauze is of considerable value in small quantities in abdominal work, we must always bear in mind the danger of the postoperative compli- cation of iodoform poisoning. In an attempt to discover the cause of the skin eruptions seen so often after abdominal operations, the author found that these occurred most often in pa- tients who were given an enema of soapsuds made from common 3^ellow soap, but if Castile soap were substi- tuted no eruption followed! This was corroborated by the fact that in ex- changing the yellow for the Castile soap in other patients who had these erup- tions it was found that the j^ellow soap produced rashes, whereas the Castile soap did not. It was then found that the cheap and common yellow soap con- tained a considerable quantity of resin, and to this the writer believes the cause of many of the rashes seen after ab- dominal section must be attributed. F. J. Shepherd (Jour, of Cutaneous Dis., July, 1909). Uncontrollable _ vomiting imme- diately following operation is prob- ably due to excessive stimulation of the nerves of the stomach through shock, or from the irritation of ether w^hich is being excreted by the glands of the stomach, and it seems to be due also at times to reversed peris- talsis of the upper part of the bowel, throwing contents of the duodenum into the stomach, and the continuance of the wave of reversed peristalsis to the point of including the entire stom- ach. This complication sometimes be- comes so dangerous that we must stop it by the chief means at our control, giving the patient the harmful mor- phine. Preperitoneal hernia is sometimes the cause for ileus with its vomiting and other train of symptoms, but it is not likely to occur in cases in which the operator is aware of the danger of this complication, and has guarded against it. Properitoneal hernia oc- curs in cases in which there has been defective suturing of the peritoneal layer of the abdominal wall after operation, and a small knuckle of bowel is forced by vomiting or cough into the space between the peritoneum and muscular abdominal wall. Hernia into a rent in the omentum may occur as a postoperative compli- cation, and, if, in the course of separat- ing adhesions, the operator has left any small openings in the omentum, these should be extended clear to the margin of the omentum, or closed by suture. In any event, possibility of hernia complication should be foreseen in all work which deals with the omen- tum, if rents are left unclosed. Perforation of the bowel some- times occurs as a postoperative com- plication at the site where a rigid drainage tube or bulky drainage ap- paratus has caused an undue amount of pressure, and perforative ulcer may occur a few da3^s after the operation at the site of a gastroenterostomy, if the bowel has been fastened so far away from the pylorus that acid con- tents of the stomach escape directly into the bowel at the point of junc- ture. Postoperative phlebitis occurs often enough to require attention. It may appear two weeks after an aseptic operation, and its origin is not well understood. As a postoperative com- plication in appendicitis, it sometimes 1—2 18 ABDOMEN, SURGERY OF (MORRIS). appears as an inflammation of the left iliac vein or left saphenous vein, and occurs in fact at a distance quite as often as at the site of operation. While causing- a high degree of dis- comfort and prolonging the period of illness, it is not often an absolutely dangerous complication. If abscesses are formed, they are apt to remain localized rather than to give rise to septic embolism. Pylephlebitis does not often occur as a postoperative complication, ex- cepting, in cases in which we have evidences of its presence in advance of operation, but abscess of the liver may appear so late after an abdominal operation that the relationship be- tween the primary focus of infection in the peritonal cavity and the liver abscess may be lost sight of. A patient may even leave the hospital, and his home, and travel to a dis- tance for recuperation, with beginning abscess of the liver, the treatment for which will receive consideration under the heading of that subject. Secondary abscess may appear at the site of an infection which has been cared for at the time of opera- tion, but such secondary abscess is prone to liquefy newly coagulated lymph toward the external abdominal incision, and to follow this line of least resistance, rather than to extend in other directions. Mesenteric thrombosis not mark- edly present at the time of an opera- tion may increase to become a post- operative menace, due probably to injury of the veins in the course of an operation, but the complication is rare. Bladder complications do not call for special consideration in this arti- cle. The bladder sometimes refuses to contract in a normal way after various abdominal operations. This is sometimes due to nothing more serious than the unaccustomed re- cumbent position of the patient, or to physic influence, although shock sometimes leads to disturbance of the innervation of the bladder, and at the same time we are apt to have hypose- cretion of urine due to a similar influ- ence upon the kidneys. It is best to avoid using a catheter if possible for emptying the bladder, and it is seldom necessary, excepting when we have di- rect evidence of an overfull bladder. Otherwise it is best to resort to such resources as massage of the bladder above the pubes, and the sound of trickling water upon a warm bed- pan placed beneath the patient. If we begin too early to use the catheter, there is a tendency for the bladder to depend upon that resource for some days, and sometimes for as long as the patient remains in bed, if we begin with the mistaken idea that prompt use of the catheter will simplify matters. Postoperative psychoses occasion- ally occur after abdonainal operations, and the operation is commonly held by relatives of the patient to be the primary cause. Such disturbances usually mean the precipitation of impending psychoses which were de- veloping in advance of the operation, but kept in check by the will of the patient until the shock and surround- ings of the operation relaxed that control. Such psychoses may be due to central causes, but are also some- times toxic in origin, as the abdom- inal surgeon sees them, and such psychoses precipitated by operation may be really on the road to elimina- tion, due to removal of the origin of the toxic impression, ABDOMEN, SURGERY OF (MORRIS). 19 Peritoneal adhesions causing- trou- ble subsequent to operation receive consideration along- with that general subject elsewhere in the article. Postoperative pneumonia occurs, according "to various authors who have tabulated many thousands of cases, in from 2 to 5 per cent, of all abdominal operations, although in practice one may have series of one or two hundred operations without a single case of pneumonia, and it is very much less frequent today as the result of our refinement in technique than it was ten years ago. True croupous or lobar pneumonia, lobular pneumonia and hypostatic pneumonia may all stand in direct relationship to causes which are more or less under control by the surgeon. The development of true lobar pneumonia, developing immediately after an operation, seems to the author to be more than a coincidence. The dis- turbance incident to any abdominal operation may lower the vitality of the patient in such a way that the omnipresent pneumococcus ma}^ sud- denly spring into activity, particu- larly if ether has been the anesthetic. We have recent knowledge that in- fections of various sorts may begin quickly in animals under the influence of that anesthetic. The shorter the period of anesthesia, and of operative procedure which lessens general re- sistance, the less we shall probably have of true lobar pneumonia, which has generally been held to be merely coincidental. Hypostatic pneumonia after abdom- inal operations may appear for the same reasons that it appears else- where, but neither hypostatic nor true lobar pneumonia are so distinctly traced as postoperative complications as is lobular pneumonia, and this lobular pneumonia is the particular one with which we usually have to deal. According to statistics, lobular pneumonia occurs more often after abdominal operations on the aged, and more often in men than in women, but the latter feature of the statistics does not have special refer- ence to abdominal operations. While general anesthetics are all more or less irritating to the bronchial mucosa, and postoperative vomiting is a factor allowing aspiration of mucus or substances from the stom- ach, there are other features leading to a special preponderance of lobular pneumonia after laparotom}-. The pain following abdominal operations interferes with full range of the muscles of respiration and favors pul- monary stasis, but direct infection of the lungs 'by bacteria may occur in three ways : by way of the mucous membrane, the blood- and lymph- vessels. After abdominal operations, with a tendency to pulmonary stasis because of limited respiration on account of abdominal pain, and reten- tion of matters which would be ex- pectorated if coughing w^ere not so painful, bacteria arriving at the lungs from the abdominal region by w^ay of the blood- and lymph- vessels meet with resistance which is less than normal. The author believes that long exposure of the peritoneum in the course of an ordinary operation may lead to the carrying of large numbers of air bacteria indirectly to the lung's without complete destruc- tion en route by phagocytes, and it is his impression that these cases are not infrequent. Embolic pneumonia and its common sequence of lung abscess by infection through the 20 ABDOMEN, SURGERY OF (MORRIS). blood-stream no doubt occurs from the handling of thrombosed vessels, and, while we recognize certain cases of pneumonia directly due to the presence of the larger emboli, it is probable that we have many other cases in which minute emboli give rise to complications which appear a few days after operation. Pleurisy frequently follows opera- tions upon the liver and gall-bladder, if these operations are for cases with infection. Here it is probable that infection is transmitted by way of the lymphatics through the diaphragm to the pleura, and the neighboring lung becomes next infected, giving us sometimes the dangerous pleural pneumonia. The postoperative com- plication of pleurisy or of pleural pneumonia cannot well be guarded against, but we may anticipate the danger of postoperative lobular pneu- monia, and lessen this complication very distinctly in several ways : by avoiding as far as possible unneces- sarily prolonged operations with the accompanying long period of anes- thesia; by maintaining the body warmth of the patient, and by allow- ing the patient postures which favor expectoration. It is probable that the Fowler position after operation, while not particularly favoring ex- pectoration, may lessen the danger from embolic pneumonia to some extent. Fistulas from the alimentary tract and bile-tract are sometimes annoy- ing as postoperative complications, but when not formed purposely for useful purposes they have a remark- able tendency to close spontaneously if left alone. Very much harm is done almost as a matter of routine at the present moment by surgeons, house staff assistants and nurses in their eft'orts at keeping such fistulse carefully cleansed. Antiseptics intro- duced into such fistulae cause disturb- ance of the delicate new cells which are being thrown out for purposes of repair, and even so harmless a solu- tion as saline solution is commonly injurious in fistulse. Employment of hydrogen dioxide, which cleanses fistulse in a most attractive way, is one of the most injurious of resources, because it destroys new cells quite as readily as it destroys pus. In cases in which we have reason to suspect that a fistula is kept open by some- thing at the bottom of the fistula, as a knot of unabsorbed ligature, a con- cretion, a bit of fecal matter, or other foreign body, we shall usually need to operate, for efforts at closing such fistulse are usually very futile until the foreign body is out. Excepting in cases in which we believe that a foreign body lies at the bottom of the fistula, our treatment had best be a treatment of neglect, doing nothing whatsoever in the way of cleansing the fistula, and simply using an external dressing for the purpose of cleanliness. Under this treatment new repair cells quickly form connective tissue, and such con- nective tissue, according to its well- known habit, contracts regularly and closes fistula. There are a few cases in which epithelium will move down- ward from the skin and upward from the bowel, forming an epithelial covering for the walls of a short fistula, and when such short fistulse are seen to have an epithelial lining this may be destroyed by leaving 95 per cent. carbolic acid along the line of the fistula for half a minute, and then neutralizing it with alcohol. After ABDOMEN, SURGERY OF (MORRIS). 21 the destruction of epithelium in this way by carbohc acid, new cells arc formed, but we must be sure that epithelial cells do not again cover the surface, and to guard against this the highly astringent subsulphate of iron is effective as an astringent which will not allow new epithelial cells to grow, but which does not prevent the development of connective-tissue cells, although connective tissue formation in such cases is tedious. One of the most persistent fistulas in the author's practice followed an operation for perforating ulcer of the duodenum, in a patient whose large size and desperate condition did not allow detailed work at the ulcer site at the time of operation. This fistula discharged pancreatic secretion, bile and chyme for some months, but finally closed spontaneously. As a rule, it is best to allow the patient with a postoperative fistula to get out of bed as soon as the wound is secured in the ordinary way, and the patient then goes about his ordinary occupation and engages in all sorts of activities, wath no attention to the fistula beyond the ^vearing of a small external pad of gauze for the purpose of neatness. Objects left behind after abdominal operations have led to complications in imposing array among statistics, and the gauze pad has been the chief offender. Reports of 100 cases of foreign bodies left in the abdomen after celiotomy. Fifty-eight patients recovered ; 42 died. Twenty-nine times a sponge was lost, twenty-eight times a tampon or gauze compress, four times a drainage-tube, and nineteen times artery forceps. In a number of instances two foreign bodies were left in. The sponges were generally recovered by second section. The majority of tampons and com- presses were discharged spontaneously through the rectum. Neugebaucr (Zen- tralbl. fiir Chir., Nu. 3, 1900). The writer has collected ISS cases in which foreign bodies were left in the abdominal cavity, sugg-^sting how fre- quent this serious accident is. The foreign body may cauce an acute or a low and protracted form of sepsis; be encapsulated and retained for months or years ; or be extruded through the wound, or into the hollow viscera ; or, more rarely, through the cicatrix. The accident has occurred despite repeated counts of sponges, and the plan of attaching tapes to the sponges is shown to be fallible. In a number of instances a sponge was torn in two during the operation. It is ad- vised that abdominal operation be done with the simplest equipment practicable. The responsibility rests with the nurse or assistant charged with the enumera- tion of the sponges and instruments, not the operator. Schachner (Annals of Surg., Nov., 1901). In 1'899 the writer found records of 108 cases, and in 1904 he had collected 88 more — a total of 236 cases, not to mention a number of others in which the correct details are not known. Netigebauer (Archiv fiir Gynak., Bd. Ixxxii, F. V. Winckel Nu., 1907). When one or more objects have been left behind in the peritoneal cavity the patient may go on to recovery, but usually there is a persistent nausea and a higher degree of local tender- ness and discomfort than we can usually account for, and the persist- ence of such condition of nausea and distress at the site of an operation may lead one to feel that it is best to reopen the abdominal cavity and search for a foreign body which has been left* behind. This postoperative complication is not so easily guarded against as one might imagine; but gauze for intra-abdominal work, to which tapes have been attached in the form of a long roll, one end of 22 ABDOMEN, SURGERY OF (MORRIS). which is always left outside of the abdomen to guard against accident, should be employed. Case in which, after removing a piece of gauze which had remained in the cavity for two months, the writer was obhged to resect the intestine in three places, the patient eventually- making a perfect recovery. He reports 17 cases in which gauze was left after operation, only one of which terminated fatally. In 9 the foreign body was dis- charged spontaneously, in 8 removed by operation, but in none were such extensive lesions found as in the case reported. Kayser (Archiv fiir Gynak., Bd. Ixviii, Hft. 2, 1903). Case of simulated ovarian tumor which proved on operation to be a completely encysted compress, relic of some former surgical intervention. Ex- periments on animals confirmed the possibility that an overlooked sterile compress can be thus enc3-sted, and also, further, that such a compress may work its way through into the gut and be spontaneously evacuated. He has found 41 cases on record of a compress having been left in the abdomen. In 9 the patients died soon after, wath symptoms of peritonitis. Riese (Ar- chiv fiir klin. Chir., Bd. Ixxiii, Xu. 4, 1904). Case of an old woman who had re- tained a long Terrier compression for- ceps (22 cm. long) in her peritoneal cavity for seven years. She complained of pains in the abdomen and noted a projecting point of some sort at the lower part of the abdominal wall. The forceps could be felt in Douglas's space by rectal examination, and it was removed through a posterior vaginal incision. The patient made a good re- covery. Grousdieff (Roussky Vratch, July 29, 1906). The writer attaches each compress or piece of gauze, used after the abdomen is opened, to the wire basket in which they were sterilized. Only large com- presses of several layers of gauze are used, and to each compress is attached a piece of narrow tape over six feet long. The free ends of the tapes are passed through the meshes of the wire basket and tied together. The basket may be placed on the floor under the table. The tapes are not annoying after one is used to them. Wechsberg (Zentralbl. fur Gynak., Xu. 12, 1907). Case in which a patient apparently secreted portions of gauze in her vagina after an abdominal operation, with the view of misleading her family attendant into the belief that they had been left in the abdomen after opera- tion and were escaping through a fis- tulous opening. The writer uncovered the trick, and reports the case as pos- sibly throwing a sidelight on the sub- ject of some alleged cases of foreign bodies in the abdomen, and as a source of blackmail. M. F. Porter (Jour. Indiana State Med. Assoc, April, 1908). Secondary hemorrhage as a post- operative complication occurs more often in abdominal surgery than else- where, because of violent vomiting, which dislodges sutures and liga- tures. This must always be borne in mind, and we avoid the accident by introducing as few mass ligatures as possible, and ligating vessels sep- arately. Very many cases of second- ary hemorrhage have occurred after ligation of the broad mesentery of the appendix, or of a broad ligament, because contraction of the psoas and iliac muscles, in addition to the other muscular contractions in vomiting, has a tendency to broaden out the peritoneal base and force off such ligatures, unless they have been tied with caution. Secondary hemorrhage occurs also when violent vomiting has caused fine sutures of silk or thread to cut out under tension, and for this rea- son the author favors sutures of larger caliber than are commonly employed. Where large vessels have been opened, and secondary hemorrhage occurs marked by the ordinary signs of increasing thirst, restlessness, ABDOMEN, SURGERY OF (MORRIS). 23 pallor, pain and rapid pulse, we must reopen the abdominal cavity for securing bleeding points and remov- ing blood, and this is usually a very dangerous procedure because of the condition of the patient, requiring preparation for direct infusion of blood or introduction of intravenous saline solution at the moment the abdomen is reopened. Another form of- secondary hemorrhage occurring after operation is common when the force of the arterial pulse is sufficient to give I'is a tcrgo to blood in veins torn in separating adhesions, and which are not bleeding much at the time when the operation is completed. Since von Eiselberg published his first observation on gastric and intes- tinal hemorrhages following operations (1899) many other authors have writ- ten on the subject. Most of them are in accord with A'on Eiselberg's theory of the causation of these hemorrhages; namel3% that they result from throm- botic and embolic processes in the territory of the gastrointestinal circu- lation. The author has studied 30 cases of gastric and intestinal hemorrhages after operation. All these cases were oper- ated upon for acute or chronic ab- dominal conditions ; 17 patients died after the operative procedures. At the post-mortem examinations, in most of the cases, very little could be found to account for the ofttimes profuse bleed- mg during life. It may m general be stated, however, that the anatomical alterations consist in hemorrhages into the mucous membrane, hemorrhagic erosions, or small ulcers. These lesions are to be found in the stomach or duo- denum ; the remainder of the intestinal tract is usually negative. These ana- tomical changes result from injury to the corresponding blood-vessels. Such injury may be: 1. Blocking of the veins from retrograde emboli or from a progressing venous thrombosis. 2. Paralysis of the circulation in localized areas, the eflfect of the circulating poison or, in rare cases, the result of an affection of the central nervous system. The gastrointestinal hemorrhages oc- cur most frequently in the first three days after operation. When the con- dition from which the patient is suf- fering is not fatal the gastric or in- testinal lesions rapidly get well ; the lesions are thus not true ulcers. The prognosis in individuals suffering from profuse hemorrhages is, in the presence of a general infection, very poor. J. R. von Winniwa-rter (Archiv f. klin., Bd. xcv, Theil 1, 1911; Amer. Jour, of Surg., Sept., 1911). After any aseptic abdominal opera- tion considerable blood may escape into the peritoneal cavity without causing a great degree of disturbance beyond the increase in local pain, which is the characteristic sign of such hemorrhage. Aseptic blood in the peritoneal cavity is still in the circulation in a way, be- cause the peritoneal cavity is a lymph- chamber, and the serous remains of the blood which escape in the course of coagulation are taken up into the blood circulation again. Morphine lessens the hemorrhage and strych- nine increases it. Bearing these facts in mind, we may sometimes give the dangerous morphine to advantage, or withhold the strychnine unless it is greatly required. The writer reports 5 cases of collapse of the lungs after abdominal opera- tions. The symptoms are sudden dysp- nea and C3'anosis, with, perhaps, pain in the lower part of the chest and a slight cough. On the same side as the operation there is dullness at the base, with weakness of the breath sounds, which ultimately become inaudible. The movements on the healthy side, on the other hand, are exaggerated, and the lung apparently becomes enlarged through a process of compensation. Pasteur (London Lancet, Oct. 8, 1910). 24 ABDOMEN, SURGERY OF (MORRIS). TOILET OF THE PERITO- NEUM. — The peritoneum protects itself so well, if given opportunity, that we need pay very little atten- tion to securing- asepsis of any part of the abdominal cavity while we are at work. If pus escapes upon normal peritoneum when abscesses are opened, it commonly causes no harm, even though it be left upon the peritoneum when we are through with the operation. There are two reasons for this. Bacteria are chiefly at work in the tissues rather than in the pus proper, and the latter is often practically sterile, even in the presence of advancing infection. By pus I do not mean intraperitoneal fluids teem- ing with bacteria, but these are for the most part not walled in like pus. The principle, however, of treatment is practically the same ; for where such fluids occur any special effort at securing asepsis would be futile, and, more than that, likely to be harmful. We may quickly arrange drainage for such septic fluids, but efforts at wiping or washing them out are apt to lead to injury of the endothelial covering of the peritoneum, and to defeat the object of our good inten- tions. When fluids carrying bacteria or sterile pus in quantity should be re- moved, it is best to do it very gently by quick absorption into masses of absorbent gauze, rather than by sponging or flushing, and we take good care at the same time to avoid the wiping which injures endothe- lium. Where stomach or bowel con- tents are likely to escape in the course of an operation, it is well to protect the field with absorbent gauze, but such gauze adheres quickly and firmly to normal peritoneum, with injury to its endothelium. Where we can apply the resource of placing a layer of rubber dam between perito- neum and gauze while we are at work, we guard the peritoneum in the best way. The peritoneum, while pro- tecting itself remarkably against in- fective material, is disabled by the washing and wiping commonly em- ployed, and particularly by the appli- cation of germicides, almost any one of which in the peritoneal cavity is productive of damage. A peritoneum which would be per- fectly safe, even though considerable septic fluid were left upon it, may when disabled start out on^ a career of infection which would have been avoided if we had not tried in a crude way to make the peritoneum ideally clean. In the vicinity of the focus of infection within the peritoneal cavity a local hyperleucocytosis becomes established with extreme rapidity, and this does away with the necessity for much of the work in toilet of the peritoneum described by authors in general. There are occasions in which it is desirable to evacuate very large quantities of pus or septic fluids quickly, and for this purpose hydro- gen dioxide may be used, provided that all exits are kept free, and that the only peritoneum with which it comes in contact is peritoneum al- ready damaged. Hydrogen dioxide damages normal peritoneum instan- taneously, and is to be used only where the peritoneum has already suf- fered great damage, but in such situa- tions it throws out pus and septic fluids in a great foaming mass, and, this mass removed, saline solution may- follow; leaving the cavity very clean. ABDOMEN, SURGERY OF (MORRIS). 25 While hydrogen dioxide is germicidal, its value rests in its mechanical effect in throwing out albuminous fluids and debris rapidly, rather than in securing asepsis where it is not needed, and when efforts to secure it through the use of germicides are damaging. For most cleansing purposes in the peritoneal cavity physiologic salt solution is the best, although even that is to be used with caution. If it is not employed with too much force or removed too vigorously it has a field of value. The solution of nine- tenths of 1 per cent., isotonic for human blood-serum, is more benign than the commonly emplo3^ed six- tenths of 1 per cent, which is isotonic for frogs' blood, and which had its origin in the laboratories. The saline solution should be sterilized by boiling. Sterile water, even though boiled, should never be used within the peritoneal cavity unless it contains salt. The reason why water without salt should not be used is because it is corrosive. Its corrosive nature may be noted at once by dropping it in the eye, which leads to immediate smarting and burning of the conjunc- tiva. Water without salt is so destructive to delicate tissues in laboratory work, and the fact is so well known, that it is a strange omis- sion on the part of many authors to neglect to state the dangerous char- acter of water without salt. The reason why even sterile pure water is corrosive is because an osmosis of salts fro-m the body cells immediately occurs in the presence of water not containing those salts in the proportion in which they are found in the body cells. Chloride of sodium, however, being the chief salt involved, is the only one which we need to add to the water for prac- tical purposes in routine work. Dawbarn poured milk representing septic fluid into the peritoneal cavity of a cadaver, and then set to work to find the best way to get all of the milk out again, and after a very great deal of flushing and spong- ing found that some milk still re- mained. This showed how impossible it is to remove the septic fluid by any mechanical toilet of the peritoneum, and demonstrates the degree of damage to peritoneum which will occur incidentally through our efforts. Consequently the toilet of the peri- toneum is best left in part to the peritoneum itself, aided by such resources as we have learned do not cause damage. As the result of experimentation some authors have closed the peritoneal cavity com- pletely without drainage in cases in which it was known that some septic areas remained behind, depending upon the peritoneum to dispose of any sepsis after the chief focus of infection had been removed. While primary union often occurs in such cases, the author believes that at the present time it is best to use small capillary drainage apparatus for removing culture fluids from the septic site. DRAINAGE OF THE PERI- TONEAL CAVITY.— Because of at- mospheric pressure upon the abdom- inal contents, any free fluid within the peritoneal cavity has a tendency to follow the line of least resistance to the surface, and if this fluid is given direction by way of small capil- lary drains we fulfill the general indi- cations in drainage, but posture of the patient is an aid under some cir- 26 ABDOMEN, SURGERY OF (MORRIS). cumstances; and the Fowler position, in which the upper part of the body is raised in bed to an angle which will allow fluids to gravitate to the drain in the lower part of the abdomen, is at times very useful. The only objection to the Fowler position is the call for rather more work on the part of the heart in u very weak patient. In tlie upper part of the abdomen we have a natural mechanical situa- tion, aiding drainage from the bile- tract region, in what is known as Morison's pouch, the space between the liver, above, and the stomach and colon, below. Blood, bile or septic fluids escaping into this pouch have a tendency to make their way directly to the surface at this point, instead of spreading into the general peri- toneal cavity below, and this tendency is so marked that a very little capil- lary drainage carried to the bile-tract region suffices to clear the area of culture media. It even allows us to do away with suturing the common bile-duct in many cases in which this has been opened for removing a cal- culus. Abdominal drainage is well con- ducted by any of the means described under the head of drainage apparatus, and the author feels that it is always best to employ capillary drainage, rather than drainage through tubes which carry no gauze wick. When a tube without gauze wick is filled with fluid, the column of fluid in the tube exerts hydrostatic pressure of con- siderable degree, which is met by the atmospheric pressure of the viscera, to be sure, but drainage through a simple tube cannot be so free as when fluids are guided through the tube by absorbent gauze with its high degree of capillary power. Drainage appara- tus should be carried as little as pos- sible among intestinal loops, because such drainage apparently acts as a foreign body, and the peritoneum rapidly throwing out lymph because of the offense seals in such drainage apparatus and deprives it quickly of its usefulness. If the abdominal work carries us to the pelvis, there is sometimes an inclination for the surgeon to add vaginal drainage, because the Douglas pouch represents the lowest part of the abdominal cavity, and one would naturally feel that fluids would all gravitate to this lowest point. This is not quite true, however, in practice, as atmospheric pressure has a~ tendency to force even pelvic fluids to the midline incision in the abdomen, with or without encourage- ment from capillary drains, and the advantage of depending upon drain- age through an abdominal incision rather than through a vaginal incision depends upon the comparative ease with which the area of the abdominal incision is kept aseptic. Drainage in the vaginal region is in an area much more difficult of maintaining in a degree of relative asepsis. The author formerly felt that it was an advantage to insert drainage apparatus at more than one point in the abdominal wall at points that seemed natural places for collection of peritoneal fluid, but of late years, in a series of many hundreds of abdominal operations sufficient to demonstrate the real requirements, he has found that one point for drain- age in the lower abdomen will suffice, and the only additional point used for drainage for many years has been in reference to Morison's pouch, which ABDOMEN, SURGERY OF (MORRIS). 27 amounts practically to a separate cavity more distinct than the cavity of the pelvis so far as the cjuestion of the nccessitv for drainag'e devices is concerned. We need to give aid to a single incision drainage at times by the addition of posture. In order to carry out the principles of capillary drainage it is essential for one to be familiar with the mechanical principles involved, and to make fre- quent change of the external mass of gauze to keep the capillary drain at work within the abdomen. In cases in which fluids drained from the peritoneal cavity are irritating to the skin, the skin may be dried tem- porarily, and then covered in the vicinit}^ with a thin layer of collodion or of vaselin. In addition to the drain for the peritoneal cavity, it is important, on closing the abdominal incision, to leave a tiny wick drain for twenty-four hours, extending be- tween the muscle layer and the skin. This can rest between the sutures in such a way as to interfere not at all with final primary union. At the end of twenty-four hours, or at the time of the first dressing, it may be pulled out, and will be found to have drained out as a rule quite a little serum or free fat, or both, which would have been a menace as a culture medium. Excepting in patients with a very thin adipose layer, it is well to make it a rule to introduce this tiny drain at any convenient point between the sutures, and to remove it on the fol- lowing day. HEMOSTASIS.— A few technical points belong to hemostasis in abdom- inal surger}^ Where it is possible to use torsion instead of ligatures — and this covers very much of the field — we can avoid ligatures, the presence of which causes the peritoneum to throw out plastic lymph in the vicin- ity for its protection, very much as the mollusk throws a layer of nacre over a grain of sand in' the shell. Where it is necessary to use ligatures we avoid including much mass in the ligature, because, the larger the mass, ,the greater the tendency for the peri- toneum to throw out reparative lymph which will lead to adhesion formation subsequently. We have also to remember that the efforts of vomiting after an abdominal opera- tion have a tendency to pull off certain ligatures, and consequently we must leave a considerable mass of tissue outside of the knot. Such mass of tissue is not likely to slough, as some operators fear, because it is kept alive by lymph circulation in the vicinity, and has a tendency to grad- ually becorne absorbed in a very benign way, because of the fact that it is tissue belonging to the indi- vidual. Hemostasis of the cut margins of the alimentary tract cannot readily be obtained by ligating, and conse- quently we employ the suture here instead, for the most part, and snugly drawn running sutures suffice for the purpose. EXTERNAL INCISIONS.— The ultimate success of an abdominal operation often depends largely upon the choice of the external incision, and we have two especial points to bear in mind : consideration of the best route for getting to any objective point within the abdominal cavity, and at the same time the best way for avoiding imperfect repair of the abdominal wall and unsightly scars. This includes a consideration of avoiding nerves which supply mus- cles, because a temporary or perma- 28 ABDOMEN, SURGERY OF (MORRIS). nent paralysis of certain abdominal muscles was a very annoying post- operative complication before sur- geons began to give attention to this matter. To reach an objective point in the peritoneal cavity, and at the same time avoid the complication due to muscles cut transversely, we may practically cover the ground by stat- ing that it is well to plan to make separate division of each layer — skin, adipose tissue, fascia, muscle and parietal peritoneum — and, further, to make blunt dissection as far as pos- sible of each muscle, even though this sometimes leads to openings crossing each other at somewhat dif- ferent angles. Stretching of the muscle wound with the fingers, how- ever, does away with most of the awkwardness of a situation where split muscles, after blunt dissection, as it is called, lie at different angles. When, for any reason, it becomes necessary to cut transversely across a muscle we must mark well the point at which such transverse inci- sion was made for the purpose of making accurate repair subsequently, otherwise the muscles acting in their lines of traction during the course of the operation will smooth out angles more by transverse incisions, and it is difficult to restore these angles again. On general principles our incisions are to be made directly over the objective point, but because of the ease with which an incision is made into the abdominal cavity in the median line, and the ease with which such an incision is repaired, the mid- line incision should be used for per- haps the larger part of our abdominal work. The size of incisions will depend largely upon the operator. One must make as large an incision as he needs for working freely and safely, but, if experience allows an operator to make his incisions shorter and shorter safely in any particular field of abdominal work, the patient will have the advantage of less danger from subsequent hernia, less shock, and less noticeable scars. Small incisions are dangerous for the beginner, and plenty of room is desirable on his account, but he may adopt the middle ground of beginning with a compara- tively small incision, and then enlarg- ing it as occasion requires. If the abdomen requires opening- in two dift'erent localities at the same sitting, there is frequently an advan- tage in making two or more small separate openings, rather than ex- tending a large one to reach distant points, such as often occurs in cases of intestinal obstruction, where one is not sure of the point of the obstruc- tion. If through the first incision, in a case of obstruction, one does not readily reach the point at which the constriction occurs, he is likely to add much more to the serious condition of the patient if he makes a large incision and pulls the bowel out from that than he is if he makes more than one incision small, and then passes the bowel between his fingers at that point without drawing it out upon the abdominal wall. Special incisions will be noted in connection with cer- tain operations, the above covering only a general principle. When we have occasion to open the abdomen at the site of a former operation, it is well to carry the inci- sion through normal skin on either side of the scar line for two reasons : because of the advantage of removing the scar tissue in some cases, and ABDOMEN, SURGERY OF (MORRIS). 29 because in opening" at the site of an old scar one may run across adhesions of abdominal viscera of which he was not aware, and they may l)e injured. The safe way for entering- along the site of an old scar, and for leaving the viscera in good condition for repair subsequently, is to go down through normal tissue on either side of the scar until muscle sheath is definitely reached, and then snipping muscle sheath until the muscle beneath is seen. The sheath can then be opened freely on either side of the scar without dan- ger. If there is any question about adhesions being present at just this point of dangerous character, we ex- tend the incision through the sheath of muscle to some point above or below the scar, where we may enter the peri- toneal cavity at a point free from ad- hesions, being extended at a free point large enough to admit the finger. The finger is then carried back along the peritoneal side of the scar line, and adhesions if present are separated. This having been done, the posterior sheath of the muscle and transversalis fascia and peritoneum are safely cut along the entire line of the scar, and the parts left in excellent position for correct apposition subsequently. One must always be on guard against small hernial protrusions into scar sites, and a small knuckle of bowel may be adherent in such pro- trusions without having leci to symp- toms sufficient for one to suspect its presence. Ordinarily, on reaching the peritoneum or subperitoneal fat, it is not necessary to pick it up and divide between forceps, if one has reason to believe that no adhesions occur at that point. Under ordinary circum- stances, the various la3^ers of the abdominal wall having been opened down to the peritoneum, or peritoneal or subperitoneal fat, these structures may be made tense between two lingers of one hand, and the points of scissors then introduced into this tense area nearly parallel with the plane of the abdominal wall, a neat entrance into the peritoneal cavity is made with celerity. This opening can then be enlarged to any desired extent with the scissors, or in many cases by stretching. Closure of the abdominal incision may also be described in a general way to cover most of the principles involved. The first suture of the peritoneal incision should consist of the finest catgut, because, the smaller the strand of catgut, the less peri- toneal irritation from the suture, and consequently less tendency to adhe- sions of the omentum which reaches out to wall-in points of irritation within its range. A fine strand of catgut is also a distinct advantage along the line that would be touched by the liver, which slides along the ab- dominal wall with each respiratory movement. Suturing the incision in the ab- dominal wall in layers gives a more satisfactory and stronger looking wound histologically than the en masse suture. Wounds sutured in layers Were the stronger after two weeks, the strength of the scar having been tested by an actual pull. Judged from a histologic study, the suture in layers is also more desirable than the suture en masse be- cause in this way in the process of repair the strong trabecular tissue aris- ing by proliferation from the fascia united with tissue of its own kind, thereby increasing the strength of the scar and decreasing the time necessary for repair. Violent manipulations of the edges of an abdominal incision should be avoided with the same care as has been recog- 30 ABDOMEN, SURGERY OF (MORRIS). nized as essential to good results in the handling of the intestines or stomach. Murphy (Boston Med. and Surg. Jour., . March 7, 1907). In experimental work with animals in the course of which the author closed peritoneal incisions wath rather large strands of catgut or silk for the purpose of saving time, he ob- served that adhesions of intraperi- toneal structures of some sort along the suture line are practically uni- versal. He observed that the smaller the strand of catgut, the less post- operative adhesions occurred, and although such adhesions commonly become absorbed they remain just often enough in practical surgery to make it a A^ery general point to avoid them as much as we can. Very little strength indeed is required for ap- proximating peritoneal margins, and a suture which would be absorbed in forty-eight hours is all that is re- quired, and a very small strand at that. In the closure of an abdominal in- cision the writer overlaps the cut edges of the rectus fascia. The peritoneum is sutured with catgut, and the same suture is used to whip together the muscle. On the right side of the wound the fascia is separated back from the muscle for from 1 to 3 cm. ; likewise on the left side. Tension sutures are then introduced through the skin about 3 cm. from the edge of the wound, passing through the fat and the fascia about 1 cm. from the edge, then in and out through the fascia on the left side from 1 cm. to 3 cm. from the edge, and back through the fascia on the right side, then out through the fat and skin on the left side. The sutures are placed from 4 to 5 cm. apart. Next the edge of the overlapping fascia is whipped down with chromic catgut, and the skin sutures with a buttonhole stitch. If the ends of the tension sutures are drawn taut, the fascia will overlap, and the whipping down of the edge will be facilitated. Gauze saturated with 70 per cent, alcohol is placed over the wound, and the tension sutures are tied over the gauze. The tens'on sutures are removed in from ten to fourteen days. Lucas-Championniere conceived the idea of overlapping the fascia in the operation for inguinal hernia, and em- ployed the method as early as or even earlier than 1892. To Dr. Charles P. Noble is due the credit of being the first to use, describe, and make popular the method in America. He began to overlap the fascia in 1894 and used it as a routine procedure in the closure of all abdominal incisions after 1896. The method of Lucas-Championniere is now used with many slight modifications in technique by surgeons all over the country. S. E. Tracy (Surg., Gynec, and Obstet., April and Sept., 1911). It is the sheaths of the muscles upon which we depend for strength when closing an abdominal incision. Suturing of the sheaths of the mus- cles is carried out neatly by using a continuous suture of chromic gut along the posterior sheath first, and then returning along the anterior sheath without introducing sutures into the muscle itself at all when the incision is made in the median line of the abdomen, and the same principle can be used in several parts of the abdominal w^all. Muscle belly does not hold sutures so well as muscle sheaths, and there are few situations where it is necessary to introduce sutures into the muscle belly. By bringing the posterior and anterior sheaths of muscles into their respective normal positions, atmospheric pres- sure carries the bellies together much more evenly than we could do it with sutures. Several fanciful methods for sutur- ing the various structures, of the abdominal wall have been described, ABDOMEN, SURGERY OF (MORRIS). 31 but it is 111 it necessary to dn aiiylliini;' more than to lea\'e structures as we found them as nearly as possible. Where one can catch the transversalis fascia along- with the posterior sheath of a muscle in a suture, it is well to do so. In cases in which there may be need for reopening- the abdomen sub- scquentl}', interrupted sutures of the muscle sheath for a part or all of the wa}^ are of advantage, because then we reopen onh^ to the extent neces- sar3\ AMiere a drain has been left in an incision, the suture running up to the drain may be followed by a pro- visional interrupted suture, if it is desired to close the incision com- pletely when the drain is removed, but this is seldom necessary, for proper suturing up to the small drains wdiich are now in vogue will allow of the walls falling together naturally enough wdien the drain is removed. One disadvantage of carrying the sutures through muscle tissue is the danger of the sutures cutting through such tissue wdien the patient vomits. This space then fills with blood which must be replaced by new tissue cells, and it usually is so replaced if the blood, as a culture medium, does not become exposed to infection from the suture, or some other source. For the muscle-fascia suture, chromic cat- gut, or kangaroo tendon is desirable, because they last so much longer than simply prepared catgut, but not so long as to constitute a source of irri- tation, as a rule. Kangaroo tendon seems to be much more benign than chromic catgut, and it lasts rather longer in the tissues, unless the cat- gut has been chromicized in a way which makes it too hard. A\ liere one needs to introduce in- terrupted tension sutures, there is nothing better than kangaroo tendon passed through muscle sheath, care- fully avoiding the fat, into which no tension suture should ever be intro- duced. When closing the adipose layer of the abdominal wall, it is ex- tremely important to avoid allowing any sort of suture to enter any fatty structure. The reason for this is because the entrance of any suture, or even the needle carrying the suture, into the adipose layer allows free oil to escape and to follow the course of the needle or suture, and such free oil, according to tiie principle of hydrostatics, wall begin to travel, opening up lines for infection in many cases. Where a very small amount of oil is set free along suture lines it is no doubt absorbed in many cases, but nevertheless always introduces a danger which is unnecessary, because w^e can apply a principle in mechanics commonly overlooked which allows us to do away with any suturing through an}' adipose layer of the abdominal wall. This principle is the one Avhich is employed by the boy who lifts stones after pressing down upon them a disk of w^et leather to which a string is attached in the middle. It is the principle of making use of atmospheric pressure. When the suturing of muscle sheath has been completed, if the adipose layers of the abdominal wall are then pressed together with the hands, they adhere firmly under atmospheric pres- sure the moment that the skin is sutured. It is somewhat difficult at the end of forty-eight hours to sepa- rate fatty tissues along the original line, if one has occasion for any reason Z2 ABDOMEN, SURGERY OF (MORRIS). to re-enter the abdominal cavity. The question of suturing the adipose layer then may be disposed of by saying simply, Do not suture adipose tissue at all. To overcome in most instances the difficulties of intra-abdominal operation in stout patients, the writer resorts to a large excision of skin and fat from the overweighted abdominal wall, re- moving a skin section either in the transverse or in a vertical direction cor- responding to or at right angles with the incision, about 8 or 10 inches in length by 3 or 4 inches in width. This does away with the thickness of the wall down to the fascia, while from the fascia inward the difference between different abdomens is not great. If the patient is excessively fat, one will then naturally do a regular lipectomy opera- tion. This serves the same purpose and is done the same as the lesser pro- cedure here described. The writer em- phasizes the value of removing wedges of skin and fat in patients who are not troubled with obesity, but simply and solely for getting rid of a part of the thickness of the abdominal wall and making the field of the operation more accessible. An oval or an elliptical excision is made, cutting right down to the strong fascia overlying the rectus and oblique muscles. All bleeding vessels ought to be carefully tied. It is a good plan to slope the edges of the incision a little inward. When this piece of skin and fat is removed the operator then finds it much easier to open the abdominal wall and operate than in a similar case in which he has to retract this embar- rassing mass of tissue as well. The writer closes such a wound with a fine catgut suture, catching a distinct layer of fascia about the middle of the fat, silkworm-gut sutures uniting both skin and adipose tissue. Kelly (Annals of Surg., March, 1911). In suturing the skin the use of the subcuticular suture avoids scarring with a needle, and it also avoids the danpfer of making stab cultures of the Staphylococcus alhus, which is found regularly as an inhabitant of the hair- follicles of the skin. AVhere very heavy abdominal walls are to be sup- ported, we may fortify the skin sutures by placing squares of zinc oxide plaster at a short distance from the line of incision on either side of the incision, and then lacing these squares together through eyelet holes placed in the margins. To avoid infecting the wound with the lacing, a thin layer of dressing is first placed next the wound, and then the squares of adhesive plaster laced together over this. We thus avoid altogether the necessity for introduc- tion of deep through-and-through sutures, which in the past have been commonly used for supporting over- heavy abdominal walls. To avoid unsightly scars of the skin due to stretching out and widen- ing of the scar line after union is complete, we put a single layer of gauze or chenille over the line of incision, and then pour on collodion. This collodion-gauze dressing may remain in place for two or three weeks if one wishes, and it consti- tutes a very neat resource for avoid- ing scarring of the abdominal wall for people who have a perfectly legiti- mate vanity in the matter. The Pfannenstiel incision for lapa- rotomy is commended by the writer, who employed it in 150 cases, ?>6 of which were cases of carcinoma oper- ated by Wertheim's method (removal of the iliac glands). It is easy, the liability to hernia is decidedly dimin- ished, the mortality is probably less than that of the medi?n incision, and the only contraindications are those in which the vaginal route can be used, large fibroids, and cases in which there are many adhesions. Vertes (Zen- tralbl. fiir Gynak., Sept. 24, 1904). ABDOMEN, SURGERY OF (MORRIS). 33 Pfanncnstiel's incision may be used with good results in the Wcrthcim operation and for the removal of ovarian tumors if the cyst is punctured. It is not suitable in suppurative or tuberculous cases. It is believed to have important advantages over the median incision in many cases. Helsted (Zen- tralbl. fiir Gynak., Bd. xxxii, S. 248, 1908) . The Pfannenstiel transverse incision, as shown by over 1000 cases, aflfords a better ultimate outcome than the longi- tudinal incision, even in cases with du- bious asepsis. The tendency to post- operative hernia is less, the patients are able to be up earlier, and the scar is less prominent. Jaschke (Miinch. med. Woch., Nov. 1, 1910). Of 581 laparotomies performed dur- ing two years at the Tubingen clinic, Pfanncnstiel's suprasymphyseal trans- verse fascial incision was employed in 550. Where great haste was indicated, as in a ruptured extra-uterine preg- nancy, the median incision was used. Of the entire number, 84 could be re- examined. Of these, 3 showed herniae in the scar. Of the entire number of cases, 418 healed without suppuration, 109 suppurated, and 23 died. R. Klotz (Zentralbl. fiir Gynak., May 21, 1910). EXPLORATORY OPERA- TIONS. — Very few exploratory operations should be done in abdom- inal surger)^ The method no doubt makes diagnosis easier for the sur- geon, but a more difficult matter for the patient, and it is highly important to make use of all available diagnostic resources before taking active steps in an operative way. Where an ex- ploratory operation really needs to be done, however, it is best to make as small an incision as will suffice for the purpose. There are cases, for instance, in which we need to know if adhesions in the bile-tract region are complicating a loose kidney, or an appendix operation; and an explora- tory operation, if small, for the pur- pose of determining that point is frequently in order. Then again, after traumatisms and perforations, the peritoneal cavity can contain blood, chyme, fecal matter or gas, which might be overlooked if one were too conservative about making explorator}-' incisions. In the pres- ence of traumatic shock, ordinary diagnostic resources may fail us, and lead us to employ what older sur- geons are apt to consider the resource of the tyro, namely, the exploratory incision. PERITONEAL ADHESIONS.— Perhaps the most potent single factor in surgery of the abdomen relates to peritoneal adhesions. They lead to a large part of the constipation from which the public is suffering; to an extremely important part of the obscure dyspepsias; to various local areas of pain and tenderness, and fre- quently enough to acute disasters. The surgery of peritoneal adhesions belongs to the surgery of the future for the reason that such adhesions are commonly overlooked by diagnosti- cians at the present time, and only a trifling percentage of cases of gastric and bowel disturbances are placed where they belong in cause and effect relationship to adhesions. The new work of filling the stomach with bis- muth solution and then making fluoro- scopic examination to determine points of interference with gastric motility is now allowing us to make the diagnosis of gastric adhesions freely. In post-mortem work we find peri- toneal adhesions at some point in pretty much every abdominal cavity, in adults at least, and the argument that these have not caused trouble during the patient's lifetime includes 1—3 34 ABDOMEN, SURGERY OF (MORRIS). the idea that the patient is to have made the diagnosis himself, and to have informed his physician in the ordinary course of narration of his troubles. In this article the subject of peritoneal adhesions can receive nothing more than brief treatment, but it may be disposed of in a general way which includes most of the prin- ciples. The surgeon has to consider the matter of separating peritoneal adhe- sions when they are found to give trouble, and to prevent their recur- rence. He has to take steps in his operative work which will guard against the formation of adhesions resulting from his work. On the other hand, he has to resort to the use of peritoneal adhesions established for his own purposes in many parts of abdominal work. In cases in which we wish to make use of peri- toneal adhesions it is important to scarify the peritoneum in the vicinity with the point of a needle in order to make sure of the free exudation of lymph together with destruction of part of the endothelial layer. The desirability of this scarification is ex- perienced in laboratory work where one is working with animals, and it leads to the feeling that sometimes we do not obtain adhesions enough for safety in some kinds of bowel work, unless scarification has insured their production. When we wish to prevent the re-formation of adhesions which had formed in advance of operation, many resources are of more or less value, but the author has chiefly depended upon two. These consist in the use of the aristol film, and the Cargile membrane made of the sterilized peritoneum of the ox. Aristol film is obtained by sprinkling aristol freely over the oozing surface from which adhesions have been separated, press- ing the aristol upon these tissues firmly with a pad of gauze, and then leaving the area exposed to the air for a moment until the lymph-coagu- lum engages most of the aristol in its mesh. This presents a mechanical obstacle to the re-formation of adhe- sions. The author has found aristol in the tissues of animals after ex- perimentation, several months after operation. This material probably disappears in time through slow liquefaction in the fat of cells which are undergoing retrograde metamor- phosis. To prevent the re-formation of peri- toneal adhesions by using Cargile membrane, this material is laid upon oozing surfaces from which adhesions have been separated, and it may be caught at several points with strands of very fine catgut in case it does not adhere well enough naturally. Fingers and instruments must be very dry while applying this animal membrane ; otherwise, it has a tendency to adhere to the fingers and instru- ments, rather than to the tissues of the patient. Cargile membrane is best transferred from a pad of dry gauze to the incised tissues. Animal membrane used in this way acts like the aristol film in presenting a mechanical obsta- cle to readhesion, but, unlike the aristol film, it has a tendency to undergo very rapid absorption in the peri- toneal cavity, remaining sufficiently long, however, as a rule, to serve as a conductor for new endothelium beneath its protecting surface. Lubri- cating adhesion areas with sterile oil at the time of operation is favored by some surgeons, on the ground that per- ABDOMEN, SURGERY OF (MORRIS). 35 istalsis keeps oiled tissues moving too freely to allow of adhesicnis. Adhesions for the most part under- go absorption by lymphaties under ordinary physiologic conditions, but where there has been much disturb- ance of tissue, infective or traumatic, the connective tissue which replaces the reparative lymph may remain permanently. It may act in various ways': by inhibiting peristalsis of the bowel and causing constipation, or exposing the patient to the danger of angulation of the bowel at adherent points. Adhesions may cause local irritation and discomfort only, or they ma}^ lead to complete strangulation of any of the tubular structures. They may become pulled out into long strands which ensnare the bowel, or wdiich roll the omentum into abnormal positions, and they may prevent the normal gliding of viscera, and give rise to distant reflex dis- turbances. In separating recently formed adhe- sions, it is best to separate them in as limited a way as will suffice for the completion of our work. The reason for this is because recently separated new adhesions are prone to re-form imanediately in spite of all our efforts, and they may re-form in such a way as to be more injurious than when gradually arranged according to na- ture's plans. To avoid the danger of formation of adhesions which were not present at the time of an operation we avoid rough handling of the peritoneum, which not only increases operative shock, but which stimulates the peri- toneum to throw out an undue amount of lymph. The danger of the formation of such adhesions following traumatism produced by the operator is sometimes greater than the danger from adhesions which form under local septic conditions. When in the course of operative work it becomes necessary to with- draw loops of bowel, omentum, or other intra-abdominal structures, it is important to prevent them from be- coming dry, chilled or exposed to the vast numbers of bacteria constantly falling upon them from the air, and this is obviated by covering exposed surfaces with a thin sheet of rubber dam or of gutta-percha tissue while we are at work. Gauze as a protect- ive agent is objectionable, because it injures the endothelial surfaces at once unless it is quite wet with saline solution, and has a special tendency to cause subsequent adhesion forma- tion. Some peritoneums do not form adhesions of consequence, even under marked provocation, while in other cases they appear despite all precau- tions. Consequently in abdominal surgery we must always have in mind the possibility of adhesion formation which may nullify our best efforts in an operative way. Traumatism of the peritoneum is particularly to be avoided when we wish to sponge out fluids from the peritoneal cavity, and this sponging can often be done be- tween the fingers of the operator's two hands. He places his hands about the field which is to be sponged in such a way as to make a little well down to the fluid, and the assistant, carrying gauze into the abdominal cavity, brushes the gauze repeatedly against the fingers of the operator, rather than against the delicate peri- toneum. The two points at w^hich we need to open the peritoneal cavity most 36 ABDOMEN, SURGERY OF (MORRIS). often for relief of adhesions are in the bile-tract region and in the cecal reg'ion. The incision for reaching adhesions in the bile-tract region is commonly made along the free border of the ribs over the adhesion area, and in the cecal region the ordinary incision for reaching the appendix suffices. INTESTINAL SUTURES.— Operations on the intestinal tract, despite their number and variety, can be reduced to a few simple steps of technique of which the most impor- tant element is the application of sutures and other retentive apparatus. In excision the principal stage of the operation is with the insertion of sutures. In primary anastomoses the ,apolication of the suture constitutes most of the operation. The cutting, consisting of making a communicat- ing opening after the suturing, is partly done. A general outline of suturing and its substitute procedures is therefore necessitated. To secure union in most wounds of the bowel a continuous suture of fine catgut is first passed through both mucous and muscular coats, and the peritoneum is closed over all with a continuous Lembert suture of fine silk. Silk or linen thread are necessary for all sutures of the bowel which are to hold more than a few hours, for the reason that catgut is digested very quickly, if it enters the secret- ing glands of the bowel, and it is commonly taken up also with great rapidity by the peritoneum. This two- plane suture known as the Czerny- Lembert is the evolution of years of inte^inal surgery, and is so firm as to prevent any possibility of leakage, but the apposition of the two peri- toneal surfaces insures peritoneal union almost immediately. In most cases it is best to scarify the peritoneum with the point of a needle wherever peritoneal adhesion is desired. This scarification with the needle insures the exudation of a large amount of reparative lymph. Any narrowing of the intestinal caliber under this suture is for the most part temporary, as expansion of the bowel will take pla-ce at that point later, and even the loss of a third of its circumference does not lead to actual stenosis. Any operation which consists in the closure of a wound in the long axis of the bowel involves in general no different suturing. This applies also to certain operations for pyloro- plasty and gastroplasty when a trans- verse incision is changed into a vertical one with a resulting increase of caliber. Whenever a cut surface of intestine does not enter into the restoration of continuity, it must be closed by a suture in the same way and under the same principle as linear wounds. Sutures of this type are applied to the cut surface of the stomach or intestine when these do not enter directly into anastomosis. In pylorectomy for cancer by Bill- roth's first method the cut stomach is simply sutured down to a point which makes the caliber the same as the caliber of the cut duodenum. A cut end of intestine may also be closed by Lembert sutures, for the principle remains always the same. When two cut surfaces are to be directly united by so-called end-to- end anastomosis the double plane of suture is applied as before, but the exigencies here are such that it is sometimes advisable to Insert some ABDOMEN, SURGERY OF (MORRIS). 37 of the peritoneal sutures first. Thus the serous sutures are phiced for about one-half the extent of the open- ing" to be closed ; then the deep pene- trating layer is inserted for the entire circumference, and finally the balance of the serous sutures are inserted. This plan of suturing is followed in a great variety of procedures, and as a rule for end-to-end anastomoses and implantations and secondary suturing in general. In primary anastomoses the principle is the same, some of the suturing being done in the interest of accurate coaptation before the anasto- motic opening is made. Thus, the parts to be joined having been placed in jux- taposition, with the fingers or with clamps, the two portions of gut are first joined by a number of serous sutures, about half the number to be required eventually. The opening is then made and the all-embracing layer of continuous catgut serves to unite the edges of the same, after which the serous suture is completed. To prevent small masses of mucosa from pouting beyond the suture line while invaginating the mucosa by the ordinarj^ methods of suture, the writer passes the suture from the mucosa out- ward through all the coats of the in- testine, instead of from without in, as is usually done. V. Schmieden (Zen- tralbl. f. Chir., April 15, 1911). McGraw Ligature. — A loop of bowel is brought against the portion of stomach with which it is to be con- nected, and the two structures are fastened together with a continuous durable Lembert suture for a distance of two and one-half inches. The stomach and bowel are then fastened together with a McGraw strand of solid rubber introduced with a large needle, preferably the Hagedorn full- curve type. The needle is passed through the wall of the stomach to the lumen, and then brought out again at a point two inches away. The needle traverses the wall of the intestine in tlie same way. The rubber strand then being drawn tight is tied in such a wa}^ as to constrict the included parts as snugl}^ as pos- sible. The elastic-rubber knot is still further held by tying it with a strand of silk or linen. The next step com- pleting the operation consists in ap- proximating the portions of stomach and bowel which were left free after the preliminary suturing was done. The McGraw ligature was devised originally for gastroenterostomy, but is useful as well for enteroenteros- tomy. Murphy's Button. — Wherever great speed in operating is a desideratum Murphy's button gives an advantage, and if it were not for the fact that buttons are sometimes retained, or that they sometimes give rise to com- plications per sc, a vei*y large part of our intestinal anastomosis work could be done with the aid of this ingenious resource. Two-stage Operations. — Some of the procedures for establishing gas- trostomy, enterostomy and colostomy are performed in two stages, the delay being for the purpose of allowing adhesions to form about the incisions and thereby protect the peritoneal cavity. Any operation whatever in which the external wound is not com- pletely closed may become a two- stage procedure if a special operation is necessary to close the wound. As a rule, however, a considerable inter- val elapses in such cases, too long in fact to enable us to regard it as a single operative intervention. AVhen Avounds are closed outright there is a 38 ABDOMEN, SURGERY OF (MORRIS). possibility that they may at once require reopening for hemorrhage or sepsis. Hence, despite modern asepsis which has enabled us to operate so extensively in one stage, the abdom- inal operator is constantly exposed to the possibility of operating in succes- sive stages. SURGICAL DISEASES OF THE STOMACH.— We shall first enumer- ate the disorders in which surgical procedures are necessary, and then de- scribe under a special heading the va- rious operations resorted to. Gastric and Duodenal Ulcers. — These require a variety of surgical pro- cedures at various stages of their de- velopment. Recent or older ulcers may cause fatal hematemesis, per- forative peritonitis, and crippling ad- hesions. From their location near the pylorus, actual or healed ulcers may cause pyloric stenosis. It must not be forgotten, however, that gastric and duodenal ulcer is a malady largely amenable to medical treat- ment, some forms not requiring sur- gery at all, but surgical intervention is indicated just as soon as medical resources lose efficiency, and at an earlier period than is customary as yet. The better diagnoses made by physicians in late years, and the ex- tremely satisfactory surgery of the present day bring the question of time for operation to a point which can generally be agreed upon by expert physicians and surgeons. Gastric ulcers are frequently multi- ple, and unless one is aware of this fact he may overlook others while caring for the first one which appears in the course of an operation. An active ulcer of the stomach may be surrounded by latent ulcers, or by scars which need excision, or which call for gastroenterostomy quite as much as the acute condition. Perforating ulcer of the stomach is the one most often calling for imme- diate operation, while the chronic changes of the stomach due to scarring from old ulceration allow of more de- liberate action. The so-called bleeding ulcer with- out induration or tendency to per- foration, while chiefly medical, some- times calls for surgical relief, and it is sometimes very difficult to find the bleeding point; but, if the stomach is opened at a point not far from the pylorus, pressure of the finger upon various folds and rugae or gentle wiping with a small gauze pad will excite hemorrhage anew. The ar- teries leading to this area may be ligated or separated, or, if the site is far enough away from the pylorus to avoid the danger of stenosis, a simple infolding of this part of the stomach wall with sutures results in putting this part of the stomach at rest out of the range of peristalsis, with a ten- dency to cure of the ulcer. Even a chronic ulcer thrown out of the range of peristalsis by infolding of the stomach wall may sometimes go on to cure, but in the latter class of cases it is usually best to excise and to perform a gastroenterostomy. If the pancreas is involved in an operation for ulcer of the stomach, any escape of pancreatic secretion may cause local necrosis of tissues. Where the pyloric portion of the stomach is much scarred from old ulceration, or engaged in active ulceration, complete excision of this part of the stomach followed by some form of intestinal anastomosis is called for. Ulcer of the stomach at a distance from the pylorus causes some- ABDOMEN, SURGERY OF (MORRIS). 39 times hour-glass stomach through contraction of its scars, and the opera- tion for this condition is referred to elsewhere. Duodenal nicer is the lesion met in nearly two-thirds of the cases person- ally seen. Unless an ulcer is demon- strated or hemorrhage requires it, oper- ation is not advised. Gastrojejunos- tomy is done for duodenal ulcer; Finney's gastroduodenostomy for py- loric stricture. Proximal gastrojeju- nostomy or the whole area excised in hour-glass contraction. For calloused nicer of the pyloric end partial gas- trectomy is performed; the upper end of the duodenum is closed, and pos- terior gastrojejunostomy is performed independently. Of 234 patients oper- ated more than two years before, 189 were cured, 21 improved, 10 were un- improved, while 14 died from various disorders. Mayo (Trans. Amer. Surg. Assoc, p. 142, 1908). Of 205 cases in which operation for chronic gastric or duodenal ulcers had been performed the results two years after operation were as follows : Cured 148, relieved 5, doubtful 9, not improved 12; of 14 not heard from, 11 could be considered as cured. Deaths from operation 2, gastric cancer 7, various disorders 8. The following practical points: The operative treat- ment of stomach disorders should be confined exclusively to those cases in which an organic lesion is present. If one makes a diagnostic mistake, and displays upon the operating table a per- fectly healthy stomach, gastroenteros- tomy should not be performed. In cases of acute perforation, the perfora- tion should be closed or the ulcer ex- cised. If the ulcer is prepyloric or duodenal, gastroenterostomy should be performed. If an ulcer is situated upon the lesser curvature, it should be excised to forestall the development of malignant disease. If an ulcer is prepyloric, pyloric, or duodenal, gas- troenterostomy should be performed. When possible, the ulcer should be infolded, since hemorrhage and per- foration have occurred from ulcers months or even years after the per- formance of gastroenterostomy. The most satisfactory method of gastro- enterostomy is the posterior, no-loop operation, with an almost vertical appli- cation of the bowel to the stomach. Regurgitant vomiting occurs as a re- sult of the loop operation, whether anterior or posterior. It is almost cer- tainly relieved by enteroanastomosis. In slighter cases the vomiting of bile may be relieved by lavage continued for some weeks. Moynihan (Trans. Amer. Surg. Assoc, p. 129, 1908). The various resources for giving gastric and pyloric ulcer a chance to heal spontaneously without excision of the involved area would often be preferable, were it not for the fact that cancerous degeneration of the embryonic blind tubules at old ulcer sites is a frequent occurrence. An inexperienced operator had better attempt a primary anastomosis perhaps and risk the cancer. Jejunos- tomy purely for artificial feeding may be done to prolong life in cases where the patient is unable to withstand a prolonged operation. AVhen the sur- geon is first summoned after perfora- tion has occurred, it is not only neces- sary to expose and suture the opening and cleanse the peritoneum, but it is often advisable to take advantage of the opportunity for performing a radical operation, if one is actually indicated. This is also the case often- times in emergency intervention for hemorrhage from an ulcer, and in pen- etrating wounds of the stomach it is further necessary to cleanse the peri- toneal cavity in the vicinity. Carcinoma.— The most radical pro- cedures are indicated only when there is some expectation of cure. With early recognition and improved tech- nique the operative mortality is ■40 ABDOMEN, SURGERY OF (MORRIS). slowly diminishing-, and operative procedures for comfort of the patient, rather than for cure within the three- year limit, are increasing- in propor- tion. A preliminary laparotomy is often required to make a diagnosis of operability in cancer. It is often advisable to add a gastrotomy, as otherwise early malignant disease has been overlooked. The only operation for radical cure is partial gastrectomy with extirpa- tion of neighboring lymph-nodes. Since patients with well-recognized cancer of the stomach seldom live beyond a year and suffer greatly, palliative operations are indicated in theory, but it must be remembered that the mortality is rather high in such intervention. The resulting prolongation of life is also so slight 'that in ordinary cases the risk would hardly be worth while were it not for the considerable mitigation of suffer- ing. When a palliative operation is undertaken, one with a minimum of intervention is indicated. Jejunos- tomy is therefore indicated on theory for artificial alimentation and com- plete rest of the stomach. In certain cases a gastroenterostomy may be preferable. The surgeon demands too much when he requests the practitioner to turn over cases of gastric cancer to him early, since diagnosis cannot be made sufficiently early. It "were better if he were asked to turn over to him all cases of pyloric obstruction, without waiting for chemical analyses, which at best are uncertain, or for the effects of medi- cines, none of which relieve mechanical obstruction. Mayo (Jour. Amer. Med. . Assoc, Aug. 15, 1908). Congenital Stenosis of Pylorus. — Patients with this affection, even when severe, have been known to recover under medical treatment, while opera- tion for radical cure has a high mortality, excepting at the hands of experts. Einhorn has recently devised an apparatus for dilating the con- stricted pylorus. If medical measures fail, gastroenterostomy is indicated early. Hour-glass Stomach, — This condi- tion is considered by some under the results of gastric ulcer, its usual causation. When it is discovered by exploratory laparotomy, or, better, with the fluoroscope, gastroplasty or gastro- gastrostomy may be indicated, the former for enlarging the diameter of the constricted portion, and the latter for establishing a new communication between the stomach pouches when the first-named intervention is impracti- cable. Since some operators perform a secondary gastroenterostomy in such cases to avert the necessity for a pos- sible second operation, it becomes a question whether a primary anastomo- sis is not the indication of choice. The latter in any case may be made with one or both stomach pouches, accord- ing to circumstances. Non-obstructive or Atonic Dilata- tion. — Atonic dilatation of the stom- ach or gastric myasthenia, like pylorospasm and relaxation of the pylorus, is only a symptom of some- thing else which needs to be worked out before we consider any operative work, but when the patient is losing ground in spite of other treatment, and we have pyloric obstruction due to kinking, a gastrojejunostomy or Finney's operation will make the work of the physician easier. Fin- ney's operation is preferable in cases in which the gastric motility is not much impaired. Gastric adhesions involving the stomach lessen the ABDOMEN, SURGERY OF (MORRIS)." 41 movements of the nnisciilnris of the stomach, disturb circulation, and pro- duce disturl)ances which predispose to ulceration, and a simple separa- tion of these adhesions in some cases of chronic ulcer of the stomach or pylorospasm or relaxed pylorus obviates need of other treatment. The operation of gastroplication, however, is usually performed for non-obstructive or atonic dilatation, with or without a secondary gastro- enterostomy; but there are very many cases of atonic dilatation which do not properly belong to surgery at all, and w^e must look for these con- ditions as reflex from some peripheral irritation, or some central nervous derangement. Atonic dilatation maj^ result from exhaustion of the mus- cularis due to persistent attempts for years at overcoming partial obstruction at the pylorus, due to the presence of adhesions or ulcer scars. It may be due to the influence of distant periph- eral irritation, such as loose kidney or eye-strain, or to fibroid degeneration of the appendix. All these possible factors must be very carefully excluded one by one, and all three are at the present day generally overlooked by diagnosti- cians. Atonic dilatation occurring with certain psychoses, while belong- ing in the medical class, may never- theless sometimes warrant surgical intervention. Gastroptosis. — The operation of gastropexy or omentoplication for shortening the suspensory (gastro- hepatic) ligaments of the stomach is indicated in this condition, if the gastroptosis occurs singly, but it is apt to be associated with panptosis, due to relaxation of peritoneal sup- ports of intra-abdominal organs ; so that at the same time we usually need to shorten the suspensory liga- ment of the liver, repair a diastasis of the rectus muscles, and perhaps fix loose kidneys in place. This severe operation makes it advisable to ac- complish all that is possible with external supports before resorting to operative procedures. Alost of the pa- tients with visceral ptoses are neuras- thenics, and surgery is of temporary avail only, — to be avoided if possible. Foreign Bodies. — Gastrotomy for the removal of foreign bodies is occa- sionally indicated, and does not differ from ordinary exploratory gastrot- omy, excepting that the incision may be made ver}' small in some cases, and just large enough to allow the entrance of forceps, which may be guided to the object through the aid of the fluoroscopic screen. This latter resource may also be used for reaching small objects in any part of the intestinal tract. Case in which 103 nails, 3 screws, 1 brass chain, 1 safety pin, and 1 sewing needle were removed from the stomach. The patient recovered, but five weeks later pains in the abdomen developed, particularly in the cecal region, which necessitated a reopening of the ab- dominal cavity. No more foreign bodies were found, but some adhesions were broken up. After that the pa- tient remained free from pain, so that evidently the renewed pains were occa- sioned by the formation of adhesions in the abdominal cavity. Borchardt (Berl. klin. WocK, Feb. 21, 1910). Stricture of the • Esophagus. — Gas- trostomy is required for some cases of stricture of the esophagus, to furnish access from two directions for dilatation purposes. TYPICAL OPERATIONS UPON THE STOMACH.— Gastroplication. — This operation, which is intended 42 ABDOMEN, SURGERY OF (MORRIS). to reduce the size of the stomach by infolding- its anterior wall, has been done successfully for simple non- obstructive dilatation, as well as for cases of pyloric obstruction due to the presence of bile-tract adhesions or ulcer scars. In several cases in which gastroplication seemed to be indi- cated because of dilatation secondary to the presence of adhesions, a simple separation of such adhesions, together with gastric lavage and massage subse- quently, has allowed the stomach to re- gain its normal dimensions. The principle of the operation involves the introduction of sutures placed within the seromuscular tissue. The more numerous and the longer the sutures, the greater the reduction in the capacity of the organ. The interrupted sutures are inserted at the lesser curvature, and passed in and out at intervals of one inch apart, until the anterior wall has been traversed without tying any sutures. They should be parallel in their course ; the end sutures must not be placed so as to be in danger of con- stricting the lumina of the esophageal or pyloric orifices. The sutures should be tied only when all have been placed in a row ready for knotting. If one suture were to be knotted in advance of, i.e., before, the introduction of the next one, it would run the operator along in an undesirable plane, for mechani- cal reasons evident while one is operating. The anterior wall will be puckered, creased or reefed ac- cording to the technique used, with resulting restoration of the natural capacity of the stomach. The sutures may be inserted in series of super- imposed planes when the dilatation is excessive. After gastroplication a cross-sec- tion of the organ shows a series of plaits if one plane of sutures is used; while, if several planes are super- posed, a sort of diaphragm projects across the cavity. These formations tend to undergo some atrophy. Although the normal size of the organ is restored, the shape is not, and the tendency of the posterior wall to pouch must sometimes be offset by a posterior gastroenteros- tomy. It has even been counselled to perform the latter as a matter of routine. A form of gastroplication has also been performed for gastric ulcer. The reef of the stomach wall which is the seat of the lesion is thus placed in relative rest, and under appropriate medical measures the ulcer may dis- appear during the atrophy. Two suture points usually suffice. Natu- rally the operation is best suited to ulcer of the anterior wall. Gastric Omentoplication. — Gastric omentoplication may be mentioned in this connection. This operation con- sists in taking a tuck in the suspen- sory ligaments of the stomach, and is indicated in gastroptosis. These por- tions of the lesser omentum known respectively as the gastrohepatic and gastrosplenic ligaments are sutured in three superposed planes with mattress sutures, the deepest being inserted for a very short distance, one-half inch to one inch near the pylorus. The next plane projects well beyond the confines of the first, while the third corresponds to the amplitude of the tuck to be made. The sutures are then tied in the order of insertion. It must be borne in mind that the aim of omentoplica- tion is to secure elevation without ABDOMEN, SURGERY OF (MORRIS). 43 compromising- the mobility of the stomacli. Gastrotomy. — Incision of tlie stom- ach is indicated primarily for explora- tion of the stomach, and at the same time when required for the lemoval of foreign bodies, tumors, etc., check- ing hemorrhage, and dilating- stric- tures at either orifice. It is always desirable after the laparotomy incision to examine the stomach thoroughly from without before incising its wall. The technique for incising the stom- ach is practically the same in different operations, although the site and ex- tent may var}^ with the condition to be treated. The usual incision is made in the long diameter as far as possible from large blood-vessels, and is not less than three or more than five inches long. It is advisable to wash out the stomach before opera- tion, but when this for any reason has not been done the organ must be evacuated by sponging gently with gauze or flushing with a siphon. Before incision the stomach must have been walled off from the peri- toneal cavity with gauze. After the purpose of the operation has been ful- filled, the gastric incision is closed with one or more planes of con- tinuous silk or linen sutures of the Lembert type. , When gastric ulcer is present some additions to the technique may be required. When the operation has been undertaken for hemorrhage from the ulcer, the latter must, if possible, be excised, and if an ulcer is found it is always best excised irrespective of the question of hemor- rhage. It may, however, be impracti- cable to excise, from the position of the ulcer, or. because of multiple ulcers or bleeding points, or the source of the hemorrhage may be ol)scure. Under such circumstances hemostatic procedures may be un- available, and may even aggravate the state of affairs. The only resource in such cases is to perform gastro- jejunostomy. Whenever an ulcer can be excised, the wound is closed first with catgut sutures, and a Lembert silk or linen serous suture must be superposed. When the ulcer is seated on the posterior wall with implication of the serous coat, it can hardly be dealt with through the anterior incision, and therefore an incision must be made through the transverse meso- colon, and the posterior wall of the stomach brought into view. When the pylorus is the seat of the ulcer, simple excision will be inadvisable because of subsequent stenosis, and' pyloroplasty will be indicated. When there is, besides, any evidence of esoph- ageal stricture, great care should be taken to perform gastrostomy by a typ- ical method, unless there is a possibil- ity that the obstruction can be relieved and the treatment completed from above. It would be impracticable to turn an ordinary gastrotomy incision into a gastrostomy^ fistula. Pyloroplasty (Heinecke - Mikulicz Operation). — This operation consists in restoring the original caliber of the pylorus when it is the seat of a simple stricture, or when suture following excision of an ulcer would result in pyloric stenosis. As cicatricial stric- ture of this orifice is due usually to the healing of ulcers, the operation is practically associated with this condi- tion. Only a single procedure known as the Heinecke-Mikulicz operation is current in the narrower sense of the word, as other operations to which 44 ABDOMEN, SURGERY OF (MORRIS). the name is given are in part gastro- duodenostomies. The technique is as follows : The stomach having been exposed by a median incision, the pylorus is drawn out, walled off from the peritoneal cavity, and incised. The presence of adhesions renders this stage difficult and sometimes furnishes a contrain- dication. The incision may be made after an assistant has approximated the stomach and duodenum, each at a point some three inches beyond the stricture. The incision while made in the long axis of the pyloric end, extending from duodenum to stom- ach, is really made from following the pyloric curve, of a horseshoe shape. Any redundant tissue is ex- cised. If a fresh ulcer is present most authors prefer to do a gastroduo- denostomy. In order now to enlarge the pyloric lumen, forceps applied to the middle of each lip of the wound are made to pull it into a straight transverse incision. In this position it is sutured in two planes including the peritoneal layer, unusual care being required because the incision is not sutured in its original plane. Despite the recommendations of Mikulicz and other eminent surgeons, the operation has many drawbacks. Adhesions are likely to result, and whether from this or other causes the stenosis may reappear. The indica- tions therefore are, as a rule, better carried out by performing some form of gastroduodenostomy or pylorec- tomy. Pyloroplasty by Finney's (Gould's) Method and Gastroduodenostomy. — In both of these procedures an anas-, tomosis is made between the stomach and duodenum, but the objects are entirely unlike, being in Finney's operation the widening of a stenosed pyloric orifice, Avhile in the latter the pylorus is excluded outright by a short circuit. Gastroduodenostomy does not differ essentially from gas- troenterostomy in general save that the duodenum mmst be mobilized beforehand. As that step is also required in Finney's pyloroplasty, the latter alone needs a detailed descrip- tion. The operative success will be due to the mobility of the duodenum, which may be and usually is more or less immobilized by secondary adhe- sions, and to such extent sometimes as to appear inoperable. Aside from adhesions the anatomic relations may be such as to require considerable operative manipulation to make the parts accessible, sometimes division of gastric ligaments. Traction sutures may then be inserted outside of the area to be incised for the purpose of steadying and tightening the tissue, but here it is better to use clamps, as in Gould's modified operation, which brings pyloroplasty in the same class as other anastomoses. The clamps grasp the duodenum and stomach in the long diameter — not in the trans- verse diameter, which would be the case in an exclusion of short-circuit anastomosis — with one clamp secur- ing the duodenum and the other the stomach just above the greater curvature ; the two are brought side by side and the two portions of intestine united by continuous sero- muscular sutures. A U-shaped inci- sion is now made, the bend of which corresponds to the pylorus. Redundant mucous membrane is clipped off; the resulting diaphragm or tongue is overcast with a second row of continuous sutures, simple ABDOMEN, SURGERY OF (MORRIS). 45 communication now being established between the duodenum and stomach at the natural orifice. An elliptic space remains to be closed with two planes of sutures, one all-embracing and the other serous and muscular. Gastrostomy. — Hacker's OpcratioJi. — This procedure is rather a small gastrotomy left unsutured than a true gastrostomy, in the modern sense of the term. It is recommended chiefly in emergencies. The stomach having been exposed and temporar}^ traction sutures passed through its wall to steady the organ, two planes of permanent sutures are inserted on either edge of the wound. The first plane passes through the abdominal wall only, including the peritoneum; the second, placed just within the others, includes in its grasp the walls of the stomach, but without entering the cavity. The sutures are then tied and cut close, so that the stomach is fixed to the abdominal wall. Addi- tional smaller sutures are left in place, and the wound packed with gauze. At a subsequent period, usually the following day or the second day, the wall of the stomach is opened with a knife, the wound being one- half inch long or just the size to contain a tube which should fit closel3^ The traction sutures should now be withdrawn. The abdominal incision for this operation should be three inches long and vertical in direction, slightly over an inch to the left of the linea alba, and beginning about one inch beneath the costal arch. AVhen the rectus muscle is exposed the anterior fascia is divided with the scissorSj but the belly of the muscle is separated bluntly. The posterior layer of the sheath is again divided with the scissors, exposing the peritoneum. This is opened only sufficiently to admit the finger, but subsequently prolonged with blunt scissors, and the peritoneum and muscle sutured with catgut. Franck's operation is a so-called valve operation, in which the portion of stomach wall to be incised is passed out of a relativel}^ large orifice under a bridge of skin, and finally out of a smaller incision, in which local- ity it is incised. The layer incision is known as Fenger's and runs parallel to the costal arch and about one inch below the latter, starting to the left of the ensiform cartilage and not exceeding two inches in length. When the parietal peritoneum is divided it is sutured to the muscles of the abdom- inal wall. AMth two fingers in this opening the anterior wall of the stomach is drawn out and the apex of the resulting cone transfixed with a traction suture^, while a running silk suture unites the base of the cone to the edges of the wound, all the tissues being embraced except the skin and the gastric mucosa. The lesser incision is parallel to the first and seated an inch above the margin of the costal arch. Its length should not exceed one inch. The tissues between the two incisions are then detached from the subcutaneous structures, when with the aid of the traction suture the apex of the cone is drawn under the bridge of skin and out of the lesser opening, to the edges of which it is sutured. The major orifice is then closed and the apex of the stomach, cone opened, a tube being placed within the canal. The Fenger incision may be replaced by a vertical one, as advised by Robson and others. 46 ABDOMEN, SURGERY OF (MORRIS). WitseVs Operation. — The canal, which acts as a valve, passes ob- liquely through the wall of the stom- ach. The anterior surface of the latter is exposed in the usual manner and sutured to the wound; an opening is then made in the central portion, toward the greater curvature. Into this a soft catheter is passed; the portion outside the stomach is laid flat against the latter, and directed downward and outward. Sutures are now passed through the seromuscular coats of the stomach over the tube and through the oppo- site side so that when tightened the tube is covered by a fold of stomach wall. The first suture point is seated one inch from the opening in the stomach and the entire length of the canal should be about an mch and a half. The abdominal wound is closed down on the free end of the tube, which is left projecting. Kader's Operation. — The tube enters the stomach directly instead of ob- liquely, and the canal is formed by producing an artificial thickening of the stomach with certain planes of suturing. Thus with the tube in situ, two folds of stomach wall are formed by inserting sutures twice through the wall — one to each side of the tube. These are tightened and cut close, and similar sutures are next inserted just outside the first. Each plane comprises four sutures. The canal thus produced is about half an inch long and has a good valvular action. A similar canal may be produced by several planes of purse-string sutures, as recommended by the late Dr. Senn. Author's Operation. — The author constructs a fistula lined with epithe- lium;, by utilizing long skin flaps. At the left costal border, over the chosen stomach region, make an incision five inches long through the skin and sub- cutaneous tissues directly cephalad from the costal border. Make a simi- lar incision on either side of the first incision, giving two ribbons of skin each one inch in width. A transverse incision at the cephalad end of the par- allel incisions frees the ends of the skin ribbons. The skin ribbons are next freed throughout their length, but remain attached at the costal bor~ der. The epithelial surfaces of the skin ribbons are placed in apposition and a running suture of catgut unites their margins. This transforms the ribbons into a tube of skin. The stonv ach is exposed and opened. The free end of skin tube is sutured with silk to the mucosa of the stomach. A rubber tube is passed through the skin tube. One end of the rubber tube is to re- main in the lumen of the stomach un- til repair of the wound is complete. The other end of the rubber tube emerges from the skin tube on the ab- dominal wall, and serves for introduc- ing nourishment. When the skin tube with its contained rubber tube follows the stomach into place, the remaining structures to be sutured have fallen to- gether in such a way that the character of final suturing is apparent, and needs no description. After repair of the wound is sufficient, at the end of a few days, the rubber tube is removed. This leaves a fistula lined with epithelium extending between abdominal skin and stomach mucosa. The stomach has drawn the skin tube into position at such an angle that atmospheric pres- sure keeps the skin tube closed, except- ing at times when food is to be intro- duced. ABDOMEN, SURGERY QF (MORRIS). 47 The writer makes an incision in tlic abdominal wall in the median line, from the tip of the xiphoid cartilage downward 3 or 4 inches. The left hand is then introduced into the wound and the abdominal wall on the left side grasped between the middle finger and thumb. In this way the left rectus muscle is located. With a long teno- tome an opening is made through the substance of the left rectus from the wound surface to emerge on the skin surface a few centimeters within the outer border of the rectus. This open- ing is widened by cutting upward and downward and dividing the rectus into two equal layers, an anterior and a posterior. The size of this passageway should correspond to that of the por- tion of the stom.ach which is to be drawn through. This portion of the stomach is then drawn through with a suitable forceps and its base sewed to the posterior edge of the median end of the passageway with 3 catgut su- tures. The opposite surface of the base is then sutured to the peritoneum and rectus on the opposite side of the median wound. The deep edges of the upper and lower portions of the median wound are then brought together by sutures. The end of the projecting portion of the stomach is now con- ducted through the tunnel made for it in the rectus muscle and skin, and its apex is fastened to the skin edges of the small lateral external opening. The large median wound is then closed over the projecting portion of stomach by two layers of sutures, one for the fascia and the other for the skin. Finally, the emerging end of the stomach is opened and its edges sutured to the skin. This portion provides a strong, permanent sphincter for the gastrostomy opening and makes it continent. Lafaro (Deut. Zeit. f. Chir., Bd. cviii, S. 307, 1911; Amer. Jour. Med. Sci., April, 1911). Gastrorrhaphy. — The operation comprises working beyond an emer- genc}^ suture of the stomach wall for traumatisms, the latter including perforation from gastric ulcer. But since gastrorrhaphy is involved in suturing a gastrotomy wound there is little to be said under a special heading beyond the statement that some modifications arise from the nature of the injury. While the operation is readily performed after incised and lacerated wounds, but few victims of such injuries recover — practically none after gunshot wounds. The technique of closing stomach wounds is described with gastrotomy. Report of 218 cases from the opera- tive clinic at Rochester from January 1, 1905, to April 1, 1909. Eight were from the duodenum, and of these all were simple ulcers. The remaining 210 were from the stomach. Of these, 47 were ulcers without suspicion of carcinoma, 2 were sarcomas, 2 adenomas, and 1 a diverticulum. Of the remaining 158 in the stomach, 5 were ulcers with enough microscopic appearance to place them in the doubtful class as possible transition cases. Of the remaining 153 cases, which were undoubted carcinoma, 109, or 71 per cent., presented sufficient microscopic evidences of previous ulcer to warrant grouping them as- carcinoma developing on previous ulcer. Whereas, theoretically at least, it has been con- sidered probable for many years that there was an immediate relationship between gastric ulcer and carcinoma, the profession has never before been treated to a paper so convincing, both because of its source and because of its individual excellence. Generally speak- ing, the writers show that a little more than two-thirds of a very long series of carcinomas undoubtedly took their origin in pre-existing ulcers. Wilson and MacCarty (Amer. Jour. Med. Sci., Dec, 1909). Report of 12 successive perforations of the stomach or duodenum with 11 recoveries, in which great importance was attached to rapid operation; no irrigation; multiple drainage (one tube to the site of perforation, a second and third in the right and left lumbar 48 ABDOMEN, SURGERY OF (MORRIS). region, and a fourth in the suprapubic region if fluid exists in the pelvis) ; elevation of the patient's body; early- feeding by the mouth and continuous saline irrigation by rectum imme- diately after operation. Carwardine (Lancet, vol. i, p. 239, 1910). According to the author's experience, the prognosis in perforating gastric and duodenal ulcers is fairly good if opera- tion be resorted to during the first twelve hours v^rhen the pulse rate does not exceed 100, while it is quite un- favorable if the pulse is 120 or over. As regards treatment, suture of the perforation after excision of the mar- gins of the ulcer or of the entire ulcerated area and very gentle removal of the exudate from the abdominal cavity are indicated in suitable cases. This should be followed by gastro- enterostomy only in patients operated on during the first twelve hours in whom the general condition is com- paratively good and when the history reveals undoubted symptoms of pyloric stenosis or where the pylorus is found to be stenosed. Of the ulcers observed 94 were localized, T(i to the stomach and 18 to the duodenum. No better illustration of the importance of early operation is afforded than the fact that two-thirds of the cases operated upon during the first twelve hours recovered. G. Petren (Beitrag. z. klin. Chir., Bd. Ixxii, Hft. 2, 1911). In the treatment of severe gastric hemorrhage Rovsing's method, which the writer has employed since two years, has proved very serviceable. It consists of the introduction of a dia- phanoscope, an especially devised instru- ment, through an incision in the stom- ach, thus permitting of direct inspection of its walls. This method permits of the detection of very small ulcerations, no larger than a pea, while any bleeding vessel can usually be seen. The hemor- rhage is arrested by applying a ligature, taking in the entire thickness of the stomach wall, and this area buried by one or two purse-string sutures. After removal of the diaphanoscope the gas- tric wound is sutured. In 4 or 5 cases of severe hemorrhage this procedure caused arrest of the bleeding. L. Kraft (Archiv f. klin. Chir., Bd. xciii, Hft. 3, 1911). Gastroplasty. — Gastroplasty is a procedure which is indicated only in hour-glass stomach, and differs but slightly from pyloroplasty, the con- striction of the organ taking the place of the pylorus. As in Finney's pyloroplasty, the two portions of the stomach are first brought together by sutures or clamps and a horseshoe incision made around the suture line at a distance of one-fourth inch. The inner or posterior edge of the wound having been stitched by a continuous suture, the outer or anterior edge is similarly treated. The communica- tion between the two halves of the stomach is thereby greatly amplified. Reinforcing sutures will probably be required for the anterior sutures. Gastroplasty may also be per- formed along the lines laid down for the Heinecke-Mikulicz pyloroplasty, in which a transverse incision is changed to a vertical one. The value of the operation is in question. Gastrogastrostomy. — Like gastro- plasty the operation is indicated only in hour-glass stomach. It consists of a simple anastomosis between the halves of the stomach, which then possesses two distinct communicating passages. The two stomach pouches are sutured together with a continu- ous Lembert silk suture along one side. The two pouches are next incised, and the cut surfaces joined -as in gastroenterostomy, and final suturing completes the apposition of the pouches. Partial Gastrectomy. — Partial gas- trectomy, the name of which is self- ABDOMEN, SURGERY OF (MORRIS). 49 explanatory, is undertaken chiefly for cancer of the p}-lorus, and to a certain extent for cancer of the stomach proper, gastric ulcer, and hour-glass stomach. AX'hen performed for benign ulceration the cases selected are those near the pylorus when the lesion is unusuall}' large, indurated or multi- ple. AMien done for hour-glass stom- ach the constriction between the storiiach pouches is the seat of an ulcer, and the excision can be com- bined with gastrogastrostomy. Technically the mere excision of a bleeding ulcer anywhere in the stomach is a partial gastrectomy, but in the tA^pical operation the pylorus must be sacrificed, and therefore the continuity of the digestive tube must be restored by some form of gastro- enterostomy, either gastroduodenos- tomy by end-to-end anastomosis, a gastroduodenostomy by implanting the duodenum in the stomach wall, or an ordinary gastroenterostomy. Partial gastrectomy has been divided into a typical and a cylindrical method, but the former, which relates only to incision of ulcer areas in the stomach proper, is sufficiently com- prehended under gastrotomy. Cylin- drical gastrotomy is also termed pylorectomy, since the pylorus is always excised completely, alone or with more or less of the entire con- tinuous gastric wall. Over a third of the organ may thus be sacrificed. BillrotJi's Operation. — The original method practised by this surgeon was to excise the p3'lorus and the neces- sary portion of the stomach wall, and to suture the cut end of the stomach until it reached the size of the duo- denum. The two cut ends were then joined by end-to-end anastomosis. At a later period the same surgeon preferred to close up both cut ends and perform a posterior gastrojeju- nostomy. Billroth prefaced his pylorotomy by ligating the vessels of the greater and lesser curvatures, and next tied ofT the peritoneal attachments (gas- trohepatic and gastrocolic ligaments). This mobilization enables the p^dorus to be drawn out of the external inci- sion. Clamps are then applied to either side of the p3dorus, two pairs each to duodenum and stomach, at a distance of an inch from the diseased area. Fingers or clamps may be used on the proximal sides. The stomach and then the duodenum are divided between the clamps. The divided end of the stomach is sutured, after complete hemostasis is secured with a running suture of chromicized gut, passed through-and-through on each side in order to secure some inversion. The suture is carried from above downward to such a distance that the unstitched portion corresponds in size to the cut surface of the duo- denum. A second through-and- through suture plane is added and serves to further invert the wound edges. The duodenum is not divided until the stomach has been sutured. The two divided ends are now partly joined by a continuous Lemberf suture, leaving room to apply an in- folding through-and-through suture of chromicized catgut within the plane of the outside suture, which latter is then completed. Kochcr's Operation. — In this method the cut end of the stomach is com- pletely closed while the cut end of the duodenum is implanted into the posterior wall of the stomach. The pylorectomy itself does not dififer 50 ABDOMEN, SURGERY OF (MORRIS). essentially from that of Billroth. The divided end of the stomach is completely closed by two planes of sutures, an inner continuous through- and-through suture of chromicized gut, and a Lembert suture outside of it. The essential part of the opera- tion consists in the gastroduodenos- tomy by which the cut edge of the duodenum is implanted about two inches behind the closed wound of the stomach. The duodenum held in position with fingers is first made fast to the stomach by a running Lembert suture inserted at the point of contact with the stomach and occupying one-half of the gut just back of the cut edge. The stomach is then incised just beyond this suture line in such manner that the two edges may be exactly approximated. The anastomosis is now made with a continuous interior suture of chromi- cized gut, and the original outside suture is completed. The interior anastomosis suture is inserted by the through-and-through method, and traverses all the coats of the intestine. Hartmann's operation differs from the preceding in that it includes ex- tirpation of the lymph-nodes which are seated within the gastrohepatic ligament. It is therefore only appli- cable to cancer of the pylorus in a more or less advanced but still oper- able stage. The operation proper and its termination by gastroduodenos- tomy or gastroenterostomy is not different materially from the pre- ceding. Maya's operation is also a radical procedure, and involves not only extirpation of lymphatics draining the pyloric area, but an unusual degree of removal of stomach, includ- ing all the lesser curvature. The stomach is closed entirely, and con- tinuity restored by any of the methods in vogue. The mortality if lowered (1) by pro- tecting the operative field against the escape of gastric contents during the operation ; (2) by using a combination of morphine, hyoscine, and chloroform for narcosis, thus reducing the likeli- hood of pneumonia; (3) by limiting the operation to patients in whom the hemoglobin percentage is relatively high. In such cases the stomach may be resected some centimeters beyond the disease. Czerny (Annales Intern. de Chir. Gastro-Intes., vol. ii, p. 61, 1908). Review of 266 partial gastrectomies involving the pyloric end of the stom- ach performed in the Saint Mary's Hospital, Rochester, between April 21, 1897, and Jan. 27, 1910. There were 34 deaths from the operation, a mortality of 12.4 per cent. Some of the patients are still living eight years after the operation. The writer does not believe the pessimism as regards this operation to be justified by the facts. He calls attention to two important indications for operation in gastric cancer : 1. Food remnants found repeatedly in the stomach after twelve hours should, when taken in connection with the clinical history, call for a surgical con- sultation, which in a large majority of cases will lead to an exploratory opera- tion. 2. The finding of a movable tumor in the pyloric end of the stomach cannot be overestimated as to its sur- gical significance. Gastric cancer by itself does not give, he is convinced, characteristic symptoms during the cur- able stage. But if it is situated in the pyloric end of the stomach mechanical conditions are early induced which afford most valuable information. An effort should always be made to remove the lymphatic area, whether diseased or not. It must be removed before the lymphatics are infected. Prophylaxis of gastric cancer can be aided by the excision of calloused gastric ulcers, which are its origin in 70 per cent. A typical resection necessitates the re^ ABDOMEN, SURGERY OF (MORRIS). 51 moral of all that part of the stomach lying to the right of a line dropped vcrticall}^ from the cardiac orifice, though in some cases more of the fun- dus must be removed on account of the direct extension of the disease. As a general rule, it will be most convenient to make the separation of the superior border of the stomach first, beginning the operation by (a) ligation of the superior pyloric vessel, (b) the gastric, (c) the felt gastroepiploic, (d) the gastroduodenal vessels. As each vessel is secured, the glandular separation is effected. In doing the anterior gastro- jejunostomy he usually follows the method of Hartmann, i.e., the two-row suture method with slight modifications. Generally speaking, the Kocher method of joining the jejunum to the stomach is not so satisfactory as the Billroth No. 2 method, i.e., closing both the end of the duodenum and the stomach and making an independent gastrojejunos- tomy. When the patient is in good condition the operation has an operative mortality of under S per cent. In ad- vanced cases, the resection is worth the risk, considering the short lease of life of patients left without it. W. J. Mayo (Jour. Amer. Med. Assoc, May 14, 1910). Complete Gastrectomy. — This oper- ation, including- subtotal gastrectomy, is now practicable as a method, and has radically cured perhaps a very few individuals of cancer, but is seldom attempted, the operative mor- tality being very great and cases suit- able for such intervention seldom recognized in time. Removal of the stomach is not a difficult operation at all, but search for and removal of lymph-nodes must be very thorough. The removal is followed by an end- to-end anastomosis made between the duodenum and esophagus, or the cut end of the former ma}" be closed and the esophagus implanted into the jejunum. The author has found it much easier to do the work if a small part of the cardiac end of the stomach is allowed to remain. In 76 cases of cancer of the stomach during the last ten years, the growth was inoperable in 21; in 11 cases a radical operation was undertaken. Of these, 7 were completely cured; in the other 4 the operation was at- tempted as a last resort without much hope of permanent success. In the cured patients nine-tenths of the stomach had been removed; the age of the patients ranged from 38 to 75. Direct anastomosis between the stomach and duodenum was possible in all but 1 of these cases; 2 of this group of 7 cured patients have suc- cumbed since to an intercurrent afifection. The others are in good health to date, the postoperative life being over five years in one instance. Boeckel (Bull, de I'Acad. de med., Oct. 4, 1910). Case of complete gastrectomy in a man aged 43. The whole organ was removed. The cut end of the esophagus was stitthed to the side of a loop of jejunum. The patient made a good recovery from the operation. During the three years and eight months that he lived after the operation he was under constant observation. He was perfectly well up to the early part of the j^ear 1910, v.'hen he began to show the evidences of a profound anemia. He was strikingly pale and breathless, and he lost weight. Under treatment, however, he improved, and in May, 1910, his color had returned and he was able to ride and drive and attend to matters on the farm. In August, 1910, he began to fail again ; he became easily tired, though he still tried to carry out the greater part of his work. His appetite remained good and he had no indigestion. In October, the signs of anemia reappeared, he grew much weaker, and had to cease work. He began again to lose weight, his appetite vanished, .and he vomited occasionally. There were no abnormal signs of any kind in the chest or abdomen through- out the illness. Soon after Christmas, 1910, he had to take to his bed, and he died on the last day of January, 52 ABDOMEN, SURGERY OF (MORRIS). 1911. He had gained 38 pounds after the operation, and he held the gain for nearly three years. His appetite was good, he experienced the sensation of hunger, and he was able to eat ordinary foods. Moynihan (Lancet, Aug. 12, 1911). SURGICAL DISEASES OF THE PERITONEUM.— Septic Peritonitis, — This condition being in the great majority of cases secondary to some suppurative process either within or without the peritoneal cavity, the treatment cannot be considered inde- pendently of that of the primary condition, which consists fundament- ally of incision and drainage of or removal of the pyogenic focus. The conditions likely to give rise to peri- tonitis are separately mentioned. If the focus is outside the peritoneal cavity, the latter need not necessarily be opened, because the peritoneum rapidly guards itself by hyperleuco- cytosis after a focus of infection is cared for. If the focus is in the peri- toneal cavity, it may or may not be advisable to treat the peritoneum actively. If the peritonitis comes from an intestinal perforation an enterorrhaphy may be required, but it is often safer to make temporary drainage, and fistulse following have a tendency to close spontaneously. Other cases may require excision, as when a portion of the gut is gangren- ous. In many cases, however, posture and drainage alone are indicated, and any unnecessary handling of the peri- toneum is to be deprecated. Only when drainage cannot offer a pros- pect of self-limitation of the process is a thorough cleansing of the peri- toneum indicated, and this is best accomplished by flushing with hot saline solution through short incision, and the glass tube. Results obtained in 100 well-marked cases of diffuse septic peritonitis re- sulting from inflammation of the vermi- form appendix. The cases were treated by the author and by George R. Fow- ler. Sixty-seven of the cases recov- ered. Of the 33 deaths, 17 occurred within twenty-four hours of operation. The salient points in the treatment of these cases were : A small incision and the avoidance of eventration; thorough cleansing of the primary focus of in- fection and removal of the appendix. Evacuation and cleansing of all acces- sory abscess cavities and the pelvis be- fore washing out the peritoneal cavity. A rapid systematic flushing of the peri- toneal cavity with sodium peroxide solution followed by hot saline. The continuance of the saline flushing until the sutures are placed, and for the most part tied. The provision of proper drainage of septic fluid into the pelvis, of a large glass tube containing a capil- lary drainage strip emerging through the lower angle of the wound or, in females, by a large-caliber rubber tube filled with wicking passed through a posterior colpotomy incision. The drainage of accessory abscess cavities with gauze or wicking. The elevation of the head of the bed to accelerate the drainage of septic fluid into the pelvis, where it can be removed throvigh the glass tube, or, in case of vaginal drain- age, find a ready exit. R. S. Fowler (Med. News, May 28, 1904). Murphy's treatment consists in mak- ing a small opening 'in the abdomen, doing such operation at the point of origin of the peritonitis as is required, the introduction of a large drainage- tube into the pelvis, placing the patient in a sitting posture of 35 to 40 degrees, and the administration of a salt solu- tion every two hours per rectum. An important feature of the treatment is to avoid handling the intestines or peritoneum more than is absolutely necessary. It is remarkable how much salt solution is absorbed and how it increases elimination by the kidneys. As much as 18 pints of water may be administered by the rectum in twenty-four hours and all ABDOMEN, SURGERY OF (MORRIS). 53 retained; this is only accomplished, however, by elevating the douche bag but eighteen inches above the bed and allowing the solution to flow into the bowel very slowly. The rectal tube can be kept in twenty-four to forty-eight hours. Water should also be administered by the mouth. Gibbon (New York Med. Jour., April 7, 1906). The mortality of general peritonitis of but a few years ago (65 per cent. in 1069 collected cases between 1888 to 1904, 55 per cent, in 400 cases between 1900 to 1904, SO per cent, in the Mayo clinic) is remarkable in its contrast with that of J. B.' Murphy in December, 1906, i.e., 38 consecutive cases with but a single death, and that from pneu- monia on the sixth day. It was Murphy's protest against gen- eral irrigation of the abdomen, show- ing that the higher mortality rested with those who used it, that first at- tracted the attention of surgeons. His first paper dealt with 5 cases (includ- ing 1 typhoid case) without a death, was followed in October, 1906, with 28 cases with 1 death, and up to his last paper includes 48 consecutive cases with only 2 deaths. These astounding results have been recently also con- firmed in England. Moynihan states that, in his opinion, and as a result of a fairly large experience of the method, "there are few therapevttic measures equal to it," and Cawardine considers it "the most valuable suggestion of recent times." The principles laid down by Murphy are : 1. Operate early. 2. Operate quickly. Murphy gives ten minutes as the average time in which to close the gastric or duodenal opening, or to re- move the offending appendix or tubes. 3. The anesthetic must always be ether, if the patient can stand it; if not, then a local anesthetic. Stiles's work has shown how dangerous chloroform is in acute suppurative conditions, in the production and retention of acetone. 4. It is a fatal mistake to mop, wash, or handle the intestine. The peri- toneum is essentially an absorbing sur- face; carmine granules injected into its cavity are rapidly absorbed, especially in its upper half, and conveyed by the lymph-stream to the general circulation. Organisms similarly do harm by the rapid absorption of their toxins in a similar manner. Lymph, like any other granulating surface, is protective, and tends to prevent this absorption. All undue manipulation of such lymph- covered surfaces, or lymph removal by sponging, washing, or mopping, will in- crease, therefore, the danger of septic absorption. 5. The Fowler position Peritonitis treated by the Murphy method. and a suprapubic drain. The object of the Fowler position is to allow the dis- charges to gravitate toward the pelvis, and away from the danger zone of the diaphragm. The patient, as soon as he has recovered from the anesthetic, is placed in the sitting posture, so that the abdominal cavity is vertical in position, and drainage is instituted by placing a large drain in the pelvis through a stab wound above the pubis. This drainage- tube is three-fourths to one inch in diameter, about eight inches long, glass, and goes down tj the pouch of Doug- las in the female, and the rectovesical in the male. In this position the tube is almost horizontal ; and if it is filled S4 ABDOMEN, SURGERY OF (MORRIS). with fluid, each excursion of the dia- phragm will pump a small quantity of it out into the dressings. The hole is now at the most dependent part of the abdominal cavity. 6. Proctoclysis or the absorption of large quantities of saline by the rectum for the first two days after operation. As soon as possible after the operation, a tube having numerous holes in it and one- half inch in diameter is inserted into the rectum for about two to three inches. This is connected by means of a rubber tube of the same diameter with a container suspended from four to tweh^e inches above the plane of the patient's couch, and the whole is filled with warm saline. By means of this head of water (it need onU'- be four to six inches in height, as a rule) saline gradually trickles into the rectum at about the rate of three- quarters to one pint an hour. The temperature of the saline is kept at 100° F. and sho ild never reach 106° F., or it will not be retained. The object is not for the saline to act as an enema, but to be given so slowly that it is absorbed as fast as it flows in. If the patient feels a desire to defecate, it means that the rectum is becoming so distended that the head of water is too great, and that it must be decreased. Should the desire be- come overwhelming, then the saline is shut off for a time until the desire disappears. R. E. Kelly (Liverpool Medico-Chir. Jour., July, 1909). Out of a series of 167 cases of dif- fuse septic peritonitis from appendicitis operated on by the writer at varying intervals following perforation up to January, 1909, there were but 15 pa- tients operated on within twenty-four hours of the onset. Patients with dif- fuse septic peritonitis from appendicitis operated on within twenty-four hours of the onset of the disease, i.e., before the peritoneum is infiltrated, recover, providing the primary focus is removed quickly without damaging the absorb- ing power of the peritoneum, irrespect- ive of feeding or enemas, providing the absorbing power of the peritoneum is properly used. Fowler (Surg., Gynec, and Obstet, Nov., 1909). The writer treated some 15 cases of diffuse peritonitis with intravenous in- jections of adrenalin. In every in- stance, there was a marked improve- ment in the pulse fo. a short time; but this disappeared in a few minutes, and in one or two hours the effect had passed away. In a few patients, the increased pressure in the vessels con- tinued, and these patients recovered. The symptoms, however, were indis- tinguishable from those which follow an injection of normal saline solution. These results coincide exactly with the experiments upon animals. Adrenalin is well known to excite an increased tension in the blood-vessels, which lasts only a few minutes. This is equally true whether the animal is in a normal condition or has an acute peritonitis. The improvement in the arterial ten- sion lasts somewhat longer when the adrenalin is given with a saline trans- fusion than it does when the adrenalin is given alone. Heineke (Zentralbl. f. Chir., S. 72, Beilage, 1909). Tuberculous Peritonitis. — In theory the local focus of disease which has caused an extension of the process to the peritoneum should be excised, whether this is in the intestine, Fallo- pian tube, appendix, or other remov- able tissues. But this is not always practicable, and, furthermore, patients often recover under simple laparot- omy and drainag-e. The author in a series of experiments with animals some years ago came to the conclu- sion that this cure of tuberculosis of the peritoneum after opening" the peri- toneal cavity was due to the presence of toxins developed from bacteria which grew in the culture medium of peritoneal exudate exposed by way of the drainage-tube. This was in fact true, and the cultures of tubercle bacilli in test-tubes were instantly killed by toxins extracted from such fluid and applied to the cultures. A later theory, however, and one ABDOMEN, SURGERY OF (MORRIS). 55 which is borne out l)y hilcr studies, is that the tubercle bacilli are de- stroyed by phagocytes in the course of the intense h}perleucocytosis wliich promptly follows opening' of the peri- toneal cavity for any purpose. The idea that such hvperleucocytosis proves destructive to the tubercle bacilli is further substantiated by the fact that various substances injected into the peritoneal cavity have proved effective in the same way, and for the destruction of tubercle bacilli in the peritoneum it apparently matters little which method for exciting exag- gerated hyperleucocytosis is chosen, so long as we bring about that phe- nomenon. The onset of symptoms as shown by a study of 122 cases is often sudden and stormy, both in the cases where there is ascitic fluid present and where it is absent. Fluid can go quickly and improvement take place very rapidly both with and without an operation. Tuberculous peritonitis can be latent, unsuspected, so far as symptoms are concerned, and it can remain apparently unchanged for months after active symptoms have subsided and the pa- tient returned to apparent health. Foci for the infection of the general peritoneum have not been found in the Fallopian tubes or in the vermiform appendix in this group of cases. Operation should only be undertaken when there is some distress from the distention ; it is better to wait for a period with the patient at rest and under the same hygienic conditions to which any case of pulmonary tuber- culosis would naturally be subjected, namely, rest, fresh air, good food, and, later, mode -ate regulated exercise. If after six or eight weeks there is no improve-nent in the symptoms opera- tion should be considered. When once the disease is arrested, whether by operation or hygienic meth- ods of treatment, the patients must be taught to regulate their lives with the same care that they would had their disease been located in the lungs. A. K. Stone (Boston Med. and Surg. Tour., May 7, 1908). Ascites. — We speak of surgical treatment of ascites rather than of cirrhosis of the liver in cases of the latter disease, 1:)ecause the operation has probably little influence upon the liver itself. Ascites and hydroperi- toneum from whatever cause may be relieved temporarily by paracentesis. The incidental laparotom}^ with drainage corrects the condition for the time being. We have to be par- ticularly careful to guard the peri- toneum against infection in many of these cases, for the reason that the current of lymph is outward from the peritoneum, and it becomes exposed to various bacteria. AAHien the cur- rent is inward, as in normal condi- tions, there is destruction of entering bacteria by the action of blood- and body- cells. Study of the accidents which may follow paracentesis for ascites. These may be classed into five principal cate- gories, viz. : serous anemia, icterus gravis, hemorrhages of the abdominal wall, hemorrhages of the digestive canal, and cardiac dilatation a vacuo. 1. In every case of cirrhosis the physi- cian should rigidl}^ insist on the proper diet and treatment and not waste time with half-measures. 2. In every case of puncture for ascites the condition of the heart should be investigated, and when indicated a preventive cardiac tonic treatment instituted. All the ele- ments of prognosis should be weighed in each particular case. 3 A small trocar should be used, the dorsal de- cubitus should be maintained, and a very firm bandage should be placed about the body immediately and kept in place for a week or longer if the patient gets up. The place of election should be at the junction of the middle and outer thirds of the umbilicoiliac 56 ABDOMEN, SURGERY OF (MORRIS). line. 4. After the operation the pa- tient should not be left, but should be closely watched in order to be able to institute in time any medication which ■ may be necessitated by the occurrence of any of the above-mentioned acci- dents. Perrin (Presse med., Sept. 23, 1908). Omentopexy or the Talma-Drum- mond operation has for its aim the establishment of adhesions between the omentum and parietal peritoneum. These adhesions become filled with capillary blood-vessels in time, and the free network of small new vessels constitutes a A'enous anastomosis around the area of obstructed circu- lation. This work may be done by in- troducing numerous pinpoint sutures, or by pulling the omentum between the transversalis fascia and the pos- terior sheath of the rectus muscle, and fixing it there. In addition to establishing a new circulation by the roundabout way of adhesions of the omentum, it is well to scarify the cephalad surface of the liver and the corresponding perito- neum of the diaphragm. This may be done very rapidly by the use of a nailbrush with the bristles cut very short. The peritoneum which has been denuded of its endothelium in this way throws out abundant lymph and makes extensive adhesions, which later are filled with new capillaries. The operation seldom accomplishes the object for which it is intended in a satisfactory way, because it is commonly used as a last resource when changes in the liver have be- come too far advanced. The opera- tion performed before ascites has become a disturbing feature is some- times distiilctly of value, particularly when the omentum is fixed to struc- tures extra to the peritoneum. The more popular method is indirect anastomosis, which mgiy be done either by sewing the omentum to the liver and diaphragm, by sewing the omentum to the skin of the abdominal wall, by fastening it between the outer layer of , the peritoneum and the muscular part of the abdominal wall, or only to the surface of the parietal peritoneum. The two latter methods are emploj-ed most frequently. Drainage is unneces- sary. Local anesthesia is often suffi- cient for the operation. Of 108 cases which the author has collected, 58 were improved or cured, 14 were not im-. proved, and 36 died. The results in hypertrophic cirrhosis seem to have been somewhat better than in atrophic, 66 per cent, of the former recovering and only 45 per cent, of the latter. Turgard (Annales de la Polyclinique de Lille, Xos. 5 and 6, 1904). Three cases of cirrhosis of the liver with ascites in which the writer made an exploratory laparotomy and twelve others in which he performed the Talma operation. Three of the pa- tients in the latter group were restored to health. The results are better, the earlier the operation is done. None of the patients was permanently cured whose ascites was due to peritonitis rather than to the cirrhosis. Lieblein (Mitt. a. d. Grenz. d. Med. u. Chin, Bd. xviii, Nu. 5. 1908). The benefit of the Talma operation for Banti's disease is due to the lapa- rotomy and the resulting hyperemia rather than to the omentopex3^ The latter helps, but the hyperemia from the laparotomy is the main factor, as determined in the course of 10 such cases. In operating the writer aims to induce hyperemia as much as possible and to remove all traces of the ascites. If the kidneys are functioning defect- ively, absorption of ascitic fluid left behind may prove fatal. He knows of two such deaths, and warns that pro- nounced kidney disease contraindicates the operation, and that in all cases the general anesthesia should be as slight as possible. Bogojawlensky (Zentralbl. f. Chir., Feb. 27, 1909). Congenital Cysts of the Mesentery. (//. C. Deaver.) Annals of Surgery. ABDOMEN, SURGERY OF (MORRIS). 57 Three cases in which the writer fol- lowed Ruotle's method of treating chronic ascites with cirrhosis of the liver by suturing the peripheral end of the saphenous vein, severed 8 cm. above its mouth, to the peritoneum just above Poupart's ligament. In the first case, a man of 38, the patient is well, with no return of ascites after the operation a year ago ; in this case omentopexy, de- capsulation of both kidneys, and con- tinuous abdominal drainage had failed to cure. In the 2 other cases the ascites was the result of pericarditic pseudocirrhosis of the liver ; here none of the operations done, including the Ruotle, gave relief. T. Soyesima (Deut. Zeit. f. Chir., April, 1909). Surgery of the Mesentery and Omentum. — Aside from surgical af- fections which involve the mesentery along with the intestine, the former suffers from surgical affections pecu- liar to itself, more especially solid tumors and cysts in the omentum and mesenteric folds. They do not, as a rule, cause acute or complete ileus, but cause pressure symptoms, and if left alone tend to set up low- grade peritonitis and adhesions to neighboring viscera. These growths should be extirpated whenever operable. Cysts with dense adhesions and chylous cysts can only be managed by drainage. There are four ways of dealing with congenital intramesenteric cysts: (1) by aspiration ; (2) by cystostomy and drainage, with or without the use of caustics; (3) by enucleation, and (4) by resection of the involved intestinal segment. The first method is obsolete, the second is useful in the presence of numerous adhesions, the third is ideal when practicable, and the fourth is the best in multiple juxtaposed cysts when too much surgical interference, as from dealing with cysts one by one, carries more risk than simple resection. Four personal cases. H. C. Deaver (Annals of Surg., May, 1909). SURGICAL DISEASES OF THE INTESTINES.— Ileus.— Most of the conditions which require surgical in- tervention for the intestine, excepting traumatisms, are brought about by ileus or intestinal obstruction of some form. This is not the place to discuss the manifold agencies which produce obstruction, nor their recognition be- fore operation. Once acute obstruction is evident, the surgeon is usually obliged to open the abdomen, his course afterward depending on the nature of the obstruction. In conditions like in- tussusception, volvulus, intestinal hernia, or obstruction adhesions, the obstructed loop is released, and steps described for the separate conditions are taken to prevent a recurrence of the trouble. If the mesentery is too long, or the intestine too mobile, a reef may be taken in the former, or the latter . may be anchored to the abdominal wall or excised. If the intestine has become strangulated and is gangrenous, enterectomy is indicated with secondary anasto- mosis. If the obstruction is from foreign bodies, as with round-worms or gall-stones, for instance, the sub- stance should be worked back to an empty portion of intestine, and an enterectomy or colectomy for foreign bodies performed. If the loop of intes- tine shows serious changes as a result of obstruction, a temporary artificial anus may be advisable. Excision is seldom required in such cases. In cases of acute ileus from any cause secondary peritonitis may develop and require treatment (see Peritoni- tis). While acute ileus may result from stricture or tumors, such condi- tions are much more apt to produce chronic stenosis, while ultimately if left alone will produce chronic ileus. 58 ABDOMEN, SURGERY OF (MORRIS). Such cases naturally tend to come to operation before ileus develops. Benign growths and cysts of the mesentery, and similar formations which do not compromise the integ- rity of the intestine may be removed without much interference with the latter. Tumors of the gut itself necessitate excision of the latter with secondar}^ anastomosis, or establish- ment of artificial anus. Tubercu- lous strictures are treated by entero- clusion, or enterostomy for drainage, excision being, as a rule, contrain- dicated. The same is the alternative in inoperable carcinoma. Volvulus. — Volvulus most often oc- curs in the pelvic colon, and conse- quently does not belong to this group of articles, but it may occur in the sigmoid or cecal region. In the latter case, after untwisting the volvulus and separating any peritoneal ad- hesions, a rectal tube should be passed and the poisonous contents of the volvulus massaged gently but rapidly toward the rectum, provided that no gangrene of the volvulus be present. The prevention of recur- rence by approximation to the an- terior abdominal wall by Roser's method is uncertain, and the author favors complete excision of the part of the bowel engaged in volvulus, as this can readily enough be spared, and an end-to-end or lateral anastomosis of the remaining segment of bowel ful- fills the indication. Volvulus of the cecal region occurs when there is a congenital form of defect giving a sort of mesocecum which may be quite long. Excision of the cecum and intestinal anastomosis are pref- erable to any attempt at preventing the recurrence of twisting of the cecum. Volvulus of the small intestine occurs most frequently when the coil of bowel is caught by an adhesion band, and peristaltic progress may loop the bowel in such a way as to cause torsion. To test the viability of strangulated intestine the writer proceeds as fol- lows : He relieves the constriction at the neck of the sac and reduces the affected part of the intestine into the abdominal cavity, but he retains a por- tion of adjacent and contiguous intes- tine in the wound so as to be able to withdraw and inspect the suspected loop. After from three to five minutes after reduction he again inspects the loop. All traction on the mesentery is thus avoided, and the intestine is kept warm and moist in its natural habitat. Infection of the hernial sac or ad- vanced impairment of circulation with beginning gangrene contraindicates this method. S. C. Plummer (Surg., Gynec, and Obstet, June, 1911). Localized paralysis of the bowel occurring in typhoid fever may lead to this twisting of the bowel upon itself, and the twisted part can best be excised if the patient's condition allows it. Intussusception. — In a child with the patient under an anesthetic, an intussusception can sometimes be re- duced by tlie hands on the abdomen, but the last inch is very diiificult of reduction, and we are likel}^ to do damage by persistent efforts. There is the same objection to water injec- tion, as we cannot know whether the last inch has been reduced or not. Furthermore it is very easy to rupture the bowel of a child. We may reduce an intussusception better through a very short incision, even though children bear the operation so badly. Perhaps it is best not to apply many of the resources for intussus- ception described in the older text- ABDOMEN, SURGERY OF (MORRIS). 59 books, with the exception of operation by immediate laparotomy. Tliere is no occasion in this article to describe the many varieties of intussusception, because the principles of treatment are practically the same in all. Re- duction of intussusception is so likely to be followed by recurrence that operation is an addition that is preferable in many cases. The part of the bowel engaged in intussuscep- tion is of no value, and consequently excision of the bowel with anasto- mosis is in order, unless the patient is in a desperate condition, in which case we may simply approximate any two loops of bowel above or below the intussusception and unite these in the common way with a Lembert suture. Intussusception cannot progress beyond the point at which such anas- tomosis has been made. In emergency cases of intussuscep- tion, with the patient in extremis, the author likes the method of making a quick lateral anastomosis immediately above and below the area involved in the intussusception. If two traction sutures are used for approximating the loops of bowel to be anastomosed the work can be done very quickly and with little traumatism. The results of this procedure in emergency cases would seem almost to justify the simple resource as a regu- lar procedure. Intussusception cannot progress beyond the sutured area. The invaginated part of the bowel in the intussusception may slough or undergo subsequent atrophic changes without adding a serious feature. Typhlitis. — Not readily distinguish- able from appendicitis, and is usually treated by simple opening of the abscess and drainage. Meckel's Diverticulum. — One of the remains of the vitelline duct is some- times attached to the convex border of the intestine, and varies consider- ably in range, as well as in character. In some cases it closely resembles the part of bowel from which it springs. Consequently all varieties call for their respective forms of treatment. Sometimes the entire tube remains as an opening at the umbilicus, but more commonly we have only the patent part of the tube near the bowel with a cord-like remainder extending to the umbilicus. Foreign bodies may escape into this diverticulum, or ordinary intestinal contents may result in exciting inflammation; Ad- hesions may produce angulation of the tube, interfering with circulation and leading to infection. Sometimes the diverticulum acts as a constrict- ing band in intestinal obstruction, in which case it takes part in acute in- flammatory process and may become gangrenous. Volvulus of the diver- ticulum may occur. Diverticula of the colon may occur at any point, and often consist of anatomic defects opening into epi- ploic appendages. Increased pressure within the bowel at any time may lead to considerable enlargement of one or more such diverticula, and later with obstruction and inflam- mation. Epiploic appendages when twisted upon their long axes may become congested and even gangrenous in very fleshy patients, but the treat- ment is simply for abscess which fol- lows. Diverticulitis of the sigmoid region is the most common, giving symp- toms quite similar to those of appen- dicitis, excepting for location of tender- 60 ABDOMEN, SURGERY OF (MORRIS). ness. The infiltrated tissues may re- spond to external applications of heat or cold, but frequently we must oper- ate for the abscess which remains. Wounds, Perforation from Within, etc. — In cases of solution of continu- ity in the intestine, whether from penetrating- wounds from without or perforation from ulcers within, the course of procedure is the same. Laparotomy is performed and the wound or perforation sutured, unless the wounds are multiple and so close together that suture would cause too great a reduction of caliber, in which case an anastomosis may be neces- sary. In one case of lacerated and con- tused ileum, the author quickly covered perforations with cargile membrane without suturing. The patient recov- ered without fistula. If large blood- vessels have been wounded they must be ligated. In all these cases it is nec- essary to carefully cleanse the perito- neal cavity in the vicinity. The ques- tion of subsequent drainage depends on the individual case and the sur- geon's point of view. TYPICAL OPERATIONS OF THE INTESTINE.— Enterorrhaphy. — This term is applied to suture of the intestine for wounds or ulcers which are not extensive enough to require excision and anastomosis. The chief amount of intervention is in connection with the external inci- sions and examination of the intestine to determine the extent of the injury, which may involve more than the bowel itself. Hemostasis and cleans- ing of the peritoneal cavity will necessarily be required in traumatism from without, as well as in perforat- ing ulcer from within. It will often be necessary to incise the mesentery in order to complete the examination, and these incisions must always be sutured in such a way as to leave no point uncovered by peritoneum. Perforation may, as a rule, be sutured without preliminary excision of tissue. The suture should run parallel with the long diameter save when the traumatism is near the pylorus. In this locality it should be applied in the transverse diameter. It is exceptional for an external traumatism to consist onl}^ of a single perforation of the intestine, for, as a rule, not only is the bowel itself penetrated doubly, but other portions of intestine and mesentery are in- volved in the knife or bullet wound. Hence single isolated trauma occurs most naturally from the internal perforations. ]\Iultiple perforations of the bowel and mesentery are adaptable for suture, no matter how numerous, if they are not too close together; but, when a portion of bowel is, so to speak, riddled by bullet or other wounds, it should be excised, unless the author's resource in one case quoted above introduces a principle in addition. For suturing perforations a few points of interrupted Lembert silk or linen suture are usually sufficient. In multiple perforation or when there is suspicion of such, it is advisable to suture as soon as the wound is located, and before proceeding with further examination. The rule for determining the pos- sible limit of suture in contrast to excision is this : if the suture of one or more openings does not diminish the caliber of the intestine by more than a third, suture is indicated in place of excision. In perforation from typhoid ulcer ABDOMEN, SURGERY OF (MORRIS). 61 multiple traumatism is unusual, and the lesion in most cases is seated not far from the ileocecal valve. ( )wing to the general state of the patient the operation must be rapidly done, as a rule. An appendicitis incision usually suffices. The perforation is closed at once by a few interrupted sutures, or a purse-string suture. Cases of typhoid perforation do occur in which, either from the size, number or complica- tions of the lesion, enterostomy or enterectomy is required, but the con- dition of the patient sometimes makes it desirable to quickly fasten the bowel opening near to the external opening, and to do a secondary exci- sion operation after recovery from the typhoid. The friable character of tissues distended with serous in- filtrates also makes this expediency work necessary when the friable tis- sues refuse to bend freely to sutures. Even after simple suture it may not be advisable to close the abdominal wound, in contradistinction to the course pursued in suture of external wounds. The presence of peritonitis with adhesions may make it advan- tageous to leave the lower angle of the wound open for the purpose of a little drainage. Review of the literature of intestinal perforation in typhoid fever showed that those operated upon in which per- foration was found consisted of 269 cases (from 1903 to 1909) ; 156 of this num-ber resulted fatally, giving a mor- tality of 57.99 per cent., while Harte and Ashhurst (all cases from 1884 to 1903), in a similar study, found 311 cases, with a mortality of 73.31 percent. While it is true that in the number of cases reported during the previous twenty years the proportion should be much greater, when we consider the rapid strides in other abdominal oper- ations during this period, it is also true that the mortality shows improvement, but certainly this improvement is not as great as has been accomplished in other surgical conditions. During the period 1903-1909 nothing new has been developed which will aid in the diag- nosis, and, while a great deal has been said about treatment, very little real value has been adde ". to the treatment. Charles Bagley, Jr. (Surg., Gynec, and Obstet., Aug., 1911), In a search through the literature since 1903, the writer found 133 re- ported cases of typhoid fever in which perforation occurred and was closed by suture. Of this number 68.5 per cent, died and 31.5 per cent, recovered. When we compare the percentage of recoveries with the figures of Harte and Ashhurst's 25.97 per cent., made in 1904, and Piatt's 20.3 per cent., made in 1899, and Keen's 19.36 per cent., made in 1898, and Fitz's 10 per cent., made in 1891, we cannot help but con- clude that -real progress is being made in dealing with this heretofore-fatal complication of typhoid fever. Com- bining his own 133 cases with the 362 collected by Harte and Ashhurst, we have a grand total of 495 cases, of which 27.4 per cent, recovered and 72.53 per cent. died. These figures probably express fairly accurately the results of the surgical treatment of per- foration in typhoid at the present time. G. D. Head (Jour. Minn. State Med. Assoc, Aug. 1, 1911). Enterectomy. — Excision of portions | of intestine is performed for a great variety of conditions, such as trau- matism, malignant tumors, actual or impending gangrene, etc. It is indi- cated, therefore, as an operation of choice or necessity in many of the conditions which constitute or give rise to ileus. The part to be removed may vary in length from two or three inches to a number of feet. In enter- ectomy, as in similar operations, the actual operation requires much less time and a much simpler technique 62 ABDOMEN, SURGERY OF (MORRIS). than the secondary stage of restoring the continuity of the intestine. There is in fact but one technique for the former, while the latter is not only practicable by quite different opera- tions, but each operation may be per- formed by a number of different methods. For the performance of the enter- ectomy proper, it is necessary to excise a portion of intestine with a certain amount of mesentery. After the external incisions and exploration of the abdomen the portion of intes- tine to be excised is, if necessary, freed from adhesions. This coil of intestine should be milked into the portions of the gut continuous, for which purpose the fingers of assist- ants must be used. After one-half of I the coil is thus emptied in one direc- tion the fingers should compress the gut to prevent re-entrance of intes- tinal contents ; the other extremity is then similarly treated. Instead of the fingers of assistants, clamps may be applied, one at either end and some inches beyond the segment of gut to be excised. Loops of gauze may also be used, but in such a case the mesentery must be penetrated, and it is best to use the fingers of assistants as far as possible. Before excising, the mesentery must be ligated off close to the intes- tine, — about one inch distance. An approximate rule is to place a catgut ligature for every inch of mesentery. Another is to ligate less rather than more mesentery than is apparently called for. This is done on the prin- ciple of overcorrection, because if too much mesentery is sacrificed the edges of the anastomosis to be per- formed may suffer gangrene from interference with blood-supply. When all preliminaries have been completed the gut with its mesenteric stump is removed by means of the scissors. Series of 22 cases in which from 192 to 520 cm. of the small intestine were resected for various reasons. The pa- tients did not seem to be incommoded by the loss of such a stretch of intes- tine, and all were in good health at last accounts, except for a tendency to diarrhea in a few cases and the death of one patient three weeks after re- moval of cancer with metastases. In a personal case described, on account of sarcoma of the root of the mesentery, the author removed the entire ileum and part of the jejunum, a total resection of 510 cm., or 17 feet, of the small intestine. The patient gained twelve pounds in three months, with normal stools, but the malignant disease re- curred after five months, and the pa- tient, a blacksmith of 21, was dismissed as incurable. No metastases were de- tected at the primary operation. The good functional results in these cases justify resection of two-thirds or even more of the small intestine when re- quired. Storp (Deut. Zeit. f. Chir., Bd. Ixxxvii, Nu. 4-6, 1907). Research on dogs and pigs, showing the late effects on the animals of various operations on the large intes- tine. The animals all became emaci- ated or died after unilateral subtotal exclusion or resection of the large in- testine with ileosigmoidostomy. On the other hand, the animals bore without apparent injury resection of the ileo- cecal segment. Simple ileosigmoid anastomosis also proved harmless for dogs and pigs, both at the time and months later. Simple ileosigmoid anastomosis, however, always proved fatal for herbivorous animals, as also exclusion of the large intestine. Total exclusion of the large intestine, with an anus at the end of the small intestine, always entailed the death of the dogs in tjn days and of the pigs in thirty — sooner than in death from starvation. Alglave (Revue de Gynec, Pozzi's, vol. xi, No. 1, 1907). ABDOMEN, SURGERY OF (MORRIS). 63 111 5 pcrsoiKil cases of resection of the small intestine fd. xviii, Nu. 1, 1907). A complication of considerable grav- ity is peptic ulcer of the jejunum, at- tributed once to the action of digestive enzymes, but now regarded as having a common origin with ordinary gastric and duodenal ulcer, viz., hyperacidity (hyperchlorhydria) and toxic injury of terminal arteries. To lessen the fre- quenc}^ of this complication it is ad- visable that every patient to be operated upon be first treated for hyperchlorhydria. Peptic ulcers of the jejunum run a similar course to that of ulcers higher up, terminating at times in perforation. At Feurer's clinic at St. Gallen, there have been 117 cases of gastroenteros- tomy. The use of this operation for cancer is growing constantly less, as the conditions are much better after resection of the pylorus. The mortality after resection has been only 16.66 per cent, of 42 cases, and zero in the last series of 20, while that of the gastro- enterostomies was 25.64 per cent. Delaloye (Deut. Zeit. f. Chir., Bd. Ixxxiii, Nu. 5-6, 1907). At Hochenegg's clinic at Vienna, there were 56 cases of gastroenteros- tomy in which a sufficient interval has elapsed since the operation to judge of the permanent results. In 64 per cent, the patients had been entirely and in 24 per cent, almost entirely relieved of all disturbances by the intervention. The operation not only put an end to the disturbances from the stenosis, but was followed by the healing of the ulcer. Schulz (Deut. Zeit. f. Chir., June, 1907). Report of 230 operations on the stomach, 112 of which were for malig- nant disease, from Schloffer's clinic at Innsbruck. In 82.6 per cent, of the 74 cases in which gastroenterostomy was done for a non-malignant affection, the patients were permanently cured (46) or materially improved (11). Of the 16 patients with cancer treated by resec- tion, 4 arc still living, 1 after three and a half years; t' e average survival was from two to nearly three years. Of the 69 cancer gastroenterostomies, 4 patients are still living, over a year since the operation. Kindl (Beitrage z. klin. Chir., May, 1909). Condition of the patient one year or more after gastroenterostomy in 175 cases, 150 benign, 25 malignant: — Benign Cases (150). — The immediate mortality (death within thirty-five days) was 10 per cent. Eighteen died within the first year (12 per cent.) ; 22 died of their gastric disorder within five years (14.6 per cent.). Six pa- tients are alive, but have been operated vipon within one year. Of the 126 patients who survived the operation, and have been under obser- vation for one year or more, 81 (or nearly two-thirds) were reported as entirely recovered, or well; 8 as much better, and 31 (nearly 1 in 4) as little or no better. Of the 150 patients, 89, or 60 per' cent., were much better or entirely well ; fully 30 per cent, died or were little or no better at the time of report. Twenty-five cancer cases are re- ported, 20 being in men. Ten patients died within one month of the operation, an immediate mortality of 40 per cent. One is still living, two years after operation, another six months, and an- other four months. Ten patients lived more than four months after operation. Six of these were temporarily much improved, and gains of weight ranging from eighteen to forty-seven pounds are recorded. Two patients received no benefit at all from the operation. Bettmann and White (Med. Record, Oct. 9, 1909). Results of Roentgen examination of 40 patients from a few months to six years after gastroenterostomy to de- termine its ultimate action. The author found that the stomach em.ptied itself in from ten to twenty-five minutes in 9 cases, in from twenty to fifty minutes in 15, and in about ninety minutes in 15. The gastroenterostomy thus answered 70 ABDOMEN, SURGERY OF (MORRIS). its purpose of rapid draining away the contents of the stomach in nearly every case, and this effect was obtained whether the pylorus had previously been permeable or not. A. Pers (Ugeskrift for Laeger, Sept. 30, 1909). A male baby, aged 6 weeks, was sub- mitted to gastroenterostomy for con- genital stenosis of the pylorus. At the age of 5^ months the baby weighed 12 pounds 12 ounces, having gained 4 pounds since operation. The figures indicate that the digestion and absorp- tion of the fat and nitrogen were nor- mal in this baby three and one-half months after the operation, and they are evidence that the operation of gas- troenterostomy does not change the powers of digestion of these two food components and agree with the results published by the writer in earlier inves- tigations. Talbot (Boston Med. and Surg. Jour., April 14, 1910) . Fatal postoperative diarrhea some- times occurs. Its nature is obscure and seems to depend upon derange- ment of bowel function due to shock to the sympathetic ganglia. End-to-end Anastomosis after En- terectomy. — This may be efifected by suture, or Murphy's button. The suture methods in use comprise the simple direct suture, the combination of suture and invagination, the Connell method, etc. Simple Suture. — The mesentery is first united by transfixing both the cut edge of the gut just beside the mesentery, and then the latter close to its insertion. The same through- and-through suture is then passed in the reverse order through the opposite mesentery and gut. A duplicate suture is now passed through the other side, or the same suture may have its other end threaded in a needle and be used for this purpose. When this suture is tightened the gap in the mesentery is closed with approximation of the cut ends. The remaining step is suture of the latter, and this may be done by carrying the original two-tailed mesenteric suture from its knot around the circum- ference of the gut on either side until most of the circumference has been sutured. The opening which remains is closed with an outside Lembert suture. The rent in the mesentery is closed with a few points of catgut. Maiinsell's Method. — The divided surfaces of intestine are placed in rough apposition by four traction sutures at equidistant points, the first at the mesenteric insertion. The next step is to introduce a pair of forceps through the intestinal wall from without inward, and to this end a slit is made in the long diameter of the bowel, one (either side) segment opposite the mesenteric insertion and about one and one-half inches from the cut edge. With this forceps the loose ends of the traction su- tures, previously twisted together, are tightened with production of an in- A'agination of the distal into the proximate segment, the two serous coats being in contact. In this posi- tion the two edges are united with a chromicized-gut suture applied through-and-through, the traction su- tures are removed, and the invagi- nated segment replaced. An external durable Lembert suture is now ap- plied. Connell Method. — As in the preced- ing operation, four traction sutures are applied, and the two cut edges of intestine are sutured, one-fourth at a time. The traction sutures which limit each quadrant are tightened in turn, and the intervening intestine joined by applying a right-angled through-and-through suture. As soon ABDOMEN, SURGERY OF (MORRIS). 71 as a portion of the gut is reunited one of the tractors becomes unneces- sary and is removed. At the close of the suturing the two free ends are threaded within the kunen of the intestine upon a ligature carrier, brought outside and tied, and the knot is then worked back on the inside of the gut. Murphy Button. — Purse-string su- tures are applied at either divided seg'hient and tightened upon the halves of the button. The suture for each siae is a two-tailed one, and first transfixes the mesentery at its insertion. The tails are then carried down on either aspect of the intes- tinal segment to the point opposite the mesenteric insertion, the suture of chromicized gut being- applied overhand. The tw^o tails of the suture having been tightened upon the halves of the button, these are then joined and locked. The rent in the mesentery is now repaired and an outside durable Lembert suture ap- plied over the inside suture. Great care is taken to cover the bowel inci- sion with peritoneum at the mesen- teric attachment. Lateral Anastomosis. — In this oper- ation there is no restoration of the continuity originally present, but a purely artificial opening is created between the two segments of intes- tine. Such an operation may be termed an internal enterostomy, wdiich agrees with an external colos- tomy to this extent : that in each case a fistulous communication is set up. In this connection w^e need only describe the operations of entero- enteric anastomosis and ileocolos- tomy, for the gastroenteroanasto- moses are considered elsewhere. This anastomosis may be effected in se^'eral ways — preferal^ly by su- ture, clamps, elastic ligature, or Murphy's button may be desirable in special cases. Suture. — The loop of intestine is emptied and prevented from refilling by finger pressure, clamps, or gauze loops. Excision having been per- formed, the two cut ends are closed by the insertion of inverting Lembert sutures, the slack of the mesentery being included in the inversion. A double cul-dc-sac thus results, the two parts of which are to be joined in the resulting lateral anastomosis. The two ends are apposed for a space of four inches or more, and a single line of Lembert sutures applied at their junction. The segments being now in their permanent position, they are incised close to the suture line with scissors. As a rule, the length of the incisions should be three inches. A continuous suture of chromicized gut is carried along both sides of the new opening, thus constituting the inside suture plane. The out- side plane is completed by a second durable Lembert suture. Of mechani- cal aids, Myrphy's oblong button is the best for general use, the tech- nique being akin to that of the round button for end-to-end anastomosis. When making an intestinal resection, a lateral anastomosis with a Murphy- button may be done with such rapidity that an immediate resection may safely be accompHshed. The writer uses the Hartley method in making the lateral anastomosis, dropping half of a Murphy button into each end of the gut which is left after resection, and, after closing the ends of the gut by the Lilienthal method, pushes the halves of the but- ton together. Lilienthal simply ties ofif the gut with twine instead of turning in or sewing up the end. The writer has now used it six times with six sue- 72 ABDOMEN, SURGERY OF (MORRIS). cesses. In 3 cases of strangulated hernia, he resected, made a lateral anas- tomosis with the Murphy button by the Hartley method, tied off the ends of the gut with fine linen or silk by the Lilienthal method, cut off the ends of the silk short, and dropped the gut back, closing the abdomen without a drain. In another case of strangulated hernia he did the same, except that, on account of the evident infection, he in- serted a rubber drain down to the closed peritoneum. Wallace (Amer. Jour, of Surg., Jan., 1911). cially multiple ones), and malignant disease. Operative exclusion of the colon is indicated as a last resort, but in a per- sonal case it gave excellent results, freeing the patient, a woman of 28, from intestinal disturbances of several years' standing, probably due to sagging of the colon and chronic colitis. The fistula in the cecum still persists, but causes no annoyance, and the patient has gained 20 pounds in the two years since. Hirschel (Beitrage z. klin. Chir., Dec, 1909). Closed. Open. Oblong Murphy button. Enteroexclusion. — The temporary operation is not a procedure compara- tive to enterectomy. It is without some of the dangers of the radical operation, and may be performed rapidly. The operation consists in division of the intestine and lateral enteroanastomosis, or, in the case of the colon, enteroimplantation, A dis- eased portion of the intestine which would otherwise demand extirpation is then excluded from the intestine. If the distal end is closed the opera- tion is known as partial or unilateral exclusion; but, if it is also made the subject of an anastomosis, the intervention is known as double or complete occlusion. The chief indi- cations are tuberculosis, fistulae (espe- Unilateral Exclusion. — No attempt is made to close the excluded loop at its lower extremity, which is just above the anastomosis, as there is no danger of stagnation of feces in this locality. Technically the operation is well adapted for the use of Murphy buttons. No details need be given, as these are identical with the details of anastomoses after excisions. Its chief use is in emergency cases. Bilateral Exclusion. — Both ends of the excluded loop are closed, and either two anastomoses are made or one end only is anastomosed while the other is left in the external wound. AVhen the operation has been done for actual intestinal fistulse, both ends of the loop may be closed, as ABDOMEN, SURGERY OE (MORRIS). 73 the loop will then be drained suffi- ciently through the hstulous open- ings. If exclusion is done for carcinoma it is better to leave one end of the loop in the external wound, for, when the operation has been done for an}- incurable condition, exclusion must be followed sooner or later by excision. Enterostomy, Jejunostomy, Ileos- tomy. — The establishment of an arti- ficial opening- in the small intestine is not necessarily for the purpose of establishing- an anus contra naturam, but may be done simply for relief of distention or, like gastrostomy, for the introduction of nutriment. The only condition justifying this form of intervention is an absolutely irre- mediable stricture of the pylorus with resulting- starvation. The operation may be done like a gastrostomy, using a tube or catheter. It is preferable, however, to sacrifice the integrity of the intestine by divi- sion and anastomosis, leaving a cut end in the external wound. The point selected is in the jejunum, about eight inches below the duodeno- jejunal angle. The intestine is divided at this point and the central end implanted • six or eight inches farther along the gut. The peripheral end is not treated like the stomach cone in gastrostomy, i.e., it is passed out of the external incision, beneath the skin, and out at a special opening (see Gastrostomy). The original wound is closed plane by plane while the fistular wound is sutured to the divided intestine. The writer, in an investigation of all gastrojejunostomies done by him in St. Mary's Hospital to ascertain whether jejunal ulcer had followed, found that out of 1141 gastrojejunostomies 715 were performed for duodenal and gas- tric ulcer, 167 for carcinomatous ob- struction of the pylorus, and 259 in connection with partial gastrectomy, most of which were for cancer. Not a single case of jejunal ul'^er had de- veloped, nor did any case appear at the clinic in cases operated by other sur- geons. W. J. Mayo (Surg., Gynec. and Obstet., March, 1910). Case operated on for ulcer of the stomach in which a posterior no-loop gastroenterostomy has been performed. The operation, while it relieved the original symptoms, caused frequent vomiting of biliary and pancreatic fluids, due to some spur or kink left after the anastomosis. The operation performed for the relief of this re- gurgitant vomiting consisted in anas- tomosing the ascending or ter:iinal por- tion o^ the duodenum — just as it turns upward — to the jejunum. It is not necessarily tedious or difficult and has the advantage of producing drainage of the duodenum directly into the jejunum — a safety valve, so to speak, in the operation ' of the gastroenterostomy — which can be done either at the time of the gastroenterostomy operation or later if needed. Since his operation in this case, the writer has twice operated on the cadaver, and had no difficulty in pulling a loop of duodenum through the covering perit neum and making the anastomosis. The operation will not have to be done very often, but may at times be of marked value. P. S. Mon- cure (Jour. Amer. Med, Assoc, March- 18, 1911). Ileostomy is sometimes performed for establishing an artificial anus, necessarily in cases where ileocolos- tomy or simple colostomy is insuffi- cient for drainage. The lowest pos- sible part of the ileum is selected, the incision being made one and one-half inches above Poupart's ligament. In this operation- it is not necessary to divide the intestine, and the technique does not differ from that of ordinary colostomy. 74 ABDOMEN, SURGERY OF (MORRIS). Report of 68 cases in which jejunos- tomy has been performed during the last ten years. The technique was Eisel- berg's adaptation to the jejunum of Witzel's obHquely imbedded tube. It is a simple operation, while it insures complete continence for fluids, and the fistula closes spontaneously when its purpose has been accomplished and the drain holding it open is removed. One of its great advantages is that the pa- tient can be well nourished until normal conditions can be restored. This is particularly important in case of ulcer. Lempp (Archiv fitr klin. Chir., Bd. Ixxvi, Nu. 1-2, 1905). Report of 25 operations in which jejunostomy was done by Garre at Ivonigsberg. The operations were for cancer in 20 cases, and for ulcer or its complications in the others. One pa- tient succumbed to hemorrhage from a hemorrhagic ulcer, another to peri- tonitic complications of a very large cancer, another to marasmus from car- cinomatosis peritonitis with ascites, and another with cancer to pulmonary em- bolism — a total mortality of 4 out of 25 cases. Loyal (Beitrage z. klin. Chir., von Bruns, Bd. li, Nu. 3, 1907). Jejunostomy does not merit the dis- credit into which it has fallen, in the view of many surgeons. The results are good when a simple technique is employed. Preference is given to two methods of operation : the q,ne pro- posed by Drucbert, in which a canal is made leading out from the intestine be- tween the serous and the muscular coats of the intestine ; the 'her proposed by Eiselberg and Witzel, in which the canal is made along the wall of the intestine by plicating it over a catheter as in the similar method of performing a gas- trostomy. The chief object of any method is to obtain an opening in the bowel which will be continent. It should be one that can be easily and rapidly made and one that may be only temporary. More complicated opera- tions do not accomplish more than these simple ones, and are not toler- ated so well by the enfeebled patients. Delore and Thevenot (Archiv gen. d. chir., vol. ii, p. 237, 1908). SURGERY OF THE APPEN- DIX. — The appendix, while nomi- nally a portion of the colon, is subject to peculiar affections which, in them- selves often trivial, are prone to give rise to the most serious surgical com- plications. The mere removal of the appendix makes up a small portion of the actual surgery of this organ, which includes the surgical manage- ment of appendix-abscesses, appen- dix-peritonitis, and other complica- tions. Hence the description of appendectomy as a typical operation representing the surgery of the organ is a small part of the subject, and re- quires elaboration only because of the different complications surrounding the work. The typical operation in a case of early infection, or in fibroid degener- ation of the appendix, consists in bringing the appendix to the outside of the abdomen, ligating it like an artery with catgut at two points, one- fourth inch apart. We sever the appendix between these two points of ligation and carry a drop of 95 per cent, carbolic acid into the lumen of each stump. The scissors or knife with which the severing is done is not used again at the operation, because the instrument is now infected, and is to be put aside in a safe place. The carbolic acid has sterilized the tissues with which it has come in contact instantly, and in order to stop any further and undesirable action we neutralize the carbolic acid with a few drops of alcohol applied with a pledget of cotton. The next step is ligation of the mesappendix with catgut at as many points as desirable in any particular case. In some cases the mesappendix allows a safe ligation with a single ABDOMEN, SURGERY OF (MORRIS). 75 lig^aturc. In other cases where it has a particularly broad attachment, four or five ligatures may be required. It is quite as important in ligating' mes- appendix as in ligating broad liga- ment after an operation for ovariot- omy, not to include too much tissue in any one ligature, and not to cut the stumps too short above the lig'a- ture, for the reason that vomiting and other movements subsequent to the operation are particularly apt to force off these ligatures and give rise to secondary hemorrhage or opening of the lumen of the appendix. The last step after cutting away the mesap- pendix consists in scarifying the peritoneum of the cecum near the stump of the appendix that is left, with the point of a needle, in order to insure an abundance of lymph exuda- tion which W'ill wall in the stump. The author has employed practi- cally all of the fanciful methods of treatment of the stump which have been described by authors, and has dropped all but this simple method, which saves time. At one hospital where four thousand appendectomies performed by this method have been tabulated, there were only two cases of trouble due to the form of pro- cedure, and both of these were due to the slipping of a ligature, both liga- tures having been tied by the same member of the house staff, who may not have learned to tie square knots, or who may have cut stumps too short. Where old adhesions make it difficult to bring the appendix out upon the abdominal wall, this simple method of treatment of the stump does away with many difficulties. In cases of acute infection with abscess, with dense new or old adhe- sions, it is extremely unwise to at- tempt to bring the cecum to the surface in order to carry out peculiar methods of treatment of the stump of the appendix, and in such cases it will suffice if we snap a pair of forceps upon the appendix close to the cecum, and remove the appendix with the finger without further detail, unless one wishes to leave another pair of forceps on the mesappendix. The forceps left in place for twenty-four hours serve to protect also the small drain placed alongside. At the end of twenty-four hours the forceps may be removed, and no more attention given to the stump of the appen- dix. In these far-advanced cases the arteries of the mesappendix have commonly been occluded by pro- liferating endarteritis and the veins are filled with thrombi, so that the hemorrhage amounts to nothing more than a moderate degree of oozing cared for by the capillary drain. Such simple treatment does away with a great part of the dangerously severe part of operative work which in the third era of surgery has often been thought necessary. Treatment of abscesses and peritonitis of appen- dix origin is discussed under the general head elsewhere in the article. See also Appendicostomy and the article on Appendicitis in the second volume of this work. Series of 110 operations showing the advantage of simplicity in operating, with mortality. Nearly one-half of the patients were under 15 years of age. Sixty-four were acute cases, the pa- tients being operated upon either in the interval or at a late non-purulent stage. In 44 acute cases, operation was done on the first, second, or third day. Two patients were operated upon the fourth day, 1 on the fifth, 1 on the sixth, 4 in the seventh, 5 on the eighth, 2 on the tenth, 1 on the eleventh, 3 on 7(> ABDOMEN, SURGERY OF (MORRIS). the twelfth, and 1 on the twenty-third day. This tends to show that the risk of operation on any particular day is not unduly great. The writer empha- sizes the advantage of a small incision, the quick drainage of the appendicular site if pus is there, the removal of the appendix only if it is easily reached, the absolute neglect of the remainder of the peritoneal cavity except as it may be favorably influenced by the drainage. Dowd (Annals of Surg., Oct., 1909). The writer has lost no patient upon whom he operated within thirty-six hours of the attack. During the past five years he has had nine deaths fol- lowing operations performed between the second and eighth days of the attack. Only one of these deaths oc- curred in his hospital practice, and others were all after operation per- formed at the homes of the patients. When a patient suffering with appen- dicitis of more than forty-eight hours' duration cannot safely be transported to the hospital, he should be put on the Ochsner treatment and o^^eration post- poned until the acute inflammition has subsided. When the abdomen has fin- ally become flat, pain and tenderness have disappeared, and the pulse and temperature have become normal, the appendix may be safely removed. Col- 'lins (111. Med. Jour., Oct., 1909). Chronic appendicitis, so-called, is not always relieved by appendicectomy. A Lane kink near the ileocecal valve may be the real cause of obstruction and simulate the above condition. The main symptoms as described by Stierlin are as follows : There are attacks of colic, mainly located in the region of the cecum and ascending colon, unaccom- panied by any rise in temperature, and often associated with continued pain- ful sensations in this region ; the pain may also involve the region of the stomach. It may last for a longer or shorter time. Chronic obstinate con- stipation is present, alternating with short periods of diarrhea; these latter usually occur at the end of an attack of colic. A tumor of a balloon-like char- acter is felt in the region of the cecum. which, upon palpation, gives forth gurgling sounds, and which may or may not be painful; it is often distinctly movable. Hofmeister (Beitr. z. klin. Chin, Bd. Ixxi, Hft. 2, 1911). Colostomy. — Now and then it be- comes necessary to perform colostomy for patients suffering from chronic ob- struction induced by a growth, stric- ture, angulation, adhesion, volvulus, invagination, foreign body, diver- ticulum, or enteroptosis, after other measures have been tried and failed. Again, an artificial anus is sometimes made to relieve patients suffering from membranous catarrh, the various types of ulcerative colitis and multi- ple polypi, but this procedure is not so popular for this purpose as it was before the advent of appendicostomy and cecostomy. An artificial anus should never be made except as a dernier ressort be- cause of its unnatural location, the odors which emanate from it, the necessity of wearing a bandage, and, further, because a serious operation is required when the time for its closure arrives. An artificial anus may be tem- porary when made as a preliminary step to excision and resection or until such time as the condition, for the relief of which it was made, has been cured; or permanent, when the open- ing is to remain through life. It is not necessary to spend as much time in the formation of a tem- porary anus as it is in the making of a permanent anus, because the former is to be of short duration and the patient can bear the annoyance for a short time. In permanent colostomy it is of the utmost importance to pro- vide for the patient's comfort by making the opening in such a way ABDOMEN, SURGERY OF (MORRIS). 71 that he may not ha\'e painful evacua- tions, complete fecal incontinence or procidentia. Formerly there was considerable discussion as to which was the better procedure, inguinal or lumbar colos- tomy ; but lately the latter has fallen completely into disuse because the operation is more difficult, a suitable spur cannot be made, and the anus is situated where the patient cannot easily attend to it, while the former operation is devoid of all of these dis- advantages. Except where there are special reasons for doing otherwise, the colonic aperture should be made of fair size and as low down in the bowel as possible, because here the feces are more solid and give less trouble than when the anus is estab- lished at or near the cecum. An anal opening should never be made in the small bowel because, when this is done there is a constant discharge of fluid through it, which annoys the patient and keeps the skin continually excoriated. The majority of surgeons concen- trate their efforts toward the forma- tion of a proper spur and the produc- tion of the double-barrel-gun effect, to prevent any of the feces from reaching the rectum, but do compara- tively little toward providing an anus over which the patient can exert a fair degree of control. The Murphy button is a suitable and proper instrument for the establishment of an anastomosis in the large intestine. The danger that the anastomosis with the button will not be efficient when proper technique is used in connection with a good button is no greater than when anastomosis is made by means of sutures. The chief danger from the button lies in the arrest of the button by means of dried fecal matter or a foreign body, as a cherry or plum stone. In the after-treatment it should be seen that the bowels are emptied at proper intervals. At the first indication of obstruction of the bowels the anas- tomosis should be examined. The Murphy button in the large intestine affords the easy technique and the brevity of the operation it does else- where. Miihsam (Dcut. Zeit. f. Chir., Bd. 105, Hft. 3-4, 1910). Report of 19 cases of primary re- section of the large intestine at von Eiselberg's clinic at Vienna. Three of the patients did not survive the opera- tion ; one of this group had had a febrile sore throat a short time before, and the fatal peritonitis was due ex- clusively to streptococci. The operation should have been postponed to allow time for the streptococcus infection to die out. In another similar case, al- though the patient recovered, yet strep- tococcus peritonitis followed the angina and streptococci could be cultivated from the .blood. In the third case the patient was doing well up to the fifth day after extensive resection of stomach and intestine, but then a suture on the ascending colon gave way. In all the other cases the wound healed by pri- mary intention. Haberer (Archiv f. klin. Chir., Bd. xciv, Nu. 4, 1911). G ant's Colostomy. — The sigmoid is reached and isolated through a two- inch incision which crosses a line ex- tending from the umbilicus to the an- terior superior spine of the ilium, at the inner border of the oblique mus- cles ; working outward, the transver- salis is separated from the internal oblique muscle. Math the index and middle fingers, for about one and one- half inches. The fingers are then forced upward through the oblique muscles and then over the external oblique and inward to the incision, separating the subcutaneous fat from the muscle. A loop of the sigmoid is now hooked up and then made to traverse the 7^ ABDOMEN, SURGERY OF (MORRIS). route taken by the fingers, which makes it pass outward between the internal oblique and the transversalis muscles, and then through the in- ternal and external obliques and finally over the latter back to the incision. Again, when it is sutured after, being made taut to avoid the possibility of subsequent procidentia, the angles of the wound are approxi- mated by two chromicized catgut sutures, which pass through the skin and fascia on one side of the incision and then beneath the longitudinal band of the sigmoid and out through the same structures on the other side, where they are tied. After the gut has been attached to the skin by a few plain catgut sutures it is sur- rounded by a bird's nest dressing to prevent its being pressed upon, covered with rubber tissue lubricated with sterile vaselin to prevent stick- ing of the gauze to the bowel, and then the outer dressing and binder are applied. The intestine is not opened until after the third day, except when there is a marked distention; under such circumstances it is punctured at any time after six hours and amputated later. The projecting piece of gut is quickly and painlessly removed by injecting a small quantity of a one- eighth per cent, eucain solution into its mesentery. Cutting of the bowel proper causes no pain and does not require anesthetizing. By a few cuts of the scissors, the intestine is amputated about one- quarter of an inch from the skin, bleeding points are ligated en- masse, and hemorrhage from oozing surfaces is controlled by hot-water compresses or the cautery. The raw edges left are encouraged to heal rapidly by the occasional application of 6 p(n- cent, silver nitrate. When the obstruction is located above the sigmoid, the steps in the operation must necessarily be modified to meet the indications, but the changes in the technique will suggest themselves to the surgeon in individual cases. Patients have but little control over an artificial anus for the first few days, no matter what operation is performed, because the soreness of the wound and the irritability of the intestine excite frequent and strong peristalsis and the involuntary dis- charge of the feces. This procedure has the advantage over other colostomies in that but one incision is made and, further, because it gives the patient a more perfect control over the movements than do other colostomies. According to Gant, patients oper- ated upon in this way except during the first few days rarely complain of the involuntary escape of gas and ordinarily do not have an evacuation until they have taken a mild laxative or stimulated peristalsis by a small enema. It requires very little time to perform, colostomy for a patient and the operation is practically devoid of danger, but the reverse obtains in the operation for its closure, as usually done by intestinal anastomosis. To avoid the dangers which accom- pany joining of the two ends of gut, Gant has devised a special plan for closing artificial ani. Some years ago he invented a clamp, which has proved useful in the closing of colos- tomy openings. Its weight is imper- ceptible to the patient, and when in place the shank, which is bent at an angle to the clamp, lies flat upon the ABDOMEN, SURGERY OF (MORRIS). 79 abdomen. The jaws are fenestrated, one-halt inch broad and one and one- fourth inches in length. It is applied as follows : The clamp is placed in the applicator forceps, which are so adjusted that the jaws of the clamp remain open to the fullest extent. The parts having been cleansed, the partition between the upper and low^er colostom}'- openings is stripped to dislodge any coil of the intestine which might otherwise be injured. The writer describes the following method calculated to insure sphincteric control after colostomy; The rectus is split vertically and the sigmoid is drawn out and divided at a convenient point. The lower segment is closed and replaced in the abdomen. The upper segment is made less bulky by removing the appendices epiploicse and freeing it of mesenteric f-it, but with- out in any wa}' interfering with its blood-supply. The artificial sphincter is then made in the following manner: A loop of muscle-fibers is separated Operation for sphincter control after colostomy. (Eyall.) (Clinical Journal.) The clamp is then applied, one blade in each opening, and pushed down sufficiently to inckide the entire spur, when it is released from the instru- ment. It is allowed to remain //; situ until the spur is divided and it comes away unaided, which is usually from six to nine days later. The clamp causes slight soreness, but no acute pain. To avoid complications, the patient had best remain quietly in bed until it sloughs out. AVhen the partition has been successfully de- stroyed the skin and edges of the opening are freshened under local anesthesia and closed with catgut or silk, and, in case there is considerable tension, the wound is supported by Avell-adjusted adhesive straps. from the posterior aspect of the rectus on either side of the wound. Each loop is then drawn over to the opposite side of the wound, so that one loop over- laps the other. The overlapping loops thus form a ring and through this the bowel segment is drawn. Sutures are then inserted to keep the muscle- fibers together above and bslow wdiere the bowel comes through. Anchoring stitches are inserted through the skin and muscle inside to keep the bowel in position. The w^ound is then closed above and below the bowel, and the cut edges of the latter are sutured to the skin. A double sphincter is thus formed consisting of longitudinal and circular fibers. The longitudinal fibers are those of the anterior portion of the rectus, and the circular fibers are formed by the loops from the posterior part of the rectus. This operation can be modified by making double loops on each side and making them overlap one 80 ABDOMEN, SURGERY OF (MORRIS). another alternately. A similar opera- tion can be, and has been, carried through the external oblique, and like- wise can be done wherever the bowel is brought through muscle. A some- what similar operation can be per- formed for gastrostomy and appendicos- tomy. C. Ryall (Clinical Journal, Xov. 11, 1908). Lilienthal's Colostomy. — The for- mation of an artificial anus for the per- manent relief of obstruction of the lower bowel is regarded by most sur- geons as a loathsome makeshift for the prolongation of life. The mental picture of such an opening suggests the constant uncontrollable discharge of feces and flatus, the painful and an- noying dermatitis in the neighborhood of the exposed mucosa, and the neces- sity for constant change of dressings — in short, a condition of actual and per- manent disability for the ordinary duties and pleasures of life. For at least eight years Lilienthal has been performing an operation which obviates nearly all the discomfort and filthiness of colostomy. The patients have absolute control of the bowels and can even hold a considerable quantity of fluid injected into the colon. The bowels move once or twice a day, the patient knows when the movements are about to occur, and — not by any means the least advantage — he is not annoyed by the necessity for wearing an appli- ance for obturation. The operation has been tested many times, and the pa- tients have been for the most part . carefully followed up. A description of the steps of the operation follows : — An incision about 3^2 inches long, more or less, is made over the outer third of the left rectus muscle and par- allel with its fibers. The upper end of this incision is just about on a line be- tween the umbilicus and the left an- terior superior iliac spine, but the exact length and location of the wound de- pends somewhat on the amount of sub- cutaneous fat present. Through this incision the fingers explore the abdom- inal organs and the type and limitations of the stricture or tumor are learned. The sigmoid flexure, be it well devel- oped or not, is drawn out. As is well known, this part of the intestine varies greatly in length, but all is taken out which can.be withdrawn vrithout ten- sion. The two legs of the loop are separated as widely as possible, the upper leg being sutured to the perito- neum and posterior rectus sheath in the upper angle of the wound, and the lower is sutured in a similar manner to the inferior angle. Silk or linen thread is the suture material, and the stitch- ing is done by the continuous method, every third stitch being tied so as to avoid purse-stringing. The mesosig- moid is now sutured through and through to the peritoneum on each side (Fig. 1 in the annexed plates). At the lower leg of the loop the gut is doubly, ligated very tightly with heavy silk or cotton twine. Section is carefully made between the ligatures, taking care to avoid soiling from the small amount of imprisoned intestinal contents. Pure carbolic acid on a gauze sponge is used to sterilize the mucosa. Chain ligatures of catgut or silk are now passed through the mesosigmoid so as to prevent hemorrhage, and this membrane is then cut across. We now have a short piece of sigmoid, the dis- tal leg of the loop in the lower angle of the wound, and a long piece sutured in the upper angle of the wound. The remainder of the mesosigmoid is cut away from the long piece of intestine, freeing it completely. The entire wound is now protected by gauze pack- The Dotted Line Shows Line of Section. The Blunt Retractor Holds Outer Third of Rectus Muscle Together with Skin and Aponeurosis. {Howard LUienthal.) Annals of Surgery. Redundant Bowel and Mesocolon Cut Away. Twisting of the Intestine Begun. {Howard Lilienthal.) Annals of Surgery. Twist Complete and Maintained in Position by Anchor Sutures Holding Sigmoid to Aponeurosis. (Howard Lilienthal.) Annals of Surgery. |r~ Operation Complete. Aponeurosis Further Stitched to Intestme and Wound Closed with the Exception of the Skin. (Howard Lilienthal.) Annals of Surgery. ABDOMEN, SURGERY OF (MORRIS). 81 ings, the peritoneum by our previous procedures being entirely closed off by suture. We should have about 3 or 4 inches of free sigmoid at the upper angle of the wound. If there is more it should be ablated. Four equidistant clamps are now placed at the edge of this upper piece of intestine ; the gloved finger is inserted into the lumen of the gut to the place where it is held to the peritoneum by suture ; an assistant rotates the clamps so as to twist the gut around its longitudinal axis, after the manner described by Gersuny, from 180 to 360 degrees according to the texture and thickness of the walls of the sigmoid w'ith which we are working. By withdrawing and rein- serting the finger from time to time the degree of constriction which this ma- neuver produces may be accurately gauged. When this seems to be suffi- cient for the purpose — a matter of in- dividual judgment — a few interrupted silk or linen sutures passed through the visceral peritoneum and submucosa to the aponeurosis of the external oblique hold the rotated gut in posi- tion. It is now necessary to make sure by re-examination that a sufficient twist has been accomplished. If this seems satisfactory more sutures should be put in to hold the gut firmly to the apo- neurosis. In examining with the finger now w-e find a double sphincter, the first one at the twist ; the second, more an angulation than a sphincter, at the point of peritoneal fixation. A few chromic gut sutures close the portion of the remaining wound in the aponeu- rosis. The sphincteric action is main- tained by the fibers of the rectus muscle as well as by the twist in the intestine. A large-sized, rather stiff- walled rubber rectal tube, not a woven one, is now^ inserted about six inches into the intestine and is tied in place, a single light suture passing through its walls guarding against its accidental extrusion. The remainder of the w^ound is left open and packed with gauze while the tube is led off into a receptacle at the side of the bed. These wounds always become more or less infected, but I have encountered a true phlegmon only once and then a single incision sufficed for its drainage. About a week after the operation the tube may be withdrawn and the re- dundant sigmoid burned off with the actual cautery. Anesthesia is not nec- essary. Even then it will be found that repeated cauterizations will be required during the course of the healing in order to bring the intestinal mucosa to the skin level. Daily irrigations through the tube should be practised so as to keep the patient's bowels open. The string around the lower piece of intestine should be removed in three or four days ; otherwise, there might be danger of complete and permanent closure, and it is necessary to main- tain patency here for the sake of drainage. The control of the bowels is learned gradually by the patient, and he is as- sisted by a constipating diet and, for the first few weeks, small doses of deodorized tincture of opium and of subgallate of bismuth, 20 grains three to five times a day. It takes about a month for the final result to be at- tained, but the functional result in all uncomplicated cases will be found per- fect. Appendicostomy and Cecostomy. — These operations are useful in the treatment of disease located in the colon, but, when the disturbance lies within the small bowel or involves it 1-6 82 ABDOMEN, SURGERY OF (MORRIS). and the large intestine, Gant's cecos- tomy, which provides a means by which the treatment can be directly applied to both, should be substituted. It is frequently impossible to deter- mine whether the disease is limited to the colon or not, and because of this and the fact that this operation is no more difficult or dangerous than appendicostomy and ordinary cecos- tomy, and is equally effective both when the lesions are located in the small intestine, the large bowel or both, Gant believes his to be the most desirable procedure and that event- ually it will be employed almost, if not quite, to the exclusion of appendi- costomy and cecostomy in the direct treatment of intestinal affections. Appendicostomy. — Some surgeons do not open the appendix during the operation because they fear infection. This practice, Gant believes, is bad except when it is obvious that the appendix is not obstructed, because he has encountered three failures fol- lowing it; in one the appendix was too short, in another it was strictured, and in still another it was blocked by an encysted grapeseed. He immediately amiputates the ap- pendix and introduces the probe- pointed appendiceal irrigator, then nothing can interfere with postoper- ative irrigation, but when the appen- dix is diseased . it is removed and cecostomy is performed. It is impor- tant that the irrigations be started at once when patients suffering from ulcerative colitis are despondent, greatly debilitated, have many move- ments, lose considerable blood, and suffer from insomnia and autointoxi- cation. To meet these conditions Gant has devised a technique for appendicos- tomy which provides for irrigation both during and following the opera- tion, since the adoption of which his patients have gained very much more rapidly than formerly, when the ap- pendix was not opened for several days, during which time nothing was done to relieve them. Now and then a stitch abscess has occurred, but other complications have not arisen during or following the operation. Briefly described, the following are the steps: 1. The appendix is ap- proached through a gridiron incision and located by tracing the anterior longitudinal band downward, when it and the cecum are freed and brought outside. 2. The cecum is drawn first to one side and then the other by an assistant, while the parietal perito- neum is removed at the sides of the incision to insure union between it and the transversalis fascia, or the peritoneum is left intact when the gut is to be brought into contact with it. 3. The appendix is freed and straightened by ligating and dividing adhesions and the mesentery at about one-fourth inch from it. 4. After the cecum has been scarified, two sero- muscular suspensory sutures are in- troduced on either side and near the base of the appendix, each taking- three bites in the gut. 5. By means of a strong, long-handled needle, the anchoring stitches are in turn carried through the entire thickness of the abdomen and clamped with forceps, but when the intestine is joined directly to the peritoneum the bowel is anchored by chromicized gut su- tures, including the parietal perito- neum and transversalis fascia. 6. Having surrounded the appendix with gauze, a traction suture is introduced to steady it while it is being ampu- ABDOMEN, SURGERY OF (MORRIS). 83 tated, cauterized, and prol:»ed. 7. A Gant appendiceal irrigator closed with a stopper is introduced and the ap- pendix ligated above it. 8. The ap- pendix is placed in the lower angle of the wound, pointing- upward to prevent leakage later, and anchored by two seromuscular chromicized-gut sutures, which include the trans- versalis fascia. 9. The abdominal layers are then separately approxi- mated by interrupted or continuous stitches, after which the cecal sus- pensory sutures are tied across rubber tubes. 10. The appendiceal irrigator is prevented from slipping out by the adjustment of adhesive straps or by means of attached pieces of tape which encircle the body. 11. In urgent cases from one to three pints of a warm saline solution are imme- diately injected into the colon, when the stopper is introduced to prevent leakage. 12. The wound is sealed by means of cotton and collodion, and is protected further by split gauze pads which overlap each other when placed about the appendix. 13. The outer end of the irrigator is surrounded by twisted gauze strips to prevent pres- sure upon it when the outer dressings composed of gauze pads or cotton and a many-tailed binder are adjusted. Appcndicocecostomy. — On six differ- ent occasions Gant has been com- pelled to abandon appendicostomy for cecostomy because the appendix was too short, strictured, or blocked by a grapeseed which rendered it unfit for irrigating purposes or had sloughed off following appendicos- tomy. In each instance, after the appendix had been amputated or inverted, a catheter was introduced through the appendiceal stump or opening and fastened by a purse- string suture introduced at or near its Ijase. The cecum was suspended and the rest of the operation performed as in appendicostomy. Two patients suffered from diar- rhea induced by ulcerative lesions in the colon. In these cases the catheter was introduced a short way into the cecum, providing for colonic irriga- tion. The others were afflicted with enterocolitis, and it was thought ad- visable to irrigate both the large and small intestines. This was accom- plished by guiding a catheter across the cecum through the ileocecal valve into the small bowel. This procedure is termed "appcndicocecostomy." The principal objections to this operation are (1) that a change of catheters is impossible because the appendiceal and ileocecal openings are nearly on the same level, and (2) because the appendiceal aperture is so small that two catheters of suffi- cient size cannot be introduced to provide for large and small bowel irrigation. Cecostomy. — Experience has dem- onstrated to Gant's satisfaction that cecostomy is preferable to appendi- costomy in the direct treating of intestinal disease. A comparative study of the advantages of cecostomy and the disadvantages of appendicos- tomy, as enumerated below, will show why the former should take prefer- ence over the latter. The advantages of the cecostomy operation, and more especially the writer's cecostomy, which provides a means of irrigating both the large and small intestine, are: 1. Owing to the fact that the cecum lies against the inner abdominal parietes, it can be easily anchored without angulating 84 ABDOMEN, SURGERY OF (MORRIS). or twisting the bowel. 2. Since the opening is opposite the ileocecal valve, a catheter can be introduced into the small bowel for irrigating purposes or the siphoning of its con- tents for examination. 3. The cecal opening can invariably be made of a suitable size. 4. The circular, valve- like projection formed around the catheter by the infolding purse-string sutures prevents leakage. 5. The catheter can be changed without diffi- culty. 6. Closure of the opening fol- lows withdrawal of the catheter and a few applications of the copper stick or cautery. 7. Owing to the natural position of the cecum, there is less tension and pain following its anchor- age to the abdomen than occurs after appendicostomy. 8. This cecostomy may be employed in the treatment of lesions located anywhere in the intes- tinal canal, while appendicostomy is limited to those in the colon. The disadvantages of appendicos- tomy are the following: 1. The ap- pendix is more difficult to bring up for anchorage than the cecum because of its deeper and more uncertain position, and because it is frequently bound down by adhesions or a short mesentery. 2. Anchoring of the ap- pendix causes angulation or twisting of the cecum, which, in turn, may induce constipation, discomfort, or pain. 3. When the cecum about the appendiceal base is caught in the wound, it induces nausea and vomit- ing until detached (writer's case). 4. When the appendix is small, short, strictured, bound down by adhesions, blocked, or is otherwise diseased, it is useless for irrigating purposes. 5. Irrigation is frequently difficult and unsatisfactory because of the small appendiceal opening. 6. Pain follow- ing appendicostomy is much greater than after cecostomy owing to the pulling upon the appendix by the loaded cecum, the periappendiceal adhesions, or the squeezing of the attached mesentery when the wound is closed tightly about it. 7. Fre- quent dilatation or the insertion of a catheter is often necessary to keep the opening sufficiently large. 8. Death has followed injection of the irrigating fluid into the abdomen beside the appendix where an interne mistook an opening in the wound for that of the appendix. 9. After a cure it is more difficult to close the ap- pendiceal than the cecal outlet, and frequently appendectomy is impera- tive. 10. Appendicostomy frequently fails because the appendix slips back into the abdomen or retracts suffi- ciently to make irrigation almost or quite impossible. 11. The appendix has been known to slough off on several occasions owing to tension, its constriction by the sutures or destruc- tion of its blood-supply making subse- quent cecostomy necessary. 12. Appen- dicostomy is not effective when the disease is located in the small intes- tine. 13. Appendicitis requiring ap- pendectomy following closure of the appendiceal outlet has occurred. 14. Owing to the irritation caused by the catheter or treatment the mucosa may become so inflamed and swollen, ulcerated or strictured, that irrigation must be abandoned. 15. Finally, ac- cording to Reed, the catheter causes the wall of the appendix frequently to perish in a few days. Cecostomy zvitli an Arrangement for Irrigating both the Small Intestine and Colon. — Gant has described what he believes to be an original way of irri- eatine both the small and large bowel Abdomen, surgery of (morris). 85 through the same opening in the cecum — an operation which, for want of a better name, lie has designated "cecostomy with an arrangement for irrigating both the small intestine and colon." Pie believes his cecostomy is su- perior because the technique is simple, the operation requires no more time than others, there is less leakage owing to tlie purse-string infolding being substituted for his lateral sutures, both the small and large bowel can be irrigated by the attendant or patient, a firmer support is obtained by attaching the cecum to the transversalis fascia than to the parietal peritoneum, and the opening heals spontaneously after the cathe- ters are removed. Briefly described, the steps in Gant's cecostomy are: 1. Through a two-inch intermuscular incision made directly over the cecum, it and the lowermost part of the ileum are withdrawn and the edges of the wound covered with gauze hand- kerchiefs. 2. The anterior surface of the cecum is scarified after the as- cending colon and ileum have been clamped to prevent soiling of the wound when the bowel is opened. 3. Four linen seromuscular purse-string sutures are introduced into the an- terior wall of the cecum opposite the ileocecal valve, and the bowel is opened inside the suture line. 4. The gut is grasped at the juncture of the large and small intestines and held in such a way that the ileocecal valve rests betAveen the thumb and fingers of the left hand. A Gant catheter guide is then passed directly across the cecum and through the ileocecal valve into the small intestine, aided by the thumb and fingers. 5. The guide is held by an assistant while the obturator is removed and a cathe- ter is introduced into the small bowel. It is then removed and the catheter firmly held in the small gut by an assistant until anchored to the cecum by catgut sutures to prevent its slip- ping out during the operation. 6. A short rubber tube three inches long is projected into the cecum for an inch or more and anchored beside the one in the small gut. 7. The infold- ing- purse-string sutures are now tied, forming a cone-shaped valve above the catheters to prevent leakage of gas and feces. 8. After removal of the clamps, the cecum is scarified and anchored to the transversalis fascia, denuded of its peritoneum by through- and-through suspension sutures of linen, or by chromicized catgut stitches, including the fascia, when the two peritoneal surfaces are to be approximated. 9. The wound is closed by the layer method and the catheters are fastened by stitching or by encircling them with an adhesive strip to hold them together, and crossing this at a right angle with a second piece of plaster placed be- tween the catheter to prevent their slipping out. 10. The ends of the catheters are closed with cravat clamps to prevent leakage, and the operation is completed by applying the dressings above the projecting tubes. One catheter is left longer than the other or is identified in some way in order that the interne or nurse may know zvhich is in the large and zvJiich in the small intestine when time for irrigation arrives. To avoid danger from infection treatment is not begun before the fifth day except when urgent. ABDOMEN, SURGERY OF (MORRIS). The catheter may be readily changed by cutting the attached ad- hesive strips and withdrawing the one projecting into the cecum. Gant's catheter guide is then passed over the other into the small intestine, where it is retained until the old tube has been removed and a new one in- troduced. A second piece of catheter is then placed in the cecum and both are prevented from slipping out by adjusting fresh adhesive straps after the manner already described. Before deciding upon the above technique Gant irrigated the small intestine by passing a glass or silver catheter through a cecal opening, past the ileocecal valve, into the small gut each time it was irrigated, but this practice was abandoned as impracti- cable because of the difficulty en- countered in locating and passing the valve, and, further, because the patient could not irrigate himself in this way. Gant has had no reason to suspect that peristalsis forced the catheter out of the small intestine into the cecum except in one of his first cecostomies, where the tube was cut short and projected only one inch beyond the ileocecal valve instead of several, as it should. He feels confi- dent that the catheter remained in the small gut in his other cases be- cause (a) water injected through the colonic pipe was evacuated much quicker than when it was deposited in the small bowel; (&) when a minute quantity of a 10 per cent, solution of methylene-blue was in- jected through the former, it appeared in the urine more quickly than when introduced through the catheter in the small gut, and (c) the catheter guide could be carried over the tube in the small intestine and the latter could be removed and replaced with a new one at will, and, further, (d) fluid feces could be withdrawn more quickly and frequently through the pipe in the small intestine than through the colonic catheter. To avoid possible expulsion of the catheter from the ileum, catheters made of silk, silver, glass, and soft rubber reinforced by an inner metal tubing which cannot be forced out of the bowel owing to their non-flexi- bility are employed. Only that portion of the latter projecting into the small bowel was reinforced, and as a result it served the desired pur- pose and caused but little irritation because it was soft and flexible. This cecostomy permits the attendant or the patient to irrigate the small and large intestines at will, and the fluid may be siphoned or allowed to escape through the anus and the catheter can be changed quickly as often as is necessary. Enterocolonic Irrigator. — An instru- ment successfully employed by Gant several times in the direct treatment of intestinal affections involving both the large and small intestines. It is made both of rubber and metal, and has worked exceedingly well in the few cases in which it has been used. When it is in position, the attached inflating bag lies in the small intes- tine at or near the ileocecal valve, and when distended prevents the escape of the solution into the cecum, there- by enabling the attendant to accu- rately gauge the amount of fluid deposited in the small bowel and to retain it there as long as required. By means of this twin-tube irrigator, the small and large intestines can be quickly and scientifically flushed. AUDOMEN, SURGERY OF (MORRIS). a; singly or tog-ether, by the physician, nurse, or patient. The steps in cecostomy, when the irrigator is employed, are similar to those already described when separate catheters are used, except that the Gant catheter guide is unnecessary and the apparatus is retained in posi- tion l\v attached pieces of tape which encircle the body. Indications for Direct Bowel Treat- nieiit. — This form of treatment has a much wider field of usefulness than the profession at present realizes. ]\Iost physicians and surgeons who have practised it at all appear to labor under the impression that it is limited to the colon and is indicated only in ulcerative lesions of the large bowel causing diarrhea. Gant has called attention to the fact that this type of cecostomy is indicated in the treatment of intesti- nal parasites, enteritis, enterocolitis, and catarrhal, tuberculous, syphilitic, dysenteric and gonorrheal colitis ; ordinary and pernicious anemia ; the many manifestations dependent upon intestinal autointoxication, ptomain poisoning, diarrhea of adults and children, intestinal feeding, malnutri- tion, and following operations upon the mouth, throat, esophagus or stomach ; in gastric stricture, ulcer, cancer and other disturbances where rest of the organ is indicated. Gant also called attention to the fact that by means of his cecostomy various intestinal diseases could be investi- gated, and that the procedure could be used to determine the amount and nature of the intestinal juices and dis- charges, the character of the feces, the action of salines and other cathar- tics injected directly into the small and large bowel, and the marked im- mediate vasomotor effect following hot and cold enteroclysis and many other interesting problems. The writer has reported several cases successfully treated by his opera- tion. While he has had no personal experience with it in the treatment of cholera and typhoid fever, he believes that it is indicated and in the future would be used in the treatment of these and nearly if not all other non-ob- structing diseases of the small and large bowel. Gant has also pointed out the use- fulness of appendicostomy and cecos- tomy as a means of drainage when the cecum or other part of the colon was excluded. He has also employed appendicostomy and. cecostomy a number of times when operating for mechanical constipation where colitis was a complication, and also in the palliative treatment of obstipation where the patient declined to have the cause of the obstruction removed and yet suffered from deplorable autointoxication or recurring impac- tion. Gant has also performed cecostomy once for the relief of septic peritonitis, but the patient was almost moribund and the operation failed. Reed was more fortunate in the two cases in which he resorted to cecostomy. This authority has also recorded a case of "defective flora" of the colon which was improved by the injection of the needed bacteria through a cecostomy opening, has called atten- tion to its usefulness in the treatment of intussusception, and emphasizes many other important points concern- ing cecostomy and appendicostomy. Following direct treatment, the condition of the patient becomes rapidly better and manifestations ABDOMEN, SURGERY OF (MORRIS). such as anemia and those induced by autointoxication rapidly disappear, and in cases of diarrhea the frequency of the stools generally diminishes and the amount of blood, pus, and mucus passed becomes markedly less. The good results following the irrigating treatment are due mainly to the mechanical action of the fluid in cleansing and stimulating the ulcers and removing retained toxins, and not to its temperature or chemical contents. Solutions should always be employed at the bodily temperature or warmer because of their soothing effect upon the irritated bowel, and not cold or at a freezing point, as recommended by some authors, be- cause when injected ice cold they excite enterospasm and cause much un- necessary suffering. Briefly stated, the most reliable, stimulating, and soothing remedies to employ are weak solutions of boric acid, quinine, formalin, Hydrastis, krameria and soda, silver nitrate, and those of a soothing nature are kero- sene, liquid paraffin or olive oil, ac- cording to indications. The stimulat- ing solutions are used stronger when ulceration is extensive and the oils warm when the gut is irritable. Owing to our recent knowledge of diseases of the colon, the internists agree that the treatment of these dis- eases by medication is generally un- satisfactory. The great length of the intestinal tract and the many chemical changes taking place before medica- ments reach the colon are the two principal reasons why cecectomy or ap- pendicostomy should be practised. The posterior position of the appendix and the necessity for rotating the colon about half way on its axis, the "possible sloughing of the appendix are the chief reasons why cecostomy should be done instead of appendicostomy. The tech- nique is as follows : A gridiron incision is made, the cecum brought up and held by rubber-covered forceps, and a suit- able point selected for the fistula. This opening preferably should be made opposite the ileocecal valve, so that irrigation of the small intestine can be done as easily as of the large intestine ; 2 or 3 purse-string sutures of linen are inserted, and a small opening made in the bowel with scissors. A No. 10 soft-rubber catheter is in- serted into the bowel for a distance of about four inches; the sutures are tied, inverting the head of the colon, which produces a valve at the point, and pre- vents leakage. The cecum is attached to the parietal peritoneum with chromic catgut. The catheter should be fas- tened to the abdominal wall by one silk suture. The diseases which most fre- quently require cecostomy are amebic dysentery, tuberculosis, hemorrhage, ul- cerations, colitis, chronic catarrhal coli- tis, and syphilitic colitis. W. M. Beach (Penna. Med. Jour., March, 1911; Amer. Jour, of Gastroenterology, June, 1911). Colectomy. — Excision of the colon is performed for malignant disease, including tuberculosis and gangrene, but in practice the operation, like colostomy, is confined to cecectomy and sigmoidectomy, unless the morbid process directly involves the trans- verse colon, where the hepatic or splenic flexure is usually the seat of the disease. Cecectomy. — This operation, while so named, is by no means limited to the cecum, for it is usually necessary to remove either the ascending colon or a portion of ileum or of both intes- tines together. Hence such interven- tion may be termed ileocolectomy, ascending colectomy, etc., according to the individual case. The incision is made in the middle line, unless the diagnosis has been made so well that the operator can ABDOMEN, SURGERY OF (MORRIS). 89 incise directly over the growth. As in all similar cases, the gut is mobi- lized, brought out and walled off with gauze, while it is emptied and clamped or held empty by assistants' fingers or tape. The technique differs little from that of enterectomy of the small bowel. The mesentery is tied oft' and then divided, the large bowel excised and the operation completed by restoring the continuity of the intestine. As the cecum and ap- pendix have been sacrificed, it is necessary to secure an anastomosis between the ileum and transverse or descending colon. An end-to-end anastomosis is hardly practicable because of the disparity in size between the small and large bowel. Hence a lateral anastomosis or an implantation is indicated, which may be made by suture or button. The technique is that usually pur- sued in all intestinal anastomoses. Lateral anastomoses are practi- cable when the ileum is to be united with the neighboring ascending colon. No attempt is made to provide for a cecal pouch or ileocecal valve, but the two ends are joined after the cut end of the colon has been closed. It is sometimes advisable to im- plant the ileum in the descending colon or sigmoid flexure (ileosigmoid- ostom}^). This would be necessary if the ascending colon were sacrificed. The general tendency is to regard total resection as indicated only when all other methods of treatment have failed. The writer reports a case in which after exposure of the intus- susception which involved the ileum about a hand's breadth from the cecum it was found impossible to reduce the invagination. It was resected and the bowel ends united by circular suture. The patient recovered and was dis- charged one month after the operation. Three months later the patient was again examined and found well, and six months pregnant. She was delivered successfully. Leichenstern found that in 479 cases of invagination spontaneous reduction of the invagination occurred in 15 cases ; also in 15.6 per cent, of the cases of invagination of the ileum, with a mortality of 42.6 per cent. We cannot, therefore, rely upon this method of treatment. The writer agrees with Rydigier in the following conclusions on the treatment of intussusception : In acute invagination operation should be performed as soon as possible after properly employed non-operative meas- ures have been tried without success. When a laparotomy has been done, dis- invagination is to be preferred when it can be carried out without special diffi- culty. If the intestinal wall at any place in the area of invagination is suspicious, a strip of iodoform gauze should be introduced to this place or the affected area excluded from the abdominal cavity. Resection of the whole invagination is indicated when the intestinal wall shows marked changes or threatens perforation. The employment of an artificial anus, or enteroanastomosis, is to be condemned. The author believes that in ileocecal and colon invagination, when disin- vagination has been difficult and the serous surface of the intussuscipiens is intact, the intussusceptum may be re- sected. In case, however, the invag- ination is only a short one, a total re- section should be done, because of the better prospects of a radical cure, al- though one should also take into account the general condition and age of the patient. If very short, unless reduced with very little difficulty, re- section is to be preferred to all other methods. But even when the invag- ination is easily reduced, a secondary resection must be kept in mind, since it is the only sure means for the pre- vention of a recurrence. Haagn (Deut. Zeit. f. Chir., S. 142, 1911). Sigmoidectomy. — As the sigmoid flexure is a favorite seat for cancerous 90 ABDOMEN, SURGERY OF (MORRIS). growths it is often necessary to excise this portion of the bowel. In some cases no attempt is made to restore the continuity of the bowel, but the operation is terminated by forming an artificial anus. If, how- ever, the sigmoid is movable and the tumor can be removed cleanly, an end-to-end anastom.osis may be made. Even when the rectum needs removal with the sigmoid, operators have pre- ferred to draw down the sound intes- tine and suture it to the anal region. SURGICAL AFFECTIONS OF THE PANCREAS.— These comprise inflammation, cancer, cysts and cal- culi. There are no typical operations for these afifections, or upon the pan- creas and its duct for any conditions. The most important and special in- dications for operative interference in morbid states of the pancreas are : 1. Injuries to the pancreas from stab or bullet wounds, or severe contusions in the epigastric region. 2. Inflammations — (o) acute hemorrhagic pancreatitis; (&) subacute pancreatitis; (c) chronic pancreatitis. 3. Pancreatic cysts. Mc- Reynolds (Wash. Med. Annals, May, 1908). Acute Pancreatitis. — In this condi- tion the pancreatic juice escapes into the tissues of the pancreas and into the peritoneal cavity, and the effect of its irritating influence is very de- structive. The reddish, purulent fluid in the vicinity can be removed by a drain, and tense parts of the pancreas can be scarified to allow some of the interstitial exudates of the pancreas to drain out. Drainage is essential after removing tumors, or after an injury to the pancreas in order to dispose of the irritating pan- creatic secretion. The escape of pancreatic secretion from an injured gland reduces living fat in this vicinity into its fatty acid and glycerin, due to a ferment in the pancreatic fluid. The glycerin is absorbed and the fatty acid which remains makes a combination with lime salts, with the effect of produc- ing small areas of dull white at points where the reaction has taken place. Acute pancreatitis should be the occasion for prompt abdominal sec- tion for the severe and fulminating symptoms usually present, and emer- gency laparotomy would in any case be required. If the patients have not died outright of collapse or peritoni- tis, the fat necrosis or some other secondary condition will demand operation. Report on diagnostic value of Cam- midge reaction based on 501- examina- tions. Of 26 patients who were shown to have pancreatitis, only 9 (35 per cent.) gave a positive reaction, and, even of these, 7, in one or more of the series of 3 tests, gave negative results. Of the 74 sick persons without pan- creatitis, 35 (47 per cent.) gave one or more positive reactions. Of the 207 sick persons who, in all probability, had no pancreatitis, 73 (35 per cent.) were positive. Of the 17 well persons, 5 (30 per cent.) were positive. Even when the most elaborate care is exercised to follow the technique of Mr. Cam- midge's "C" reaction, in the most uni- form manner, if knowledge of the clin- ical histories and other factors of the personal equation be eliminated, the end results, judged by Mr. Cammidge's own criteria, must be considered, as a means of diagnosticating disease of the pan- creas, as both valueless and misleading. Wilson (Surg., Gynec, and Obstet., Aug., 1910). Report on diagnostic value of Cam- midge test as studied in dogs. The Cammidge test is of little value in es- tablishing the diagnosis of acute pan- creatitis in dogs. If the test is nega- tive, it is pretty strong evidence against an acute pancreatitis. It is of even less ABDOMEN, SURGERY OF (MORRIS). 91 value in the condition of chronic pan- creatitis in dogs and may be consistently absent, even in extreme grades of this disease. A positive Cammidge test is not infrequent in normal dogs and men. The Cammidge test is almost constantly present in chloroform poison- ing in dogs — a condition in which there is cr.treme liver necrosis and cell autol- ysis. It may be present in cases of pneumonia, or in any condition where there is active cell destruction and autolysis. It may be produced experi- mentally almost at will by intraperi- toneal injections of hydrolytic cleavage products. These split products may be prepared by boiling pneumonic lung- tissue (dog or man), or thymus, for hours with dilute acid, neutralizing, filtering, and concentrating to a clear fluid. Whipple Chaffee and Fisher (Johns Hopkins Hosp. Bull, Nov., 1910). The pancreas may be reached either above or below the stomach, through a second incision into the omentum or mesocolon, after making a suitable external incision. A counteropening through the lumbar region may be necessary for drainage. If an abscess is still intact it should be opened wherever most accessible. The in- frequency, fatal character, and opera- tive mortality (chiefly unavoidable) do not justify us in devoting much space to abscess of the pancreas, the treatment of which largely resolves itself into management of the second- ary conditions to which it gives rise. Shallow incisions followed by simple wick drainage carried to the pancreas certainly serve to remove poisonous exudates to advantage in some cases of acute pancreatitis, and even the simple use of wick drains without scarification of the pancreas is some- times followed by good results. We must leave room when draining to allow necrotic masses to escape. In acute hemorrhagic pancreatitis the gravity of the affection is due to the necrotic destruction of the pancreas rather than to the hemorrhage. Chronic pancreatitis consecutive to gall-stones is a well-individualized morbid entity, and the cure after effectual drainage of the bile passages proves its dependence on the lithiasis. The operation is more successful the earlier it is done, before glycosuria reveals disturbance in the internal secretion. Cappelli (Policlin- ico, Aug., 1909, Surg. Sect.). Cancer. — A radical operation for cancer of the pancreas is hardly to be considered, and the only palliative procedure recognized is done for the relief of obstruction of the intestine or bile-tract. Cysts. — As a rule these can only be dealt with by incision and drainage. In a few cases small encysted collec- tions of fluid affecting only a portion of the organ_ have been excised out- right. In a few other cases cysts have first been opened and drained and then excised as a subsequent stage of procedure. Report of 16 operated cases: 2 of pancreatic cyst, 1 of pancreatic car- cinoma, 3 of acute purulent and 5 of chronic pancreatitis, and 5 of hemor- rhages into the pancreas. The writer cautions against exploratory punctures for diagnostic purposes, and emphasizes the impossibility of differentiating be- tween pancreatitic cancer and chronic pancreatitis. Necrosis of the pancreas may be the result of inflammation or hemorrhage, while fat necrosis is due to the escape of pancreatic secretion into the intra-acinous structures, this occurring most frequently after hemor- rhage, and less often after pancreatitis. Of the 5 cases in which operation was done for hemorrhage, 1 recovered be- cause the condition was recognized early and surgical intervention was promptly resorted to. Bode (Beitrage z. klin. Chir., Bd. Ixxi, Hft. 3, 1911). 92 ABDOMEN, SURGERY OF (MORRIS). Calculi. — When, as occasionally happens, the pancreatic duct is ob- structed by a calculus the condition cannot be diagnosticated readily, but is recognized when operating for some other condition, usually for gall-stones. A pancreatic calculus may sometimes be distinguished from a gall-stone with the fluoroscope. The indication is then the same as in obstruction of the common duct. One of the few surgeons who have discussed typical pancreatic opera- tions is Villan, but it is not easy to determine what, if any, portion of the work he describes has been done on the living human being. For those interested we append a synopsis of his work. Villan considers the surgical man- agement of pancreatic diseases as well as the typical operations, but it is doubtful if any of the latter have at- tained sufficient dignity to be thus regarded. The term pancreatotomy is applied to incision of any portion of the organ or its surrounding tissues, for any purpose. If followed by suture it is termed pancreatorrhaphy. Pancrea- tostomy or fistulation of the pancreas is simply pancreatotomy with drain- age, and is a frequent procedure in the surgical treatment of cysts, abscesses, etc. Pancreatectomy, par- tial or total excision, is used chiefly in tumors of the organ (and in trau- matisms and connection). These operations will be considered else- where in detail. Pancreaticotomy, pancreaticostomy, and pancreatic an- astomoses will also be considered in detail. Pancreatectomy. — This is neces- sarily partial. It has been done only to the extent of excising tumors. The tumor must first be freed from any attachment to neighboring organs as well as from the pancreas itself. The excision of the tail of the pancreas is attended with much less danger. The tumors here are more likely to be pedunculated. IMedian laparotomy is followed by liberation of the tumor, traction and application of strong forceps or ligatures, which prevent the entry of blood and pancreatic juice into the peritoneal cavity. The pedicle is then divided and cut and sutured, peritoneum sutured, and wound closed. It is often prudent to tampon and drain. Excision of the head of the pancreas is difficult and dangerous. Either a part or the whole may require removal. The tumor is detached with scissors and bleeding vessels ligated. The ducts of Wirsung and Santorini should be left intact, although the preservation of either one will suffice. If Wirsung's duct should be divided it is usually sutured, and the same is true of the common bile-duct should it be injured, although at- mospheric pressure will sometimes serve to restore continuity of wound margins well enough. The operation is finished by suturing the remains of the pancreas to the duodenum. If the entire head of the pancreas is to be extirpated, it is necessary first to ligate the pancreatic duodenal artery and the right gastroepiploic. The duodenum must not be separated from the superior mesenteric artery. Wirsung's duct and the common duct must be kept intact when possible; otherwise they must be preserved by anastomosis. The entire pancreas can hardly be excised as a routine procedure, al- though the operation may be sue- ABDOMEN, SURGERY OF (MORRIS). 93 cessfully performed on animals and even man. It is followed by diabetes mellitus. Case of resection of part of the pan- creas ; approximately two-thirds of the gland was replaced by the tumor. The results of the experimental work done by Halsted, Flexner, Opie, and Coffey in this country, and abroad by Pawlow, Biondi, Desjardins, Robson, and a host of others, may be simmied up as fol- lows : Total pancreatectomy is followed in a short time by the death of the animal. Partial pancreatectomy, on the other hand, permits of an indefinite existence, compensatory regeneration and hypertrophy not infrequently taking place. In properl}' selected cases and under favorable conditions, followed by care- ful protection of the field of operation by peritoneum and provision for the escape of the pancreatic secretion by ample gauze drainage, operations in- volving resection and suture of the pancreas were followed by surprisingly good results. J. M. T. Finney (Annals of Surg., June, 1910). Pancreaticotomy. — This operation consists in incising the pancreatic duct for calculi. The duct, as in the corresponding operation on the common bile-duct, may be approached directly or through the duodenum. Simple Pancrcaticotomy.-^Aiter lap- arotomy and exploration, if a cal- culus is found therein, the canal is incised, and the concrements remoA^ed by forceps or other apparatus de- signed for the purpose. Suturing of the cut duct is not necessary. A fistula naturally remains (pancreati- costomy), but has a tendency to close spontaneously. Transduodenal Pancreaticotomy. — The duodenum is lifted upward. In- cision should be made in the anterior portion, and while some surgeons advocate a transverse, others prefer a horizontal incision. The ampulla of Vater should now be located, and if a pancreatic stone is present the opening may be incised in order to extract it. Suture of the incision is not necessary. Cathetering of the pancreatic duct and crushing of large calculi are recent procedures in connection with this operation. Pancreaticostomy and pancreatico- enterostomy have been done very ex- tensively in animal experiment. In human surgery, incision of the pan- creatic duct with drainage has been practised, but the operation of pan- creaticoenterostomy, which conserves the pancreatic juice in the intestine, is much more rational, and in several instances anastomoses have been ef- fected between the canal of Wirsung and some part of the digestive tract. The pancreaticoduodenal region is exposed as for pancreaticotomy. Sutures or Murphy's button may be used. The dilated duct should be freed from adhesions and either grafted into the intestine or, what is preferable, a lateral anastomosis may be made. Pancreatic fluid coming in contact with the other tissues may cause local or distant necroses. SURGICAL AFFECTIONS OF THE SPLEEN.— Abscess.— Splenic and perisplenic abscess will in all likelihood end fatally unless some imusual path is taken by the burrow- ing pus. Incision and drainage is the usual procedure, but, if the spleen is freely movable or readily freed from adhesions, splenectomy may be the indication of choice. Cysts. — Simple and parasitic cysts of the spleen are best treated by inci- sion and drainagfe in the same wav as 94 ABDOMEN, SURGERY OF (MORRIS). we treat abscesses. If the spleen is not bound down by adhesions, the operation may be done more safely as a two-stage procedure, the first of which consists in suturing the cyst Avail to the abdominal parietes with- out opening of the former, and wait- ing for forty-eight hours for the formation of protecting adhesions. Splenomegaly. — Enlarged spleen from whatever cause is usually left to medical resources, unless it becomes so large as to cause serious pressure symptoms, in which case removal of the spleen may become a necessity. Floating Spleen. — AVhile spleno- pexy has been sometimes done for this condition, most operators prefer the more radical removal of the spleen because of the difficulty of holding this organ with sutures, due to its friable tissues. The spleen may be iixed through an incision made obliquely along the left costal margin to the C|uadratus lumborum muscle. The patient is placed in the abdominal position upon a pad or air cushion similar to that used for forcing the kidneys against the abdominal wall. The peritoneal surface of the spleen is scarified, and so is the correspond- ing peritoneum of the abdominal wall. Kangaroo-tendon interrupted sutures entered at the lowest margin of the spleen serve to fasten it nearly in normal position, and a packing of gauze with a protecting apron of gutta- percha tissue . gives support until supporting adhesions have formed. Rydygier, for fixing the spleen, makes an incision in the middle line of the abdomen high up, and forms a pocket in the parietal peritoneum through a transverse peritoneal incision, and then with the fingers forms a pouch, into which the lower half of the spleen fits. The spleen is secured in this pouch by a few points of suture. Neoplasms. — Solid tumors of all kinds and tuberculosis require early removal of the spleen. TYPICAL OPERATION OF THE SPLEEN.— Splenectomy.— The typical external incision is median in traumatic cases (not considered here), but in all others either the semilunar line or one following the costal arch at a distance of an inch or so gives better access to the pedicle. The next stage is purely exploratory and involves division of peritoneum and examination for ad- hesions. If there are no diaphrag- matic or pancreatic adhesions, it is usually possible to isolate the organ, although extensive ligation may be required. It is sometimes necessary to free the spleen from the pancreas by sacrificing a portion of the latter. The organ is then lifted out of the wound, and packed about with gauze. It must be remembered that the spleen is very easily wounded before it can be ligated oft", and that profuse parenchymatous oozing will then delay the operation. As in other operations on abdominal viscera, traction on the pedicle may induce shock, because of the intimate con- nection with the solar plexus. The next stage consists in ligating the spleen vessels, which is accom- plished by tying off the splenorenal ligaments and gastrosplenic omentum and ligation of the A^essels of the hilum. The latter is naturally the ideal choice, but the delay involved adds to the dangers of shock, and unless the patient is in sound condi- tion to withstand operation it may be advisable to transfix the pedicle in one or two planes according to its ABDOMEN, SURGERY OF (MORRIS). 95 width, and ligate each l)y ilscU'. It is well til luiN'e apparatus ready for intra \eni>us infusion, which may l)e begun at any moment that danger from hemorrhage appears. The after-treatment calls for no special principles. When the danger from hemorrhage or sepsis appears to be slight, the external wound may be closed at once. The position of the patient during operation is important. A large sand- bag should be placed under the back, under the upper end of the spleen, and the foot of the table lowered about six inches. The incision may- be median or through the left rectus muscle, preferably the latter. Tt should be ample, and, if necessary, a transverse incision may be made from the upper end of the primary wound parallel to and half an inch below the lower border of the ribs. The splenophrenic ligament should be first attacked. The operator, covering the spleen with gauze, draws it to the right, while an assist- ant draws the left lip of the wound to the left. Where possible, the splenic ligaments and all vascular ad- hesions should be doubly ligated in sections and cut between the liga- tures; but when this is difficult the ligaments may all be clamped and the blood-supply entirely cut off in this way. The spleen may then be removed and the clamps afterward sewed round and removed as in oophorectomy. In difficult cases with extensive adhesions it is possible to grasp all the gastrosplenic ligament between the index and middle fingers of the left hand and to apply a long, curved, rubber-covered clamp. After securing this ligament fir^t, the other ligaments may then be clamped or ligated and cut, after which adhesions may be rapidly separated and the bleeding controlled by gauze packing. Carr (New York Med. Jour., Feb. 16, 1907). When a spleen is removed in a case in which there is not a splenic leukemia of advanced character, the operation is f|uite as safe as is the one for removal of the thyroid or of the uterus or any other simple operation, provided that the same systematic plan is followed. There should be no severe traction on the pedicle of the spleen or great manipulation of the veins, because they are exceedingly friable. After sever- ing the pedicle below, care should be taken to protect the smaller veins which often enter the spleen from above. If one is careless, one will find that some of the large veins which pass through the accessory ligament aie exceedingly troublesome, but when these things are looked after in patieuts not suffering from splenic leukemia the operation is a safe one. The author has had one of these patients go through a severe pneumonia afterward under the care of one of our best internists, who found no difference whatever in the course of the disease. If the leucocytosis is higher than 50,000, then one can count on a fatal hemorrhage after the splenec- tomy. The writer states that his ex- perience in 15 or 20 cases is not suffi- cient to be of any value except as a guide. If there is leucocytosis accom- panied by a rise in temperature, then, of course, there is no occasion for the operation, because one would no more operate in this chronic condition while there is an acute infectious condition present than for any other chronic sur- gical condition. Therefore, if the leu- cocytosis is the result of the leukemia, one must be guarded in the operation, and not fear hemorrhage from the large vessels at all, but hemorrhage from the small adhesions. The blood will con- tinue to ooze out. Gauze may be sutured over the surface, and the blood will ooze out of the stitch holes. It will ooze out, no matter what one does in these cases of advanced splenic leu- kemia. A. J. Ochsner (Jour. Amer. Med. Assoc, Jan. 1. 1910). The writer usually uses an incision through the left semilunar line, carry- ing, if necessary, the upper end along the costal margin to the ensiform car- tilage. He has not found Myer's pro- cedure of cutting the costal cartilage.^ 96 ABDOMEN, SURGERY OF (MORRIS). necessary as yet, but in some cases a left transversal incision joining the longitudinal is convenient. In advanced disease, adhesions, especially to the diaphragm, are occasionally difficult to separate until after the splenic pedicle has been secured. To grasp this vas- cular pedicle temporarily in rubber- covered elastic clamps is the most im- portant step in the operation if the vessels are fairly sound. This must be very carefully done on account of the delicacy of the splenic veins. To grasp the pedicle securely the organ should be turned over, at least enough to grasp the vessels in the hand. With the fingers and blunt dissection, a pass- age is made around the pedicle and a clamp applied and tightened enough to control the circulation until the spleen can be entirely separated and delivered outside the wound. If ex- tirpation is the object of the opera- tion the pedicle can be secured at any time after the application of the elastic clamp, which is applied as close to the root as possible, so as to leave distal to it ample space for ligation. If partial resection is to be done, temporary compression of the pedicle seems harmless if there are no gross vessel-wall changes, and after the use of the clamp the desired amount can be resected and the hemorrhage controlled by buttonhole catgut suturing with a round needle, as in liver resec- tion. "It has been shown experimen- tally that reduction of the artificial supply by ligation resiilts in atrophy of the spleen, and, so long as the veins are left intact, necrosis does not occur. If the splenic artery divides in the hilum, ligation of branches would appear to be an active competitor of partial splenec- tomy. We have not found the marked alterations in the walls of the blood- vessels which have been shown to be often present at post mortem, and which probably represent a terminal condition." W. J. Mayo (Jour. Amer. Med. Assoc, Jan. 1, 1910). Four cases of splenectomy upon malarial spleens. The first case was operated upon four and a half hours after rupture of the enlarged spleen by injury. The patient died a few hours after operation, primarily from the hemorrhage which followed the rupture. The remaining 3 cases recovered from the operation with much improved health, and have remained free from the malarial paroxysms to which they had been subject. Statistics of this operation show that in 24 cases col- lected by Bessel-Hagen up to 1890 the mortality was 65 per cent., while in 64 cases operated upon in the following decade it was 25 per cent. Solieri (Archiv ffir klin. Chir., Bd. 92, Hft. 2, 1910). SURGICAL DISEASES OF THE LIVER AND BILIARY PASS- AGES. — The chief occasion for sur- gical intervention in these localities is gall-stone disease and its numerous consequences, for the relief of which t3'pical operations are required. Sur- gical affections of the liver proper, while numerous, are less frequent, and for the most part are relieved by simple general procedures, as incision and drainage. Abscess of the Liver. — Here may be considered abscess of the liver proper, and suppurative pericystitis. As soon as the diagnosis is made the pus should be drawn off with an aspirating apparatus, and most sur- geons prefer to make an exploratory incision for this purpose. In some cases it may be necessaiy to excise one or more ribs and go through the pleura, in which case the operation should consist of two stages in order to allow protective adhesions to form. After the pus has been removed an incision should be made of such character as to insure complete drain- age, and the abscess cavity allowed to close. If much liver tissue has to be divided to expose the abscess cavity, it will be necessary to use the cautery for hemostasis. Subphrenic abscess may be con- sidered here, although it may occur ABDOMEN, SURGERY OF (MORRIS). 97 on the left side and have no connec- tion with the liver. The ii^eneral principles of operation here are the same as in abscess of the li\'er — ex- ploration, aspiration, and eventually incision and drainage. It may be necessary to g"0 through the thoracic wall. Cysts of the Liver. — Hydatids should be extirpated if possible, the operation amounting to hepatectomy, which see. So radical a procedure is seldom carried out, and the usual inter- vention, both for hydatids and non- parasitic cysts, is incision and drain- age, with the possibility of going through the thoracic wall. The oper- ation may be done in two stages with an interval for the formation of ad- hesions, or it may be done in a single sitting, the cyst being sutured to the operation wound before incision. Neoplasms. — A single focus of pri- mary cancer may sometimes be removed by hepatectomy ; sarcoma is inoperable. Cirrhosis, — This has been con- sidered under Ascites (Surgery of Peritoneum). Hepatoptosis. — Hepatopexy is done usually in conjunction with other operations. The liver is scarified or brushed on the cephalad surface, and one of several methods in addition for retaining it in situ are essayed. The author includes shortening of the sus- pensory ligament. Cholelithiasis. — Simple accumula- tion of gall-stones, apart from the complication and secondary mischief, demands surgical removal. The choice then lies between cholecystos- tomy and cholecystectomy. Cholecystitis. — When the gall-blad- der has become chronically inflamed, altered by disease and adhesions, it 1- should be extirpated. Partial chole- cystectomy is not looked upon with favor. If the process is relatively mild, with the ducts free and intact, cholecystostomy may suffice, but, like the appendix, a gall-ldadder once infected is always infected. Obliteration of Bile-passages from Without. — This is most commonly due to cancer, but may be due to other tumors and inflammatory processes. The typical operation for obstruction from without is an anastomosis between gall-bladder and intestine (cholecystenterostomy). When this is contraindicated perma- nent drainage by a biliary fistula (cholecystostomy) is the only resort. TYPICAL OPERATIONS ON BILIARY PASSAGES AND LIVER. — These are few in number, viz., cystostomy, cystectomy, and cho- ledochotomy, cholecystenterostomy, excision of liver. Other operative procedures appear to necessitate only general principles, such as explora- tory laparotomy, evacuation of pus, etc. The typical operations on the biliary passages are performed for cholelithiasis, incidentally including chronic cholecystitis. Analysis of 350 operative gall-bladder cases, derived mainly from material furnished by A. J. Ochsner. Where the benefit derived from the operation has not been unquestionable the result is stated as unimproved. In 245 cases where gall-stones were found, 79 per cent, report themselves entirely cured by the operation and 6 per cent, consider themselves as cured though still suf- fering from minor discomforts. This gives 85 per cent, good results. Twenty-one, or 9 per cent., are classed as improved, and IS, or 6 per cent, as doubtful. The writer's conclusions are as follows : 1. In the hands of those qualified to undertake the work, the 98 ABDOMEN, SURGERY OF (MORRIS). operative treatment of gall-stone dis- ease is one of the most satisfactory branches of surgery, and the cures may be safely estimated at over 80 per cent., while the majority of the remainder are so much benefited as to justify the operation. 2. The most favorable cases in all respects are those in which the stones are still confined to the gall- bladder. The operative mortality in these uncomplicated cases is almost nil, and the proven end results are prac- tically all that could be desired. These two facts in themselves should enable us to settle any question as to the proper time for operation. 3. The most important principle of gall-stone surgery is the complete removal of the stones, with the least possible damage to the biliary tract. Overlooked stones are probably the most important simple cause of uncured patients. 4. If, as a result of the operation, all obstructions within the biliary tract are removed, a cure is almost certain to result. No evidence has been found in this series of cases to show that cholecystectomy should ever be the operation of choice in gall-stone cases, unless there be chronic cystic duct obstruction or the gall-bladder so diseased as to make a cholecystectomy technically safer and easier to perform than a cholecystos- tomy. 5. Every effort should be made to guard against postoperative hernia. 6. A guarded prognosis should be given in cases complicated by pelvic lesions. 7. In our series, cases of cholecystitis without stones have not shown better results than could probably have been attained by medical means, and unless better results are attained in this class of cases in the future sur- geons should learn to avoid them. E. M. Stanton (Jour. Amer. Med. Assoc, Aug. 5, 1911). Simple Cystotomy. — The gall-blad- der, having been exposed, is incised between two toothed forceps, and the stones if present removed with finger or blunt curet, taking care to remove all possible concrements, some of which may lie close to or in the open- ing of the cystic duct. One finger should be applied along the bladder externally, to aid in localizing con- crements. Folds and diverticula resulting from cholecystitis may con- tain concrements. The cystic duct and common duct must be palpated and, if stones are contained therein, choledochotomy may be required. The author prefers amputation of the greater part of the gall-bladder as a rule, because it removes an infected structure and avoids the distress caused by the lower margin of the liver impinging upon a gall-bladder sutured to the abdominal wall. Cyst ostomy. — Cystostomy with Drainage. — This form of cystostomy is really then a partial cystectomy. The tube remains in position eight or ten days, the bile escaping freely. After the tube has been withdrawn, a little bile may escape up to a week or so longer. As a rule, these fistulse close spontaneously without trouble. Cystectomy. — Surgeons have proved by experience that cystostomy had many drawbacks. It is the con- servative method, but leaves behind a diseased gall-bladder, which invites new surgical disorders. Adhesions which are invariably present cause the organ to lose its mobility, thus increasing the liability to further in- fection. Cystectomy, an operation originally performed only on suspi- cion of cancer, has been the choice of the author for some years, the sug- gestion having come from Langen- beck's discovery of the safety of extirpation of the organ originally, and this idea confirmed by many operators later. Excepting in cases of cancer the author prefers the same operation for cystectomy that he does for cys- ABDOMEN, SURGERY OF (MORRIS). 99 tosUuiU', for the reasDii thai the small portion of i^all-bladdcr which is al- lowed to remain alUnvs of easier fastening to the drainage tnbe, and lessens the annoyance of hemorrhage from the artery and vein of the cystic duct. TccJuiiquc. — The gall-bladder, hav- ing been exposed, is freed from adhe- sions and from the normal peritoneal reflection to the surface of the liver. The presence or absence of gall- stones in the bladder is only of inci- dental importance, because it is for infection of the gall-bladder that the operation is done. The freed gall- bladder can be handled very much as one v^ould handle the appendix, and the operation from this stage on is somewhat similar. Any bile or con- cretions which are found in the lower part of the gall-bladder or the cystic duct are stripped out with the fingers into the cavity of the gall-bladder proper, which remains unopened. The part which has been emptied by strip- ping with the fingers is then ligated or clamped with a pair of forceps to prevent the return of contents to the region of the operation. A longi- tudinal incision large enough to allow the entrance of a small soft- rubber catheter is then made below the clamp or ligature, and extending as far as or into the lumen of the cystic duct. The catheter is intro- duced into this opening and tied in place with a catgut suture piercing the wall of the cystic duct and cathe- ter alike. This avoids displacement caused by vomiting. The next step consists in tying another catgut suture snugly around the cystic duct or the lower portion of the gall- bladder so firmly as to cut off all circulation in the walls. The Sfall- Idadder is then ami)utated between the clamp and ligature, and the lumen of the slump at the point of com- pression by the ligature may be steri- lized like the stump of the appendix, by brushing it with 95 per cent, car- bolic acid neutralized a moment later with alcohol. The catheter, acting as a drainage tube, is then left escap- ing from any convenient angle of the wound of the abdominal wall. In two or three days the constricting suture is usually absorbed and the flow of bile then begins through the tube, which can be removed at any time subsequently, because the suture of catgut fastening the catheter to the cystic duct is absorbed at the same time with the constricting suture. The advantage of this tech- nique is that peritoneal adhesions have had time to wall in the area of operation so* that bile or septic fluid escaping from the region of the stump makes its way safely to the surface. Sometimes it is an advantage to split the catheter longitudinally through- out its entire length, and to lay a strand of gauze loosely in the cathe- ter because this gives us capillary attraction to help in guiding bile or septic fluid to the surface; and if the walls of the catheter are prevented from closing entirely, any blood or other fluid between the stump and the external incision is drawn out the same way by capillarity. Some surgeons do not consider partial excision as a typical operation. They state that cases occur in which the gall-bladder is so fragile that its liberation would be impossible, but such cases make a small part of the ones actually dealt with in practice, and practically the same principles can be observed. 100 ABDOMEN, SURGERY OF (MORRIS). The writer's only contraindications to choiecystectomy are : 1. Grave com- plicating diseases, e.g., typhoid fever. Even in the latter, he advocates sub- sequent ren::oval of the gall-bladder to prevent as far as possible the patient becoming a typhoid carrier. 2. Com- plete obstructive jaundice. A second- stage removal of the gall-bladder is also indicated here, especially if the patient has signs of hepatic cirrhosis. 3. In aged or feeble patients and in those who take the anesthetic badly, so as to save time and shock. H. Lilien- thal (N. Y. Med. Jour., July 1, 1911). Choledochotomy. — This operation comes into play Avhen after cystec- tomy the common duct or the hepatic duct is found diseased or containing concrements. A wide external inci- sion is requisite when it is believed that this operation is indicated. Ex- posure may be difficult on account of the conformation of the thorax, or when adiposity interferes. It may be necessary in such cases for an assist- ant to draw aside all the surrounding viscera widely with the liands^ with gauze beneath the fingers. If adhe- sions are absent the common duct may be lifted into the field with the fingers or a pair of padded forceps. The peritoneal covering is slit. The large vessels — hepatic artery and portal vein — behind the biliary pas- sages are to be avoided. A small vessel running obliquely across these must be held aside or tied and divided. Two lymph-glands in this locality may be so enlarged and in- flamed as to simulate concrements. The common duct must now be examined for concrements and in- flamrnation. If concrements are pal- pable, the duct is opened between slipnooses or forceps. Bile will at once escape and must be caught up with gauze pledgets and the stones, if present, removed with small forceps or curets. As a rule, however, extensive ad- hesions are present, and the opera- tion is much more complicated. These adhesions must be separated as far as possible, and if the cystic duct has not already been opened it should be incised. If the object were not primarily to extirpate the gall- bladder, this should now be done and the cystic duct divided. The chole- dochus should next be sounded through the opening, the finger pal- pating the outside of the canal. If concrements are present, the cystic duct may be laid open slowly until the common duct is reached.- By the aid of small curets and forceps, and palpation externally, small concre- ments may be extracted. If neces- sar}"- the incision may be continued into the common duct as far as the duodenum. Extraction of stones from an inflamed or dilated chole- dochus requires the same precautions as in the case of the gall-bladder. That portion of the duct behind the duodenum is very difficult of access, unless the reflection of peritoneum from the duodenum is first cut away. In cases of this sort it has been neces- sary to enter the duodenum. The conservative method is to draw the duodenum to one side after freeing the peritoneum, but this is believed by some to affect the nutri- tion of the latter unfavorably. A drainage tube is inserted into the choledochus, and the latter sutured up to the tube by most operators, but the author usuall}^ dispenses with sutures, excepting the single one for holding the tube in place, because the walls of the duct normally fall together well, and atmospheric pres- ABDOMEN, SURGERY OF (MORRIS). 101 sure keeps the cut margins together as well as sutures would do it, unless much unusual injury has been caused b_y the operative work. Case of bile fistula in which it was not possible to utilize the hepatic duct for drainage; the writer consequently sutured the duodenum directly to the main intrahepatic biliary duct. Doberer (\\'icncr klin. Woch., Oct. 13, 1910). Cholecystenterostomy. — A typical operation indicated is closure of the biliary passages from without. A long abdominal incision is required, oblique or angular, beginning at the ensiform cartilage and carried down through the right rectus muscle. The intestines are controlled by gauze. If gall-stones are present they are removed, and it must also be determined that suspected cancer of the pancreas is not a calculus in the pancreatic region. A choice of intes- tinal locality for anastomosis is then in order. The duodenum is the ideal region, but in practice a high jejunal anasto- mosis is often preferable. The gall- bladder is emptied upon gauze, and the apex seized with a clamp. A loop of jejunum is similarly held with the fingers. Both structures are opened to the extent of a finger-tip, as in gastroenterostomy, and the suture is also performed as in the latter. This locality may be fortified with omen- tum, if the operator wishes. The Alurphy button is useful for this anastomosis and is used by many operators, but simple suture suffices for most cases. Excision of Liver; Hepatectomy. — Indicated in tumors chiefly, inckiding cysts, and sometimes after trauma- tisms. When a pedicle is present or the mass occupies the margin of the liver, hepatectomy is very easily per- formed by the aid of ligation. When this is impossible the mass is removed step by step, followed by ligation of all bleeding vessels. It is often possible to ligate these in ad- vance of division v/ith a needle armed with catgut. After extirpation it is in order to ligate all lumina of blood- vessels with the aid of a needle rather than with forceps, and then suture the liver with catgut. Buried sutures are undesirable for the liver, however, as blood and bile seep into them. Pressure may be brought to bear for controlling hemorrhage that is not from spouting vessels, in some cases. Pressure is obtained by carrying a long catgut ligature deeply through the wound in the liver, and fastening each end of catgut to a broad plate of sheet lead. If the entering end of catgut is first fastened to its respect- ive plate of lead, the emerging end of catgut can be tightened to any de- sirable extent before fastening it to the second lead plate. Ears fash- ioned on the lead plates can be bent over to hold the catgut ends, and silk strands fastened to the plates and led out of the wound serve for removing the plates eventually when the catgut is absorbed. More than one pair of plates may be used for an extensive liver wound. Extensive resections of the liver can be carried out with the most simple means. If care is taken not to stretch the vessels in cutting through the liver and not to pull them out, it is not diffi- cult to apply hemostatic forceps and to apply a ligature, while the vessels which are cut obliquely have to be taken care of by circular suture. Com- pression suture of the wound in the liver and catgut suture of the surface are the safest means of hemostasis. It is best to press together two wounded 102 ABDOMINAL INJURIES (LAPLACE). surfaces of the liver by suture, and, therefore, whenever possible, to make the resection in the shape of a wedge placed in an approximately vertical direction to the margin of the organ. Garre (Surg., Gynec. and Obstet., Sept., 1907). Robert T. Morris, M.D., New York. ABDOMINAL INJURIES.— Under this heading- will be considered the broad field of injuries of external origin to which the abdomen and the abdominal viscera are liable. These include contusions, which are impor- tant mainly because of the lesions to which the intra-abdominal organs are exposed;- non-penetrating zvounds, in which the abdominal walls alone are injured, and penetrating zvounds, in which the walls and the abdominal viscera are penetrated. CONTUSION OF THE ABDO- MEN.— SYMPTOMS.— Whether caused by blows, kicks, spent bullets, the passage of heavy bodies — such as vehicles — over the abdomen, etc., the symptoms attending a contusion in this region are not always such as to call attention to the seriousness of the lesion present. The gravest ab- dominal injuries may coexist with practically no external or general in- dication of mischief, the patient walk- ing a long distance, perhaps, without experiencing anything more than slight local pain where the blow had been received. Case of patient run over by a milk wagon, in which no serious disturbance manifested itself until about eleven weeks after the injury occurred. The patient then noticed a lump about the size of a hen's egg near McBurney's point. Two weeks later the swelling ruptured and some pus was discharged. The mass consisted of suppurating omentum, with partial rupture of the aponeuroses of the external oblique and a localized rupture of the muscular por- tion of the internal oblique and trans- versalis muscles. Recovery followed suitable treatment. Kahlke (Surg., Gynec. and Obstet., Feb., 1907). Intestinal lesions produced by blunt force are most frequently encountered in males during youth and early man- hood, and in females during childhood, these, of course, being the periods of greatest exposure to trauma. Pre-ex- isting lesions, such as hernias, ulcers, adhesions, etc., increase the liability of rupture should trauma occur. Lax ab- dominal muscles afford less protection than a wall which is contracted, and hence very sudden accidents are more frequently the cause of visceral lesion than those in which the patient has some warning. All parts of the gastro- intestinal tract have been injured, to say nothing of the other abdominal viscera, but the ileum and jejunum are more often involved, the colon and stomach less frequently. Thus in 219 cases, the small intestine was affected 172 times, the large 26 times, and the stomach only 21 times. That vomiting is apt to arise sooner if the lesion be above the level of the umbilicus than if it be below is probable. Stone (Annals of Surg., Sept., 1910). In all injuries of the abdominal viscera without external lesions careful examination is necessary and contin- uance of the observation kept up over a period of several days or more. No matter how slight the S}'mptoms refer- able to the abdomen, the possibility of visceral injury must be considered, re- gardless of the point of injury or the external force employed. The degree of violence has often no relation to the extent or severity of the injury to the internal organs, and an investigation as to the exact details of the accident or violence is essential for the diagnosis. Blows, kicks, and crushing violence cause most of the intestinal injuries; compressive force is the most common cause of liver trauma, and concussion is responsible for most of the splenic rup- tures. The presence or absence of ABDOMINAL INJURIES (LAPLACE). 103 peristalsis is of the utmost dicignostic and prognostic importance and lias not been duly appreciated. The early pres- ence of a peristalsis indicates that the abdomen or its contents have received some shock or violence, and its per- sistence or recurrence is a conclusive proof of internal or visceral injury. Any decided lessening of peristalsis is a danger signal if it occurs more than three or four hours after the injury. Active peristalsis, on the other hand, is always encouraging. There are no ■pathognomonic symptoms of abdominal injuries, most of them being common to all injuries, but, in general, progress- ively increasing shock indicates trauma of the solid organs, while early symp- toms of peritonitis follow that of the stomach or intestines. Pain as an in- itial symptom is important only as call- ing attention to the fact that an injury may have occurred and, possibly, by its location, showing the possible site of the injury. Shock has no diagnostic value except by its progress or course, which is of great importance. H. H. Sherk (Jour. Amer. Med. Assoc, March, 1911). Althoug-h the abdominal walls may be but' slightly injured, the lesions may consist of extensive extravasa- tions of blood between the layers, or sufficient laceration of the muscular and other tissues to give rise to more or less local sloughing. Such lesions of the abdominal wall, however, are not always accompanied by injury of the abdominal organs. Usually, in these cases, according to Scudder, the greater the force the greater the injury, but a trivial blow may result in serious damage to intra- abdominal viscera. A hollow organ, if distended, is more vulnerable than if empty. Inquiry should be made as to the last mealtime and as to the last micturition. The exact direction of the blow is important. The clothes of the patient sometimes offer some indication as to the injury. A trifling superficial injury of the aljdominal wall may be associated with serious internal lesions, owing to the resistance offered by the ab- dominal walls and the fragility of the abdominal organs. The external ap- pearances, therefore, should not be taken as a criterion. From observations of some twenty cases of visceral injury, following- contusion 'of the abdomen, verified by operation or autopsy by Brewer, the most prominent were pain, tender- ness and muscular rigidity, and like- wise the most reliable. The deep- seated, localized pain following injury, especially increased by pressure, and accompanying local or general mus- cular rigidity, is one of the most constant signs of intra-abdominal injury. Brewer holds that the asso- ciation of these three symptoms is almost pathognomonic of abdominal irritation. Pain, however, is often present, with tenderness, in injuries limited to the abdominal wall; but in these instances muscular rigidity is generally absent. In the absence of subcutaneous pain localized tender- ness with rigidity is strongly sug- gestive of visceral injury. Of the three symptoms, muscular rigidity is the most reliable, and sometimes the only sign. In the absence of other diseased conditions spasm of one or more of the abdominal muscles fol- lowing the traumatism may be looked upon as nature's effort to protect an injured organ from further irritation. Vomiting is a symptom often present, but not always an accompaniment of severe visceral injury. It is com- monly present with involvement of the stomach and upper part of the intestinal tube, and with injuries resulting in severe shock. The signs 104 ABDOMINAL INJURIES (LAPLACE). of free fluid in the abdominal cavity are very suggestive. In most cases, however, severe contusions of the abdominal wall, whether the deep organs are involved or not, are followed by agonizing pain in the region of the injury, rest- lessness, nausea or vomiting, marked prostration (indicated by a small, rapid, and irregular pulse), pallor (sometimes attaining lividity), cold sweats, rigidity of the abdominal wall, meteorism, anxiety, and fear of a fatal issue. A very rapid and considerable me- teoric distention coming on after a contusion of the abdomen does not of itself, in the absence of characteristic signs and when the pulse is good, point to a rupture of any of the viscera, or to an internal hemorrhage. Lejars (Semaine medicale, Oct. 30, 1907). All these symptoms bear the im- print of a severe nervous commotion, and, if the extensive distribution of the sympathetic nervous system in the abdominal cavity is borne in mind, the fact will become evident that symptoms usually witnessed im- mediately after the receipt of the injury are due mainly to the influence of the concussion upon the sym- pathetic supply. Sudden death has been known to follow a violent blow, especially when received in the region of the solar plexus. Any contusion of the abdomen may induce symptoms of shock. It is im- possible to determine the extent of the internal injury from the presence or the intensity of the shock or the total absence of signs of shock. The writer has had patients with severe laceration of the liver or rupture of the bowel who^ were able to repair to the hospital on foot. Subnormal temperature may be due to the shock and anemia; fever soon after the trauma shows an in- flammatory process. The pulse and heart action are not influenced by in- ternal injury except in case of anemia or peritonitis. Nausea and vomiting do not necessarily accompany anatomic injury. Foderl (Med. Klinik, Oct. 30, 1910). The pain varies according to the location of the traumatism and the sensitiveness of the patient. Very severe at first, it usually becomes less marked after a few hours. It is greatly influenced by shock, profound prostration reducing its intensity by reducing sensation. Great restless- ness usually accompanies abdominal pain after injuries, as well as during other diseases, such as appendicitis, when the suffering is due to a local- ized trouble. The pain may be radiated in various directions, — the shoulder, the umbilicus, the left axilla, the testicles, etc., — according to the site of the primary lesion. Local tenderness is usually marked over the site of the traumatism. Rigidity of the abdominal muscles, attended with dullness, even slight in degree, and local tenderness, are most valuable points in the diagnosis of these injuries, and where they exist, and espe- cially if a blood-count shows an active leucocytosis, operation is demanded and no time should be lost in performing it. It is very hard to convince the patient and his friends of the actual condition, and they will invariably plead for delay. The serious condition should be early pointed out, and every effort made to secure consent to operate while the con- dition of the patient renders success probable. These cases are most inevitably fatal without operation, and the effect of an exploratory incision while the patient is in a fair condition is not serious enough to counterbalance the advantages to be gained if rupture of any of the organs is found to exist. W. G. Weaver (Penna. Med. Jour., July, 1904), Protest against the administration of opium or other narcotics until the diag- nosis is positive, because they obscure the clinical picture, the diagnosis, and ABDOMINAL INJURIES (LAPLACE). 105 the indications for treatment. They should be reserved for use in cases in which the diagnosis is positive, or in which both removal and operation are impossible on account of surrounding conditions, or in those cases in which the inj.ury is so serious that death is inevitable. Foderl (Med. Klinik, Oct. 30, 1910). The vomiting- varies greatly in intensity from mere nausea to the most violent expulsive efforts, which are liable, by the strain upon the abdominal organs, to suddenly in- crease the extent of the lesions. The vomited matter sometimes contains blood, especially if the upper portion of the digestive tract is involved in the injury. Constant and persistent vomiting- tends to indicate a contu- sion accompanied by visceral lesions. According to Berndt, in simple cases the vomiting is repeated but two or three times. When the intestine is ruptured the vomiting is persistent and intractable and liver-dullness is absent. The degree of shock depends upon the nature and extent of the injury and especially upon the amount of blood lost. When the signs of col- lapse gradually become more marked, internal hemorrhage from rupture of one or more of the viscera is to be feared. The pulse, usually rapid and weak at first, gradually becomes stronger and slower if a favorable reaction is about to take place. If, on the con- trary, an unfavorable course is being taken and some complication is to occur, its rapidity and tension may become increased. Irregularity is not a favorable indication if it per- sists. Temperature is independent of the pulse, except when a favorable reaction is taking place, when it may return to the normal line after havinsf gone beyond or below it. The usual belief that a subnormal temperature always follows internal hemorrhage is fallacious ; for it may also be raised. The temperature, therefore, is of no value as a guide. Hematemesis may assist in estab- lishing the diagnosis of lesion in the stomach or the upper portion of the intestinal tract, while the presence of blood in the stools may do the same as regards lesions of the intestines as a whole, including the colon. But, in itself, this symptom is, by no means, characteristic, since a violent strain may cause sudden engorge- ment of pharyngeal, gastric, rectal, or hemorrhoidal vessels and then, several days after the accident, blood- rupture ensue. Even when present, streaks in vomited matter or stools are not always indicative of an alarm- ing condition. Blood in the urine is a more reliable sign of lesion in the urinary tract, especially the kidney and bladder. Anuria is also indicative of lesions in these organs ; but, as shock frequently arrests the flow of urine, it is only valuable as a symptom after all symp- toms of shock have passed. Hemorrhage into the orbits and from the ears are occasionally met with "when the concussion has been very severe. This symptom does not necessarily indicate that the injury is an unusually dangerous one. A few hours after the accident the pain usually becomes reduced; the patient may be more quiet and, per- haps, somnolent, although the pulse remains in its former condition. This period lasts between twelve and twenty-four hours. If at the end of this time there be no complication, 106 ABDOMINAL INJURIES (LAPLACE). a visceral lesion is probably not present. If, on the contrary, the symptoms gradually increase in in- tensity, the likelihood of grave injury is very great. In the light of present knowledge, however, the practitioner should not delay active procedures until the patient's life becomes compromised by permitting the mechanical injury produced to start an infectious proc- ess, when the manner in which the injury was inflicted and the force ap- plied tend to suggest serious internal lesion. An exploratory incision is sometimes permissible (see colored plate). A measure aim jst devoid of danger is the simple, exploratory abdominal inci- sion, to determine whether or no a visceral lesion exists. It is a well- demonstrated fact that any fluid or ex- travasated matter in the peritoneal cavity will almost invariably present itself under the line of incision where the cavity has been entered, being forced there by the intra-abdominal pressure, and it is on this principle that abdominal drainage can be effected against gravity. The writer has seen a large collection of pus in the pelvic cavity drained through an opening in the belly so com- pletely that at the autopsy not a spoonful remained. It follows, then, that in many cases at least a simple incision through the abdominal wall will be all that is necessary to reveal even a small ex- travasation through a ruptured yiscus. Of course, there will be cases in which the rupture is so minute as to preclude extravasation at the onset, and such will be overlooked. In doing this little operation, for, as a rule, a short incision will be as effectual as a longer one, it is absolutely necessary that all bleeding be checked before opening the peri- toneum, lest some of the blood should find its way into the cavity and obscure the findings. When and where shall the exploratory incision be made ? At the earliest possible moment, for in this lies the salvation of the patient, and in the absence of contraindications it should be made in the median line between the umbilicus and pubes. D. Tod Gilliam (Monthly Cyclo. of Pract. Med., May, 1907). Two classes of cases should not be operated on at first: (1) Cases in which little or no shock is present, and in which there are absolutely no localizing signs ; (2) cases in which profound shock, amounting perhaps to collapse, exists. Immediate operation is de- manded in persistent moderate shock, with or without localizing signs. Im- mediate operation is indicated in cases of progressing hemorrhage, and in cases of peritoneal infection. Scudder (Bos- ton Med. and Surg. Jour., May 2, 1901). Any injury to the abdomen, though no external injury occur, may be asso- ciated with damage to the intestine or other viscera. An exploratory opera- tion is justifiable in cases with distinct rigidity. An operation is absolutely indicated when there is, besides rigidity, pain, tenderness, vomiting, shock, dull- ness, or other symptoms indicative of some intra-abdominal disturbance. Cases not operated upon are lost. The impor- tance of early operation cannot be emphasized too strongly. At present the death-rate is about 75 to 80 per cent. Flint (Med. Record, Feb. 18, 1905). Series of 64 cases in which the duo- denum was the seat of the lesion. An operation was done in 28 cases, but in 6 the perforation was not discovered, and in 7 the patients succumbed to shock, hemorrhage or complications. Injury of the duodenum may be fol- lowed by thrombosis of, the portal vein. Notwithstanding the bad prognosis, treatment can be by operative measures only. Small holes in the duodenum may be sutured, but extensive injury requires resection of the intestine. It is not particularly difficult and proved success- ful in the case reported, as also in others on record. Transient glycosuria was observed in this case and also in several in the literature. Meerwein (Beitrage z. klin. Chir., liii, Nu. 3, 1907). Cases illustrating the fact that the advantages of an early operation are too Abdominal injuries (LapLace). 107 great to warrant waiting until alarming symptoms develop before operating. The diagnosis is not only dillicult at first, but frequently impossible, espe- cially when there is shock. It is better to operate prudently in a doubtful case than to run the risk of compromising the chances of success should operation he necessary. Patry (Revue nied. de la Suisse Romande, Feb. 20, 1909). DIAGNOSIS.— In abdominal con- tusions the diagnosis should primarily be based upon the history of the acci- dent, the manner in which the injury occurred, the shape of the body, or - bodies, by means of which the trau- matism was inflicted, and the degree of percussive force applied, and, secondarily, upon the symptoms present. The diagnosis of traumatic lesions of the abdomen is most difficult, the symp- toms being variable. When there is an element of doubt in diagnosis, lapa- rotomy is indicated. History and nature of injury may be the only indications, but early laparotomy will improve the percentage of recoveries. Laparotomy as a means of diagnosis is without danger. Sellenings (N. Y. Med. Jour., Jan. 19.. 1907). Method of abdominal diagnosis which, although purely clinical, is known and largely used abroad, but in spite of its great usefulness is seldom heard of here. This is the practice of making abdominal or bimanual vaginal examination of patients while in a hot bath. Unless one has tried this pro- cedure, it is difficult to conceive of its immense usefulness, for in many, if not most, instances the abdominal relaxation obtained is quite equal to that obtained under an anesthetic, with the added advantage that the patient can help the examiner by voluntary movements, such as deep inspiration, holding the breath, etc. This can be done in an ordinary bathtub, in water as hot as the pa- tient can bear; or if it is desirable to have the patient higher in the tub, a long sheet may be let down over the tub into the water and fastened about the ends of the tub by knotting the corners under the rolling edge. Carter (Med. Record, May 7, 1910). Lesions of the Intestinal Tract. — Various theories have been ad\anced as to the manner in which rupture of the intestine is brought about, but experiments have shown that squeez- ing 'of the gut between the com- pressed abdominal wall and the verte- bral column is the main mechanical factor brought into action. Five cases of subcutaneous rupture of the intestines, with three recoveries. All the patients in this series were injured in one or two ways. Either the patient fell heavily, striking the front wall of his abdomen on some hard angular body, or else a heavy body fell on him while supine. The wrjter believes that in this way the bowel is cut in two by the angle or promontory of the sacrum, against which it is forced when the anterior- abdominal wall is pushed against the spine. Andrews (Surg., Gynec. and Obstet., June, 1906). Crushing against the ilium is rarely produced. Another, although rare, cause of rupture is the presence, in the intestinal tract, of liquid or semi- liquid material, the sudden circum- scribed pressure exerted upon the gut causing it to burst, through overdis- tention. The small intestine' is the seat of lesion in 75 per cent, of the cases of rupture in the course of the intestinal canal. Hence the impor- tance of carefully ascertaining in each case the direction from which the percussive force came, the inten- sity of that force, and the relative position of the organs between the site of pressure and the spinal column. Another factor of importance in es- tablishing a diagnosis is the size of the instrument causing the injury. 108 ABDOMINAL INJURIES (LAPLACE). Lesions of the digestive canal, for instance, are usually the result of violent and sudden percussion pro- duced by a body over a limited sur- face of the abdominal wall. The predisposing factors are the presence of solid, semisolid, or fluid matter in the hollow viscera; lean- ness of the individual, and intestinal adhesions. Any of the above accidental causes of injury being fulfilled, rupture of some portion of the gastrointestinal tract is likely, especially if there is loss of consciousness at the time of the accident, followed by collapse, severe pain, a rapid and weak pulse, vomiting, tympanites due to the escape of intestinal gas into the ab- , dominal cavity, and tenderness and rigidity of the abdominal walls. Summary of 64 cases found in the literature of injuries of the duodenum from contusions, besides one of his own. Among the symptoms noted were bilious vomiting soon after the accident, rigid abdominal walls, absence of an area of dullness over the liver, localized pain and shock. Frankel lays great stress on the slow rise of the temperature from hour to hour. Pulse above 100, if hemorrhage can be excluded, speaks in favor of rupture of the intestines and incipient peritonitis. Circumscribed pain and tenderness are indications for ex- ploratory laparotomy. Meerwein (Bei- trage z. klin. Chir., liii, Nu. 3, 1907). The wound of entrance made by modern projectiles may be smaller than the diameter of the bullet. The firing distance is of great importance. At a distance less than 300 meters the explosive manifestations are very marked; in distances over 300 meters pure perforations are produced. The power of penetration may have been lessened, so that the projectile may lodge in any organ of the body; secondary infection of other organs may follow. The frequent shooting in the reclining position leads to very complex injuries. The bullet may enter the apex of the lung and have its exit in the floor of the pelvis. The caliber of the wound is narrow in the glandular organs of the ab- domen. The entrance and exit wound may be of the same size; in exceptional cases only is the wound of exit lacerated. In grazing shots the borders of the wound are sharp and well defined. The caliber of the wound is more circumscribed in the pancreas and kidney than in the spleen or liver. The abdominal organs may be crushed by shots at close quarters. Von Doche (Mili- taerarzt, July, 1909). Such a diagnosis is further strength- ened by hematemesis or bloody stools, the former tending to indicate a lesion of the stomach. Death occurs in 96 per cent, of such cases if un- operated. There are two chief mechanisms by which lesions of the intestine by ab- dominal contusions are produced: (1) Crushing of the bowel against the ver- tebral column, and (2) bursting of a loop of gut. The former is the more common, the dangerous blows being directed anteroposteriorly if applied in the median line, or obliquely inward if applied laterally, in either case pressing the bowel forcibly against the spine. Much less dangerous are blows directed obliquely outward if applied to the median line, or those directed almost parallel to the anterior abdominal wall. The smaller the st-iking surface of the agent the greater the risk of intestinal lesion, the parenchymatous organs being especially involved when the striking surface is large. The mucous mem- brane gives way first, then the muscular, and lastly the serous coat, so that the resulting wound is funnel-shaped with the base directed internally. For a lesion to be produced by bursting, the communication of the intestinal loop with the loops above and below must be momentarily intercepted by the injuring force, the loop must be distended with fluid or gas, and the striking surface is usually large. The serous coat gives ABDOMINAL INJURIES (LAPLACE). 109 way first, and the wound is funnel- shaped with the base external. The rupture usually occurs at the summit of the loop. C. Dambrin (Revue de chi- rurgie, vol. xxix, No. 3, p. 457, 1904). Case of traumatic rupture of the intestine by indirect violence in a woman of 26 whose previous health had been good. While hurrying into her house to escape a thunder-storm she slipped and fell, striking the ground upon the right buttock. She had just partaken of a hearty supper. No immediate alarm- ing symptoms were noticed. She was awakened in the middle of the night by severe abdominal pains. The abdominal symptoms rapidly increased, and two days after the fall the patient was in a critical condition. The temperature was 104.3°, the pulse 140. There was marked tympany. Case in which, on opening the ab- domen, there escaped cloudy fluid, but no gas. On separating the adhesions which had formed about the great omentum there was a gush of fluid heavily loaded with fibrinous flakes. The small intestine was distended and of a bluish-black color. A small per- foration was discovered on the convex surface of the lower portion of the jejunum. This was sutured into the abdominal wound. The abdomen was drained. The shock of the operation was considerable, but on the second day there was improvement. The fistula persisted. Three months later, the fis- tula continuing to discharge, the patient had become alarmingly weak owing to the failure in assimilation of food, all effort to heal the fistula having failed. A second operation was done, the fistula was closed, and the continuity of the gut restored. Recovery was rapid, and in the next few months she gained 25 pounds in weight. E. J. Senn (Amer. Jour. Med. Sciences, June, 1904). The effects of contusions of the abdo- men upon the intestinal ligaments, upon the mesocolon and the mesentery, have not been much studied. The intestinal arteries that are injured in lacerations of the mesentery are the superior and inferior mesenteric arteries or their branches. A wound of the secondary branch of the superior mesentery far from the intestine does not, owing to the richness of the anastomosis, cause gangrene of the intestine; but, if the branches are cut or injured near the intestines, gangrene will follow. Here are some of the results of the experi- ments: Section of the superior mesen- teric artery; gangrene of a long portion of the small intestine; section 8 centim- eters in length, along the border of the mesentery in such a way that all the recti vessels are divid'^d close to the intestine; gangrene of the intestine for 4 centimeters ; incision of the mesentery, 5 centimeters from the mesenteric bor- der of the intestine; placque of super- ficial gangrene of the intestine; incision 8 centimeters from the mesenteric bor- der of the intestine; intestine is not involved. The closer these lesions are to the intestine, the more serious are their consequences. These anatomical and physiological notions have their importance in thera- peutics ; in fact, early death from hemorrhage is inevitable if one does not intervene surgically. If, perchance, pa- tient should survive this hemorrhage, he soon would be exposed to gangrene of the intestine and to peritonitis. Hence, early laparotomy is indicated in these cases. Every time the tear is located near the intestine an enterectomy of the corresponding intestinal zone is indi- cated. If it is parallel to the axis of the mesentery and at some distance from the mesenteric border of the gut, simple ligation of the vessel will suffice. Fur- ther, one can fix an omental graft upon the intestine so as to assure collateral circulation. A. Labastie (Arch. gen. de chir., Jan. 25, 1908). Study based on 2500 cases recorded in various hospitals. It has been recom- mended that the abdomen should be explored in all cases of severe' ab- dominal_ injury, and that the question of diagnosis may be left until the parts have been actually exposed by opera- tion. There can be no doubt that the exact lesion or lesions may sometimes be difficult or even impossible to define, but an attempt should faithfully be made to come to a conclusion before the no ABDOMINAL INJURIES (LAPLACE). abdomen is opened; an operation should not be done "on the chance," but all the symptoms carefully noted and weighed after a S3^stematic examination of the patient. If it is possible to ascertain the exact part of the body struck by the force which caused the injury, then one can make an approximate guess as to the organ ruptured, for it is generally lying beneath, between that point and the spine, and incision over this area gives direct access to the damaged structure. W. H. Battle (Practitioner, July, 1910). In the differential diagnosis of ab- dominal contusion the greatest feature for an early recognition of the existing conditions is whether there is unilateral or general tension of the abdommal wall, unless there is considerable blood- suffusion at the injured place. Aside from the reflex tension of the ab- dominal muscles, a slight, but distinct exacerbation of the general condition during the first few hours following the injury is a point of import:mce. With very careful observation, three or four hours may be allowed to elapse, but even then there is the possibility of error. Koerte reported a case where he was absolutely certain of his diag- nosis and had decided to operate ; the patient, however, refused operation and made a smooth recovery. In the most favorable cases, where is but a slight tear, the mucous mem- brane will prolapse and occlude the aperture. Neighboring loops or thi omentum will form a layer over the lesion with agglutination or adhesion, so that recovery may take place. If there is exudation of intestinal contents, a circumscribed, encysted abscess may form which is capable of resorption, or secondary perforation into the intestine or outward may occur ; but it is equally possible that pus will find -the danger- ous route into the free abdominal cavity. In the most unfavorable cases there is neither occlusion nor abscess formation ; the inflammation will rapidly spread over large areas or over the entire peritoneum and cannot be checked. As early as four hours, exudate may be found ; likewise, fibrinous deposits on the various loops. The more or less fulminating course is not only depend- ent upon the quantity of the exudate, but also on its infectious nature. This differs in the various sections of the gastrointestinal tract, as has been sho'.vn by Brunner, and, according to him, the greatest weight attarhcs to ' phyrical factors (variations in consistency) favoring the propagation oT infectious material. For this reason h; considers lacerations of the small intestine more dangerous than those of the large in- testine, as in the former the quantity of bacteria increases toward the cecum. Statistics show the rarity of cases in which the most favorable course, as depicted above, takes place. Of 160 cases of subcutaneous inte:tinal rui- ture in which the expectant treatment was instituted, 149 died; of tho 11 which recovered, 10 had to be operated dur- ing treatment for fecal abscesses and fistulse. These figures furnish, in the writer's opinion, clear and distinct proof for the insufficiency of expectant treatment, which, indeed, should be totally discarded. Enderlen (Post- Graduate, July, 1911). Lesions of the Stomach. — Blows seldom cause rupture of the stomach, the elasticity of the organ, even when containing liquid or semiliquid ma- terial, being such as to cause it to escape injury under sudden impact or great pressure. It is also pro- tected by the lower ribs, the liver, and the intestines. Nevertheless, this organ is occasionally involved in traumatism affecting other abdom- inal viscera. In the majority of cases the rent is found near the pyloric orifice, but the greater curvature may be the seat of the lesion, while the entire organ is occasionall}^ torn from end to end. In the latter case, however, death ensues almost imme- diately in practically all cases. Pres- sure during lavage of the stomach ABDOMINAL INJURIES (LAPLACE). Ill ma}' also cause laceration of the mucous membrane. In the case of incomplete tears there ma}' l)e hematemesis and severe localized pain resembling' that of gas- tric ulcer, — gnawing' and burning' in cliaracter. This is followed l^y local- ized inrtammation Avith tendency to the formation of adhesions. Hemor- rhage between the coats of the stom- ach may also occur in incomplete tears, a cyst-like pocket being formed. Molent pressure upon the stomacli may cause it to be crushed ag-ainst the spinal column, and the mucous surfaces be lacerated by interpressure of the anterior and posterior walls of the org-an. In such a case a marked lesion necessarily folloAvs, g'iving rise to copious hematemesis. Rupture of the stomach implicates the peritoneal coat in the majority of cases, the elasticity of the peritoneal investment being less than that of the two internal coats : muscular and mucous. The contents of the stom- ach, or a portion of them, escape into the peritoneal cavity and cause severe suffering and shock, followed promptly by death or septic peritoni- tis. Bryant teaches that a ruptured intestine is probably present, though this is not certain, when, after a diffuse injury to the abdomen or a severe local injury as the immediate result of the accident, there is little collapse, and when vomiting soon be- comes a prominent and persistent symptom, with lasting local pain and great thirst, with or without abdom- inal enlargement. According' to Gluzinski, two signs which enable the physician to diag- nose the occurrence of intestinal per- foration before peritonitis has had tim-e to manifest itself: 1, distinct- ness of the murmurs of the heart and respiration during auscultation of the al)domen, due to the presence of in- testinal gases in the peritoneal cavity. 2, change in the pulse, which, at the moment of perforation, becomes accel- erated, to slacken some hours later, owing to the absorption of putrid gases acting as cardiac poison. Four symptoms of internal abdominal injury are especially important and trustworthy: 1. Permanent and pro- gressive feebleness and frequency of the pulse, especially if combined with pallor, a general state of anxiety, of depression, or of delirious excitement. Abdominal tenderness soon after in- jury or after the onset of acute symp- toms may indicate hemorrhage rather than inflammation. 2. Loss of liver dullness with progressive gaseous distention of the abdomen, or ten- derness and resistance of the parietes. This indicates perforation of the gastrointestinal tract. 3. Limited dullness on percussion without dis- tention is also produced in some cases of perforation. 4. Shifting dull- ness in one or both flanks as is observed in cases of ruptured bladder or large hemorrhage. C. A. Ballance (Lancet, Oct. 29, 1904). Case in which laparotomy, after a severe contusion of the abdomen, re- vealed an extensive tear of the mesen- tery as the only resultant injury. Gan- grene of the ileum had commenced as a result of the laceration of the nutrient A'essels. Reinecke (Miinch. med. Woch., Sept. 8, 1908). Lesions of the Liver. — The liver, owing to its friable nature, its size, and its anatomical position, is the organ most frequently injured, be- cause indirect concussion may cause a profound lesion. A fall from a great height into water may thus cause a gaping rent of the capsule and parenchyma and open a large number of vessels. Severe and sud- den blows of any kind, especially 112 ABDOMINAL INJURIES (LAPLACE). those involving much surface, over the abdominal wall may thus cause injury to this organ. Again, its soft- ness, which may be increased by hypertrophy, cause it to yield readily to the crushing produced by carriage- wheels, car-bumpers, etc. The severity of all the general symptoms is usually increased. The pain, when the liver is seriously in- jured, is peculiar; it radiates from the right hypochondrium to the waist, the scrobiculus cordis, or the scapular region. The respiration is generally embarrassed; there is marked shock. Examination of the feces may show the absence of bile, especially if the bile-duct is ruptured : an occasional complication. The dissemination of bile in the system causes itching and, after a time, jaundice. The escape of bile into the peritoneal cavity may not give rise to peritonitis, however, this fluid being aseptic. A serous exudate may result from the irrita- tion caused by its presence, forming a composite fluid which may be re- tained in the peritoneal cavity a con- siderable time. Rupture of the liver is an extremely fatal accident, and the symptoms which ensue are usually marked and serious. Shock is present, frequently passing into collapse and death. Short of this there are vomiting, rapid pulse and res- piration, pallor, etc. In this accident rigidity of the abdominal wall is very evident, so that it may appear board- like. Tenderness becomes localized to the hepatic region, and there is shifting dullness in the flanks with the ordinary symptoms of loss of blood, according to the amount of it which is effused; the man becoming restless with a rapid, weak pulse, sighing respiration, and what is called "air hunger." Jaundice may be a late symptom and is there- fore of no use in the early diagnosis, which is so* very important. There is, as might be expected, much variation in the size of the rupture, which is usually on the convex surface of the right lobe ; the combined statis- tics of Mayer and Ogston give 3 right lobe to 1 left lobe as the proportions. Shock in this injury may not be evident when the patient first comes under observation. When leaving the Royal Free Hospital some years ago the writer saw a woman of 59 brought in, who had been run over in the street a few minutes earlier. She was excited, and resented examination. There were no marks on the abdomen, no dullness in the flanks, or rigidity of the muscles. It was difficult to induce her to remain in the hospital, yet three hours later the abdomen was full of blood, and she did not survive operation to arrest the bleeding for very long. The liver was extensively torn, and the kidney showed a recent laceration ; there were other injuries also. W. H. Battle (Practi- tioner, July, 1910). The most reliable symptom is the defense inusculaire emphasized by Hart- mann and Trendelenburg. Rigidity is not the proper term for this condition, for rigidity rather denotes a tetanic state of the abdominal muscles, whether stimulated by pressure of the hand or not. It is not marked, except in the gravest cases, shortly after injury, but develops in the following few hours from irritation of the peritoneum by the hemorrhage of intestinal contents from rupture of the intestines. It was especially mentioned twenty-four times in the 44 cases, and in the remainder other signs, notably those of internal hemorrhage, were so marked that it was not noted in the history. Never- theless, it is not an infallible symptom, as proved by 2 cases related by Baum. Riebel (Quarterly Bull. N. W. Univ. Med. School, Sept., 1910). A rent is probable after a severe injury if there is collapse, if the pulse becomes more rapid and small, if the patient shows signs of exsanguinity, if the area of liver-dullness on per- cussion is increased, and if pain ABDOMINAL INJURIES (LAPLACE). 113 radiating- to the scapular region is complained of. Severe injury may exist, however, without these indica- tions. The liver is injured with greater fre- quency than any other abdominal viscus. Of 365 cases of subcutaneous injuries of solid viscera the liver was injured in 189. The spleen, kidney, and pancreas combined in but 179. The factors which favor a high percentage of injury are : (1) It lies wedged between the ribs and vertebral column, and (2) it is very heavy and elastic and only slightly movable. It is nine times as heavy as the spleen and ten times as heavy as the kidney. Furthermore, the physiological function of digestion renders it more liable to injurj-, since the gland is en- gorged with blood. Again the organ is particularly Hable to disease. Alco- holism, tuberculosis, malarial lesions, new growths and the production of fibrous tissue rendering it even more friable than in its normal condition. B. T. Tilton (Annals of Surg., Jan., 1905). Case in which a man, 19 years old, suffered from a contusion, with possible rupture of the liver. Four days later jaundice appeared on the sclerse and biliary coloring matters in the urine. The jaundice spread thence over the entire skin of the body, the urine became dark brown, and from the seventh day on the patient suffered from extremely severe attacks of colic. At the beginning of the third week the area of liver dullness was markedly small. The attacks of colic were as- cribed to adhesions, and finally lapa- rotomy was performed with a view to their relief. About 4 liters of bile- stained ascitic fluid escaped when the peritoneal cavity was opened, numerous adhesions were broken up, and a fibrin- ous exudate was wiped away from the surface of the intestines. Palpation of the liver revealed that that organ was very atrophic, but no operative measures were directed to its relief, and the wound w^as closed. At first little change was produced in the condition of the patient. Ten days after the operation an abscess was opened in the cicatrix, and then he began to improve. The area of liver dullness gradually increased until it finally reached the bor^ der of the ribs in the right mammillary area, but its lower margin could not be felt on palpation. The general health of the patient had also become very good. Mekus (Miinch. med. Woch., Jan. 8, 1907). History of 8 cases of injury of the liver in which an operation was per- formed in less than four hours in all but one, in which the interval was ten hours. They emphasized the advantage of suturing the wound in the liver when- ever it is at all possible. The writer sutures through a tampon to prevent bleeding later. He has recently ex- amined 3 of the patients after an interval of from several months to two and a quarter years, and found them entirely well and free from disturbances of any kind. Noetzel (Beitrage z. klin. Chir., xlviii, Nu. 2, 1906) . Case of subcutaneous injury to the right lobe of the liver. The patient had fallen from his horse and his abdomen had borne the weight of the horse and of the saddle. Diagnosis of internal hemorrhage was made. After a minute exploration of the abdominal cavity, a bleeding wound of the right lobe of the liver was seen. The hemorrhage was stopped by tamponade ; the patient re- covered. The diagnosis is to be made only after the abdominal wall has been opened, and then it is made by seeing the seat of hemorrhage. We are still in doubt as to which way is better, to suture these wounds of the liver, or to pack them. The author pre- fers packing. He thinks it is more rapid, less difficult, and more reliable. The liver must be compressed from below up toward the diaphragm. Only iodoform gauze should be used. Yon Kippel (Arch. gen. de chir., Dec, 1907). Seven cases of injury of the liver in which surgical treatment was success- ful in 3. The injuries in the cases with a favorable outcome were : A bullet wound, a kick from a horse, and injury from being run over. The others were 1— s 114 ABDOMINAL INJURIES (LAPLACE). very serious contusions with other injuries. Rigidity extended over the entire abdomen in every case, and the pain on palpation was also diffuse, although more pronounced on the right side. Tamponing alone arrested the hemorrhage in the three favorable cases. The pulse gave no signs of the internal bleeding, being relatively good even in the most rapidly fatal cases. In one instance the gauze tampon answered a double purpose, draining a pus pocket that developed between the diaphragm and the liver. The writer's experience confirms the value of tamponing as the best, safest, most rapid and effectual method of arresting hemorrhage in case of rupture of the liver, although a suture may be advisable for a smooth and conveniently located stab wound. Dencks (Deut. Zeit. f. Chir., Ixxxii, Nu. 4-6, 1907). In the diagnosis of injury of the liver bradycardia is a suggestive sign. In one case the liver had been ruptured by the kick of a horse and the pulse was only 48. In the other case the liver had been sutured and the pulse was 52. Several writers have men- tioned bradycardia with injury of the liver, and ascribe diagnostic importance to it. The writer experimented on animals to determine the influence on the pulse of injury of liver and spleen. The results with 20 animals showed that bradycardia is a characteristic symptom of injury of the liver, but that its absence does not exclude injury of this organ. Finsterer (Archiv f. klin. Chir., Bd. xcv, Nu. 2, 1911). In 8 cases of rupture of the liver operated in the last five years, the writer noted that in 2 of the cases the fundus of the eye showed changes re- calling those of albuminuric retinitis. These patients were men of 18 and 30 with severe contusion of the liver region and rupture of the liver requir- ing suture. In 1 case the changes in the fundus had subsided by the end of the second day. Tietze (Archiv f. klin. Chir., Bd. xcv, Nu. 2, 1911). Lesions of the Gall-bladder or Biliary Ducts, — Blows and other con- ditions capable of causing hepatic rents sometimes implicate these organs in the lesion. There may be severe pain in the right hypochon- drium if a rupture exists, vomiting of food and bile, and icterus. The urine is usually dark-mahogany and the stools ash-gray in color. Tender- ness over the hepatic region is usually marked. The intensity of the symp- toms depend to a degree upon the quantity of bile voided into the abdominal cavity ; but, this secretion being aseptic, peritonitis only occurs as a complication when the perito- neum is itself implicated in the trau- matism, or when the lesion is at the junction of the biliary tract and the intestinal canal, the latter in that case acting as a source of infection. Escape of venous blood with or with- out bile, particularly in stab wounds over the region of the liver, is a very important sign. Hepatic injuries usually cause pain to ra:diate to the right shoul- der. Inasmuch as there is also local pain on respiration, the chest does move as much on the right as on the left. This may lead to a misconstruction of the diagnosis, for it suggests to the casual observer thoracic injury. The blood gravitates into the right iliac fossa and may give well-marked dullness. Disappearance of liver dullness is due to beginning tympanites and is therefore not of great diagnostic importance. Jaundice is occasionally present, but usually does not appear until the second or fourth day. Ludwig found it 24 times in 267 cases. Its presence usually signifies injuries of the bile-duct. B. T. Tilton (Annals of Surg., Jan., 1905). Lesions of the Spleen. — The causes of injury to this organ are the same as those of the liver. Rents^ san- guineous infiltration, and partial crushing are the lesions most fre- quently observed. Enlargement of spleen through a malarial cachexia ABDOMINAL INJURIES (LAPLACE). 115 renders it susceptible to lesions which traumatism would not give rise to were it in its normal state. In extensive lesions copious hemor- rhai^e usually takes place and death rapidly follows. If the lesion present is less severe, however, and the hemor- rhage be moderate, there is tendency to collapse, increasing pallor, and a feeling of suffocation. The latter symptom and severe radiating pain in the region of the spleen are gener- ally present, besides the signs pecul- iar to all abdominal injuries. If the patient survives sufficiently long the immediate effects of the traumatism, peritonitis or' abscess and other com- plications frequently result. Severe local pain generally continues for some time, and chills are not infre- quent. Percussion shows the organ to be more or less enlarged. According to Trendelenburg, vomit- ing is a most important guide in the diagnosis of rupture of the spleen ; in simple contusion of the alimentary tract it seldom if ever occurs. History of 6 patients whose spleens were removed on account of the injury of the organ. There was no symptom specially characteristic of such injury, though signs of irritation of the peri- toneum from effusion of blood de- manded prompt intervention. Severe pain at the point of injury invari- ably accompanied serious damage with- in, however. In one of the cases the early intraperitoneal hemorrhage stopped spontaneously, but commenced again the third da}^ requiring operative measures. Noetzel (Beitrage z. klin. Chir., xlviii, Nu. 2, 1906). Case of a girl of 4 who had been run ■over by a cab. The symptoms of shock subsided, the pulse became slower and fuller, and not until after seven hours were signs of internal hemorrhage observed. The abdominal walls did not become rigid until ten hours after the accident ; the child had vomited blood twice during the interim. The abdomen was opened at about the twentieth hour and the ruptured spleen removed with the apparent complete recovery. The lower pole of the organ had been partly torn off. In a case in which the symp- toms indicated rupture of the spleen th? exploratory laparotomy revealed merely a few small subserous hemorrhages, and the abdomen was sutured without fur- ther intervention, followed by the com- plete recovery. Georgi (Miinch. med. Woch., liii, Nu. 15, 1906). A healthy spleen is seldom injured; the organ is usually already enlarged by some pathologic process or infection. Slight injury may cause only an absorb- able hematoma, or, if infected, an abscess and adhesions which maj' dis- charge through adjacent hollow organs. Such outcome, however, is rare ; the tear is usually through the envelope and rapid hemorrhage, calling for quick surgical intervention, occurs. E. J. Senn (Jour. Amer. Med. Assoc, Mar. 23, 1907). Case of rupture of the spleen. The patient had received a violent trauma- tism in the left hypochondriac region, and had a few fainting spells. There was abdominal distention and tender- ness. An exploratory laparotomy having shown serious intra-abdominal hemor- rhage, the spleen was found torn and was extirpated. Raoul Baudet (Medecin Praticien, 1907; Surg., Gynec. and Obstet., July, 1908). The symptoms of traumatic rupture of the spleen are essentially those of internal hemorrhage, and the diagnosis is usually not made tmtil after ab- dominal section. The symptoms are obscure so far as enabling the distinc- tion whether the spleen or some other abdominal viscera is ruptured. How- ever, there should be no difficulty in diagnosticating the existence of hemor- rhage into the abdominal cavity, and, when this condition is recognized, ab- dominal section is indicated. The incision should be made over the region of greatest dullness, if this can be determined. If percussion elicits a note 116 ABDOMINAL INJURIES (LAPLACE). of higher pitch in one flank than in the other, a valuable hint as to the source of hemorrhage has been obtained. Should the hemorrhage be sufficiently severe to give a percussion note of equal dullness in all regions the indication is to make the incision in the middle line. The treatment is essentially surgical, the object being the control of hemorrhage, and all authorities are agreed that this end is most certainly accomplished by splenectomy. The mortality following removal of the healthy spleen for rup- ture is about 40 per cent., wrhereas that of non-operative treatment is probably 100 per cent. Watkins (Med. Rec, Mar. 14, 1908). Lesions of the Kidneys. — The kidney is firmly held in place by its attachments, while its consistence is such as to preclude elasticity. Hence, a blow or undue pressure may cause rupture. All the causes of injury that may take part in the production of lesions elsewhere may also induce renal lesions, which may consist of contusion, rupture, or laceration. Study of 5 personal cases and of 660 cases gathered from literature. The causes of rupture were varying, mus- cular action causing 10 per cent. The author was struck by the slight force necessary for rupture to take place. A blow over the front of the abdomen with the patient on his back was one of the causes of rupture. The kidney was never ruptured on one side with an ac- companying injury to an organ on the opposite side. Intraperitoneal symp- toms were usually due to rupture of the peritoneum. Tumor formation occurred in 143 cases. Hemorrhage was the fre- quent cause of death. In all the cases there was a striking absence of injury to the omentum or the intestine. Indications for operation : (1) Marked and persistent hemorrhage ; (2) pres- ence of a rapidly increasing tumor or area of dullness in the loin; (3) de- velopment of a tumor in the loin ten days or more aiter injury; (4) imme- diate operation when there are signs of free fluid in the abdominal cavity; peritonitis or other peritoneal injuries. Watson (Trans. Amer. Assoc, of Genito-Urin. Surg. ; Amer. Med., May 30, 1903). The kidneys are not properly ab- dominal organs, being extraperitoneal, but their injuries are comparatively fre- quent, especially in young males, owing to their greater exposure. The mechan- ism is usually a bending or fracture of the lower ribs. One cause of the infre- quency of the accident in women may be the mode of dress, the corset pro- tecting the organ, though the greater thickness of tissues and the wider spread of the iliac crests are also sug- gested as factors by Kuster. E. J. Senn (Jour. Amer. Med. Assoc, Mar. 23, 1907). Case in which the patient was kicked in the kidney region by a horse. The rupture occurred at the farthest point of the organ, the kidney having probably been dashed against the spine. Suarez (Annales d. Mai. d. Org. Gen.-Urin., xxiv, No. 17, 1907). In the rapid recent increase in the number of reported cases, there is reason to believe that subparietal rup- ture of the kidney is more frequent than the literature would lead one to believe. Shock, injury to other organs, and external evidence of trauma are frequently absent. A history of an abdominal contusion, followed by rigid- ity and hematuria, is sufficient data to lead to an exposure of the organ. Slight lesions and complete rupture of the kidney cannot be differentiated by clinical signs or symptoms. Proof that there is an absence of serious rupture is tailed for before instituting the so- called expectant treatment. Nephrec- tomy should be reserved for very ex- tensive disintegration of the organ. Conservative treatment, preferably by suture, is indicated in the majority of cases. Connell (Jour. Amer. Med. Assoc, March 25, 1911). Besides the symptoms common' to severe abdominal traumatism there may be increased pain in the lumbar region with radiations in the direc- tion of the pubis and rigidity of the ABDOMINAL INJURIES (LAPLACE). u; muscles. Dullness on percussion is sometimes elicited. Anuria may also occur, but this is not a characteristic sign. Hematuria is an important in- dication of renal leceration, however, although it may not present itself at once ; it may be followed by the ap- pearance of pus. The catheter should be used in these. Retraction of the testicles is also said to occur (Rayer). The ureter is very rarely involved; when it is, the symptoms are not modified. Enlargement of the lumbar and hypochondriac regions is present in the majority of severe cases, but may supervene late in the history of the case. Thanks to the compensatory work of the uninjured kidney, the mortality of renal lesions is not so marked as when other abdominal organs are injured. Even severe wounds have been known to heal. If large renal vessels are torn, marked lividity occurs, the patient rapidly becoming exsanguine. Death may thus follow very soon. Involvement of the peritoneum in the injury is promptly followed by peritonitis, the signs of this affection appearing a few hours after the receipt of the injury. Sepsis is not an infrequent complication in un- operated cases. Case of a boy, aged 16 years, who had fallen a distance of 2 meters during play, striking his back. Pain over the kidneys developed, but not sufficient to force him to stay in bed until the tenth day, when he began to vomit and de- velop an intense diarrhea. He bled from the nose and gums, and numerous petechiae appeared over arms and legs. On the fifteenth day he voided bloody urine. The flanks were dull, the abdo- men distended and tympanitic. Rectal examination showed a mass behind the bladder. Four weeks later a second purpuric eruption appeared all over the body. The urine was still bloody, and an ascitic accumulation was noted with- in the abdominal cavity. The red cor- puscles were reduced to 3,200,000; there were 334,000 hemoblasts; the blood did not clot nearly as readily as normally, and numerous myelocytes were present. Complete recovery ultimately resulted. E. Lenoble (Arch, des mal. du ccEur, i, 475, 1906). Two cases in which both patients fell on the loin, the one falling on the edge of a stair, the other on the edge of a pail. In both cases blood was present in the urine immediately after the acci- dent and the ruptured kidney could be felt by palpation. In both cases it extended round the abdomen toward the umbilicus and was tender to touch, the swelling being clearly behind the peri- toneum. Andrew (Lancet, Jan. 26, 1907). Case of a man who was under treat- ment for about three weeks with the clinical diagnosis of contusion of the right kidney, hemothorax on the left side, and possible injury to the pancreas. Autopsy showed that there had been a total rupture of the left lobe of the liver, which was in the process of spon- taneous healing. Chiari (Berl. klin. Woch., Sept. 7, 1908). In complete subparietal rupture of the kidney the patient will, as a rule, give a history of having received a severe blow in the side. The examination re- veals a tumor in the loin. There is, as a rule, hematuria. The patient is in a state of profound shock. These symptoms, with evidences of internal hemorrhage, should lead one to treat the patient for rupture of the kidney. Prognosis depends upon the delay in applying the proper treatment. The primary mortality is due to hemorrhage, while secondary deaths are caused by infection, which may be hematogenous or ascending in origin. The mortality of all cases of subparietal ruptures of the kidney has been estimated at from 32 to 92 per cent. Bugbee (Med. Record, Nov. 5, 1910). Owing to the rapid recent increase in the number of reported cases there is 118 ABDOMINAL INJURIES (LAPLACE). reason to believe that subparietal rup- ture of the kidney is more frequent than the literature would lead one to believe. Shock, injury to other organs, and ex- ternal evidence of trauma are fre- quently absent. A history of an ab- dominal contusion, followed by rigidity and hematuria, is sufficient data to lead to an exposure of the organ. Slight lesions and complete rupture of the kidney cannot be differentiated by clin- ical signs of symptoms. F. G. Connell (Jour. Amer. Med. Assoc, March 25, 1911). The recent statistics of traumatic lesions of the kidney which showed a mortality of 14.6 per cent, in 143 cases with a conservative operation and of 16.7 per cent, in 131 nephrectomies, while 20.6 per cent, of the 427 patients not submitted to operative treatment died, are suggestive when we consider that only the severest cases are oper- ated. The main points are to determine whether the vessels and the kidney pel- vis are torn and whether there is infec- tion. The intensity of the hematuria is not always an index of this. Cystos- copy, supplemented possibly by catheteri- zation of the ureters, alone elucidates these conditions by showing whether the urine is being regularly expelled in a strong jet from the ureter mouth. If the urine is blood-stained, this shows which kidney is injured and that the pelvis and ureter are not torn, and that the passage from the pelvis to the bladder is open. If the bloody urine is expelled in approximately normal amounts and rhythm, conservative treat- ment is indicated, but, if no blood or urine enters the bladder from the in- jured kidney and none can be obtained through the introduced ureter catheter or there is merely blood or a few clots, there is evidently some laceration of the pelvis, permitting escape of the urine into the surrounding tissues, or the kidney has been destroyed to such an extent that the secretion of urine is arrested. In either case operative treat- ment is imperative. If stagnating urine is found in the pelvis, this excludes laceration. Operative measures should not be delayed. Stagnation of urine in the pelvis may cause intense pain, which evacuation of the urine relieves. Voelcker (Beitrage z. klin. Chir., Bd. Ixxii, Nu. 3, 1911). PROGNOSIS.— Death almost in- variably attended rupture of the in- testinal tract prior to the introduc- tion of exploratory abdominal sec- tion, and prompt resort to active surgical procedures, when necessary, is indicated. As to the liver, as late as 1864 wounds of this organ were considered as practically hopeless in every in- stance. While a very small propor- tion of these cases recover without surgical interference, as is shown by the scars occasionally found in the hepatic parenchyma, the fact remains that an exploratory laparotomy, per- mitting the surgeon quickly to arrest the loss of blood in case of hemor- rhage and to rid the peritoneal cavity of accumulated extraneous fluids, has greatly reduced the mortality. The prognosis becomes much more un- favorable when peritonitis has set in, but a fatal issue may sometimes be averted, even in advanced cases of this complication, by surgical inter- vention. Mayer in 1872 published statistics of 135 cases of subcutaneous traumatic rupture of the liver in conjunction with subcutaneous abdominal injuries. He gave a mortality of 86.7 per cent. Edler's compilation of 189 cases in 1887 showed a mortality of 85.7 per cent, for all cases and 78.2 per ^ent. for uncom- plicated cases. One-third of all the cases died of hemorrhage. More re- cent collections of cases are as follows : Terrier and Auvray 5 deaths in 11 cases. Frankel, 1901, 17 deaths in 31 cases. Wilms reported all cases occur- ring in the Leipzig Clinic during five years with 3 recoveries in 19 cases. Giordano's collection of 257 cases shows a mortality of 40 per cent. He con- ABDOMINAL INJURIES (LAPLACE). 119 eludes that results have improved eon- siderahl}^ since Edler's time. Riebel (Quarterly Bull. N. W. Univ. Med. School, Sept., 1910). The same remarks apply to rupture of the gall-bladder. Slight contusions of spleen heal readily, but rents and tears of any importance are frequently followed by fatal hemorrhage. Abscesses oc- casionally complicate convalescence. The great majority of cases of rupture of the kidney that recover are those in which the initial lesion had been comparatively slight. In the graver cases, in which there is copious hemorrhage into the peri- nephric tissues or into the peritoneal cavity, of which the growing exsan- guinity of the patient is an indication, the prognosis depends upon the speed with which adequate surgical procedures are instituted. Occasion- ally, however, the blood is held in check by the renal capsule. Two cases in which a contusion re- duced the secreting power of the kidney. In the first case the kidney was injured by a kick from a horse, and a latent nephritis developed with tendency to formation of stones; in the second case the blow left a cicatrix, palpable two years later, which interfered with the secretion of the organ, but did not seem to impair the general health. The prog- nosis in contusions of the kidney de- pends on the presence or absence of infection. The other kidney does not suffer unless the contusion is compli- cated by an infectious process. Simonin (Presse med.. Mar. 13, 1909). The prognosis depends greatly, therefore, upon the patient's ability to stand operative procedures suitable to establish a positive diagnosis and bring the lesion that may at any moment destroy life within the imme- diate reach of art's highest powers. When serious injury is rendered prob- able by the nature of the accident, and the symptoms present also indi- cate a serious lesion, an exploratory incision, if the patient is not past relief, a careful examination of the organs involved, arrest of hemor- rhage, closure of the disrupted tis- sues, or cleansing of the abdominal cavity may save him even when his condition appears almost hopeless. Again, the prognosis is influenced by the time elapsing between the accident and the institution of surgi- cal procedures. The sooner they are resorted to, all things considered, the greater the chances of success. No case can be considered as hope- less unless a subnormal temperature, cold and cyanosed extremities, and other signs indicate that the end is near. Even when performed late in the history of the case, adequate operat- ive measures sometimes prove suc- cessful. The mortality in injuries of the kidney is, under the best surgical procedures, about 30 per cent. Death in these cases, if not immediate, as the result of shock, or hemorrhage, or injury to other important organs, is due (1) to anuria, (2) to infection, or (3) to secondary hemorrhage. Anuria is probably due to a reflex contraction of vessels in the sound kidney owing to stimulation of the splanchnics and the vagus endings (Masius). Secondary hemorrhage may not occur for a week or ten days after injury and is then due to a dis- integration of blood-clots, which are acted upon by the urine. Infection may be (a) local, with deep cellulitis and subsequent general involvement; (b) peritonitis, or (c) an ascending involvement of the opposite kidney due to the breaking down of blood- clots in the bladder. Crawford (Amer. Jour, of Surg., Feb., 1908). 120 ABDOMINAL INJURIES (LAPLACE). The early recognition of a rupture of the bladder greatly influences the prognosis. About 60 per cent, of the most unpromising lesion, intraperi- toneal laceration, are saved by prompt surgical measures. The remaining 40 per cent, are unsuccessful mainly on account of delay in resorting to abdominal section. A favorable re- sult has, nevertheless, followed lap- arotomy as much as fifty-four hours after the rupture. TREATMENT. — Shock. — Shock or collapse, though unreliable as a sign of severe injury to the abdom- inal viscera, is, nevertheless, an alarming condition, especially if the temperature is subnormal and the breath is shallow, and it should at once receive attention. The patient is placed in bed with the head low, and a free supply of pure air insured, supplemented with oxygen if prac- ticable. Hot-water bottles are placed around him and he is covered with blankets previously warmed, if pos- sible, or wrung out of hot water. Two main elements have to be borne in mind in this class of cases : (1) that the state of shock is due to a direct commotion of the sympa- thetic system with probable inhibition of the heart's action, and (2) the pos- sibility of an internal lesion which may involve death by exsanguination or the outpour into the peritoneal cavity of gastric or intestinal fluids. While the first condition calls for stimulants adapted to sustain the flag- ging heart and restore the action of the vasomotor, the agents employed should not be administered by the mouth, since, in case of rupture of the stomach, the duodenum, or jeju- num, a portion, at least, of the fluid may be added to those that may have found their way into the peritoneal cavity. Rectal and subcutaneous in- jections should be resorted to. If no remedy be at hand, subcuta- neous injections of 1 dram of whisky or brandy may be employed, and re- peated every five or six minutes until reaction occurs. A turpentine stupe or a fresh mustard poultice (not plaster) over the xiphoid cartilage, and a rectal injection composed of a tablespoonful of turpentine, a raw egg, and a teacupful of warm water, sometimes act with surprising rapid- ity. Hypodermic injections of ether, or, better still, tincture of digitalis with %2o grain of atropine, repeated in fifteen minutes, are necessary to sustain cardiac action. After the second dose the digitalis may be in- jected alone several times more. These measures are greatly assisted by galvanic stimulation of the phrenic nerve, the negative pole, moistened in a solution of chloride of ammonium, being applied to the neck in the de- pression immediately in front of the sternomastoid muscle, and the posi- tive over the epigastrium. These means are sometimes ineffi- cient and hypodermoclysis should be performed. If a fatal issue seems inevitable, saline transfusion is indi- cated. In abdominal injuries due to blunt force the symptoms are referable to the abdominal wall and cavity, or both. Pain may be severe or slight. As an early symptom vomiting is constant, distention may be slow or rapid, rigidity develops later, shock may or may not be present. The temperature and pulse, particularly the latter, are considered of great importance. Opium, even in small doses, renders the diagnosis of such injuries difficult, and should never be administered early. After an ab- dominal injury, if there is tenderness, ABDOI^NAL INJURIES (LAPLACE). 121 acceleration of the pulse tending to in- crease ever so slightly, together with abdominal distention and a rise in tem- perature, the diagnosis of a grave injury is made absolute. In most cases but a few hours of close observation are required to establish the diagnosis. In such cases exploratory laparotomy should be performed at once unless the condition is so desperate that anesthesia means certain death. Fowler (N. Y. Med. Jour., Aug. 19, 1899). In cases of abdominal contusion the surgeon before operating should wait for some symptom or symptoms indica- tive of intestinal injury. As in the presence of shock a diagnosis of intes- tinal injury caniiot be made, the author would wait for reaction to take place. No one symptom is pathognomonic of intestinal injury, but the two most re- liable are gradually increasing rigidity and an anxious, careworn, and painful expression of the face. The latter, which comes on after reaction has taken place and, it is supposed, is con- comitant with development of peri- tonitis, is regarded as the most posi- tive of all the syinptoms of severe intra-abdominal injury. In the next group the author would place deep and perhaps radiating abdominal pain, respiration becoming more and more thoracic, vomiting after re- action, abdominal distention, increas- ing pulse-rate, and secondary fall in temperature. The subject of a severe abdominal contusion should, it is urged, be carefully and constantly watched. While advising delay in doubtful cases, the author does not mean that the surgeon should wait for serious symptoms to become so pro- nounced that a positive diagnosis is assured, for then operative intervention is, for the most part, too late. There is a positive midway between operating on every case and waiting for an assured diagnosis, where the surgeon can say that, owing to the gradual appearance of certain symptoms, there is fair reason to think that the intestinal tract may be injured, and that an immediate opera- tion will give the best chance. Le Conte (Annals of Surg., April, 1903). Immediate laparotomy is urged when the abdominal walls are rigid and there is local tenderness after a contusion, and when these symptoms display a tendency to increase rather than to sub- side. There is more shock when the injury is from an object acting on a large expanse of the abdomen rather than from the kick of a horse or the like. Normal temperature and full pulse do not exclude serious internal injury, and there was no vomiting in one of the most severe cases. Cautious percussion may reveal dullness corre- sponding to an effusion of blood, bile, stomach or intestine content or urine, and its progress can be thus traced in some cases. Schmidt (Deut. med. Woch., xxxii, Nu. 44, 1906). Analysis of 17 cases of subcutaneous injury of the digestive tract in which an operation was resorted to, showing that operative treatment is imperative at the earliest possible moment when there is a probability that the stomach or intestines have been injured by a contusion. If the shock is too pro- nouncecl for immediate operation, every effort must be made to bring the pa- tient out of the shock, with restor- atives and saline infusion. In case of small circumscribed injuries, it may be sufficient to suture the wound in the intestine and to reinforce it with serosa drawn up over it, but in case of exten- sive injury it is better to resect the injured portion. Even if the patient is not seen until after the peritonitis is established, an operation is always justified, although the prospects of saving life are then small. Careful rinsing out of the entire abdominal* cavity with large amounts of sterile salt solution should never be omitted, as this is the only means of cleansing the peri- toneal cavity of infectious material. Voswinckel (Archiv f. klin. Med., Ixxix, No. 2, 1906). Treatment of contusion of the abdo- men, based on 48 severe personal cases. In 31 cases the operation was performed early; 22 of these patients recovered, and 9 died; all the 6 patients with a tardy operation recovered also. Modern surgery can command incipient peri- 122 ABDOMINAL INJURIES' (LAPLACE). tonitis, but in the later stages it is difficult to handle. The vital energies can be sustained by administering saline solutions in extensive hemor- rhage. If the vital energies have already ebbed too low, then the sur- geon is pow^erless. In one of the writer's cases the intraperitoneal part of the full bladder had ruptured and a loop of small intestine had fallen into the organ. He sutured the bladder and transplanted the attach- ment of the peritoneum to the bladder, suturing it at a point lower down than normal, and thus making the seat of the wound extraperitoneal. There is no danger of peritonitis from rupture of the bladder if the rupture is entirely extraperitoneal. Hildebrand (Berl. klin. Woch., xliv, Nu. 1, 1907). Immediate aseptic abdominal section is indicated in every doubtful case of abdominal injury. Important points in the surgical treatment of abdominal in- juries : 1. Apply active measures to overcome or lessen shock, unless signs of active hemorrhage make quick action imperative. A reasonable time (one- half to three hours) may be allowed in cases of profound shock, to promote a helpful reaction. 2. Cleanse the skin as thoroughly and as widely as in any other abdominal case, notwithstanding the presence of indication for rapid work. 3. Precede an exploration by an intravenous saline infusion or a trans- fusion of blood when symptoms of hemorrhage are marked. As Crile has noted, "We may in this way transform a hopeless case into an average risk." 4. Make the search for intra-abdominal injuries thorough and systematic. 5. Cleanse the peritoneum thoroughly of septic material and blood, or fluid of any kind. This is best done by large gauze sponges, followed by copious irri- gation, leaving the abdomen partly filled with saline solution. 6. Secure absolute hemostasis and water-tight repair of all wounds and ruptures. 7. Introduce drains whenever viscera have been penetrated or ruptured. 8. Use intra- venous infusions of normal saline solution freely postoperatively in cases of marked shock or acute anemia. 9. Adopt the Fowler posi- tion and the live coil in all cases as soon as reaction from shock is ob- tained. 10. If intestinal paresis su- pervenes, lavage every four hours will accomplish more than enemata. Goodrich (Amer. Jour, of Surg., Jan., 1911). Reaction. — As soon as reaction oc- curs in these cases another danger threatens the patient, that of hemor- rhage, which the state of collapse has so far prevented to a degree, unless an extensive injury has caused over- whelming exsanguination. In this event, however, the patient's recovery from the preliminary shock would hardly have taken place. Hence the necessity of closely watching the sufferer. Cases of prolonged collapse some- times turn out to be trivial, while a short period of it may be the prelude to the most grave complications. The former cases are, unfortunately, rare, and profound shock of any dura- tion should be looked upon with sus- picion. This is especially the case when a second period of shock is passed through — the "relapsing col- lapse" of Bryant — indicative of a secondary hemorrhage or the giving way or separation of some damaged tissues. That cases clearly showing by their history and the active symptoms a grave injury should be submitted to surgical measures as early as pos- sible will hardly be gainsaid in the light of our present knowledge. An equally positive conclusion, based on every means of diagnosis available, will alone warrant the assertion that no serious injury is present; but, if, on the other hand, doubt exists, abdominal section will alone .insure the patient adequate protection. If ABDOMINAL INJURIES (LAPLACE). 123 nothing be found, no harm will have been done if precepts governing- asep- tic surgery have been closely fol- lowed ; if a rent in the liver, an intestinal tear or rupture, a serious hemorrhage be discovered and ade- quately dealt with, the patient will have received the benefit of all our art's resources. The seat of rupture being located, the nature of the injury will deter- rhine the procedure to follow, linear enterorrhaphy being indicated in longitudinal ruptures, and circular enterorrhaphy in complete ruptures. These procedures are now generally preferred to an artificial anus. It is sometimes impossible to adjust ade- quately the edges of the wound, owing to the condition of the margin, and an omental graft must be used to cover the contused area so as to avoid a secondary perforation. Considerable extravasation of feces, blood, and other liquid or semiliquid material may have occurred into the peritoneal cavity. All chances for further contamination of the intes- tinal tract having thus been removed by closure of the rupture, the peri- toneal cavity should be carefully cleansed by flushing with warm, steri- lized water, a soft aseptic sponge being employed to mop gently all the surfaces that may, in any way, have come in contact with the infectious fluids. The cavity is then closed and free drainage insured. Satisfactory results are obtained even in cases in which very great in- jury and ample opportunity for infec- tion of all wounds have markedly compromised the issue. The after-treatment should be based upon the necessity of insuring rest for the intestinal tract for a few days. This may be carried out by administering opiates. The patient's strength should be sustained by means of nutrient, but small and fre- quently administered, enemata. Under all circumstances, an abdom- inal injury should cause the patient to be watched several days. After an uncomplicated injury he should re- main in bed and be placed on a milk diet for a few days. Anodyne appli- cations over the abdomen and a little morphine, internally, if there is pain, is all that is usually required in these cases. In the less fortunate the pro- cedure to be adapted varies according to the organ involved. Intestines. — The probability of a rupture having been recognized, the abdomen should be opened by an in- cision through the linea alba, and any hemorrhage quickly arrested. The next step is to locate the visceral injury. Of importance in this connection is the fact that in the majority of cases the rupture is due to compression against the spinal column. The spot over the abdo- men upon which the blow carried being considered as the one end of an imaginary line and the center of the vertebral column as the other end, the probabilities are that the rupture will be found near the linear axis. Again, if the rupture cannot be readily found, hydrogen may be gently insufflated into the rectum, as advised by Senn, and the spot from which the gas escapes will indicate the location of the rupture, — approxi- mately, in the case of the small intes- tine, and accurately below the ileo- cecal valve. Disorders, or lesions other than those sought after, are misleading 124 ABDOMINAL INJURIES (LAPLACE). conditions that should be borne in mind. Lesions of the jejunum are some- times difficult to locate. Given a case in which an injury to the abdomen occurred which is liable to produce rupture of the intestine, and the abdominal wall is found rigid and the patient suffering from pain in that region, one should not hesitate to operate, even in the absence of all other symptoms. Golden (Annals of Surg., Nov., 1906). Two cases of rupture of the intestine successfully operated. One patient was struck in the epigastric region. Lapa- rotomy was performed four hours after the accident and a large tear v/as found in the upper part of the jejunum, in- volving nearly one-half of the circum- ference of the bowel, but being placed obliquely to its long axis just beyond the duodenojejunal junction. The tear was closed with interrupted Halsted stitches and a few supporting Lembert stitches. The second patient was pinned against some railway sleepers by the arm of a crane. In this case the lapa- rotomy was done six hours after the accident. The jejunum was completely torn through transversely in its whole circumference, and including two or three inches of its mesentery. The bowel was united with Lembert sutures. Both patients recovered promptly. Mole (Bristol Medico-Chir. Jour., March, 1907). Diffused rigidity of the abdominal wall in a case of contusion of this region, even in the absence of any other serious symptom, is a decided indication for immediate laparotomy, while the absence of contracture, whatever may be the extent and gravity of the asso- ciated symptoms, contraindicates sur- gical intervention. Of 10 cases in which, owing to the presence of this symptom, laparotomy was performed, this treat- ment proved successful in 9. Of 17 cases of severe abdominal contusion in which no operative treatment was ap- plied in consequence of the absence of rigidity, all ended in recovery. Hart- mann (Bull, et Mem. de la Soc. de Chir., Mar. 12, 1901). Reviews of 19 operations performed on patients who suffered from rupture of the intestine, resulting from blows upon the abdomen. Not infrequently such injury will end fatally unless immediate operation is done. The ab- dominal viscera, although they have no bony wall to protect them in front, are protected from injury by their position, and by the immediate involuntary con- traction of the abdominal muscles which takes place the moment a coming blow is seen or expected. In injuries sus- tained through contests of physical strength, blows upon the abdomen are comparatively rare on account of the protected position in which the abdomen is held. The author comes, therefore, to the conclusion that, where rupture of the intestine takes place, the intestine is generally caught between the body which causes the blow upon the abdo- men and one of the bony structures which form its posterior walls. F. B. Lund (Boston Med. and Surg. Jour., Nov. 20, 1905). Stomach. — When the symptoms of complete tear are recognized, the presence of the organ's contents in the abdominal cavity render an imme- diate laparotomy imperative. The incision should include the tissues between the xiphoid cartilage and the umbilicus. If the tear cannot be quickly found, repetition of the infla- tion with hydrogen-gas will help to locate it. As soon as located any bleeding vessel should be ligated, and the stomach evacuated and cleansed through the adventitious opening of any substance that may have re- mained in it. If the wound be a lacerated one, it may be necessary t-o pare its edges. This being done, the tear is clpsed, the mucous membrane being united with a continuous or interrupted suture, cut short, and the muscular and serous coats by the Lines of Incision for Abdominal Exploration and Operation (Laplace). 1, median line; 2, for liver and gall-bladder; 3, for pyloric end of stomach and duodenum; 4, 4', for upper abdomen, including stomach and pancreas; 5, for spleen; 6, for tail of pancreas or greater curvature of the stomach; 7, umbilicus, median line; 8, 8', 9, 9', 10, 10', for intestines according to location of injury, 8 being the best for appendix as it severs no muscular fibers: 11, vermiform appendix; 12, McBurney's line; 13, cecum and ileum; 14, anterior superior spinous process of the ileum; 15, 16, 17, 18, defective incisions for appendicitis: they cut across deep muscular fibers; 19, 19', for inguinal hernia; 20, 20', 21, 21', for bladder according to location of injury. ABDOMINAL INJURIES (LAPLACE). 125 continttotts Lembert suture. Closure of the laceration having- removed all danger of further extravasation into the peritoneal cavity, the latter must be flushed with warm, sterilized water and mopped out with a soft sponge. The cavity is then closed and a drain left if the peritoneal sur- faces have been exposed to contami- nation for some time. Liver. — Especially when the history of the case seems to indicate the pos- sibility of a lesion of this organ is careful watching imperatively de- manded, owing to the violent hemor- rhages which they involve. Either this complication or peritonitis having been recognized, the abdomen should be opened at once in the middle line. The abdominal wound should be large enough, if possible, for the surgeon to see the liver, but in every case he ought to make a careful ex- ploration with his finger, especially directing- his attention to the convex and posterior surfaces of the organ. When a rupture is found, the wound may either be cauterized, plugged, or sutured. Plugging with antiseptic or aseptic gauze seems to give the best results, one end of the gauze being left out at the angle of the abdominal wound. The plug should be removed not earlier than the forty-eighth hour, lest there should be a recurrence of the hemorrhage, and not later than the fourth day, lest a biliary fistula should be formed. When the bleed- ing is very severe, sponges mounted on holders appear to produce more satisfactory pressure than simple plugging, which is, perhaps, better reserved for slighter injuries. Hot- water irrigation may be of advantage in these cases. A ligature should be applied to any large vessel which is seen to have been torn. Sutures are particularly useful when the lacera- tion extends deeply into the substance of the liver, since by their means the edges of the wound may be brought lightly together and the bleeding can be controlled. Drainage of the pelvic pouch, by an opening just above the pubis, serves best to give free pas- sage to subsequent discharges. The capsule should be included in the stitches. The prognosis is very un- favorable when peritonitis has oc- curred, but something may still be done to prevent the fatal issue by opening and afterward draining the abdominal cavity. Spleen. — After a simple contusion the spleen soon returns to its normal condition without further trouble, and a few days in bed, coupled with strapping of the side to limit motion, usually suffice. When, however, there is laceration of the parenchyma the convalescence is slow, abscesses following- in quick succession. After a time these cease and recovery is un- interrupted. Symptomatic treatment, revulsion over the organ, and tonics may shorten the duration of such cases. When the symptoms do indicate that exsanguination of the patient is taking place, death will most prob- ably follow, although the hemorrhage is not as copious as it can be in tears of the liver^ the splenic capsule being more elastic than that of the latter organ. Removal of the organ should be resorted to. The abdominal wall is opened by means of an incision through the left semilunar line and the peritoneum is freely opened. The hand being introduced into the cavity, all adhesions are torn up and the 126 ABDOMINAL INJURIES (LAPLACE). organ is brought to view. The vessels entering the hikim are then clamped and the organ is removed. The stump is ligated and, after spong- ing out the abdominal cavity, the wound is closed. A study of a personal case of rupture of the spleen, and 70 cases recorded in the literature since 1891, showed that immediate operation is indicated in all cases as soon as the diagnosis is made, even though there may not be much hope of saving the patient's life. In the 70 cases referred to, 42 patients were operated on ; of these, 27 lived and 15 died, a mortality of 36 per cent. All those not operated on died. The causes of failure after operation were perito- nitis of other viscera, especially the left kidney; injuries of the left pleura, other injuries, such as fracture of the base of the skull, and operation per- formed too late. The majority of pa- tients show no abnormal effect except a transient anemia and leucocytosis, which swings back to normal in about a month, and an enlargement of the lymph-glands, most often the left axillary and inguinal. Simpson (Lan- cet, Aug. 11, 1906). Case showing that extirpation of the spleen is the best means of treating traumatic rupture of the organ. No functional hypertrophy of any other organ was observed in this case, nor any signs of disturbances from lack of functioning of the spleen. Borelius (Zeit. f. klin. Med., Ixiii, Nu. 1-4, 1907). Of the 103 cases of traumatic rup- ture of the spleen, reports of which have been published, the injury has been inflicted by the kick of a horse in 11 instances. In a case personally observed, treated by splenectomy, sys- tematic examination of the blood showed that the removal of the spleen had absolutely no ill effects. Horz (Beitrage z. klin. Chir., 1, Nu. 1, 1907). Summary of cases of rupture of the spleen reported in literature : Unop- erated: Of 220 cases, 17 patients recov- ered — mortality, 92.3 per cent. Opera- tive results : Splenectomy, 67 cases, 38 patients recovered, 29 died — mortality, 56.7 per cent. ; splenorrhaphy, 2 cases, 1 patient recovered, 1 died — mortality, 50 per cent. ; tamponade, 6 cases, 5 pa- tients recovered, 1 died — mortality, 83.3 per cent. In the splenectomies, 13 patients had complicating injuries, of which 9 died. In 2 which recovered, the complications were unimportant. Ross (Annals of Surg., July, 1908). Case of rupture of the spleen in a boy of seven years who had been run over by a cart. Operation by Mr. D'Arcy Power. Chloroform was ad- ministered and a vertical incision was made ZY2 inches long through the left rectus muscle above the umbilicus, Ij^ inches from the middle line. The peri- toneal cavity was opened and was found to contain a quantit}^ of blood- clot and blood which was washed out with saline solution at a temperature of 110°. The anterior surface of the left lobe of the liver was found to be grazed over an area of about the size of a crown piece, but had stopped bleeding. The spleen was drawn out of the wound and was found to be badly lacerated, the lower third of the organ was almost separated from the rest, and there were extensive lacerations in the region of the hilum. The organ was held in place by a mere strand of mes- entery which ruptured when an attempt was made to ligature it. As bleeding had also stopped in the spleen, some of the arteries of which were very definitely thrombosed, no attempt was made to recover and ligature the ped- icle. The bleeding through the peri- toneal opening had never been very free during the operation, but a drainage tube was left in the wound to be an index of possible further hemorrhage. The child came through the operation very well, and there was no further ex- tensive hemorrhage, the drainage tube being removed on the sixth day, when the pulse had quieted down to 100. The patient made an uneventful recovery. T. S. Lukis (Lancet, June 19, 1909). Kidney. — The majority of mild cases of perirenal extravasations of blood and urine recover as the result ABDOMINAL INJURIES (LAPLACE). 127 of rest and expectant treatment. The patient should be kept in l)ed and his diet limited to litiuids, the best of which is milk ; this beverage requires, besides, the least physiological labor from the injured organ. The nourish- ment of the patient may further be sustained by rectal injections of beef- tea, and these should entirely be resorted to if there is vomiting, the latter tending greatly to encourage hemorrhage. Details of 5 cases. The patients were men between 25 and 42, a woman of 30, and a boy of 12. Unless there are signs of internal hemorrhage, abso- lute repose and ice to the kidney re- gion are indicated. The patients were all dismissed in good condition after operative intervention. Yoshikawa (Beitrage z. klin. Chir., Jan., 1909). When hemorrhage occurs in the direction of the bladder, there is likely to be accumulation of blood- clots, which, if small, will readily pass out with the urine. Frequently, however, the clots are large and cause retention of urine and marked tenes- mus. A large catheter should there- fore be introduced and kept in situ when the hematuria is marked, and the bladder occasionally washed out with a weak boric acid solution. Median urethrotomy to remove clots and relieve retention sometimes be- comes necessary in these cases. When the symptoms do not improve under these measures, an incision should be made, exposing the seat of injury, the extravasation removed, and the parts restored, by appropriate measures, to their normal conforma- tion. According to Keen, hematuria is valuable only as showing the fact of rupture of the kidney, but not as a symptom by which to decide on operating. It is not the visible loss of blood by the bladder, but the easily overlooked, but far from dangerous, bleeding into the peri- nephric tissues, or into the peritoneal cavity, that should receive the chief attention. Case of rupture of both kidneys, with intraperitoneal hemorrhage, in a girl aged 16 years, who fell a height of four feet from a car, landing on her abdo- men across a rail. She felt that she "had torn something loose on the in- side," and, although she had some pain, she walked home, a distance of about a quarter of a mile. When seen, about an hour later, she had a temperature of 98° and, a pulse of 127, with other symp- toms indicating severe shock. She vomited a greenish material several times. The abdomen was distended, the right rectus rigid, the right kidney region tender, with dullness on the right side, especially in the right iliac fossa (the patient was lying on her right side). By catheter two ounces of very bloody urine were withdrawn. Intraperitoneal rupture of the right kidney was diagnosed. Owing to ob- jections on the part of the patient and her parents the operation was not begun until about eighteen hours after the accident. She stood the operation well for the first hour, but later did poorly because of the great loss of blood. A large quantity of blood and urine was found in the peritoneal cav- ity, which was cleaned out and flushed with normal salt solution. The right kidney was found low in the abdomen, lying directly in front and over the third and fourth lumbar vertebrse. It showed three transverse rents and was tied at its lower pole to the left kid- ney by a dense fibrous band a half-inch in diameter (horseshoe kidney?). The left kidney was literally torn into frag- ments, entirely without a capsule, and separated from the ureter. The ves- sels of the left kidney were ligated and all the pieces removed. A portion of the right kidney, which had been mashed into a pulp, was removed also. The remaining portion of the right kid- 128 ABDOMINAL INJURIES (LAPLACE). ney (not more than two-fifths of the original kidney substance) was in a very bad condition and showed two rents. It was packed with gauze. The abdomen was filled with normal saline solution after repeated flush- ings, then closed with through-and- through sutures of silkworm-gut, and drained. After-treatment for the shock was carried out. From the time the reaction set in, ten hours after the operation, the patient did well. The gauze was removed on the sixth day. A urinary sinus followed, through which most of the urine passed for the next five days. It closed on the sixteenth day. The patient sat up on the thirteenth day and left the hospital on the twenty- third day. She has enjoyed good health ever since (now more than six months) and passes a normal amount of urine. A. L. Franklin (Amer. Jour, of Surg., Oct., 1906). .' The dangers of rupture of the kidney are mainly hemorrhage and sepsis. When, therefore, the symp- toms are such as to indicate marked hemorrhage or sepsis, and especially if a tumor form quickly in the lum- bar region, an exploratory operation should at once be done. If severe laceration be present, or the kidney's functions be practically compromised, or the hemorrhage be such as to require ligation of the renal vessels, lumbar nephrectomy should- immedi- ately be performed, primary nephrec- tomy being safer than secondary re- moval of the organ. Bladder. — When a patient presents the history of a severe abdominal contusion or crushing, followed by inability to micturate, the catheter should at once be used. The presence of hematuria will indicate a lesion in the urinary tract, kidney, or bladder. If the urine with- drawn is observed to be well mixed with blood and, instead of red, it ap- pear brown and smoky, the lesion is probably one of the kidney. If, on the contrary, the urine be bright red, the probability is that the bladder has been torn. In the latter condition the diagnosis may also be assisted by the quantity of fluid passed at a given time. If, when the catheter is intro- duced and after a history marked with shock, no urine is obtained, the chances are that not only the bladder has been ruptured, but that the laceration is extensive, the opening having allowed the vesical fluids to escape into the abdominal cavity. A free flow, on the contrary, would tend to show that the tear, if any exist, is small. Of course, the invagination of the intestines into the vesical open- ing, or a valve-shaped laceration, may cause the same favorable signs to exist, thus misleading the diagnosti- cian. Very small lesions may be present, sufficient to allow the urine to escape, drop by drop, into the sur- rounding parts. Detection of them is very difficult, the subsequent com- plications alone showing the presence of extravasated fluids. The presence of any tear, except very small ones, may also be ascer- tained by injecting a weak boric acid solution into the organ, through the catheter. If a rupture be present, the bladder will not fill and rise above the pubis. Filtered air may be used for the same purpose, but it is less satisfactory, owing to the danger of secondary collapse. The urine may have passed into the prevesical connective tissue out- side the peritoneum, or the vesico- rectal or vesicouterine space, owing to a rupture in these locations. This constitutes the extraperitoneal lesion. Cellulitis and sloughing rapidly ensue ABDOMINAL INJURIES (LAPLACE). 129 without subsequent involvement of any organ in the neighborhood of the lesion, the vagina, the rectum, etc., the patient dying from septicemia. According to Sieur, the most impor- tant signs of vesical rupture are: a peculiar pain felt at the time of the injury; chilling of the surface of the body, which persists for some time; an urgent desire to micturate, which the patient cannot satisfy; the ab- sence of any vesical swelling above and behind the pubes, and also the absence or the presence, but in very small quantity, of urine in the blad- der. Catheterizing, though valuable, ought not to be practised except with great caution. Pathology of rupture of the bladder based on 3 personal cases and those found in literature. In many instances the rupture was not diagnosed until too late for surgical intervention. The mortality of rupture of the bladcjer has dropped from 43.5 per cent, in 1895 to 30.5 per cent, in 1905, when operative treatment can be instituted in time. It is especially important to bear in mind the possibility of rupture of the blad- der from its being pushed down into the small pelvis by some "physiologic trauma," the attachment to the omen- tum tearing out a piece of the attached bladder wall where it joins the rear wall, when cicatricial changes have in- duced unyielding adhesions. Golden- berg (Beitrage z. klin. Chir., Jan., 1909). To ascertain whether a tear be extraperitoneal or not, a measured quantity of a weak boric acid solution is injected through the catheter. If the full amount is not recovered, the chances are that the rupture is extra- peritoneal. Rupture into the peritoneal cavity, the intraperitoneal form of lesion, is less urgent as far as symptoms go. One, and even two, days may elapse before active symptoms appear; but, when they do, rapid progress toward a fatal issue from general peritonitis is the rule. Uncomplicated contusion of the bladder readily yields to a few days' rest, the application of ice, and general symptomatic treatment. When, however, there is cause for suspecting a rupture from the nature of the accident or the violence of the blow, the catheter should at once be introduced. The presence of blood renders operative interference im- perative. After the rectum has been distended with a rectal bag an inci- sion three inches long is made in the middle line of the hypogastrium, beginning half an inch below the upper edge of the pubes, as in supra- pubic lithotomy. The peritoneum is then carefully rolled up, along- with the prevesical fat. The bladder being thus exposed, search for the rupture is the next step. The rent is usually found along the posterior surface vertically down from the urachus ; frequently an extravasation of blood and urine indicates the spot. Occasionally, however, considerable difficulty is experienced, and opening of the organ is necessary so as to permit the in- troduction of the finger, and thus allow of exploration of its inner surface. The rupture may be extraperi- toneal or intraperitoneal. If an intra- peritoneal laceration is found, the incision should be extended upward, the peritoneal cavity opened, and the cystic wound closed with fine silk by means of Lembert sutures, one-eighth of an inch apart, including only the peritoneal and muscular coats. The mucous membrane of the bladder should be respected. Important, in this connection, is the necessity of 1—9 130 ABDOMINAL INJURIES (LAPLACE). ascertaining- that the sutures will hold ; this may be done by distending the bladder with a lukewarm milk or an alkaline solution. The abdominal cavity is then care- fully irrigated and closed, leaving a drain if there is any possibility that fluids will accumulate in any of the surrounding tissues. Henry Morris holds that there is great danger in delaying operation in these cases; the decomposition of the clots and the cystitis which is excited by their presence, as well as the fre- quent catheterization needed, exposes the patient to all the dangers of sup- puration of the wounded kidney, and also to the risk of infection. WOUNDS OF THE ABDOMEN. — Wounds of the abdomen may be non-penetrating, when the abdominal walls alone are injured, and penetrat- ing, when the peritoneum is included in the lesion, irrespective of the in- strument (pistol, knife, etc.) with which the lesion is produced. Non-penetrating Wounds. — Non- penetrating wounds are usually due to pointed cutting or blunt instru- ments. The lesions caused by a pointed in- strument, involving the skin and muscles only, are usually very slight. ,With due aseptic precautions careful exploration of the wound with the finger may be resorted to if the visceral examination does not suffice. Probes had better not be used, lest the wound be transformed into a penetrating one. Lesions caused by cutting instru- ments (knives, swords, etc.) vary in importance according to their depth and length. When the muscles are cut, the support for the abdominal organs is compromised, and ventral hernia may follow, unless great care be taken when the wound is closed. Lesions caused by blunt bodies (such as shot, glancing bullets, and fragments of shells, etc.) are usually attended by symptoms of contusions corresponding in intensity with the force of the blow. Severe laceration of the abdominal tissues may thus be caused and death occur from intes- tinal lesions. The hemorrhage attending these various kinds of wounds is usually slight. There is considerable ecchy- mosis, but this soon disappears. Oc- casionally shots or bullets become imbedded in the abdominal tissues. Treatment. — After carefully arrest- ing bleeding, cleansing, and disin- fecting the wound, the tissues are united. In deep incised wounds the prevention of ventral hernia should be borne in mind, and the cut mus- cular tissues broug^ht accurately to- gether by means of catgut sutures. This being done, silk sutures are also introduced and brought out to the surface, thus including the muscles and skin. Capillary drains are alone to be used, if drainage is at all neces- sary, larger drains affording oppor- tunity for the formation of a ventral hernia. The abdomen should be sup- ported by means of a bandage applied over the dressing and the patient kept in bed until complete repair of the wound has taken place ; from two to five weeks, as a rule. The bandage should be carried long after recovery, and the patient be warned of the danger he might incu-r by violent movement or strain. Penetrating Wounds. — The soft- ness of the tissues of the abdominal parietes causes them to be easil)^ penetrated, and the organs within the ABDOMINAL INJURIES (LAPLACE). 131 eavlt}' arc all vulnerable for the same reason. The interstices between them occasionally allow the harmless passage of a weapon or bullet, but such cases are extremely rare, only nine such cases ha^■ing• been recorded during" the Rebellion. The missile may graze the perito- neum and barely miss it along with the deeper organs. Unfortunately wounds causing laceration of one or more of the abdominal viscera are the most frequent, and their fatality is proverbial unless a timely diagnosis allow of prompt protective measures. As is the case in contusions, the direction from which the missile or stab comes is of great importance. A bullet arriving from the side and striking near the linea alba would probably create a buttonhole wound or bury itself in the abdominal walls. A bullet coming from the front, on the contrary, would most probably perforate the organs in its axial line of flight. If the bullet has passed through the body an imaginary line between the entrance and exit will probably indicate the organs injured, including, of course, the peritoneum. Here again, however, the spinal column may cause deviation when the initial velocity of the bullet is small, and a deceptive line of injury furnished. To positively determine the course of a bullet is difficult in many cases. In stab wounds the opening is fre- quently of a sufficient size to permit prolapse of the omentum : an evident proof that the abdominal cavity has been penetrated. This rarely occurs in bullet wounds unless a large pro- jectile, or a bullet coming from either side of victim, has caused com- paratively large solution of continuity of the tissues. Prolapse of the omen- tum is most frequently observed in lesions of the left side. Coils of the small intestines arc also frequently prolapsed and, in rare cases, the stomach, the liver, or the spleen have appeared between the lips of the wound. Symptoms. — As is the case after contusion, penetrating wounds of the abdomen may give rise to no symp- toms capable of affording any reliable clue to the extent of the internal in- juries. Profound shock may be pres- ent and no serious lesion exist. Severely injured individuals may, on the contrary, present no acute symptoms and, perhaps, walk or ride a considerable distance before show- ing noticeable evidence of their condi- tion. Profuse hemorrhage alone gives rise to symptoms denoting a grave lesion: rapidly progressive exsangui- nation or acute anemia; nausea or vomiting; weak, rapid, and some- times irregular pulse; dilated pupils; cold sweats ; yawning, ending in con- vulsions and coma. Shock is likely to be progressive in these cases. The only symptoms that are present in practically all cases are pallor and vomiting: the accompani- ments of any severe blow on the abdomen, and therefore of no value whatever as differential signs. The temperature is of no assistance in these cases. In penetrating wounds of the abdo- men there are absolutely no known symptoms which indicate injury to any of the viscera, except those noted in connection with the urinary tract, stomach, and occasionally the lower bowel. Except those relating to gen- eral shock, all symptoms following such wounds indicate either internal hemor-' 132 ABDOMINAL INJURIES (LAPLACE). rhage or peritonitis. To wait for symp- toms of perforation of the intestines means to wait until peritonitis has de- veloped ; therefore every bullet or stab wound which penetrates the abdominal cavity should be operated on at the earliest possible moment in order to anticipate the advent of peritonitis. No time should be wasted in attempting to demonstrate the presence or absence of intestinal perforation by such means as the rectal insufflation or gases or vapors, or the analysis of recollected in- traperitoneally injected air or liquids. It is essential to systematically ex- amine the entire gastrointestinal canal in all cases, regardless of the point of entrance of the wounding body. When- ever the alimentary canal has been perforated, suitable drains (the author prefers the so-called cigarette drain) should be placed either through the operative incisions or counterincisions, as may appear best suited to the indi- vidual case. M. L. Harris (Annals of Surg., March, 1904). DIAGNOSIS.— On general prin- ciples dangerous complications are to be expected when marked shock, nausea, vomiting, hiccough, anxiety, intense thirst (indicating a probable involvement of the peritoneum), and insomnia are present. Besides these indications there are others peculiar to each organ which greatly assist in establishing at least an approximately certain diagnosis. Intestines. — xAccording to Senn, bullets striking the abdomen antero- posteriorly rarely cause more than four perforations, while oblique or transverse shots are likely to produce a much larger number of lesions : from fourteen to sixteen. On general principles, however, a penetrating wound may always be considered as having caused a lesion of the intes- tines. The early diagnosis of multiple per- forations is difficult, _sometimes impos- sible. Every gunshot wound of the abdomen should be looked upon as penetrating and complicated by visceral injury, especially by wounds of the in- testine, unless there is absolute proof that it is not penetrating. Whenever possible a median exploratory laparot- omy should be done, without regard to the seat of the wound. The intestine should be explored systematically in its whole extent, with as little eviscera- tion as possible. After repair of the lesion a careful toilet of the peritoneum should be provided whenever there has been a considerable escape of feces. Sourdat (Rev. de chir., xxviii, 72>2), 1908) . Whenever there is acute abdominal pain the possibility of perforation of some part of the alimentary canal should be considered, and the patient should not be dismissed until the pos- sibility of such an accident can be definitely excluded. If the symptoms point rather definitely to perforation, but there is still some doubt as to diag- nosis, an exploratory operation is safer than delay. Shock is no contraindica- tion to operation, which should be as expeditious as possible, only necessary work being done and artistic ideals be- ing left for less urgent conditions. The writer thinks that appendiceal per- foration is more frequent than is gen- erally supposed, but, as in gall-bladder perforations, there is some protection by adhesion, though unfortunately these are not always life-saving. B. B. Davis (Jour. Amer. Med. Assoc, May 14, 1910). The most important symptom is the escape of intestinal gases and more or less fluid substances through the wound. The mere presence of emphysema around the wound is of no value, however, since air is gener- ally forced into the wound by the. bullet. Case of a boy 14 years of age who was shot in the abdomen at close range with a large revolver. He presented an irregularly circular wound about one-half inch across just inside the ABDOMINAL INJURIES (LAPLACE). 133 anterior superior spine on the right side. There had been very Httle bleed- ing from the wound ; there was no escape of gas or fluid nor any viscus present. The abdomen was generally resistant, both flanks were dull, but the dullness was not movable. Liver dull- ness appeared normal. The pulse was over 160, respiration rapid and shallow, pupils dilated and expression anxious. The patient did not complain of pain and had passed clear urine since receiv- ing the injury. The bowels had not moved. There was a good deal of shock; nevertheless the abdomen was opened immediately in the midline, below the umbilicus, by an incision about three inches long. Much blood and some fecal material of small gut consistency came away. The small in- testine was delivered and almost at once a wound perforating both sides of the gut was found. Near it was a lacera- tion on the antimesenteric side of the gut about one and one-half inches long. There was also much bruising of the mesentery between these two. The three wounds were closed in the usual way. Further examination showed seven more traumatic perfora- tions of gut and mesentery within a distance of six feet. All this and the boy's condition made the case seem so hopeless that the abdominal opening was closed with through-and-through sutures after a large drainage wick had been placed in the lower angle extend- ing freely into the abdomen. He was freely stimulated, given all the milk he could take and repeated large enemas. The drainage wick was re- moved on the second day and not re- inserted. On the third day a small amount of. fecal matter was passed by rectum and daily thereafter the quan- tity coming away naturally increased, and that by the wound decreased. With the first stool by rectum the boy's con- dition improved and it did so steadily and without further setback. One month after the accident the boy was up and about, and it was found that he had been eating rice, bananas, fish and cakes for ten days previously. Fysche (Montreal Med. Jour., May, 1909). Free hemorrhage from the wound tends to indicate an intestinal lesion ; if the stools also contain blood the diagnosis may be considered as certain. Probes have been discarded in penetrating wounds, owing to the irregular course followed by the bul- let in many cases and the danger of creating a false passage. Digital ex- ploration of small wounds furnish but little information, while in bullet wounds there is danger of pushing into the peritoneal cavity what for- eign substances may happen to be present. The majority of surgeons now favor enlargement by an incision at least two inches in length, intersecting the bullet or incised wound. Layer after layer of tissue is carefully dissected on each side of the track, the walls of which, in gunshot wounds, are usually darker than the normal tissues, owing to contact with the lead or powder- products of combustion. Using the grooved director to divide the tissues and the hemostatic forceps to grasp any bleeding vessel, the peritoneum is finally reached, when the certainty that a penetrating wound is present or not may be established. If prac- tised with strict aseptic precautions, this procedure does not expose the patient. Stomach. — Hematemesis is a fre- quent symptom of penetrating wound of this organ and a much more valuable one than in contusion, since, in the latter, a slight laceration of the mucous membrane may produce it. The blood may be piu-e, but in the majority of instances it is mixed with partially digested alimentary semi- liquid material. If the wound is suffi- ciently large to allow the contents to 134 ABDOMINAL INJURIES (LAPLACE). escape through it the nature of the injury is, of course, clear, but an important complication is to be ap- prehended : extravasation into the peritoneal cavity capable of causing peritonitis. If this is circumscribed, adhesions are formed and the patient recovers. Frequently, however, gen- eral peritonitis follows, ending in death. Hence the importance of an early recognition of extravasation. Besides hematemesis and the pres- ence of gastric fluids, there are usually present in such injuries the marked symptoms witnessed in cases of contusion : rapidly progressive anemia, pallor, fluttering pulse, etc. Case in which the exit hole made by the bullet in the stomach could not be found, though it had unmistakably passed entirely through it. The patient recovered normally. Research on ani- mals has also shown that the hole m.ade as the bullet passes out of the stomach is usually a small slit, discovered with difficulty. The entering hole is much larger and the stomach contents, if they escape at all, do so through this first opening. When the entering hole is not more than 7 or 8 mm. in diam- eter, it is wisest to abandon the search for the other opening if it does not readily present. The abdomen can be sutured with confidence, as the mucosa plugs the second opening. Von Frisch (Archiv f. klin. Chir., Ixxiii, Nu. 3, 1904). Liver. — A wound of the liver gives rise to all the symptoms observed when a contusion has caused lacera- tion of the organ : Intermittent pain, radiating in various directions, espe- cially toward the shoulder, if the convex portion of the organ is torn, and in the direction of the waist, if the concave or inferior portion of the organ is the seat of injury. There is marked pallor, superficial itching, and, later on, jaundice. The stools may be clay-colored, thus indicating the absence of bile. The hemorrhage varies in these cases according to the cause of the lesion; one caused by a bullet is prone to be accompanied by consider- able and frequently fatal bleeding. Stab wounds, when the weapon is not large, do not give rise to considerable hemorrhage. A copious flow of blood from a wound in the hepatic region indicates that the liver is involved. The flow of bile through the wound is a A^aluable sign, but it is seldom that this secretion can be obtained alone, blood being usually mixed with it. If the shock is progressive it means internal hemorrhage. When a patient is first seen he may be profoundly shocked and not be much disturbed ; but if he continues to become more shocked, it means hemorrhage. Shock at the time of injury does not mean hemorrhage, but later on it does. L. McLane Tiffany (Pacific Record of Med. and Surg., Feb. 15, 1896). In very severe cases the prognosis is exceedingly grave, no matter how early intervention may have been practised. Hemorrhage was the cause of death in 69 out of 162 fatal cases. Abscess and peritonitis are of course responsible for many deaths. In all probability there are many mild cases of liver laceration which go on to entire recovery without ever having been diagnosed. Of 25 cases of hepatic injury occurring in the last ten years in the New York hos- pitals, which were uncomplicated by serious lesions of other abdominal or- gans, 12 were ruptures, 9 gunshot wounds, 4 stab wounds. Eleven deaths resulted, being a mortality of 44 per cent. B. T. Tilton (Annals of Surgery, Jan., 1905). The gall-bladder when distended is easily ruptured and gives rise to violent symptoms, especially if already infected, septic peritonitis being inevitable.. E. J. ABDOMINAL INJURIES (LAPLACE). 135 Senn (Jour. Anicr. Med. Assoc, Mar. 23, 1907). In some instances extensive lacera- tions of various organs may give rise to no preliminary morbid phenomena. Thus, W. L. Robinson reported fatal cases of marked laceration of liver and bowel in which there was neither shock, hemorrhage, nor high pulse. Spleen. — In cases in which the spleen is wounded the diagnosis can easily be established by the location of the external opening and the direc- tion of the track. As is the case in contusion, there is marked local pain and profuse bleeding, which, if the organ is greatl}^ lacerated, may soon prove fatal. This is apt to occur after gunshot wounds at close range, the organ under such circum- stances becoming pulpified. Punc- ture wounds are less likely to produce fatal hemorrhage. Pain in the left shoulder has been considered a diag- nostic of value. Although many successful operations have been done of late for wounds of the spleen, little attention is being paid to a very valuable diagnostic sign. Case of wound of the spleen in a healthy j^oung man in which the physi- cian who saw the case soon after the accident made a diagnosis of simple contusion of the abdomen. The family physician who was called in a little later found, in addition to pain in the whole abdomen, severe pain in the left shoul- der. Because of the increasing shock, the distention of the abdomen, the marked right-sided rigidity, and the severe tenderness in the region of the spleen, a wound of the spleen was diagnosticated. The writer first saw the patient in the evening, and agreed with the diagnosis. He was partic- ularly impressed with the fact that the patient's chief complaint was of the pain in the shoulder. Immediate lapa- rotomy established a wounded spleen. This organ, which was exposed with much difficulty because adherent to the diaphragm, showed two large rents, one near the hilum and the other on the convex surface. Splenectomy was per- formed, and three weeks later the pa- tient was discharged cured. Pain re- ferred to the right shoulder is very characteristic of abscess of the liver. This applies as well to the left shoulder in the case of the spleen. It is ex- plained by the association between the phrenic and fourth cervical nerves. Levy (Zentralbl. f. Chin, Bd. xxxvii, S. 1577, 1910). Kidneys. — ■ Symptoms frequently accompanying wounds of the abdom- inal organs — extreme pallor, weak pulse, cold extremities, nausea, and vomiting — are apt to be most marked when, besides the organ itself, the peritoneum has been pierced. A wound of the kidney gives rise to severe pain in the majority of cases, but this symptom may be absent. As. in cases of laceration, the pain radiates in various directions,, especially in the direction of the ex- ternal genital organs. The testicle of the corresponding side, besides being the seat of considerable suffering, is frequently raised by spasmodic con- tractions of the scrotum. At first a small quantity of bloody urine may be passed, but this is often followed by vesical tenesmus and complete retention, due to the pres- ence of clots in the bladder. Much information is sometimes ob- tained by a close examination of the wound of exit. If the track of Xhe bullet be anteroposterior and the missile have entered from the front and penetrated the kidney, the exit wound will be found in the lumbar region. It is frequently found in this situation to contain urine, a positive indication that the organ or its annex, the ureter, has been wounded. 136 ABDOMINAL INJURIES (LAPLACE). The diagnosis of gunshot wounds in- volving the kidney may sometimes be made from the objective signs of injury of the kidney; in other cases the symp- toms will be those of shock and intra- abdominal bleeding, as in stab and in- cised wounds. The cardinal signs are hematuria and the escape of urine from the external wound. Owing to the nar- row wound of entrance, this latter sign is much less common in gunshot in- juries. If either ureter is plugged by a clot, severe renal colic may be present. In gunshot wounds involving the ab- dominal viscera, operated in foi" the control of bleeding or for the repair of wounds of the hollow viscera, it will be rare that the surgeon can diagnosticate injury of the kidney before opening the abdomen, unless hematuria or kidney colic have existed. Johnson (Annals of Surg., Oct., 1909). If the wound of entrance be in the back, its location over the site of the kidney may suggest a lesion of the latter ; but the urine test will only be of value if the projectile only pene- trate the kidney without perforating it. If it penetrate the organ, the ex- travasation will take place into the peritoneal cavity. The same will be the case if the missile enter from the front without going through the organ. Bullets buried in the renal parenchyma either become encysted or cause abscesses, and pass out through the ureters or into the ad- joining parts. Bladder. — The symptoms vary ac- cording to the location of the wound. A perforation between the symphysis and the peritoneum above does not give rise to general symptoms ; whereas shock, pallor, weak pulse, vomiting, etc., may be much marked when the peritoneum is involved in the injury. In all cases, however, severe pain is experienced at the site of the lesion and radiating to the thighs and testicles. The passage of urine soon becomes very difficult and spasmodic. It may be voided, drop by drop, for a long while, notwithstanding the efforts of the patient, then suddenly gush out for a few moments and again flow slowly. This symptom may be due to accumulation of clots or to spasm of the urethra. If the catheter is passed, hematuria becomes evident when the bladder has been pene- trated : a characteristic sign. As in the case of rupture due to contusion, infiltration may take place through the wound into the neighbor- ing tissues ; any obstacle to the free passage of urine greatly encourages this. Hence the necessity, in all bladder lesions, of keeping the organ as free as possible by the frequent use of the catheter. Two important clinical features pres- ent in cases of traumatic ruptures of the bladder that are not noted by the classical authorities: (1) The persist- ent uniform capacity of the bladder, and (2) the manner in which the blad- der may be refilled after complete evacuation by the catheter. The first is explained by the fact that the rupture is situated in the upper part of the blad- der, the lower part of which still acts as a reservoir. When the urine reaches the level of the rupture it escapes into the abdominal cavity. Repeated cathe- terization will, therefore, withdraw each time about the same quantity of urine, but it does not influence the urine in the abdominal cavity. The second symptom is due to a change in position from the recumbent, in which the urine is evacu- ated by the catheter, to the upright, in which the bladder is immediately re- filled by the urine which has escaped through the rupture into the lower part of the abdominal cavity, and which now as readily returns to the bladder, as shown by cadaveric experimentation. ABDOMINAL INJURIES (LAPLACE). 137 Two etiological factors were noted in these cases, the tolerance of the blad- der, which can be distended to the point of rnptnre, and the degeneration of the muscle which causes a diminished re- sistance to distention. Morel (Annales des mal. des organes genito-urin., June 1, 1906). PROGNOSIS.— The statistics so far pul)lislied differ so widely that it is difficult to reach a definite con- clusion. It is certain, however, that gunshot wounds are more frequently fatal than stab wounds, but that stab wounds, in which the peritoneum is penetrated, are fully as fatal as gun- shot wounds. The kind of weapon inflicting the injury plays an important role in this connection. A triple-edged bayonet is more likely to produce a serious laceration than a flat blade. Again, wounds caused by small weapons, such as a Flobert rifle, for instance, would hardly produce lesions to be compared to the old Enfield or Minie rifles, which sometimes caused a large portion of an organ to protrude through a wound of exit the size of an apple. Portions of the solid viscera are sometimes cut ofif or shot off, leaving a gaping tear, which greatly com- promises the issue. Again, as is often the case with the liver, the bullet, or any foreign material dragged in by the latter, may lead to complications which greatly reduce the chances of recovery. An important factor is the time elapsing between the receipt of the injury and that at which competent treatment is applied in mild cases. This is especially true as regards the early utilization of surgical measures when these become necessary. The sooner these are instituted, the more favorable the prognosis, especially during the first ten hours. The relation between spontaneous cures and operative interference as worked by Eisendrath in 1902 is about as follows : — Spontaneous Recoveries. PER CENT. Spleen 15.8 Liver 21.8 Intestines 7. Kidney (extraperitoneal) 70. Kidney (intraperitoneal) 0. Bladder (intraperitoneal) 2. Bladder (extraperitoneal) 11. Operative Recoveries. PExC CENT. 56. (50 cases). 59.5 {2,7 cases). 48. (42 cases prior to 1896). 50. (38 cases since 1896). 80. 100. ( 6 cases). 52. (43 cases). . 30. (last 15. years).— Mitchell. Hence the need of abandoning our policy of expectancy and delay and to recognize our duty as soon as even a probable diagnosis of rupture of one of the abdominal viscera without external signs has been made. Rather a few laparotomies in vain than allow the former mortality rate to continue. Intestines. — The prognosis depends greatly upon the nature of the lesions. Stab wounds opening the intestine lengthwise, if small, often heal of their own accord; transverse wounds are more serious, while complete sec- tion of the bowel is a very dangerous complication. Gunshot wounds show a great fatality. Prior to the intro- duction of antiseptic surgery the mortality exceeded 90 per cent. ; since then, the mortality has been de- creased to 43 per cent, in cases oper- ated during the first twelve hours. i3S ABDOMINAL INJURIES (LAPLACE). When all surgeons will handle the intestines with gentleness, operate quickly, and otherwise reduce the chances of shock, it is probable that the prognosis will be greatly im- proved. Perforations of the descend- ing colon and sigmoid flexure are seldom fatal ; those of the transverse colon give a worse prognosis, by the formation of fistulse, adhesions, and abnormal communications. Again, diai^thetic conditions may compromise recovery. Notwithstanding great injury and other conditions greatly reducing the chances of recovery, recoveries are occasionally obtained. Statistics collected by various writers, according to Conner, showed the mortality to range from 65.6 per cent, to 70.67 per cent. Shock is one of the chief causes of these results. Case of a penetrating wound of the abdomen in which there were 19 per- forations in the small intestines, besides a number of wounds in the mesentery. Operation was performed on the day following the injury, and fifty-one days afterward he was perfectly well. Iden (Medical Record, Nov. IS, 1905). Stomach. — Uncomplicated wounds of this organ frequently yield without trouble when the bullet, blade, or other instrument causing the perfora- tion is small, especially if the stomach was empty at the time the injury was inflicted. The mucous membrane bulges out and forms a plug which obturates the hole until reparative processes have sealed the aperture on the peritoneal side. Complicated cases, in which the lesions are exten- sive, soon reach a fatal issue if de- prived of timely surgical intervention. Liver. — The prognosis of wounds of the liver depends mainly upon the complications. If the patient does not die from hemorrhage soon after the receipt of the injury, he is still' exposed to the results of extravasa- tion into the peritoneal cavity, the presence in the liver of a foreign body, — the bullet and what material it may have forced into the wounds, — etc. Peritonitis, hepatitis, and ab- scess are, therefore, dangers to be taken into consideration. Hepatitis and abscess are much less to be feared, however, from stab wounds, no foreign body being left behind, unless, as in dueling, the sword-point strike the spinal column, causing the blade to break. In such an event, however, the hemorrhage would probably prove mortal very rapidly. As to mortality, the statistics of Edler, Mayer, and others show it to average about 50 per cent., including the cases attended by complications. Spleen. — Slight punctured wounds of the spleen are not mortal unless complicated with laceration of a large artery. They are sometimes followed by abscesses which heal after a pro- longed period in the great majority of cases. Severe punctured wounds are dangerous in proportion, but, if the primary hemorrhage is not such as to cause an early fatal issue, the chances of recovery are about those of slight wounds. Gunshot wounds are much more serious as a result of rupture of the spleen taking place under the con- cussion. When the bullet is large and its velocity is great, fatal hemor- rhage quickly ensues. Rupture of the spleen may also occur during convalescence. During the War of the Rebellion the proportion of deaths was 93 per cent. In civil life, however, the weapons used are, as a rule, less ABDOMINAL INJURIES (LAPLACE). 139 powerful, and it is probable that the mortality, especiall}' since antiseptic surgery has been generally utilized, is much smaller. The predilection of this organ for abscess greatly darkens the prospects of recovery. Kidneys. — Complications are also to be feared in lesions of this organ, namely : peritonitis, nephritis, and secondary hemorrhage. Again, the position of the kidney makes it prob- able that other organs are also injured in the majority of cases. The direc- tion from which the bullet or stab came, the length of the penetrating blade, etc., are important factors when the nature of the injury is to be determined. Bladder. — Gunshot wounds of the bladder are always serious as far as complications are concerned, rectal, vaginal, perineal, and scrotal fistulse being very frequent. As to the mortality of penetrating wounds of the bladder, it is not so great as in lesions of any of the other abdominal organs. Stab wounds are more frequently mortal than uncom- plicated bullet wounds, the propor- tions being 29 per cent, in the former and 17 per cent, in the latter. When, however, osseous lesions are also present, penetration or fracture of the pelvis, etc., the mortality reaches 29 per cent. Injuries of the bladder are most frequent in males, owing to greater exposure, and perhaps to anatomic causes. Distention is one of the main factors: an empty bladder is rarel}- injured, except with fracture of the pelvis. The majority of "bladder tears are intraperitoneal, and rapid pro- gressive peritonitis results unless prevented by radical surgery. Viru- lent sepsis follows the extraperi- toneal rupture. E. J. Senn (Jour. Amer. Med. Assoc, Mar. 23, 1907). TREATMENT.— The preliminary measures indicated in the treatment of complicated contusions of the abdomen are also applicable in that of penetrating wounds of that cavity. Protrusion of portions of the intes- tines, the mesentery, and the omen- tum through the external wound is an early complication met with in many cases of penetrating wound. If the protruding mass be intestinal and in good condition it should at once be returned into the abdomen. An easy way of accomplishing this (recom- mended by Levis) is to raise the middle of the patient's body by means of a pillow, the hands, etc., while he is lying on his back. The anterior portion of the pelvis is thus separated to an abnormal degree from the anterior portion of the thorax, and the increased room in the abdominal cavity thus obtained causes the intes- tines to spread out, as it were, and, their weight causing traction upon the protruding loop, the latter quickly slips in. At times the accumulation of gas or fecal matter checks its inward progress ; the gas can easily be let out by inserting a clean hypodermic needle into the projecting bowel; the fecal matter can also be reduced in quantity b}^ drawing out an addi- tional portion of the gut — thus in- creasing the size of the loop — and gently pressing small portions of the contents into the unprolapsed bowel, thus diminishing the tension of the protruded mass. It is sometimes necessar}'- to enlarge the abdominal wound. If the projecting mass be greatly inflamed the latter procedure is unavoidable. If it be gangrenous it had better be incised and the forma- tion of a fecal fistula permitted. 140 ABDOMINAL INJURIES (LAPLACE). To obtain a closure that will prevent hernia and protect the abdominal wound against infection, the writer recom- mends the following method : The ordinary "gridiron" operation is done, and the peritoneum is then caught up and incised in the line of the skin in- cision; each side of the peritoneal wound is then drawn out and sutured to the skin on both sides with a run- ning suture of catgut or a few inter- rupted sutures. Retractors may then be put in and the adhesions broken up and the appendix removed; one or two small drains are now placed, and each end of the incision closed around them by means of one or two through-and- through silkworm-gut sutures. To in- sure better approximation of the deep layer of muscles a silkworm-gut su- ture m.ay be placed on either side of the skin incision before the peritoneum is opened, and left to be tied when the operation is completed. Torrance (Therap. Gaz., Jan., 1909). An omental protrusion, if healthy, can be immediately returned, but if greatly inflamed or gangrenous it should be transfixed near the abdom- inal wall and tied with a double liga- ture ; then excised. The stump is then secured in the deeper portion of the wound with ligatures and adhe- sive strips. Punctured wounds of the abdomen are frequently recovered from spon- taneously, owing to the absence of serious visceral lesions. The same statement may be made as regards bullet wounds, but with less empha- sis. That laparotomy should be per- formed in every case is a view that widespread clinical testimony does not sustain ; but that a wound of suffi- cient importance to cause anxiety be enlarged down to the peritoneum to allow of a careful examination and adequate procedures, if need be, and that laparotomy proper should be re- served for lesions which, from the nature of the symptoms, tend toward a fatal issue, are in keeping with the teachings of the most advanced, but safe, surgery. Active operative intervention, when admitted by the general condition of the wounded, and the surrounding cir- cumstances, is indicated in all cases of perforating wounds of the abdominal cavity, with the exception of wounds inflicted with the modern small-caliber undeformed rifle bullet. In these cases expectant treatment gives the best re- sults. All those wounded in the abdo- men need full rest, at least for one week after the infliction of the wound. Wreden (Military Surgeon, March, 1907). Case of extensive gunshot wound caused by the accidental discharge of both barrels of a shotgun in contact with the body. The contents of the two barrels struck the abdomen at and above the left superior spine of the ilium, and came out at and above the iliosacral joint, tearing away all the soft tissue from the crest of the ilium and the crest itself, above a line drawn from a point one inch back of the anterior superior process, around the outside of the bone to the upper limit of the sacroiliac joint. The joint was not entered, but two transverse proc- esses of vertebrae were blown off and many pieces of detached bone were scattered throughout the soft tissues. The peritoneal cavity was entered, ex- posing the sigmoid flexure, the lower pole of the left kidney, and the ante- rior end of the floating rib. It could not at first be determined whether the sigmoid was perforated or not, but in one or two days leakage of gas showed that it had been injured. The lumbar muscle was practically destroyed. As there were no signs of serious hemor- rhage and it was recognized that the wound had been practically sterilized by the burning of the discharge, the attending practitioner wisely refrained from overmuch probing or interference, merely removing loose and dead tissue, clothing, etc., and applying a sterile dressing. In about two weeks the pa- ABDOMINAL INJURIES (LAPLACE). 141 ticnt was taken b\- train to New York, about 1000 miles. There it was found necessary to remove the anterior part of the crest of the ilium, which had be- come denuded of periosteum, and other portions of embedded bone that were found, and zinc plaster was used to narrow the wound. Another operation was performed four months later, anas- tomosing the under surface of the transverse colon, between the meso- colon and omentum at the junction of the middle and left third of the meso- colon with that portion of the sigmoid which could most easil}^ be brought into apposition. A fourth operation was undertaken, still a year later, to close the intestinal opening and furnish a parietal peritoneum, against which the intestine could rest, thus minimizing chances of adhesion and protecting against ulcerative processes in the ex- posed intestinal area; to find an ex- ternal covering for what must be a large hernia, and to devise a means for controlling its extension and future enlargement. The patient, at the time of report, two j'ears after operation, was in excellent health, able to perform all the duties and functions of life, walking four or five miles a day for recreation. Polk (Abstract in Jour. Amer. Med. Assoc, from Med. Rec, Apr. 18, 1908). In all penetrating wounds of the abdomen seen within twelve hours of the injury, operation should be done promptly. The incision should be large enough to insure a thorough survey of the abdominal viscera without unduly exposing them. Extensive evisceration is unnecessar}^ and unjustifiable, greatly increasing the mortality. Unless the peritoneum is extensively soiled, intes- tinal contents should be wiped away with salt gauze sponges, irrigation do- ing more harm than good. If the closure of the perforation or destruc- tion of blood-supply threatens seriously the usefulness of a portion of the bowel, resection should be done. If the peritoneal cavity is generally or exten- sively soiled, or if there is any con- siderable oozing, drainage is safer; otherwise, the incision may be closed. Postoperative treatment- is very im- portant. If there is no lesion in the large bowel salt solution and coffee, of each, 150 c.c, should be given per rectum every four hours. Branch (Annals of Surg., Aug., 1911). When surg-ical measures become necessary, including- enlargement of the wound, the patient should be placed under an anesthetic. The rectum should be emptied b}^ copious injections containing a tablespoonful of glycerin to the pint. A subcu- taneous injection of morphine (%^ grain) is recommended by many sur- geons. If, however, there is a tend- ency to shock without much pain, this agent had better be withheld. Rectal injections of whisky and warm water, 2 ounces of the former and 4 of the latter, is useful to sustain cardiac action. It may be repeated in an hour i£ evidences of impending shock are still present. If, after a careful examination of the enlarged wound, it is found that the peritoneum is not involved, the exposed tissues are carefully cleansed and the wound is closed, deep sutures being used to hold the tissues in ac- curate apposition. As already stated, the possibility of ventral hernia should be borne in mind: the patient should be kept in bed for some time and a bandage be worn until all local weakness has disappeared. If, after a stab wound, the parietal peritoneum alone is found incised or penetrated and there is no evidence that the organs behind have suftered injur}'-, the tissues must be cleansed with great care and the peritoneal flaps broug-ht together, the serous surfaces being kept in contact. A continuous catgut suture is used for the peritoneum; the muscles and skin 142 ABDOMINAL INJURIES (LAPLACE). are then united and the Avound is closed. The measures ah'eady out- Hned to prevent ventral hernia are also indicated for the deeper wound. V\'hen laparotomy becomes neces- sary the incision should be made in a spot affording- the operator the great- est opportunity for a wide field of action, and should be sufficiently long. AMien performed for the arrest of dangerous hemorrhage, a long median incision will enable the sur- geon to reach any organ with ease : an important factor, for the missile or blade inflicting the injury may have traversed harmlessly between several coils of intestine and have caused a rent in the organ most remote from the point of entrance. Again, the incision should be free, so as to make it possible to easily reach all parts of the abdomen to allow of a thorough removal of all extravasations which might otherwise ultimately cause complications. As the late Nicholas Senn taught, one of the important elements of suc- cess in the treatment of gunshot and stab wounds of the stomach is time. Unnecessary time lost in finding and suturing the visceral wounds is a source of immediate danger to life which should be eliminated as far as possible by means which enable the surgeon to make a quick and correct diagnosis, and by resorting to a method of suturing which closes the wound safely and securely with the least possible delay, and which leaves it in a condition most favorable for speedy definite healing. It is well known that small penetrating wounds of the stomach often heal without operative intervention. By contrac- tion and relative displacement of the different muscular lavers of the thick wall of the stomach the tubular Avound is contracted and obstructed sufficiently to prevent leakage until the canal on the peritoneal side becomes hermetically sealed by firm plastic adhesions which prevent ex- travasation during the time required for the repair of the visceral wound. If in larger wounds of the stomach the same degree of occlusion can be accomplished by the simplest me- chanical means, then such a pro- cedure should take the place of the more time-consuming methods of su- turing now in general use. This can be accomplished with the purse-string suture. In gunshot injuries the defect in the stomach-wall is circular and the wound-margins contused; hence the deep sutures could at first furnish a barrier to the escape of stomach-con- tents only for a short time, as their hold in the necrosed tissues would be imperfect and only of brief dura- tion. In short round wounds the cir- cular suture is the one which will bring and hold together in permanent uninterrupted contact the serous sur- faces in the most efficient manner. In the treatment of gunshot wounds of the stomach the principal object of suturing should be to close the per- foration in such a way as to guard securely against extravasation, and at the same time approximate and hold in apposition a maximum surface by intact healthy peritoneum. This is accomplished by making a cone of the injured part of the stomach with the apex corresponding with the wound directed toward the lumen of the organ. The purse-s-tring suture applied in the manner that Avill be described in the experimental part of this paper will maintain this cone ABDOMINAL INJURIES (LAPLACE). 143 until the healing" of the visceral wound has advanced sufficiently to render further mechanical support superfluous. The cone on the mucous side of the stomach acts in the manner of a valve, which in itself is- an ef- fective barrier against the escape of stomacli-contents, while the circular suture constitutes almost an absolute safeguard ag-ainst leakage, and brings in contact the serous surfaces in the interior of the cone. For wounds of the posterior wall of the stomach the author recommends a purse-string suture of heavy durable catgut to be applied through the anterior wound. The anterior wound is closed with a purse-string suture of silk of medium size applied to the base of the cone on the serous side. It is desirable that the circular suture should cause no necrosis of the included tissues. By using an absorbable suture in closing the posterior wound in the interior of the stomach this object is gained, as only a small part of the thickness of the stomach-wall is subjected to pres- sure, and the tension caused by the ligature is gradually lessened by sof- tening of its material, and is entirely removed by the absorption and diges- tion of the ligature in less than three weeks. The wound of the posterior wall of the stomach is found and made ac- cessible by inserting through the an- terior wound a grasping forceps with which the posterior wall is seized at a point where, from the course of the bullet, the second wound is supposed to be located. Through a wound large enough to admit the index finger the greater part of the posterior wall of the stomach can be made acces- sible to sight and touch, and the perforation can be located and closed with the purse-string suture in a few moments. In doul^tful cases inflation of the stomach should invariably be practised for the detection of a second and possibly a third perforation. The experiments demonstrated the safety of the circular suture in the treatment of gunshot and other pene- trating wounds of the stomach. All of the animals operated upon in this manner recovered and the repair of the injuries as shown by the specimens are ideal. The absence of adhesions over the posterior wound and their constant presence over the anterior wound indicate that the presence of the silk ligature and the needle punctures were the causes of the circumscribed plastic peritonitis which produced them. In none of the specimens could any indications be found of necrosis of any of the inverted tissues, and included in part by the circular suture. In the course of three weeks the continuity of the mucosa at the seat of the injury was completely restored. The result of these experiences has convinced the author that the circular suture compares favorably with the methods of suturing in general use, and besides has the great advantages over them in the case of its applica- tion and the saving of much valuable time. Suturing of the posterior wound by partial eversion of the stomach through the anterior obviates un- necessary handling of the organ and the necessity of interfering with the vascular supply incident to exposure of the posterior wound, as is done by the methods most generally practised. If extravasation into the retrogas- tric space has taken place, flushing through the posterior wound and a 144 ABDOMINAL INJURIES (LAPLACE). vertical slit in the gastrocolic liga- ment and gauze drainage through the latter are invariably indicated. (N. Senn.) The stomach and the transverse colon are best brought to view by an incision through the rectus muscle. In the case of the stomach hernia of the mucous membrane will facilitate recognition of the lesion. The as- cending colon requires lateral incision on the right side, and the descending on the left. These also should be sufficiently long to facilitate the search for the injury or injuries that may be present in the organ itself and beyond. The incision may be such as to intersect the wound of entrance. This is desirable at all times, the aim being, of course, to always avoid un- necessary solutions of continuity. Such an incision can fortunately be made in many of the cases in which the hemorrhage is not formidable. Hemorrhage. — When the abdom- inal cavity is opened and the hemor- rhage, which is usually more venous than arterial, is marked, the blood rapidly accumulates in the most de- pressed portion of the cavity from an invisible source. To mop out the blood with sponges is generally rec- ommended ; but such a procedure does not cause the hemorrhage to cease, — the first desideratum. In these formi- dable cases an assistant should at once introduce his hand through the wound — hence the advisability of a long incision — and compress the ab- dominal aorta below the diaphragm. This procedure immediately checks the flow. Six personal cases of injury of the liver in which is emphasized the value of controlling liver hemorrhage by su- ture, making the peritoneal toilet by dry sponging instead of irrigation, and the avoidance of package and drainage. J. E. Cannaday (Lancet-Clinic, Nov. 10, 1906). If any difficulty is experienced, the digital pressure upon the aorta may, for an instant, be decreased, and a sudden gush will point to at least the direction from which the blood comes. The necessary steps are then taken to arrest the flow, and the abdominal aorta is released as soon as possible, — not suddenly, but by a gradual re- duction of pressure. The measures to be employed in arresting hemorrhage vary according to the organ involved. Gunshot wounds of the liver are frequently stellate, and rents, radiating from the bullet-track in various directions, greatly increase the bleeding surface, the parenchyma in this organ taking part to a great degree in the emission of blood. To force resilient sponges into these tears is to increase their depth. If the wound be not very ex- tensive, it may be sutured with catgut or cauterized with the actual cautery. If the wound is extensive it had better be packed with long strips of iodo- form gauze, one end of which is brought out of the external wound. The modern tendency in wounds of the liver is toward early laparotomy. Open wounds should, without excep- tion, be treated by enlargement of the wound, exposure of the liver, and de- termination of the site and extent of the injury. Care should be taken to examine the . entire liver, as a second wound may remain urmoticed and give rise to fatal bleeding. The best meth- ods of stopping hemorrhage are by the use of sutures or gauze packing. If the. former are used they should include considerable liver tissue at the edges of the wound and, if possible, go down to ABDOMINAL INJURIES (LAPLACE). 145 its full depth. Gauze packing is par- ticularly suitable for contused wounds, gunshot wounds and punctured woimds, and is, furthermore, a useful addition to suture. The thermocautery is of very little value in arresting hemor- rhage from the liver. The blood and bile can easily be removed by flushing the abdomen with hot saline solution or by dry sponging. Drainage is em- ployed in subcutaneous wounds chiefly for the purpose of arresting hemor- • rhage. Tilton (Annals of Surg., Jan., 1905). When the intestinal injury and intra- peritoneal hemorrhage occur together and the blood is extravasated more quickly than the intestinal contents the hemorrhage acts mechanically, and per- haps also by its protective power, to encapsulate the peritonitis. The hem- orrhage will be brought to a standstill more quickly by the tension of the ab- dominal walls, the flatulence, and paralysis of the intestine when a mesen- teric vessel at its juncture with the intestine is injured. An intraperitoneal hemorrhage may thus act to reduce the threatening danger of an injury to the intestine imder favorable conditions. Gutzeit (Miinch. med. Woch., June 29, 1909). The spleen is next in order as to profuseness of hemorrhage. The same procedures may be adopted as for the liver, but the introduction of iodoform strips is to be preferred. If these means fail, splenectomy is the only measure left. Particulars of 3 cases of injury of the spleen, bullet wounds in 2 and laceration in the other case, which ter- minated fatally from internal hemor- rhage. The spleen was removed in the other patients. One was a man of 66, and the remarkably slow recovery was a noticeable feature. It seemed as if the lack of regeneration of the blood from the absence of the spleen retarded convalescence. An accessory spleen was found in the other patient, a young man of 27, and his prompt re- covery may have been facilitated by the presence of this compensating organ. Graf (Miinch. med. Woch., lii, Nu. 44, 1905). The writer has collected 70 cases of rupture of the spleen recorded since 1891, which are reported with sufficient fullness to admit of some comparison. From the standpoint of treatment there are four groups of cases: (1) those in which the patients die at once or within a few minutes of the accident — which hardly come within the range of surgery, as no case of successful op- eration has been done within the first hour; (2) those in which the symp- toms are delayed from twenty-four hours to fifteen days; (3) those — the majority — in which, after the initial shock of accident is recovered from, symptoms of hemorrhage appear within one to twenty-four hours; (4) the few cases in which the symptoms of rupture of the spleen are present which gradually recover without operation. All of these patients should be operated upon. G. S. Simpson (Lancet, Aug. 11, 1906).. Tears in the spleen cause hemor- rhage. This may be slight and cease spontaneously. But it may go on until the patient has become dangerously anemic. At times operation is done on such cases, and it is found that the bleeding from a tear in the spleen has stopped, or at most requires a small plugging with iodoform gauze. In other cases the tear may be so large that no other means are left than re- moval of the organ. This must be done without hesitation. O. Hilde- brandt (Berl. klin. Woch., Jan. 7, 1907). Sometimes a portion of the organ projects through the wound; removal of the protruding portion should be practised after passing a ligature around the mass. The walls of the stomach and intes- tines may also give rise to marked hemorrhage notwithstanding their comparative thinness. The number of vessels coursing through them, however, is very great. In these 1—10 146 ABDOMINAL INJURIES (LAPLACE). cases it is best to hem the margins of the wounds with fine silk. The bladder may be treated in the same way. The mesentery sometimes bleeds profusely when perforated. The mesenteric vessels should be ligated en masse with fine silk. Hemorrhage of the kidney is ar- rested in the majority of cases by iodoform-gauze package. If this should prove inefifectual the organ must be exposed and the vessels tied if possible. If not, nephrotomy or nephrectomy should be resorted to. The latter operation does away with the chances of complication attending the former, while the kidney of the other side assumes the function of both. Injuries to the kidneys are common. At times one or two small tears may be seen on the surface, or the tears may be deep ; and again, the whole organ may be crushed into two parts. The kidney is usualh'- crushed against the first lumbar vertebra. The first class of case shows a short lasting hematuria, but no anemia, while if the tears are deeper the hemorrhage may last for some time. In the case of a completely torn organ one finds very extreme anemia, great pallor, cold clammy skin, and restlessness. The abdomen is ex- cessively tender, the pulse is thready, and the impression is obtained that the patient is dying rapidly from loss of blood. If the abdomen is opened, huge effusions of blood are found, and in the midst of the blood the kidney lies buried. One only has a short time during which one can still save the pa- tient. For the first two classes one waits for matters to develop, but in the third class one must operate and re- move the kidney at once. O. Hilde- brandt (Berl. klin. Woch., Jan. 7, 1907). Four cases of rupture of the kidney treated conservatively, rather than by nephrectomy. The abundant literature of the subject shows that the advan- tage lies with conservative treatment. Surgical interference should aim to control hemorrhage and prevent ex- travasation of blood and urine into the tissues and abdominal cavity, also to treat other organs which may have been injured simultaneously, and, finally, to place the injured kidney under conditions which shall be most favorable for repair, including the pro- viding of means against the occurrence of infection. An operation, if indi- cated, should not be delayed. The in- jury is so slight in many cases that an operation is not required. The condi- tions must be carefully weighed to de- cide between an abdominal or a lumbar incision. Neilson (Amer. Jour. Med. Sci., Jan., 1908). The tampon should be employed in tho?*^ cases in which there are no im- mediate signs of injury of the kidney or in which these signs come on slowly. In these cases we may consider that the lesions are benign and the hemo- stasis due to spontaneous clotting. Bleeding may, however, occur later in these cases, from the withdrawal of the tampon or the separation of a slough. Of 6 cases of nephrectomy for gunshot wounds of the kidney, 3 re- covered and 3 died. Anuria is due in the greater number of cases to a reflex inhibition, produced by the trauma of the injured kidney upon its fellow, and signifies only an important lesion of the renal parenchyma. The coexist- ence of a wound of entrance in the lumbar region is an indication for an exploratory incision. Clement (Ann. d. mal. d. org. gen.-urin., p. 1281, 1909). Perforation. — The fact that the in- testines are, at times, perforated in twenty spots by a bullet suggests the considerable degree of care that should be given to this part of the procedure, which is carried out in the following way: The perforation nearest the rectum having been de- tected, the portion of intestine per- forated is gently brought into full view. An assistant causes the gas in ABDOMINAL INJURIES (LAPLACE). 147 the portion of gut below the lacera- tion to escape through the latter by slight pressure. This being done, the next step is to ascertain whether there is another perforation above. A fresh, aseptic glass tube is placed at the end of the insufflating tube and introduced into the wound with the tip directed away from the rectum. The assistant now being directed to compress the intestine below the per- foration, a small amount of gas blown above the latter will inflate the upper segment if there is no opening, or indicate the location of the perfora- tion if there is one. As soon as the latter is detected, the tube is with- drawn, the neighboring intestine on each side of the first perforation is disinfected, and the opening is closed. This procedure is renewed until all perforations have been found and closed. This plan renders unneces- sary the removal of the intestines from the abdominal cavity during any part of the operation, the source of complications in many cases, and of death by aggravated shock in others, and is now recommended by the majority of American surgeons. Case of a man aged 28 years, who was accidentally shot in the abdomen in the region of McBurney's point, with a 32-caliber revolver. About four hours later the abdomen was opened in the median line and was found full of blood. Nineteen perforations of the small intestine were discovered, as well as several wounds of the mesentery. At one place there were five perfora- tions in four inches of gut, necessi- tating resection. End-to-end anasto- mosis was done, using the Cushing suture, and the other perforations were closed with purse-string sutures. The intestines were cleaned with gauze, wet with hot salt solution, and the wound closed without drainage. The opera- tion consumed two and one-half hours, and at its close the pulse was imper- ceptible at the radial, facial, and tem- poral arteries, and the heart beats were from 170 to 180 a minute. In spite of the grave condition of shock, the pa- tient rallied very quickly, and the wound healed by primary intention, the man returning to his work, perfectly well, fifty-one days after the operation. Iden (Med. Rec, Nov. 18, 1905). There is great ground for the ob- jection to Senn's method, made by many surgeons, as regards its use for purposes of diagnosis prior to lapar- otomy, but, in the detection of per- forations after the abdomen has been opened, it is of value, and may be used, at times, to great advantage. The manner of closing the wound is that indicated for lacerations fol- lowing blows. The stomach and in- testinal perforations being treated in the same way, the margins of the wound are turned inward and the serous surfaces are united by a con- tinuous, fine-silk Lembert suture or by interrupted sutures, including the serous and muscular coats and the submucosa. These are cut short and left in, being eventually discharged per aniim. At times the tissues around a per- foration are sufficiently contused to render an omental graft necessary. Enterectomy is sometimes required, and not infrequently exsections of the intestine are necessary. In that case the intervening portion, if it is not too long, had better be resected, thus avoiding a double operation in the continuity of the gut. After the active measures described have been carried out the extravasa- tion of the contents of the stomach or intestines may make it necessary to flush the peritoneal cavity. Warm, sterilized water should be used, but 148 ABDOMINAL INJURIES (LAPLACE). care should be taken not to handle the intestines roughly. By turning the patient on his side- the fluid is poured out. The abdominal cavity is then dried with large sponges wrung out of warm, sterilized water. Chill- ing of the viscera should be carefully avoided, and the parts should be exposed to the air as short a time as possible. Drainage is sometimes necessary, especially for wounds of the solid viscera, such as the liver, spleen, kidneys, etc., in which active meas ures were not resorted to early. The weight of evidence, however, stands in favor of dispensing with drainage whenever it is possible. Whenever the muscular wall is rigid, no time should be lost before operating, or at all events seeking the assistance of the surgeon. The rigidity is due to beginning peritonitis, which is well marked within two and a half hours of the injury. If one operates in severe cases early one can obtain much more favorable results than one used to get when one waited for the signs of peri- tonitis to develop. . Out of 12 cases of intestinal injury, the writer saved 5 by operation. O. Hildebrandt (Berl. klin. Woch., Jan. 7, 1907). Previous to 1890 few cases of intes- tinal rupture were treated surgically, and the result was usually a fatal one. From 1894 to 1904 there were 32 re- coveries reported in English, Ameri- can, French, and German literature. Though the accident is relatively rare, it is not infrequent in occupations in which traumatism by squeezing is of common occurrence. Lumbermen and coal miners are exposed to such acci- dents. Rupture usually occurs where the motility of the gut is restricted by a short mesentery. The omentum usu- ally escapes serious injury, while the mesentery undergoes injury similar to that which is sustained by the gut. Conditions are more favorable for an operation when the accident occurs sev- eral hours after a meal. Golden (Annals of Surg., Nov., 1906). If the intestine is perforated and not repaired the patient will die. The in- strument inflicting the operation is not a matter of much moment. Prompt and immediate operation is imperative. It is undesirable to probe or unneces- sarily manipulate the wound with the object of cleansing it. Excluding wounds of the abdominal region and those which give rise to dangerous hemorrhage, or pressure of the brain, and finally those in which the position of the bullet is clearly made out and its removal is not fraught with danger, simple aseptic dressing and awaiting developments is unquestionably the best policy. Of course, where bones are broken the ordinary treatment of bone fractures is in order. Shiels (Amer. Jour, of Surg., Aug., 1908). To summarize : we will say that immediate exploration of the abdom- inal cavity is indicated as soon as it is suspected to have been penetrated or in any way injured by a trauma- tism. The injury to its contents must then be repaired under strict aseptic precautions. The value of salt-solution flushing is emphasized by the results of practical experience. Should no lesion be found, the mere exploration should result in no serious damage. After-treatment. — Food should be withheld for thirty-six hours, but a little water and brandy, in teaspoon- ful doses, may be allowed, especially if there is any degree of shock. In that case it is advisable also to use stimulants by the rectum or sub- cutaneously. Nutritive enemata of beef-tea and milk are necessary to sustain the patient's powers. Proctoclysis of normal salt solu- tion according to the Murphy gradual method should be resorted to. The head of the bed should be raised to ABDOMINAL INJURIES (LAPLACE). 149 apply the Fowler principle favoring the gathering of secretions in the pelvis, where the absorption is less rapid. When the patient is placed in the bed [semisitting with pillows under the knees — the Fowler position], quan- tities of warm salt solution are passed slowly into the rectum. The mucous membrane of the large intestine ab- sorbs fluid with great rapidity when that portion of the gut is in its nor- mal condition of moderate distention. Ovepdistention leads to spasm, which expels the fluid. Hence the fluid must be given at low pressure and adminis- tration should be continuous. The sim- plest sort of apparatus consists of a fountain syringe, a large rubber tube, and a rectal tip of hard rubber. The nozzle that is used is angled, has one opening on the end and several on the side, and this nozzle is passed so that the angle fits to the sphincter. The tube is strapped to the thighs by ad- hesive plaster. The hose that comes from the nozzle is attached to a reser- voir, the base of which is hung from 4 to 6 inches above the level of the patient's buttocks, and the fluid, there- fore, enters the rectum only about as fast as the rectum will absorb it. The reservoir is kept hot by bags of hot water. The fluid is allowed to enter continuously, unless it should run out from the side of the tube ; if this hap- pens, the flow may be cut off for a short time and then allowed to begin again. Gas from the bowel passes into the openings of the tube, and every now and then bubbles up through the reservoir. By this continuous, low- pressure instillation (protoclysis) an enormous quantity of fluid is absorbed by the rectum. In some cases a num- ber of quarts are taken up in twenty- four hours. The absorption of this fluid greatly increases the amount of urine eliminated and stimulates the heart. The reservoir must not be high. Increase of pressure will cause expul- sion of fluid and defeat the possibility of continuous administration. ■ The plan so often followed of keeping the reservoir high and limiting the flow by a clip on the tube is a mistake. Murphy says : "It should never have a headway of more than 15 inches hydrostatic pressure, and it gives the best and most uniform results at 4 to 7 inches" (Jour. Amer. Med. Assoc, April 17, 1909). A straight tube is sometimes responsi- ble for expulsion of the fluid, because it touches the posterior rectal wall of a patient in Fowler's position. J. C. Da Costa (Modern Surgery, p. 1007, 1910). During- this procedure no food should be given by the mouth. If the patient is weak, rectal alimenta- tion is indicated. In the less severe cases liquid food may be permitted by the evening of the second day, and soft, easily digested food after a week, rectal alimentation being continued until then. The sutures can be removed on the ninth day. The closure of the external wound must be complete before the patient can be allowed to leave his bed, and the danger of a ventral hernia should be counter- acted by means of an abdominal supporter. Hypodermic injections of strych- nine, Yqq to Yso grain, three times a day, according to indications, will prove most effectual in maintaining the strength of the patient and toning the muscular wall of the intestine. Wounds Due to Military Firearms. [See supra, Penetrating Wounds, for details.] During the Franco-Prussian War German soldiers were frequently found suffering from wounds of so frightful a nature that the French were accused of using explosive bullets contrary to the International Convention to that effect. AVounded limbs showed lesions of so destruc- tive a character that the hole made 150 ABDOMINAL INJURIES (LAPLACE). was a magma of muscle, tendon, bone, blood, etc. Dead subjects were found with their heads completely shat- tered, the brains being scattered on all sides. The good faith of the French was soon demonstrated, how- ever, experiments having shown that their rifle, the Chassepot, was capable, when fired at close quarters, of creat- ing unusual lesions on account of tlie initial velocity and the greater rota- tion of the bullet. This was attrib- uted mainly to the reduced diameter of the bore, 11 millimeters, and to the increased quantity of powder used. In 1886 France adopted 8 milli- meters as the caliber of her military arm, and the other nations soon fol- lowed her example. The United States Government adopted two calibers, one of 7.62 millimeters for the army, and one of 6 millimeters for the navy. Contrary to all expecta- tions, the effects noted in recent wars, the war between Chili and Peru, in which a 7.6-millimeter caliber was used; that between China and Japan, in which a 7.9-millimeter was used on the Japanese side, and the more recent Chitral expeditions and Abys- sinian campaigns, in which 7.9-milli- meter and 6.5-millimeter arms, re- spectively, were employed, were less destructive than the larger calibers, while the wounds caused by them healed with greater rapidity than those following lesions due to the action of larger balls. During the Chilian AVar there were instances where men completely perforated through the chest would suffer from slight shock, a slight hemoptysis, and soon be out. This radical difference between the destructive power of large and small calibers, or, rather, between the de- structive effects of an arm such as the Chassepot (11 millimeters) and the modern rifle (6 to 8 millimeters), IS mainly attributed to the fact that lead was formerly employed in the manufacture of bullets ; whereas, at present, in order to avoid destruction of the bullet during its progress through the barrel, resulting from the great increase 'of the powder-charge, and with the view of reducing the weight carried by the soldier, owing to the introduction of repeating arms, the bullet itself is either made of some hard metal, or it is covered with some such substance as nickel, steel, German silver, etc. These physical features, added to the smaller diameter of the projectile, the much greater velocity with which it travels, its more or less pointed tip, cause it to penetrate soft tissues as would a long, thin blade, separat- ing rather than destroying them. Therefore perforations in a muscle are clean-cut; at times their walls are even collapsed; as a rule, the channel is about the size of the bullet ; large blood-vessels are severed and bleed until the heart ceases to beat, etc. jVIajor Lynch, of the U. S. Army, states that there is considerable dif- ference between the Russian and Japanese rifles. The former has a caliber of 7.6 millimeters; its cartridge weighs 24 grams. The bullet weighs 14 grams and has a jacket of cupro- nickel. Its initial velocity is 2015 feet per second. The Japanese rifle is 6.50 millimeters in caliber; the cartridge weighs 22 grams ; the charge is 2.10 grams of smokeless powder. The bullet, which weighs 11/^ grams, is 32 millimeters long and is made of hard lead, with a German silver jacket. The initial ABDOMINAL INJURIES (LAPLACE). 151 velocity is 2356 feet per second. The different initial velocity, etc., of the Japanese, as compared with the Rus- sion rifle bullet, according to Major Lynch, was not found of great impor- tance, so far as the effects produced by it on the tissues of men hit were concerned, though it is possible that more Russian bullets lodged. The difference in caliber of the two rifles was responsible, however, for very great differences in the wounds caused by them. The wounds due to the Russian bullets were always of a much more severe character. While from the surgical standpoint the ex- tremely small caliber of the Japanese rifle is desirable, it is a great question if they have not carried their desire for long range, flat trajectory, and light w^eight of cartridge too far, and have thus sacrificed the stopping power of the bullet to such an extent that their weapon does not yield the best results in war. Certainly, a man hit with the Japanese bullet will come on when it has passed through his body anywhere, except at a vital point. The wound of entrance of the Russian bullet was naturally of larger size than that of the Japanese, as was also the wound of exit. The greater destructive effect of the former was, however, most manifest when bone tissue was struck in its course through the body. Bone was almost always extremely comminuted, and the wound of exit caused by the bullet after passage through bone was large. In the winter, at least, many rifle bullets, the Russian more than the Japanese, were deformed by striking hard ground or frozen walls, and wounds produced by such bullets were of course always destructive to both soft and bony tissue on account of the large wounding surface of the missile. Shrapnel bullet wounds were also always of a severe charac- ter, both on account of the large size of the shrapnel bullet and because of the material of which it was made — soft lead, which is so liable to defor- mation. Wounds produced by pieces of shell were even more severe, and frightful injuries were caused by hand grenades. With the last, tissues were so lacerated and torn generally that amputation of injured limbs was almost invariably required. Foreign bodies were not frequently carried into wounds by the Japanese unde- formed bullets, and were still more rare with the Russian undeformed bullets. With both deformed they were not uncommon. The shrapnel ball also frequently drove foreign material from the men's clothing into wounds. Fragments of shell some- times did so, but often tore their way through, carrying everything in their path before them. With hand gre- nades not only were particles of cloth- ing sometimes carried into wounds by fragments, but stones and dirt were frequently driven in by the explosion. On the whole, we may conclude that the arms now furnished to armies give rise to injuries far more severe, as a rule, than those met with in civil life, when weapons of various kinds, imparting to bullets a much smaller velocity, are used. Shock is corre- spondingly more severe, and greater conservatism, in the remedial methods adopted, is necessary. Treves,- Makins and Senn teach that gunshot wounds of the abdomen re- ceived in war do better when let alone. In civil life the experience of all sur- geons is, that those patients operated 152 ABORTION (WRIGHT). on promptly frequently recover; those treated expectantly usually die. Five personal cases in which recovery fol- lowed operation in 4. Holladay (N. Y. Med. Jour., Sept. 26, 1908). The general aim should be to pre- vent infection by careful cleansing of exposed tissues, but also to avoid the risk of inflicting additional injury by injudicious instrumental interference and manipulation of the wound. Though the writer thinks the saying of the English surgeon, that "A soldier shot in the abdomen will live if left alone and will die if operated upon," must be taken cum grano salis, he nevertheless pleads for conservative treatment. After abdominal gunshot injury, rest and absolute denial of food and drink is of prime importance. Every soldier should know this. Trans- portation, if necessary, must be done carefully. Treves reports that all the patients carried from a steep hill with abdominal gunshot injuries died. All patients should be kept at least eight days in the neighborhood of the battle- field. For twenty-four to thirty-six hours the patients receive no food or drink, then teaspoonful doses of water, tea, and gradually milk. No solid food for fourteen days. At first much morphine must be used. Persistent vomiting may be alleviated by lavage, provided the stomach is not injured. Hildebrandt (Der Militararzt; Mili- tary Surgeon, Mar., 1909). The value of laparotomy for wounds of the small intestine on the battlefield almost unanimously condemned in gen- eral discussion by military surgeons. In the China-Japan, United States-Cuba, Tirah, Transvaal, and Russia-Japan campaigns, operative death was prac- tically universal. This is mainly be- cause facilities are lacking at the front, while the patient is frequently hours on the ground before being operated. Conversely, spontaneous recovery often follows wounds of the intestines by high-velocity and small-caliber bullets. The mucous membrane blocks the open- ing or muscle-fibers approximate, thus preventing the escape of septic contents. This is soon followed by formation of adhesions. Transactions of the Societe de Medecine Militaire (Arch, provin- ciales de Chir., vol. xviii, p. 267, 1909). Ernest Laplace, Philadelphia. ABORTION.— DEFINITION. — Abortion is the expulsion or removal of the fructified ovum before the fe- tus is viable, — meaning by the term "viable" that the fetus has reached such a stage of development that it can live, thrive and grow, after birth. We cannot say definitely when the fetus reaches that stage, but it has been the custom to consider that it becomes viable at the end of the seventh lunar month or the twenty- eighth week of pregnancy. Still, a very young fetus may breathe after delivery. This occurred, for ex- ample, in 3 cases (2 in the fifteenth and 1 in the nineteenth weeks, re- spectively) reported by Glockner. In the first of these there were six re- spiratory movements before and five after severing the cord, the fetus living one hour. In the second case the fetus lived an hour and a half and breathed five times. The third fetus lived but half an hour and breathed eight times. The autopsy showed air in the stomach, but the lungs were empty. From a clinical standpoint, how- ever, the fetus is not viable before the end of the seventh calendar month. [It was hoped by many a few years ago that by means of the modern incubator, and by a special kind of feeding (gavage), fetuses younger than twenty-eight weeks might be raised. The public were much in- terested. Ingenious mechanics invented many sorts of incubators, some of which were very complicated and very expensive. ABORTION (WRIGHT). 153 These have, in the majority of cases, proved very disappointing. A. H. Wkight.] Premature labor or delivery means the termination of pregnancy between the end of the seventh month and full term. In certain cases it is difficult to distinguish between late abortion and early premature labor. As to the time of occurrence, it has seemed convenient to consider two varieties : early abortion, when it occurs before or about the end of the third month of pregnancy^ and late abortion, when it occurs between the latter part of the third month and the end of the seventh month of preg- nancy. Three varieties as to the methods of occurrence are also recognized : the spontaneous, when the abortion occurs without any outside interfer- ence, and is caused by some abnormal condition of the mother or fetus; the accidental, when the abortion is due to accident; and the induced, when the abortion is produced artificially by interference from outside. Induced abortion is deemed legitimate when it is produced by a physician for just cause. The cause is considered just only when the abortion is induced to save the mother's life which otherwise is imperiled. When the abortion is induced without such just cause, that is, when it is done for improper or immoral reasons, whether by the mother or the professional abortionist, it is known both from a medical and legal standpoint as criminal abortion. The proportion of abortions to labors at term from 1898 to 1904, in six of the Maternity Hospitals of Paris, has risen from about 5.6 to about- 16 per cent. More than one-half of these cases are provoked by criminal operations of some kind or other. . The proportion of premature labors has also increased considerably. This state of things is due to the tone of modern novels, and to the unhampered propagation of so- called neomalthusian ideas, to books and pamphlets, published and sold broadcast, describing various methods for preventing conception. Doleris (C. r. Soc. obst., gyn., pa^d., Feb., 1905). The number of abortions requiring treatment in the public hospitals of Paris is said to have tripled during the last few years ; Treub estimates the criminal abortions as 10 per cent, of all observed in Amsterdam, and others there estimate the proportion up to 33 per cent. ; at Utrecht, nearly 14 per cent. ; at Groningen, 24 per cent., and the author cites several American authorities and others to show^ the in- creasing importance of this subject. Warning against making a local ex- amination of a woman threatened with abortion. If absolutely compelled to make an examination, the finger should never be introduced until after the ex- ternal genitals have been prepared as for a vaginal hysterectomy ; otherwise, puerperal infection is likely to ensue sooner or later and the physician alone will be responsible for it. De Bovis (Semaine medicale, Oct. 26, 1910). Three cases of fatal mercurial poison- ing from bichloride tablets used to pro- duce abortion. In one of these the young woman introduced into the vagina to produce abortion 6 bichloride tablets, each containing 7.3 grains. This produced severe and burning pain and such muscular spasm that the patient could not remove them. A physician was promptly summoned, who gave vaginal douches of warm water and morphine hypodermically. The patient speedily developed intense symptoms of mercurial poisoning, and died four days later. At autopsy an intense necrotic exfoliative enterocolitis was present, most severe in the rectum. The proc- ess was distinct as high as the duo- denum. There was also necrosis of the muscular walls of the vagina and vaginal portion of the cervix. The broad ligaments. Fallopian tubes, and ovaries were necrotic, but above the internal os the lining of the uterus was 154 ABORTION (WRIGHT). normal. There was no evidence of peri- tonitis. Schildecker (Amer. Jour, of Obstet., March, 1911). As to frequency, it is impossible to estimate even approximately the pro- portion of pregnancies terminating in spontaneous abortions. Women who object to having large families have such a multitude of expedients to cut short their- pregnancies, and fre- quently conceal their methods so carefully, that our estimates as to percentages cannot be exact. From the results of our experience in private practice it is indicated that abortion occurs from accident or spontaneously in 1 out of 10 pregnancies, that is, 10 per cent. However, if we include induced abortions (legitimate and criminal), it is probable that abortion occurs in 3 out of 10 pregnancies, that is, in 30 per cent. The figures of the Paris Maternite from 1897 to 1905, as collected by G. Rimette, show 9875 pregnancies, 1457 abortions, 627 spontaneous abortions, 414 complicated abortions, 367 infected abortions, and 27 deaths from abortion. Michailofif, who bases his figures on 257,988 births in one of the Russian maternities, found that the proportion of abortions to full-term deliveries was about 1 to 10. Keyssner, in his polyclinic material, found 469 abortions to 2623 confinements, or 1 to 5.6. The figures of hospitals are bound to be faulty, since they omit the numerous cases that are taken care of at home. Even polyclinics, where the physician attends the patients at their home, do not give an accurate idea as to fre- quency, for many mothers have an abortion with hardly an untoward symptom and absolutely without med- ical attention. As Chazan points out, the only ac- curate statistics are those obtained through the patient's anamnesis. The evidence thus far at hand from such sources is very insufificient. For this reason the author undertook the labor of looking over the clinical records of 600 patients treated at the gynecological clinic of the Washington University Hospital. He found that 348 out of these 600 women had been pregnant. Of this number there were 870 full- . term pregnancies by 293 mothers, 371 abortions by 201 mothers, 36 confess- edly criminal abortions, 50 women who developed some gynecologic disease after abortion. This would make the ratio of abortions to confinements, i to 2.3. This means that every third pregnancy does not develop to viability, a loss to the world of one-third of all the children that are conceived. F. J. Taussig (Amer. Jour, of Obstet., Oct., 1908). Miscarriage. — We consider abortion and miscarriage are synonymous terms. In former times the terms were not considered so, nor are they now in some quarters. Many, if not all, of the Rotunda men, and some obstetricians of North America, still use the term miscarriage in the old- fashioned way. According to them, miscarriage is a term applied to the expulsion of the ovum between the beginning of the fourth and the end of the seventh month, that is, between the time of the complete formation of the placenta and the time that the fetus becomes viable. Those who thus define miscarriage say that abor- tion is the term applied to the expul- sion of the ovum before the end of the third month, that is, before the com- plete formation of the placenta. [It should be remembered that a large proportion of the laity think that abortion is the term used when the uterus has been emptied by artificial interference. It is well, therefore, for the physician when speaking to his patients to use the term miscarriage. Some women are offended if the physician hints at the possibility of their having had an abortion. A. H. Wright.] SYMPTOMS.— The symptoms of abortion are hemorrhage, a brown ABORTION (WRIGHT). 155 discharge after the death of the ovum, pains in the pelvis, complete or partial dilatation of the os uteri, expulsion of the whole or part of the ovum. The hemorrhage in the majority of abortions is not profuse, and may continue a long time. In a certain class of cases, however, the hemor- rhage is very profuse and sometimes causes death. Some think that hemor- rhage in earh^ abortion is never pro- fuse enough to cause death. Cer- tainly the hemorrhage before the formation of the placenta is seldom dangerous to life. There are excep- tions to this rule, however; but, so far as we know, the majority of the fatalities from hemorrhage in early abortion occur in cases of criminal abortion where sharp or pointed in- struments are used. Case of fatal hemorrhage in a multip- ara of 44 years, four months pregnant. The hemorrhages had recurred daily for eight weeks, but were severe only during the last two weeks, causing marked anemia and exhaustion. The uterus was emptied under anesthesia after dilatation of the uterus, but this was followed by bleeding which hot irrigation, saline solution, massage, or tamponing failed to control. The uterus was then removed through the vagina in nine minutes, but, although no blood was lost, the patient gradually sank. Careful macroscopic and micro- scopic examination of the organ failed to reveal any morbid condition of any kind. Henze (Zentralbl. fiir Gynak., Nu. 29, 1908). In considering the symptomatology of abortion, however, it is very im- portant to obtain a clear conception of the two varieties commonly recognized, viz. : the "threatened" and the "in- evitable." [The importance of this distinction asserts itself in connection with treatment. In the case of threatened abortion we are in doubt as to whether the uterus will be emptied or not, and our treatment aims at controlling the influences which are producing the symp- toms of abortion, such as hemorrhage and uterine contractions. In the case of inevi- table abortion the contents of the uterus will be held or partially expelled by nature's efforts, and we pursue a line of treatment entirely different from that adopted for threatened abortion. Our aim now is to as- sist nature in expelling the contents of the uterus as soon as possible with safety to the mother. A. H. Wright.] The symptoms of threatened abor- tion are hemorrhage, pelvic pain and perhaps a slight dilatation of the os, especially in multiparse. The hemor- rhage, as already mentioned, is com- paratively slight in a large proportion of cases, and may continue for nine or ten weeks or longer without ending in actual abortion. The pains which are caused by uterine contractions may be fairly severe and may con- tinue for -some time without causing the expulsion of the ovum. External hemorrhage is not only the most important, but the most common premonitory symptom of abortion, and although it may be induced, atony of the uterus is its most frequent cause. Under such circumstances it may appear as early as the sixth week of pregnancy, about the time when the serotinal ves- sels begin to undergo rapid enlargement in response to the stimulation of the placental chorion. Hemorrhage may also be due to deficiency of calcium and potassium in the muscular substance of the uterus, or to the presence of some toxic material impairing the tone and responsive power of the organ. In such cases potassium iodide and calcium chloride are given to remove deleterious substances or to supply those which are deficient. When the muscular energy of the uterus is impaired there is often enfeeblement of the nerve energy also, and strychnine, arsenic, digitalis, or phosphorus may be given with benefit. Pain is the other all-important prodro- mal symptom of abortion. It may be 156 ABORTION (WRIGHT). noted when the uterus does not ade- quately respond to and fails to expand correlatively with the developing ovum. The uterine tissues, again, may be re- sponsive enough, but they may be re- strained by adhesions. Abortion not infrequently results from physical or mental shock, or a combination of both influences. After the tenth or twelfth week of pregnancy the uterus may be injured directly by a blow on the lower abdomen, and abortion may more or less quickly ensue. But usually there is extravasation of blood from rupture of the functionally active maternal ves- sels ; the blood may never make its escape externally, and pain may be the only symptom. No drugs should be given in such cases; absolute rest is the best treatment. Necrosis of the amniochorion is a very rare cause of abortion, and it determines this event by allowing the amniotic fluid to escape. J. Oliver (Brit. Med. Jour., Nov. 30, 1907). In inevitable abortion there are also hemorrhage, pelvic pains and more or less dilatation of the os, but these phenomena are more severe and pro- nounced. It is sometimes, in fact, very difficult to decide when an abor- tion becomes inevitable. Probably the safest guide is the hemorrhage. If the fetus is dead, or if the mem- branes are ruptured, abortion is also deemed inevitable. No definite rules can be given in this regard. That abortion is inevitable when the membranes are ruptured is generally believed to be true in every case, but 3 personal cases have proven to be exceptions. In the first, a' young woman in her first pregnancy, a fall caused rupture of the membranes at about the end of the sixth month ; a large quantity of amniotic fluid escaped, and pains came on with some dilata- tion of the OS. With rest in bed and a free use of viburnum the patient re- covered and went on to end of seventh month, when there were pains again ; the same treatment was followed by the same result, and the writer delivered her at full time of a healthy boy. In the second case the membranes rup- tured during the eighth month, but was not delivered until the end of the full term of a living, healthy boy. In the third case the membranes had ruptured three weeks before the present writing and had not delivered yet. J. R. N. Smith (Communication to the Editor, 1908). [This communication is interesting, but the writer furnishes no evidence to show that the discharge of the fluid in any of the 3 cases was due to rupture of the mem- branes. It seems probable that the discharge of watery fluid in each instance was due to that mysterious condition the nature of which we know but little about — hydrorrhoea gravidarum, or decidual endometritis. A. H. Wright.] The symptomatology of abortion varies, of course, to a certain extent according to the time at w^hich it occurs. As carefully collated by Lu- taud, of Paris, the symptoms at the different periods are briefly as fol- lows : — Abortion During the First Month. — This usually gives rise to symptoms simulating those of retarded menstru- ation. Slight pains in the back in the region of the uterus are complained of; the symptoms, in this particular, resemble those of normal labor, but are very much less marked. Blood, blood-clots, and flakes of the mucous membrane of the uterus are gradually expelled during several days. The ovum is expelled entire, but it is so small that it is rarely discovered. Abortion During the Second Month. — Inasmuch as the uterus has de- cidedly increased in size as compared with its size in the first month, the contractions and pains are compara- tively stronger. The embro is usu- ally expelled inclosed in the unbroken ABORTION (WRIGHT). 157 membranes. Sometimes, however, the latter are ruptured. The embryo and membranes may be detached from the uterus in two ways : — (a) P)}' hemorrhage between the membranes and the uterus^ followed by uterine contraction. {b) By contraction of the uterus, followed by hemorrhage. In the lat- ter case the abortion is more pro- longed, the membranes being de- tached but slowly from the uterus. If the embryo be still living, the abortion lasts longer, and the hemor- rhage is greater. If the embryo be dead, the whole is usually expelled like a foreign body, and without rup- ture of the membranes. Examination of the uterus will show that it is increased in volume and situated lower down in the pelvis than normally. The cervix is dilated, softened, and filled with blood-clots. The dilatation is more marked in multiparse than in primiparse. The cervix, though dilated, does not become effaced, and the embryo contained in the unruptured mem- branes may pass through the cervix and be expelled. If the membranes are ruptured, however, the embryo passes by itself, the very thin umbili- cal cord breaks, and the cervix closes. The membranes are, in this latter case, expelled later on. The mem- branes are ruptured about once in every 2 cases. Abortion from the Beginning of the Third to the End of the Fourth Month. — This occurs nearly always in two stages, the first consisting in the expulsion of the fetus, and the second in the expulsion of the membranes and placenta. The cervix in this form of abortion tends to diminish in length. The uterine contractions act more power- fully than in the previous forms of abortion. Under their influence the membranes are ruptured and the fetus is expelled. The placenta may still be adherent ; the cervix then closes again, and the placenta and membranes are ex- pelled later on. Hemorrhage is likely to accompany the delivery of the placenta and membranes, especially when the former is only partly de- tached. Under these circumstances each uterine contraction is accompa- nied by hemorrhage. The placenta may be already de- tached when the fetus is expelled; in such a case it is likely to be expelled immediately after the latter, before the cervix closes, but part of the decidua may remain in the uterus after delivery of the placenta. This occurs most . frequently when the fetus is dead. Statistics show that retention of the placenta occurs most frequently dur- ing this period. Abortion During the Fifth and Sixth Months. — The fetus and pla- centa are almost always expelled sep- arately. Uterine contraction is more marked; the cervix tends to become more effaced and to dilate. Delivery of the placenta usually fol- lows delivery of the fetus rapidly, and the tendency to hemorrhage is less marked than in the previous forms of abortion. Of 501 cases of abortion analyzed by Varnier and Brion, the fetus, or embryo, and the placenta were ex- pelled separately in 453, and together in 48 cases. When the delivery oc- curred in two stages, the time found to elapse between the expulsion of the 158 ABORTION (WRIGHT). fetus and that of the placenta was as follows: 120 cases, within 15 min- utes; 81 cases, from 15 to 30 minutes; 78 cases, from 30 to 60 minutes; 83 cases, from 1 to 4 hours. AVhenever the placenta and mem- branes are not expelled within four hours after the expulsion of the fetus, or embryo, there is retention of the membranes and placenta. Abortion may take place suddenly, or resemble, in that particular, the irregular periodicity of normal labor, with more or less hemorrhage. It may, indeed, last several days, owing to weakness of the uterine contrac- tions or adhesions to the uterus or retention in the cervix of the masses to be expelled. (Rokitansky, Schii- lein.) Sudden or rapid abortion is frequent during the first two months; when the expulsion takes place after the third month it generally presents the characters of normal delivery. The menstruation returns earlier after abortion than after a normal labor. Englander, in a recent (1906) study of 57 cases of abortion, under- taken to ascertain the period of their first subsequent menstruation, found that in 64.9 per cent, the menses re- appeared in four weeks ; in five weeks in 14 per cent. The remainder varied, 1 patient going as long as six weeks after the abortion before menstru- ating. After labor, it is usually six to eight weeks before patients men- struate. DANGERS.— Just as parturition may be attended by deviations from the normal, so may abortion. Retention of the placenta occurs fre- quently. The latter is sometimes ex- pelled safely after some days, either entire or in pieces, but prolonged re- tention exposes the patient to hemof- rhage, toxemia, and septicemia. When completely detached, though retained, the placenta gives rise to no hemor- rhage, but if only partially detached such is not the case and copious hem- orrhage may thus be produced. In 15,000 cases of abortion, fever oc- curred in IS per cent. Of 633 patients, 182 had chills before they came under active treatment. Among the 15,000 patients were 450 who were severely infected; of these 94 died. In 82 cases autopsy was made. Those cases showed the most severe symptoms in which the longest time elapsed before the uterus was completely emptied. Fever often ceased when the uterine contents were expelled. These were cases of pure sapremia in which the bacilli present were only mildly infective. It is of the utmost importance that no artificial wound be made in the lining membrane of the uterus. In these cases neither incision nor forcible dilatation should be practised, but if necessary the cervix should be tamponed with gauze until the uterus is sufficiently open to permit the removal of its contents with the finger. No sharp instrument should be ■employed in the treatment of abortion. Seegert (Zeit. f. Geb. u. Gyn., Bd. Ivii, H. 3, 1906). The general symptoms that follow hemorrhage (a weak pulse, vertigo, fainting, etc.) occur only when the loss of blood has been severe. Under these conditions septicemia, as evidenced by fetid lochia, chills, and high tempera- ture, is a probable complication. En- dometritis, salpingitis, and peritonitis have also been witnessed under such conditions. Tetanus is also another possible complication of these cases. Case of tetanus after abortion. The latter occurred during the third month. The uterus was properly cleared, but on the ninth day the temperature rose, then fell after an injection of collargo- lin. Trismus was observed on the next day, followed by tetanus, which grew ABORTION (WRIGHT). 159 worse till the fifteenth day. Nunicrous injections of Behring's tetanus anti- toxin were administered, and recovery followed. Osterloh (Monats. f. Geb. u. Gyn., Aug., 1902). ETIOLOGY AND PATHOGEN- ESIS. — There has been much theoriz- ing as to the causes of abortion, and in man}^ instances, the explanations and complicated classifications vouch- safed have obscured the subject in- stead of elucidating it. The causes of abortion are usually considered in an unsystematic and illogical way. We should differentiate between conditions of the uterus which predispose to expulsion of the ovum and conditions which excite the uterus to get rid of its contents. The predis- posing causes are : 1. Increased sensi- tiveness to nerve irritation (tempera- ment, frequent abortions, menstrual period). 2. Greater tendency to pla- cental thrombosis (inflammation of endometrium, congestion). 3. Lessened resistance to expulsion (cervical tears or amputation). The exciting causes are : 1. Mechan- ical Irritation: (a) transmitted (blow, fall, dancing, railroad journey, lifting heavy objects, constipation) ; (b) direct, (1) to outside of uterus (adhesions, malposition, tumors, examination, lapa- rotomy) ; (2) to inside of uterus (in- struments, hemorrhagic exudates, hy- dramnios, tumors). 2. Thermic Irritation: (a) general (sea-bath) ; (b) local (hot douche, sitz-bath). 3. Toxic Irritation-: (a) chemical toxins (ergot, carbon dioxide, lead poisoning) ; (b) bacterial toxins (ma- ternal small-pox, measles, etc.) ; (c) placental toxins, hyperemesis, chorea, eclampsia. 4. Nerve Irritation: (a) psychic (fright, pain, shock) ; (b) reflex (ex- ternal genitals, breast, nose). 5. Death of Fetus: (a) congenital inanition (illness bf parents, alcoholism, too frequent coitus) ; (b) congenital deformities (primary in ovum, amniotic adhesions) ; (c) interference with nu- trition : (1) maternal (anemia, tuber- culosis) ; (2) placental (mole degen- eration, thrombosis) ; (3) umbilical (twisted cord, true knot, constrictions) ; ((/) infectious diseases (syphilis, small- pox, typhoid, pneumonia, etc.) ; (e) hyperpyrexia. Taussig (Amer. Jour, of Obstet., Oct., 1908). Series of cases from Aschoff's insti- tute in Freiburg in which specimens of Fallopian tubes removed after cases of abortion were examined It was found that after a normal pregnancy in labor there was no inflammatory re- action in the Fallopian tubes, but that after dilatation of the cervix with laminary tents, although careful asepsis had been employed in a large majority of cases, there was an inflammation of the tube which had gone on to purulent salpingitis and lymphangitis. This path- ological observation is increased evi- dence of the difficulty of conducting vaginal operations aseptically. Amers- bach (Monatssch. fiir Geburts. u. Gynak., Bd. xxxii, Hft. 4, 1910). It is generally recognized, however, that the causes may be of maternal, paternal, and fetal origin. Maternal Causes. — Most cases of abortion are generally attributed to traumatisms, falls, blows — a cause not infrequently met with in the slums — the likelihood of premature delivery being decreased in proportion as the blow or other injury is remote from the region of the uterus. Operations, even sometimes when insignificant, have produced abortion. The so- called "aborting habit" is also recog- nized as a potent factor in this con- nection; but this expression doubtless covers, in most instances, some hidden and probably removable cause. In most cases the actual cause of a miscarriage escapes observation. Com- monly it is attributed to a vague trau- matism; often to a fall on the stairs. In reality the pathogeny of abortion is as follows : The ovum plays the part of a foreign body and is expelled, first, 160 ABORTION (WRIGHT). when it is itself changed by death, separation, or other cause, though con- tained in a normal uterus ; second, when, whether healthy or not, it is con- tained in an intolerant uterus. The causes which may produce these con- ditions are changes in the ovum, patho- logical conditions in the uterus, faults in the general health of the woman, and vitiation of the spermatozoa. Trau- matism varies greatly in its power to interrupt pregnancy according to its intensity, the seat of its application, its severity and repetition, the age of the fetus, and the degree of the idiosyn- cratic irritability of the uterus. Bon- naire (Presse medical. May 3, 1905). The predominating- cause, however, according to statistics^ is syphilis, to which are attributed over one-fourth of the "cases. When it is contracted before conception, abortion occurs re- peatedly — early when the infection is of recent date, but gradually nearer term as the contamination is more remote. There comes a time, there- fore, when normal delivery becomes possible. Next in order are malpositions and inflammatory disorders and tumors of the uterus and its adnexa, including ovarian cysts. Laceration of the cer- vix has recently attracted attention as a cause of abortion. The tear may be limited to the cervix, or it may extend upward to the body of the organ; or again the rupture may occur above the external os. Charpentier refers to three distinct local uterine conditions in otherwise healthy women: 1. Ill-developed uter- us ; the muscular coat does not readily soften, yet remains very irritable. Rare. 2. Displacements, especially flexions. Spur at the angle of flexion hypertrophies interferes with uterine development. 3. Congestion of the body and cervix, due to idiosyncrasies. Endometritis. Lacerations of the cervix, especially those of some depth, are a frequent cause of abortion. A primipara can usually give some cause for an abor- tion, such as a misstep or a fall, but in those who have previously borne children, where there is a fissure ex- tending as high as the internal os that will admit the tip of the index finger, or the integrity of the lower uterine segments is lost, predisposition to abor- tion is undoubted. R. W. Rogers (Montreal Med. Jour., April, 1902). One of the rarer causes of abortion is laceration of the cervix; but if the laceration is repaired a subsequent pregnancy will often proceed to term, as the writer has seen happen twice in 11 cases. Among other causes of habitual abortion not generally known are residues of past inflammation of the pelvic peritoneum, three or four instances of which he has met with. Sterility is usually associated with exu- dations in the parametrium, and even should conception occur the pregnancy seldom persists to term. The writer has also seen abortion due to fibroma of the uterus, four times ; to heart disease, three times ; to diabetes mel- litus, twice ; to hydramnios in two in- stances, and to pulmonary emphysema in one. Kleinwaechter (Zeit. f. Geb. u. Gyn., Bd. xlix, H. i, 1903). Case of a primigravida, in whom it was necessary to terminate an early pregnancy. Iodoform gauze was intro- duced into the cervix, followed by the development of considerable pain. The temperature rose also ; the pulse in- creased in frequency; the uterus be- came very sensitive, and there was a fetid mucous discharge. To hasten the emptying of the uterus, tents and bou- gies were used. This was followed by increase in pain. Twenty-four hours afterward examination showed that the cervix had not dilated, but had rup- tured above the external os. It was necessary to empty the uterus com- pletely under anesthesia and to remove portions of the cervix which had al- ready been torn. The patient recov- ered, the tears healing by granulation. Blumreich (Zentralbl. f. Gyn., Nu. 29, 1907). ABORTION (WRIGHT). 161 Debilitating influences of various kinds, such as insufficient food, ex- cessive pliysical labor or fatigue, men- tal and physical shock, the abuse of alcohol, tobacco (women employed in cigar, cigarette, etc., factories), car- bonic oxide (as shown by the frequent occurrence of abortion in cooks) and lead, including paternal intoxication by this metal, tend also to bring on miscarriage. In south Yorkshire 10 out of IS women who suffered from lead poison- ing admitted that they had used lead as an abortifacient. In 11 of the case? abortion had actually occurred. The fact is important, and shows that lead poisoning must be kept in mind when such symptoms as abdominal pain, vomiting, and constipation are present in women who are supposed to be pregnant. Thomson and Littlejohn (Edinburgh Med. Jour., June, 1905). Great shock or injury is sometimes better borne by pregnant women than frequently repeated shock, e.g., the use of the sewing machine with the foot. The author reports cases illustrating the fact that motoring during the early months of pregnancy is frequently fol- lowed by abortion. The danger seems to lie in the fact that the rapid motion of a motor car subjects the patient to many small, frequent jars. The char- acteristic of abortion following motor- ing is its slow and insidious develop- ment without bright hemorrhage or pain. These abortions are, as a rule, incomplete, and require curetting. While motoring is dangerous in early preg- nancy, in the later months of gesta- tion and with reasonable precautions as to smoothness of roads and mod- eration of speed it may prove ex- ceedingly useful. Davis (Medical Record, Jan. 30, 1909). Debilitating diseases have also been found to induce it. Influenza, in which the general adynamia is marked, has been recorded as a cause. In Asiatic cholera, abortion is -almost invariably produced. Conversely, conditions which tend to exaggerate the contractility of the uterine muscle are also recognized causes. Ergot, copper sulphate and other "abortifacients" are familiar agents of this class. This evil action has also been attributed to quinine, but there is reason to believe that this valuable remedy should not be with- held in pregnant women, when in- dicated therapeutically, especially in view of the fact that malaria itself tends to cause abortion. Thus, in a study of the action of quinine on pregnant women, Frederici found that in 49 pregnancies quinine had been used in 47, the patients suffering more or less severely from malarial fever ; 47 terminated at the usual period by the birth of a child, and 2 aborted. In these 2 cases he deems it extremely probable that the high fever from which they suffered was instrumental in producing abortion. He concluded that medicinal doses of quinine were powerless to induce abortion. Case of a hospital nurse, pregnant two months, who attempted to induce abortion by injecting into the uterus 1 gram of Fehling's solution. She reported her act within half an hour. The symptoms she then presented were extreme anxiety, coolness of the skin, and decided slowness of the pulse. There was no bleeding. The following day the pulse had become improved, there was considerable vomiting, and the urine was extremely dark. The urine gradually became bloody, and at the end of five days showed many casts. All the toxic symptoms gradually dis- appeared, but no abortion took place. Tantzscher (Zentralbl. f. innere Med., Jan. 5, 1907). Infectious diseases provoke abor- tion in a large proportion of cases when the febrile period is reached. It occurs in about two-thirds of preg- 1—11 162 ABORTION (WRIGHT). nant women attacked by typhoid fever, especially during the earlier months. Uterine hemorrhage is usu- ally the first symptom observed. Thus Sacquin colFected 310 cases, and found abortion in 199; while Martinet found 66 abortions in 109 cases. Small-pox causes abortion in about 40 per cent, of the pregnant women it attacks and the mortality is about 50 per cent., but is nearly 100 per cent. in the confluent type. In varioloid the child sometimes remains unaf- fected. The disease may also develop during convalescence. Abortion dur- ing variola is apt to be attended with more than the ordinary hemorrhage. Arnaud has reported several serious cases occurring during convalescence after small-pox. The grave symp- toms are attributed to the retention of the fetus, which died during the acute stage of small-pox, and was fre- quently only expelled during or after convalescence. Measles is an infrequent complica- tion of pregnancy, but, as observed by KlotZj it causes abortion in the majority of such instances. Pneu- monia frequently appears as an addi- tional complication. Scarlatina is also infrequently observed in preg- nant women, though it is commonly observed during the parturient state. Pneumonia causes abortion in about one-third of the pregnant women it attacks early and in two-thirds of those which contract the disease late. In the latter cases the fetus, though viable when born, may soon die of the infection after birth. The sta- tistics of 213 cases of pneumonia during pregnancy published by Flatte showed that the pregnancy was inter- rupted in 118 cases, there being 42 abortions and 76 premature deliveries. Death of the mother occurred in 75 cases among the 213: a mortality of 35 per cent. The mortality of the mother was greater in premature de- liveries than in abortion. Pulmonary tuberculosis, owing to its exhausting influence upon the nu- tritional resources of the body, renders it unfit to carry the fetus to term when the morbid process is far advanced. Abortion is relatively frequent in such cases, its occurrence and the viability of the child depending upon the stage of the disease. Chorea, though a rare complication of pregnancy, causes abortion in one- half of the cases, and is especially observed in primiparse. If the de- livery occurs sufficiently late, the child may live, but is frequently, affected with chorea. The chorea sometimes ceases after delivery. Cardiac diseases influence preg- nancy when it is sufficiently marked to impair the general circulation. Acute pericarditis practically has no morbid influence on gestation, but chronic pericarditis is deemed per- nicious. Acute endocarditis assumes increased virulence during pregnancy, its tendency being to become ulcera- tive, and to entail a fatal ending. Icterus, in its various forms, some- times complicates pregnancy. Even simple catarrhal icterus may cause abortion, but in icterus gravis it occurs always and usually proves fatal. In the epidemic icterus of preg- nancy, the probability that abortion will occur is somewhat smaller, while the mortality is not as great. Preg- nancy not only aggravates even sim- ple icterus, but it increases the tend- ency to yellow atrophy of the liver. Paternal and Fetal Causes. — The influence of syphilis on abortion has ABORTION (WRIGHT). 163 been reviewed; in most instances it is acquired from the male directly, either before or after conception, the disease being communicated to the fetus, in the latter case, through the placenta. In accord with Colles's law, the fetus may, as is well known, inherit the paternal syphilis, while the mother re- mains immune. Abortion may thus be caused through maternal or fetal S3-philis acquired from the father. Any condition such as senility, al- coholism, overwork, etc., which tends to lower the vitality of the father tends also to weaken the offspring and pro- mote the tendency to miscarriage in the mother. Certain occupations which expose the patient to the action of certain poisons, mercury, phosphorus, or lead, for instance, tend in the same direction. Besides the features which tend to compromise the development of the fetus that have been referred to, it is itself subject to injuries communi- cated from the exterior, blows, shocks, penetrating wounds (knife, bullets, etc.), etc. The application of X-rays has recently been added to the list of known causes. Experiments on guinea-pigs which fully confirm those of Tellner, showing that even short exposures of the abdo- men to the action of the rays is Hable to destroy the life of a fetus even shortly before term. Alterations were found in the ovaries suggesting ster- ility. The cause of the fetal death could not be determined macroscopi- cally. Lengfellner (Miinch. med. Woch., Nu. 44, 1906). Case of a tuberculous patient in whom it was determined to interrupt pregnancy with the hope of checking the tuberculous process. Twenty-five applications of the Rontgen rays were made, each lasting from five to ten minutes. After each five days a pause of one day was allowed to intervene JK'forc new applications were made. The regions over the ovaries and the thyroid gland were chosen for the ap- plications. Especial care was used to avoid injury to the skin. Spontaneous abortion occurred with free hemor- rhage, which ceased when the uterine contents were expelled. No vaginal examination was made during the case, so that the effect is attributable entirely to the Rontgen rays. Fraenkel (Zen- tralbl. f. Gyn., Nu. 31, 1907). Low or vicious attachment of the placenta, degeneration of the chronic villosities, hydramnios are the remain- ing main abnormalities which affect directly the fetus and cause its pre- mature elimination by the uterus. PROGNOSIS.— Considerable loss of blood may occur in a case of threatened abortion, and yet the pa- tient, when properly treated, proceeds to full term. Cases of spontaneous abortion unattended by complications practically always recover. The de- gree of antisepsis has much to do with the result however; while, for example, in Pinard's service where rigorous asepsis was observed the mortality was only 0.81 per cent. ; cor- responding cases (which included fa- vorable and unfavorable) outside his services reached 27.5 per cent. Six hundred and ten cases treated at the Boston City Hospital (1892-1902) ; 29 deaths, or 4.75 per cent. They in- cluded a large proportion of induced and neglected cases. The deaths in- clude cases with pre-existing typhoid and pneumonia. With two exceptions those of the 29 deaths obviously due to the miscarriage were caused by septic pneumonia following a miscar- riage between four and six months. The other 2 were due to sepsis after abortion at the third month. There were 418 cases treated as out- patients of the Boston Lying-in Kr- - pital (1892-1902). There were S acdtb?, or 1.2 per cent. ; 1 case caui<3 not be 164 ABORTION (WRIGHT). traced. The S deaths were due to (Ij typhoid; (2) pyonephrosis; (3) pulmo- nary emboHsm; (4 and 5) sepsis. Of the 1028 cases but 7 were twin preg- nancies. Friedman (Boston Med. and Surg. Jour., Nov. 20, 1902). TREATMENT. — Treatment of Threatened Abortion. — When the symptoms of threatened abortion ap- pear we should endeavor to stop the morbid process^ especially when the hemorrhage is not copious, the pains .are not severe, and there is no evi- dence of the escape of liquor amnii. Our chief aim should be to keep the ■patient absolutely quiet, by ordering her to bed, and relieve the pains due to uterine contractions by means of 'Opiates in suitable doses. Opium :seems to be better than morphine, even when the latter is given h3^poder- mically. The tincture of opium, 30 minims (2 Gm.) should be given by the mouth, followed by 15 minims (1 Gm.) every hour, repeated three or four times if required. Or, better still, 2 grs. (0.13 Gm.) of the aqueous extract of opium can be given as a rectal suppositor}^, and 1 gr. (0.065 Gm.) every hour afterward, three or four times if needed. If morphine be preferred, ^ gr. (0.032 Gm.) may be given hypodermically, and /4 gr.' ((0.016 Gm.) every hour, therefore, 'for three or four doses if required. An excellent plan when one wishes iSpeedy effect from the opiate is to rgive at once Y^ gr. (0.032 Gm.) mor- phine hypodermically, and 15 minims (0.92 Gm.) of tincture of opium by the mouth every hour afterward, or 1 gr. (0.065 Gm.) of extract of opium in a suppository every hour afterward for three or four doses if required. [Some physicians will consider that such dosage is large. Many physicians and ob- stetricians grew timid about the use of opium because of the violent antiopium riots that broke out in many surgical camps about twenty years ago, after Lawson Tait told the abdominal surgeons of the world that opium was an abomination which must be discarded in their work forevermore. The pendulum has turned, however, and is going the other way. A. H. Wright.] We ought, of course, to consider that opium should be given with great care. At the same time, the writer thinks it absurd to give, for instance, 10 minims (0.61 Gm.) of tincture of opium by the mouth, three times a day, for the pains of threatened abortion. As a rule such doses will have no good effect, because they will not relieve the pains, and they may have a bad effect by causing constipa- tion. Opium does cause constipation, and thus interferes with elimination, but the writer does not admit that it causes complete paresis of the intes- tines. Sepsis alone causes that kind of paresis. The constipation caused by opium can be easily overcome by the admin- istration of ordinary laxatives. If, however, the physician who has given opium in the case of threatened abor- tion is afraid to use mild cathartics for constipation, he might order an ordinary enema. Some years ago the administration of viburnum prunifolium was sup- posed to have a good effect in cases of threatened abortion. The result of recent experience does not indicate that such supposition is correct. The writer considers it practically w^orth- less. The fluidextract, % to 1 dram every three hours, or 10 drops every hour, with chloral hydrate 8 grains, have, however, been found effective in arresting uterine contractions when opium could not be used or when its constipating effects might prove ABORTION (WRIGHT). 165 detrimental. Or, chloral hydrate, 10 grains, and potassium bromide, 20 grains every two or three hours, may he preferahle, since the hypnotic tends to insure the ahsolute rest and quiet that should he ohserved to ohtain a sat- isfactory result. Codeine is preferred to other opiates hy some obstetricians. Treatment of Inevitable Abortion. — There never lias been, and probably never will be, a consensus of opinion among obstetricians as to the treat- ment of abortion. It seems conven- ient to consider that there are three general plans : expectant treatment, treatment by tamponade, forced dila- tation of the cervix and curettement. Expectant Plan. — The term expect- ant is not a good one as a rule, and it becomes most unsuitable if it is mis- understood. [A prominent gynecologist once wrote : 'Tn my early experience, cases of abortion were treated by the so-called expectant plan, a wretched makeshift, and one that should never be entertained. This plan consists of daily visits by the doctor, who trusts en- tirely to Dame Nature without giving her any assistance. When fever sets in it is looked upon as a calamity that could not be avoided. The mother dies from what is called a bad hemorrhage, and a life is lost that should have been saved." It is possible that grossly incompetent practitioners allow their patients thus to die without giving any assistance, but we have never seen anything of the sort. We wish to state positively that the above description of expectant treatment is incorrect. No good obstetrician has ever advocated anything so absurd as this sort of do nothing treatment. A. H. Weight.] Lusk was perhaps the most prom- inent advocate of the expectant plan of treatment. He urged that, when in the third month the ovum is thrown off without the rupture of the mem- branes, the hemorrhage rarely as- sumes dangerous proportions, and explained how the uterine contrac- tions sometimes pressed the ovum into the cervix. During these uterine contractions the ovum descends and tlic upper portion of the body of the uterus retracts. Some coagulation of the blood takes place between the ovum and the retracted uterine walls, while the ovum forms a tampon which fills the cervix like a ball valve, and thus restrains the hemorrhage. When there is no interference, the ovum, after being retained for a time Ovum, five weeks. as described, is frequently expelled entire, leaving the uterus in the best possible condition for satisfactory in- volution. In such cases, and they are by no means uncommon, nature has done well. Why should we try to improve or interfere with such mag- nificent work? Removal of the Uterine Contents. — It should be definitely understood that, while nature is doing good work, we should watch carefully, and be ready to assist when her efforts have ceased to be efficacious. When the os and cervical canal are sufficiently dilated to allow the introduction of the finger into the uterine cavity, and the uterine 166 ABORTION (WRIGHT). contents are not extruded, we should interfere, and endeavor to empty the uterus. We should presume, unless there is positive proof to the contrary, that the ovum is intact, and should not be broken. The author epitomizes the consensus of opinion in regard to the indications for therapeutic abortion. Should thera- peutic abortion be used to save a func- tion or a sense? Germann has made a thorough study of the eye troubles in- cident to pregnancy, and concludes that eye complications dangerous to sight, such as ulcerative keratitis, justify the termination of pregnancy with the ob- ject of saving as much sight as possible to the mother. The several forms of autointoxication frequently produce eye diseases which justify abortion. Shall therapeutic abortion be resorted to to save the life of the mother when the termination of that life seems other- wise inevitable? Today, when the ma- ternal mortality from Cesarean sec- tion in elective and uninfected cases is practically nil, the physician has no right to sacrifice the fetus, since he has this method of delivery at command. In hyperemesis, or incoercible vomit- ing of pregnancy, which occurs once in about 1000 pregnancies, the mortality is about 50 per cent, under treatment by drugs alone. The question as to when abortion should be induced to save the patient's life has been satisfactorily an- swered by Norris, who, after painting a graphic picture of the earlier stage of this condition, and describing the final stage when the "typhoid" state appears, with rapid, feeble pulse, weak- ened heart-sounds, fever, restlessness, diminished urine with albumin and casts, and finally delirium, stupor, coma and death, observes that "induction of abortion, to avail, must not be delayed until this typhoid condition appears ; it must be resorted to in the earlier stage." In tuberculosis, artificial termination of pregnancy promises good results only when practised in the early months. Rosthorn favors induction of abortion in tuberculous processes, whether new or old, while Kuttner says that with- out interruption of pregnancy the prognosis in tuberculosis of the larynx is exceedingly unfavorable for both mother and child. Many authorities might be cited to show that the inter- ruption of pregnancy had been followed by marked improvement in the patient. Chronic nephritis is often an indica- tion for therapeutic abortion, and among others which have been deemed justifiable indications may be mentioned mitral or aortic lesions, pyelitis and pyelonephritis, advanced diabetes, hy- dramnios when associated with crip- pled respiration or severe diaphrag- matic pain, leukemia, pernicious ane- mia, violent chorea, loss of sleep, and continued emaciation. Melancholia may demand operation if the condition is manifestly growing worse, and Jewett believes that, in hysterical epi- lepsy, pregnancy should be interrupted. Wilmer Krusen (Therap. Gaz., Mar. 15, 1910). The following course is recom- mended: Place the patient across the bed, in the lithotomy position, and with the external hand endeavor to depress the uterus through the ab- dominal wall until the index finger of the other hand (carefully asepticized) can be passed through the os and up to the fundus. An anesthetic is only occasionally required. Pass the fin- ger up on the lateral wall of the uterus until it is above the ovum, at or near the opening of one of the Fallopian tubes; then pass it across the fundus to the neighborhood of the other Fallopian tube, and sweep down this wall, driving the contents of the uterus before it. In these manipu- lations try to avoid rupturing the ovum. If unable to remove the ute- rine contents in the way described, one should try the following Rotunda procedure : Take the finger out of the uterus and place it under the fundus, that is to say, in the anterior fornix if ABORTION (WRIGHT). 167 the uterus is normal in position, and in tlie posterior fornix if the uterus is retroverted. Sink the other hand into the abdomen and compress the body between the two hands. The ovum is then driven out of the uterus into the vagina and removed (Jellett). It is well to remember that there is a period between early and late abor- tion — say, in the latter part of the third month — when it is difficult, with the finger-tip, to make out the placenta, because it feels exactly like the endometrium. It js possible under such circumstances to make the mistake of imagining that the uterus is empty while the thin, broad placenta is completely ad- herent. In such a case it is better to try to remove this placenta by scraping with the finger-tip, as the use of the metallic curette under such circumstances is dangerous. Analysis of 750 cases of abortion of the out-patient department of the Chi- cago Lying-in Hospital, and treated at their homes. The routine treatment adopted in the 276 cases of threatened hemorrhage was absolute rest in bed, with morphine and codeine every four hours, with saline purgatives where needed. When malposition of the uterus was present, this defect was cor- rected. The pregnancy was saved in 72.8 per cent, of the cases. The in- evitable abortions were treated by pack- ing and curetting with the finger when possible, using the curette only when absolutely necessary, excepting in chronic cases. All the mothers re- covered. Summary of conclusions : Absolute rest was imperative; blood loss should always be prevented : cotton pledgets are preferable for tampons to gauze, being firmer; whenever possible empty- ing of the uterus should be done with the finger; laminary tents are difficult to sterilize ; in acute abortion steel curettes are especially liable to produce abortion ; curetting should always be carried out with surgical precautions ; curetting is not indicated when the uterus is empty ; ergot is indicated after the uterus has been emptied ; when the uterus cavity is septic, the uterus should be emptied and disin- fected; when infection has spread to the peritoneum and uterine adnexa it is best to leave the uterus alone. Stowe (Surg., Gynec. and Obstet., Jan., 1910). The Tampon. — The vaginal tampon (or plug, as it is still termed by many in Great Britain) has been used for various obstetrical purposes for cen- turies. [It is interesting to go back to the time of Smellie and to learn his clear views as to its use. We extract the following from one of his reports, slightly changed in phraseology for the sake of brevity: "In the year 1750 I was called to see a woman three months gone with child. She had been seized with flooding and had been treated for some hours. When I arrived she was exhausted, faint, and had slight pains. As the danger seemed pressing, I took the hint from Hoffmann, and stuffed the vagina tight with fine tow dipped in oxycrate (vinegar and water), which immediately stopped the discharge. I then prescribed an anodyne draught. She dozed a little, and between her dozing every now and then had slight pains, though the flooding did not return. Toward morning the pains grew so strong that the tow was forced away, together with the abortion, about the size of a goose-egg, and some coagulated blood. In such cases the strong pressure of the plug in the vagina seems to dam up the internal flooding, which, by distending the uterus, brings on labor pains." (At this time Smellie had been about thirty years in practice.) About one hundred and twenty- eight years after this, i.e., in 1878, McClin- tock, of Dublin, in commenting on these opinions expressed by Smellie, said that he readily attributed the hemostatic effects of the plug to its "strong pressure in the vagina, damming up the internal flooding, which, by distending the uterus, brings on labor pains." McCIintock goes on to say: "The occurrence of the pains which so commonly follow the use of the 168 ABORTION (WRIGHT). plug may, perhaps, be partly due to the cause assigned by him, but this increased ex- pulsive action is merely attributable to the influence exerted by the plug on the vaginal surface, the nerves of which part, when irritated, powerfully exciting or bearing down the contractions of the uterus." The opinions thus expressed were in ac- cordance with the practice carried out in the Rotunda for many years before that time, and which have not been materially changed up to the present time. These old-fashioned procedures came into disrepute in certain quarters about thirty Vagina ballema (gauze packing). j^ears ago. The strenuous gynecologist with his metallic dilators and scrapers came to the fore, and introduced his modern methods, which will be referred to again. We believe that treatment by tamponade is the safest and best kind in all varieties of inevitable abortion, whether complete or incomplete. A. H. Wright.] There are two kinds of tamponade : the vaginal and uterovaginal. Vaginal Tamponade. — In order to be efficient the vaginal tamponade should be properly done. Although it is one of the simplest of obstetrical opera- tions it appears that in the majority of cases it is imperfectly carried out. In the first place the vagina cannot be property plugged while the patient is lying on her back, or on her side. The patient must be put in the Sims (semipronej position. The perineum and pelvic floor must be thoroughly retracted by a Sims speculum, and the vagina properly ballooned, so that its vault, thus distended, may be com- pletely filled by the material used for the packing. It is only necessary to pack tightly the upper two-thirds or three-fourths of the vagina. The mistake commonly made of packing tightly the entrance of the vagina generally causes great pain, and fre- quently retention of urine, by pres- sure on the urethra. The tampon checks the hemorrhage, dilates the cervix, assists further sep- aration of the ovum by damming back the blood, and induces uterine con- tractions. The writer, like Smellie, prefers an antiseptic plug, and uses material impregnated with 5 per cent. iodoform. A simple sterile plug is introduced by some, but an antiseptic plug is better. The former becomes foul in about twelve hours, while the latter (when iodoform is used) re- mains sweet for two or three days. The ordinary iodoform gauze is not suitable however, because it is too coarse in texture, that is, too much like a sieve. The blood easily runs through it. Therefore, the writer prefers to use a rather fine cheesecloth impreg- nated with the iodoform. [It is prepared for me by Miss Margaret Lash, as follows : Take 4 yards of cheese- cloth (good qiiality) 27 inches wide ; tear (not cut) into strips 4j4 inches wide and full length ; sterilize these strips, and then boil in sterile water; ring them as dry as possible (having hands covered by sterile gloves) and thoroughly saturate them in the following preparation : 8 ounces of a 1 per cent, solution of carbolic acid in sterilized water, and enough Castile soap to make suds; 3 drams and 1 scruple of iodoform ABORTION (WRIGHT), 169 powder ; mix thoroughly in sterile basin with sterilized pestle or glass rod. After thoroughly saturating the strips, wring as dry as possible, and pack the gauze strips one after another into sterilized glass jars, and seal down while moist. One strip 4^^ inches wide by 4 yards long is ample for most vaginal tampons. This happens to be one- half of a square yard, that is, 3 feet by one foot and a half. A. H. Wright.] The method of procedure for early abortion is as follows : Place the pa- tient in the Sims position, introduce a Sims speculum, and let the assistant retract the perineum and pelvic floor (or use two fingers of one hand for such retraction, as recommended by Schauta) ; introduce the continuous strip of iodoformed cheesecloth, and firmly pack the vault of the vagina. In doing- this one should use not the point of a sound or forceps with fine points, but something with a fairly large surface. My custom is to use the handle of a uterine sound when packing tightly. Continue the pack- ing until the upper three-quarters of the vagina is filled, and then allow the end of the strip to hang out at the vulva. If in a few hours strong pains occur, indicating that regular uterine contractions are taking place, take hold of the end of the strip and pull out the material forming the plug. It may be that by this time the ovum has been separated and expelled from the uterus. If such pains do not occur remove the tampon in twenty- four hours. There will then probably be some slight dilatation of the os, but not enough perhaps to allow the introduction of the finger. Introduce a second tampon as before. The tam- ponade may be kept up with safety for many days (a week or more) if the plug is renewed every twenty-four hours. It is unnecessary for the first two or three days to introduce any of the iodoformed strip inside the uterus, because the aim is to cause uterine contractions that will expel the entire ovum. If it is found, after the removal of the second or third tampon, that the OS and cervical canal are sufificiently dilated to allow the introduction of the finger, we may explore the interior of the uterus, as recommended in con- nection with the expectant plan, and endeavor to remove the complete ovum. If, however, a portion of the ovum has come away, the uterovagi- nal tamponade becomes the proper procedure. It may be well now to repeat that the object of the vaginal tamponade is to cause the expulsion of the en- tire ovum during early abortion, that is, before the complete placenta is formed. The object of the utero- vaginal tamponade is to empty the uterus in case of incomplete abortion (whether early or late), and also in case of late abortion, that is, after the complete placenta has been formed. Uterovaginal Tamponade. — This pro- cedure is divided into two stages : 1, the packing of the uterus ; 2, the pack- ing of the vagina. In packing the uterus it is generally more convenient to place the patient on her back in the lithotomy position, on a couch, on a table, or across the bed. Introduce a weight speculum, seize the anterior lip of the uterus with a volsellum forceps, and use slight traction. Ordinary iodo- form gauze one-half to one inch wide is now pushed as far up as possible into the uterine cavity, employing a fine curved pair of uterine forceps, a uterine gauze packer, or a uterine sound to do so. In order to carrv out the second 170 ABORTION (WRIGHT). stage of the operation the patient is placed in the Sims position, and the end of the narrow strip, the greater portion of which has been passed into the uterus, is tied to the wider strip used for the vaginal tamponade. After retracting the perineum and pelvic floor, the upper three-fourths of the vagina is packed tightly in the manner previously described. If strong uterine contractions occur the double plug and ovum may be expelled together. If no strong ute- rine contractions commence withdraw tampon in twenty-four hours, and in- troduce a new one. This procedure means, of course, that the membranes will be punctured, if they were not previously ruptured. This is suitable for all cases of abortion between the end of the third and the end of the seventh month. In the seventh month we must consider the possibility of the expulsion of a living child. In helping delivery during this month, and sometimes in the fifth or sixth month, one may introduce a gum elas- tic bougie (English No. 12) within the uterus or a medium-sized rectal tube (H. U. Little), as recommended by Krause, and follow with the vaginal tamponade. However, the introduction of the gauze through the cervical canal and into the lower uterine segment, with the vaginal tamponade, is gener- ally quite sufficient to produce efficient uterine contractions. The best method to adopt to incur little risk for the patient : No inter- ference is necessary in ordinary cases except in cases of severe anemia pro- duced by a profuse hemorrhage or by long-continued slighter bleeding, when portions of the ovum are retained, and in cases which have become septic. The most rational method of arresting hemorrhage is to remove the ovum com- pletely. If this has left the body of the uterus, and is retained partially or totally in the cervix or vagina, a spec- ulum should be introduced, and, if the finger cannot easily complete the re- moval, ovum forceps may be used. When the ovum is still in the body of the uterus, one or two fingers should be introduced, and — while counterpressure is exercised by the other hand from the abdominal wall — the sac separated completely from the uterine wall. Once it has been separated, it can usually be removed by combined action of the internal finger and expression from without. The whole process can be made more easy if one seizes the an- terior lip of the cervix with volsellum forceps (double-toothed), and admin- isters an anesthetic. The operator must not be disturbed by the hemor- rhage, but must rely on the fact that this will cease on" completion of the abortion. If the cervix is not permeable for the finger, thorough plugging of the uterus, cervix, and vagina with sterile iodoform gauze is then indicated. The cervix is brought into view with a Sims speculum, the direction of its canal is ascertained by means of a uterine cathe- ter or sound, and the size of the uterus by bimanual examination, and not by the sound. The vagina is to be thor- oughly irrigated, cleansed, and dried, and then the strips of gauze introduced with smooth ovum forceps. All one's efforts should be directed toward keep- ing the ovum intact. At times it may be necessary to substitute a sound for the forceps in packing the uterus. If the ovum is not cast oixt after twenty- four hours, the plugging is to be re- moved, the passage again thoroughly disinfected, and a second packing un- dertaken. Sellheim (Miinch. med. Woch., March 11, 1902). The treatment of abortion is consid- ered by the writer under three heads: (1) imminent abortion may be pre- vented by absolute rest in bed and the use of drugs like codeine and vibur- num prunifolium; (2) progressing abortion, and (3) incomplete abortion may be assisted to a spontaneous ter- mination by a hot vaginal antiseptic ABORTION (WRIGHT). 171 douche and vaginal gauze packing. An oxytocic should be administered in- ternally. If the result is not satisfactory after twenty-four hours, the partially dilated cervical canal should be packed with gauze and the vagina below tightly filled with the same material. Uterine contraction will thus be usually incited and everything expelled. If too much bleeding is going on, the uterus may be emptied with the finger or placenta forceps, and ergot administered, two or three doses usually sufficing. H. J. Boldt (Jour. Amer. Med. Assoc, Mar. 17, 1906). Table containing the kernel of the operative indications. If conscien- tiously followed, it will, the writer believes, lead to considerable improve- ment in the practitioner's treatment of abortion and miscarriage. tion is injected. Of course, careful asepsis must be maintained. In giving the injection it is best to use a Sims speculum. If results are not prompt, the injection may be repeated in a few minutes. Crasser (Centralbl. f. Gynak., Nu. 25, 1909). Conclusions based on the results in 2000 cases of miscarriage: 1. Spontane- ous emptying of the uterus takes place in but about 13.2 per cent, of all miscar- riages. 2. The likelihood of a miscar- riage to complete itself increases with the duration of pregnancy. 3. When it becom.es necessary to use artificial means to complete the miscarriage, the finger followed by the curette in later miscarriages, and the curette alone in the earlier months of pregnancy, has given uniformly satisfactory results. 4. Experience has shown that where the Outline of Treatment in. Abortion and Miscarriage. Ovum re- tained. Ovisac or placenta retained. Placental pieces or decidua retained. FiEST Six Weeks of Preg- nancy. Cervix closed. Cervical and vaginal tam- ponade. Uterine tam- ponade. Dull curette. Cervix open. Removal with one finger. Removal with, o-vum for- ceps under guidance of finger. Dull curette. Seventh to the Thirteenth Week. Cervix closed. Cervix open. Cervical and Removal with vaginal tam- one finger, ponade. Uterine tam- Removal with ponade. one finger Dull curette. Dull curette under guid- ance of finger. Fourth to the Sixth Month. Cervix closed. Cervix open. Tamponade or Removal with dilate with two fingers, small Voor- hees bag. Tamponade or Removal with dilate with | one or two finger. fingers. Curette care- Removal with fully or di- late to admit finger. one finger. F. J. Taussig- (Surg;., Gynec. and Obstet.. May, 1909). For several years the writer has been in the habit of injecting adrenalin into the uterine cervix in cases in which there was bleeding after abortion with retention of the placenta. It not only controls the bleeding, but aids in the expulsion of the placenta. He believes that the method is safe and efficacious, and prompt in its influence. Two to three drops of adrenalin solution mixed with 1 c.c. of physiological salt solu- cervix is extremely rigid it is better to introduce the curette and break up the fetus and placenta and remove them piecemeal than to attempt to dilate the cervix sufficiently to introduce the fin- ger. 5. Packing the vagina and lower segment of the uterus is an unsatisfac- tory and often unsuccessful method of emptying the uterus. No success what- ever was obtained in treating incom- plete miscarriages in this way. 6. Pack- 172 ASORTION (WRIGHT). ing is, however, of great value in two classes of cases: First, in exsanguin- ated patients to stop the hemorrhage and give the woman a chance to re- cover somewhat from the loss of blood before emptying the uterus. Second, when the cervix is very rigid, a tight cervical pack for twenty-four hours will soften it so that dilatation may be attempted with safety. 7. The results of artificial methods are as good as, but not better than, where nature has suc- ceeded in emptying the uterus. 8. Arti- ficial methods are necessary in a major- ity of cases, however, simply because nature has failed. 9. In infected cases the essential thing is to get rid of the infectious material by emptying the uterus, the particular method employed making little difference. 10. The later in pregnancy miscarriage occurs, the smaller the liability to become infected, but the greater the likelihood of de- veloping grave septic complications if infection does take place. 11. The mortality is practically the same at all periods of pregnancy. 12. Induced abortions have a greater mortality than accidental. The mortality of patients admitted to the hospital aft^r criminal abortions was 10 per cent. E. B. Young and J. T. Williams (Boston Med. and Surg. Jour., June 22, 1911). Treatment o£ Incomplete Abortion. — Some authors state that the uterus may be emptied at once, the cervical canal being dilated and the finger or curette or both being used. Occasion- ally the finger may be used v^ith ad- vantage when the cervical canal is well dilated, but we do not advise the use of the curette. Others hold that we should not interfere until there is decomposition of the ovum or danger- ous hemorrhage. We do not approve of this kind of expectant treatment. Without discussing these or other methods of treatment we recommend the uterovaginal iodoform tamponade for all kinds of incomplete abortion, whether occurring before Or after the formation of the placenta. In these cases there is nearly always some dilatation of the cervical canal, gen- erally enough to allow the introduc- tion within the uterus of a narrow strip of iodoform gauze. If the canal which was once slightly dilated has again become so contracted that no gauze can be passed through it we may do the vaginal tamponade as be- fore directed, and thereby cause suffi- cient dilatation for our purposes. If we use the iodoform gauze or cheese- icloth instead of ordinary sterile gauze, we do not fear the danger of decom- position which is said by some to occur in the uterine cavity about the vaginal plug. If, however, one fears such an occurrence he should remove the vaginal plug in ten or twelve hours, instead of waiting twenty-four hours, as we have generally recom- mended. The uterovaginal tamponade may be repeated several days if con- sidered necessary. If after waiting one or two weeks the accoucheur has reason to fear that some portions of the egg have been retained, and there are no signs of sepsis, he may use a dull curette with great care. Sepsis with incomplete abortion is a very serious complication. The curette, whether dull or sharp, should never be used when there is septic endometritis or even saprophytic in- fection. The finger may be used very gently to remove debris when the cervical canal is sufficiently dilated. Then use an intrauterine douche of warm salt solution. After the douche is used introduce iodoform gauze (the coarser, the better) into the uterus, and place a certain amount in the vagina without packing tightly. Leave ABORTION (WRIGHT). 173 this in six hours, and then remove. After this removal keep the patient as much as possible in Fowler's position, that is, a half-sitting position, to facili- tate drainage. Apart from such local treatment carry out the usual line of treatment recommended for puerperal infection. Method of dealing with an infection after an abortion. The cavity of the uterus is first cleaned out to prevent the continued absorption of toxins from any infectious material which may be present, and thus, at least, limit the in- tensity of the process. For this the fin- ger alone is employed, or combined with the curette. The cavity of the uterus is washed out with hot saline and 2 ounces of peroxide of hydrogen; it is then cleansed with saline solution and sponged dry. After this 2 or 3 drams of iodoform powder are placed in the uterine cavity, which is then packed with sterile gauze. Now the cul-de-sac is freely opened, and, after evacuating any fluid which may be present, it is irrigated with hot saline, followed by 2 ounces of peroxide of hydrogen. This in turn is washed out and the cavity wiped dry. Last, 2 or 3 drams of ster- ilized iodoform powder are dusted into the cul-de-sac, after which it is packed tightly with strips of sterile gauze. By this procedure the author believes that two advantages are obtained: (1) by evacuating the fluid from the cul-de- sac further absorption is prevented; (2) the ovaries and Fallopian tubes are saved by preventing adhesions which would almost invariably form as a re- sult of the organization of the exudate. Personal experience has shown that the secretions from the uterine cavity are almost always sterile, while organisms are invariably found in the exudate in the cul-de-sac. Hunter Robb (Amer. Gyn., June, 1903). Continuous or frequent irrigations urged to prevent absorption from the lochia and thereby the production of the toxemic element of puerperal sep- sis. Weil (N. Y. Med. Jour., May 18, 1911). When a septic abortion is recog- nized it must first be determined that the infection has not extended beyond the uterus before active treatment is in- stituted. When the diagnosis of septic abortion has been confirmed and the disease is confined to the uterus the next procedure of the physician should be determined by the bacteriological ex- amination, except when there is con- siderable hemorrhage ; in these cases immediate curettage is indicated. If the bacteriological examination reveals the presence of streptococci, staphy- lococci, bacteria coli, or the ordinary saprophytes curettage should be prac- tised and no serious results are to be expected. But if the examination re- veals the presence of hemolytic strep- tococci, especially if in pure cultures and with distinct hemolysis, the writer advises against any local intervention, as the danger involved is very great. The treatment should be general, to increase the power of resistance of the organism in the expectation that the infection will be overcome by local re- action. Ergotin treatment is indicated to limit absorption through a firm con- traction of the uterine wall and at the same time favor expulsion of the re- mains of the fetus. Winter (Med. Klinik, April 16, 1911). Winter's advice not to interfere in septic abortion, except in the case of hemorrhage, until several weeks have passed, all symptoms of infection hav- ing disappeared, and the uterus is not completely empty, is only valid in one respect, viz., the liability of multiple infections from curetting, a sharp rise in temperature nearly always following the operation. Many cases would ter- minate fatally, however, were it not for timely curetting. Many conservative gynecologists confine themselves to for- ceps, sponges, or the finger and never use the curette. De Bovis (Semaine med., July 26, 1911). Curettage and Emptying the Uterus at a Single Sitting. — This operation may be occasionally justifiable when there appears to be urgent need of rapid emptying of the uterus. Whether this be true or not it is 174 ABORTION (WRIGHT). recognized as a legitimate operation by some of the best obstetricians and gynecologists in the world. A brief description of the procedure is there- fore given. Anesthetize the patient, place her in the lithotomy position "across bed," preferably on a Kelly pad. Prepare external parts and vagina as for vaginal hysterectomy, using espe- cially green soap and hot water, and a hot solution of lysol or other germi- cide. Introduce a weight speculum, secure the anterior lip of the cervix with volsellum forceps, introduce a branched steel instrument into the cervical canal, and dilate ; then intro- duce a curette into the interior of the uterus and scrape out its contents. Some operators then wash out the interior of the uterus with an antisep- tic solution, while others use the uterine iodoform tamponade. Two hundred and seven cases per- sonally treated with curette. Sequelae were met with in 34.4 per cent., com- pared with 92.4 in those in which it was not employed. In the former, the menses were regularly re-established in 60 per cent., pregnancy to term supervened in 53 per cent., abortion re- curred in only 13 per cent., and sterility prevailed in 32.3 per cent. When the curette was not used and fingers were, regular menstruation in 39.4 per cent., pregnancy to term also in 39.4, repeated abortion in 47.3, and sterility in 25.1. The cases were all treated upon the same general principles, and the curette was only employed in the presence of the strongest indications. Schaeffer (Deut. Prax., Nos. 1-3 and 5-8, 1901). An incomplete abortion may be rec- ognized by the bloody charge, sepsis or failure of involution as instanced by the soft,. boggy uterus, the patulous cervix, and the detection during the examina- tion of fragments of the ovum. On the other hand, if the abortion has been wholly completed, that is, if the entire uterine contents, including the hyper- trophied decidua, have been completely expelled, the uterus is firmly contracted and the os is closed. The management of incomplete abortions is purely sur- gical, for drugs have little or no effect on the expulsion of retained portions of the ovum. Hemorrhage, sepsis and adrenal inflammations, with their com- plicating sequelae, can alone be con- trolled and avoided by prompt aseptic emptying of the uterus. Here again, as in the treatment of inevitable abor- tions, the strictest asepsis and the most delicate skill are necessary to evacuate the uterus without traumatizing the pas- sages. No expectant plan of treatment has given any satisfaction ; the situa- tion should be explained to the family, as well as the dangers from the possi- ble sequelae and the necessary opera- tion made. J. O. Polak (Long Island Med. Jour., June, 1907). Treatment of Criminal Abortion. — In the majority of cases of criminal abortion we have incomplete abor- tion with sepsis. We have to con- sider at the same time that some injury may have been done by the operator in his manipulations. One of the most common of such injuries is puncture of the uterine wall. The possibility of such injury should make us doubly careful in our methods of treatment. In performing an autopsy upon a woman who is supposed to have at- tempted abortion search should be made for the embryo or pieces of it, or for the placenta. If the uterus is empty, the thickness of its walls must be measured, and the insertion of the placenta sought, as this can be recog- nized up to the tenth day after the ex- pulsion of the embryo. This is possi- ble even later, if the uterus is kept in 90 per cent, alcohol. The examination of the ovaries is of only relative im- portance, as no positive signs exist there. Stains of meconium, if found, will prove the abortion. If an instru- ment has been used to cause abortion, traces of the damage done by it will ABORTION (WRIGHT). 175 be seen. This is cspeciallj' true when the nterus has been perforated, llron- ardel (Jour, des Pratieiens, Jan. 13, 190n. Six hinidred and ninety-eight cases of abortion witnessed, supposed to be spon- taneous. Four of the women died, that is, 0.57 per cent. During the same period 44 cases of criminal abortion were treated; tlie niortalit}' was 56.8 per cent., that is, only 19 women re- covered. In the presence of a complete or incomplete abortion, due unmistak- ably to mechanical measures, or even when such abortive measures are sus- pected, and in absence of any compli- cation, early evacuation of the uterus is required. If septic accidents have already developed, evacuation is still more urgent, and general measures are also indicated. Ma3'grier (L'Obste- trique, July 4, 1902). When the patient is kept in an aseptic condition, that is, without local exam- ination or other maneuvers, and hot douches are given only in numbers sufficient to combat alarming hemor- rhage, the temperature keeps within normal range. Careful watching may show a slight rise ; at the same time slight hemorrhage may recur or a very slight fetid odor may be noticed in the secretions-. These signs show that the fetus is dead, that the placenta has become a foreign body, and that the uterus is trying to expel it. This is the time for curetting if spontaneous ex- pulsion does not rapidly follow. At this time the operation is easy and with- out danger. In case of primary uterine infection with temperature above 38° C, the curette should be used at once. It is easy to order injections at 45° or 48° C. (113° or 118° F.), but they are generally given tepid and thus only aggravate the tendency to hemorrhage. Each douche should be preceded by a careful toilet of the external genitals. In curetting wait until the uterus con- tracts, curetting gently during the period of relaxation after a contraction, and using the largest curette possible. Curette at the moment when the placenta is almost entirely separated and the uterus offers a thick and re^ sisting wall. Perforation may well be feared when there is infection in the uterus, for then one's hand is forced and the curetting may be done while the placenta is still too firmly adherent. De Bovis (Semaine med., No. 43, 1910). Treatment of Patient with "Abort- ing Habit." — Wlien we have treated a certain patient for two or three threatened abortions which have be- come inevitable, the presence of syph- iHs should be carefully inquired into. If there is a syphilitic taint, or even a suspicion of it, both patient and hus- band should be placed under constitu- tional treatment. Malformations, dis- placements and other abnormalities of the uterus, and other conditions which act as direct causes of abortion may, of course, prevail in these cases, and should be carefully soug-ht after. Two cases in which the writer was able to correct a tendency to habitual abortion by the systematic introduction into the uterus of a suction cannula. It not only induces hyperemia in the organ, but stimulates it to muscular contractions, this exercise aiding in re- storing normal conditions. In the first case he applied the cannula for half an hour at a time, at twenty sittings in the course of seven weeks ; in the sec- ond case the cannula was left for ten hours at a time, the procedure being repeated eight times in the course of one month. Both women have since borne healthy children, although there was a history of five and three abor- tions, respectively; the patients were 27 and 23 years old. Turan (Deut. med. Woch., May 5, 1910). Apart from such considerations, rest and quiet are the important ele- ments in the treatment of such cases. The patient should be kept in bed or on a lounge from two days before the time of menstruation until three days after it ceases. In addition, if the patient is restless or sleepless, she 176 ABORTION (WRIGHT). should receive enough opium or other hypnotic, such as veronal, to make her sleep at least fairly well every night. During intervals she should have a moderate amount of exercise in the open air, and suitable tonics. Strong purgatives, vaginal douching, sports, and all kinds of fatiguing work should be carefully avoided. In case of re- troversion or retroflexion, the displace- ment should be corrected, introducing, if necessary, a suitable pessary, and leaving it until about the end of the fourth month. ABERRANT FORMS.— The rec- ognition of such conditions obviously is of great diagnostic importance. Missed Abortion. — The retention of the ovum within the uterus after its death is thus termed. The death of the ovum may occur before or after the formation of the placenta, but it is most apt to happen in the third month. This is probably due to the fact that at that time the egg is to some extent loosened on account of the atrophy of a large portion of the chorionic villi. The death of the fe- tus frequently occurs, however, in the fourth, fifth, sixth or seventh month, and in a certain proportion of these cases the abortions are "missed." The term missed abortion is inap- propriate, as it is used as a synonym for delayed abortion. The period from the death of the fetus until it is ex- truded is unusually prolonged, and it undergoes important changes — those due to- a cessation of vitality. This period may be devoid of symptoms, and as a rule the embryo has been dead some weeks or months before the patient comes under observation. J. Oliver (N. Y. Med. Jour., Dec. 3, 1904). It is a singular fact, in connection with a case of missed abortion, that the dead ovum frequently or generally remains in the uterus quiescent until term. In some cases the dead ovum still remains quiescent for an indefinite time, even after term,. Although we cannot speak very definitely, we know that the dead ovum may remain in the uterus without any change in struc- ture for one, two or more years. At least such appears to be the opinion of the majority of obstetricians at the present time. Case in which a dead fetus had been carried in utero for probably six and a half months without causing physical disturbance. One month after the last menstrual period, she began to show symptoms of pregnancy, morning sick- ness, enlargement of the breasts, etc. At about the fifth month from the time her menses ceased she commenced to look for signs of "life," which did not appear. Ascribing her symptoms to early menopause, she ceased to give herself a thought about her condition, gained in weight, and felt quite com- fortable. On March 12, 1911, at about 3 A.M., she commenced to have cramp- like pains and expelled a sac which on examination proved to be a fetus of about three and a half months, with cord and placenta connected. Micro- scopically the placenta showed a fatty degeneration of the entire mass. The fetus was of a dark and brownish black. Ohlbaum (Med. Record, Aug. 26, 1911). [This fact is sometimes of great impor- tance from a medicolegal standpoint. The case of Kitson vs. Playfair, which was tried in England about fourteen years ago, created intense interest. Dr. Playfair, the distin- guished teacher and writer on obstetrics and gynecology, while treating in an ordinary professional way Mrs. Kitson, the wife of Mrs. Playfair's brother, emptied the uterus, and found something like fresh placenta. Examination under the microscope confirmed his suspicion, and he expressed the opinion that there had been a recent incomplete abor- tion. As Mrs. Kitson had not seen her hus- band for over a year (he being in India and ABORTION (WRIGHT). 177 she in Lingland) this meant a charge of im- morality. Dr. Playfair informed his wife, and Mrs. Kitson was dismissed in disgrace from her ordinary circle of relatives and acquaintances. The husband in consequence entered action against Dr. Playfair. At the trial several leading obstetricians agreed with Playfair, while others took the opposite view, and said the substance removed might have been the result of a conception at least eighteen months before. The case was decided in favor of Mrs. Kitson, and Play- fair was compelled to pay a large amount for "damages." The suit cost him altogether over $50,000. We may add that many at the time of the trial thought that, even if Dr. Playfair had been correct in his contention, he was not justified in revealing a profes- sional secret. A. H. Wright.] Mole. — When the dead ovum or a portion of it is retained in the uterus it is called by many a mole. When there has been extravasation of blood between the layers of the membranes or into the substance of the decidua, coagulation takes place and the mass with its clot or clots is called a "blood mole." When there has been repeated extravasation of blood within the ovum the blood-strata undergo partial organization and the mass is called a "flesh mole." This flesh mole retains to some extent its attachment to the uterine wall, and in some cases after partial detachment may form new at- tachments. Under such circumstances the detention of the mass within the uterus may be much prolonged, as before mentioned. The fleshy mole is undoubtedly a form of the process known as "abor- tion," but the obstetrician should re- member that the pathological changes which produce it may occur at very different stages of pregnancy. The precise time at which the arrest of nor- mal pregnancy occurs cannot always be determined by examination of a fleshy mole. Neumann (Monats. f. Geburt. H. Gyn., Feb., 1897). In tuberose fleshy mole, abortion is produced in the following manner : There is an undue blocking of the se- rotinal sinuses in the large-celled layer, leading to a slow engorgement of the intervillous circulation. This will bulge out the choriobasal septa, and, as these tack down the chorion at definite points, the amnion and chorion will bulge up between. This produces the tuberose swellings. The embryo dies as the re- sult of this interference with the cir- culation, and its death is "secondary." The placenta becomes a thrombosed mass and is retained a certain time before expulsion. The primary link in the chain of events is the excessive clotting in the serotinal sinuses from a cause as yet unknown. D. Berry Hart (Jour, of Obstet. and Gynec. Brit. Em- pire, May, 1902). Treatment of Uterine Flesh Mole. — There is far from a consensus of opinion as to the treatment of such a mole. Some say leave it alone if there are not disturbing symptoms ; others say -empty the uterus at once when a diagnosis is made. It hap- pens that a diagnosis is frequently difficult or impossible, and it also hap- pens that in the majority of cases the mole is expelled from the uterus with- in a reasonable time. The general practitioner will be on the safe side not to interfere unless serious symp- toms arise. If very serious symptoms do appear he should at once do the uterovaginal tamponade as before recommended. Hydatiform Mole (syncytioma bc- nignum, vesicular mole^ myxoma chorii). — This is a vesicular tumor within the uterus formed by sim- ple hyperplasia or cystic degeneration of the villi of the chorion at any time during pregnancy, but most fre- quently in the early months, and often after abortion. The accoucheur, in considering the symptoms of a supposed abortion, 1—12 178 ABORTION (WRIGHT). should ever keep in view hydatiform mole and chorion epithelioma, because early diagnosis and prompt treatment of both neoplasms are so extremely im- portant. The first symptom of the former is a discharge of a bloody fluid which is sometimes said to resemble currant juice. Our first suspicion is generally threatened abortion. If the discharge becomes more watery in ap- pearance, if vesicles are expelled, or if the uterus increases abnormally in size, v/e should suspect a vesicular mole. Generally we have to be guided by two symptoms, hemorrhage, and ab- normal -increase in the size of the uterus. Treatment of Hydatiform Mole. — The condition is serious and prompt treatment is required. The uterus should be emptied as soon as pos- sible. The following is recommended : Dilate the cervical canal with Hegar's dilators, then introduce a sea-tangled tent, then plug the vagina as before described. If strong uterine contrac- tions come on within a short time re- move the tampon and tent. If such contractions do not come on remove the tampon and tent in twenty-four hours, then do the uterovaginal tam- ponade as thoroughly as possible. This will, as a rule, be sufficient to cause efficient uterine contractions which will expel the mole. If there is any doubt as to such expulsion ex- plore with the finger gently, and scrape the uterine wall with its tip. The metallic curette is especially dan- gerous in this case because the uterine walls are more or less weakened by the invasion of the cystic villi. Occa- sionally it may be advisable to use a dull curette, but this should be con- sidered a misfortune, and great care should be exercised. Chorioepithelioma (chorion epithe- lioma, syncytioma malignum, de- ciduoma malignum, choriocarcinoma). — This is a very malignant form of epithelioma developed from the epithelial layers covering the villi of the chorion. It is usually associated with abortion, and in 50 per cent, of the cases is preceded by hydatiform mole. We are told that it may occur after labor following full term, but the writer has not met such a case. Obstetricians have for some time con- sidered that this form of epithelioma is always associated with -pregnancy. Some surgeons have said recently that tumors simulating chorion epi- thelioma have been found not only in women in the absence of pregnancy, but also in men, and that all such have arisen in pre-existing" teratomata. Obstetricians, however, do not believe that such tumors are really chorio- epitheliomata. Metastatic deposits, even more malignant than the original tumor, soon appear in various parts of the body, especially in the vagina and lungs. Hemorrhage is the earliest and most persistent symptom. The flow is at first red, but soon becomes dark and offensive. The uterus grows rapidly and is often perceptibly soft in one or more places. A hemorrhage is serious when it becomes in the slight- est degree offensive. Scrapings from the uterine wall may be examined microscopically. Treatment of Chorion Epithelioma. — A radical operation is immediately indicated. The uterus, appendages, and metastatic deposits, especially if any be found in the vagina and vulva, should be removed. INDUCED ABORTION.— Induc- tion of abortion is very grave in any ABORTION (WRIGHT). 179 case, and should never he decided on ivitlwut a consultation. Indications. — It may be said in a general way that, in any case where the life of the patient is imperiled by the continuation of pregnancy, abor- tion should be induced. In nearly all cases, however, w^hen serious disease is present it should receive prompt and careful treatment. That death of the embryo or fetus is a positive indication for the induction of abor- tion need scarcely be emphasized. Tuberculosis. — It was a few years ago (and is now we fear) the custom of some physicians to induce abortion in all pregnant women suffering from tuberculosis. We have to consider, how^ever, that in the light of our present-day knowledge tuberculosis is a curable disease in the pregnant Woman as well as in the non-pregnant one. If, then, our patient has tuber- culosis during pregnancy it is our duty to treat the tuberculosis and not to murder the unborn child. This should be our general rule. In a few exceptional cases (and they are very few), especially when the morbid process is far advanced, the uterus should be emptied. Cardiac Disease. — In a large majority of women who have heart disease, pregnancy does not produce effects sufficiently serious to justify the in- duction of abortion. If, however, as happens in a small proportion of cases, especially when there is mitral stenosis, such symptoms as hemop- tysis, precordial distress, palpitation, and great debility appear, and grow steadily worse, under appropriate treatment, the induction of abortion should be considered. Excessive Vomiting of Pregnancy. — We have recently learned that the pernicious vomiting of pregnancy is due, in some cases at least, to peculiar disturbances of metabolism which produce a toxemia. Chemical exam- ination of the urine shows a decrease of the amount of nitrogen excreted as urea, and an increase of the amount excreted as ammonia. In normal pregnancy, the quantity of ammonia excreted (the ammonia coefficient) is 4 to 5 per cent. In pregnancy with this form of toxemia, it may rise to 10, 20, or 40 per cent., or even higher. Williams thinks that when the am- monia coefficient exceeds 10 per cent, the pregnancy should be immediately terminated. We have found, how- ever, that in some cases the ammonia coefficient may considerably exceed 10 per cent., and the patient may re- cover without the termination of preg- nancy. It is hoped that further in- vestigation' will lead to conclusions which we shall all accept. We agree with Williams to some extent, how- ever, and believe that when the am- monia coefficient reaches 10 per cent, the patient is in a dangerous condi- tion, and needs prompt and suitable treatment. If in spite of such treat- ment carried out for one to two weeks she grows steadily worse, pregnancy should be terminated. The practitioner who does not de- pend on this chemical test should be guided by the symptoms and condi- tion of the patient. Indeed no one should neglect a careful study of all symptoms. It is very important that we should not wait too long. We have certainly much to learn yet re- specting this very perplexing subject. We have occasionally found that the results of interference even in appar- ently favorable cases are sadly dis- appointing. 180 ABORTION (WRIGHT). In hyperemesis with marked and progressive exhaustion, especially as indicated by weekly loss of weight, when the usual dietetic and medicinal measures have failed, no time should be lost in emptying the uterus. Under the combined effects of toxins and starvation the woman's strength fails insidiously and often the end comes abruptly. Lives are lost by too long delay. Serious complications, advanced cardiac disease and certain others, em- phasize the necessity for intervention. Jewett (N. Y. State Jour, of Med., Mar., 1908). General Toxemia of Pregnancy. — No definite statement can be made as to the exact time when interference is desirable in case of general toxemia of pregnancy. Apart from excessive vomiting in connection with toxemia we fear especially eclampsia. Before the onset of convulsions the induction of abortion is very rarely considered necessary. Convulsions, as a rule, do not occur in the early months of pregnancy; when they occur in the later months an immediate delivery is considered necessary. A vaginal Caesarean section is probably safer than rapid dilatation of the cervix with quick extraction. Both opera- tions, however, are serious, and the careful, conservative physician will prefer to resort to safer procedures. The importance of great haste in emptying the uterus has been grossly exaggerated in recent years. We think this is especially true as to eclampsia. Chronic Nephritis. — Induction of abortion is not, as a rule, indicated in cases of chronic nephritis. Occasion- ally the symptoms grow so serious, in spite of suitable treatment, that the patient's life is endangered. Under such circumstances the uterus should be emptied. Disorders of vision dur- mg pregnancy are very serious m pa- tients who have chronic interstitial ne- phritis. Partial or complete blindness in such cases generally indicates a fatal termination. On the other hand, one may have absolute blindness due en- tirely to a state of autointoxication. In such a case the ophthalmic changes are not marked as a rule, and the sight generally returns soon after the uterus is emptied. Herringham (Brit. Med. Jour., May 7, 1910) states that this transient form of blindness is never found in uremia or associated with chronic interstitial nephritis. Retinitis. — Affections of the eyes should be carefully studied. Retinitis should receive prompt attention. If the symptoms grow worse instead of better after treatment for a few days, interference may become necessary. In cases of retinitis with white plaques, and dimness or loss of vision, asso- ciated with serious albuminuria, abor- tion should be induced at once. Colin Campbell (oculist) agrees with Her- ringham and various modern pathol- ogists as to the great difference be- tween a retinitis due to an old chronic nephritis and a retinitis caused by autointoxication of pregnancy. He says the retinitis of pregnancy has a bright outlook compared with that of nephritis. Examination of the urine will materially aid a coming to an un- derstanding of the condition. "In pre- existing nephritis the quantity is usually greater, the urea and nitrogen more nearly full normal, and the albumin and casts more abundant. In pre-eclamptic cases the uric acid and the amidoacids are markedly increased" (Can. Jour, of Med. and Surg., Oct., 1910). It may be stated in a general way that such untoward symptoms occurring early are much more serious than similar ABORTION (WRIGHT). 181 Symptoms which may appear late in pregnancy. Pyelitis. — PyeHtis due to toxemia of pregnancy is not very uncommon, althtiugh, until recently, it was not recognized as a separate entity. In- terference with pregnancy is not gen- erally required. If, however, the tem- perature keeps above normal for four weeks ; if there is much pus in the urine; if the leucocyte count is high, abortion should be induced. It is better if possible, however, to defer interference until the child has be- come viable. Antc-partum Hemorrhages. — Hemor- rhage from placenta prsevia is our chief concern in this connection. If inter- ference becomes necessary we should employ the vaginal tamponade, and should never dilate the cervix to the slightest degree. If the hemorrhage is increased by complete or partial sep- aration of a placenta normally situated the same rule as to treatment applies. Such hemorrhages do not occur fre- quently before the child is viable, and, consequently, need not be discussed in detail here. Retroflexion of the Uterus. — When serious symptoms appear because of retroflexion or retroversion of the uterus, and the misplacement cannot be corrected, it may become necessary to interfere. In the majority of such cases abortion takes place without any interference. Contracted Pelvis. — The induction of abortion in cases of contracted pelvis was for a long time considered indi- cated. We hope it is generally con- ceded now that such a procedure is both incorrect and sinful. We have learned in recent years that conservative Cassarean section, done at the proper time with reasonable care and skill, is one of the safest and best operations now known to surgery. Such having been demonstrated, we have done well in ceasing to destroy unborn children because of contracted pelvis. Hydramnios. — When the hyclram- nios causes the distention which seri- ously afl:'ects the mother's health we may have to consider the desirability of emptying the uterus. In such cases, however, we can generally wait until the child becomes viable. Appendicitis, Ovarian Tumor, and Other Abdominal Grozvths. — Abortion should not be induced for any of these conditions. The ordinary operation for the disease or new growth should be performed. Goiter. — As a rule there should be no interference, at least until the child is viable. Myoma Uteri. — No interference with pregnancy -is indicated as a rule. In a limited proportion of cases one or more fibroids may be so situated that delivery in the ordinary way is a physical impos- sibility ; but, even under such circum- stances, the induction of abortion is very rarely indicated. We may, how- ever, meet a uterus in which the growth would interfere with normal delivery, but in this case the child might be delivered by Csesarean section if pregnancy went on to term. Women with very bad fibroids seldom conceive, and when they do early abortion is apt to occur. Chorea. — In a certain proportion of severe cases of chorea the patient goes from bad to worse, notwithstanding suitable treatment. In very serious cases the woman grows worse very rapidly and dies unless the uterus is emptied. In many cases this serious procedure, unfortunately, does not save the patient. 1S2 ABORTION (WRIGHT). The induction of an abortion justi- fiable in pernicious hyperemesis, in some cases of chorea, in certain forms of convulsive seizures, nephritis pre- ceding or manifesting itself early in pregnancy, and in certain cases of contracted pelvis. If the well-knov/n bougie method does not bring about the desired result in from twenty-four to forty-eight hours, it may be sup- planted with a tampon of gauze carried into the uterine interior. H. J. Boldt (Jour. Am. Med. Assoc, Mar. 17, 1906). Method of Inducing Abortion. — For the inckiction of abortion we employ the methods and procedures generally used Amnionic sac containing embryo and waters. The thick decidua retained in uterus. (Seven weeks.) in cases of inevitable abortion (see p. 165). When speaking about the treat- ment of the latter we had in view the fact that nature, chiefly through uterine contractions, and hemorrhages, had done something, perhaps much, in the process of abortion. The ovum has been more or less loosened from its at- tachments, and the cervix has perhaps been more or less dilated. In consider- ing the induction of abortion, we as- sume, on the other hand, that the ovum is pretty firmly attached to its moorings, and that the cervical canal is not dilated. Under such circumstances it is more difficult to empty the uterus. The fol- lowing recommendations are made for the induction of abortion at different periods of pregnancy up to the seventh month. This course seems advisable, although it will mean a certain amount of repetition : — In any case prepare the patient as for vaginal hysterectomy, or as before described, for curettage (see p. 173). Pregnancy, three months, showing fetus below. Placenta formed. First or Second Month. — Introduce a vaginal tampon of iodoform cheese- cloth as before described. This may be removed, and reintroduced, every twenty-four hours for five or six days. In many cases these vaginal tampons will not produce the desired result, even in five or six days. Under such cir- cumstances one may introduce a narrow strip of iodoform gauze within the uterus after the first or second day. If, in doing this, one punctures the mem- ABORTION (WRIGHT). 183 brane. no serious harm will be clone. After such introduction, practise vagi- nal tamponade. It may be necessary to do more than the introduction of the gauze; if so, adopt the old-fashioned method of introducing a uterine sound, and purposely puncture the membranes if possible. This is suitable, especially in cases of pernicious vomiting, because such puncture allows tlie escape of the liquor amnii, and such escape often causes the serious symptoms to subside immediately. It happens that in certain cases it is difficult to puncture the mem- branes because the deciduum is thick, tough and elastic. Tliird Month. — Carry out the methods recommended for the first and second months. There is less chance of causing the expulsion of the entire ovum and on that account it is not well to w^ait long before invading the interior of the uterus. FourtJi and Fifth Months. — Practise a uterovaginal tamponade as before described as rapidly and thoroughly as possible. SixtJi and Seventh Months. — Intro- duce a vaginal tampon, remove in twenty-four hours, place patient in lithotomy "across bed" position: intro- duce a weight speculum, seize the anterior lip of the cervix, pass a gum- elastic or hard-rubber bougie, or a medium-sized rectal tube within the uterus, between the membranes and uterine wall to the fundus if possible. Then place woman in Sims's position, and plug vault of the vagina tightly. Labor will generally come on in a few hours, and the uterine contents will soon be expelled. It is sometimes ad- visable to introduce the bougie in the fifth month. We find that in some cases the tam- ponades are not efficient, and we are compelled to adopt more forceful pro- cedures. As before mentioned we think the use of the metallic dilator and sharp curette in the "single sitting" operation is always dangerous. If this statement is true, or even half-true, it is sad to notice that some of our ablest authors in recent textbooks say that "the in- duction of abortion is practically free from danger if perfect asepsis is observed." This operation is especially dangerous in the class of cases included in this chapter because the patient is generally in a bad physical condition from the complication which calls for the termination of pregnancy, as, for instance, pernicious vomiting. It is generally an easy matter, espe- cially after a vaginal tampon has been in place twenty-four hours, to dilate the cervix with the Hegar dilators suffi- ciently to allow the introduction of the gauze within the uterine cavity. We also recommended the use of the laminaria (sea-tangle) tent for dilata- tion. It is said, however, that there is great danger of infection from the use of any tent for such purpose. There was, of course, much reason for such fear many years ago when the sponge, tupelo and laminaria tents were not sterile, and, in addition, were not used in an aseptic way; but during recent years we have been able to get excellent sterile laminaria tents that are perfectly safe if used in a cleanly way. Similar objections have been raised against tampons because they also were unsafe as used many years ago, but the tampon medicated with iodoform or other suitable antiseptic is as safe as anything that can be introduced within the uterine cavity. It is thought by some that there is danger from the use of the bougie according to Krause's method, but, if the bougie is made per- 184 ABORTION, TUBAL (DEAVER). fectly sterile by boiling and is carefully used, the danger therefrom is very slight. It is well to remember, how- ever, that there is always some danger in connection with any obstetrical operation through want of care on our part. We should ever make a con- tinuous effort to guard against such danger. A. H. Wright, Toronto. ABORTION, TUBAL.— DEFINITION.— Early interruption, i.e., abortion, is the natural outcome of extra-uterine pregnancy, whether by reasons of insufficient blood- supply or unfavorable mechanical conditions for the continued develop- ment of the fetus. [A brief review of the history of this im- portant suijject ought to possess for us more than ordinary interest because of the impor- tant role played in its development by one almost of our own number and generation in whom we may take a pardonable local pride. I refer to the illustrious and lamented John S. Parry. He was not the first to write upon the subject. Indeed, Albucasis, the Arabian, in th"e eleventh century recognized and described a case of extra-uterine preg- nancy. Nor was he the first to grasp the possibilities of operative treatment in the emergency of rupture. That was proposed by Harbert, of New York, in 1849. The merit of Parry consisted not only in grasping the significance of the catastrophe and the correct mode of meeting the emergency, but in applying his philosophical mind and schol- arly attainments to the production of a mono- graph which by its masterly marshaling of facts and lucidity of deduction should have quieted the doubts of Thomas. He was able to collect for his book, which was published in 1876, 500 cases reported in the literature. Of 499, in which the result was stated, 366 died and 163 recovered. Of the deaths, 174 had been from rupture. Of these deaths 81 had died within 24 hours. These figures were his text. He began his sermon with this sentence : "From the middle of the eleventh century, when Albucasis described the first known case of extra-uterine preg- nancy, men have doubtless watched the life ebb rapidly from the pale victim of this acci- dent, but have never raised a hand to help her." Then, though not himself a surgeon, he points out the plain surgical indications. In the same year as the publication of his monograph he died, doubtless depriving the world of one who was destined to become one of its greatest figures in the advance- ment of medicine. Parry was a pupil of my father, who often used to speak of his stu- dious habits and scholarly grasp. He was by nature fitted for mental leadership. The honor of performing the first opera- tion for this emergency went to Lawson Tait in 1883. He had been earnestly solicited to operate for this condition in 1881 by a physi- cian who had correctly diagnosed a case of rupture with internal hemorrhage. He re- fused, and the patient died shortly after. Unfortunately the first patient operated on died also, but his change of heart was com- plete, and, correctly attributing his failure in the first case to faulty technique, he altered his method and continued to operate all such cases. Of the next 40 cases only 1 died. Truly a brilliant record which was not long in converting the medical fraternity. The original microscopical preparations of Tait in which he demonstrated his ideas on extra-uterine pregnancy and pelvic hemato- cele which, before him, were in a very con- fused state are still to be seen in the mu- seum of the Royal College of Physicians in London. There are many other names of more or less importance in connection with the de- velopment of the subject, but these two are central and all we have space to consider. John B. Deaver.] SYMPTOMS.— The symptoms of extra-uterine pregnancy include those due solely to the condition of preg- nancy and those which arise only from its abnormal situation. Inas- much as the majority of cases termi- nate within three months, at which ordinary signs of pregnancy are not usually pronounced, we do not often get much help from the symptoms belonging to the first group. Yet ABORTION, TUBAL (DEAVER). 185 such symptoms and signs as enlarge- ment of the breasts, the presence of colostrum, cessation of menstruation, increased vascularity of the genitalia, softening" of the cervix and body of the uterus with slight enlargement, disturbances of the bowels or bladder, morning nausea, and the abnormal appetite, cravings or sensations which the multipara sometimes recognizes, are occasionally of confirmatory value. It would be desirable to make the diagnosis before rupture were it pos- sible to do so. Unfortunately a large percentage of cases give such trifling evidence of the true condition, if indeed there be any prodromal symp- toms at all, that no suspicion is aroused. Still it is occasionally pos- sible to make the diagnosis and it should be our efl'ort to do so. One operator, Baldwin, of Columbus, Ohio, has reported 11 such cases. A prolonged continuous blood-stained uterine discharge is an important aid in differentiating tubal abortion; even if the proportion of blood is small its persistence for two up to five weeks is characteristic, and absence of blood in the vaginal discharge is strong evidence against a recent hematocele. The sHght hemorrhage seems to persist longer after tubal abortion than after rup- ture. Incomplete expulsion of the ovum is also liable to keep up the hemorrhagic discharge, and the writer relates some instances of such reten- tion of the placenta with the tube open and of total retention with the tube closed. The small encapsulated collec- tion of blood may be taken for a ^ fibroma, and the resulting disturbances for inflammatory processes in the ad- nexa or in the uterus. Certain cases of tubal abortion have been diagnosed as a hemorrhagic metritis, and the uterus was curetted when this organ was sound and the trouble was in the tube beyond the reach of the curette. F. Lejars (Semaine medicale, July 13, 1910). A new sign of tubal pregnancy is a more or less striking paleness of the cervix. The absence of this paleness does not, however, exclude this condi- tion, but its presence, when not due to obvious other causes, is almost pathog- nomonic. It is only present, however, in those cases of tubal gestation in which there is bleeding from the uterus, and onl}' while this bleeding is actively going on. Golden (W. Va. Med. Jour., May, 1911). The diagnosis in these cases rests upon : first, a consideration of the his- tory. Important points for considera- tion are the age of the patient, exposure to pregnancy and the pre- sumptive signs and symptoms, a history indicative of an antecedent tubal inflammation, a previous period of sterility usually of some years. This last point has been observed by all students of the condition and Parry remarks on what he calls "the previous inaptitude for conception" of these patients. Amenorrhea of shorter or longer duration is a fairly constant feature and is followed in the majority of instances by irregular bleeding from the uterus, sometimes profuse, some- times a mere staining. The history of passing bits of tissue or the demon- stration of decidua in the discharge is important. Pain if felt before rupture consists frequently in vague uneasy sensa- tions in the pelvis. Sometimes it is more severe, colicky in type and ac- companied b}' nausea. In cases which show any of these suspicious symptoms an internal ex- amination should not be neglected. The demonstration of a pelvic mass lying outside of the uterus, in the presence of a probable pregnancy, is a very suspicious circumstance. If this mass should correspond in size 186 ABORTION, TUBAL (DEAVER). with the duration of pregnancy, if it should be located in the course of the tube, if it be movable, moderately soft and very tender, we may fairly conclude we are dealing with a case of extra-uterine pregnancy. It must be remembered that it is sometimes easy to mistake a retroflexed preg- nant uterus for an extra-uterine preg- nancy. Review of 36 cases simulating tubal pregnancy. The following conditions may be mistaken for the latter : 1, an acute exacerbation of a dormant gonorrheal pyosalpinx ; 2, sudden ex- tension of a uterine gonorrhea to the tubes and peritoneum ; 3, an early abor- tion if associated with salpingitis or a tumor; 4, an irregularly softened, mis- placed, hyperesthetic uterus associated with tubal enlargement; 5, an unsus- pected tumor associated with symptoms of early pregnancy; 6, ovarian hemor- rhage or tubal hemorrhage from other conditions ; 7, sudden and rapidly pro- gressive salpingitis, appendicitis, and gastrointestinal perforations. Crossen (Jour. Amer. Med. Assoc, Feb. 12, 1910). Often before a diagnosis can be made, usually before the diagnosis is made rupture of the tube or extensive separation and hemorrhage from the placental site supervenes. It was formerly thought that rupture was the most common outcome of tubal pregnancy. More careful examina- tion of the specimens, however, has shown us that in many cases of sup- posed rupture we are dealing with a case of tubal abortion with hemor- rhage from the site of implantation. Moreover, hemorrhage from this source, while less violent as a rule than in rupture, may be very severe and even fatal. Frequently, however, it is comparatively slow and by slow leakage is responsible for the majority of hematoceles which we find. Recent statistics indicate that these tubal abortions occur more frequently than does rupture. The tragic stage, how- ever, may follow either process. [The idea that rupture is not so frequent as has been supposed and therefore an extra- uterine pregnancy is not so dangerous a condition is fallacious. It is a matter of common knowledge that tubal abortion may give rise to a condition as serious as any of the accidents of ectopic pregnancy. I should not feel it necessary to insist on this fact were it not for an impression which is going abroad in regard to treatment, which I shall consider later. John B. Deaver.] A positive diagnosis before a rupture has been rare, but there are many in- stances in which a strong presumptive diagnosis should have been made and for lack of which the patient suffers. Most cases, however, do not come under the physician's notice until rupture, the symptoms being not much different from those of normal pregnancy. There is usually a cessation of men- struation for one or more periods, and in this case, with rupture threatening, it is usually re-established, irregular as to time, and of a tarry, sticky character which, according to some observers, is pathognomonic. The pain is usually cramp-like, occurring at intervals for several days, and following it there is a dark, sanguineous discharge, probably due to a partial rupture of the gesta- tion sac. Microscopic examination will reveal traces of decidua in most cases. While the history of the case is im- portant, a careful and thorough exam- ination is advisable and great care should be employed to avoid rupturing the sac. The rupture in the doctor's office is a frightful accident — one which greatly involves his responsib'lity. L. G. Bowers (Jour. Amer. Med. Assoc, Feb. 12, 1910). Rupture is the most serious acci- dent of ectopic gestation. It may take place very early and be the first symptom. Cases have been reported of rupture in the first or second weeks of pregnancy. Usually it occurs in the second or third months, but occa- ABORTION, TUBAL (DEAVER). 187 sionally may be delayed into the later months. Secondary rupture may oc- cur at any time after primary rupture up to term. Rupture is usually ushered in by severe lancinating pain in the hypogastrium, accompanied by shock, sometimes by syncope and frequently by nausea or vomiting. of the abdomen which is readily dis- tinguished from the usual rigidity of inflammation of the peritoneum. There are the symptoms of rupture and of hemorrhage per se. They are not always so frank and outspoken and in order to be sure of our ground it is frequently necessary to bring to Differential Diagnosis between Extra-uterine Pregnancy and Early Abortion Based on a Careful Study of 28 Cases. Extra-uterine Pregnancy. 1. Advent is sudden. 2. Pain is severe very early. 3. Blanching of the face early. 4. Pulse very feeble and rapid early. 5. Hemorrhage usually not severe, but per- sists, even after the uterus has been thoroughly emptied. 6. At iirst there is no elevation of tem- perature, and later it is rarely above 101° F. 7. At one side of the uterus there is usu- ally a very tender tumor, which is, as a rule, movable. %. Boggy feeling behind the uterus. 9. Usually the cervix is very slightly open. 10. Shreds, decidual membrane and blood only escape. 11. Late there will be marked diminution of the hemoglobin (30 per cent, to 70 per cent.). 12. Rarely, if ever, polynuclear leucocytes. 13. If the cul-de-sac of Douglas is opened, blood will escape with possibly an embryo. Ralph Waldo (Archives of Diag., Oct., 1908) Early Abortion in Uterine Pregnancy. Rarely sudden. Not severe early. Blanching of the face late, if ever. Pulse strong and full until late. Hemorrhage usually severe early and mark- edly, diminishes after the uterus is emptied and ceases entirely in a few days. Frequently, especially if there is sepsis, the temperature is very much elevated. There is no tumor unless there is infection, and then it is rarely movable. Not present. It is open, especially if part of the products of conception are still in the uterus. An embryo may be found; if not, the mi- croscope will show chorionic villi. No marked diminution of hemoglobin. Frequently present, especially if there is in- fection. No blood will escape. Following this the symptoms of in- ternal hemorrhages make their ap- pearance. Increasing pallor, rapid and weak pulse, sighing and labored respiration and air hunger, dimming of vision, with increasing but slight distention of the abdomen, signs of fluid in the flanks, general abdominal tenderness most marked in the hypo- gastrium and a peculiar doughy feel our aid the history and the internal examination. In this condition as in so many others, the classical picture in toto is rarely seen and it has happened, paradoxically enough, as Douglas remarks, that many more diagnoses are made nowadays since the integrity of all the classical symp- toms have been repeatedly attacked than when a clear average picture had 188 ABOEIION, TUBAL (DEAVER). been drawn and accepted. It will do then to know that the three cardinal symptoms are pain, menstrual irregu- larities and tumor if we appreciate their variability. Conclusions based on a study of 214 cases : 1. Irregular flowing seems to play the important part given it in the books as a symptom of extra-uterine pregnancy. 2. The importance of a long period of sterility as a cause of extra-uterine pregnancy does not seem to be borne out by these statistics. 3. Conditions possibly leading to extra- uterine pregnancy: The fact that cystic ovaries, disease of the opposite tube, adhesions, or a previous miscarriage occurred in over 83 per cent, of 202 cases is suggestive, and is in agree- ment with authorities as to the possible relation of such conditions to extra- uterine pregnancy. 4. The fact that in only 26.5 per cent, of 207 cases the pain was sudden is of interest. In about three-fourths of the cases the sudden severe pain was preceded by pain of less severity, coming on gradually. 5. Of considerable interest is the leucocytosis observed in the cases in shock. This is apparently a perfect example of leu- cocytosis after hemorrhage. The find- ing of a temperature of 100° or over in 43.4 per cent, of the cases, and of a temperature of 101° or over in 14.4 per cent, of cases, is also of interest. Ordi- narily it is supposed these cases rarely have any fever. Coues (Boston Med. and Surg. Jour., May 11, 1911). [The question of great and timely interest in connection with the treatment of extra- uterine pregnancy has to do with the man- agement of the case at the time of rup- ture, with associated hemorrhage and shock. Thanks to the early operation these com- plications are rare nowadays, but I fear, if the advocates of delayed treatment secure a following in the profession, that these cases may occur more frequently, and that cases which would be noted in the statistics of extreme conservatives as cures will later succumb to a condition which is the direct result of the Fabian policy. John B. Deaver.] COMPLICATIONS.— I have al- ready pointed out that spontaneous cures may occur without leaving- a dangerous condition behind and have remarked on the rarity of such a favorable outcome. More usual is it for a collection of blood, often very large, to be left as a foreign body in the peritoneum. These collections or hematoceles excite a reactive peritonitis which serves to glue together the intestines and encapsulate the mass of clots. Absorption and organization of such a clot may take place, but is usually very slow. In the mean time not in- frequently infection occurs. The danger of this is apparent when we realize that an hematocele is nothing but a most inviting medium for bac- terial growth, situated about the rectum or lower bowel, which harbors the most virulent bacteria. [An infected hematocele is a serious con- dition and demands prompt evacuation and drainage. This is best done by way of the vagina, if possible. At times it is necessary to attack it by the abdominal route, accept- ing the danger of a subsequent peritonitis. John B. Deavee.] Obstruction of the bowel is men- tioned by Parry as the cause of death in a number of instances. The mechanism of this is by the peritoneal adhesions set up by the old extrava- sation of blood or a degenerated fetus in neglected cases. Case of extra-uterine gestation sac which ruptured into the large intestine. A five-months fetus with cord and placenta was passed from the rectum, and the patient .recovered. Martin (Munch, med. Woch., Aug. 21, 1906). A pregnancy which is allowed after rupture to develop free in the ab- domen or in the broad ligament later furnishes a very difficult problem to ABORTION, TUBAL (DEAVER). 189 the surgeon owing to the danger in dealing with the placental site, and the mortality in such cases is much higher than in the early cases. Left entirely to itself the fetus often be- comes infected, and the earliest records we have of extra-uterine preg- nancies are of cases in which this oc- curred, the resulting abscess later spontaneously discharging through .the abdominal walls, when its nature was surmised by the appearance of degenerated fetal parts in the dis- charge. Sepsis, exhaustion and death were noted in 54 of Parry's cases. Case of ruptured ectopic pregnancy which presented the combination of a ruptured ectopic pregnancy in which the following points of interest were noted: 1. Recovery following a ruptured ec- topic gestation with a streptococcus in- fection of the sac and the peritoneal cavity, with a patient so alarmingly ill. 2. The presence of the indurated mass in the right quadrant of the abdomen which suggested an inflammatory con- dition, although in consequence of the finding of the streptococcus in the cul- de-sac and the cavity of the uterus an abdominal section seemed to be inad- visable at the time of the first operation. 3. The finding of streptococci in tha fluid aspirated from the abdominal mass, showing that the peritonitis was spreading and calling for an immediate abdominal operation. Hunter Robb (Cleveland Med. Jour., April, 1911). ETIOLOGY AND PATHOGEN- ESIS. — In attempting to get a clear idea concerning the causation of extra-uterine pregnancy, one is quite awed and overcome by the vast number of hypotheses which have been advanced to account for this curious anomaly. [It reminds us of the wealth of therapeutic suggestions with which we are favored in the case of diseases as yet ;-esistant to all modes of treatment. It is not surprising that there is still considerable obscurity in the etiology. A correct understanding of the pathology of any condition presupposes a fairly exact knowledge of the normal phys- iology of the parts. There still exist many problems connected with maturation, ovula- tion, impregnation, implantation and devel- opment. Some of these problems carry us well back into the shadowy realms of the beginnings of life itself, that ultima Thule of the biologist. The incompleteness of our information concerning these abstruse secrets of nature forces us here, as in so many other medical problems, to resort to the methods of induc- tion and experience, and if we have not yet arrived at the point where we may safely take the inductive hazard it is because we may not yet have appreciated fully the say- ing of old Ambroise Pare that "such matters cannot be determined by sitting down and thinking, but by hard unremitting toil." Gradually, however, our knowledge of the normal functions of procreation has been expanding and a sufficient number of cases have been observed, recorded and analyzed to enable us to recognize certain factors which evi'dently play an important part in the etiology. John B. Leaver.] Lawson Tait originally thought that the ciliary current of the mucous membrane of the tubes and that of the uterus was in opposite direc- tions, that of the tubes being directed toward the uterus and that of the uterus moving upward, thus forming a natural meeting place of sperm and ovum at the fundus. He*considered it abnormal for spermatozoa to gain an entrance into the tubes and held that impregnation occurring in the tubes through this accidental invasion of the spermatozoon was very likely to give rise to tubal pregnancy. This beautifully simple conception has yielded to the iconoclastic power of observed facts. We now know that the ciliary current of the uterus as well as that in the tubes is downward. We know that the spermatozoa can 190 ABORTION, TUBAL (DEAVER). readily stem this current, their rate of speed being" calculated by Henle as 1 cm. in three minutes. We know that they quite regularly obtain entrance into the tubes and swarm up its lumen and it seems quite probable, if not certain, that impregnation in the tube is common, if not the regular method. Once fertilization has taken place develop ment begins at once. The ovum, comparable in many respects to a parasite, rapidly throws out the chori- onic villi which lay hold on the maternal tissues and by erosion secure anchorage and open up the intervillous blood spaces. Just how soon the ovum displays these grasp- ing tendencies is unknown. The • youngest ovum of which we know was discovered by Peters in the uterus of a woman who committed suicide three days after missing her period. It measured .6 x .8 x 1.3 milli- meters and was firmly implanted with numerous projecting villi in the process of formation. Certainly this ovum was less than a week old. Just what condition must be met by the maternal tissues to permit of implan- tation is uncertain. Webster is quite certain that there must be a decidual reaction and a number of observers have reported having seen decidual formation in the tubes. Normally the oosperm is swept down into the uterus before it effects a lodgment. The forces which accom- plish this movement are the peristalsis of the tube and the action of the cilia. Whatever delays the ovum in transit, permitting it to put out the anchoring villi, in the presence of a suitable soil, renders imminent the occurrence of an extra-uterine gestation. Forty-one cases of bilateral tubal pregnancy found on record to which the writers add a case in which there was a twin pregnancy in one tube and a simultaneous single pregnancy in the other. The size of the three 3-months fetuses proved that the pregnancies were practically simultaneous. In only 15 cases on record was the tubal preg- nancy simultaneous on both sides. P. Launay and Seguinot (Revue de Chir- urgie, April, 1911). As to the nature of the soil required by the ovum we are not so certain. Concerning the influence of delay which is governed by mechanical causes everyone is agreed. These causes may be classified as : — 1. Malformation: as diverticula, accessory ostia, and persistence of the greatly convoluted fetal contour of the tubes. 2. Obstruction from within : as in tubal polypi and torsion of the tube. 3. Obstruction from without : as in myoma and peritoneal bands and adhesions. 4. Inflammation, which acts by de- stroying the motor power of cilia and musculature and secondarily by the formation of different types of ob- struction. 5. Excessive size of the ovum itself, as in the delay which occurs in external migration of the ovum. The importance of the inflamma- tory factor in the etiology of ectopic gestation is becoming more and more appreciated and is even of use in the diagnosis, a history indicating more or less pronounced salpingitis tending to arouse our suspicions of the greater possibility of an extra-uterine preg- nancy in a doubtful case. An analysis of 170 cases in the author's cJinic showed that tubal preg- nancy sometimes results from an infan- ABORTION, TUBAL (DEzWER). 191 tile condition of spiral torsion of the tubes, but chiefly from residues of old gonorrheal or inflammatory puerperal processes. In the diagnosis inflamma- tory conditions may be differentiated from ectopic gestation by the leucocyte count and by puncture of the posterior vaginal wall. Fehling (Arch. f. Gynak., Bd. 92, Hft. 1, 1911). According to the site of Implanta- tion we recognize several varieties : — ■ .1. The interstitial, located in that part of the tube which pierces the uterine wall. 2. The isthmial. 3. The ampullar. 4. The infundibular. 5. The ovarian. These are the primary forms. Later the gestation sac by reason of rupture or growth may change its position, giving rise to the secondary forms. Thus the interstitial form may be converted into an intra-uterine by rupture into the cavity of the uterus, into an abdominal by rupture into the general cavity or into an intraliga- mentary by escape between the layers of the broad ligament. The isthmial and ampullar forms similarly may become tuboabdominal, tubo-ovarian, abdominal or intraligamentary. An infundibular or ovarian pregnancy always tends to become abdominal. The last-named condition is one of the greatest curiosities of abdominal pathology. All the undoubted cases of ovarian pregnancy so far observed can be numbered on the fingers. The interstitial and infundibular forms are almost as great rarities ; so that for practical purposes we have to do only with cases primarily isthmial or ampullar, of which the latter are most numerous, and with the forms second- ary to these primary varieties. Case of extra-uterine pregnancy in which the fetus was discharged by the rectum. Notwithstanding a pelvic ab- scess, an intestinovaginal fistula, gen- eral adhesive peritonitis, and phlebitis of both legs, the case ended in recovery. J. R. Laughlin (Jour. Amer. Med. Assoc, May 21, 1910). Extra-uterine pregnancy assumes pathological significance when it under- goes ectopic attachment. The tubal ovum has a parasitic action, malignant in that it destroys maternal tissues; it embeds itself in the tube wall, and tends to the death of the mother. The growth of the ovum or the enlarge- ment of the dead ovum mass, thinning and destroying the tube wall, leads to ■ almost certain rupture of the tube. Primary rupture may be partial or complete and fatal. If incomplete, sub- sequent ruptures will be almost certain to follow. With rupture free hemor- rhage occurs, which may prove fatal. There may be one rapid fatal hemor- rhage or a series of minor hemor- rhages. . If death does not occur from hemorrhage, the blood and the ovum in the abdominal cavity may act as imitating foreign substances which lead to loss of function and pathological changes in the viscera, to local or gen- eral infection, thrombosis, embolism, etc. The dead ovum is almost as harm- ful as the living one, from the stand- point of rupture, and may be more harmful as a focus of infection. C. W. Barrett (Amer. Jour, of Obstet, June, 1911). The natural outcome of extra-uter- ine pregnancy, as stated in the defini- tion, is early interruption, whether by reasons of insufficient blood supply or unfavorable mechanical conditions for the continued development of the fetus. The most common event is the formation of a tubal mole from the slow leakage of blood about the sac. This soon results in the death of the fetus and cessation of growth. In this way spontaneous recovery may 192 ABORTION, TUBAL (DEAVER). occur. I have several times in the course of pelvic operations encoun- tered old tubal hematomata which Avere clearly the result of a pre- vious tubal pregnancy which had terminated itself and retrogressed without giving the patient any great inconvenience. That this is not a frequent occurrence our clinical ex- perience and the infrequency of such operative findings testify. There is evidence to show that even after the death of the fetus the chorionic villi may continue to grow and exert an erosive action on the wall of the tube which, coupled with the distention due to hemorrhage, may bring about a rupture. More common than this is the gradual extrusion of the mole from the fimbriated extremity, a process known as tubal abortion. Rupture of the tube and tubal abor- tion may take place rapidly without the previous formation of a mole. These are apt to be the fulminating cases. Hemorrhage is more free in case of rupture than in abortion as a rule : more free in rupture into the general abdominal cavity than in rupture into the broad ligament, more free when the site of rupture involves the pla- cental attachment, and more free at the cornual end of the tube than at the ampullar end. [This latter tendency was tersely expressed by Formad, who used to say, "Ruptured cornual cases belong to the coroner ; rup- tured ampullar to the surgeon." Surgery in its march has modified this statement, but it still serves to point out the relative dangers. John B. Deaver.] Hemorrhage is the outcome of extra-uterine pregnancy which chiefly concerns us from a practical stand- point. It is probable that no case of ectopic gestation occurs which is not accompanied by hemorrhage at some time. It may, however, be early or late, slow or rapid, slight in amount or profuse. It is the chief, though not the only, factor in the production of so-called shock, and is the main agent in a fatal outcome. I shall have more to say concerning hemor- rhage under the question of treat- ment. If the patient be fortunate enough to survive the primary rupture and the fetus live, she still has to face the possibility of a second rupture of the gestation sac in its new position. Occasionally an extra-uterine preg- nancy may progress to term. Usually this is rendered possible by the escape of the fetus within its amniotic sac into the general abdominal cavity, the placenta remaining attached at the primary site. In this event, after a spurious labor at term, the fetus dies and offers an inviting site for in- fection. [Operation is here indicated on the same principle as in the case of any foreign body which threatens the host. This holds true in spite of the well-known fact that in some instances the fetus has caused little harrti, being converted into a lithopedion or adi- pocere. Such a late terminal event presup- poses a series of diagnostic failures which we trust, now that the condition is so well known and understood, may not come to pass. John B. Deaver.] TREATMENT.— This involves a discussion of the immediate consider- ations concerning an active versus expectant mode of treatment in cases of rupture. [It has long been my practice to operate every acute case of extra-uterine pregnancy without delay and my results have been so uniformly good that it would never have occurred to me to reopen the question. Robb, in 1907, came forward with the as- ABORTION, TUBAL (DEAVER). 193 sertion that surgeons were losing many of their desperate cases from ovcrhastc in operating during shock. He believes that shock is mainly due to the elTect of the acci- dent of rupture upon the nervous system, that it would be a great rarity for a patient to bleed to death and that cases in which the loss of blood in itself would be sufficient to bring about a fatal termination would seldom be seen in time to save the patient. He bolsters his position by animal experi- ments, having observed that dogs do not die of hemorrhage even after section of the uterine and ovarian vessels. Just what he considers the cause of death in these cases is not clear. The coroner's statistics of Dr. Formad, though he admits that it is on record that in certain instances the amount of blood which was found was enough to fill the abdominal cavity, Robb dismisses by saying that "such statements are entirely too meager to give us any def- inite knowledge, nor can they be entirely depended on." He also says in 'this regard that "in a given fatal case it must also be proven that there were no other and possibly equally important factors in the causation of the fatal result." He not only doubts that the coroner saw the blood, but he invites us to prove that the patient did not die of cere- bral apoplexy instead of abdominal hemor- rhage. As for the animal experiments I can only say that, if he has not seen a woman die from hemorrhage from a uterine artery, he has been more fortunate than I have been, and that I therefore still resort to the old- fashioned expedient of tying as secure a knot about that vessel as I am able. John B. Deaver.] Formerly it was not such an un- common thing for these patients to bleed to death. Of the 500 cases reported by Parry there were 336 deaths, 174 of which were from rupture and hemorrhage. Of 113 of these in which the time of death was stated 81 had died at the end of 24 hours and at the end of 48 hours only 15 were left alive. Of course this gives a greatly ex- aggerated idea of the danger because in those days only the evident and severe cases were noted. Still it serves to show that, without opera- tion, death, which was shown by autopsy to be associated with exces- sive hemorrhage, was not so un- common a sequel If these deaths were not due to hemorrhage, what did cause them? [Has anyone seen a death from shock of rupture with an. insignificant or even a mod- erate amount of blood in the peritoneal cav- ity? In the cases which I have seen in this so-called state of shock, the condition of the patient bore a striking parallelism with the amount of blood found in the abdominal cavity. I wish to enter a strong protest against the loose use of the term shock in this condition as well as the vicious tendency of such flashy phrases as "adding shock to shock. John B. Deaver.] The great danger in these cases is not from the shock of rupture, but from the subsequent hemorrhage. Or, to be very conservative, severe hemorrhage is necessary to produce the fatal outcome. Let us consider for a moment this factor, shock. It is known that any acute lesion of the peritoneum produces, through shock to the great abdominal nerve centers, a certain train of symptoms, whether the lesion be due to rupture of the appendix, twisted pedicle of an ova- rian tumor, passage of gall-stones, acute strangulation of the intestine, or rupture of an extra-uterine preg- nancy, and to this train of symptoms Giibler has given the name "perito- nism." These symptoms are inde- pendent of inflammation or of septic intoxication. They are : pain, pro- found exhaustion, distressful anxiety, pallor ; soft, quick pulse ; cold extremi- ties, shallow respiration, nausea and vomiting. These vary In degree and are common in some degree to all cases in which there has been a wide -13 194 ABORTION, TUBAL (DEAVER). and abrupt impression upon the nerve centers of the abdomen. This is the train of symptoms which follow im- mediately upon an acute rupture of the gestation sac and gives the picture properly denominated as shock. This shock as such is practically never fatal. Clinical evidence is conclusive on this point. We do not find our patients dropping over dead from acute strangulation, twisted pedicles or tubal ruptures. The shock exerts its maximum influence at the moment of the tearing injury to the perito- neum and sympathetic trunks and practically ceases at once with the release of tension after the laceration has been effected. This factor is sudden, momentary, expends its energy and ceases. Reaction begins, or would begin at once, either spon- taneously or with the aid of stimu- lants. This sudden insult to the peritoneum and the great sympathetic centers is not what places the patient's life in jeopardy and holds her hover- ing in the balance for hours. This is but the advance agent of the real executioner, hemorrhage. Read in the same order as before, leaving off the pain in the beginning, we have in the symptoms of shock the symptomatology of hemorrhage : Pro- found exhaustion, distressful anxiety, pallor; soft, quick pulse; cold extrem- ities, shallow respiration, air hunger, nausea and vomiting. [Who is that man who will tell us in these cases where shock leaves off and hemor- rhage begins to play the leading role ? I feel most strongly that we are dealing here with a wrong use of words, that there is a sophistical "nigger in the woodpile." I do not believe that the patients reported by the advocates of the expectant treatment as suf- fering from shock were suft'ering from pri- mary shock, but instead from shock plus hemorrhage, and that, by the time they were seen by the surgeon, that hemorrhage was playing by far the chief role. Those patients who are fortunate enough to lose but a small quantity of blood at the time of rup- ture react from the shock with considerable promptitude. By the time proper surgical intervention can be brought to bear, their condition is such as to give the surgeon little immediate anxiety as far as the shock of operation is concerned. These patients should be operated at once on account of the danger of secondary rupture or a re- newal of bleeding. They should all get well. John B. Deaveu,] An immediate operation detracts nothing from the chances, but guards against imminent danger. Those patients who, when seen an hour or several hours after rupture (I am speaking of conditions as we find them, for. patients do not come to a hospital or doctor's office to be handy at the time of rupture), are hanging in the balance with the symptoms some are pleased to call shock are not suffering from shock, but rather of shock plus hemorrhage, shock in small type, hemorrhage in large red capitals, and the examples of reaction are not proofs of the wisdom of wait- ing, but of the fact that many desper- ate cases will stop just short of bleed- ing to death if left to themselves, a fact which has for years been patent to all. The necessity for surgical interfer- ence lies in the fact that one can never foretell the result if a case is left to nature. Tubal abortion usually oc- curs before the sixth week of impreg- nation, pregnancy being usually ar- rested thereby. H. C. Coe (Annals of Gynec. and Ped., Jan., 1906). There are certain factors which would favor the cessation of bleeding, such as a long and voluminous sig- moid or omentum wedging down in the pelvis, butj as we are not often ABORTION, TUBAL (DEAVER). 195 furnished with a diagram of interior arrangements in these cases, we do not know whetlicr these stanch allies are on the ground. The character of the rent and the coagulability of the blood we cannot estimate. [As sure as there are immutable laws of hydrostatics and of the circulation of the blood, these patients have died in the past in considerable numbers from hemorrhage and occasional!}^ die today from that cause, and the only reason more do not die of it is be- cause of the early operation practised by clinical surgeons. I am willing to grant that a patient should not have a "penknife" operation done on her before she has recovered from her first faint. There is reason in all things. It is equally true that a patient in articnlo mortis should not be subjected to operation. "The re- sources of surgery are rarely successful when practised on the dying. These princi- ples, however, should not be made use of to attack a mode of treatment which has been crowned with the highest success. John B. Deavee.] The quicker a woman with ectopic gestation is operated upon, the better are her chances for recovery. Further- more with few exceptions, the opera- tions should be done by the abdominal route, and the element of time be con- sidered as important. A quick oper- ator's patients have a better chance than have those of a slow operator. A care- ful peritoneal toilet is not desirable ; re- move the large blood-clots that are readily accessible and close the abdomen without drainage. H. J. Boldt (Mo. Cyclo., April, 1908). The pathology of the condition shows that treatment directed toward the kill- ing of the ovum is irrational. Patients in good condition, with or without rup- ture, are almost certain to have future trouble, and should be operated upon as soon as possible. Patients in bad con- dition, with concealed hemorrhage, show collapse according to the loss of blood, and rational treatment should aim to stop further hemorrhage. Open- ing the abdomen and ligating the proper vessels is the only way to effectively control internal hemorrhage, and when done rapidly and carefully does not tax the patient severely. Universal clinical experience and study of the pathology of this condition show the danger of delay. While the patient is living, the more desperate the case, the greater the need of immediate action. C. W. Bar- rett (Amer. Jour, of Obstet., June, 1911). My position then is this : A con- tinuance of the collapsed condition, commonly, and as I believe erron- eously, termed shock, for a longer time than one hour indicates that a considerable hemorrhage has oc- curred and may be continuing'. The surgical indications are clear — stop the bleeding-; stimulate. Let us not revert to the dark ages in the ranks of those who "watched the life ebb rapidly from the pale victim of this accident, but never raised a hand to help her." According to Schauta, the maternal mortality in non-operative cases is 68.8 per -cent. The writer is inclined to feel that this percentage is too high, that more cases of ectopic gestation escape recognition and live than we have sus- pected. At the Columbus Hospital op- eration is always resorted to, and, per- formed speedily and promptly, should not give a mortality of over 2 per cent. The dangers are from shock, hemor- rhage, sepsis, exhaustion, and intestinal obstruction. J. M. Keyes (N. Y. Med. Jour., Aug. 6, 1910). Since 1900 I have had 110 cases of extra-uterine pregnancy, many of them of the acute type, without a death. My procedure in these urgent cases is as follows : If the condition be very low, stimulation is begun on admission by hypodermoclysis and strychnine. If there is extreme rest- lessness, morphine is a valuable ad- junct. 196 ABORTION, TUBAL (DEAVER). They are placed on the table with as little disturbance as possible and a light quick etherization given. Prep- aration is rapidly completed and intravenous transfusion of normal saline solution started as the abdom- inal incision is made. "Get in quickly, get out quicker" applies here as forci- bly as anywhere in surgery. The offending tube and ovary are re- moved. The clots are scooped out, and, if the condition of the patient warrants, the abdomen is flushed out and filled with normal saline before closure. In 70 cases of extra-uterine pregnancy encountered by the writer the fetus was found behind the uterus e'ght times, four times in the tube, in 1 partly in the tube and partly in a sac, in 2 in a small sac near the tube, once in a cavity formed by the tube and ovary, once on top of the bladder, and once on top of the uterus. In 13 it was found in the lower part of the abdominal cavity. In two instances the fetal structures were apparently safely implanted among loops of intestine. In one of these a living 4-nionths fetus was found. In this instance the history did not clearly determine the date of expulsion from the ruptured tubs. The routes em- ployed for operation in his series were the abdominal fifty times, the vaginal nine, and the vaginal immediately fol- lowed by the abdominal or vice versa eleven times. Bovee (Amer. Jour, of Obstet., April, 1910). I have frequently seen the patient go off the table with a far stronger pulse and in better condition than before the operation, a sufficient ref- utation of the charge of "adding shock to shock." I have rather re- fused to allow hemorrhage to be added to hemorrhage, and now I am not afraid to fill her vessels with suffi- cient fluid to satisfy the mechanical needs of the circulation. [My last case before this article was writ- ten happened to be most appropriate to this discussion : A young won)an, aged 24, mar- ried three years, with nothing of note in her past history. She had had one child nine months ago, which died in January. No miscarriages. Menstruation had always been regular and norm.al up to her January period, which she missed. At the February period she bled quite profusely and for a longer time than usual. No staining since. Suddenly at 6 a.m. on February 12th, dur- ing coitus, she had an acute pain in the lower left side of the abdomen, followed in a few minutes by syncope. Soon she recovered, but fainted several times in the course of the morning, and vomited several times. Grad- ually grew weaker and grew short of breath. On examination she did not have a particle of color in her skin or lips. Expression was anxious : she was restless and dyspneic. The pulse was about 180 and barely per- ceptible. Her abdomen was moderately dis- tended and tender in left side low down. Vaginal examination was negative except for tenderness in the left lateral fornix. She was taken to the operating room and subcutaneous infusion started with the ether. Preparation having been quickly accom- plished, the operation and intravenous trans- fusion were started together. A left-sided tubal pregnancy (see colored plate) the size of a hickory nut was found in the isthmial portion about 2 cm. from the cornual ex- tremity. ■ Through the tube was a perfora- tion only about as large as a pinhead. No time was wasted in determining whether there was any active bleeding. Tube and ovary were removed. As the patient's con- dition was improving on the table, I washed out the blood, of which there was a large quantity, and filled the abdomen before clos- ure with salt solution. Her pulse, which before the operation was 180, at the end of the operation was 140 and much improved in quality. She was put back in bed and continuous proctoclysis started. John B. Deaver.] I wish to call attention to the value or rather necessity of filling the empty blood-vessels with saline in these depleted cases. In the above case, the amounts used were as fol- lows : By hypodermoclysis at the cr ABSCESS (WITHERSTINE). 197 beg-inning-, 1000 c.c. Intravenous transfusion during; the operation 2000 c.c. Left in the abdomen at least 1500 c.c. Then in the twelve hours after operation her thirsty vessels absorbed by way of the large bowel 4000 c.c. additional. Nearly nine liters of saline, over two gallons of fluid to meet the mechanical needs of the circulation. AMthout this saline my patient would have run grave danger of dying on the table. As the intra-abdominal pressure is released by incision the blood flows into the "splanchnic tank" and from the great depletion due to hemorrhage nothing is left in the great vessels for the heart to pump. The medullary vessels are asphyxiated and death results. This restoration of the fluid volume of the blood is a most impor- tant point and will eliminate what is I suspect, the most potent factor in that additional shock so feared by the misguided advocates of expectancy. It is now universally agreed that dur- ing active hemorrhage consequent on tubal rupture or abortion the correct treatment is to open the abdomen and remove the gestation sac. In the writer's series of cases this was done in 16. In 2 of these the patients when seen were collapsed and almost pulse- less. Their condition warranted only slight anesthesia, and after removing the ruptured tube the abdomen was closed without any attempt to clear out the blood-clot which filled the abdomen. From the writer's experience in these cases immediate operation, even in the collapsed condition of the patient, is better than temporizing with saline infusion in the hope of improving the condition of the pulse before operating. The best way to improve the pulse is first to open the abdomen and remove the source of bleeding, and then admin- ister salines. In 14 cases so treated the condition of the patient permitted of the delay necessary for preparatory treatment and for the removal of all blood-clots from the abdomen. Kynoch (Lancet, June 10, 1911). John B. Deaver, Philadelphia. ABSCESS.— DEFINITION.— A circumscribed collection of pus in an adventitious cavity, the result of local- ized inflammation due to infection by pus-forming microbes, differing from diffuse suppuration which is not cir- cumscribed and from purulent effusion or empyema which is found in a natural or pre-existing cavity, as the pleura, pericardium, mastoid cells, etc. VARIETIES.— An abscess may be acute, or zvarm, when due to pus- microbes only: staphylococci, strepto- cocci, and others ; chronic, or cold, when due to a specific microbe, especially that of tuberculosis. Abscesses have been classified ac- cording to : — 1. Etiology. — Atheromatous, em- bolic, fecal (stercoraceous), metastatic, miliary, ossifluent, puerperal, pyemic, residual, symptomatic or congestive, tropical, tubercular (strumous, lym- phatic, or scrofulous), etc.. 2. Pathology. — Acute or warm, canalicular, caseous, chronic or cold, critical, gangrenous (anthrax), lig- neous, perforating, phlegmonous, etc. 3. Location (Organ or Tissue In- volved). — Alveolar (gum, jaw, teeth), of axilla, bone (subperiosteal), brain (cerebral, cerebellar), bursal, corneal (hypopyon), deep, dorsal, follicular, hepatic, of hip-joint, iliac, ischiorectal, lacunar, lumbar, mammary (milk, weid or weed, breast), marginal, mediastinal, meningeal (extradural, subdural), of neck, nephritic and perinephritic, of nose, of palate, palmar, of pancreas, perityphlitic, popliteal, of prostate, psoas, rectal, retropharyngeal, of skin 198 ABSCESS (WITHERSTINE). (furunculosis), of scalp, of space of Retzius ( preperitoneal cavity), spinal or vertebral, of spleen, superficial, thecal, urethral and periurethral, vulvo- vaginal (Bartholinian ), etc. All the above varieties will be considered under their respective anatomical heads. ACUTE, OR WARM.— Symptoms. — An acute abscess may be either su- perficial or deep. When it is superficial the local symptoms predominate ; when it is deep the general symptoms are more marked. The pain, due to compression of the nerves by the disturbed tissues, varies in degree with the density of the parts involved, the local supply of sensitive nerves, and the tension produced by the inflammatory products. In superficial abscess the pain is generally localized in the center of the swelling, and is sharp and lancinating; in deep abscess it is more diffuse and dull. Redness is due to engorgement of the local blood-supply, and the swelling to the inordinate distention of the ves- sels and the secondar}- escape of blood- plasma, colorless corpuscles, etc., into surrounding tissues. It may become very great in certain regions, such as the lids, the lips, etc., in which the cellular tissue is lax. As the purulent foci run together and form a single cavity, the center of the tumefaction becomes soft, and darker in color, and the abscess is said to be "pointing." Edematous infiltration in superficial abscess denotes the presence of pus ; in deep abscess subcellular edematous in- filtration is an important sign of deep suppuration. Local heat, throbbing, and tension are mechanical results of the causes of tu- mefaction tending to decrease as the formation of pus progresses. Hyperpyrexia is in relation with the location of the abscess, the ease with which the pus-microbes can enter the circulation, and the amount of pus and necrotic tissues present. In superficial abscess there is but little rise of tem- perature, but in deep abscesses it some- times reaches 104° F. (40° C.) at the time the wall of granulation tissue is established. A remission of about one degree each morning usually takes place. When the pus has found an issue, or has become completely sur- rounded by the limiting membrane, the intensity of the fever is usually reduced. In a superficial abscess, if a chill oc- cur, it is usually very slight, and ap- pears between the fourth and the eighth day. It indicates the formation of pus. In a deep abscess a chill generally occurs, lasting from a few moments to half an hour. Fluctuation is generally obtained when the purulent focus has been formed. A sharp localized pain on pressure over the apex of the swelling obtained at this time supports the likeli- hood that pus is present, but fluctua- tion is liable to be a misleading symptom. Interference with motion or the normal functions of a part is sometimes produced through the proximity of an abscess. In deep-seated abscess any or all of the general symptoms of abscess may be lacking, except loss of flesh and strength. This is especially true of hepatic or cerebral abscess. The symp- toms usually present are local tender- ness and pain, pressure symptoms, overlying edema, brawniness, muscular rigidity and ankylosis of neighboring joints, in addition to the symptoms of acute suppuration — fever, chills, sweats, anorexia, restlessness, etc. ABSCESS (WITHERSTINE). 199 Etiology. — Inflammation clue tc) trau- matisms and lesions of all kinds, espe- cially the introduction of foreign bodies under the epidermis, are the usual causes of abscess. While l)l(nvs do not apparently produce superficial lesions in the majority of cases, the fact remains that an invisible abrasion may be present and serve as a channel for the introduction of the pyogenic organ- ism. The cutaneous glands, through weakened local resistance, may also become the transmitting media. Any cause removing the epithelial layer of the mucous membrane may also form the primary etiological factor of an abscess in the membrane or in the sub- mucous connective tissue. Abscesses also arise in connection with the various septic fevers. The three essentials in the formation of an abscess are : pyogenic organisms in sufficient numbers and virulence, their proper implantation within the tissues, and a sufficiently low resisting power, either local or general. Pathology. — While several varieties of micro-organisms are found in the pus of an acute abscess, the principal ones wdiich ordinarily cause purulent inflammation are the Staphylococcus pyogenes {aureus and albus), Strepto- coccus pyogenes^ Micrococcus gonor- rhocce, Bacterium coli commune, Bac- terium pyocyaneum, pncumococcus, and the Sarcina tetragena. Less frequent in the production of suppuration are the typhoid bacillus, the influenza bacillus, the diphtheria bacillus, the actinom3^ces, etc. Suppuration can occur in man with- out the presence of bacteria. Both in animals and in man, suppuration may- be due to the irritation of chemicals. Investigators have shown that suppura- tion is only a certain stage of inflam- mation, not a separate qualitative form of inflammation. The serous formation of blebs and bullae becomes purulent without the presence of bacteria. Karl Kreibich (Wiener klin. Woch., June 13, 1901). Case of subcutaneous abscesses due to the gonococcus in a child 2 years of age. The little patient developed an acute anterior urethritis and areas of induration to the left and right of the anus. All were found to contain pus in which gonococci were present. Ger- shel (Med. Record, Feb. 7, 1903). Chronic suppurative processes are very frequently unattended by fever, while acute suppurative processes are frequently unattended by fever. In a g^iven case, therefore, the absence of fever must have little weight by itself in excluding the possibility of suppu- ration. Since a rise of temperature above 100° F. occurs in about two- thirds of all aseptic cases, the pres- ence of fever alone must have little weight in making a diagnosis of sup- puration. Lyman Allen (Inter. Jour, of Surg., Feb., 1905). In the common acute type of gland- ular suppuration in infancy and early childhood suppuration is not diffuse, but more or less limited by the line of the distended capsule of the gland. The infection having been brought under control by the sacrifice of the paren- chyma of the gland, nature seeks as speedily as possible to evacuate the pus and detritus. Therefore, in incising such abscesses a destructive process should not be checked by heroic meas- ures, but the requisite amount of aid just given to complete a conservative process. Southworth (Archives of Pediatrics, Sept., 1911). Suppuration is almost invariably pre- ceded by inflammation due to the pyogenic micro-organisms. The first effect of the bacterial toxins on the local circulation is to cause an increased rapidity of the flow of blood in the part, the vessels becoming engorged and dilated. This is succeeded by slowing of the current and passage through the vascular walls and into the surrounding 200 ABSCESS (WITHERSTINE). tissues of colorless corpuscles (leuco- cytes), a few red corpuscles, and blood- plasma, the latter of which become coagulated and finally softened. One or several cavities are thus formed ; but, if the cavities are multiple, the barriers usually soften and a single focus is established. The pus is composed of the corpuscles which perish in the cavity thus formed, the broken-down remains of tissue, and the plasma. At a distance from the location of the abscess the circulation is normal, but, as the diseased area is approached, the slowing of the blood-current becomes gradually more evident, until a zone of living leucocytes is met, forming a pro- tective barrier around the abscess cavity. The surrounding parts also become permeated with new vessels, and a zone of granulation tissue (the pyogenic membrane of older writers) is formed. The spread of the suppuration being thus checked, the pus is forced to the surface because it finds the least resistance in that direction ; but, if an aponeurosis or fascia interfere, it bur- rows until an exit is found. The role of the white corpuscles (leu- cocytes) has been interpreted in various ways; Cohnheim considered them as elements of repair; others have attrib- uted to them the role of scavengers. The accepted theory at present, how- ever, is that of Metchnikoff, who con- siders them able to attack and destroy invading organisms. The process is termed by him phagocytosis, the cells being called phagocytes (^ayw, to eat, and KUTos, a cell). The dead leucocytes in pus must be looked upon as the cells that have been brought up rapidly to interfere with the spread or diffusion of the products of the micro-organisms ; a large number of these cells coming in contact with the poison in a concentrated form may succumb to its action ; but before doing so they are able to deal with a certain quantity of the poisonous material, breaking it down and rendering it inert. Other cells are constantly being brought up to assist these, until, at length, the bacteria are completely hemmed in. They live for a short time on the dead tissues ; but, being localized by the barrier of leucocytes, they ultimately die, either from inanition or because they are poisoned by their own prod- ucts or by immunizing constituents of the blood-plasma. It is found very frequently on opening an abscess that no organisms can be seen, those that were originally present appearing to have undergone degenerative changes and to have been taken up by the phag- ocytes, or devouring cells. The process includes, according to Sajous, participation of the proteolytic or peptonizing action of enzymes in the serum supplied in large quantities to the abscess. The prevailing view is that these are produced by the pyogenic bacteria. From his viewpoint (see "Internal Secretions," vol. ii, 4th ed., 1911, p. 907) these ferments are se- creted (though originally derived from the pancreas, thyroid, and adrenals) by phagocytes (Metchnikofif's trypsic cy- tase), themselves and their hquefying action has for its purpose to destroy the bacteria and their toxins in the ab- scess. The pathogenic organisms are first sensitized and softened by opso- nins and agglutinins (thyroid secre- tion), and thus rendered vulnerable not only to the digestive action of the phag- ocytes when ingested by these cells, but to the ferments (trypsin mainly) they contribute to the abscess fluids, in which they accumulate in large numbers. Differential Diagnosis. — Fluctua- ABSCESS (WITHERSTINE). 201 tion only indicating the presence of lluitl. tlie presence of tliis sign without the other symptoms mentioned should inspire great circumspection, especially if surgical measures are cmpU)yo(l. Aneurism is the most dangerous con- dition to fear. It has, however, a less acute history, a peculiar thrill and ex- pansile pulsation, and can only exist in close proximity to a large vessel. Certain semisolid growths may sim- ulate an ahscess. A\'hen the possibility of an aneurism has been eliminated, a fine trocar or exploring needle, if care- fully used, will determine the diagnosis. Prognosis. — This depends upon the general health of the patient. In the robust a suppurative process usually reaches the stage of resolution without giving rise to complications. In indi- viduals weakened by disease, hereditary or acquired, an abscess may be pro- tracted and exhaustive, and diffusion is more likely to occur if resisting tissues interfere with the superficial evacuation of the pus. Deep abscesses are espe- cially prone to become protracted through this cause, the resistance of muscular aponeuroses, etc., forcing the pus into the cellular interstices. Fistu- lous tracts, or large suppurative areas, are thus created, and the patient may succumb to blood poisoning or asthenia. Treatment. — General Measures. — Rest and elevation of the affected region, if possible; salines, if purgation is necessary. Easily assimilable food, but not low diet; avoidance of stimu- lating beverages, alcohol, coffee, etc. Internal Remedies. — If the case is seen early the suppuration can some- times be arrested by the use of one of the following agents, supplemented by one of the local applications : Tincture of aconite, 3 to 10 drops every hour, closely watching the patient's pulse ; tincture of veratrum viride, 1 drop every hour until the pulse becomes slower, the skin moist, and slight nausea occurs; or calcium sulphide (sulphurated lime), Yu) grain every hour; or, again, I^ Sulphate of quinine, 1 grain. E.vt. of nux vomica, ]/^ grain. For one pill, to be taken every three hours. Many incipient abscesses disappear under the internal use of the hypophos- phites of potassium, sodium, and cal- cium. They also act as an excellent prophylactic, if given before pus has formed. Tousey believes them to be more efficient than calcium sulphide. The combination used by Tousey is 5 grains of calcium hypophosphite, and 2 grains each of the sodium and potas- sium hypophosphites, administered in syrup or two capsules, followed by half a glassful of cold water. Fresh brewers' yeast in doses of oj to oij in water or undiluted, just before or during meals, is a favorite remedy with many, although' diarrhea some- times results, even when the yeast is fresh. A substitute preparation is made by macerating compressed yeast in water. Desiccated yeast is also used. In addition to these internal remedies, we should not forget that stimulation, nutrition and general hygienic measures are of considerable value. Thyroid gland in doses of 1 or 2 grains three times daily hastens the disappearance of abscesses, by increas- ing the proportion of opsonins in the blood (Sajous). The authors report on the use of fresh normal blood-serum from the horse or from cattle in the local treat- ment of acute suppurative processes in 100 cases. The pus was first aspirated, serum next injected to rinse out the cavity, using a needle closed at the end, but with a row of openings just above 202 ABSCESS (WITHERSTINE). it; then the excess of fluid aspirated, and the opening covered with a bit of sterile gauze held by adhesive. It is important that all the excess of serum be removed from the cavity ; otherwise, symptoms of serum intoxication may follow. The serum apparently produces both a passive and an active immunity, stimulating leucocytosis and phagocyto- sis. Better healing can be obtained by this method, according to the authors, than in any other way. Acute abscesses in the soft parts, whatever be the micro- organism present, show especially good results. One treatment with the serum generally suffices. L. Fejes and E. Gergo (Mitteilungen aus den Grenzge- bieten der Medizin und Chirurgie, xxiii, 1911). External Remedies, — The surface is carefully cleansed with antiseptic soap and sprayed with a 2 per cent, carbolic acid solution, or with hydrogen per- oxide, every two hours, the atomizer being used for ten minutes at each sit- ting. (Verneuil.) Compresses dipped in hot 1 : 4000 corrosive sublimate solution are very effective. If abscess is upon an ex- tremity, a 1 : 4000 corrosive sublimate solution may be employed as a bath for the limb, the latter being left in the solution several hours at a time. A solution of nitrate of silver (30 grains to the ounce) may be applied frequently with a camel's hair pencil. Tincture of iodine may be applied in the same manner every three hours. When the surface becomes very tender, belladonna ointment may be rubbed in every two hours. In abscesses characterized by very severe pain a 10 per cent, solution of cocaine may be introduced by cata- phoresis, the anode sponge of a gal- vanic battery being applied to the part. The sittings should last five minutes, and be repeated every three hours, the current not exceeding 5 milliamperes. During the intervals warm fomenta- tions — with borated, camphorated, or pure water — are of great value. Encouraging results obtained in the treatment of tendon-sheath phlegmons and suppurating inflammation in gen- eral with superheated air, applied with an ordinary apparatus. It is used twice a day for two or three hours each time, maintaining a temperature of from 90° to 110° C. (194° to 230° F.) within the frame at half its height. Thus ar- ranged, the temperature on the skin averaged 44° or 47° C. (111° or 116° F.), and the acceleration and sweating induced seemed to keep the temperature of the skin within due bounds. The ap- plications of the hot air are made the da}'- after the abscess has been incised and evacuated, and the cavity packed with iodoform gauze. He also states that neglected injuries of the fingers which v/ould otherwise have necessi- tated amputation healed under this hot-air treatment without requiring operative measures, and recovery was hastened. This treatment also caused an abolition of pain. (Zentralblatt fiir Chir., Oct. 24, 1908.) Pads of gauze wrung out of hot boric acid solution (an ounce to a quart of water), applied as hot as the patient can bear them, and well covered with oiled silk to keep in the heat and mois- ture, are the best; wherever applicable, as with the hands or feet, the inflamed part should preferably be submerged every hour for a period of five to ten minutes in the hot boric solution itself. Wright's Bacterial Vaccines. — Treatment of staphylococcus and strep- tococcus infections (abscess, suppura- tion, etc.) by the therapeutic inoculation of staphylococcus and streptococcus vaccines, as suggested and developed by Sir A. E. Wright, of London, has found many endorsers. A bacterial vaccine is a sterilized, standardized emulsion of the infecting micro-organ- ism. It is made by scraping the film of ABSCESS (WITHERSTINE). 203 a recent agar culture into a 1 per cent, salt solution, sterilizing at 60° C. (140° P\), and subsequently standardizing to a given number of micro-organisms per cubic centimeter. The method is, how- ever, a new and complex one, and, until its use has been more thoroughly ex- plored, it should only be employed under the guidance of an expert. Whether an opsonic control of the in- jections will always be necessary still remains to be shown, but in all cases the use of the vaccines should be pre- ceded by a most careful bacteriological examination, and the particular vaccine should be prepared for each individual patient. The dose of staphylococcus vaccine is 100 to 1000 millions; an inoculation being made every ten days. The dose of streptococcus vaccine which is more toxic than staphylococ- cus is 20 to 60 millions ; the inoculations being repeated weekly or every two or three Aveeks. The writer has tried the vaccine treatment of staphylococcus affec- tions in 20 cases and obtained en- couraging results, especially for re- curring furuncles. Jensen (Hospital- stidende, Mar. 3, 1909). Wright's comparatively simple the- ory of opsonins and its practical application have been rendered need- lessly confusing to the average prac- titioner. As Wright points out, the great causes of failure in previous tuberculin treatment was the giving of too large injections and too fre- quent repetition of the dose, causing a marked negative phase and keeping it up. The writer has had remark- able success in various tj^pes of sta- phylococcus infections; obstinate cases of acne and furunculosis, im- petigo, palmar abscess, and in a very distressing case of what had been called psoriasis, but which he thinks was an extraordinary case of staphy- lococcic dermatitis, and which jaelded rapidly to opsonic treatment with an autogenic culture of Staphylococcus aureus. A. P. Ohlmacher (Jour. Amer. Med. Assoc, P>b., 1907;. Case of furunculosis, subperiosteal abscess of the head, and necrosis of the bones of the skull treated by oper- ation and autogenous vaccine. Staphy- lococcus aureus was ""ecovered from the parietal abscess and from the blood. An autogenous vaccine was made, and 4 doses were given at intervals of four days. The first dose was 50,000 000, the second 100,000,000, and the last 2 150,000,000. With no constitutional re- action, the local condition rapidly im- proved. The general condition of the patient improved, but a portion of the bone at the base of the abscess was denuded and necrosed. At a later date this sequestrum was removed and the patient was given 3 more injections of the autogenous vaccine at four days' interval, each dose being 150,000.000. Within three weeks the patient was in normal condition. The author urges preference for the autogenous vaccine. G. G. Ro'ss (Monthly Cyclo. and Med. Bull., Sept., 1910). Bier's hyperemia treatment (passive congestion or artificial hyperemia) of acute abscesses has given excellent results as to immediate relief of pain and reduction of inflammation. Inflammation, according to Bier, does not in itself represent a diseased condi- tion, but is a phenomenon indicating the body's attempt to resist a deleterious invasion. To increase this beneficent inflammatory hyperemia resulting from the fight of the living body against in- vasion, is the aim of Bier's hyperemic treatment. The blood must, however, continue to circulate ; there must never be a stasis of the blood. Bier's method artificially increases the redness, heat, and swelling, three of the four symp- toms of acute inflammation. He dis- cards all means that tend to subdue inflammation. Bier produces this hyperemia by any 204 ABSCESS (WITHERSTINE). or all of three methods : Elastic band- age or band, cupping glasses, and hot air. In the use of the elastic bandage, it should cause slight obstruction to the return of the blood, but not sufficiently firm as to obliterate the pulse beat below or be in the least way annoyable to the jDatient. The technique is correct if there is absolutely no increase of pain, and if there is visible hyperemia of the parts subjected to treatment; the portion distal to the bandage must appear bluish or bluish red — never white. All dress- ings should be removed while the com- pressing elastic bandage is in place, the wounds or bruises being covered with sterile gauze kept in place by a loosely applied towel. Under hyperemic treat- ment any abscess must be opened and pus evacuated. Acute inflammatory processes require application of the hyperemic treatment for twenty to twenty-four hours per day. In chronic cases, especially if tuberculous, shorter sittings, from two to four hours per day. In the use of suction apparatus or cupping glasses to produce obstructive hyperemia, the skin should turn red or bluish red, but never white ; circulation must not be interrupted. The vacuum apparatus of large size is supplied with a suction pump. These suction glasses are applied for five minutes, six times daily, with intervals of three minutes between applications, in order to give the edema and hyperemic swell- ing an opportunity to disappear. Thus the entire time of treatment is three- quarters of an hour each day. Treatment of acute abscess by passive congestion has given excellent results. Cases of purulent arthritis, suppuration of tendon sheaths, and acute abscesses and carbuncles have shown without ex- ception almost immediate relief of pain and reduction of inflammation. The ab- scess either became "cold" or its con- tents changed to serum or were re- sorbed. Purulent arthritis was treated with passive motion after all pain had been relieved. The writer selected 15 of the 110 cases cited for brief descrip- tion in the article. All cases were quickly cured, and it was only rarely necessary to open the abscess. Of the 15 cases reported, 8 were resolved, 3 were opened, and 4 were discharging when admitted. Bier (Miinch. med. Woch., Jan. 31, 1905). By means of artificial hyperemia, we can often abort an infective process and save the breaking down of tissue, or, if at the beginning of treatment the proc- ess has gone on to the breaking down of tissues, the hyperemic method assists in quickening the process of expulsion of the products of infection and also the process of repair. J. H. Beaty (Jour. Minn. State Med. Assoc, Jan. 15, 1908). In the use of hot air to produce hyperemia we produce an arterial hyperemia which differs from the ob- struction or venous hyperemia. The effect of hot-air hyperemia is also dif- ferent upon the body and also upon the pathologic process. This last method is apparently not used in the treatment of abscess. The author comments on the value of Wright's solution of sodium chlo- ride, 4 per cent., and sodium citrate, 1 per cent., as an agent for promot- ing drainage of abscesses. The hy- pertonic solution of sodium chloride by osmosis brings about a flow of lymph through the abscess walls, while the sodium citrate, by precipi- tating the calcium salts in the lymph, prevents the latter from clotting, and thus perpetuates the discharge. The lymph and 4 per cent, salt solution both antagonize the bacteria. The technique of treating an abscess by this plan is described as follows: The abscess is opened by a wound as small as will allow the cavity to be wiped out, or thoroughly emptied by ABSCESS (WITHERSTINE). 205 expression. The surrounding skin is well cleaned with 70 per cent, alcohol and smeared up to the very mouth of the wound with boric acid or euca- lyptus vaselin, in order to avoid skin irritation from the salt solution. If the skin tension closes the opening a bit of rubber dam may be put in. The wound is covered with a volumi- nous pad of gauze or of absorbent cotton covered with gauze, dripping wet with hot salt and citrate solu- tion. A many-tailed bandage or some other application holds the poultice in position, and the part is put at rest. Outside the dressing may be applied a hot flaxseed poultice or a hot-water bottle. In any case, as often as the dressing gets cold, more of the hot solution is poured over the whole dressing to wet and warm it again, or the dressing is removed and the whole part soaked, if possible, or bathed with the same solution. The solution is contraindicated if there is a tendency to persistent ooz- ing of blood from the wound, and where the formation of protective adhesions is desirable. Inguinal and axillary bubo, abscess of neck, septic fingers, mastoid wounds, otitis media after paracen- tesis, all drain well under this method. The solution should be used only for the first thirty-six to seventy-two hours after operation, during the acute stage of inflammation. The wound is then filled with glycerin or balsam of Peru. L. R. G. Crandon (Annals of Surg., Oct., 1910). The iodoform bone-wax recom- mended by von Mosetig-Moorhof tried in 5 cases, in which the wax failed and was discharged. It is of value as a filling in selected cases of circumscribed abscess cavities in Lone. Its use shortens the convales- cence and makes the dressings easy and painless. Simmons (Annals of Surg., Jan., 1911). Bismuth paste injection is an agree- able procedure for the physician and patient, practically painless and free from risk, and of value in the treat- ment of chronic fistulse and abscess cavities. It is an excellent diagno.stic auxiliary for determining the course and point of origin of fistulse and ab- scesses, and, therefore, of great value in preventing incomplete and useless oper- ations. The bismuth injections exert a pronounced efifect in relief of symp- toms by diminishing pain and secretion and curing eczema, and in some cases suffice to efifect a complete cure. H. H. Schmid (Wiener klin. Woch., Nu. 7, 1911). Antiferment Treatment. — This so- called "physiologic treatment" was recently introduced by Miiller and Peiser. It is based on the antagonistic action the proteolytic ferment derived from leucocytes is supposed to meet from an antiferment in the blood- serum, especially in morbid effusions. This antiferment can be obtained from the patient's own blood-serum, after venesection or from puncture fluids. The contents of the abscess being aspirated, the antiferment is then in- jected into the cavity with the same needle, enough being introduced to fill it without distending it. The contents of the abscess are then again removed and the cavity is once more filled with fresh antiferment. This is repeated the next day if the area is still sensitive, the antiferment being left in. This method has not as yet been tried sufificiently to warrant an expression as to its merits. No incision is required with this tech- nique ; it is applicable only when a mastitis or other process is tending to abscess formation. Thirteen typical cases of abscesses, felons, etc., are de- scribed out of an experience of 100 cases, to show the advantages of this treatment. The antiferment attracted to the spot is probably the main factor in the benefit from hyperemic treat- ment. A serum rich in antiferment can be kept on ice for several weeks in stoppered vessels. It should be tested from time to time to determine its strength. The larger the proportion of antiferment, the better and longer the 206 ABSCESS (WITHERSTINE). serum keeps. Miiller and Peiser (Bei- trage z. klin. Chir., Oct., 1908). The antiferment serum not only sup- plies the ferment which protects against proteolysis, but at the same time it sup- plies vitally active leucocytes, opsonins, complements and amboceptors, either supplying them from without or attract- ing them to the spot, and thus summon- ing the most powerful defenses of the organism. Kolaczek (Beitrage z. klin. Chir., Dec, 1908). The writer does not use the ready- made ferment, but injects a solution of sodium nuclein to induce leucocytosis in the tuberculous abscess. This is supplemented later by Roentgen-ray treatment. His first case was a tuber- culous abscess in the soft parts of the thigh, which healed completely in three sittings after it had long resisted ordi- nary treatment. Goldenberg (Miinch. med. Woch., Jan. 5, 1909). Results in Dollinger's surgical service at Budapest with the Miiller antifer- ment treatment in 160 cases. This physiological treatment proved satisfac- tory in nearly every instance. Its spe- cial field is for abscesses unless they are unusually extensive and deep, or the patient much debilitated, in which case incision is necessary; otherwise all that is necessary is to paint the outside with iodine, aspirate the contents of the abscess with a puncture needle and then inject pure serum, thus rinsing out the cavity, after which serum to an amount- representing one-third or one-half the amount of abscess contents withdrawn is injected, and a scrap of gauze is laid over the puncture hole and held in place with a strip of plaster. An abscess containing from 1 to 5 c.c. of pus heals in three days ; larger ones, containing from 20 to 50 c.c. of pus, heal in about eleven days. The absence of a scar is one of the great advantages of the method, and the functional re- sult is always better, as conditions are more physiological. The writer has never encountered any signs of anaph- ylaxis, and the abscess never pro- gressed except in a single instance, in a very debilitated patient. Gergo (Deut. Zeit. f. Chir., Jan., 1910). The writer has tried the injection of leucofermantin into abscesses — a treat- ment based upon the fact that a proteo- lytic ferment is found in the polymor- phonuclear leucocytes. A fairly large needle was used for aspiration and in- jection, and, after evacuating the ab- scess, he injected and withdrew a small quantity of serum, so as to clean out the cavity as thoroughly as possible before making the final injection, which was allowed to remain ; a moist aseptic dressing was then applied. If the aspi- ration had to be repeated, the needle was inserted through the old puncture, so as to save pain. The quantity of serum left in varied, according to the size of the abscess, from 2 to IS c.c. The author feels convinced that the principle on which the method is based is sound, and that it opens up a new pathway in the physiological treatment of suppurative inflammation. Mac- Ewan (Brit. Med. Jour., Jan. 22, 1910). Antiferment serum exerts a slight degree of curative action upon sup- puration, but must be brought into intimate contact with the whole, of the suppurating surface. It is suited only for superficial, well-defined ab- scesses. Boit (Med. Klinik, Apr. 16, 1911). Surgical Measures. — Incision and drainage tersely indicate the surgical treatment of acute abscess. If sup- puration cannot be avoided, the ab- scess should be opened under rigid asepsis, as soon as an adequate quan- tity of pus has formed to constitute an abscess sufficient in size to be recognized b}^ the surgeon as such (Senn), or as soon as the presence of pus has been determined by the ex- ploring needle or syringe. An early incision prevents excessive loss of tis- sue, less deformity and leaves smaller scar. If a local anesthetic is necessary, one of the following may be used : Twenty drops of a 1 to 5 per cent, solution of cocaine introduced sub- ABSCESS (WITHERSTINE). 207 cutaneously near the abscess- ether sprayed over the seat of the abscess until local numbness is experienced ; chloride of methyl or chloride of ethyl vapor. The latter is especially effica- cious ; the parts turn white when ready, — generalh' in about two min- utes. Seltzer water spurted over the surface may be used to advantage when none of the other agents can be obtained. To open an ordinary abscess a single small incision suffices; but, if it is large, several small incisions should be made to render perfect evacuation of its contents possible by drainage. If the abscess is super- ficial, the skin alone should be cut, but if it is deep seated the skin and fascia should be incised and the grooved director, or the points of a pair of forceps, used to reach the pus, the opening being kept patent with forceps. The cavity is then thor- oughl}^ emptied and syringed out with 1 : 10,000 corrosive sublimate solu- tion, or, better, with normal salt solu- tion or boric acid solution, until the fluid comes out perfectly clear. Pres- sure with the fingers is to be avoided, but loose necrotic tissue should be re- moved if it can be done without injury to surrounding structures. The incision and its surroundings are then carefully washed with one of the solutions mentioned, and an aseptic drainage-tube inserted. The wound is dusted with iodoform or dermatol, and an antiseptic dressing is applied, exerting slight pressure with bandage. If the abscess is deep, the drainage- tube should be shortened dail}^; if it is superficial, the drainage-tube can be withdrawn the second or third day. Drainage b}^ means of rubber drain- age-tubes of sufficient size is preferred to tlie use of gauze. Two tubes placed side by side facilitate irrigation when necessary. A good plan is to incise the abscess freely, evacuate its contents, wipe off the wall with 10 per cent, iodoform gauze, aided by the curette, clean the cavity as perfectly as possible, usin.c^' gauze freely to wipe out all debris. The wound is closed with sutures placed as deeply as possible to ap- proximate wide areas of tissue. Pres- sure is kept up over the abscess to prevent its filling with serum, and a firm antiseptic dressing is applied. The result in the majority of cases has been excellent. In only 7 cases was there any breaking down of the wound and a resulting sinus. Iodo- form emulsion was abandoned on ac- count of the dehydrating action of the glycerin. In 48 of his cases the cavity has remained perfectly closed and aseptic for periods varying from four months to six years. Starr (Brit.. Med. Jour., Oct. 13, 1906). When it is necessary to traverse the peritoneal or pleural cavity in order to reach a collection of pus, infection may be avoided by carefully packing off the cavity with gauze, so as to form a sort of well with the abscess at the bottom. The kind of dressing used after the abscess has been opened will depend upon the condition of the parts. If there be much infiltration of the tis- sues, swelling, and pain, a hot, moist antiseptic dressing is to be applied, as it favors absorption and is at the same time soothing to the patient. Any weak antiseptic solution (barring car- bolic acid for fear of gangrene) may he used, as boric acid, bichloride of mercury (not stronger than 1 to 20,- 000), or normal salt solution. The dressings (wet or dry) while suffi- ciently firm to favor collapse and adhesion of abscess walls should yet 208 ABSCESS (WITHERSTINE). be loose enough to permit of easy absorption and evaporation of dis- charges. A generous dressing of gauze covered with absorbent cotton is advised. Thirty-two cases of abscess treated by the Otis method : The skin about the affected area is scrubbed with green soap and washed with sulphuric ether and then with bichloride (1 to 1000). A narrow bistoury is then inserted into the abscess cavity, and the contents gently, but thoroughly, squeezed out ; the cavity is irrigated with bichloride (1 to 1000) and immediately filled to moderate distention with warm iodo- form ointment (10 per cent, iodo- form and vaselin), care being taken not to use a sufficient degree of heat to liberate free iodine. An ordinary glass gonorrheal syringe is used, the plunger being removed, -and the barrel warmed in the flame of an alcohol lamp and filled with ointment by means of a spat- ula. On finishing the injection, at the instant of withdrawing the syringe from the wound, a compress wet with cold bichloride solution is applied, which in- stantly solidifies the ointment at the ori- fice, preventing the escape of that into the abscess cavity. Edwin M. Has- brouck (N. Y. Med. Jour., June 13, 1896) . Puncture and disinfection recom- mended for abscess instead of incision and drainage, in order to avoid muti- lating scars and slow convalescence. The writer's method is as follows : 1. After careful disinfection, and under infiltration anesthesia, he punctures the most dependent portion with a large trocar or pointed scalpel, and gently expresses the pus. This is better than aspiration. 2. The cavity is then thor- oughly irrigated through the trocar with a 1 : 1000 solution of corrosive sub- limate. This can be used in large quan- tities, as the abscess wall does not ab- sorb. He has found this strength most satisfactory. 3. The remnants of the corrosive sublimate solution are care- fully squeezed out and the abscess is partly distended with a solution of from 5 to 10 per cent, iodoform glycerin. A moist dressing with a firm pressure bandage is then applied. This method is useful in every form of acute exter- nal abscess, following the principle originally laid down by Henle for cold abscess. To date the writer has treated 2)1 cases with good results in all ex- cept abscesses of caseous tuberculous glands, which generally required a sec- ondary curetting, though they were none the worse for the preliminary con- servative treatment. DeWitt Stetten (Jour. Amer. Med. Assoc, May 11, 1907). Peroxide of hydrogen is prophylactic and curative medicament in the treat- ment of suppurative skin lesions so common in infants. A twelve-volume solution is ample as a skin-wash twice daily. This rapidly cures superficial lesions. Abscesses must obviously be evacuated before the peroxide solution is used. Cochart (Jour, de Med. de Paris, April 21, 1901). Personal method. 1. Cleanse the skin as in operating on sterile tissues. 2. Make an incision long enough to per- mit of the pus being freely evacuated and the pyogenic membrane rubbed clean and smooth with gauze wrapped around the finger. 3. Having emptied the abscess cavity as completely as pos- sible, pack it tightly with gauze (1 to 1000 mercury bichloride gauze, dry) and apply a wool dressing and bandage as firmly as possible. 4. At the end of forty-eight hours remove the packing and dress the wound as if it were a simple incision, that is, do not pack or drain at all, but simply fix a gauze and wool dressing firmly in place with a bandage. This dressing will require changing only once in three or four days until the incision is soundly healed, the sides of the abscess cavity will unite promptly, and there is no outpouring of pus from it. From the time when the packing is removed it is practically a simple incised wound that is being treated. There results rapid healing; the constitutional symptoms are gotten rid of almost at once ; as the dressing re- quires renewal very seldom the doctor can do it himself and so avoid the risk ABSCESS (WITHERSTINE). 209 of a secondary mixed infection. J. Phillips (Brit. Med. Jonr., M-iy 16, 1908). COLD, OR TUBERCULOUS, ABSCESS.— Symptoms.— These ab- scesses frequently attain a large size, and last for months without their pres- ence being detected. Besides failing general health, the symptoms of the causative trouble are the only prom- in-ent ones. The spine, the hips, the genitourinary tract, and the lymphatic glands are the organs most prone to tuberculous disorders giving rise to cold abscesses. They sometimes ap- pear several months and even years after the beginning of the primary disease. The general symptoms of tuberculous abscesses do not closely resemble those of ordinary suppuration, but vary with the resisting powers of the individual. There is nearly always a slight evening rise in temperature (hectic) followed by a subnormal temperature in the morning. Loss of flesh and strength and the presence of anemia, more or less marked, are usual, although they may not occur unless mixed infection (tubercular and purulent) takes place. There is no leucocytosis. Amyloid (albumi- noid) degeneration may appear as a later phenomenon. The local symptoms are as a rule very slight, and are indicative of the effects of pressure upon organs or nerves rather than activity in the abscess itself. Large fluctuating abscesses may exist in various parts of the body, even about joints, without serious dis- comfort to the patient. No pain is experienced as a rule; cold abscesses are not even tender to the touch. There is no redness until the abscess is about to break, the focus of the liquid mass being otherwise too deeply seated, the skin covering the abscess remaining white or normal in color unless the abscess be just be- neath the surface, which phenomenon has caused the name "white swelling" to be applied in tuberculosis of the knee. The above symptoms usually follow or are coincident with the sudden appearance of a swelling. Though generally soft, it may be hard, and sug-gest a tumor in the vicinity of the spinal column (Pott's disease), above or below Poupart's ligament, after burrowing along the psoas muscle (psoas abscess), on the inner aspect of the thigh, or in the lumbar region (lumbar abscess), etc. In the neck cold abscesses are usually due to dis- ease of the neighboring cervical lymphatic glands. The skin either remains normal or gradually becomes thinned and softened until an external opening is formed. Fluctuation, usually detected with ease, is sometimes hidden by a thick investing layer of lymph, which gives the mass a peculiar tension, suggest- ing a lipoma or some other hard growth. Aneurisms sometimes con- vey the sensation produced by a cold abscess : a fact to be borne in mind when operative procedures are under consideration. Pathology. — A cold abscess can al- ways be traced to a specific inflam- matory process, and almost invariably to one of a tubercular nature. Where the confluent masses in the center of a nodule begin to break down, there is formed a collection of material sur- rounded by tuberculous tissue. This material becomes infiltrated with leu- cocytes, and thus is produced a cavity containing fluid fatty material, frag- t-w 210 ABSCESS (WITHERSTINE). ments of cells^ and leucocytes, around which there is granulation tissue filled with tubercles. In this way a tuber- culous abscess is formed. It seems at times to be quite a matter of accident whether the abscess breaks into the joint or finds its way by a more cir- cuitous route into the surrounding connective tissue. As the tubercu- lous masses spread, caseation takes place at dififerent points in the wall, and the masses are discharged into the cavity of the abscess ; but the spread of the abscess is effected gen- erally by what is termed ''burrowing of pus." This burrowing occurs in various directions, and large collec- tions of pus altogether out of propor- tion to the original lesion are formed, and are known as cold abscesses. AMiat has been called a chronic ab- scess is A'ery often no abscess at all. In tubercular processes the product of tissue proliferation undergoes co- agulation necrosis, and disintegrates into a granular mass, which, when mixed with a sufficient quantity of serum, forms an emulsion that micro- scopically resembles pus, but under the microscope shows none of the histological elements which are found in true pus. An abscess can only be called such if it contains pus. A true chronic abscess can originate in a tubercular, actinomycotic, or syph- ilitic lesion, when the granulation tissue is secondarily infected by the localization of pus-microbes, which convert the embryonal cells into pus- corpuscles. Differential Diagnosis. — The con- comitant disorder usuall}^ makes a diagnosis easy in a case of cold ab- scess ; but occasionally the swelling is the only indication of ill health, and it is important to determine^ under such circumstances, the nature of the pus. The macroscopical appearances of "laudable" pus and of "sanious" pus are frequently so similar that a dc z'isu diagnosis is not justified. Bac- teriological examination of the con- tents of such abscesses will show con- clusively whether they are true pus- containing abscesses or whether or not they are pseudo-abscesses. If cultivations are made of their con- tents, pus-microbes will grow upon proper nutrient media if it be a true abscess, while from the contents of a pseudo-abscess only the microbes of the primary infection can be cul- tivated. The information obtained by the discovery of the essential cause can be confirmed by inoculation experiments. Prognosis. — The walls of cold ab- scesses are usually tense and tough, and are lined with cheesy tuberculous material. They do not tend to col- lapse, as is the case with acute absces- ses, and for that reason are healed with difficulty. AMien, however, the seat of the original trouble can be reached and successfully treated, the fluid in the parts of the abscess tract is absorbed, and the caseous matter undergoes calcification. This fortu- nate issue of the case is seldom met with, however, and the abscess usu- ally continues, the primary etiological factor acting as a drain for the dis- eased area. The prognosis, therefore, depends upon the result obtained in the treatment of the latter. Surgical Treatment. — Experience has shown that when such a cold, or tuberculous, abscess opens spontane- ously, or is incised in a careless wa3^ profuse suppuration and hectic fever follow, with only too often a speedy fatal result from septic infection. ABSCESS (WITHERSTINE). 211 Unless the surroundings of the patient admit of carrying' out the antiseptic treatment to its full and perfect extent, a chronic abscess should not be evac- uated by incision. It should be aspi- rated. When an incision can be made, it should be free, and the cavity should be thoroughly curetted, cleansed, irri- gated with normal salt solution or a solution of boric acid, disinfected, and iodoformized, then sutured, drained, and treated as a recent wound. The early recognition of cold ab- scesses will enable one to dissipate or to nip them in the bud. When they are present at the time the cases come un- der observation, they should be treated with indifference so long as they do not interfere with the proper adjustment of good protection apparatus. If they are in the way, or if they show a dis- position to burrow and encroach on parts that it is desirable to keep free from such invasion, aspiration should be resorted to and cultures made in order to determine their virulency. If aspiration fails, incisions under rigid asepsis, large enough only to permit evacuation of the contents, should be relied on, and the introduction of chem- icals should be refrained from. The wound should be closed by suture under the same rigid asepsis. When the ab- scess lies directly over a bone focus that can be easily reached, the incision should be made large enough to re- move the focus, and at the same time permit removal by curette or scissors of the lining of the sac and all necrotic tissue contiguous thereto. It should then be closed aseptically, employing drainage for not over forty-eight hours. If longer drainage is demanded, means should be devised by which asepsis in dressings may be continued indefinitely, and a mixed infection looked on as a calamity. Sinuses should be well drained, the foci on which they depend should be treated if involving joints by perfect and long-continued immobiliza- tion, with due regard to fresh air and a high state of nutrition. V. P. Gibney (Jour. Amer. Med. Assoc, Oct. 29, 1904) . Conclusions based on 26 reported examinations of tuberculous ab- scesses: Tuberculous abscesses will frequently disappear under thorough protective treatment, and will not re- quire an incision. Exploratory punc- ture of the joints shotild be made early, and of the abscess preceding any operation, for diagnostic pur- poses. The method of operation should be decided on from the results of the laboratory examinations. When the abscess is reported sterile it should be thoroughly incised, curetted, and closed without drainage, under the most careful aseptic precautions. When the abscess report shows large numbers of tubercle bacilli, the in- cision should be cauterized before the sac is incised, with thorough cu- rettage, partial closure, and drainage for not over forty-eight hours, the strictest asepsis being maintained. When the cultures show mixed in- fection the abscess should be incised, thoroughly curetted, washed with a formalin solution, partially closed aseptically, and drained for not over forty-eight hours. If the clinical symptoms and X-ray show an ac- cessible focus of disease this should be thoroughly removed at the same time the abscess is incised, by curet- tage, erasion, partial closure, and drainage for a short period. Cultures should be taken from sinuses, and, if sterile, the sinus should be treated by absolute, thorough, and complete im- mobilization of the tuberculous area, with partial closure and aseptic dressings. If the cuUvres taken from the sinuses show tubercle bacilli the part should be thoroughly curetted, immobilized, and treated with a sat- urated solution of methylene blue. If the cultures from the sinuses show mixed infection they should be thor- oughly curetted under strict aseptic precautions, the diseased part should be immobilized, and the general con- dition should be treated by serum therapy. Young (Amer. Jour, of Orthop. Surg., July, 1907). 212 ABSCESS (WITHERSTINE). On general principles, necrosed or detached bone should be looked for in all cases. Strict antiseptic precautions are imperative to avoid mixed infection (bacilli of tuberculosis and pyogenic cocci). Preliminary precautions should be taken to meet violent hemorrhage due to vascular erosion. When there is local inflammation and spontaneous opening of the abscess is probable, there should be a free inci- sion, a thorough scraping of its walls with Volkmann's curette to transform the suppurating surfaces into bleeding ones. The cavity is then cleansed with a 5 per cent, solution of carbolic acid, a long drain is applied, and the wound is stitched as far as the drain. An anti- septic dressing is then applied. (Volk- mann, Trelat, Pozzi.)^ After opening the abscess the cavity may be washed out with peroxide of hydrogen in 10 per cent, solution or packed with iodoform gauze. Removal of the limiting sac is then performed by decortication, the steps being: free incision, the sac detached with finger or spatula and removal, and the cavity closed immediately. (Lannelongue.) The removal of the limiting sac is facilitated by filling the wound with paraffin ; the mass can then be removed as if it were a lipoma. (Cazin.) A psoas abscess should be opened in the loin and groin when possible. In the loin the incision should be made through the external and internal ob- lique, transversalis, and lumbar fascia, along the outer edge of the erector spine to the edge of the quadratus lumborum. The latter muscle and the transversalis fascia are divided on a level with the tip of the second or third lumbar trans- verse process, avoiding the lumbar ar- teries. The sheath and the psoas are then perforated with the finger or a trocar. A counteropening is then made below Poupart's ligament to form a tunnel, into which a large-size drainage- tube is inserted. This is replaced, later on, by a tube at each end to obtain oblit- eration, beginning from the center of the canal. If one incision is preferred the loin should be selected. Aspiration and Injections. — When no local inflammation indicates that the abscess is soon to open, the fluid may be withdrawn with a large aspirator; a 5 per cent, solution of carbolic acid is injected and then aspirated. This pro- cedure is renewed until the solution withdrawn is perfectly clear. A Lister bandage is then applied, insuring slight pressure. Five days later the treatment is renewed. About five sittings are re- quired. (Boeckel.) Injection fluids: Iodoform, 1 part; ether, 5 parts ; distilled water, 5 parts. Injection not to be renewed while iodo- form is being excreted in the urine. (Mosetig-Moorhof, Verneuil.) Less painful is a mixture of 1 part of iodoform to 10 of glycerin (Billroth) or of olive oil (Bruns). Intoxication may be prevented by sterilizing the iodoform and excipient (except ether) by heating at 212° F. separately. (Tillmann.) Mixture used for injections into cavi- ties of tuberculous abscesses after as- piration: Iodoform, 5 grams; ether, 10 grams ; guaiacol and creosote, 2 grams of each, and sterilized olive oil, 100 c.c. Solutions of iodoform com- bined with ether were also commonly- used. Out of 29 cases of spinal caries with abscesses, 27 were cured, 2 remain with sinuses which are not infected and in which the discharge is diminishing and the general condition is good. There were 33 cases of hip disease; of these, 32 patients were cured, 1 re- mained with a sinus. In this case the sinus was serious, due to a secondary ACETANILIDE (SAJOUS). 213 infection caused by improper steriliza- tion. The number of aspirations was from 1 to 21 in each case. At a crip- ples' home 23 closed tuberculous ab- scesses connected with lesions in the spine, hip, and knee were treated by- aspiration ; 8 spinal abscesses were as- pirated. The greatest number of as- pirations required for any one case was 12 ; the average number required was 3. All the patients are apparently cured, and in no case has a sinus formed. Thirteen cases of abscess in connection with tuberculous disease of the hip were treated by aspiration. Of these 12 patients had been apparently cured. In 1 case a small sinus persists, but is not infected. The greatest number of aspirations required for any one case was 14. The average number was 4. Two abscesses in connection with the knee-joint have been similarly treated, and both patients are apparently well. Calve and Gauvain (Lancet, Mar. 5, 1910). Boric acid, a 4 per cent, solution, may be used as above (Menard), or naph- thol and camphor, 1 part each. About thirty sittings are usually required. The lesion being a tuberculous one, the general system should be treated ac- cordingly. Nutritious food, including a free supply of milk and eggs, pure air, sunlight, and sea-air, if possible, are indicated, as well as tonics and alteratives (codliver oil and hypo- phosphites, iodine, iodides, arsenic, quinine, strychnine, etc.). In the Middlesex Hospital, London, Kellock obtained good results from the use of sulphur in tuberculous sinuses and cavities, and remarks the superior- ity of this agent over iodoform under similar conditions. J. R. Eastman (Jour. Indiana State Med. Assoc, Jan. 15, 1908). One hundred cases of tuberculous abscess, including tuberculosis of bony structures, joints, lymph-glands, tendons, etc., were treated with tryp- sin by the writer. The procedure is described as follows: 0.1 Gm. of trypsin is introduced in sterile flasks of 10 c.c. size, and the mouths of the flasks plugged with cotton. Before using, each flask is filled with normal saline, giving a 1 per cent, solution of trypsin. The mixture should be freshly prepared each day, as it is unstable. The abscesses are entered with a large trocar and emptied as much as possible by pressure. One to 2 cm. of the trypsin solution is then injected and the opening cov- ered with adhesive plaster. Injec- tions are given every five to seven days. Joint cases are always immo- bilized in plaster dressings. After a few injections the pus, orig- inally yellowish, assumes a brownish- red color, owing to admixture of blood, and resembles an emulsion. This method gives good results in "ganglion" and cold abscesses of small size. Small, bony foci may also be cured. In burrowing abscess for- mations trypsin has no particular advantage over iodoform and glyce- rin. It should not be used at all in cases of joint tuberculosis with ex- tensive bony foci, or in lymphatic foci which have not yet become soft- ened or are in the stage of caseation. No untoward results followed the in- jections, except slight pain, lasting a half to one hour, and in some in- stances a painful edema surrounding the focus, generally only temporary, but sometimes persistent. A. Briining (Deut. med. Woch., Sept. 1, 1910). C. Sumner Witherstine, Philadelphia. A. C. E. MIXTURE. See Chloro- form. ACETANILIDE. — Acetanilidum, formerl}' known under the name of antifebrine, is obtained by boiling aniline with glacial acetic acid. It is the monacetyl derivative [CgHs.NH.- CH3CO] of aniline. PROPERTIES. — Acetanilide oc- curs as a white or colorless shining powder or as crystalline laminse. It 214 ACETANILIDE (SAJOUS). is odorless, but has a slightly burning and bitter taste. DOSE. — The dose of acetanilide is 3 to 5 grains (0.2 to 0.325 Gm.) in adults; the tendency, however, is to employ smaller quantities. In chil- dren, according to Griffith, the coal- tar products of this class are well borne; % to >< grain (0.016 to 0.033 Gm.) may be given at 6 months, increasing the dose by Yi^ grain with each year, until the adult dose is reached. The action of acetanilide should be closely watched in weak subjects and in hysterical women. Out of 274 observers who stated that they used acetanilide, 17, or 6.2 per cent, employed less than 2 grains as a mini- mum dose for adults; 113, or 41.2 per cent., employed 2.5 grains or less as a minimum dose, and 155, or 56.5 per cent., employed from 3 to 5 grains as a minimum dose. Two hundred and fort}^ or a little over 87.5 per cent., never exceeded a dose of 5 grains, and 34, or not quite 12.5 per cent., employed doses exceeding 5 grains. An examination of a number of pre- scriptions for adults on file in vari- ous pharmacies in Washington, D. C, brought into court as evidence, showed the average dose of acetanilide pre- scribed was 2.43 grains. Kebler, Mor- gan and Rupp (U. S. Dept. of Agricul., Bureau of Chemistry, Bulletin No. 126, July 3, 1909). MODES OF ADMINISTRA- TION. — Acetanilide is insoluble in glycerin, slightly soluble in water (1 grain in 3 fluidrams of cold, and 1 grain in 18 minims of hot, water), but completely so in alcohol (1 grain in 2^^ minims), and readily in ether (1 grain in 18 minims). It is readily suspended in syrupy mixtures and can be given with most drugs thus administered. Acetanilide is also dispensed by druggists in the form of tablets, which are quite taste- less when taken with a mouthful of water. It may be given in the form of powders or in dilute alcoholic solutions. There is also available the official compound acetanilide powder {^pul- vis acetanilidi compo situs), contain- ing acetanilide, 7 parts; caffeine, 1 part, and sodium bicarbonate (to in- crease the solubility of the acetani- lide), 2 parts, the dose of which is 5 to 10 grains (0.3 to 0.6 Gm.). While acetanilide is not soluble and is readily suspended in syrupy mixtures, it can be combined with ammonia in any of its forms, salicylic acid, nux vomica, digitalis, codeine, creosote, po- tassium bromide, etc. A prescription can therefore be elaborated that can be much more accurately adapted to the case in hand than any of the ready- made combinations. The foundation of most of the coal-tar product combina- tions is acetanilide, which has been com- bined with bicarbonate of soda, caffeine, carbonate of ammonia, etc. The com- bination may be chemical or mechanical, it matters little which, as it is practically broken up in the body into acetanilide radicals and other constituents. L. Fau- geres Bishop (Med. News, June 10, 1899). Various combinations of acetanilide with other drugs (adjuvants and corri- ^ents) may be made to meet the exi- gencies of practice, some of which are as follows : — B AcetaniUdi^ gr. xij (0.800). Caffeince citratce .... gr. iij (0.200). CamphorcE mouo- brom gr. vj (0.400). Misce et fiant capsulse no. vj. Note. — The caffeine and camphor are used as corrigents to the acetanilide. B Acetanilidi gr. xv (1.000). Sodii bicarbonatis .. gr. x (0.650). Ammonii carbonatis. gr. xv (1.000). Misce et fiant capsulse (not pulveres) no. x. Note. — The sodium bicarbonate aids in the assimilation of the acetanilide, while the ammonium carbonate acts as a corrigent. ACETANILIDE (SAJOUS). 215 T}. .■Iccfaiiilidi gr. XX (1.300). Sodii bicarboiiatis. gr. xv (1.000). Caffcimc gr. vj (0.400). Acidi citrici gr. x (0.650). Misce et fiant capsulne (not pulvcrcs) no. X. Note. — The caffeine and citric acid in the above should be mixed and slightly- moistened; this allows the formation of a fresh preparation of citrated caffeine ; it should then be dried and mixed with the other ingredients. B AcefanUidi gr. xx (1.300). Sodii bicarboiiatis. gr. xx (1.300). Sodii salicylatis . Siss (6.000). Misce et fiant chartulje no. x. Note. — The sodium salicylate is used as a synergist to the acetanilide. ^ Acetanilidi gr. xx (1.300). Potassii broiiiidi . gr. xxx (2.000). Sacchari lactis ... gr. xv (1.000). Misce et fiant chartulas no. vj. Note. — The potassium bromide is used as a synergist to the acetanilide. I^. Acetanilidi gr. xxv (1.600). Potassii broinidi . gr. xv (1.000). Caffeincc cit rates . gr. v (0.325). Misce et fiant capsulas no. x. B. Acetanilidi gr. xxv (1.600). Sodii bicarboiiatis. gr. x (0.650). CaffeincB citrafce . gr. vj (0.400). Caiiiplwro' mono- bromated gr. vj (0.400). Misce et fiant capsulse no. x. IJ Acetanilidi gr. x (0.650). Sodii bromidi gr. L (3.250). Extracti hyoscy- ami gr. v (0.325). Caffeiiice citratce . gr. v (0.325). AIorpliiiicesnlphatis.gr. % (0.013). Misce et fiant tabellae (or capsulas) no. X. Note. — The sodium bromide, extract of hyoscyamus, and morphine sulphate all act as synergists to the acetanilide, while the caffeine corrects their action. B Acetanilidi gr. xx (1.300). Quinincc sulphatis gr. xx (1.300). Extracti Jiyoscy- ami gr. v (0.325). Extracti cannabis Ind gr. iiss (0.163). Arseni trioxidi .. gr. %o (0.0065). Strvchnince sul- phatis gr. % (0.013). Misce et fiant tabellas (or capsulse) no. x. Note. — The strychnine sulphate is used instead of the caffeine as a cor- rigent. B Acetanilidi Sj (4.000). Ziiici oxidi 3j (4.000). Amyli q. s. ad l] (32.000). Misce et fiat pulvis. Sig. : Use as a dusting powder. T^ Acetanilidi 3j (4.000). Adipis lance 3ij (8.000). Petrolati ..q, s. ad §j (32.000). Misce et fiat unguentum. IJ Antipyrince 3j (4.000). Caffeines citratce .. gr. xx (1.300). Aquce destillatce . iSiv (120.000). Misce et fiat solutio. Sig. : Teaspoonful as required. Note. — In the above prescription anti- pyrin is used, as it is very soluble, while acetanilide is almost insoluble. W. H. Foreman and J. H. Gertler (Jour. In- diana State Med. Assoc, June 15, 1909) . It has been supposed that the addi- tion of caffeine to acetanilide decreased its toxicity, and, therefore, the likeli- hood of untoward effects. Hale has shown experimentally, however, that such was not the case, and, indeed, that it greatly increased it. Sodium bicar- bonate, on the other hand, tends to les- sen the toxic effects of acetanilide upon the heart. By experiments on the hearts of warm- and cold- blooded animals the writer found caffeine of little or no benefit in acetanilide poisoning in so far as the cardiac energy and the blood- pressure were concerned, and that it apparently exerts a harmful effect in some cases. But there appeared, espe- cially in the dog, to be a well-established antagonism on the heart rate which, however, would probably be insufficient to be of any value in cases of poisoning in man. Feeding experiments demon- strated the absence of antagonism be- tween acetanilide and caffeine, in all cases the addition of the latter drug causing death more quickly or with a smaller dose. This, in connection with the imperfect antagonism to the heart action, makes the use of caffeine in acetanilide mixtures especially question- able. Sodium bicarbonate, in contrast, lessens the toxicity of acetanilide, both 216 ACETANILIDE (SAJOUS). in its action on the heart and on the intact animal, increasing the duration of life or making the use of a larger dose of acetanilide necessary to cause death. Hale (Jour, of Pharmacol, and Exper. Therap., Aug., 1909). INCOMPATIBLES.— Acetanilide forms insoluble compounds with the bromides and iodides in aqueous solu- tion, and a soft mass on trituration with chloral, carbolic acid, thymol, or resorcinol. According- to Blackwood, unexpected and often alarming effects are observed when calomel is given with any coal-tar product. CONTRAINDICATIONS. — Ace- tanilide should not be used when the heart is fatty, weak, or enlarged ; in blood disorders such as pernicious anaemia characterized by cell destruc- tion ; in phthisis or other exhausting diseases, and in pregnant or nursing women. It has been urged against the coal-tar derivatives that, although they relieve pain, they do not procure sleep. In the first place this is an error; they do in- duce somnolence, though this is much less marked than when opiates are used. But even were it true, — nothing pre- vents the simultaneous use of safe soporifics, such as the bromides or chloral hydrate. There is, in fact, a distinct advantage in their employment concomitantly, since the dose of either agent — acetanilide and ammonium bromide, let us say — can be made smaller, 2 grains of the former and 10 of the latter being quite sufficient in most cases to relieve pain and insure prolonged sleep. Antipyrin and phe- nacetin are quite as efficient when thus administered, but somewhat larger doses, 4 grains, are needed. Though acetanilide is not soluble in water, it is readily suspended in syrupy mixtures, which will also take up ammonivim bromide very readily. Far from being harmful, in the hands of the profession, the coal-tar deriva- tives have furnished us the only means to avoid the use of the opiates which, notwithstanding the great service they have rendered humanity, have left in their train victims in numbers untold, and the shadows of which hover at once before the modern practitioner's mind when he is called upon to alleviate suffering. Sajous (Monthly Cyclo. and Med. Bull, March, 1910). PHYSIOLOGICAL ACTION.— As Antipyretic.-— In the normal sub- ject, the temperature, according to Nothnagel and Rossbach and most authorities, is lowered only when toxic doses are given. _ Not so, how- ever, when fcA^er is present. Here a small dose suffices to produce a marked fall. Dujardin-Beaumetz, for example, witnessed a decline of 3° C. (5.4° F.) and cyanosis in a case of typhoid fever in which 7^ grains (0.5 Gm.) had been administered. Manquat states that 1^^ to 3 grains (0.1 to 0.2 Gm.) suffice to influence the temperature, acetanilide, accord- ing to Krieger, Cahn and Hepp, being far more active in this particular than antipyrine. Sweating and chills are occasionally observed. The investigations of Hare • and Evans suggested that the fall of tem- perature produced in febrile cases was due to a decreased heat-production and increased heat-dissipation. But Wood, having found that the rectal temperature not only did not fall as did that of the surface, but that it rose, concludes that the experiments of Hare and Evans "cannot be used to explain how antifebrin reduces the .temperature." Moreover, most Euro- pean investigators, Lepine, Podanow- sky and others, hold that acetanilide acts by depressing the heat-center. According to Cushny, it affects the nervous heat-regulating mechanism in such a manner as to lower the level ACETANILIDE (SAJOUS). 217 at which the bod3^-temperature is maintained, the loss of heat necessary to produce the fall in temperature be- ing accomplished by dilatation of the cutaneous vessels. The manner in which acetanilide acts as an anti- pyretic is stated by Butler to be far from understood. [The antipyretic action of acetanilide be- comes plain when new factors, brought out by ni}^ own labors, are also taken into ac- count. The adrenal and thyroid secretions (see "Internal Secretions," p. 1008) are the blood constituents which sustain general oxi- dation and metabolism. As the blood enters all tissues through their arterioles, constric- tion of these minute vessels must necessarily reduce the quantity of blood admitted into the tissues, and thus inhibit oxidation, i.e., heat production. This is precisely what acetanilide brings about by exciting directly the sympathetic center, which, as I have shown (loc. cit., p. 982), governs the caliber of the arterioles. This mechanism explains, moreover, all the above experimental and clinical data. A small dose suffices to reduce fever, though in- active in the normal subject, for example, because the sympathetic center is already, during fever, the seat of undue metabolism and, therefore, oversensitive; cyanosis is pro- duced by large doses because they constrict abnormally the arterioles and cause local ac- cumulation of CO2 ; chills are excited by lowering of the surface temperature caused by the deficient supply of arterial blood in- cident upon the constriction of the arterioles, etc. C. E. DE M. S.] Action as Analgesic. — According to the prevailing view, acetanilide acts directly as a sedative upon the nerv- ous system, especially upon the sen- sory portion of the spinal cord; with toxic doses the effect may extend to total loss of reflex action and sensory and motor paralysis, the muscles be- ing influenced only directly. Wood holds that, "directly or indirectly, ace- tanilide affects the cerebral function," though at a certain stage of its toxic action consciousness may be uninflu- enced while the rest of the nervous system is clearly affected. Bokai ascribes the effects of acetanilide to paralysis of the motor nerve-endings in the muscles, sufficiently prolonged exposure of the latter to the poison also annulling their ability to con- tract. Cushn}^, referring to this and other coal-tar products, states that "by man}^ they are supposed to have a sedative or depressant effect on the nervous system." The analgesic action of acetanilide is generally as- cribed to this supposed sedative eft'ect, though all agree that applied locally to the tissues it acts as a stimulant or mild irritant. [These various opinions involve the as- sumption that a dose of acetanilide dissolved in the thirteen pints of blood the vessels of an adult contain will make a sufficiently strong solution to act directly on the central or peripheral sensory elements. Clinically such a solution in water, when injected di- rectly into the tissues, has no local effect other than that produced by water without acetanilide. The above explanations have, therefore, no foundation in fact. On the other hand, the analgesic action of acetanilide is clearly explained by the mode of action I have pointed out : By ex- citing the sympathetic center, it causes con- striction of all arterioles, and, by thus reduc- ing the volume of blood admitted into the diseased area, it counteracts the cause of the pain therein — the hyperemia. C. E. de M. S.] Action on the Blood. — The cyanosis produced by excessive doses of ace- tanilide is ascribed by Lepine, He- nocque and others to transformation of the hemoglobin into methemoglo- bin, and by Vierordt, Halliday and others to the reduced haemoglobin as it occurs in venous blood. Some con- tend that the red corpuscles are dis- organized, while others hold that they remain intact. 218 ACETANILIDE (SAJOUS). [AA'hen the dose is excessive or from one cause or another the sympathetic center is oversensitive, the arterioles are so constricted that the volume of blood admitted into the tissues is inadequate. The oxygen supply being deficient in proportion, the blood be- comes venous prematurely and cyanosis en- sues. When still further reduced the hemo- globin breaks down and methemoglobin ap- pears in the blood. The view of Vierordt and others that the cyanosis is due to reduced hemoglobin is thus sustained. But this applies as well to methemoglobinemia, since, as I have shown (see "Internal Secretions," 3d ed., pp. 102 and 828), this phenomenon is produced when the connecting link between the hematin and the albuminous constituent, the oxygen-laden adrenal secretion, is taken up by a powerful reducing agent — the tissues in the present in- stance. C. E. DE M. S.] Action on the Circulation. — Injec- tions of acetanilide in animals have been found to cause at lirst a slight increase in the number and force of the heart-beats, with corresponding- rise of blood-pressure. Later, and also from the first with larger doses, circulatory depression is observed. In febrile patients the lowering of temperature produced by the drug is often accompanied by reduction in the frequency and size of the pulse. Large doses are said to depress the heart directl}'-. [These phenomena are the normal results of the exciting action of the drug upon the sympathetic center and the resulting con- striction of the arterioles. Those of the heart admitting less blood into its muscular walls, the force of its contractions and their number are reduced. The heart's action may be arrested by the same process. C. E. DE M. S.] UNTOWARD EFFECTS AND ACUTE POISONING.— The symp- toms of poisoning include primarily the cyanosis, which begins at the lips and then extends, gradually becoming more intense, over the face and the rest of the body, and is accompanied by profuse sweating and prostration. In some cases there is ashen lividity and the temperature falls rapidly to 95° F. or lower. The pupils are dilated and fixed. The respiration is slow and shallow, and the pulse be- comes steadily weaker and then irreg- ular and fluttering. Somnolence, un- consciousness and coma, and cardiac arrest follow. In some instances sudden heart-failure occurs soon after the onset of the symptoms, the organ being arrested in diastole. Erythem- atous or urticarial skin eruptions and disorders of hearing are occasion- ally observed. [Acetanilide proves toxic, from my view- point, when it causes sufficient constriction of the arterioles (by exciting the sympa- thetic center") to prevent the entrance of blood into the tissue capillaries, thus ar- resting function. As the vascular constric- tion increases, cyanosis deepens, and the skin becomes livid ; the spiral muscles of the sweat-glands being deprived of blood, they are relaxed, and profuse sweating occurs; the pupillary sphincters being relaxed through the same process, the pupils dilate. The fail- ure of the skeletal muscles to receive blood accounts for the prostration, while a similar deficiency of blood in the myocardium ex- plains the weakening pulse and the cardiac arrest in diastole. The cerebral ischemia being no less complete, somnolence, uncon- sciousness and coma occur in more or less rapid succession. The occasional presence of deafness is due to the inadequate supply of blood to the aural apparatus that results from undue constric- tion of the arterioles. The same process ex- plains the cutaneous eruptions, since the slowing of the blood-stream in the tissues interferes with the carrying ofif of waste products from the skin. C. E. de M.. S.] Case of a man, aged 45, suffering from a form of intermittent fever. The patient complained of almost unbearable headache; pulse, 120; respirations, 23; temperature, 104.8° F. Ten grains of acetanilide were given, and about twenty ACETANILIDE (SAJOUS). 219 minutes later the patient said his head- The character of these cases and the ache was relieved, and that he felt doses used were as follows : — easier. About forty-five minutes after t,„^„ „. / , .,,> r^ t, k • . •'. Pneumonia (child). . .One-half grain every 2 the drug was administered all sweating hours until 2 grains t J 1- 1.- c ■ were taken. ceased, and a peculiar sensation of Capillary bronchitis warmth under the skin was complained ^'^^'''^^ ^'^"'^11 doses frequently repeated. of. To this, in twelve or fifteen mm- Capillary bronchitis , J r 1 • J. -i. 1 • u-i (child) Small doses frequently utes, was added intense itching, while repeated. in three or four minutes the whole body Typhoid Five grains every 4 hours presented a general erythematous con- Headache About 20 grains. ,.^. rr-, .■ r c Headache Thirty grains (?). dition. The entire surface was of a M^o^a^vio "o • >>* i r t irleadacne Orangeine taken freely brighter red than that of a typical case Headache Thirteen or fourteen 5-grain of scarlet fever, and, like the scarlatina ^ per cent, strength. An aqueous solution may be used as spray and as a deodorizer and antiseptic for stools, sputum, etc. Therapeutics. — Acetozone is used for its marked oxidizing and germicidal action mainly for the treatment of diseased mucous membranes. It has been credited with a favorable action in typhoid fever, the main effect being decrease of the fetor of the stools, subsidence of the tympanites and diarrhea, and prevention of hyper- P3^rexia. Good results have been obtained in Asiatic cholera. In ophthalmology, a solution of 1 grain to 2 ounces of water, instilling 1 drop or 2 every hour, has been found useful in corneal infections. In laryngology, tonsillitis and atrophic rhi- nitis have seemed to be beneficially in- fluenced. This applies also to infected wounds, gonorrhea, and chancroid. It has been found an excellent deodorant in gan- grene and malignant small-pox. S. ACETPARAMIDOSALOL. See Salophen. AGETPHENETIDIN.- (acetphenetidinum; para-acetpheneti- din), commonly known under the pro- prietary name of pJienacetin, is a coal- tar product, obtained by treating para- phenetidin with glacial acetic acid. It is an acetyl derivative [C6H4. OC2H5. NHCH;;CO] of para-amidophenol. , PROPERTIES.— Acetphenetidin oc- curs in the form of a white, odorless, and practically tasteless powder, com- posed of small, needle-like or scaly crys- tals. DOSE.— Five to 10 grains (0.32 to 0.65 gram) in adults ; 1 to 5 grains (0.065 to 0.32 gram), according to age, in chil- dren. The maximum amount to be given in twenty-four hours, according to Pouchet, is 30 to 45 grains (2.0 to 3.0 grams), which should be distributed during the day in several doses, each not exceeding 7% grains (0.5 gram). The tendency is toward a marked decrease of this amount. Out of 297 observers using acet- phenetidin, 10, or 33 per cent., em- ployed less than 2 grains as a minimum dose for adults ; 90, or 30.3 per cent., employed 2.5 grains or less as a mini- mum dose ; 188, or 63.3 per cent, em- ployed from 3 to S grains as a minimum dose ; 89, or 29.9 per cent., used doses exceeding 5 grains, while 208, or 70 per cent, never exceeded a dose of 5 grains. An examination of a number of prescriptions for adults on file in vari- ous pharmacies in Washington, D. C, showed that the average dose of acet- phenetidin prescribed was 1.92 grains. Kebler, Morgan, and Rupp (U. S. Dept of Agricul., Bureau of Chemistry, Bull. No. 126, July 3, 1909). MODES OF ADMINISTRA- TION. — Acetphenetidin is almost in- soluble in cold water (1 grain in 2 ounces), more freely soluble in boiling water (1 grain in 1 dram), and read- ily so in alcohol (1 grain in 12 minims) ; it will also dissolve in glycerin and lac- tic acid. Being almost tasteless, it is easily taken in powder form ; it can also be given in capsules, cachets, or tablets. When combined with other remedies in liquid preparations it is best kept in solution by dilute alcohol. Thus a mix- ture of acetphenetidin, sodium bromide, and caffeine in the adjuvant elixir is frequently prescribed for the relief of headache. A good formula is the following : — 244 ACETPHENETIDIN (SAJOUS). R. Acetphenetidini gr. xv (1.0 Gm.). Caffeines citrates gr. viij (0.5 Gm.). Sodii bromidi 3j (4.0 Gm.). Elixir adjuvantis ... Sj (30.0 c.c). M. Sig. : Two teaspoonfuls, repeated if necessary. Shake well. Where nausea and vomiting accom- pany headache, oral administration be- ing, therefore, unsuitable, acetpheneti- din may be administered by the rectum in 1 or 2 drams of water (Brunton). Acetphenetidin is sometimes used lo- cally in powder form or in an ointment or alcoholic preparation. INCOMPAT IBILITIES.— Acet-' phenetidin is incompatible with iodine, nitric acid, and oxidizing agents gener- ally; also with chloral hydrate, phenol, and salicylic acid. CONTRAINDICATIONS.— These are the same as those of acetanilide {q.v.), though the dangers from its use are less marked than with the latter drug. It is advisable not to employ it in cases of heart disease, pulmonary tuberculosis, grave anemia, or in per- sons markedly enfeebled from any other cause. PHYSIOLOGICAL ACTION.— As Antipyretic. — Acetphenetidin is the safest and most frequently employed of antipyretic remedies. In common with acetanilid, it has little or no influ- ence on the temperature of normal indi- viduals in therapeutic doses, but causes a fall in febrile cases. According to Crombie and Hirschfelder, the greatest reduction is not produced until three or four hours after administration. The average decline may be put down as 3.6° F. (2° C; Manquat). The reduc- tion may last six to eight hours, and is free of unpleasant effects, excepting a mild sweat (Pesce). Cerna and Carter found that acetphenetidin produced a very slight fall of temperature during the first and second hours after inges- tion, and that the effect reaches its height in the third hour. They believe that the fall of temperature results chiefly from a decrease in heat produc- tion, together with a slight increase in the heat dissipation, less marked than in the case of antipyrin. Probably the delayed action of the drug depends on its insolubility. It should be mentioned, however, that certain authors describe its effect as teing more prompt, and comparable with that of acetanilide. With regard to the manner in which the antipyretic effect is produced, the prevailing belief is that it depresses the heat-regulating centers. [Viewed from my standpoint, the action of acetphenetidin dififers only from that of acetanilide {q.v.) in that it excites less violently the sympathetic center, owing to its greater insolubility. As the sympa- thetic center governs the caliber of the arterioles (see "Internal Secretions," vol. ii, 1907), its excitation causes constriction of these small vessels and a reduction of the volume of arterial blood admitted into the tissues. This entails a reduction of temperature in the latter, (1) owing to the lowered metabolic activity which the dimi- nution of arterial blood in the superficial tissues entails, and (2) because the adre- nals and the thyroid, which jointly, as I have shown, supply the substances which in the blood sustain oxidation and metab- olism, are themselves rendered less active by the diminished blood-supply. It is therefore, by exciting the sympathetic center, that acetphenetidin produces its effects. This reduces heat production by inhibiting both the functional activity of the adrenals and thyroid and tissue metabolism. C. E. de M. S.] As Analgesic. — Acetphenetidin is considered to exert a sedative effect upon the nervous system. Its anodyne influence is more marked than that of acetanilide or antipyrin. It is believed to depress the nerve-centers, in common with the other antipyretics, but it has probably also some action on the sen- sory nerves, since it frequently relieves ACETPHENEtlDIN (SAJOUS). 245 neuralgic pain without giving evidence of any central depressant action by the production of drowsiness or mental apathy. Injected into animals, large doses of acetphenetidin are required before its effects on the nervous system appear. Using doses of 0.5 to 1 Gm. per kilo of body weight in rabbits, Mahnert ob- served merely a muscular weakness, lasting a few hours, which he ascribed to a depressing action on the spinal cord. With doses of 3 Gm. per kilo he obtained a short period of spinal excita- tion, followed by one of complete motor and sensory paralysis, with loss of re- flexes and early death. In frogs the preliminary spinal excitation may be such as to produce convulsions. In mammals convulsions produced by the antipyretics may be of cerebral, spinal, or, possibly, asphyxial origin (Cushny). H. C. Wood, Jr., and H. B. Wood watched the effects of acetphenetidin on frogs when absorbed through the skin from a saturated solution. Like Mahnert, they noted a sluggishness of movement and loss of muscular power, proceeding steadily to complete paraly- sis, with final cessation of the heart beats. In addition, they found that the motor nerves and the muscles, though soaked in saturated acetphenetidin so- lution, continued responsive to electric stimulation throughout the period of ac- tion of the drug, and even after death, and concluded, therefore, that the loss of reflexes and paralysis observed had been of spinal origin. They ascertained that doses of 0.5 Gm. per kilo, injected into the jugular vein of a dog, caused death from paralysis of respiration. Local applications of acetphenetidin have some analgesic effect. [The reduction of pain is also due to the constriction of the arterioles the drug pro- duces. Less blood being admitted into the painful area, the sensory nerve terminals are no longer hyperemic, and they cease to trans- mit painful impressions. The same process explains all the experi- mental phenomena : the muscular sluggish- ness, the paralysis, the cardiac arrest, etc., since diminution of the blood supplied to a tissue reduces in proportion its functional activity. The convulsions are due to the accumulation of toxic wastes (as in epilepsy, tetanus, etc.), owing to imperfect catabolism, the latter process being under the dependence of the (now inhibited) adrenals and thyroid. C. E. DE M. S.] On the Circulation. — Conflicting views have been advanced by different observers concerning the effects of the drug on the blood-pressure. Cerna and Carter found that, in moderate doses, it caused a rise of the arterial pressure by directly stimulating the heart's action, and also, probably, the vasomotor sys- tem, while in large doses it decreased the pressure, chiefly by its influence on the heart. They also state that acet- phenetidin tends to increase the pulse rate, mainly by cardiac stimulation, and possibly, also, by influencing the cardio- accelerator apparatus, while later, es- pecially with large doses, it decreases it primarily by stimulating the cardio- inhibitory centers, and later by depress- ing the heart. Ott and H. C. Wood, Jr., on the contrary, assert from their experiments that acetphenetidin does not influence the blood-pressure. Mah- nert considers the drug to be antago- nistic to strychnine in its physiological action, large doses producing paralysis of the cardiac and respiratory centers. In the early stage of its action, however, it is believed to stimulate these centers for a time. [The influence on blood-pressure noticed by some observers is due to the fact that the constriction of the arterioles produced by the drug causes these vessels to impede the flow of blood into the capillaries, and to 246 ACETPHENETiDIN (SAJOUS). cause the blood to accumulate behind the obstruction, thus causing a back pressure in the large vessels. As soon as the dose is large enough to inhibit the heart's action by reducing the blood supplied to its walls, this organ is unable to keep up the pressure — in keeping with Cerna and Carter's view. Large doses thus fail to produce a rise of the blood-pressure. C. E. de M. S.] On the Blood. — Alterations in the blood are much more rarely caused by acetphenetidin in moderate doses than by acetanilide. The formation of met- hemoglobin has, however, been ob- served in a few cases. According to Cushny, this untoward result is due to the action of para-amidophenol, into which the drug is gradually decomposed in the organism. Cerna and Carter were unable to produce methemoglobi- nemia in their experiments on animals. Acetphenetidin is said to have a slightly stimulating influence on the sweat-glands, which is not possessed by the other antipyretics. [When the dose is very large or the sympathetic center is abnormally sensitive, the arterioles are sufficiently contracted to reduce the supply of blood to the tissues be- low their normal needs. The blood is not only rendered venous abnormally soon under these conditions by the intense reducing power of the tissues, but the hemoglobin molecule itself is broken down, methemo- globin being formed. C. E. DE M. S.] Elimination. — Acetphenetidin is be- lieved to be eliminated chiefly in an al- tered condition, losing its acetyl radicle in transit through the organism, and ap- pearing in the urine as glycuronates of phenetidin (Cushny). The gastric and pancreatic juices being without influ- ence on the drug m vitro, F. Miiller be- lieves that the decomposition must oc- cur after it has been absorbed. Accord- ing to Gueorguievsky, the elimination by the urine begins in twenty minutes and proceeds rapidly. Perchloride of iron added to this urine causes a Bur- gundy red color to appear. Acetphe- netidin may also be eliminated in part by the skin, since Hirschmann not infre- quently found large numbers of crystals precisely similar to those of the drug on the skin of persons to whom it had been administered. UNTOWARD EFFECTS AND POISONING.— H. C. Wood states that no symptoms are produced by the therapeutic dose of this drug. Even large doses of it have been given so often without markedly un- pleasant results that, in contrast with acetanilide and antipyrin, it has fre- quently been described as non-toxic. Massive doses, however, and even mod- erate doses in certain susceptible indi- viduals, have been known to cause un- toward effects similar to those of the other coal-tar antipyretics. The most commonly observed of these have been profuse sweating, somnolence, lassitude, sometimes accompanied by nausea, ver- tigo, or chilliness. In more severe cases there have occurred cyanosis, beginning and most marked in the face, lips, and finger-tips, then becoming general ; pros- tration, vomiting, palpitation, dyspnea, anxious expression, followed by col- lapse, which occasionally is fatal. The blood may be darkened by the forma- tion of methemoglobin. The urine has been found to contain blood (Kronig). In a case reported by Hollopeter three doses, of 7 grains each, of phenacetin sufficed to produce in a woman severe precordial pains, great dyspnea, general lividity, somewhat dilated pupils, and collapse, with unconsciousness ; recovery took place after a week. Cutaneous eruptions, usually urticarial, are some- times caused, though less frequently than by antipyrin. As with acetanilide, the onset of the symptoms is frequently sudden and unexpected, the patient hav- ACETPHENETIDIN (SAJOUS). 247 ing previously borne repeated doses without harmful effect. [All the morbid effects of large doses of acetphenetidin are the result of the excess- ive constriction of the arterioles it causes. The sweating' is due to ischemic relaxation of the spiral muscles of the sweat-glands; the vertigo and somnolence to cerebral ischemia; lassitude to the same condition of the muscles; the chilliness and cyanosis to cutaneous ischemia and the too rapid conversion of arterial into venous blood, etc. C. E. DE M. S.] Case of a woman suffering from ovaritis and acute dysmenorrhea, who took 5 to 8 cachets containing each 10 grains (0.65 Gm.) ' of acetphenetidin in twenty-four hours. She suddenly complained of palpitation of the heart ; her face was brilliantly scarlet with the exception of the bridge of the nose and the upper lip, which were markedly pal- lid ; the pulse was extremely rapid, and she also sufifered from headache, dysp- nea, and diaphoresis. There was no urinary or gastric disturbance. John Harold (Practitioner, Dec, 1894). Two cases in which acetphenetidin caused dyspnea and orthopnea. In the first case 15 grains (1 Gm.) every four hours were taken for some time with impunity, but after thirty-six hours the patient repeated the dose in two hours, the result being marked shortness of breath and extreme restlessness. In the second case 20 grains (1.3 Gm.) were administered every two hours until 2 drams (8 Gm.) had been taken, when dyspnea resulted and continued for an hour. J. L. Lackie (Medical Press and Circular, Aug. 28, 1895). Fatal case of acetphenetidin poison- ing in a boy 17 years old suffering from chronic middle-ear disease, who had taken 4 powders, of 15 grains each, within three weeks. Sepsis having set in, a fifth dose, taken one evening, brought on vomiting, followed by gid- diness, great weakness, and cyanosis of the face and lips. The temperature was 102.2° F., the pupils, of medium size, the pulse weak, and the pa- tient complained of headache, vomiting, and diarrhea. The conjunctivae were slightly yellowish, and a general icteric appearance followed, combined with blucness of the lips, ears, hands, and feet. The blood contained red cells in various stages of dissolution and of different sizes and shapes. Particles of hemoglobin were set free in the plasma. There was marked leucocytosis. The urine, obtained by catheter, was thick, dark reddish brown in color, later con- taining masses of almost pure blood. Death occurred in two days, with uni- versal methemoglobinemia. G. Kronig (Berl. klin. Woch., Nov. 18, 1895). Eight grains of acetphenetidin taken every three hours for headache. After the third dose, the patient became very ill, and his face became pale. Shiver- ing, cold perspiration, and dyspnea fol- lowed. Wheals developed on the backs of the hands and right shoulder, and the face became swollen and of a mahogany color. Recovery followed. W. A. Betts (Brit. Med. Jour., Jan. 18, 1896). Petechial eruption on the legs, fol- lowed in a week by ulceration, reported as the result of taking acetphenetidin. Upon stopping the drug the ulcers quickly healed, but after another dose of llYi grains they reappeared. M. Hirschfeld (Deut. med. Woch., Nu. 31, 1905). The exhibition of 15 grains of acet- phenetidin every two hours for twenty- four hours resulted in marked feeble- ness, followed by symptoms of collapse, with faintness, dizziness, dyspnea, cya- nosis of the limbs, combined with a gen- eral yellowish-gray color, pain over the heart, nausea, and a rapid, weak pulse. On the following day a macular erup- tion made its appearance. Recovery- took place in five days. J. Meurice (Ann. de la Soc. de Med. de Gand., No. 85, 1905). Fatal case of poisoning in a woman of 50 suffering from muscular rheuma- tism, who had taken on the same day 2 powders each containing 15 grains of acetphenetidin and 3 grains of caffeine sodiobenzoate. Marked pallor appeared, followed by profuse sweating, nausea, vomiting of a cerebral type, and 248 ACETPHENETIDIN (SAJOUS). restlessness. An injection of camphor and a small dose of morphine were given. On the next day the condition became worse, notwithstanding cam- phor injections every two hours, am- monia, and an injection of normal saline. In the afternoon the patient became unconscious. The pulse was 120; respirations, 30. Progressive cya- nosis of the face and limbs ended in death from vasomotor paralysis the same evening. The urine was of a porter-brown color, gave the reactions for methemoglobin, and showed evi- dence of parenchymatous nephritis in the presence of albumin with hyaline and granular casts. The blood exam- ined after death showed leucocytosis and marked pallor of certain of the erythrocytes. The autopsy revealed fatty and parenchymatous degeneration of the heart, marked hyperemia and edema of the viscera, general arterio- sclerosis, and acute nephritis. The writer believes that alcohol taken with or before the administration of coal-tar antipyretics favors the occur- rence of symptoms of poisoning, and that alcohol is, therefore, contraindi- cated in all cases of collapse due to these drugs. The subjects most in- tolerant of the coal-tar antipyretics are those that normally perspire freely. K. E. Russow (St. Petersburger med. Woch., Feb. 8, 1908). [The remark of Russow that alcohol tends to aggravate acetphenetidin poisoning is sustained by my views. While the latter tends to interfere with oxidation by diminish- ing the volume of blood admitted into the tissues, alcohol becomes oxidized at the ex- pense of the blood, thus increasing the tox- icity of the acetphenetidin. C. E. de M. S.] A girl of 163^ years, in good general health, but having a headache and feel- ing that she had taken cold, took 2 headache tablets and went to bed. About an hour and a half later her lips and face began to grow blue, and a physician was sent for. Responding at once, he found the girl with pro- nounced cardiac weakness and edema of the lungs. Before any remedy could be administered she died. The tablets she had taken, labeled "Dan- bury's headache tablets," were subse- quently found on examination to con- tain acetphenetidin. G. L. Tobey (Mo. Bull., State Board of Health of Mass., Jan., 1908). Of 70 cases reported by 41 observers in the literature from 1887 to 1907, 3, or 4.2 per cent., terminated fatally. Sixty-three of the 70 cases were re- ported during the years 1887-90, i.e., in the period just following the advent of acetphenetidin as a medicinal agent, when the drug was used freely in asthenic as well as sthenic affections. The most prominent ill efifect was gen- eral systemic depression, which was present in 38.5 per cent, of the cases. In 17.1 per cent., it amounted to actual collapse. Cyanosis was reported in 34.3 per cent, of the cases, skin affections of various kinds in 30 per cent., dyspnea in 14.3 per cent., and disturbances of the renal function in 10 per cent. Kebler, Morgan, and Rupp (U. S. Dept. of Agricul., Bureau of Chemistry, Bull. No. 126, July 3, 1909). Of 306 physicians questioned on the subject of acetphenetidin poisoning, 66, or 21.5 per cent., stated that they had observed instances of poisoning (as compared with 76 per cent, of 288 physicians having seen instances of acetanilide poisoning). These 66 ob- servers reported 95 cases of poisoning by acetphenetidin, including 7 deaths, i.e., 7.3 per cent. The character of the fatal cases and the doses used were as follows : — Pneumonia, 70 grains daily for two days ; died suddenly. Influenza, 5 grains every three hours ; not over 6 doses. Bronchitis (1 year), 2 grains every three hours ; 5 doses ; died twelve hours after last dose. Typhoid, 2^ grains every two hours until 1 scruple was taken. Headache, 10 grains. Headache (cerebral tumor), 15 grains in twelve hours. Woman, aged 76, two 3-grain doses two hours apart. Kebler, Morgan, and Rupp (U. S. Dept. of Agricul., Bureau of Chemistry, Bull. No. 126, July 3, 1909). ACETPIIENETIDIN (SAJOUS). 249 Treatment of Acute Poisoning. — No special reference to this subject having been found in the Hterature, we can only recall the plan of treatment used for poisoning by the other coal-tar deriva- tives, the toxic effects of which are iden- tical. Stimulants to the circulation and respiration, such as strychnine, atro- pine, aromatic spirits of ammonia, ether h}-podermically, and digitalis; saline solution by enteroclysis or hy- podermoclysis, etc. The application of heat to the body should never be neglected in cases of collapse. Arti- ficial respiration is always valuable, and inhalations of oxygen may be re- sorted to as an ultimate measure. [Of the foregoing the only drugs that I do not regard as harmful in cases of acet- phenetidin poisoning are, in the order given : the aromatic spirits of ammonia and the salt solution, which jointly, by increasing the alkalinity and osmotic properties and fluidity of the blood, tend to reduce its toxic action on the sympathetic center and relax the con- stricted arterioles ; the application of heat to the surface and inhalations of oxygen. Strychnine, atropine, ether, and digitalis all tend to aggravate the trouble by increasing, if anything, the constriction of the arterioles. The agents indicated — only from my view- point — are those which cause dilatation of the arterioler by depressing the sympathetic center : amyl nitrite by inhalation, and nitro- glycerin to sustain the effect, or sweet spirits of niter, the latter in full doses. C. E. DE M. S.] CHRONIC POISONING.— While not as frequent as chronic acetanilide poisoning, chronic acetphenetidin poi- soning is nonetheless fairly common. The symptoms show a great similar- ity to those produced by the habitual use of acetanilide, consisting chiefly of nervous and digestive disturbances, a cyanotic coloration of the skin, ane- mia, and weakened heart action. Case of a woman, previously "a healthy, buxom country girl," who had been addicted to the acetphenetidin habit for about seven months, ingesting from 15 to 20 grains daily. The habit was found out by her husband when her supply of the drug gave out and the local pharmacist also ran out of a sup- ply temporarily. Violent convulsive and hysterical seizures appeared, and continued until acetphenetidin had been obtained for her. The pulse rose to 170 and became feeble ; respiration, 30, spasmodic ; pupils widely dilated ; pallor and cold perspiration. The patient had over a dozen convulsions and vomited freely. Examination subsequent to the attack showed some anemia, poor com- plexion, weak circulation, pulse 124, sleep restless and troubled, digestion impaired, occasional vertigo. J. S. Davis (Amer. Med. and Surg. Bull., July, 1894). Case of acute dysentery reported in which the exhibition of approximately 3000 grains of acetphenetidin in 5-grain doses within sixty days for fever was followed by, marked depression and rapid dilatation of the heart resulting in death. The fatal ending could fairly be ascribed to chronic poisoning by the drug. A. T. White (Jour, of Tropical Med., June, 1903). From collective reports of cases it would appear that toxic manifestations are somewhat less likely to develop when acetphenetidin is taken habitu- ally than when acetanilide is the drug used. In the replies of 400 physicians to a set of questions sent out by the Bureau of Chemistry of the U. S. Department of Agriculture, 112 instances of the acetanilide habit were reported, 7 of the antipyrin habit, and 17 of the acet- phenetidin habit. The number of cases in which ill effects were observed from the use of acetanilide was 85, from antipyrin 2, and from acetphenetidin 7. The chief symptoms observed from the habitual use of these drugs were: Nervous depression, 44 cases ; cyanosis, 27; cardiac depression, 18, anemia, 15; dyspnea on exertion, 8; insomnia, 4; constipation, 3; edema, 2; increased 250 ACETPHENETIDIN (SAJOUS). headache, 2; icterus, 1; muscular twitchings, 1 ; loss of sexual power, 1. In S of the cases of acetphenetidin habit protracted ill effects were noted, as compared with 32 instances in case of acetanilide and 2 instances in case of antipyrin. The chronic symptoms oftenest noted were anemia, general debility, nervousness, and weak and irregular heart action. Kebler, Mor- gan, and Rupp (U. S. Dept of Agricul., Bureau of Chemistry, Bull. No. 126, July 3, 1909). Treatment of Chronic Poisoning. — The measures required upon with- drawal of the drug will generally com- prise the use of stimulants, saline lax- atives, and codeine, — the latter used with caution in amounts just sufficient to mitigate pain and favor sleep {v. Treatment of Chronic Acetanilide Poisoning). THERAPEUTICS.— As Antipy- retic. — Acetphenetidin is generally con- sidered the safest of the coal-tar an- tipyretics. Its effect in reducing tem- perature is marked ; as previously stated, its action begins in about thirty minutes and reaches its maximum in three to four hours. According to Heusner, 1 Gm. (15 grains) of this drug is the equal in antithermic power of 0.5 Gm. (7^ grains) of acetanilide, and 2 Gm. (30 grains) of antipyrin. The relative infrequency with which it causes cya- nosis, depression, and other unpleasant or dangerous effects recommends its general use as an antipyretic in prefer- ence to the older coal-tar remedies if used at all. The employment of anti- pyretics other than hydrotherapy and other external measures is decidedly on the wane, however, in the hands of competent clinicians. Exception to this is probably only to be made where prompt reduction of fever is required, as in cases of hy- perpyrexia; here acetanilide, whether used in conjunction with hydrothera- peutic measures or not, may prove more effective than acetphenetidin. It is be- lieved, however, that the effect of the latter drug is more lasting than that of acetanilide ; the greater tendency of which to depress the circulatory and respiratory organs should also be re- membered. As stated above, however, the use of antipyretics in the various forms of fever is now deemed inadvis- able by most authorities. Moreover, these agents, by causing the temperature records to lose their characteristic fea- tures, may impair their value for diag- nostic and prognostic purposes. The alleged prejudicial influence, on the other hand, that chemical antipyretics have been said to exert on the sub- stances of the blood-serum that antag- onize disease has been shown not to exist, at least in the case of the agglu- tinating bodies of typhoid serum (Soll- mann). When delirium is present in fever, the mild narcotic action exerted by the coal-tar antipyretics, and in par- ticular by acetphenetidin, may prove advantageous. [The cardinal feature still overlooked is that fever is the external expression of the process through which the body defends itself against infection. When hyperthermia is present (over 105.5° F.), however, there is good ground for the belief that the immuniz- ing process is so active that the blood-cells and tissues may also be digested by the defensive blood constituents (hemolysis and autolysis) along with the bacteria and their toxins. It is then, especially in such diseases as pleurisy, endocarditis, acute rheumatism, which, from my viewpoint, are mainly due to excessive proteolytic activity of the blood, that acetphenetidin can find a useful applica- tion in fever. It should be remembered that the surface temperature is often the expression of too slow elimination of heat from the superficial tissues, where the febrile process is very active, and that cool sponging by taking up ACETPHENETIDIN (SAJOUS). 251 this accumulated heat lowers the temperature promptly to the great relief of the patient. C. E. DE M. S.] As an Analgesic. — Phenacetin is chielly of value for the relief of pain, especially of pain of the nenralgic type. In pains due to gross inllammations or deep-seated distress, the result of or- ganic disease of viscera, morphine is far more effective' than phenacetin. But in ]X'uns due to nervous disorders, es- pecially neuralgia and neuritis, and in various forms of headache, acetpheneti- din has come to be considered almost as a specific. In hemicrania, in head- ache due to eye-strain or insufficiency of certain of the extraocular muscles, in intercostal neuralgia, sciatica, gastral- gia, and in the pains of tabes dorsalis, acetphenetidin frequently affords con- siderable rehef. The manner in which this drug, in common with other coal-tar antipyret- ics, acts in relieving headache has not yet been definitely ascertained. Accord- ing to Brunton, headache is associated with and caused by what he terms a "colic" of the arteries of the head, the peripheral vessels being contracted and the central vessels dilated; the drug would presumably give relief by over- coming this abnormal condition of the cephalic arteries. E. Weber has re- cently demonstrated experimentally in dogs whose brain had been exposed that coal-tar drugs cause constriction of the vessels on the surface of the cerebrum. It is well known, moreover, that caffeine, an undoubted vasoconstrictor, when combined with the coal-tar drugs, greatly assists their analgesic action in headaches. Hence it would seem as if the relief given in these cases were due, in some way, to a modification in the caliber of the vessels. [Weber's experiments (Arch. f. Physiol., p. 348, 1909) confirmed the conception of action of coal-tar antipyretics wh'ch I had advanced in 1907 in '"Internal Secretions,"' etc., vol. ii, pp. 1282 to 1299, in which I showed that the reduction of pain was du2 to constriction of the arterioles and the re- sulting diminution of arterial blood admitted to the sensory terminals. C. E. de M. S.] In acute rheumatism, acetpheneti- din has been found useful as an anal- gesic in doses of 3 to 8 grains (0.2 to 0.5 gram), given every four hours. A valuable combination is 4 grains each of acetphenetidin and salol, given three or four times daily. Eldredge counsels the administration of acetphenetidin in pow- der and salicylic acid in solution, the dose of each being regulated according to the patient's susceptibility and the severity of the attack. In cases with cardiac complications, he claims not to have observed any depressing action on the heart when the drug was given to reduce fever. Hirschfelder noted spe- cially the fact that sometimes a hyp- notic action seemed to be produced. In subacute rheumatism and in lumbago and other rheumatic muscular pains, the drug is also frequently effective. In gonorrheal rheumatism, acetphe- netidin was found by Eldredge to act well when given with potassium iodide and sodium salicylate. In influenza, acetphenetidin has be- come a favorite remedy. The pains in the head, back, and limbs are relieved, and the fever reduced. The drug may be given alone in powder form, or com- bined with other remedies, e.g., quinine. In this disease, essentially an asthenic disorder, it is important that the anal- gesia be secured with the least possible degree of general depression; hence acetphenetidin should always be given the preference over its more depressing congeners — acetanilide and antipyrin. 252 ACETYLENE. In whooping-cough, acetphenetidin diminishes the severity and frequency of the paroxysms. In children, 1 or 2 grains (0.06 to 0.013 gram), given three or four times daih^ are generally suf- ficient. Chorea has also been treated with acetphenetidin. Like the other coal- tar drugs, acetphenetidin exerts a not inconsiderable effect on the motor func- tions and reflex action, as well as on general sensibility. Hence the fact that it sometimes proves useful in this dis- order. Insomnia, the result of overwork or general nervous excitability, may yield to acetphenetidin. Kiernan reported having seen it bring on sleep in persons suft'ering from insomnia due to simple exhaustion. In view of the possible serious depressive effects from an over- dose, the likelihood of a drug habit be- ing formed, and the fact that much safer and better hypnotics are available, it seems doubtful whether the use of acetphenetidin for this purpose should be encouraged. The same is probably true of the use of acetphenetidin in the initial stage of pneumonia, in which it has been em- ployed to relieve distress, bring on sweating, reduce fever, and favor sleep. If the drug is used at all, it must surely be withdrawn as soon as the patient begins to show pronounced general de- pression and signs of lowered circula- tory activity. In pleurisy acetpheneti- din has likewise been used to relieve the pain of the initial stage. The first stage of acute coryza may be shortened by giving a few doses of acetphenetidin, which will not only pro- mote sweating and lower the tempera- ture, but also relieve the unpleasant accompanying sensations. A powder containing 5 grains (0.3 gram) each of acetphenetidin and salol, together with 1 grain (0.06 gram) of citrated caffeine, may be administered every three hours for 3 doses with advantage. In diabetes mellitus acetphenetidin, in common with other coal-tar drugs, has been prescribed, generally with but temporary benefit. Local Uses. — Acetphenetidin is sometimes used externally for its anal- gesic and antiseptic properties. Dusted in finely powdered form on the raw sur- faces of ulcerations of various kinds, it not only relieves pain, but favors the development of healthy granulations, thereby hastening the healing process. Because of its low degree of solubility in water, as compared with antipyrin and acetanilide, the likelihood of the absorption of a toxic amount of acet- phenetidin from open surfaces is somewhat less than wdth the above- mentioned agents. Nevertheless, this danger should always be kept in mind, and the external use of the drug confined to lesions covering a small area only. C. E. DE M. Sajous AND L. T. DE M. Sajous, Philadelphia. ACETYLENE.— When calcium car- bide (CaC2) is brought in contact with water, acetylene gas is formed. Being capable, when ignited, of furnishing a de- gree of light far superior to that of ordi- nary gas, acetylene has in recent years been considerably used as an illuminant. When prepared from pure calcium carbide and purified by liquefaction, it has a pleas- ant ethereal odor and can be breathed in small quantities without giving rise to ill effects. Impure gas, prepared from coal or impure lime, may contain calcium sul- phide and phosphide, and the acetylene prepared from it may then have a very unpleasant odor. Acetylene Poisoning. — Acetylene may be fatally poisonous when present in proper- ACIDITY OF THE GASTRIC CONTENTS. 253 tions as high as 40 per cent, by volunio, as shown by Grehant, Berthelot, and Mois- sant. A mixture of 20 volumes of acety- lene — prepared from calcium carbide, 20.8 volumes of oxygen, and 59.2 volumes of nitrogen — was breathed by a dog for thirty-five minutes without any marked disturbance, and 100 c.c. of the blood were found to contain 10 c.c. of acetylene. With 40 volumes of acetylene, the proportion of oxygen remaining the same, a dog died in less than an hour, owing to failure of the heart's action, and 100 c.c. of blood con- tained 20 c.c. of acetylene. With 79 vol- umes of acetylene and 21 volumes of oxy- gen the poisonous efifects were still more strongly marked. The poisonous action of acetylene itself is feeble when the blood is at the same time supplied from the air with the usual amount of oxygen. In other words, acety- lene inhaled in the open air is but slightly harmful. Brociner found that 100 volumes of blood dissolve about 80 volumes of acetj^lene; the solution shows no charac- teristic spectrum, and is reduced by am- monium sulphide as readily as ordinary arterial blood. If any compound of acety- lene and hemoglobin is formed, it is very Unstable, and is not analogous to carboxy- hemoglobin. In a closed room, however, where the oxygen is not kept up to the normal stand- ard, when the accumulation of a foreign 'gas would prevent the constant renewal of air through window and door interstices or open chimneys, and where the products of respiration would be allowed to accu- mulate, it would quickly prove mortal by paralyzing the respiratory function. Mosso and Ottolenghi found experimen- tally that acetylene has considerable toxic power. One pint of the pure gas caused severe sj^mptoms of poisoning in dogs, and even when mixed with air (20 per cent.) it proved fatal after an hour. If the gas was administered rapidly, the animal re- covered when placed in the open air, but if given slowly this did not occur, and the animals died. Thomas Oliver has shown that a mixture of air and acetylene commences to be ex- plosive when it contains 5 per cent, of acetylene, whereas it requires the presence of 8 per cent, of coal gas to make a similar mi.xturc cxplosable. If a rabbit is placed in a bell-jar into which ordinary air and acetylene are pumped, the animal seems for a long period to experience very little inconvenience. It is not until ordinary atmospheric air is excluded and only acety- lene admitted that symptoms gradually and slowly develop. After a more length- ened exposure to acetylene than that which is necessary for coal gas the animal becomes intoxicated, it falls over on its side apparently profoundly asleep, and, while all through the experiment its breathing has been somewhat short and rapid, stupor steals over the animal ap- parently painlessly. A few inhalations of atmospheric air are sufficient to restore to the animal all its faculties. Should in- halation have been pushed further and the animal have been very deeply asphyxiated, death may ensue, cyanosis, hitherto ob- served, being rapidly replaced by extreme pallor. Treatment of Acetylene Poisoning. — That fresh air should at once be given the patient need hardly be mentioned. The patient should be removed from the poisoned atmosphere into a well-ventilated room and artificial respiration practised. Hypodermic injections of strychnine and digitalis should be administered while oxygen is sent for. This gas should be inhaled as soon as practicable, while arti- ficial respiration is continued with vigor, the patient being simultaneously rubbed. Rectal injections of warm coffee are also useful. Hypodermoclysis, with epinephrin or adrenalin 1 : 1000 solution introduced drop by drop into the saline solution by pushing the hypodermic needle into the rubber pipe, is indicated in all cases of severe poisoning by the gas. In all such cases the efforts of the physi- cian should be kept up a long time, the respiration and pulse being unreliable guides as regards the presence in the sys- tem of sufficient life to render resuscitation possible. S. ACIDITY OF THE GASTRIC CONTENTS, TESTS FOR.— While the acidity of normal gastric juice is due mainly to the presence of hydrochloric acid, . departures from the normal proportion of this acid in the gastric contents have been 254 ACIDITY OF THE GASTRIC CONTENTS. found to accompany with sufficient frequency certain disorders to facilitate the recognition of these disorders. Thus, a proportion of hydrochloric acid of 0.15 to 0.3 per cent, represents the acidity found under normal conditions, i.e., euchlorhydria, but an ex- cess of acid, hyperchlorhydria, is common in gastric ulcer, gastroptosis, hysteria, tabes, and other disorders. Hypochlor- hydria, a deficiency of hydrochloric acid, also accompanies various disorders, espe- cially gastric cancer, neurasthenia, anemia, chronic gastritis of long duration, gastric neuroses, and certain diseases of the pan- creas, while achlorhydria, absence of hydro- chloric acid, is found in advanced cases of the same disorders. Again, the fact that hydrochloric acid is necessary to peptic digestion, while acting 'cs a powerful anti- septic to the ingested foodstuffs, further indicates the practical importance of ascer- taining accurately the acidit}^ of the gastric contents. To obtain accurate information, it is necessary to administer a test-meal con- taining a definite quantity of foodstuffs, and to leave the latter in the stomach a definite time. Test-meals. — Those described are gen- erally given preference: — The Ewald-Boas breakfast consists of 1 roll weighing about 35 Gm. (9 drams) and a large wineglass of 300 Gm. (10 ounces) of water. This meal should be taken early in the morning on an empty stomach, the bread being eaten slowly and the water sipped while this is done. At the end of one hour, 20 to 60 c.c. (5 to 10 drams) of the meal should be withdrawn from the stomach in the manner indicated below. The Leube-Riegel test-meal consists of beef soup, 400 c.c. (12 ounces); beefsteak finely chopped, 200 Gm. (6 ounces) ; wheat bread or potato, 50 Gm. (1.6 ounces), and water, 200 Gm. (6 ounces). The gastric contents should be removed at the end of four hours. The Salzer inetJiod inckides two meals: The first consists of 30 Gm. (1 ounce) of lean roast beef chopped very fine ; milk, 250 c.c. (8 ounces); rice, 50 Gm., and 1 soft-boiled egg. The second meal, given four hours later, is an Ewald-Boas break- fast, described above. At the end of five hours after the first meal, that is to say. one hour after the second, the gastric con- , tents is withdrawn. The Salzer test affords, in addition to the opportunity of ascertaining acidity, that of determining the motility of the gastric muscles; for if particles of meat of the first meal are still present at the end of five hours, the propulsive activity of the stomach wall is deficient. Withdrawal of Gastric Contents. — This, the next step of the examination, is car- ried out with the aid of a flexible red rub- ber tube about a yard in length, the catheter-like end of which is provided, a short distance above the tip, with a fenes- tra or opening. It is an ordinary stomach tube the upper end of which is funnel- shaped. About 2 feet above this end is a mark which, when the tube is introduced sufficiently far, i.e., when its tip reaches the bottom of the stomach, corresponds with the incisor teeth of an adult. The patient's clothing being protected with a towel tied round his or her neck, the tube, previously warmed by being placed in a bowl of warm wat r and lubri- cated with glycerin, is introduced, i.e., passed down the esophagus. This is done readily by pushing the end of the tube gently into the latter, over the epiglottis, while the patient swallows, and as often as he does so. In some cases, especially the first time, the procedure may cause gagging, but this can be avoided by pass- ing the tube on one side of the epiglottis, i.e., in either pyriform sinus. The sensi- tive surface of the pharynx is thus avoidea. To withdraw the gastric contents several ways are available. The easiest is to de- press the external end of the tube as soon as the latter is in situ, and request the pa- tient to lean forward and cough a few times or contract his abdominal muscles. An essential point, however, is that the (clean) bowl in which the gastric contents is to be collected must be considerably below the level of the patient's stomach, i.e., between his knees, so as to obtain the benefit of siphonage. The expulsion of the gastric contents is facilitated by press- ing on the stomach while the patient is coughing or contracting his abdominal m.uscles; it is further aided by having him lie down on a lounge, the bowl being placed on the floor. It is not necessary to ACIDITY OF THE GASTRIC CONTENTS. -)■■ empty the stomach, a couple of table- spoonfuls (about 30 c.c.) suflicing fur all purposes. Various pumps, aspirating bulbs, etc., have been invented to deplete the stomach, but the}'- entail the use of parts that arc difficult to clean properly, and expose the gastric mucosa to the evil effects of direct suction by the tube. Moreover, compli- cated instnmients tend to increase the timidity of the patient, which, at best, is sometimes difficult to overcome. Briefly, the above-described "simple expression method'' is, on the whole, the most satis- f act or}'. Contraindications to the Use of the Stomach Tube.^ — In a certain proportion of cases, however, even the use of the simple stomach tube may prove dangerous. They are: cases of advanced cardiac disorder; advanced arteriosclerosis, especially if there is a history of cerebral hemorrhage or "slight stroke"; elderly persons of apoplectic build. In either of these the tube ma}'' cause a sudden reflex rise of the blood-pressure and rupture of any diseased vascular tissue. A history of recent hema- temesis or of bloody or tarry stools is also a contraindication, since the bleeding may be due to gastric ulcer or cancer, which the extremity of the tube might readily abrade, and thus cause renewal of the hemorrhages. Advanced tuberculosis, marked emphysema, pregnancy, and ex- treme debility are also recognized as con- traindications. Determination of Free Acids. — The mere presence of any free acid, hydrochloric, lactic, etc., can readily be determined by using paper previously dipped in a solu- tion of Congo red and dried. This turns blue in the presence of free acids, but does not identify one acid from another. To identify hydrochloric acid, the best reagent is probably the diniethylamidoaso- bencol. It may be used in 0.5 per cent, solution or in absorbent paper allowed to dry before using. The yellow color of either becomes reddish pink in the pres- ence of hydrochloric acid. This test fur- nishes an inkling as to the degree of acidity due to the latter, for the reddish- pink color becomes much deeper in pro- portion as the percentage of acid is great. Tropeolln is another good reagent which can be used in the same manner. Its yel- lowish-brown alcoholic solution turns red in the presence of both hydrochloric acid and lactic acid; but the former can be differentiated l)y spreading a few drops of a saturated solution in a porcelain dish, and adding thereto an equal quantity of the gastric fluid. On mixing them and heating them gent'y, blue and lilac stripes (formed by hydrochloric acid only) appear. An extremely delicate test, which will detect 1 part of hydrochloric acid in 20,000 parts of water, is Guiisburg's, whose reagent consists of: — IJ Phloroghic'm 2 Gm. (30 gr.) . I'aniUin 1 Gm. (15 gr.). Absolute alcohol 30 c.c. (1 oz.). It should be kept in a dark bottle. By adding a few drops of this reagent to the gastric filtrate and allowing the mixture to evaporate to dryness, a beautiful rose- red tinge is obtained if free hydrochloric acid is present. To Ascertain the Total Acidity. — The easiest method is to add 1 drop of a 1 per cent, solution of phenolphtlialeiii to 10 c.c. (2^ drams) of the gastric fluid, after filtering the latter, and neutralizing the mixture by a given quantity of decinormal solution (about 30 grains to the pint — 2 Gm. in 500 c.c. of distilled water) of sodium hydroxide. The technique of the procedure is as follows: Place 10 c.c. of the filtered gastric fluid in a beaker, and add thereto 2 drops of phenolphthalein solution. Then add the decinormal sodium hydroxide solution from a graduated bu- rette (mixing with a glass rod) until a permanent red or reddish-pink color ap- pears, which means complete neutraliza- tion. Now, the number of c.c. (say 4 or 4.5) of sodium hydrate solution necessary to obtain the latter, as shown by the graduated burette, with a naught to the right of this figure (making 40.0 or 45.0 of the above figures), will represent the per- centage of total acidity. A watery solution of Congo red may be used instead of phenolphthalein. As we have seen, free hydrochloric acid in the gastric fluid or chyme changes the red color to blue. If, now, decinormal sodium hydrate solution (vide supra) is slowly added to the mixture until the Congo red 256 ACNE (STELWAGON). is restored, the number of cubic centi- meters of the sodium hydrate solution re- quired to obtain this result will represent the amount of free hydrochloric acid. Lactic acid, which suggests the presence of cancer or dilatation, being contained in all bakery products, in meats as sarco- lactic acid, sour milk, sauerkraut, and sour gherkins, a special meal is necessary to eliminate from the test the acid due to Strauss's separating funnel for lactic acid test. foods. A bowl of soup prepared with Knorr's oatmeal, rendered palatable by adding common salt, suffices for this pur- pose. Uffehnann's reagent may then be used. It is composed as follows: — ^ Solution of carbolic acid (4 per cent.) 10 c.c. Distilled zvater 20 c.c. Official neutral ferric chloride solution 1 drop. This should be prepared fresh for each test. Its amethyst-blue color will be turned to canary yellow when added to the gastric filtrate. A quantitative estimation of lactic acid may be obtained by Strauss's method. "A separating funnel (shown in the annexed cut) with marks at S c.c. and 25 c.c. is filled to the first mark with gastric juice and then to the second with ether. After thoroughly shaking, the fluid is allowed to ?iow out to the first mark (5 c.c), then filled with water to the second mark (25 c.c). Two drops of a 10 per cent, solution of iron chloride are then added. A beautiful green color appears in the presence of amounts exceeding 0.5 per mille." (Lenhartz-Brooks.) Butyric acid and other fatty acids, on boiling the gastric filtrate, emit a charac- teristic odor. They also turn yellowish brown in the presence of Uffehnann's solu- tion, just described. Another test is to shake the gastric product (unfiltered) with acid-free ether, and then allow the latter to evaporate. On adding calcium chloride to a watery solution of the residue, the butyric acid forms oil droplets with the characteristic odor of the acid. Acetic acid also emits a characteristic odor, that of vinegar. A small quantity of gastric filtrate, say 10 c.c, is treated with ether as above. The residue being dis- solved in a little water and neutralized with a solution of sodium carbonate, a couple of drops of a very dilute solution of ferric chloride are added. The filtrate then becomes dark red if acetic acid is present. Or a few drops of sulphuric acid and alcohol may be added to the same neutralized residue; on heating, the latter then gives off the characteristic vinegar- like odor of acetic acid. S. ACIDOSIS. TION. See AuTOiNTOxicA- ACNE.— DEFINITION.— Acne is characterized by the presence, usually on the face, of small elevations or nodosities varying" in size from a pinhead to a pea. These elevations, or pimples, are also present on the back, shoulders, and chest in many cases. SYMPTOMS.— The elevations are conical or hemispherical, and, as a ACNE (STELWAGON). 257 rule, in the earliest stage of the lesion somewhat painful, espeeially upon pressure. In most of the lesions there is a distinct tendency to sui^purative change. In the center of the lesion a whitish-}- ellow spot forms where the pus raises the epidermis. In from three to ten days, or even longer, the lesion breaks and a small amount of pus is discharged. At other times the pus dries to a thin crust, or occasion- ally the contents, especially in slug- gish lesions, are absorbed. A red elevation is left which gradually flat- tens out, leaving a brownish stain, which eventually disappears. The surrounding skin is frequently oily and shiny. Small, sluggish, abscess- like lesions, and tumors as large as a pea or a small nut, formed by reten- tion cysts of sebaceous glands, are sometimes seen ; they may gradually work to the surface or may persist for months and finally disappear or form hard spherical indurations by retrac- tion and inspissation of their contents. Scarring, usually consisting of small, white, cicatricial depressions, is to be seen as a consequence in some cases. In the majority of cases, however, permanent marks are not left. The .regions most afifected in acne are the face, shoulders, and anterior and pos- terior aspects of the shoulders. Occa- sional cases are observed in which the back, extending as far down as the sacrum, is the chief seat of the disease. In rare instances (acne cachecticorum, acne scrofulosorum, and acne medi- camentosa) the eruption may be more or less general. VARIETIES.— There are several varieties of lesion observed in acne, one kind of wdiich is apt to predomi- nate, and this has given rise to the so- called varieties of the disease. 1— : .Icnc vulgaris, or acne simplex, is, by far, the most common clinical type. Tlie lesions are usually of a mixed character, consi^^ting of blackheads, ])inhead- to pea-sized papules, papulo- pustules, and pustules. Each lesion may in its beginning have a small, red areola. There is also slight pain upon pressure. The lesions are rapid in evolution, running a course in several days to a week. As in all types, they are discrete and isolated. The term "acne papulosa" is given to a not uncommon type in which the lesions are usually small and show but little disposition to reach the pustular stage, disappearing by absorption or by desiccation and exfoliation. Acne punctata might be termed mi- nute papular, the lesions being, for the most, pinhead in size, with a central comedo, or blackhead. Acne pustulosa is another type in which the lesions go rapidly into the pustular stage, the eruption appearing, for the most part, to be made up, almost entirely, of pustules. In size they vary from a large pinhead to a large-sized pea. Acne indurata, or "tuberculosa," is a form of the eruption in which the lesions tend to be closely crowded here and there and in such places, and also with single lesions, the underly- ing base becomes hard, inflamed, and indurated, being also somewhat deep- seated. In acne phlegnionosa the inflamma- tory and suppurative process begins deep down in the sebaceous gland, forming veritable small dermic and intradermic abscesses, usually with but slight tendency to break through the surface. ■ Acne cachecticorum characterizes an acneic eruption, more or less general, ■17 258 ACNE (STELWAGON). occurring in weak, cachectic individ- uals; the lesions are livid, indolent, violet-red papulopustules of moderate and large size and of slow evolution, leaving, as a rule^ small cicatrices. Acne scrofulosorum is really a variety of the last named, — acne cachecti- corum, — occurring in those of dis- tinctly strumous or tuberculous tem- perament. Acne artificialis sen medicamentosa is a form of acneic eruption produced by the ingestion of certain drugs, as the iodides and bromides, and also by the external applications of certain reme- dies, such as tar, the paraffin oils, etc. "Acne atrophica" is a name given to those cases of acneic eruption which tend to leaA'e depressed scars. This pxobably occurs most frequently in those cases in which the lesions are sluggishly papular or papulopustular, the lesions disappearing by absorption or crusting and leaving behind small, punched-out cicatrices. Acne hypertrophica is really the op- posite of the last-named variety, and occurs in about the same kind of cases, small, whitish, connective-tissue, pinpoint or small-pea sized projecting hypertrophies marking the sites of the lesions. It is rare. ETIOLOGY.— Acne begins usually near puberty, when the pilar system is more actively developing, and the functions of the sebaceous glands like- wise ; and is more frequent among patients with digestive troubles, con- stipation, dilatation of the stomach, menstrual irregularities, the strumous diathesis, possibly the arthritic di- athesis, and disturbances of the nervous system. Acne at about the time of puberty may be of intestinal origin, and in 94.9 per cent, of a series of 33 cases of acne occurring at this age the writer found clear evidence of abnormal putre- factive changes in the intestine, as shown by the presence of an excess of indican, phenolcresol, etc., in the urine; this intestinal putrefaction may be due to the peristaltic inertia common at about the time of puberty. Although further investigations are needed to demonstrate the causal connection be- tween acne and excessive intestinal putrefaction, the writer tried the effect in cases of acne of drugs which have an anti fermentative action and which aid peristalsis, and with this object has administered a combination of 1 gram of sulphur precipitate and 0.25 gram of menthol, given two or three times a day over a period of several months. In the 33 cases of acne mentioned, which included cases of acne simplex, acne pustulosa, and acne indurata, treat- ment on these lines was very successful, substantial improvement being seen in all the cases and recovery in many. In 1 case the medicine gave rise to diarrhea with colic-like pains, but in the others there were no unpleasant side-effects. The first result of the treatment was that the stools became pultaceous and the output of phenol sank to 0.01, or at the highest to 0.07, as opposed to an average output of 0.101 gram, which had been previously ob- served. With this fall in the output of phenol improvement began, and often in the first three or four weeks the acne papules were observed to more quickly disappear ; during the next four in eight weeks, in all but 1 obstinate case, new papules appeared with much less frequency, and in 9 cases, after three months' treatment, no new pap- ules formed. Some of the cases have now been as long as eighteen months without relapse, and may be considered to have completely recovered. During the internal treatment, local treatment, although it was not altogether discon- tinued, was reduced to a minimum. Josef Kapp (Therapeutische Monats., March, 1907). It has been also alleged without, however, substantial foundation that ACNE (STELWAGON). 259 lesions of the g-enitoiirinary oi\qans and venereal excesses may proA^oke the disease. Lesions may be due to mechanical irritation caused by the product of secretion remaining in the excretory canal or gland itself. Some drugs, as already stated, — such as the bromides and iodides, — are occa- sionall_v responsible for the eruption or an increase in an already existing eruption. Certain drugs applied ex- ternally may also provoke acneic lesions, such as tar and tar products, juniper oil, and the like. Workers in paraffin and paraffin products will not infrequently be found affected Avith papules and pustules, especially those of a furuncular or abscess type. The direct local exciting factor is thought, by many, to be a micro-organism, Gilchrist's observations pointing to a specific bacillus. Up to 1899 no observer had succeeded in obtaining the acne bacilli pure from lesions of acne vulgaris or comedo, and there was practically no proof that these bacilli were the cause of acne vulgaris. Definite bacilli (Bacillus acnes), however, were found present in all smears taken from 240 typical acne lesions from 86 patients. Pure cultures were obtained from 62 lesions (chiefly acne nodules) from 29 patients. It is present as a short, thick bacillus in smears, but in culture often becomes much longer and thicker, and in old cultures assumes distinct branching forms. It is now definitely proven that this micro-organism is the primary cause of acne vulgaris. T. C. Gilchrist (Jour, of Cutan. Med., Mar., 1903). PATHOLOGY.— In most cases the process begins by a perifolliculitis, which later on gives rise to a purulent folliculitis. It would thus seem that in some cases the sebaceous glands play but a small part in the affection. In most cases, however, when come- dones are present, the sebaceous gland itself is the starting point of the in- ilammatory process. (lirocq.) Even when the focus of irritation is in the follicle, it is frequently limited to the sebaceous or sebaceous pilary canal. (E. Besnier, A. Doyon.) The papillae surroundin,? the come- done and the superficial layers of the corium are filled with blood-vessels full to repletion, and of exudation cells which are found in dilated vacuoles. (Kaposi.) If the process is very intense, the sebaceous gland may be entirely de- stroyed by the local inflammatory action, while the pilar bulba persists. (Kaposi.) The acneic process may be divided into two parts: 1. Closure of the sebaceous follicle and formation of comedo. 2. Suppuration, which only occurs in those follicles where the staphylococci aureus et albus have penetrated before the comedo formed. (Unna.) The writers have succeeded in grow- ing the Bacillus acnes under anaerobic conditions. It stains by Gram's method and often shows an irregular or beaded appearance. It is moderately wide and of variable length, especially in cultures, where it frequently shows branching forms. It forms no spores. Abstract- ing oxygen, by Wright's method, it grows on all the common media, best on glucose agar, either in suspension or slant. In bouillon it forms a white flocculent sediment. It was most easily grown from the lesions by smearing the pus on the surface of glucose-agar slants. On this medium, in the absence of oxygen, it produces fair-sized colo- nies in three to five days. It forms raised, grayish-white, opaque colonies, considerably smaller than those of the staphylococcus albus, which are purer white. On acid agar, as noted by Flem- ming, it grows in the presence of oxy- gen, but much more slowly. The ba- cillus is, therefore, essentially an an- 260 ACNE (STELWAGON). aerobe, but will grow in the presence of oxygen when planted in masses, by reason of the anaerobic conditions which are thereby created within the masses. They regard this bacillus as identical with the Bacillus acnes of Gilchrist and other observers from its similarity in morphology and cultural characteristics. From the ease with which it could be obtained from their cases when grown anaerobically, they think it can probably be cultivated from all cases of acne. Hartwell and Streeter (Boston Med. and Surg. Jour., Dec. 16, 1909). TREATMENT.— In this connec- tion acne may be divided into (1) an irritable or inflammatory variety, in which the skin is fine and thin and easily irritated by stimulating applica- tions, and where general treatment is important on account of the close union between the acneic eruption and various constitutional disturb- ances. Local treatment should, at first at least, be of a mild character. (2) An indolent variety, where the in- Bacillus acnes {Ilartioell and Streeter) Boston Medical and Surgical Journal, Dec, 16, 1909. DIAGNOSIS.— Acne is to be dif- ferentiated from the papular, papulo- pustular, and pustular syphiloderms, :and also from variola. .Syphilis. — In the syphilitic eruption the distribution is more or less general, and more acute in its outbreak, darker hued, and occurring occasionally with gpecial groupings and the presence of other symptoms of the disease. Variola.— In small-pox the premoni- tory constitutional symptoms, the sud- den outbreak, the uniformity of the lesions, and many other symptoms of differential character will serve to differentiate. tegument is thick, rough, and oily, with enlarged and obstructed gland orifices, and where the most energetic local ap- plications are well borne ; here the local treatment is important. Probably most of the cases met with occupy a middle ground between these two ex- treme varieties. General Treatment. — ■ Prophylactic measures, such as the avoidance of ex- ternal irritants, drugs and food hable to cause acne, such as coffee, tea, alcohol, pure wine, pork, veal, game too far gone, preserved fish, shellfish, fats, and cheeses. Any disorder of digestion must be ACNE (.STELWAGON). 261 counteracted in ortler to avoid the con- gestion of the face following meals. If the tongue is much coated and shows prominent papillae, the following is recommended : — I^ Sodium bicarb 10 grs. Ext. cascara sagr. liq 10-20 mins. Tiiiit. mix vomica 7-10 mins. Pcppcniiiiit zcatcr.. to make 1 fl. oz. — M. Constipation should be counteracted by g'entle aperients. Any condition capable of maintaining the sympathetic system in a state of tension — such as genitourinary troubles or affections of the nasal fossse — should be eradicated if possible. If the patient is lymphatic and has a good digestion, codliver oil is of value. Anemia or chlorosis calls for the use of chalybeates with arsenic. Iron often does harm unless its constipating effect is counteracted by using aperients. When the patient is arthritic, alkalies, especially alkaline waters, are indicated. No really specific treatment is known against acne, but the following have been recommended : — Sulphur alone : powder or tablets, or with equal parts of honey. Ichthyol (Unna) : — R Ichthyol 1-2 drs. Dist. water 5 drs. M. Sig. : Fifteen to 50 drops in water, to be taken morning and evening. Arsenic bromide in weak doses, %o grain, in acne pustulosa. (Piffard.) Mercurial preparations, such as corrosive sublimate or calomel, either alone or Avith jalap or colocynth ex- tract, have been found useful. The writer strongly recommends the old mistura acidi ferri, or Startin's solution, in plethoric girls with cos- tiveness, coated tongue and local hy- peremia, The rnixture is as follows; — - li Magnesii sulph 3j (30.00). Ferri sulph gr. x (0.65). Sodii chloridi 3ss (1.95). Acidi sulph. dil 3ij (8.00). Infiisi gent q. s. ad 5iv (120.00). As to the local treatment : 1. Wash the face well at night with cold or tepid water and good soap; tincture of green soap is desirable. Open with a sharp lance all pustules, scrape off the acne tops, use the comedo expressor, dry the face and whiten with the white lotion. 2. In the morning flick off the white powder with a soft towel. It is not then necessary to wash the face. Use the ointment of sulphur in the morning if the skin feels dry and harsh in spots or places, or apply the lotion lightly if about the house. 3. On going out use the powder as a cosmetic, and at night wash the face and begin the treatment again. Brayton (Jour. In- diana State Med. Assoc, Apr., 1908). Summary of treatment: Prohibit cakes, pies, pastries, salt meats, fish, and eating between meals. If anemic, give nourishing foods. Ferri citratis, 5ij; magnesii sulphatis, 3v; strych- ninae, gf. j; syr. zingiberis, ' §j ; aquse, 5iv. In obese, constipated, and slug- gish individuals: Potassium acetate, 3v; fl. ext. of carcara sagrada, Bij; fl. ext. of rumex, Biij; 1 dram in water half-hour before meals. Outdoor ex- ercise. Where comedones or pus- tules: Green soap, 3j; resorcin, 5j; salicylic acid, gr. v; rose-water oint- ment, §ij; to be applied at night and washed off in morning, until fair des- quamation obtained. Lotio alba (po- tassium sulphide and zinc sulphate) applied at night after using hot or cold water; friction with towel. Cocks (Med. Record, Dec. 3, 1910). Local Treatment. — Constitutional treatment will rarely succeed alone, while in a large proportion a local treat- ment by itself will be found efficacious. The majority of cases can be greatly benefited ,in a short time, and very many of them cured promptly. The indications for treatment are as fol- lows : The condition of the skin should 262 ACNE (STELWAGON). be improved so that it will no longer be a suitable culture ground for the bacillus. The follicles of the skin should be emptied of the colonies of bacilli. The skin should be constantly kept aseptic, so that any bacilli that escape on it will be killed, and no new infection of the skin will be possible. The first indication is met by attention on the patient's general health by means of baths, diet, exercise, attention to hygiene, and, lastly, drugs. The folli- cles are emptied by the use of the cu- rette, the acne lancet, and the comedo expressor. The best local application is sulphur, preferably in the form of the old lotio alba, the formula for which is : Zinc sulphate and potasE:ium sul- pheret, of each, 3i-ij ; rase water, q. s. ad §iv. This is to be shaken up before using. Resorcin is also useful, as well as sulphur soap. The use of the Roentgen ray should be limited to in- tractable cases, and requires great caution to prevent doing harm. G. T. Jackson (Med. Rec, Mar. IS, 1905). Hot-water and alcoholic lotions sometimes act promptly. In mild cases these are applied at night with very hot water, either pure or combined with cologne water or camphorated alcohol. The water is gradually re- duced until pure camphorated alcohol or cologne water is used. Boric acid or borax may be added to the lotions : 1 part to 50. Night and morning the skin should be bathed in very hot water (to re- duce the congestion), to which creolin, or a few drops of the following solu- tion, should be added : — B Corrosive sublimate 7^ grs. Tinct. of benzoin ....... 75 grs. Emulsion bitter almonds. 3675 grs. M. E. Lacour (Nord med., Aug. 15, 1900). Many of the less severe forms can be cured by prolonged bathing in hot water. The water should be soft, and the applications to the face should be made with a soft bathing sponge. The gponge, loaded with water as hot as can be borne, should be applied to the face. The bathing should last about five minutes, and should be done each night and morning ; at the same time moderate pressure is applied to the sponge. After the sponging the face should be dried on a soft towel without rubbing, and bay rum should be applied freely. The face should not be touched by the hands until the time for repeat- ing the process. W. L. Hunt (Jour, of Med. and Sci., Sept., 1904). Have patient vigorously scrub his face, every night before retiring, with green soap and hot water. After rins- ing with cold water and drying the face, the following paste is to be applied : Betanaphthol, 5 parts; precipitated sulphur, 25 parts; green soap and lanolin, of each, 35 parts. Spread this over the involved crea and allow it to remain fifteen minutes to one hour, after which it is wiped off. Length of application depends on the reaction produced; if left on too long, the skin reddens, or, after greatly prolonged contact, the epidermis desquamates. This paste acts probably by causing an inflammation of the skin, which extends along the dilated follicles, thus inhibiting the secretion and pro- ducing shrinkage of the dilated seba- ceous glands. When the condition is improved, continue the applications at longer intervals to prevent recur- rence; also scrub face every second or third night. Burke (Penna. Med. Jour., March, 1911). Instead of camphorated alcohol there have been used with success : — Alcohol, 96°, saturated with boric acid, and alcohol with salicylic acid, 1 to ZO. The latter is strong and must be used with care. Mercurial preparations have been variously extolled, but in late years have gradually given way to other more valuable remedies. Mercurial lotions are efficacious in some cases, employed as follows : — I^ Corr. subl 1 part. Alcohol, 90° 100 parts. Dist. lijater or rose water . . . 150 parts. ACNE (STELWAGON). 263 At first this solution is weakened of the disease; especially useful when with one-half its quantity of water; much seborrhea exists. In a few afterward, if no irritation lias resulted, ])atients sulphur preparations cannot be the water is gradually rcducetl until the used, owing to the irritation caused, solution is employed pure. Sulphur may be employed in the fol- Other mercurial preparations, in lowing ways : — ointment form, such as the biniodide, Sulphur soap: with hot water, the the iodochloride, white precipitate, and suds being allowed to dry on to the mercurial plaster, viz. : — face. l"he ammoniated mercurial oint- Sulphur baths, ment, 5 grains, or 30 grains to 1 Sulphur lotions: hot water with 10 ounce, is highly recommended by to 60 drops for every one-half glassful Stopford Taylor. ^f liquid potassium polysulphide. Gordon Campbell recommends the ^n effective method of using sulphur followmg procedure:— ^ is the following:— The face is to be washed with water a ff^,. ^.^c-in;,.^. , .vi i ♦. j. i Alter wasnmg with hot water and as hot as can be borne and some bland ^^^p^ ^j^^ following mixture is applied unirntatmg soap, and then, after care- ^^j^h a camel's hair brush:— fully drying the skin, the following lotion is applied once a day:— ^ Precipitated sulphur. Potassium bicarbonate, R Hydrargyri chloridi corrosivi. 12 grs. . Glycerin Spiritiis vini rcctif 6 oz.— M. j^^^^^^^ ^^^^,,^ Effect for first few days will be to Alcohol ^(^0°) of each 2 drs.-M. render condition worse; but, after this, ji^g coating is left on during night- the lotion prevents perforation of the time and washed off in the morning pustules. with an emulsion of almond oil, and External _ drug treatment in both the skin is covered with oxide of zinc acne vulgaris and acne rosacea is usu- , . ^, , ., 11 1- • ,• e 1 1- • ^1. u . 01" bismuth subnitrate ointment pow- ally disr.ppointing. Sulphur is the best . ^ external preparation. Mechanical treat- ^^^^^ O^er with fine starch. ment, such as the use of hot water, When the skin becomes irritated, the soap, massage,, and the dermal curette, sulphur paste should be discontinued is exceedingly valuable. The opsonic ^„ j ,i „ „:^„ ^: t.^^ ^ i- j i , ■, . , . . . . and the zinc ointment applied alone method m acne vulgaris is promising. ...... i. Roentgen treatment of both diseases ""*^^ ^^^ irritation has disappeared, is the most valuable. In its certainty The following are Useful : — of cure and frequency of relapse it al- ^ _ , , . . , , -r T^, , , ii' Sulphate of zinc, most approaches a specific. Ihe tech- <- 7 r r ■ „• r • ^u V • • Sulphuret of potassiuin..oi each 1-4 drs. nique of using the X-ray, say, in acne, is ' ^ ^ of paramount importance. If the ray is 4 oz. properly applied there should be few, u n -u 7^/ .^ \ ., , , . , , , I> Precip. sulphur, if any, failures and no undesirable ef- ^.r r i ^ i , , ^ . ,-, -r J- c. . TIT J hther of each 4 drs. fects. Cole (Jour. Indiana btate Med. u i i , , a n Assoc, Mar., 1909). ^-^'^"^'"^ ^^ "^^'^^^ ^ fl. oz. Formaldehyde, largely diluted, has ^ ^/''^^- •^".^^^""', 2 drs. , , . , . 1 Gum tragacanth, recently been tried with success. /-„„,a?^. c i or. •' Camphor of each 20 grs. Sulphur preparations are by far the Lime water 2 fl. oz. most valuable in the external treatment Water . . ■ ■ to make 4 fl. oz. 264 ACNE (STELWAGON). Both these lotions are often made is applied. In acne vulgaris, after more valuable by the addition of 2 to 5 steaming, strong sulphur and ichthyol , . soap is used with brisk rubbing with per cent, of resorcm. a u i -n v r-\j \r t ^ a iiesh-glove. Brownlie (N. Y. Lan- Sulphur ointments are usually made ^^^ -^^^ 1901) .in the proportion of 1 in 10, with benzo- The ' followin- resorcin paste is ated lard, smiple cerate, vaselm, vaselin recommended : and lanolin, lanolin and sweet almond . or/ c . -t> Resorcm 2>2-5 parts. oil or olive oil, or castor oil and cacao ^^^^^ oxide butter. Starch of each S parts. To the sulphur may be added oxide Vaselin 125^ parts.— M. of zinc in equal parts ; borax, 1 to 20 ; This paste may remain on a day and salicylic acid, 1 to 50; naphthol, 1 to a night and then be removed with a 10 or 1 to 20; resorcin or camphor, 1 piece -of cotton. Cure is said to be to 20 or 1 to 40. They may be per- speedy, occurring in three or five days, fumed with essence of rose, bergamot, It is a strong preparation, acting with or balsam of Peru if desired. considerable energy in some cases. Sulphur soaps are sometimes more In slight cases of acne of the face convenient ^^^ following formula is recommended : T^i j: 11 • ™ 1^^ ,.r.^A . Eau de cologne, or 90 per cent, alco- The f ollowmg may be used : — -^ i • , • ^■ ^■ -jo . . . hoi, with resorcin or salicylic acid, 2 Soap and precipitated sulphur, equal ^^ ^ ^^^ ^^^^^ ^^ sublimate or cyanide parts. of mercury. After these lotions the Soap, precipitated sulphur, and lard, skin should be slightly greased with equal parts lanolin, 10; water, 20; and rose water, Naphthol may be cautiously added ^ parts. The application of an aqueous solution of ichthyol, 5 to 10 to the first of the series. p^^ ^^^^_^ ^^ ^j^^ ^^^^^1 Leredde Among other local treatments recom- (b^h^ g^^. de therap., 1903). mended are the application to the pus- Salicylic acid acts well in from 1 to tules of carbolic acid, salicylic acid, or 31^ per cent, in various ointments. resorcin. An ointment of ichthyol, 1 Electrolysis has been recommended to 4 or 1 to 8, is also useful. f^j. ^he removal of the indurated Ichthyol is very beneficial both in masses left on the skin, acne vulgaris and acne rosacea. The i^ ^^^^ ^f ^^e back the strongest best results are obtained when external r -• 1 1 a a ... applications, as a rule, are demanded, and internal treatments are combined. ^^ . In some cases of acne rosacea in which ^i especial value m some cases is the the skin is too thin and irritable to bear liquor calcis sulphuridis (Vleminckx's even weak solutions, the internal ad- solution). This should be used at first ministration of ichthyol alone, with diluted. steaming, will be beneficial. Five grains Massage of the face is not to be of ichthyol may be given thrice daily, 7 , r after food, increasing the amount to commended for acne, often doing dis- 10 grains. Every night and morning tinct harm. the face is steamed for fifteen minutes, The comedo is in the majority of and is then washed with ichthyol soap. cases the forerunner of the acne nodule The lather is allowed to dry on the and pustule. The comedo is best re- face, after which it is gently washed moved by a comedo extractor, which off with water. After each washing should have rounded edges. The pres- ichthyol salve, if it can be borne (often sure should be moderate, and if the combined with ammoniated mercury), comedo does not escape it is best to ACNE (STELWAGON). 265 puncture with a narrow bistoury. This should be done by the physician. The papules and pustules arc treated by lancing. When more active methods are not employed, it is of value to cover the parts with mercurial plaster for a few nights. Various useful methods have been devised, the main local ap- plications consisting of sulphur, sali- cylic acid, resorcin, and soap. The best treatment, however, is the X- ray. In many cases irradiations will obviate the necessity of lancing the nodules and pustules. D. Lieberthal • (Lancet-Clinic, Dec. 30, 1905). Before undertaking the local treat- ment of acne it is well to open the pustules, empty the comedones and sebaceous cysts, etc. These measures often prove satisfactory in indurated and rebellious acne. Some observers object, however, to the use of the curette. Facial acne gives favorable results under treatment by a glass vacuum electrode excited by the Oudin reso- nator and transmitting quite a strong current. The bulb should be rubbed over the skin without breaking the contact, and at the same time a con- stant stream of tiny violet sparks should pass from parts of the bulb not in the closest contact with the skin. The face should be somewhat red after an application lasting six or eight minutes during which the elec- trode is in constant motion. The writer is most strongly opposed to the rractice of opening acne pustules. He has seen faces as badly marked as by small-pox. It seems much bet- ter to treat the ase along the follow- ing lines: Rhubarb and soda inter- nally relieve any source of irritation, such as phimosis; cleanse the skin by vigorous washirg with tar soap every night and then apply a soothing anti- septic salve, such as ung. zinci oxidi, 2 ounces (62 Gm.) ; pulv. acidi salicyl., 20 grains (1.3 Gm.). This treatment combined with that by high-frequency currents has enabled the author to permanently cure a number of cases of acne vulgaris and the disagreeable and intractable acne rosacea. Sin- clair Touscy (Amer. Jour, of Dermat., Oct., 1911). Alild X-ray exposures of short dura- tion and low vacuum may often be advantageously employed, but should be done with great caution and as an aid rather than the sole measure of treatment. Its indiscriminate and inju- dicious use is to be condemned. Treatment of acne by exposure to the X-rays tried in 15 cases. With one exception satisfactory results were obtained. The cases were not selected. R. R. Campbell (Jour. Amer. Med. Assoc, Aug. 9, 1902). In acne vulgaris which resisted all other forms of treatment, the X-rays acted very favorably. It caused absorp- tion of recent papules, and crusting over and disappearance of pustules. The best results were obtained after fairly strong cutaneous reaction took place, as indicated by marked hyper- emia and desquamation. The first effect of treatment was to aggravate the condition. As improvement was ob- served ' only after the reaction sub- sided, several. applications were neces- sary to produce a cure. Torok and Shein (Wiener klin. Rundschau, Sept. 13, 1903). Four cases of acne treated with the X-ray. Two were entirely cured, while the other showed very marked improvement and were nearly free from the disorder. The duration of the disease previous to its use varied from sixteen months to two years. The soft tube was used in every case at a distance from six to nine inches, and an exposure of about eight min- utes. This was done three times a week, requiring from five to twelve exposures. Slack Atlanta Jour.-Rec. of Med., July, 1903). In pustular and indurated acne time is usually lost by waiting. Medication will remove comedones and produce desquamation, but it has as little effect on the overactive sebaceous glands as has the X-ray; in pustular acne the rays seem to have a fourth action on the staphylococci by rendering the 266 ACNE (STELWAGON). soil inert. Care must be taken to avoid undesirable results; this is in- sured by using a very low vacuum tube with the anode at eight inches from the skin, one and a half milliam- peres of current and from five to ten minutes' exposure, according to the condition of the patient. Nine treat- ments usually show how much more will be required, and what variations of the treatment are needed. R. H. Boggs (Jour. Amer. Med. Assoc, Aug. 31, 1907). The ray treatment and the passive hyperemia treatment have much in com- mon. The bactericidal effect of the rays lies in their power to increase the local opsonic index just as it is increased by the old treatments. But the rays also bring about a vascular constriction and produce atrophy of the sebaceous glands in which all acne begins. The uncer- tainty of currents, the variance of tubes, the personal idiosyncrasy of the patient, the factors of knowledge gained by ex- perience on the part of the operators, must all be given weight, and these, collectively, make it impossible to state in any given case what the result, bene- ficial or harmful, of ray treatment may be. The legal rule is now established by precedent that, if the ray operator possesses and exercises the average knowledge of the treatment, he is not responsible for the injuries that may occur. The patient should always be warned of the dangers of the ray treat- ment. A. W. Brayton (Jour. Ind. State Med. Assoc, Apr. IS, 1908). Report of 4 cases of very disfiguring and obstinate acne keloid (dermatitis papillaris capilliti of Kaposi) success- fully treated by means of the X-rays. It produces in moderate or large doses prompt healing, even in cases which have lasted many 3'ears ; in some in- stances a single sitting may be sufficient to bring about the disappearance of the disease. Kienbock (Archiv f. Dermat. u. Syphilis, Bd. xc, H. 3, 1908). When the lesions are somewhat in- durated, the use of the actinic lamp twice weekly for periods of from fif- teen to thirty minutes has given the writer excellent results as a support- ing measure. For the deeper indura- tions the X-ray has proven very use- ful, and by many dermatologists this is the method of choice. It is, how- ever, in the long run, no more successful than some of the older methods, and should be reserved for those cases which are obstinate to other forms of treatment. The in- jection of vaccine made from dead cultures of the acne bacillus and the staphjdococcus, suspended in salt so- lution, has given good results, and, in the writer's opinion, should be given the preference over the X-ray. The reports of cases treated by vac- cine therapy also show it to be a method that is well worthy of a care- ful trial in rebellious cases. Sam- pliner (Ohio State Med. Jour., Feb., 1910). According to Bier, nature always meets a pathogenic substance with the same weapon, namely, hyperemia. This is shown either by scratching a sterile skin with a sterile needle or by infect- ing any organism with any irritating or poisonous germ, or, most commonly of all, by the reaction of the part when a small splinter is lodged in the skin. The object is to increase the blood- supply to the affected or the infected part and by so doing to increase the supply of leucocytes, and by this means either to destroy the infective germs or, by an increase of serum, to dilute the poison till harmless, or to wash away the debris or infection. Bier's method has recently been tried in acne with some degree of success. Bier's method for the treatment of acne consists in the application of dry cups to the afifected region for one-half hour once or twice a day. The suction is slight, and the cup is removed and reapplied every one or two minutes. From two to five applications must be made over the same area before im- provement is effected. The method does not prevent the appearance of new pustules, though they become less fre- ACNE (STELWAGON). 267 quent. Eight cases treated by tliis method alone produced m.irked im- provement. E. Moschowit/. (Med. Rec., Jan. 13, 1906). Bier's suction cups found useful. Applied for repeated five-minute pe- riods with three-minute intervals. Usual 1}' two to hve applications at each seance. Considerable degree of congestion, and frequently repeated treatment, required, first to large af- fected areas and afterward locally to persistent individual comedones and pustules. Increases local blood-sup- ply, encourages removal of deleteri- ous products, activates sweat-glands, and promotes action of drugs locally applied. Sibley (Lancet, Feb. 4, 1911). Sir A. E. Wright's vaccine therapy has also been used with success in acne. As this investigator explains, no attempt is made to supply to the patient pro- tective substances produced in the organism of an animal vicariously in- oculated, but the chemical machinery of the patient is induced to elaborate by its own efforts the protective secre- tion which is required for the destruc- tion of the pathogenic agent. Series of cases illustrating the fact that, while in some cases an autogen- ous vaccine of acne bacillus is neces- sary, experience has shown that in the vast majority of cases great improve- ment has been induced by the inocula- tion of a stock vaccine combined with staphylococcus if an examination of films has revealed that the organism is present. The dose used had varied from 4,000,000 to 10,000,000, and the in- terval between inoculations from one to two weeks. The guide to treatment has been the appearance of fresh lesions, either during the period of low resist- ance following the positive phase when too long an interval has been allowed to elapse or in the next two or three days after an inoculation indicating that too large a dose has been administered. By watching these signs and working the dose up till it just fails to show any "negative phase" clinically, one obtains the maximum benefit from the vaccine. In this way a large number of cases of acne in all its stages have been greatly improved, and in a fair proportion the lesions have totally disappeared. On cessation of treatment in several in- stances, especially in some cases where attendance ceased before the condition had entirely disappeared, there was a recrudescence of the disease, which, however, rapidly gave way to subse- quent treatment. Alexander Fleming (Lancet, Apr. 10, 1909). The use of polyvalent vaccine (pre- pared from cultures of staphylococcus albus, citreus and aureus) answers well enough in most cases, especially when there is much pustulation. When the chief feature is the comedo, an acne bacillus vaccine is indicated. A mixed vaccine of 200,000,000 polyvalent staphy- lococci and 8,000,000 acne bacilli is what has been used by the writer in recent cases. The dose must be gradually in- creased to the maximum wijh about ten days' interval, and the efifects very care- fully watched. He has found the treat- ment to yield brilliant results in some cases, while in others the condition re- curs shortly afterward. Walsh (Med. Press and Circular, Jan. 26, 1910). The treatment of acne vulgaris with suspensions of acne bacillus has proved, in the author's hands, since a proper technique has been adopted, the most brilliant therapeutic agent yet seen in dermatology. Some of the cases respond, as does the mem- brane in diphtheria, to its antitoxin; nothing else in medicine can compare with its action in favorable cases. There is only one drawback in these very favorabis cases, and that is the lesions undergo such complete and rapid involution that deeper and more marked scars supervene. Noth- ing demonstrates Wright's negative phase better than these suspensions in acne. Invariably two or more new lesions appear within forty-eight hours after the injection. If a large dose is given, a numerous crop can be produced, and the negative phase prolonged for days. By repeated large doses a mild case can be aggra- vated or converted into a severe one 268 ACNE ROSACEA (STELWAGON). with large cystic lesions, and, further- more, the positive phase in such in- stances is not clinically evident. Such a patient remains for some time ex- tremely sensitive to any dosage. Such has been the writer's experience with doses of 50,000,000 at seven-day in- tervals, an experience repeated sev- eral times by him. Mild cases stand a larger dose than severe ones; in the latter, continuous small doses give the best results. Engman (Interstate Med. Jour., Dec, 1910). The writer found in 28 successive cases that by painting an acne lesion with old staphylococcus vaccine it healed rapidl3\ The comedones dried up and were easily removed bj^ rub- Ling with a coarse tovv^el. Moreover, tlie large, open pores became con- stricted, leaving a perfectly normal sl;in. At first, the application caused redness with a sharp, stinging pain that lasts a few minutes, but these phen®niena become less marked as additional applications were made. Le Roy (N. Y. Med. Jour., Dec. 31, 1910). The writer, experimenting v/itli vac- cines derived from the laboratories at St. Mary's Hospital in cases of acne, either simple or complicated by suppuration, and with the addition of no local treatment, found in 9 cases of pustular acne with come- dones manifest improvement in the pustulation after the injection of mixed vaccines of microbacillus of acne plus staphylococcus. In 8 cases the eflfect was almost nil; in 3 cases there was temporary ag- gravation of the pustulation, prob- ably, as the author says, due to too close approximation of dosage; in 2 cases of pure comedo formation there was pronounced improvement. The injection consisted of 5,000,000 to 10,000,000 acne bacillus vaccine every five to ten days, and 125,000,000 to 250,000,000 staphylococcus vaccine every five, ten, or fifteen days. Lassueur (Ann. de Derm, et de Syph., July, 1910). Henry W. Stelwagon, Philadelphia. ACNE BACTERIN. TERiAL Vaccines. See Bac- ACNE ROSACEA.— DEFI- NITION. — Acne rosacea is character- ized by a chronic congestion of the face, causing vascular dilatations ; and by changes in the cutaneous glands and tissues, giving rise to seborrhea, inflam- matory acne, and hypertrophic changes. SYMPTOMS.— The nose and malar eminences are especially prone to this disorder. It may also affect the fore- head, chin,^the neighborhood of the alse nasi, the cheeks, and less commonly the side of the neck. In women the chin is occasionally invaded. There are three forms of acne rosacea. The first is the erythematous and tclangiectasic. It may be characterized by temporary congestive spots on the face, showing themselves especially after meals and in the evening. These spots may be accompanied by no other lesion. This form is usually present in connection with more or less seborrhea, especially on the nose, which is gen- erally very oily. Again, the erythema- tous variety may be characterized by small vascular dilatations on the nose or malar eminences, which dilatations develop gradually, unite with one another, and form a network. This network is uniform in hue at a dis- tance, but nearby may be seen to be formed of congested surfaces over which are spread vascular dilatations. This degree of the erythematous form is almost always accompanied by sebor- rhea, enlarged nose, and dilated glan- dular orifices, especially in women toward the menopause and in wine- drinkers. The nose may be slightly violet hued and be cold to the touch. ACNE ROSACEA (STELWAGON). 269 The second form is the erythematous acne, or true aciic rosacea. In addition to the erythematous and congestive feature, there may be found in this variety a true acneic and acne-hke ele- ment: papules, pustules and tubercles or nodules. In some cases the acne ap- pears before the congestion. There is a congestive red base with fine vascular dilatations and papulopustules of various sizes, often resting on an indurated violet-red base. In this variety there may also be in- crease in number and size of the vascular dilatations, increase in size and depth of the acneic indurations, and proliferation and hypertrophy of the derma. The third form is the hypertrophic acne, or rhinophyma. In this variety the glandular orifices are much en- larged, while the glands themselves may be ten to fifteen times increased in size. The tissues around them proliferate, forming a variety of pachyderma. The nose may be red or violet hued, covered with enlarged orifices, greatly increased in size, occasionally reaching consider- able dimensions (the so-called Pfund- nase of the Germans). Its exterior may be mammillated. (Brocq.) Two subdivisions of this form are rendered necessary by the difference in the pathology of each. The first, glandular, presents an embossed aspect, the hypertrophy being due especially to hypertrophy of the pilosebaceous glands ; the second, elephantiasic, pre- sents a smooth aspect, being due to chronic edema ; there are also vascular dilatations, with sclerosis of the derma. (Vidal and Leloir.) ETIOLOGY. — Women suffer more than men from the erythematotelangi- ectasic and acneic forms. Men only suf- fer from hypertrophic acne. It usually appears between 30 and 40 years. In women, rosacea develops usually at from 30 to 45 years, and increases de- cidedly toward the menopause, after which it may recede. It may also, how- ever, develop at puberty. In young- women and girls acne rosacea is frequently due to chlorosis, dysmenorrhea, or sterility. In some it recurs at each conception. Some authorities claim that, among the constitutional causes, heredity plays an important part. Cold feet, urethral and uterine dis- turbances, and constipation are also recorded as causes of the disease. Ex- ceptionally a factor in acne may be found in the mouth or teeth and be unilateral if the cause is one-sided (E. Besnier, Doyon). Dyspepsia, neuralgia, hemicrania, working with the head inclined forward, and disease of the nasal fossse are among the less frequent etiological factors (which affect men more than women), while high heat, overheated rooms, high wind, sea air, cold, and cold water are occasional causes, espe- cially in men. The disease may become started in people who for several years have indulged in excessive hydrothera- peutic treatment. (Kaposi.) Certain occupations which expose to heat, cold, winds, etc., such as those of coachman, baker, smith, fireman, glass- blower, may also become primary causes of the trouble. Indiscretion in diet and alcoholic beverages are well- known factors. According to Kaposi, in wine-drinkers the nose is bright red. in beer-drinkers it is violet, while in spirit-drinkers it is soft, large, and dark blue. PATHOLOGY.— The vascular dila- tations of the face have been considered by some authorities as due to circula- 270 ACXE ROSACEA (STELWAGON). tory troubles caused by compression of the veins in the cranial foramina. A certain paretic condition of the vascular walls may often be looked upon as a cause. (Brocq.) The cutaneous nerves of the region afTected have been found normal by E. Eesnier. According to Leloir and \'idal, however, there is congestion of the deeper venous network of the skin; dilatation of the same vessels and of the perifollicular vascular network, their walls being often diminished in thickness. There is also formation of new vessels. DIAGNOSIS. — Lupus Erythema- tosus. — The superficial, congestive variety shows a brighter and better defined redness; crusts or squamae on tl:e surface; sharper and more definite edges ; greater sensitiveness to pressure ; slight elevation above the surrounding surface. There are no papules, pustules, or tubercles. If any cicatrix be present, it is surely lupus erythematosus. Acne telangiectodes is an affection sui generis, and not identical with lupus follicularis disseminatus; but it is iden- tical with the acnitis of Barthelemy, and must be distinguished from the disease known as folliculitis. It pre- sents no sort of etiological relationship to tuberculosis, and should be separated from the tuberculomata and the tuber- culides. It does not take its origin in the sebaceous glands and, therefore, does not belong to acne. Pick (Archiv f. Dermat. u. Syphilis, Bd. Ixxii, H. 2, 1905). Circumscribed Congestive Sebor- rhea. — In this disorder there is a limited extent of patches, shallower and more uniform redness, with crusts covering them. Sycosis Coccogenica. — This is al- ways an inflammatory disease of the hair-follicles and perifollicular tissues. There are numerous papules and pus- tules, each perforated by a hair, and often capped by a small circular scale. The upper lip and chin are sites of predilection. The affection is usually painful. Congenital adenoma sebaceum also has a special location : the nasogenial furrow, the parts around the nose, mouth, and chin. It presents a mam- millated aspect, and its predilection for early youth and its normal evolu- tion serve to establish its identity. Eczema. — Erythematous, or pustu- lopapular, eczema of the face may som.etimes present diagnostic difficul- ties. In this disease, the more or less constant, and usually intense, itching, the serous or seropurulent secretion, and the desquamation will suffice to establish the diagnosis. Chilblains. — Changeableness of the lesions and pains are peculiar to this disorder. Acneiform Syphilides. — Here the manner in which the elements are grouped, the long duration of their evolution, their tendenc}^ to ulceration, and consecutive cicatrix are important. Rhinoscleroma. — In this disorder there are hard or ivory-like masses im- bedded in the nose. PROGNOSIS.— Acne rosacea does not always increase; it may remain stationary or even recede, especially in women after the menopause. TREATMENT. — As to general treatment, it is especially necessary to pay strict attention to the good condi- tion of the stomach and intestines, by appropriate measures and suitable diet. Purgatives are absolutely neces- sary from time to time; laxatives should frequently be given and con- stipation should be avoided (Brocq). In many cases, especially where the hemoglobin percentage is low or the ACNE ROSACEA CSTELWAGON). 271 bowels arc sluggish and irregular, the H Quinine hydrobromate, use of Startin's mixture is effective, P.ryuiinc .....of each 30 grs. the formula for which is:— Belladonna extract 6-12 grs. , , . ,,, ,, Lithium hcnaoate 30 grs. I^ Magncsn sull^liatts -i^iX' r -a- * i ; • . . Ferri sulpliatis 0.25 Excipient and glycerin q. s. Acidi sull>hurici dihiti .... 8.0 Misce. For forty pills. Sodii chloridi • 2.0 before each of the two prin- Intusi gentiance q. s. ad 120.0 . ,"= , ^. . rr^ 1 i 1-1 c } ■ cipal meals. Directions : Take a tablcspoonful m >■ half a gobletful of water one hour be- ,-„ , , , i i j i j fore each meal, using a glass tube be- Rhubarb or aloes may also be added cause of the iron.' If there is any j^ necessary. indigestion this prescription may be al ■ ^, , , , . , tcrnated with the following:— The local therapeutic agents are the _ „ . on same as in acne vulj^aris; though some IJ Papain o.v . . ,, . . ^ Sodium bicarbonate, nTitable varieties oi acne rosacea exist, Charcoal of each IG.O j^ -^ ^^gually necessary to act with Make into SO tablets. Directions: „,_„,„ pnpr2 dr. I'aselin 2 drs. Lanolin 3 drs. Ichthyol does not seem to be as effi- cacious in acne rosacea as in some other varieties of acne. (Brocq.) Unna recommends daily doses of 7^ grains of ichthyol internally and lo- tions with ichthyol dissolvedin water, washing with ichthyol soap. Steam or sulphur-water douches have also been used with good results. A solution of iodine in glycerin, ap- plied twice daily during three or four days, is recommended by Kaposi for the more severe forms, but it is dis- figuring and not advisable for patients outside of hospital wards. The commencing erythema of acne rosacea, a very troublesome and dis- figuring complaint, especially to ladies, is removed by an ointment containing 10 grains of the iodide of cadmium in 1 ounce of vaselin. It should be rubbed well into cheeks and nose at night, and washed off next morning with hot water and an overfatted soap, accompanied by massage of all the afifected skin. The iodide of cad- mium does not stain the skin and is an excellent local stimulant. If too strong it irritates. H. S. Purdon (Dublin Jour, of Med. Sci., Sept. 1, 1903). In a series of cases of acne rosacea the author succeeded in gradually re- moving the eruption by means of paint- ing with undiluted iron chloride. The applications were repeated every morn- ing and evening, and resulted in a com- plete cure. A somewhat solid crust is apt to form at the end of four or five days, and the paintings should be omitted until this £rust is cast oflf spon- taneously. When there is much tension the surface may be covered with a clean rag that has been thickly spread with Wilson's salve or some other suitable ointment. In the presence of severe inflammation an ice-bag may be ap- plied. As a rule, frequent interrup- tions are unavoidable, and the treat- ment is therefore likely to last about three or four months, until the cure is . complete. Zeissl (Miinch. med. Woch., Nu. 20, 1908). Surgical treatment in this disease is the most efficacious. (Brocq.) Electrolysis is another satisfactory method. A fine platinum needle is in- serted alongside of the vessel, and, if possible, into it, and connected with the negative pole, while the patient holds in his hand a cylinder in communication with the positive pole. A large eschar must be avoided. (Hardaway.) Electrolysis of each dilated sebaceous follicle with a negative platinum needle and a current of from 4 to 6 milliam- peres is an effective, though tedious, measure. The needle should be moved around in the follicle in order to thor- oughly destroy it. In the early stages of acne hyper- trophica, diet, a local spray of sulphur lotion, and electrolysis of the enlarged sebaceous glands are sufficient. But when hypertrophy occurs, with deform- ity and tumors of the nose, surgical measures only are satisfactory. The author prefers thermocautery to the knife, and considers grafting undesir- able if this is used. When the knife, however, is used, skin grafting may hasten recovery and prevent cicatricial contraction. Dubreuilh (Ann. de Derm, et de Syph., Nov., 1903). The ordinary galvanic or faradic currents have been recommended by Cheadle and Piffard. Scarification was formerl}^ a favorite method. The best instrument is Vidal's ordinary scarificator. The skin is cut obliquely or perpendicularly to the ACNE ROSACEA (STELWAGON). 273 vessels, then slightly obliquely across these so as to form lozenges, and as near together as possible (from 1 to V/2 mm. apart), and not deep enough to penetrate entirely through the der- mis, so as to avoid cicatrices. If there arc only a few large veins visible at the root of the nose, the writer merely pierces each of these with a galvanocautery needle; but if there are many he punctures the entire skin of the nose with points so close to- gether that no vessel can be missed, to a depth of /2 to 1/2 mm. The entire skin soon sloughs off, and the resultmg raw surface is trimmed into shape as necessary by the cautery, and dressed with an antiseptic powder (bismuth, dermaton. The skin heals in about twelve days. This method has given better results than operations with the knife or electrolysis; Bolebaum (Miinch. med. Woch., No. 52, 1904). An hour afterward the part is washed with a corrosive sublimate solution, 1 : 1000 ; then in the evening or the fol- lowing 'day compresses dipped into an ammonium hydrochlorate solution, 1 : 100, or corrosive sublimate, 1 : oOO, are applied. If too strong, warm water is to be added. If the reaction is too violent, starch poultices, bland poma- tums, or zinc oxide plasters can be employed. The treatment should be renewed in from five to eight days. Amelioration will occur in from eight to ten sessions, and marked improvement in from fifteen to twenty-five sessions. Scarifying should be begun in the lower part of the region to be operated upon, in order not to be troubled by the blood covering the surface. (E. Bes- nier, A. Doyon.) In the early stage of hypertrophic acne the scarification must be made deeper, and in many cases it is essential to also cauterize the glands deeply In the advanced hypertrophic form direct removal with the knife is the best procedure. (Rrocq.) In hypertrophic acne of the nose the writer recommends ablation with knife and scissors under cocaine anes- thesia. The disease is really an ade- noma of the sebaceous glands of the nose, and in spite of appearances is confined to the skin and its annexes, and always ceases at the margins of the nostrils. The tumor is divided vertically into two halves; each half is separated from the margin of the nos- trils, and an incision is made outside beyond the limits of the growth. The two halves are then successively re- moved en bloc or by repeated sections. The bleeding is abundant, but is, as a rule, easily controlled by pressure or by forceps. Care must be taken not to injure the fibrocartilaginous framework of the nose. It is better not to graft the wound with skin or do any autoplaitic oper.tion. In five or six weeks the skin has g-own over and cQvered the wo md. If the wound is not being covered quickly enough, grafts may be applied when granula- Sons are abundant. Mcrestin (Arch, gen. de med., vol. cxcii, p. 2330, 1903). Hypodermic injections of alcohol have recently been recommended. Phototherapy has likewise given sat- isfactory results ; both high-frequency current and the X-ray are of value m some cases. The light treatment of this form of acne should be included among the rec- ognized therapeutical measures. It brings about a cure more rapidly than chemical means (salves, etc.), and is more quickly efficacious than it is. in tuberculous or erythematous lupus. In most of the cases the cure remained perfect; in others it became so when combined with external treatment, and with the necessary attention to the vis- ceral disturbances, especially of the gastrointestinal tract. Phototherapy is specially applicable to rosaceous acne of the nose, where the lesions are often 1—18 274 ACOIX. ACOXITE (SAJOUS). much deeper than on the cheeks ; but if the action of the light is not promptly efificacious, scarification may be used at the same time. M. Leredde (Jour, des praticiens, April 18, 1903). Henry \\'. Stelwagox, Philadelphia. ACNE VACCINE. See Bac- terial Vaccixes. ACOrN, a synthetic compound used as local anesthetic, especially in dental and ophthalmic practice. It is designated as alkyloxyphenylguanidin and occurs as a white crystalline powder, readity soluble in pure cold water to the extent of 6 per cent., and in alcohol. A 1 : 200 aqueous solution injected under the skin causes a local anesthesia lasting about one hour. Acoin presents the draw- back, however, of being quite unstable, while producing greater irritation than cocaine, and is liable to produce necrosis. S. ACONITE.— The preparations of aconite usually employed are obtained from the root of the Aconitum napelhis (monkshood, wolfsbane), a conical tuber greatly resembling horse-radish. This resemblance has caused many deaths. Aconite-r-oot is, however, brown in color, and when scraped does not emit the pungent odor peculiar to horse-radish. Again, instead of irri- tating the palate, as does horse-radish, aconite-root, when masticated, soon produces in the mouth a sense of warmth and tingling, soon followed by local numbness varying in duration ac- cording to the length of time the mucous membrane is exposed to the ef- fects of the drug. Aconite owes its activity mainly to the alkaloid aconitine, of which the dried root is officially re- quired to contain 0.5 per cent. PREPARATIONS AND DOSE.— Aconite in substance is not employed, and the preparations made with the leaves are no longer official. The tincture (tinctiira aconiti, 1905 U. S. P.) is no longer stronger than the English or French tinctures. It is a 10 per cent, tincture, i.e., it contains 10 Gm. of the drug in 100 c.c. Dose, 3 to 10 minims, every three hours. Its effects should be closely vratched, especially in anemic and corpulent indi- viduals and in those addicted to alcohol. In prescribing the tincture, the 1905 U. S. P. should be specified, to avoid accidents. The fluidextract (fluidc.rtractum aco- niti, U. S. P.), ^ to 1 minim. The alkaloid aconitine {aconitina, U. S. P.), %oo grain to %oo grain (0.1 to 0.2 mg.), occurs in the form of col- orless tabular crystals slightly soluble in water^ but soluble in alcohol, ether, and chloroform. Aconitine is a very active poison and causes the responsibility of the physi- cian to be involved to a greater degree than any other toxic. Its activity is markedly increased when it is adminis- tered hypodermically, and the injections are very painful. These facts and the variations in strength of the various aconitines on the market have militated against its use, and it is best to utilize the other preparations, both of which owe their activity to aconitine. MODES OF ADMINISTRATION. — Internally aconite is usually better given in small and frequently repeated doses than in large doses at longer in- tervals. Thus the tincture may be given in 1 minim doses every hour until the desired effect has appeared or until distinct depression of the circulation indicates cessation of the drug. Aconite should be administered well diluted. In fever a dram of a mixture of 10 minims of the tincture in 4 ounces of Avater may be given every fifteen or twenty minutes. For the relief of pain, ACONITE (SAJOUS). 275 5 minims may be administered as the first dose, smaller ones being then given at short intervals. For cardiac over- activity, doses of 2 to 5 minims (0.12 to 0.30 c.c. ) may be given thrice daily. When aconite is used over a long period, a gradual increase in its action is observed. Even where indicated, aconite should not be given freely with the intention of producing powerful ef- fects, as its action in large doses is sometimes unexpectedly severe. Aconitine may be administered inter- nally in granules, in tablets or tablet triturates such as are official in the N. F., or in solution in v^•ater (1 in 3200). Tison has used aconitine nitrate dissolved in a mixture of distilled water, alcohol and glycerin, 1 minim of the solution containing ^^3200 grain of the salt. As stated above the alkaloid should be employed with great caution, as individual intolerance of it has been repeatedly observed; a third dose of M.30 grain (0.5 mg.) has been known to cause death (Lepine). Dose of yi300 grain (0.1 mg.) may be given every two or three hours, the drug being stopped when the first signs of toxic action appear; these are, accord- ing to Gubler : prickling of the tongue, a sensation of shrinkage in the face, and loss of elasticity of the muscular openings in this region. These are fol- lowed by general numbness and chilli- ness. A total amount of %oo to %5 grain (0.66 to 1.0 mg.) in twenty- four hours may be considered the limit of safety. Dujardin-Beaumetz advised never to give aconitine unless its effects can be carefully watched. LOCAL USE.— Aconite is used locally in neuralgia and skin affections, the tincture sometimes diluted with alcohol, or the linimentum aconiti et chloroformi of the N. F. (fluidext. aconit. 4.5, chloroform 12.5, in alcohol 100), being applied. The alkaloid is also sometimes used in a 2 per cent, ointment or in the oleatum aconitin?e, N. F. (2 per cent.), but should never be applied to abraded areas. Undiluted aconitine is absorbed through both mucous membranes and skin to a con- siderable extent. Subcutaneous injections of aconitine have been given for neuralgia, but the pain caused and the danger from prompt toxic effects are marked disad- vantages. INCOMPATIBILITIES.— The al- kaloid aconitine in solution (1 to 3200 being saturated) is incompatible with tannic acid, gallic acid, mercurials, and Lugol's solution ; aconitine nitrate is precipitated as the alkaloid by alkalies. AmOTg the physiological incompatibili- ties of aconite may be mentioned digi- talis, atropine, strychnine, strophanthus, ammonia and alcohol. CONTRAINDICATIONS. — By reason of its depressant action aco- nite is contraindicated in all cases in which prostration exists or. threatens. If the respiration is embarrassed; if the heart is in asystole ; if the patient is de- pressed, recourse must be had to tonics and stimulants. In bronchopneumonia, pneumonia after the primary stage, typhoid fever, phthisis, valvular affec- tions of the heart, and in all cases of collapse occurring in acute infectious diseases, aconite is particularly contra- indicated. In no case Avhere the heart is weakened or degenerated should the use of aconite be considered. Old age contraindicates its use to lower the blood-pressure in nephritis. PHYSIOLOGICAL ACTION.— AVithin half an hour after its adminis- tration, aconite commences to affect the general system, slowing and weak- 276 ACONITE (SAJOUS). ening the heart's action, lowering arte- rial tension, increasing the action of the skin and kidneys, and producing more or less muscular weakness in propor- tion to the amount taken. It causes a tingling sensation in the lips, extremi- ties, and, perhaps, the whole body; it diminishes the rapidity and depth of the respiration, and causes disorders of vision, vertigo, and loss of tactile sensi- bility and sense of pain. The effects of a therapeutic dose last three or four hours. Aconite, when administered in suffi- cient dose, is a powerful depressant of the sensory nerve ; some have believed that the stage of nerve paralysis is preceded by one of nerve stimulation, but Wood considers this doubtful. The drug paralyzes first the sensory end- organs, next the nerve-trunks, and finally the centers of sensation in the cord. The reflexes are correspondingly impaired. The power of voluntary movement, which continues after the cessation of the reflex functions, is finally lost, owing to the later action on the motor centers of the cord, and sub- sequently on the nerve-trunks. The brain is practically unaffected by aconite. Laborde and Duquesnel state that aconitine in therapeutic doses has a particular effect in modifying special sensibility in the area of the trigeminal ; they believe this effect to be exerted on the bulbar receptive nuclei of the nerve. According to Cushny, the subjective sensory phenomena resulting from the use of aconitine are due to a marked primary stimulation and secondary de- pression of the sensory end-organs, tingling and warmth locally being fol- lowed by numbness when the drug is applied to the skin or taken by the mouth. Pyraconitine, obtained from aconitine by heating to separate a molecule of acetic acid, causes no tingling of the lips or tongue. It causes slowing of the heart, partly from vagus irritation, partly from depression in function of intrinsic rhythmical and motor mechan- isms. After its administration activity of respiration is reduced (by central de- pression) to a degree incompatible with life. Neither muscular nor intramus- cular nervous tissue is strongly influ- enced by pyraconitine, but the spinal . cord is impaired in its reflex function, and there is a curious condition of ex- aggerated motilit3^ Theodore Cash and W. K. Dunstan (Brit. Med. Jour., Aug. 17, 1901). The physiological actions of aconite and veratrum viride are so similar that what is to be said of aconite can be applied with equal force to veratrum. The physiological action of aconite may -be stated thus : Primary action : stimu- lation of the peripheral nerve-endings; stimulation of the vasomotor mechan- ism; powerful stimulation of the res- piratory center. Secondary action : paralysis of the overstimulated periph- eral nerve-endings ; pronounced depres- sion of the heart; lowering of the blood-pressure; reduction of tempera- ture. W. B. Hill (Jour. Amer. Med. Assoc, Dec. 12, 1903). A\'hen aconite is applied directly to the heart, the number and force of the beats are lessened, and its action is finally arrested in diastole. It lowers the blood-pressure and pulse-rate when given internally by a direct depressant action on the heart itself, and also by stimulating the cardioinhibitory center. Laborde found, however, that the con- tractility of the cardiac muscle-fiber itself was not directly modified by aconitine. Hare has called attention to the fact that the fall in pulse-rate from poisonous doses is sometimes preceded by a quickening due to a condition of weakness and abortive cardiac action. ACONITE (SAJOUS). 277 The stage of low pulse-rate is also fol- lowed by one in which the pulse is fre- quent and irregular. Upon the vaso- motor center aconite is believed by Cash and Dunstan to have a late depres- sant effect. It also causes slowing of the respiration, with lengthening of the expiratory period, by depressing power- fully the respiratory center. According to some observers, small amounts of the drug produce, instead, stimulation of the respiratory function, while Cushny is of the opinion that aconitine has a primary exciting effect on most of the medullary centers — vagal, vaso- motor, respiratory — as well as the spinal motor centers. Aconite reduces the temperature both in health and in febrile conditions, probably through an action on the nervous heat-regulating mechanism, and by the circulatory depression it causes. It also increases the action of the skin, kidneys, and salivary glands. Increase of the gastrointestinal and biliary secretions is stated to have oc- curred. (Schrofif, Rabuteau.) [Personal researches (see "Internal Secre- tions," p. 1347) have shown that the physio- logical effects of aconite are due to its de- pressing action on the sympathetic center, which, as I have pointed out (ibid., p. 1185), governs the caliber of all arterioles. These vessels being thus caused to relax, more blood is admitted into all capillaries, and passive hyperemia of all tissues is produced. If this is slight only a feeling of warmth is experienced; if it is marked the cutaneous sensory nervous elements are sufficiently con- gested to awaken sensations of prickling and tingling. If the dose is large the dilatation of the arterioles is sufficient to reduce markedly the vis a tergo motion of the blood in the tis- sues, and, the rate of metabolism being slowed, the functions of the tissues are in- hibited; hence the lowered temperature, the numbness, and, if the dose is large enough, the paralysis. C. E. de M. S.] MODE OF ELIMINATION.— iVconite is excreted mainly by the uri- nary organs, though it has also been de- tected in small amounts in the saliva and the bile. ACONITE POISONING. — The symptoms following the ingestion of a poisonous dose usually show them- selves after a few minutes. The characteristic tingling, prickling, and subsequent numbness already mentioned rapidly extend from the mouth and fauces to the face, thence to the body and extremities. Great prostration and muscular impotency follow. Speaking requires marked effort. The skin be- comes cold and clammy, the perspira- tion covering the surface, and the tissues communicating to the hand an icy coldness. Muscular pains may be present in the early stages, especially in the face. There is often experienced marked epigastric pain with nausea and vomiting._ Later on the nausea ceases, owing to paralysis of the stomach walls. The heart-beats are greatly reduced in number and power. The pulse is usually irregular, compressible, slow, and so weak, at times, as hardly to be palpable; in the advanced stages, how- ever, it becomes abnormally frequent. The breathing is labored, irregular, and shallow, the number of respirations being at first decreased, then increased. Cyanosis may appear. The tempera- ture is lowered, sometimes considerably. The pupils may become dilated or remain of normal size and react equally ; occasionally they are contracted. Ac- cording to Manquat, they undergo fre- quent variations in size at first, then dilate. The eyes may protrude or be shrunken ; therefore they afford no dif- ferential information as to the nature of the drug used. The mind is usually clear, and the 278 ACONITE (SAjOUS). patient calm, though apprehensive of impending death. Disturbances of vision (diplopia, amblyopia) and of hearing (tinnitus, deafness), as well as vertigo, are frequently complained of. Occasionally epileptoid convulsions occur. Spasmodic purging, vi^ith rectal tenesmus and bloody stools, is occa- sionally present. Aconite causes paralysis of respira- tion and circulation, death being due to sudden arrest of the heart in diastole. [These toxic phenomena are readily ac- counted for by the interpretation of the action of aconite I have submitted above. The inhibition of function due to the dilated arterioles and the resulting delay in the arterial circulation in the muscles explain, when sufficiently marked, the great prostra- tion, the muscular impotence, the cold and clammy skin, the cold sweats, the relaxation of the stomach walls, the slow compressible pulse (owing to weakness of the cardiac muscle), etc. The vascular interference with the pro- pulsion of blood to the air-cells and the weakness of the respiratory thoracic mus- cles account for the intense dyspnea and the shallow breathing. The cause of the failure of respiration is obvious under these conditions, while the cardiac arrest in diastole points to muscular impotence of the myo- cardium in common with all other muscles. C. E. DE M. S.] Cases of criminal poisoning by aconite are rare. In the Condon case? of Springfield, Mass., the defendant pur- ' chased a two-ounce bottle of tincture of aconite, one-half of which was placed in a pint bottle of port wine and sent to the' person whose life was attempted, and who drank nearly one- half of the wine. The immediate effect was dizziness, inability to move, and a peculiar creeping sensation in the mus- cles. The vision became obscure. Life was only saved by three hours of un- tiring efforts. W. S. Magill (Med. News, May 31, 1902). Case of aconite poisoning in which the patient's condition became criti- cal; the pulse varied from 130 to 140, was extremely feeble, and at times was felt with difficulty; the extremi- ties were cold and the lips blue, but the face retained a dusky flush; the convulsive movements were increas- ing. It seemed clear that the aconite was causing extreme depression of the heart. The writer gave 10 min- ims of liquid strychnine hypodermic- ally and injected 8 ounces of hot, strong coffee slowly into the rectum, applied hot bottles, and wrapped him up in hot blankets. After about an hour, during which his condition gave rise to great anxiety, he began to rally, became semiconscious, and rambled in his speech; the convulsive movements gradually ceased and the pulse became fuller and stronger and the body surface warm. At 3 a.m. his condition had so far improved that he was left in charge of a nurse. The next morning he was better, the pulse, though still rapid, was of good quality, and, beyond being somewhat dazed and shaken, he expressed him- self as feeling very well, and refused to believe that anything serious had happened. For the next few days, during which his only complaint was of numbness and tingling in the fin- gers, he was kept at rest in bed until his circulation had resumed its usual state, which showed itself to be one of high tension, bounding vessels, and hypertrophied heart. His recollection gradually came back of having no- ticed a pungent taste with tingling of the mouth after taking his medicine, but he thought nothing of it at the time, nor did it occur to him that he had made any mistake, i.e.j that of taking a tablespoonful of a liniment containing aconite. The quantities contained in the tablespoonful dose of the liniment were 40 minims each of lin. aconiti, lin. belladonnse, lin. chloroformi, and tinct. capsici, with 80 minims of ol. gaultherise. Taking the recognized standard for aconite root as containing 0.5 per cent, of aconitine, 40 minims of lin. aconiti would be equivalent to 0.132 grain aconitine — i.e., about ys grain, or 31 times the maximum dose, which is ACONITE (SAJOUS). 279 given as %r.o grain. W. Edgeconi1)c (Lancet, Oct. 29, 1910). Case of aconite poisoning in a woman aged 45 years, a multipara, wlio had suffered from rheumatism, shortness of breath, and swollen feet. She drank by mistake about 3 ounces of a liniment. At once she recognized her mistake and experienced a hot tingling in the mouth, then numbness, giddiness, gastric pains, and soon thereafter followed by col- lapse. A druggist gave ipecacuanha wine and a strong emetic. Sickness continued, and a violent attack of clonic convulsions supervened. The medical man called in found the patient speechless, cold, pale, skin moist, pulseless, respirations very faint and irregular, and the pupils dilated and insensitive, but no ptosis. The tem- perature was 96.6° F. Terrible gastric and abdominal pains and violent irri- tation and prickling of the skin were succeeded by numbness. Three times after attacks of clonic convulsions she appeared dead, but when they ceased the mind was clear and unaffected. As a cardiac depressant, ipecacuanha had been given; a mustard emetic was now- administered to save the enfeebled heart. The head was kept low, the feet were raised, a sinapism was placed over the heart, and hot bottles and flannels were applied to the lower ex- tremities and abdomen. Strychnine and digitalis were given hypodermic- ally, and brandy was injected per rec- tum. Artificial respiration was un- ceasingly kept up. After an anxious six hours the breathing became stron- ger,' an irregular, intermitting pulse could be felt at the wrist, while the body warmth slowly returned. A little coffee and brandy were swallowed and retained. The crisis passed, and she recovered. The quantity of aconite taken may be roughly estimated as suificient to kill 6 persons. Inglis (Lancet, Jan. 21, 1911). Death occurs in from one-half to five and half hours, the average being, ac- cording to Reichert, three and one-third hours. The symptoms resulting from a poisonous dose of the alkaloid aconi- tine are the same as mentioned above, but they occur more rapidly ; hypoder- mically administered, aconitine may cause death in less than a minute. Treatment of Aconite Poisoning. — Deatli in these cases usually follows exertion by the patient. He should, therefore, be kept perfectly motionless in the recumbent position, even during emesis, his head being slightly turned and the dejections received on a towel. An important feature of the treatment is to keep the patient as warm as pos- sible by means of warm blankets and hot-vv^ater bottles, taking care not to place the latter against the skin. The head should also be kept warm. If the patient is seen early the stomach-tube should be used at once to empty the stomach. "If no stomach-tube be at hand, apomorphine, ^(2 to % grain, should be. administered hypodermically, or some other active emetic, such as zinc sulphate, 15 to 30 grains^ be given by the mouth. [From my viewpoint, apomorphine (q. v.) is contraindicated as an emetic in these cases, since it causes emesis precisely in the same way as aconite does it, i.e., by depressing the sympathetic center. The emetics which are indicated when there is any degree of depression are, mustard, zinc sulphate, etc. C. E. DE M. S.] Digitalis, sulphate of strychnine, and belladonna are the most effective rem- edies, but ether and ammonia should first be employed, owing to their great diffusibility. All these remedies should be used hypodermically, the stomach being unable to perform its functions. A dram of ether, ammonia, brandy, or whisky should at once be injected, and, after a few minutes, tincture of digi- talis, 15 minims; strychnine sulphate, %o grain; or tincture of belladonna, 10 280 ACONITE (SAJOUS). minims, according to what the practi- tioner may have. Atropine has been recommended as the most powerful antagonist to the depressing effects of aconite on the circulation and respira- tion. The dosage should be regulated so as to reach the point of physiological action by frequently repeated doses. Nitrite of amyl may be given by in- halation, and warm, very strong cof- fee be injected into the rectum. [Nitrite of amyl, according to my views (see "Internal Secretions," p. 1350), is also a paralyzant of the sympathetic center, and should not be used any more than any other nitrite. Belladonna I regard as the direct antidote of aconite, since, as stated (1907) in "Inter- nal Secretions," p. 1210, it stimulates "(1) the test-organ (anterior pituitary) and through it the adrenal center, and (2) the sympathetic center (posterior), which governs the tonus and propulsive activity of the arterioles." In other words, it counteracts precisely the paralysis of the sympathetic center caused by aconite. This proves true practically. C. E. DE M. S.] Case illustrating the physiologic antagonism between aconite and bella- donna. The patient had taken by mis- take half an ounce of a liniment com- posed of chloroform, aconite, and bel- ladonna. This means 53.3 grains of aconite root, which represents y^ grain of aconitine, of which %6 grain has been known to be fatal. He also swal- lowed 40 minims of fluidextract of belladonna (B. P.), which is equal to 0.3 grain of the total alkaloids. This would represent, approximately, thirty times the official dose of atropine. Of chloroform he took 40 minims, about eight times the official dose. The in- terest in the case lies in the fact that the lethal effect of a large dose of aconite was abolished by the simultane- ous action of a large dose of bella- donna. Muscular weakness, numbness of the extremities, and tendency to complete collapse were the only purely aconite symptoms observed. Saliva- tion, which is usually present in aconite poisoning, was absent, and the usually contracted pupil was overcome by the action of the atropine. Finally, the in- tensely depressant action of aconite on the central nervous system was coun- teracted by the stimulating influence of the belladonna. The obvious lesson to be drawn from the case is the great value which should be attached to hypodermic injections of atropine in aconite poisoning. Speirs (Brit. Med. Jour., Aug. 15, 1908). Tannic acid is useful as an antidote. Wood recommends that it be followed by an emetic and cathartic to avoid the effects of resolution of the poison by the digestive fluids. If the patient is seen when the stage of depression has begun through ab- sorption of the poison, the stomach- pump, gently used, is alone permis- sible, emetics at this stage being liable to cause arrest of the heart's action. Tincture of digitalis, in 20-minim doses, should be injected hypodermi- cally and repeated as required, besides the other measures indicated. Fric- tions under cover, the rubbing being directed over the heart, serve a useful purpose. Artificial respiration is of marked benefit and should be used per- sistently as long as any indication exists. Since the strength of the tincture has been decreased (U. S. P. 1905), the cases of poisoning have been greatly reduced, and are seldom in fact met with in hterature. Hence the fact that practically all the instances recorded in these pages antedate the year of the last Pharmacopoeia. - Twenty cases, 6 of which were fatal, found in the literature of ten years : — Case 1. Tincture, 7 drams. Recov- ery. Emetics; morphine, % grain; fluid- extract of digitalis, 6 drops; strych- nine sulphate, i/ieo grain; brandy, 1 ounce; all hypodermically. By the mouth, 2 gallons of warm water; fluid- ACONITE (SAJOUS). 281 extract of digitalis, 20 drops; coffee, 11 pints; whisky, 3 pints; extract of nux vomica, y^ fluidram; port wine, V> pint. P. F. Brick (Jour. Amer. Med. Assoc, vol. viii, p. 567, 1887). Case 2. About 8 drops of concen- trated fluidextract. Recovery. Emet- ics, coffee, whisky (dessertspoonful). Heat. Friction and sinapism. T. H. P. Baker (Amer. Pract. and News, vol. iv, N. S., p. 122, 1887). Case 3. Fleming's tincture, 1^ ounces. Recovery. Emetics, brandy, ether, digitalis, ammonia carbonate. Amy! nitrite and warmth. C. C. Brad- ley (N. Y. Med. Record, vol. xxxii, p. 155, 1887). Case 4. Tincture, >< ounce. Recov- ery. Brandy by mouth and hypoder- mically. Ether. One quart of cold, black coffee. Heat and posture. S. Barnett (N. Y. Med. Record, vol. xxxii, p. 761, 1887). Case 5. Amount not known. Patient intoxicated at the time. Symptoms of acute poisoning. Recovery. Emetics, brandy, ammonia, and digitalis by the mouth. Sixty minims of tincture of digitalis hypodermically. Heat. Clara T. Dercum (Med. and Surg. Reporter, vol. Ixi, P.T889). Case 6. Tincture, amount not known. Child, 16 months. Marked toxic symp- toms. Recovery. Brandy and fluidex- tract of digitalis frequently repeated in spite of vomiting. Byron F. Dawson (Med. and Surg. Reporter, vol. Ixii, p. 7, 1890). Case 7. Tincture, 2 drams. Death. Benjamin Edson (N. Y. Med. Record, vol. xxxviii, p. 365, 1890). Cases 8, 9, and 10. Dr. Edson men- tions certain other cases known of, but not treated by him, three of which died. The amounts taken in these were from 1 to 4 drams. Case 11. Tincture (B. P.), 1 ounce. Death in sixty-five minutes. Mustard, lavage, heat, ether, and brandy subcu- taneously. L. M. Whannel (Brit. Med. Jour., vol. ii, p. 791, 1890). Case 12. Fleming's tincture, 1 dram. Recovery. Sulphate of zinc, tincture of digitalis, 20 minims hypodermically. Whisky, 1 ounce, by the mouth, fol- lowed by calomel, 8 grains. L. M. Whannel (Brit. Med. Jour., vol. ii, p. 791, 1890). Case 13. Fleming's tincture, 1 tea- spoonful. Recovery. Mustard, spirit of ammonia comp. (B. P.), tincture of belladonna, brandy. T. F. H. Smith (Brit. Med. Jour., vol. i, p. 1109, 1893). Case 14. Fluidextract, 4 drams. Recovery. Emetics, atropine, and brandy subcutaneously. Henri E. R. Altenloh (N. Y. Med. Jour., vol. Ixvii, p. 358, 1893). Case 15. Tincture, 7>^ drams. Re- covery. Mustard, digitalis, and brandy subcutaneously; digitalis, nux vomica, and brandy by rectum ; ether and am- monia by inhalation; brandy and am- monia carbonate by mouth later. G. H. Tuttle (Boston Med. and Surg. Jour., vol. XXV, p. 678, 1891). Case 16. Mentioned by, but not seen by, Dr. Tuttle. Tincture, 5^4 drams. Death. G. H. Tuttle (Boston Med. and Surg. Jour., vol. xxv, p. 678, 1891). Case 17. Preparation not noted. Four teaspoonfuls. Recovery. Sulphate of copper, digitalis, wine by mouth; whisky by rectum ; whisky, ^25 grain strychnine, and digitalin, %o grain, hypodermically. M. A. Warriner (N. Y. Med. Record, vol. xxxix, p. 521, 1891). Case 18. Tincture, 2 drams. Recov- ery. Apomorphine, stomach-tube, tincture of digitalis, 25 minims; aro- matic spirit of ammonia, 45 minims; brandy, 2 drams subcutaneously, heat- ers, sinapism to precordia. S. Q. Robinson (Boston Med. and Surg. Jour., p. 192, 1892). Case 19. Tincture (B. P.), 30 minims. Recovery. Salt and water one and a half hours after poison. Sulphate of zinc two hours after poison. Charcoal, brandy, and water by mouth. William Hardman (Brit. Med. Jour., p. 1893). Case 20. Preparation not stated. Five drops. Recovery. Belladonna and strophanthus, champagne, brandy, heaters. J. D. Leigh (Edinburgh Med. Jour., vol. xl, p. 638, 1895). 282 ACONITE (SAJOUS). Reported by R. W. Greenleaf (Bos- ton Med. and Surg. Jour., July 15, 1897). [The tincture of aconite re- ferred to is that of the old U. S. P. — Ed.] Case of a man, aged 26, ^vho drank about three-fourths of an ounce of the tincture of aconite. He immediately discovered his mistake, and took about a tablespoonful of ground mustard in water, but could not vomit. The writer administered vider vinegar about fif- teen minutes after drinking the aconite. He drank about a half-pint and another half-pint out of a quart jar. In less than five minutes he was greatly re- lieved, and his pulse was much better. The vinegar almost immediately re- ■ lieved the burning and choking sensa- tion in his throat. His saliva, which was thick and stringy (hanging down three or four feet, at the writer's ar- rival, on his attempt to spit), did not change its character for at least half an hour. It gradually became normal. All" the symptoms gradually subsided. C. M. Swincle (Homeo. Recorder, Oct. 15, 1908). [The best remedies used in the cases col- lected b}^ Dr. Greenleaf were, from my view- point, besides belladonna: digitalis, strych- nine, coffee, ether, and strcphanthus, all of which, though indirectly in most instances, tend to stimulate the sympathetic center. Morphine, used by Dr. Brick, excites directly the sympathetic center (as do the coal-tar products), but not, as does belladonna, in such a way as to restore the propulsive activity of the arterioles. Dr. Swincle's successful use of vinegar is of special interest in view of the fact that, as stated in the section on Acetic Acid (this volume, p. 229), I ascribe the toxic action of this agent to reflex excitation of the sym- pathetic center. C. E. de M. S.] THERAPEUTICS. — Aconite is mainly used as a circulatory sedative. It lessens the blood-pressure b}^ dimin- ishing the force and rapidity of the heart's action, and is, therefore, indi- cated where a frequent and tense pulse is associated with excessive cardiac activity. It also tends to counteract spasm and relieve undue excitability of the nerve-centers, though its prop- erty of depressing the cutaneous sensory nerve-terminals is more marked, and is frequently availed of in neuralgic affections. Aconite causing increased respira- tion, it is indicated where, with a high pulse, there is dryness of the skin. The evaporation of sweat from the surface and the heat radiation due to the increased peripheral circu- lation resulting from relaxation of the cutaneous capillaries also cause a reduction of temperature. Aconite also possesses diuretic properties. Hence it appears to be endowed with all the qualities requisite in the in- cipient stage of uncomplicated in- flammatory disorders, as an anodyne sedative. In children aconite may be given whenever the spasmodic element is clearly marked: in fever preceding at- tacks of quinsy, pharyngitis, etc. ; in asthma and the asthmatic crises of bronchial adenopathy ; in pertussis and other spasmodic coughs; in laryngismus stridulus ; in palpitations associated or not with hypertrophy of the heart, and in convulsions. [The foregoing symptomatic indications are not approved by the writer, being merely offshoots of the prevailing empirical (and therefore unscientific) methods in the use of remedies. It is not to '"allay spasm," to "reduce the heart's action," or to "reduce fever" that aconite should b^ given, but only where it may aid the curative process or offset complicati- IS as shown below. C. E. DE M. S.] The physiological effects enumerated afford sufficient ground for its value in the reduction of all the phenomena at- tending the fever: high temperature, dry skin, hard and frequent pulse, etc. ACONITE (SAJOUS). 283 The tincture is preferable here, as it is in all other disorders. The best effects are produced by means of small doses. One minim is first given, then another minim in one-half hour. After that, P/2 minims are given every half-hour until the febrile symptoms are reduced or until physiological symptoms of the drug appear. Aconite should always be greatly diluted. Its antipyretic power being less than that of certain newer remedies (coal- tar antipyretics), however, the latter generally (though very much less than formerly) find more favor where a marked reduction of temperature is desired, unless the additional indica- tions for the use of aconite, such as an overactive heart, frequent pulse, or dry skin, be strongly marked. Its action in favoring perspiration may be enhanced by combination with other diaphoretics, such as the alkalies or pilocarpine. Aconite is used in the fever attend- ing the incipient stage of catarrhal disorders. It may be used as an anti- pyretic in continued fevers and in- fectious diseases, — variola, scarlatina, erysipelas, etc., — but large doses are usually required, involving corre- spondingly great danger. It is better used in moderate doses for general sedative and diaphoretic eft'ects in less severe infectious fevers, such as measles, mild scarlatina, rubella, and in the group of "ephemeral" fevers. According to Tison, aconitine re- duces the pain and shortens the duration of erysipelas; he used acon- itine nitrate in doses of %4o grain every two hours, not exceeding 10 such doses daily. In the reflex fever which some- times follows the use of the catheter it has been found very efficient by several observers. [In all these conditions the use of aconite should not aim to reduce the fever, but to aid in the destruction of the pathogenic sub- stances, toxins, toxic wastes of which the febrile process is attempting to rid the blood. This is done with the aid of the small doses indicated above. By producing a slight de- pression of the sympathetic center, these small doses cause a correspondingly slight relaxation of all arterioles; they increase the volume of blood admitted into the capillaries, and, these minute vessels being the seat of the active febrile process, they hasten its activity and favor thereby the early destruc- tion of the pathogenic substances. Clinical experience has emphasized the fact that small doses are alone beneficial. From the explanation I have given of the effects of large doses, it is obvious that, by causing excessive dilatation of the arterioles, they can arrest the febrile process and place the pa- tient at the mercy of the germs and their toxins. Large doses of aconite I deem worse than useless. C. E. de M. S.] In acute disorders of the nose, throat, and lungs the sedative effects exerted by aconite upon respiration through its influence upon the respiratory center are added to the qualities previously enumerated. Hence its value in acute coryza, pharyngitis, tonsillitis, trach- eitis, bronchitis, pleurisy, and pneu- monia. Dujardin-Beaumetz uses aconitine when the lungs are con- gested, and especially in influenza. In all of these, 2 drops of the tincture every hour should be administered until the physiological effects — tin- gling and numbness of the. lips and tongue — are experienced, when the remedy should be given less fre- quently. After the initial stage of the affections enumerated, aconite should be discontinued, especially in pneu- monia, in which affection its adminis- tration is positively harmful as soon as the asthenic stage begins. Aconite has been used in hemoptysis and epi- staxis to lower the blood-pressure and favor cessation of the hemorrhage. In 284 ACONITE (SAJOUS). the chronic disorders of the respira- tory passages — including phthisis — it is more hurtful than beneficial. In children aconite has proven useful in coryza, tonsillitis, spasmodic croup, asthma, whooping-cough, etc. [The principles outlined in the foregoing commentary are quite applicable. The phys- iological effects need not be reached, how- ever, to obtain salutary effects. It is in the early treatment of catarrhal disorders due to cold and exposure that aconite is most bene- ficial. The patient should, however, remain at home owing to the diaphoretic action of the remedy, which exposes to additional cold if exposed outdoors. C. E. de M. S.] Aconite has been employed in all forms of rheumatism, as well as in gout, to relieve pain and reduce con- gestion. It is especially indicated when the skin is dry. It is believed to have particular value in the acute rheumatic pains due to exposure. In chronic rheumatism it may be used in the form of a 2 per cent, ointment of aconitine. Hutchinson has found tincture of aconite beneficial in rheu- matic iritis. He gives 5 minims three times a day, in conjunction with potassium iodide and the alkalies. Meningitis, pericarditis, and peri- tonitis are mentioned concurrently owing to the fact that their early manifestations are equally influenced by aconite. In peritonitis especially, its effect as an anodyne tends to pre- vent vomiting: an important feature. In pericarditis it increases the chances of recovery by reducing the number of pulsations, thus prolong- ing the resting periods between beats. It should, however, be used with caution in these conditions, in view of its somewhat variable general depressant action. [It happens that the four diseases referred to in the above two paragraphs : rheumatism. meningitis, pericarditis, and peritonitis, are all ascribed by the writer to excessive activ- ity of the protective resources of the body, with autolysis of the tissue involved in these conditions as the direct pathological process. An important feature of the latter is the marked rise of blood-pressure which an ex- cess of antitoxic bodies produces; it is this feature that aconite counteracts. By depress- ing the sympathetic center it causes relaxa- tion of all arterioles, and thus lowers the blood-pressure. It is doubtful, however, whether it enhances at all the curative process. C. E. de M. S.] The sedative efi^ect of aconite upon the sensory nerves and nerve-endings has led to its frequent use, internally or locally, in neuralgia and neuritis. Certain authors consider it specially efi^ective in neuralgia of the trifacial nerve. In neuralgia of the intermittent type, a combination of aconite with quinine will often be found serviceable. In the form of neuralgia characterized by exacerbations during damp weather aconite is sometimes efifective in small doses frequently repeated. If the pain- ful spot does not cover much surface, application of the tincture over it with a camel's hair pencil contributes mark- edly to hasten the relief. The drug may also be applied as a liniment or by inunction (see Modes of Administra- tion). The pain of neuritis resulting from exposure to cold is sometimes favorably influenced by aconite. In pain due to disturbances of the central nervous structures, however, the drug has not been found of great value. [Neuralgia also includes an abnormal rise of the blood-pressure in its pathogenesis, ac- cording to the writer's interpretation of this disease (see "Internal Secretions," p. 1529), the pain being the result of congestion of the nervous elements of the affected area owing mainly to local vascular disorders. Aconite, by lowering the general vascular tension, relieves the pressure in the neuralgic area and the pain due to it, C. E. de M. S.J ACROMEGALY (LAUNOIS AND CESBRON). 285 By lowering arterial tension and diminishing the number of heart-beats it may be of marked advantage in func- tional cardiac disorders, but when organic lesions are present it had better not be used. It is not infrequently employed in uncomplicated hyper- trophy, in nervous palpitation, and in the tobacco-heart, to antagonize ex- aggerated action, but its effects should be closely watched lest incip- ient degeneration be present. The dose generally used is from 2 to 5 minims of the tincture three times daily. [One cannot be too careful in using aconite in cardiac disorders, tliough the praise ac- corded it by various authors as the ideal remedy for the diminution of the blood- pressure when the heart is exposed to ex- cessive resistance is also warranted by 'the interpretation of its physiological action I have submitted in the foregoing commen- taries. C. E. DE M. S.] Toward no drug in the entire phar- macopeia is idiosyncrasy so often mani- fested. Numerous cases are recorded of dangerous syncope, and even death having resulted from small medicinal doses of aconite .(Ferrand, Leigh, Woodbury). Ferrand, indeed, emphati- cally condemns it as a dangerous drug the use of which should be confined to the laboratory. While few would go the full length of Ferrand's condemna- tion, great caution is undoubtedly nec- essary in its employment, owing to the unexpected susceptibility which is often manifested toward its action. We may well pause before undertaking a more extensive use of this drug in cardiac therapy. Arthur R. Elliott (N. Y. Med. Jour., Jan. 9, 1904). [Since the 1905 U. S. P. has reduced the strength of the tincture, however, the dangers to which Elliott refers have been greatly re- duced. C. E. DE M. S.] A 2 per cent, ointment of the alkaloid aconitine has sometimes been applied to relieve pain and itching in affections such as herpes zoster, eczema, pruri- tus, etc. As suggested by Dr. G. W. Rob- erts, a solution of aconite in water is very efficient in stubborn pruritus. One dram (4 Gm.) of the tincture in 8 ounces (250 Gm.) of water or twice this strength may be used to "bathe" the itching area, using a soft cloth or sponge. H.T.Webster (Ellingwood's Therapeutist, Sept. 15, 1909). Dysmenorrhea due to congestion of the pelvic organs, metrorrhagia, and amenorrhea resulting from ex- posure to cold have all been mark- edly benefited by aconite. In the vomiting of pregnancy aconite in moderately large doses is often found to give relief, owing to its sedative effect upon the nervous structures involved in the reflex act. Aconite has been used with benefit in acute gonorrhea, 1 minim of the tinc- ture being given every hour (Ringer). It is also advantageous as an anodyne in epididymitis. C. E. DE M. Sajous AND L. T. DE M. Sajous, Philadelphia. See Vascu- lar System^ Disorders of, under Acroparesthesia. ACROMEGALY : PIERRE MARIE'S DISEASE. -DEFI- NITION. — Acromegaly is a general syndrome due, in almost every instance, to tumor of the hypophysis, character- ized by progressive enlargement of the osseous and other supporting tissues, and primarily and chiefly noticeable in the extremities. [Pierre Marie (Revue de Medecine, 1886, p. 297; Nouv. Iconog. de la Salpetriere, 1888; Progres Medical, March, 1889; Brain, 1889; 286 ACROMEGALY (LAUNOIS AND CESBRON). Revue de Medecine, Jan., 1890; "Legons de clinique medicale," Paris, 1896 ; Bull, ct Memoires de la Soc. Med. des Hopitaux de Paris, 1896), in 1885, wrote a monograph entitled: "De racromcgalie, hypertrophic singuliere, non-congenitale, des extremitcs superieures, inferieures et cephalique." In it he described the deformities which he had observed in 2 cases from Charcot's service at the Salpetriere, mentioning the increased bulk of the hands, feet, and of certain facial bones (nasal, malar, and inferior maxillary), the spinal curvature, as v/ell as a "family likeness" which suggested that the two cases were suffering from the same disease. This affection he regarded as a special morbid entity. He concluded his paper with the words : "There exists an affection especially characterized by hypertrophy of the feet, hands, and face, which we propose to name acromegaly (from ^xpo", extremity; /j-^yas. large), i.e., hypertrophy of the extremities; acromegaly is entirely distinct from myxe- dema, from Paget's disease, and from the leontiasis ossea of Virchow." This contribution did not appear until April, 1886, in the "Revue de Medecine." A new dystrophy had thus been added to the nosologic gamut. It presented manifesta- tions so peculiar that it could not only be differentiated from similar affections, but even recognized from a di ' mce. Verstrae- ten (Revue de Medecine, No. 5, 1889) and de Souza-Leite ("De I'Acromegalie, Maladie de Pierre Marie," These de Paris, 1890) very rightly, therefore, designated acro- megaly "Pierre Marie's disease." It is but fair to recall, however, that the deformities had be-T mentioned in a number of earlier communications, of which a list may be found in a paper by Patry (These de Paris, 1907). The most striking observa- tions were those of Saucerotte (Melanges de Chirurgie, part i, p. 407, 1801, and Mem. de I'Acad. de Chir., 1772), of Alibert (Precis theorique et pratique des maladies de la peau, t. iii, p. 317, Paris, 1882), of H. Henrot (Notes de clin. med. Reims, 1877 and 1882) ; the last of these dealt with a case of acromegaly studied and examined post mortem by one of the writers of this paper. These had remained isolated' obser- vations, however, and ranked as mere curiosi- ties. Once accurately known and described, the affection can be recognized in every case ; for this reason communications bearing on it have been rapidly accumulating. In France, Pierre Marie (Nouv. Icon, de la Salnetr., 1888; Progres Med., March, 1889; Brain, 1889; Rev. de Med., Jan., 1890) com- pleted the data presented in his first mono- graph. Guinon (Gaz. des Hop., No. 128, Nov. 9, 1889), Rauzier (Nouv. Montpellier Med., p. 623, 1893), and Blocq (Gaz. hebdom. de Med. et de Chir., 1894) reviewed thor- oughly, giving numerous references, the earlier communications on the subject, as did also Souza-Leite and Duchesneau (These de Lyons, 1901) in their theses. The latter laid the foundations for pathological studies of the dystrophy. "In other countries, the in- vestigations bearing on this affection were no less plentiful, as shown in the tables pub- lished by Collins (Jour, of Nerv. and Ment. Dis., Nos. 1 and 2, page 139) in 1893. In view of their great number, we can men- tion but a small proportion of the authors on this subject. In America: Adler, Saundby, Duller, Harris, Osborne, Graham, Hary, Packard, Dercum, Berkley, and Moncorvo Diana, Woods Hutchinson. In England : Hadden, Silcock, Waldo, Paget, Bury, Kan- tack, Waddel, Campbell, Boyce, and Beadles Whyte. In Belgium : Verstraeten. In Ger- many : Virchow, Erb, Schiiltze, Ewald Ger- hardt, Moebius, Mosler, Lethaun, Boeltz, Bier, Pel, and Fraentzel. In Italy : Caselli, Sacchi, Grocco, Bignani, Tanzi, Denti, Orsi, Bruzzi, Massalongo, Lombroso. In Russia: Burchard, Shaporonikow, Gorzatchew, Gaz- kienwiczi, Stembo. This lengthy, though very incomplete list bears witness to the interest awakened in medical circles by the study of acromegaly since the year 1886. In a second and no less fruitful period, investigators sought to determine the rela- tions between acromegaly and gigantism [Pierre Marie (Legons de clin. med., Paris, 1896; Bull, et mem. de la Soc. Med. des Hop. de Paris, 1896), Brissaud et H. Meige (Jour, de med. et de chir. prat., Jan. 25, 1895; Nouv. icon, de la Salpetr., 1897), Meige (Congres de neurol. de Grenoble,- 1902, and Arch. gen. de med., p. 410, Oct., 1902), Brissaud (Bull, de la Soc. Med. des Hop. de Paris, May 15, 1896), Launois et P. Roy (Bull de la Soc. Med. des Hop. de Paris, May 8, 1903 ; Nouv. icon, de la Salpetr., 1902; Revue neurologique, 1903; "Etudes ACROMEGALY (LAUNOIS AND CESBRON). 287 biologiqucs sur les geants," Paris, 1904), Pierre Roy (These de Paris, 1903), Woods Hutchinson (X. Y. Mod. Jour., vol. Ixxii, Nos. 3 and 4, July. 1900), Cunningham (Trans, of the Royal Irish Acad., vol. xxix, p. 553, 1891), Dana (Jour, of Nerv. and Ment. Dis., vol. xviii, 1893), Tamburini (Cen- tralhl. f. Nervenheilk., B. vii, p. 625, 1894), Tarufifi (Case della macrosomia, Annali univ. di med., p. 247, 1879), Massalongo (Riforma med., p. 157, 1892)], to ascertain the nature of certain manifestations accom- panying the deformities, such as ocular disorders [Schiiltze (Berlin klin. Woch., No. 2S, 1S89), Ruttle (Brit. Med. Jour., p. 697, Mar. 28, 1901), Pinel-Maisonneuve (Soc. franc, d'ophthalmol, Ma}% 1891), Bernhardt (Beitrage zur Symptomatol. u. Diagn. der Hirngeschwiilste, Berlin, 1881)], glycosuria [Loeb (Deutsch. Arch. f> klin. Med., B. xxxiv, p. 449, 1884, and Hypophysis cerebri und Diabetes mell., Centralbl. f. inner. Med., 1898), Hanse- mann (Ueber Akromegalie, Berlin, klin. Woch., p. 417, 1897), Hinsdale ("Acromeg- aly," p. 20, Detroit, 1898), Finzi (Boll, della Soc. Med. di Bologna, No. 4, 1894), Striim- pell (Deutsch. Zeitschr. f. Nervenheilk., 1897), P. E. Launois and P. Roy (Arch, gen de med., 1903, and Bull, de la Soc. de Biol., 1903)], the cerebral manifestations, and psychic disturbances [Soca (Sur un cas de sommeil par tumeur de I'hypo- physe)]. They were thus led on to study the relations between various disturbances and hypophyseal tumor formation [Woods Hutchinson, Modena (Rivista speriment. di freniatria, 1903), Caselli (Rivista di freniatria, Feb., 1900, and Reggio-Emilia, 1900: Studi anat. e speriment. sulla fisio- patologia della gland, pituit.), Launois and Roy (Autopsie d'un geant diabetique et acromegalique, Nouv. icon, de la Salpetr., 1903), Klaus and van der Stricht (Bull, de ' la Soc. de Med. de Gand, 1893), Fritsch and Klebs C'Ein Beitrag zur Pathol, des Riesenwuchses," Leipzig, 1884)], and to em- phasize the idea of a distinct and charac- teristic group of symptoms, — the hypophys- eal syndrome, — the existence of which was soon confirmed when the new means of exploring the cranium afforded by Roent- gen's discovery was brought into use [Beclere (Bull, de la Soc. Med. des Hop. de Paris, Dec. 5, 1902; Presse med., Dec. 9, 1903), Giordani (These de Paris, 1906), von Rutkeroski (Charite, Annalen, 1904), Schiillcr ("Die Schadelbasis ini Rontgen- bild," Hamburger Abl., 1905)]. In 1901, Frohlich (Wien. klin. Rundsch., 1901) pointed out the symptomatic value of the adipose tendency which sometimes accompanies the development of pituitary tumors; the subsequent observations of Erdheim (Ziegl. Beitr., Bd. xxxiii, 1903), of Boyce and Beadles (Jour, of Pathol, and Bacteriol., pp. 223 and 359, 1893), of von Hippel (Virchow's Archiv, Bd. cxxvi, p. 124), Mohr (Schmidt's Jahrb., Bd. xxx), Closer (Virchow's Archiv, Bd. cxxii, p. 389, 1890), and Pechkranz (Neurol. Cen- tralbl, Bd. xviii, p. 202, 1899) added pre- cision to our views on this point. In- deed, the present tendency is to divide into two groups the dystrophic manifesta- tions of the hypophyseal syndrome, some being referred, on the one hand, to the true acromegalic type of Pierre Marie, and others to the Upomafous type of Frohlich. The third, or surgical, period in the history of acromegaly [Schlosser (Wien. klin. Woch., 1906, and May 21 and 23, 1907), von Eiselberg (Centralbl. f. Chir., Aug. 29, t908), Hochnegg (ibid., p. 72, and Arch. f. klin. Chir., Sept. 2, 1908)] is of recent advent (1908). With both great boldness and assurance, operators have ad- vanced to the attack of the pituitary tumor itself, witnessed, after its removalj regres- sion of the characteristic deformities, and brought out most cogent papers in favor of the hypophyseal theory concerning the dystrophy. Launois and Cesbron.] SYMPTOMATOLOGY.— Tlie most prominent characteristic of the "acro- megahc dystropliy" is, as we have stated, a progressive enlargement of the ex- tremities. Although the deformities are particularly noticeable in naturally prominent portions of the body, they also involve other regions, such as the skull, face, spinal column, and thorax, and are very marked in these regions as well. An outline of the general appearance of the acromegalic patient — that odd, ungainly, and unharmonious creature — 288 ACROMEGALY (LAUNOIS AND CESBRON). may prove profitable before the disease is studied in detail. His enormous, clumsy hands seem all the more massive from the fact that the forearms have retained their normal proportions. They present a ''stuffed" appearance, and ter- minate in thickened, sausage-like fin- gers. His broadened feet are mere paws, with toes of exaggerated size. The face is long, the forehead narrow and retreating, and the supraorbital arches enlarged; the eyes often project forward from between the thickened eyelids ; the nose stretches out laterally its fleshy ate; the lips are enormous, especially the lower, which is everted ; the lower jaw is strongly prognathic; the tongue, unusually large, frequently protrudes from the mouth. Tliis repul- sive and beast-like head, bounded later- ally by ears of monumental size, is bent forward and set deeply between the shoulders. Though of average stature, or above the average, the subject ap- pears partially collapsed ; the curvature of his back and the thoracic deformity contribute to his humiliation, which is further accentuated by his torpid and melancholy demeanor. From a distance his appearance is so striking that the diagnosis can be made without detailed inspection. When the deformities are fully developed, all acromegalics bear a strong resemblance, and the adage, "ab nno disce omnes" is here truly appli- cable. The increased bulk of the hands is often the first change to attract atten- tion. The hands become broader and thicker without augmenting in length. The hypertrophy involves all the com- ponent tissues of the part, — bones, mus- cles., subcutaneous cellular and fatty tis- sues, and skin. The latter is hard, firm, free of edema, and somewhat darkened in color. The interphalangeal folds, ab- normally developed, extend between what may be called wads of flesh, — ^the "main capitonnee." The thenar and hypothenar eminences are greatly over- developed, and the linear grooves of the palm are transformed into deep gutters. The fingers are somewhat flattened from before backward, and are of equal thickness distally and proximally. The thumb measures up to 12 cm. in circum- ference* (Lombroso), the index finger 9 cm., and the medius 10 cm. The nails remain relatively small. They become flattened, turn up at the edges, and show longitudinal striations. In exceptional cases a club-shaped deformity of the fingers, or the presence of nodosities at the interphalangeal joints, has been noted. Notwithstanding the unusual proportions of the acromegalic hand, its functions are generally preserved, complete flexion becoming impossible, however, in cases where the palm is markedly thickened. De Souza-Leite observed the "dead finger" phenomenon twice in 38 cases. In contradistinction to this massive, voluminous, or "transverse" type, Pierre Marie has described a second variety of deformity involving the hands. In this type they again undergo a general in- crease in size, but there is added a growth in length which is about propor- tionate to that in breadth. Being longer, the hands thus appear lighter and less clumsy than in the massive form, where the overgrowth is almost solely trans- verse. This "longitudinal" type is seen more particularly in subjects in whom the dystrophy developed at a relatively early period. We have met with it in our infantile acromegalic giants. These deformities of the hand gen- erally stop at the wrist, at least during the earlier stages. Later on, the hyper- trophy becomes generalized, the other Acromegaly. (P. E. Launois.) Acromegalic Profile. (P. E. Launois.) ACROMEGALY (LAUNOIS AND CESBRON). 289 segments of the upper extremity — fore- arm and arm — being also involved. The feet, like the hands, become broader and thicker, without greatly in- creasing in length. They present the same fleshy pads, surrounded by deep grooves. The skin is darker, but is of similar consistency. The toes, especially the great toe, reach altogether remark- able dimensions, and the nails are af- fected much as in the upper extremity. According to Verstraeten, the heels are always enlarged. The h3^pertrophic en- largement generally terminates above the leg. The knee, if early involved, is enlarged but slightly, and the foot al- ways contrasts, by its exaggerated bulk, with the rest of the limb. The acromegalic fades, besides the characteristics already noted, includes a striking prominence of the supraorbital ridges, which project to an extent cor- responcUng to the degree of enlarge- ment of the frontal sinuses. The eyes are lacking in expression, and appear relatively small in comparison with the capaciousness of the orbits, notwith- standing the exophthalmos occasionally observed. The eyelids are thickened either in toto or merely in the region of the tarsal cartilages. The temporal fos- sae becoming deeper, the malar promi- nences appear to stand out more strongly. The nose undergoes general enlargement, and is distinctly broadened and flattened. Its alze are heaviest inferiorly, and the septum is doubled in thickness. The lips are enlarged, particularly the lower, which is also everted. The mouth, often half open, reveals a tongue of enormous bulk. The movements of the tongue are poorly ex- ecuted; the organ interferes with mas- tication and articulation, is frequently injured by the teeth, and sometimes shows fissures at its borders. The roof of the mouth, soft palate, f aucial pillars, tonsils, uvula, and larynx all exhibit hypertrophic changes. In female sub- jects, the thyroid cartilage, in its hyper- trophied state, recalls the "Adam's apple" normally seen in the male. Laryngoscopic examination reveals both elongation and thickening of the vocal cords. These various changes in the organ of phonation impart to the voice a distinctive deep and at the same time metallic quality. While the alterations in the superior maxilla are apparently not pronounced, those involving the lower jaw are some- times extremely marked. The chin, large and massive, projects downward and forward, forming an obtuse angle with the rami of the jaw-bone. The lower teeth, which Henrot has found to be hypertrophied, are spread apart, and, owing to their forward projection, can no longer be opposed to the upper dental arch. The profile is most characteristic, and bears witness to the extraordinary de- gree of prognathism sometimes at- tained. The description of the acro- megalic facies would not be complete without a mention of the broadened ears, with their lobules of exaggerated size. The facial skin is dry, brownish yel- low in color, and often presents warty excrescences. The hairs covering the head are individually thickened, and, taken collectively, apparently exhibit a heavier growth. The eyelashes and other short hairy appendages are also coarse and stiff. The bones of the cranium proper show modifications similar to those in the facial bones. These changes will be described later, when the results ob- tained by radiographic examination are discussed. -19 290 ACROMEGALY (LAUNOIS AND CESBRON). In the spinal region, the vertebrae, taken as a whole, show increased vol- ume. As a result, changes in the spinal curves are brought about, consisting, more specifically, of a cervicodorsal kyphosis, with or without lumbar lor- dosis and scoliosis. The thorax becomes more capacious and undergoes alterations in shape. It becomes prominent anteriorly. Though its anteroposterior diameter is increased. Acromegalic macroglossia, (P. E. Launois.) it is flattened laterally. The broadened sternum tends especially to spread out above, and develops transverse ridges. The clavicles become thickened and their curves exaggerated. The ribs come mutually into contact, or even overlap, and the costal cartilages become ossified. The lower costal arches slant downward, sometimes so markedly as to reach the crest of the ilium when the subject is in the sitting posture. The scapulae are thickened, and their acro- mial and coracoid processes stand out in bold relief beneath the skin. These deformities interfere in some degree with the~ thoracic excursions, sufficiently so, indeed, to bring about. among acromegalic subjects, a modifi- cation in the type of breathing, which becomes permanently abdominal. When they are all present in the same patient and are very pronounced, a double hump in the back may be pronounced, recall- ing the classic conformation of the Ital- Cervicodorsal kyphosis in a case of acromegaly. iPierre Marie ) ian Punchinello, whom Pierre Marie considers the ancestor of acromegalics. The dystrophy makes its first appear- ance at the distal ends of the extremi- ties. The patient's attention is often attracted to the condition by the con- stantly increasing tightness of his gloves and footwear. In some instances the family or neighbors notice changes tak- ing place in the facies. Once estab- lished, the affection progresses steadily and more or less rapidly. If the patient Acromegaly in the Aged— Strabismus. (P. E. Launois.) ACROMEGALY (LAUNOIS AND CESBRON). 291 1)C a woman, she becomes aware of the prDyressively larger size of thiml)le she re<.|uires in her sewing. The male pa- tient, on the other hand, is struck by the increasing tliameter of his headgear. From the distal portions, the changes proceed to the proximal segments of the liml)s, which, b}- their hypertrophy, may assume a markedly athletic aspect. Muscular power, however, almost al- ways shows a gradual decrease ; not- withstanding their bulk, the contractile jKiwer of the muscles does not bear the normal ratio to their size. A certain degree of muscular atrophy has occa- turbanccs. His pupil, J. B. Fournicr (These de Paris, 1896), having collected 25 cases, including 12 with autopsy, was led to distin- guish two varieties of cardiac hypertroph}-, the one, slight and without degeneration of the muscular libers ; the other, accompanied by sclerosis and atrophy of the contractile elements. Launois and Cesbron.] Symptomatically these changes in the cardiac tissues find their expression in palpitations, arrhythmia, and dyspnea, and may result finally in asystole. Syn- copal attacks are said to be not uncom- mon. Spinal deformities, when marked, may result in dilatation of the right heart. Series of thimbles used by an acromegalic woman. sionally been noted ; in a case studied by Duchesneau (These de Lyon, 1901) it was so pronounced as to lead this observer to suggest the advisability of differentiating an amyotrophic form of the disease. The muscles show no note- worthy electrical disturbances ; their ex- citability is diminished according toErb, exaggerated according to Verstraeten. The patellar reflexes are either normal, diminished, or lost; they are never ex- aggerated. In certain joints, such as the knee, wrist, and elbow, there have been ob- served enlargement and painful crac- kling, recalling somewhat the phenom- ena noted in mild arthropathies. The circulatory system presents an interesting group of alterations. Vari- cose veins are said to be frequent, and the heart is often hypertrophied. [In 1895 Huchard pointed out the existence of more or less marked cardiovascular dis- Hypertrophy of" the lymphatic vessels and glands has also been reported.' Sensation, on the whole, does not ap- pear to be affected. Unusual sensitive- ness to cold is, however, present to a certain extent. The various deformities that we have described arise and progress, as a rule, without giving rise to pain. In some instances, however, their develop- ment is accompanied by more or less severe painful crises, sometimes re- ferred to the viscera, at other times to the limbs. While sometimes taking the form of a simple myalgia, they may also develop into severe neuralgia, and are then aggravated by exposure to cold and dampness. This painful form of the disease (Sainton and State, Revue Neurologique, p. 30, 1900, and These de Paris, 1900) may also assume the rheu- matoid type when it becomes localized in a certain group of joints. 292 ACROMEGALY (LAUNOIS AND CESBRON). THE HYPOPHYSEAL SYN- DROME. — Until recent years the nat- ural history of acromegaly would have been covered by a description such as the above. The advances since made, however, both along clinical lines and in the pathology of the disease, owing to the use of the X-rays and to im- proved histological technique, have brought about modifications of our ear- lier ideas. Previously considered an in- dividual affection, to which the name "Pierre Marie's disease" had properly been applied, acromegaly was found to be, in reality, only the most peculiar and striking component of the syndrome re- sulting from tumors of the hypophysis, and it is because it has drawn our atten- tion to the hypophysis that the syn- drome due to hypophyseal growths has brought forth such a wealth of litera- ture as to make it at present, perhaps, the most abundantly discussed of the syndrome caused by brain tumors. We consider acromegaly to be an in- tegral part of the hypophyseal syn- drome, and, indeed, with the exception of certain rare cases acromegaly unac- companied by tumor of the hypophysis does not occur, while, on the other hand, the close relationship of the disease to such tumors seems established. [The rare cases referred to are critically reviewed in the important papers of Woods Hutchinson (N. Y. Med. Jour., Nos. 3 and 4, July, 1900), and of Modena (Rivista speri- mentale di freniatria, Fasc. iii and iv, 1903), and of which only one, that of Bonardi (Riforma medica, ii, 1893), is of value as evidence. Launois and Cesbron.] The affection generally makes its ap- pearance long before the other compo- nents of the syndrome, which may be interpreted as disturbances due to com- pression; on the other hand, in no case has a tumor in the region of the hypophysis been known to produce acromegaly unless developed from the hypophysis itself. Acromegaly almost certainly implies the existence of a tumor of the hypophysis. The converse is, however, not always true, every tumor of the hypophysis not necessarily resulting in acromegaly. Clinically, tumors of the pituitary, the frequency, nature and characteristics of which we shall mention later, betray their presence by an aggregate of signs and symptoms included under the term "hypophyseal syndrome." We may divide these signs and symptoms, fol- lowing the example of the obstetricians, into the three following groups: 1. Probable signs and symptoms of pitui- tary tumor. 2. Quasi-positive signs and symptoms. 3. Positive signs. The first are those of brain-tumor with special localisation. Through its increased size, the pituitary expands the bony fossa in which it is lodged and soon begins to project upward above it, indenting the lower surface of the cere- brum. It exerts more or less pressure on the neighboring structures, and causes a certain degree of increased in- tracranial tension. The earliest symptom of it is head- ache. The pain tends to become local- ized anteriorly; these patients often complain of a sensation of heaviness "which impels them half unconsciously to rub their forehead and eyes, as one does ordinarily upon awakening" (Rayer). In certain cases, the pain is more definitely localized. [In a patient under the observation of Bartels (Zeitschrift f. Augenh., xvi, pp. 407 and 530, 1906), it radiated even to the eyes, and was of great intensity. In other instances mild neuralgic states, as in the case reported by Infeld (Sitzungsb. des Vereins f. Psych, u. Neurol., Wien, 1902), may be present, or, again, severe involve- ment of the trigeminal may exist. In a ACROMEGALY (LAUNOIS AND CESBRON). 293 patient under the care of Benda (Berliner klin. Wochenschr., p. 167, 1897), the pain was so severe as. to require removal of the Gasserian ganglion. The pain has like- wise been known to extend into the occip- ital region (Bartcls), and ever to pre- dominate there. Pontoppidan (Hosp. Tid., 1897) reported the presence simultaneously discovery post mortem of an almost complete flattening of the basal convolu- tions, whereas in life only trifling mi- graine had been recorded, becomes a matter of surprise. Along with the headache should be mentioned vertigo and vomiting of cere- Young acromegalic woman. In lower right-hand corner, same patient at the age of 20, soon after onset of the affection. {P. E. Launois.) of right-sided trigeminal neuralgia and bi- lateral occipital neuralgia. The effects of the trigeminal involvement are sometimes so severe as to cause lagophthalmia or neuroparalytic keratitis, as reported by Hirschl (Wiener klin. Wochenschr., No. 10, 1899) and Griinwald (Miinch. med. Wochenschr., No. 22, 1895). Launois and Cesbron.] In some cases the progress of the disease is so nearly painless that the bral type, which are among the usual signs of intracranial tumors. With the symptoms are generally as- sociated melancholic tendencies, loss of memory, and mental and physical tor- por. Apathy sometimes reaches such a degree that the power of executing voluntary acts seems practically lost. It was very pronounced in the peculiar case described by Rayer : "During the 294 ACROMEGALY (LAUNOIS AND CESBRON). morning visit, when asked to rise, he promised to put on his clothes at once, yet at 5 o'clock in the afternoon, not- withstanding repeated requests by the nurse, he was still in bed. When obliged to relinquish his room in the daytime, he would leave only to sit motionless in an armchair or to slumber in an ad- joining room. The positions he assumed were those of an exhausted, flaccid, and semiunconscious individual." Convul- sive movements may also be observed, sometimes confined to the face, in other instances involving the limbs. ["Cardinal de Bousy," as related by R. Vieussens ("Novum vasorum corporis hu- man! systema," Amsterdam, p. 245, 1705), "at the age of 62 years was subject to con- vulsive movements affecting particularly the muscles of the eyes, lips, and tongue. At the outset of the malady the attacks were of short duration and recurred only at long intervals; later they became so frequent and were accompanied by pains of such exceeding severity as to exert a marked deleterious effect on the mental faculties, and especially on the memory, of the cardinal, who complained, in addition, of a certain sensation as of movements taking place within his head. Several apo- plectic attacks then occurred. One of these strokes was so violent that the pa- tient was stricken with right-sided hemi- plegia, which later gradually disappeared." The patient died a short time after; at the autopsy a large tumor of the hypoph- ysis was found. Launois and Cesbron.] In establishing a diagnosis of brain tumor in general, and of tumor of the hypophysis in particular, no signs should be overlooked, and we must, therefore, not forget to mention as possible symp- toms cramps, contractures (Berger, Zeitschr. f. klin. Med., liv; Stevens, British Med. Jour., April, 1903), and trismus (Koster, Hygieia, 1902). These may be related to the coexisting hydro- cephalic condition, since they disap- peared, in a patient of von Hippel ( Vir- chow's Archiv, cxxvi, p. 124), upon the removal of cerebrospinal fluid through a nasal opening. The tremor observed by Stroebe and the ataxia of the lower extremities reported by Henneberg (Neurol. Centralbl, p. 518, 1902) are probably to be referred to some similar cause. Peculiar anomalies of taste occasion- ally appear, consisting of strongly ex- pressed desires on the part of some pa- tients to eat most unusual articles of food. Tinnitus aurium, peculiar in that it appears only on the side upon which the patient is lying, has been noted (Yamaguchi, Klin. Monatsschr. f. Au- genheilkunde, 1903). Pressure may be exerted upon the sinuses adjoining the hypophysis and cause disturbances in th^ venous circu- lation, as shown by facial edema. Among the circulatory changes that may be produced is to be added to those already mentioned the somewhat para- doxical acceleration of the pulse, re- ported by Engel (Inaug. Dissert., Wien), Rosenhaupt (Berliner klin. Wochenschr., 1903), Infeld, and Bar- tels. A no less singular manifestation is lowering of the internal temperature, which, in a patient of Bartels, remained for weeks at a time between 34° and 36° C. (931/5° and 96%° F.) without the supervention of any sign of collapse. [The same phenomenon has been wit- nessed by Petrina. In a case reported by Gotzl and Erdheim (Zeitschr. f. Heilk., 1905) the temperature fluctuated for three weeks between 35° and 36° C, later fall- ing to 33° C. (91%° F.). It would be rather difficult at this time to explain the origin of such disturbances ; we shall merely point out their similarity to the phenomena observed in myxedema, in which disorder the temperature often fluctuates between 33° and 35° C, and sometimes even ACROMEGALY (LAUNOIS AND CESBRON). 295 falls below these figures. Launois and Cesbkon.] Torpor and asthenia are, as we have stated, among the ordinary manifesta- tions of acromegaly. Exaggeration of these symptoms, in the hypophyseal syndrome, may give the appearance of "sleeping spells" (Soca, Nouv. Iconog. de la Salpetriere, No. 13, p. 101, 1900), similar to those sometimes accompany- ing cerebral tumors (Raymond, Oppen- heim, Buens). True psychoses occur with extraordi- nary frequency in cases of tumor of the hypophysis. Schuster ("Psychische Storungen bei Hirntumoren"), who has made a special study of the psychic dis- turbances observed in brain tumors, be- lieves that they are met with in almost one-half of the cases of tumor of the hypophysis. This proportion will not seem surprising if we recall the fact that the first pathological observations on hypophyseal tumors were made in asy- lums for the insane (Rullier, Presenta- tion a I'Academie royale de Medecine, Oct. 7, 1823). History afifords a con- spicuous example of this in the person of Cromwell's giant porter, a maniac with prophesying tendencies, whom it was found necessary to confine. In the literature on the pathology of tumors of the hypophysis we often come across the words "amaurotic insanity" as a heading in clinical records. This accompaniment of these tumors, long overlooked, was but recently given due emphasis by Frohlich, and particularly by Cestan and Halberstadt (Revue neu- rologique, p. 1180, 1903). The various forms of delirium, delusions of persecu- tion, mystery, and the manic-depressive psychosis may be encountered. An in- teresting fact has been reported by Moutier ("Acromegalic: crises epilep- tiformes avec equivalents psychiques," Revue neurologique, Nov. 8, 1906) in the occurrence in an amblyopic acrome- galic of rather frequent epileptiform seizures, due evidently to the cerebral tumor present. In the intervals be- tween seizures he was subject to "absent periods," during which he would some- times remain perfectly still, or else per- form a large number of unreasoning acts of which he lost all remembrance after the attack had subsided. [In France, Brunet (These de Paris, 1899), Joffroy, Roubinowitch (Bulletin med- ical, 1908), and Barros (These de Paris, 1908) have made special studies of the mental condition of acromegalics. Lau- nois AND Cesbron.] Polyuria and glycosuria are often en- countered in cases of tumor of the hy- pophysis. That the presence of sugar was not more frequently reported by the earlier observers is due to the fact that they were not in the habit of ex- amining the urine in their cases system- atically. Loeb (Deutsch. Archiv f. klin. Aled., p. 449, xxxiv, 1884; Cen- tralbl. f. innere Med., 1898) was the first to point out the frequency of melituria in disease of the hypophysis. He explained it as being due to the pressure which may indirectly be ex- erted by tumors of this gland on the floor of the fourth ventricle and neigh- boring structures. [According to Pierre Marie, glycosuria occurs in one-half the cases of acromegaly. Von Hansemann (Berliner klin. Woch- enschr., p. 417, 1897) found it in but 12 of the 97 cases he collected, and Hinsdale ("Acromegaly," p. 20, Detroit, 1898) in but 14 out of 130. The figures of these last observers are not to be taken as stand- ards, however, for very often the presence of glycosuria was not tested for. All the papers bearing on this question have been brought together in the communications of Loeb, Pineles (Jahr. der Wien. Krank., iv, 1897), Caselli (Rivista di freniatria. .296 ACROMEGALY (LAUNOIS AND CESBRON). February, 1900; "Studii anatomici e speri- mentali sulla iisiopatologia della glandola pituitaria," ^Reggio-Emilia, 1900), Launois and Roy (Nouv. Iconog. de la Salpetriere, 1903; Archives generales de Medecine and Bull, de la Soc. de Biol., 1903; Bull, de la Soc. Med. des Hop. de Paris, May 8, 1903; Nouv. Iconog'. de la Salpetriere, 1902; Re- vue neurologique, 1903; "Etudes biolog- iques sur les geants," Paris, 1904; Pierre Roy, "Contribution a I'etude du gigan- tisme," These de Paris, 1903). There is a tendency among certain authors, on the basis of the association of glycosuria with acromegaly, to distinguish a special syn- drome, to which vonNoorden ("Handbuch der Stoffwechselskrankheiten," vol. ii, p. 45, 1905) has given the name "acrornegalo- diahetes." Launois and Cesbron.] Glycosuria of hypophyseal causation, though more or less constantly present, may show wide variations in intensity. In a patient of Finzi (Boll, della Soc. Med. di Bologna, No. 4, 1894), for in- stance, the sugar, after having been present in large amounts, gradually dis- appeared completely from the urine. In February, .1888, Striimpell (Deutsch. Archiv f. Nervenheilkunde, 1897) noted a marked glycosuria in one of his cases. In May of the same year the sugar had disappeared. It reappeared in October, then did not return, even after the in- gestion of a large quantity of carbohy- drates. These variations are probably to be explained, in common with the oc- ular disorders we shall discuss later, by the variations that may occur in the size of the pituitary tumors. It is rather difficult at present to explain the mode of production of hypophyseal diabetes, and the various theories advanced re- garding its pathogenesis have none of them received sufficient confirmation. Of the 176 cases of acromegaly re- ported so far, 35.5 per cent, included glycosuria as a symptom. Experiments to ascertain whether this was due to functional perversion of the pituitary, by injecting hypophyseal extract ob- tained from men and horses into dogs and rabbits. In dogs no uniform re- sults were obtained, but in rabbits a glycosuria varying from a slight trace to 4.2 per cent, always occurred. Bor- chardt (Zeit. f. klin. Med., Bd. Ixvi, S. 332, 1908). Dallemagne (Archives de Medecine experimentale, 1895), Pineles, and von Hansemann have found lesions of the pancreas at the autopsy. The first of these observers, in addition, noted the presence of small gliomatous forma- tions in the region of the fourth ven- tricle. According to Lorand (Journal medi- cal de Bruxelles, 1903), the glycosuria results from disturbance in the internal secretion of the hypophysis, and is a component of one of the polyglandular syndromes, to learn the precise nature of which investigations are now being conducted. Loeb believes it due to pressure ex- erted on the structures at the base of the brain, and, since, of all cerebral tumors, those developing from, or in the neigh- borhood of, the hypophysis are the most likely to cause glycosuria, he is of the opinion that a center regulating the metabolism of sugar exists in this re- gion. The center discovered by Claude Bernard in the floor of the fourth ven- tricle would thus not be the only one of this kind; Schiff, indeed, appears to have found other such centers in the optic thalami, crura cerebri, and pons. Eckhardt produced glycosuria in rab- bits by injuring the vermis of the cere- bellum, and, returning to clinical and pathological records, we may recall that Lepine observed diabetes in a case of softening of the central gray nuclei, and Loeb and Naunyn in cases of cerebral hemorrhage. According to the views of Sajous ACROMEGALY (LAUNOIS AND CESBRON). 297 ("The Internal Secretions and the Prin- ciples of JNIedicine," vol. i, 1903; vol. ii, 1907; Gazette des Hopitaux, Mar. 10, No. 29, 1907), who holds that a nervous center exists in the hypophysis, and that the several ductless glands are con- nected by a nervous pathway, a ready explanation is afforded. Diabetes of hy]iophyseal origin is the result of an irritation, a disturbance produced in the nervous center which the gland con- tains, in the same way that the nerve- path, in its bulbar course, is influenced by puncture of the fourth ventricle. Whether we adopt the view of Loeb, involving pressure changes, or that of Sajous, relative to nervous irritation, however, the presence of an interme- diary is further required for the produc- tion of glycosuria. According to some, this intermediary factor is the pancreas ; in the opinion of Gilbert and his follow- ers, it is the liver which, under these conditions, becomes functionally over- active; according to Sajous, it is the adrenals, to which he traced nerves from the pituitary, the adrenal secre- tion augmenting through increased oxi- dation the production of amylopsin, wdiich, in turn, increases abnormally the conversion of the hepatic glycogen into sugar. Rath, Oppenheim, Konigshoffer, and Weil have reported polydipsia together with polyuria in the entire absence of glycosuria. Bouchard has observed peptonuria and Duchesneau phospha- turia. Among the other disturbances of se- cretion, frequent and copious szveating should also be mentioned. The anatomical and functional changes taking place in the reproductive organs in acromegalic cases were early recognized. The penis, which, as Erb correctly remarks, is also an "axpov,^^ sometimes, though not regularly, attains a greater size than normal. In the fe- male, the clitoris may undergo corre- sponding hypertrophy, and the folds of skin forming its prepuce may become thickened. This enlargement of the genital or- gans should by no means be taken to imply increased functional activity. In- deed, male patients usually experience a diminution of desire and potency, wdiich may progress to complete loss of the function. In the female, the most important result is suppression of the menses, which occurs so early in the dis- ease that in many cases it may be con- sidered the initial event. The primary increase in size in the genital organs soon gives way to a true atrophy. In certain cases of hypophys- eal tumor which had not been accom- panied by acromegaly, the penis was ob- served to have dwindled to the size of the little finger, the testicles to have become small and soft, and the pubic hair diminished in amount. Pechkranz and Babinski were the first to report these changes. Roubinowitch published the interesting history of a patient, previously studied by Pierre Marie, who developed acromegaly after childbirth, and showed progressive atro- phy of the organs of generation. On the basis of published facts we may at present conclude that sexual atrophy can form part of the hypophys- eal syndrome, but that it is not inva- riably a consequence of tumors of the hypophysis. Coming on in youth, these tumors may cause arrest of development of the genital organs ; appearing later, they may cause retrogressive changes in them. The problem has not yet been solved, since it will be necessary to de- termine more precisely in w^hat measure the hypophysis is capable of producing 298 ACROMEGALY (LAUNOIS AND CESBRON). genital atrophy. The experiments of Vassale, of Caselh, and of Sacchi seem to have demonstrated that removal of the gland in young animals is without effect on their sexual development, but these animals have never survived any length of time. Moreover, a certain number of cases have been known, in- cluding those of Schmidt-Rimplex, of Gotzl and Erdheim, of Babinski (Revue Neurologique, vol. viii, p. 531, 1900), of Pechkranz, and of -Bartels, in which the tumor causing genital atrophy did not involve the hypophysis. In our description of the acromegalic dystrophy we stated that the hypertro- phic changes witnessed were due to an abnormal development in the various connective tissues. This overgrowth may, however, be limited to certain parts of these tissues, and in particular to the panniculus adiposus. In 1901, Frohlich (Wiener klin. Rundschau, 1901) drew attention to a special va- riety of adipose overgrowth occurring in cases of tumor of the hypophysis, and attaining considerable proportions. Erd- heim (Ziegler's Beitrage, Bd. 33, 1903) confirmed the association of these two conditions, and a number of cases have recently been reported. The accumula- tion of fat under these circumstances is steady and more or less rapid. It may reach an enormous extent. [A patient under the observation of Boyce and Beadles (Jour, of Pathol, and Bacteriol., pp. 223 and 359, 1893) exhibited a layer of fat several centimeters in thick- ness over the entire body. Adipose dep- osition occurs in the deeper parts as well as superficially, the great omentum, mesen- tery (von Hippel : Virchow's Archiv, cxxvi, p. 124), heart, and liver (Mohr: Schmidt's Jahrb., xxx) being invaded. A patient seen by Glaser (Virchow's Archiv, cxxii, p. 389, 1890) had enormous cheeks, which were livid and showed numerous dilated veins; Pechkranz's (Neurol. Centralbl., xviii. p. 202, 1899) case gave the impression of one suffering from anasarca, although pressure on the hands and feet failed to bring out the characteristic pitting of edema. Stewart (Boston Med. and Surg. Jour., No. 21, 1899) reported a similar ob- servation. Launois and Cesbron.] With the adipose accumulations are often associated signs of increased in- tracranial tension, and at times, as we have remarked, mental disturbances. We are not as yet in a position to ex- plain the special involvement of the re- serve tissues in this affection, but will have to limit ourselves to recalling the following interesting observation re- ported by Madelung (Langenbeck's Ar- chiv, Ixxiii, p. 1066) : A girl 6 years of age, having been shot in the head, began to put on fat six months later. Her weight doubled in the space of three years and reached 42 kg. (92 pounds). Examination with the X-rays revealed the bullet in the region of the infun- dibulum. Myxedema may form part of the hy- pophyseal syndrome. From the early observation of Norman Dalton (Lan- cet, No. 6, 1897) to that of Sainton and Rathery (Bull, de la Soc. Med. des Hop., May 8, 1908), a large number of cases have been reported which support the view that this combination may occur. The simultaneous presence of simple goiter and of Basedow's disease [Lan- cereaux (Semaine medicale, 1902 and 1905)] has likewise been reported. Al- though the association of these disor- ders is a point in favor of the existence of a polyglandular syndrome, it would be rash at this time to attempt to define the latter precisely. Ophthalmic Disorders. — The quasi- positive signs of the presence of a tumor of the hypophysis are found in a study of the ocular disorders, which result Lipomatous Type of Frohlich's Syndrome. (P. E. Launois.) ACROMEGALY (LAUNOIS AND CESBRON). 299 from the close anatomical relationship of the pituitary gland to the optic path- ways. The visual disturbances long ago attracted and retained the attention of investigators. Among the earliest ob- servations should be remembered those of Meussens (1705), and of Rullier (1823). Ocular disturbances are also mentioned in the papers of Rayer and of Friedreich. Bernhardt has summar- ized them as follows: "Slow, progress- ive amblyopia, terminating in absolute blindness. Since the latter does not re- sult from increased intracranial tension, but is generally due to pressure on the optic tracts, chiasm, and optic nerves, papillary edema is not generally present, primary atrophy taking place in most instances." As for the events related more par- ticularly to acromegaly, Pierre Marie at first recorded merely optic neuritis in mild cases, absolute blindness in ad- vanced cases. Pinel-Maisonneuve in France, Schiiltze (Berl. klin. Wochen- schr.. No. 38, 1889) in Germany, and, later, Boltz (Deutsche med. Wochen- schr., page 685, 1892), and Packard (Amer. Jour, of the Med. Sciences, p. 660, 1892), sought to emphasize the diagnostic value of bitemporal hemian- opsia, i.e., loss of vision in the lateral halves of the two visual fields, with preserv^ation of central vision. Since these earlier investigations, numerous observations have been collected; the present tendency, based on these, is even to establish a distinction between tumors arising in the hypophysis itself and those developing simply in the hypo- physeal neighborhood. The former are not, in general, accompanied by pro- nounced disturbances of vision until a rather advanced stage. The morbid change in the optic nerve, however, al- most always progresses, and leads finally to complete amaurosis of one or both eyes. The first sign afl^orded on systematic examination of the eyes is a diminution of visual acuity. But slightly marked at first, this generally undergoes grad- ual increase, absolute blindness being reached, in most instances, only after a period of ten or twelve years. Ordi- Acromegaly with tumor of pituitary and goiter. (F. E. Launois.) narily, one eye is more seriously afifected than its fellow, and shows amaurosis at an earlier period. [According to Uhthoff (Zusammenkunft der Ophthalm. Gesell., Heidelberg, Aug., 1907), unilateral amaurosis occurs in 33 per cent, of the cases. In other instances the amaurosis is bilateral (16 per cent.). The latter condition may sometimes appear at a very early stage of the disease, as in the cases reported by Leber (Archiv f. Psych., xxxi, p. 206) and Josefsohn ("Stu- dier ofver akromegalie eck hypophysis- tumor," Stockholm, 1903). In Henneberg's case total amaurosis was present thirteen years before death occurred. Launois and Cesbron.1 300 ACROMEGALY (LAUNOIS AND CESBRON). The condition sometimes runs a rapid course; it may disappear for a short time, then return and become definitely established. According to Oppenheim (Berliner klin. Wochenschr., No. 36, 1887, and No. 29, 1888), the histolog- ical structure of tumors of the hypophy- sis, which are frequently very vascular, bears a casual relation to this "oscillat- ing vision." From the rupture of ves- sels with their walls in an embryonal, formative state, followed by more or less extensive hemorrhage, sudden blindness might result. Eisenlohr (Vir- chow's Archiv, Ixviii, p. 461 ) reports the case of a man who, without having pre- viously exhibited any pronounced dis- turbance, was suddenly seized with headache, vomiting, somnolence, and convulsive movements of the upper ex- tremities. At the same time the pupils were dilated and fixed, and double am- aurosis was present. The autopsy dis- closed in the sella turcica a rounded tu- mor of the size of a cherry, the existence of which had not been suspected during life, and which had been the seat of an extensive hemorrhage. In like manner Bayley (Philadelphia Med. Jour., April, 1898) witnessed absolute blindness with partial oculomotor paralysis in a man of 50, who afterward showed a hemor- rhagic focus in the hypophysis. With these observations may be grouped those of Bassoe (Jour, of Nervous and Men- tal Diseases, Sept. and Oct., 1903) and Yamaguchi. In the case of a young girl who suffered complete loss of vision in three weeks, Woolcombe (Brit, Med, Jour., June, 1896) discovered the pres- ence of an exceedingly vascular psam- moma. Of still greater interest and impor- tance are the alterations in the fields of vision which accompany tumors of the hypophysis, and occur with particularly remarkable frequency in acromegaly. From the standpoint of diagnosis they are of primary importance. In 22 cases with autopsy in which changes in the visual fields had been re- corded, the percentage of each form of hemianopsia was as follows: Bitem- poral hemianopsia, 23 per cent. ; unilat- eral temporal hemianopsia, 23 per cent. ; homonymous hemianopsia, 9 per cent. Concentric reduction of the visual fields was recorded in 22 per cent, of the cases ; an irregular contraction in 4 per cent. ; in 9 per cent., but one quadrant was preserved; in 13 per cent, there was a central scotoma. Study of the eye symptoms in dis- ease of the pituitary body and acro- megaly based on 328 autopsies. Tem- poral hemianopsia is the most constant symptom ; typical choked disk and slight papillitis each occurred in about 5 per cent, of the cases, simple atrophic pal- lor of the disks in 20 per cent., and cen- tral scotoma only in occasional cases. Paralysis of ocular muscles, generally afifecting the oculomotor nerve, occurred in 10 per cent, of cases, and nystagmus in 6 per cent. W. Uhthoff (Lancet, Sept. 4, 1909). These results will, at first sight, ap- pear somewhat inconstant. This vari- ability in the alterations of the visual fields is, however, to be accounted for by the fact that the visual tests were made at different stages of the affection in the various cases. It is evident that hemianopsia and scotoma are the two most important of these disturbances. As Dejerine pointed out, the condi- tion present is not, strictly speaking, a true hemianopsia, since its boundaries are practically never regular in outline, and the line marking off the blind from the unaffected portions of the visual field is never exactly vertical. True hemianopsia can exist only when the lesion, situated behind the chiasm, in- ACROMEGALY (LAUNOIS AND CESBROX). 301 volves the visual pathways in that part of their course which extends from the decussation to the cerebral cortex. At the chiasm itself the nerve-fibers have not yet undergone complete separation into definite bundles, and it is here that we must seek an anatomical explanation for the irregular hemianopsia which ac- companies lesions of this portion of the optic pathway. Moreover, the most varied combina- tions of the several ocular disturbances may occur. A central scotoma, for ex- ample, may be present at first, hemia- nopsia then appearing (Pontoppidan), or hemianopsia may precede and be later supplemented with marked con- traction in the visual field (Striimpell). Hemianopsia and contraction are often found to coexist. Central scotoma is of very frequent occurrence, but does not seem to possess any special value as an indication of the lesion present, since it has been observed in cases where the visual tracts ap- peared to be crushed by the tumor, and it is difficult to understand how, under such conditions, the maculopapillary fibers could alone be affected. Indeed, from the variations in the extent of in- volvement of the visual fields no con- clusion can be reached with any degree of certainty as to the exact seat of the lesion. Changes in the visual fields are, however, almost constantly present; whenever examined for they have been found, and up to the present time Schon- born's case is, perhaps, the only one in which they were wanting. This ob- server, moreover, fails to state whether he studied the color-perception in his patient or not. Among the changes in the eye-grounds in those suft'ering from tumors of the hypophysis, simple optic atrophy should receive first mention. Papillary edema, on the other hand, is of relatively rare occurrence. [Bath, and later various other authors, among whom were Denti (Annali di Ottal- mol., XXV, p. 615), Sternberg, Oppenheim, and Schmidt-Rimpler ("Die Erkrankungen der Augen in Zusammenhang mit anderen Erkrankungen," Vienna, 1905), found it to occur much less frequently than in other varieties of cerebral tumor. According to Bartels, 40 cases with autopsy yielded the following percentages: Simple atrophy, 50 per cent.; bilateral papillary edema, 15 per cent.; neuritis followed bj^ atrophy, 15 per cent.; disks entirelj' normal, 20 per cent. Launois and Cesbron.] The uncommon occurrence of papil- lary stasis may be explained by the le- sions resulting from direct compression of the optic-nerve bundles. We can readily believe, with Terrien, that an in- timate union takes place very early be- tween the nerve-fibers and their sheaths in the visual tracts, and that the adhe- sions formed between these structures make it difficult, or even impossible, for the cerebrospinal fluid to enter the papilla. The pupillary reflexes in cases of hy- pophyseal tumor also afford an inter- esting study, in conjunction with the dis- turbances of vision already mentioned. In general, it may be said that they are always altered. In a large number of cases simple amaurosis is observed, with pupillary imm.obility as a consequence. Thus in a case reported by Selke (Inaug. Dis- sert, Konigsberg, 1891), the pupils did not react either to light or distance, though the patient could still distinguish light from darkness. In a case of un- usual interest, Berger observed during a period of temporary amaurosis loss of the reaction to light, while the reaction to distance was preserved. The light reflex later reappeared. In other cases, where the patients are still able to recog- 302 ACROMEGALY (LAUNOIS AND CESBRON). nize objects, the reflexes persist, but are less active. Yamaguchi has" even wit- nessed very slow response to light in an eye showing normal visual acuity. - Lastly, where hemianopsia exists, the hemiopic reaction may sometimes be ob- served. The well-known "hemianopsic pupillary reaction," discovered by Wer- nicke, implies inability on the part of a visual field to bring about pupillary action in response to light falling upon it. The pupillary fibers of the optic nerve pass into the anterior corpus quadrigeminum ; from here a relay of fibers starts which places them in con- nection with the nucleus of the pupil- lary sphincter, located in the central gray matter of the aqueduct of Sylvius, in the anterior portion of the common oculomotor nucleus. When these pupil- lary fibers are destroyed, as in cases where the optic tract has been crushed or has disappeared completely, the blind half of the visual field can no longer cause pupillary action. This reaction, then, is characteristic of an interruption in the optic fibers at a point between the chiasm and the corpora quadrigemina. The hemianopsic reaction of Wernicke is thus an integral part and almost ex- clusively an attribute of the syndrome resulting from disease in the hypophys- eal region. We must admit that the presence of this reaction does not appear to have been shown very often. While Josef- sohn observed it very clearly, Gotzl and Erdheim, in a case of hemianopsia re- sulting from pituitary tumor, were un- able to find it. This failure and the dearth of confirmatory observations should, perhaps, be attributed to the dif- ficulties of technique which fiave to be overcome in order to demonstrate the existence of this singular pupillary dis- turbance, which is possessed of such great clinical value for the localization of brain lesions. Radiographic Study of the Cranium. — As for the positive signs of the pres- ence of a tumor of the hypophysis, they are afforded by X-ray examination of the cranium. No sooner had Roentgen's discovery (1895) given us the power, as Giordani expressed it, "to make of the invisible an object" than the X-rays began to be utilized in the study of the skeletal dys- trophies, and of acromegaly in particu- lar. Marinesco brought out a compara- tive study of the bones of the hand in acromegaly of the massive and the giant types. The data collected by Gaston and G. Brouardel were sufficiently pre- cise to admit of the following conclu- sion^ viz., that "radiographic studies of the acromegalic hand make it possible to trace the process of central bony re- absorption and the periosteal and carti- laginous proliferation which Pierre Marie and Marinesco observed in their histological studies." To Beclere belongs the credit of hav- ing drawn from radiographic explora- tion the full measure of data to be de- rived therefrom in the study of the hy- pophyseal syndrome. His first attempts were fruitless because of an entirely abnormal thickening of the cranial bones, but his later researches, especially those carried out in cases sent him by us, were productive of more accurate results. He witnessed the simultaneous occurrence of three strongly character- istic changes: (a) A very irregular thickening of the cranial parietes: the outline of the skull, instead of being rounded, is polygonal ; the external and internal tables, always separated by an abnormal space, alternately recede and come together, giving a moniliform- ap- pearance on cross-section, (b) Exag- ACROMEGALY (LAUNOIS AND CESBRON). 303 gerated licight and depth of the frontal and maxillary sinuses, (c) A more or less marked increase in the vertical, and especially in the anteroposterior, dime^i- sions of the pituitary fossa, which, markedly altered, in most instances pre- sents the appearance of a cup. To these primary modifications must be added exaggeration of the postlambdoidal promincnee (Papillaut, Lannois, and Roy). increase in the size of the fossa can be plainly appreciated at its posterior wall. Schuller believes that enlargement of the bony cavity is the rule, even where the tumor is of relatively small size, and of slow, regalia r growth. The bony pa- rietes may, in certain cases, undergo pressure atrophy. In cases of rapidly growing tumor they likewise disappear, being invaded by the neoplastic tissue. Erdheim has established still nicer Diagram of the acromegfalic skull, worked out by P. E. Launois and P. Roy, according to the X-ray findings of Beclere. Shows increased depth of frontal sinuses, irregular thickening' of the cranial bones, abnormal projection of postlambdoidal eminence, and enlargement of sella turcica. By combining the above data we were enabled to construct a diagram of the acromegalic skull, as shown in the an- nexed illustration. By taking X-ray pictures from the facial aspect one can likewise learn of the changes occurring in the mandible and the degree of prognathism they may engender. German investigators have sought to attain further precision in their radio- graphic studies. According to von Rut- keroski, each time the hypophysis in- creases in volume the sella turcica very rapidly enlarges in all dimensions ; the distinctions. According to this author, if the tumor remains limited to the sella turcica, the latter enlarges, but its aper- ture above does not widen. If there is a tumor of the infundibulum, the upper aperture may enlarge, but the bony fossa is little altered. Lastly, if the tumor rises above the sella turcica and bulges out over it, the fossa flares out above, presenting a broad superior opening. We may agree with Furnrohr ("Die Rontgenstrahlen im Dienste der Neu- rologie," Berlin. 1906) and Sternberg, that these are altogether too fine dis- tinctions. All those who have had oc- 304 ACROMEGALY (LAUNOIS AND CESBRON). casion to study radiographic prints will readily understand that it is practically impossible to appreciate the trifling dif- ferences of shading upon which such distinctions must depend. interior of the cranium, and that the borders of the sella turcica are clearly apparent. Normally a little cup-like cavity, it becomes so large, when a tumor of the hypophysis is present, that Jean-Pierre Mazas, the griant of Jlontastruc (front and back views). {Brissaud and R. Meige.) It is, nevertheless, a fact that the diagnosis of tumor of the hypophysis cannot today be made without the assistance of the X-rays. If, taking advantage of the improved methods introduced by Beclere, w^e place in the stereoscopic apparatus a reduced image on glass, we find that the body of the sphenoid is brought out in relief in the the tips of two, three, or even more fingers can be accommodated in it. Relationship Existing Between Ac- romegaly and Gigantism. — The prob- lem concerning the relationship which gigantism bears to acromegaly is one of great interest. Our data are now sufficiently accurate to allow of its solution. ACROMEGALY (LAUNOIS AND CESBRON). 305 In his original description, Pierre Marie had clearly separated the two dystrophies. Numerous facts, however, were soon garnered which tended to overthrow this dualistic viczv. [As early as 18S9 Virchow had found reason to state that acromegaly was a sec- ondarj' condition of degeneration succeed- ing upon the excessive growth. Langer (Denkschriften der Kaiserl. Acad, der Wissensch. in Wien, xxxi, 1872), Fritsche and Klebs ("Ein Beitrag zur Pathologie "des Riesenwuchses," Leipzig, 1884), Cun- ningham (Trans, of the Royal Irish Acad- emy, xxix, p. 553, 1891), Taruffi (Annali universali di medicini, p. 247, 1879), and Tamburini ("Beitrage zur Symptomatolo- gie und Diagnostik der Hirngeschwiilste," Berlin, 1881), in examining the skeletons of giants preserved in the various mu- seums, found the characteristic deformi- ties of Marie's disease, and Massalongo ("SuH'acromegalia," Riforma medica, p. 157, 1892) felt himself justified in conclud- ing, without, however, adducing evidence of his own, that acromegaly was nothing but a delayed, abnormal form of gigant- ism. Reports of autopsies, including those of the Peruvian giant, recorded by Dana (Jour, of Nervovis and Mental Diseases, Nos. 1 and 2, p. 139, 1893), and of Lady Aama, recorded by Woods Hutchinson, as well as those performed by Buday and Janeso ("Ein Fall von pathologischen Rie- senwuchs," Deutsch. Archiv f. klin. Med., p. 385, 1898), and by Caselli, soon afforded a striking demonstration of the intimate re- lationship existing between the two dys- trophies. Launois and Cesbron.] The question was in reality brought to a focus by Brissaud and Henri Meige (Jour, de med. et de chir. pratiques, Jan. 25, 1895 ; Nouv. Iconog. de la Sal- petriere, 1897. Meige, Congres de Neu- rol, de Grenoble, 1902, and Archives gen. de Med., Oct., 1902, p. 410. Bris- saud, Bull. de. la Soc, Med. des Hop. de Paris, May 15, 1896) when they wrote: "The combination of acromegaly with gigantism is far from being a mere co- incidence, a casual meeting between two distinct pathological states : Gigantism and acromegaly are one and the same disease. What has not been given suffi- cient consideration in their reciprocal Jean-Pierre Mazas, the giant of Montastruc ■ (profile view)-. (Brissaud and H. Meige.) relations, however, is the age at which the disease makes its first appearance. If the stage in which the bony over- growth occurs belongs to adolescence and youth, the result is gigantism and not acromegaly. If, later on, after hav- ing belonged to youth, in which the stat- ure is continually increasing, it en- 1—20 306 ACROMEGALY (LAUNOIS AND" CESBRON). croaches upon the period of completed development, i.e., upon that phase of life in which no further osteogenetic growth takes place, the result is a com- bination of acromegaly with gigantism. "Gigantism is the acromegaly of the growing period ; acromegaly is the gi- Hutchinson and of one of us, published in conjunction with Pierre Roy. As viewed by the adherents of the imicist theory, acromegalic gigantism is that form of gigantism in which the characteristic loss of harmony between structure and function finds its expres- Acromegalogigantism in a Chinaman. [Matignon.) gantism of the period of completed de- velopment; acromegalogigantism is the result of a process common to gigantism and to acromegaly, overlapping from the period of adolescence into that of maturity." These constitute three fundamental propositions, which soon received con- firmation from the labors of Woods sion, to a greater or less extent, in the usual symptoms and deformations of acromegaly, after union of the epiphy- ses to the diaphyses has taken place, whether this union has been prompt or delayed. In the majority of giants almost all the stigmata of acromegaly may be recognized. Sometimes but slightly ACROMEGALY (LAUNOIS AND CESBRON). 307 marked, the significant changes can be detected only upon careful inspection; at other times very pronounced, they attract immediate attention and are equally as striking as the stature of the individual afflicted with them. The dis- Bramwell (Edin. Med. Jour., Jan., 1894, and Brit. Med. Jour., Jan. 6, 1894), Cun- ningham, Peter Bassoe, Matignon, Lau- nois, and Roy (only the principal ones being here mentioned), the dystrophy had developed to a marked degree. Jean-Pierre Mazas, the giant of Montastruc, studied by Skull of the giant Constantin (profile view). {Dufrane and P. E. Launots.) proportionate size of the hands and feet ; the homely, sometimes even repulsive facial aspect ; the evident sagging of the body, w^hich is often marked, make of the subject's gigantic stature a distinc- tion little to be envied, even in the eyes of the layman who cannot recognize the presence of acromegaly in the person before him, [In the cases reported by Brissaud and Meige, Dana, Woods Hutchinson, Byrom Brissaud and Meige, with his undersized skull, projecting superciliary ridges, and well-marked prognathism, his monstrous and grinning face, his abnormally long up- per limbs, his enormous hands and feet, his arched back and broadened thorax, re- called precisely the appearance of an an- thropoid ape; the morbid state seemed in his case to have brought about a reversion to the ancestral type. Launois and Ces- BRON.] In the course of our investigations on gigantism we were led to establish a 308 ACROMEGALY (LAUNOIS AND CESBRON). well-defined distinction between two types of giants, viz., the infantile giant, in whom the connecting cartilages have not undergone ossification and are still able to proliferate, and the acromegalic giant, in whom these cartilages have be- toward the acromegalic type, later merging into it completely. We may state, as a general conclusion, that, while all giants are not acromegalics, at least all those who are not such al- ready are apt to become acromegalics. Skull of the g-iant Constantin (anterior viewj. {Dufrane and P. E, Liunois.') come ossified and who presents bony thickenings. This distinction, having as its anatomical basis the two separate processes of cartilaginous and perios- teal ossification, though a true one mor- phologically, does not hold good indefi- nitely in time, i.e., the infantile type, having remained pure during a certain number of years, tends to progress [Though able, in the case of the giant Ch , to follow the fusion of two mor- phologically distinct types into a single type, we found it impossible to state the exact time at which this fusion took place. Becoming more and more evident as the cartilages bordering on the epiphyses di- minish in thickness and become ossified, the fusion reaches completion when the epiphyses have entirely, or almost entirely, united with the diaphyses. In the skull. ACROMEGALY (LAUNOIS AND CESBRON). 309 face, and extremities the acromegalic de- formities then make their appearance and subsequently undergo progressive develop- ment. At the autopsy both the stigmata of infantilism and the changes pertaining to acromegaly proper are recognized. In ical analysis will disclose the morbid manifestations of the hypophyseal syn- drome. That this is true is due to the fact that in all giants, whether in life by means of the X-rays, or after death Base of cranium of the elant Constantin, showing marked enlargement of sella turcica. {Dufrane and P. E. Launois.) this connection studies carried out on the body and skeleton of the giant Constantin, preserved by Dufrane in the hospital at Mons, yielded striking results. The illus- trations shovi^ing his skull and humerus will convey more to the reader than would a lengthy description. Launois and Ces- BRON.] Whatever be the variety of gigantism encountered, a properly conducted clin- on the autopsy table, the existence of a tumor of the hypophysis can be recog- nized. In 10 cases, taken from among the most recent and the most thoroughly recorded we could find, it was not once lacking. To these direct observations should be added the results obtained from studies of the skeletons of giants. Langer reports having found an in- 310 ACROMEGALY (LAUNOIS AND CESBRON). crease in the length, breadth, and depth of the sella turcica in every case, and it is well known that in pathological states, as well as normally, the dimen- sions of this bony fossa in the sphe- noid are those best suited for its con- tents. The general conclusion warranted by Humerus of the giant Constantin. Absence of union of upper epiphysis at the age of 29 years. {Dufrane and P. E. Launois.) all these mutually confirmatory data is that, whether associated with infantilism or acromegaly, gigantism always occurs in association zvith a tumor of the hy- pophysis. This assertion cannot, of course, be given as applying to all future observations, but in view of its uniform confirmation by those of the past it is, at least, very impressive. COURSE AND DURATION.— Established acromegaly is generally observed in adults, male or female. The initial dystrophic phenomena ap- pear at the age of 18 to 25 years, i.e., at the period in which, under normal conditions, growth is continued and completed. Sometimes it is headache which leads the subject to consult a physician. Other victims, frightened at seeing their hands and feet grow larger, come to find out the reason for these changes. In women the outset of the disease may be traced with some degree of probability to a period at which menstruation became irregular or ceased. We must recognize that such indications are rather vague, as is also the information obtained from the past morbid history. Sometimes in- fectious diseases are found to have ex- isted, and under these conditions the question arises in our minds whether they could not have created a disturb- ance in the hypophysis, as well as in the other ductless glands. The dystrophy seems to occur with greater frequency in women than in men. Taking the combined statistics of Souza-Leite and of Duchesneau, we find 22 men were afifected as against 31 women. While the onset of the disease is sometimes delayed (forty-nine years in a case of Schwartz), it can also be pre- cocious, and the few cases of this kind recorded have made it possible to de- scribe the acromegaly of children or of adolescents. [Virchow, in 1889, observed it in a girl 11 years of age; Beaven Rake (British Med. Jour., 1893) reported the case of a young negro; similarly, Valdes-Surmont (Presse medicale, Sept. 22, 1897) saw the first stigmata appear at 14 years. Mon- corvo recently reported the case of a girl 14 months old he had observed. This au- ACROMEGALY (LAUNOIS AND CESBRON). 311 tlior does not, however, believe that the disease was congenital, and merely states that everything points to its having be- come established very soon after birth. Launois and Cesbron.] Race is without influence in the etiol- ogy. Acromegaly has been met with in all countries and among all races. Di- rect hereditary transmission has been observed. [The observers referred to are Bonardi, . Cyon, Schwoner, and Frankel. E. Schaffer (Neurol. Centralbl., April 1, 1893) recently reported a case of transmission from mother to daughter. Friedreich claims to have observed the stigmata of acromegaly in two brothers. Launois and Cesbron.] The dystrophy follows a progressive, but extremely slow course, which can be divided into several stages. The first (stage of onset), in which the deformi- ties begin to develop, is followed by a second (sthenic stage), in which they attain their maximum. In this stage the acromegalic woman presents a most striking appearance. The increased size of her body, accentuated by hypertro- phy of the extremities; her peculiar countenance, with the lips, chin, and cheeks frequently covered with long, curly hair, and her low-pitched voice, all combine to impart a masculine ap- pearance, which is sometimes very pro- nounced. In a third stage the hypo- physeal syndrome asserts itself until its manifestations are more or less com- pletely present. The duration of the disease varies within wide limits (twenty to thirty years). In this connection Sternberg recognizes three forms of the affection : an ordinary form, running its course in eight to thirty years, and two rare forms, the one benign, which may last fifty years, the other malignant, des- troying life in three to four years. This last form, seen only 6 times out of 210 cases, is always associated, ac- cording to Gabler, with an epithelial tumor of the hypophysis. PROGNOSIS.— As for the termina- tion, it is fatal. The patient at last in- variably succumbs, either to the effects of a slowly developing cachexia, to in- tercurrent disease, or suddenly succeed- ing an attack of syncope or some cere- bral accident. If acromegaly be associated with in- fantile gigantism, the data at hand are somewhat more precise, and the onset of the disease can readily be referred to the growing period proper. DIAGNOSIS.— The external appear- ances of acromegalics are so character- istic that the diagnosis is at once mani- fest, even from a distance. There are a few disorders, however, with which acromegaly might be confounded, and which it is necessary to differentiate. In my:{-edema, the trunk and extremi- ties show enlargement, which consists, however, merely of an edematous infil- tration of the soft tissues. The thick- ened skin is bound down to the sub- jacent layers and merges into them. The round, puffy face of myxedema dif- fers radically from the ovaloid face of the acromegalic patient, in whom, be- sides, prognathism and kyphosis are characteristic features. In Paget' s disease of the bones {oste- itis deformans) there is increased thick- ness of the cranial bones and more or less marked bowing of the bones of the extremities. The thickened femora and tibia are strongly curved inward and forward, the legs are widely separated, and the trunk and neck are fixed in a position of pronounced flexion. In this affection the bones of the cranium are those involved, whereas in acromegaly the facial bones are rather affected. In the limbs the changes are limited to the 312 ACROMEGALY (LAUNOIS AND CESBRON). diaphyses of the long bones, whereas acromegaly shows a marked predilec- tion for the bones of the extremities and the extremities of these bones. Paget's disease, moreover, seldom ap- pears before the age of 40, and, differ- ently from acromegaly, attacks the va- rious bones without order or symmetry. Under the name of leontiasis ossea Virchow described a condition associ- ated with hyperostosis of the facial and cranial bones. The lumpy appearance of the exostoses and the normal propor- tions of the hands and feet are sufficient to preclude all doubt as to the nature of the affection. In erythromelalgia the face remains unchanged. The hypertrophic process involves only the soft tissues of the feet and hands, and is associated with an al- together peculiar cyanotic hue of the integument. Certain cases presenting a combina- tion of the stigmata of rickets and of the lymphatic diathesis might be taken for acromegalics. They exhibit clumsy hands and large feet, the lower lip is thickened and everted, and the face is somewhat puffy. But the extremities show nodal deformities of a special type, while prognathism, as well as macroglossia, are completely absent. It is in liypertrophic pidmonary osteo- arthropathy, the dystrophic affection seen among inveterate coughers, that confusion with acromegaly most readily arises. Pierre Marie, who was the first to recognize and describe this form of sys- tematized osteopathy, showed clearly, in a striking comparison he made of the two conditions, that the features wherein they differ are more numerous than their points of similarity. In both affections there is symmetrical hyper- trophy of the upper and lower extremi- ties, together with spinal curvature. But in pulmonary osteopathy, the hyper- trophy, which is not uniformly distrib- uted, is associated with distinct deform- ity of the parts affected. The spinal curve is altogether different from that of acromegaly, and prognathism is ab- sent. The changes are strictly confined to the bony tissues. In the hands, the distal phalanges are clubbed, resembling drumsticks ; the nails are lengthened, broadened, curved like a parrot's beak, and show cracks and longitudinal stria- tions. The carpal and metacarpal regions are practically normal. The wrist, how- ever, is thickened and greatly deformed. In the feet, the distal phalanges are clubbed, the tarsus and metatarsus rel- atively normal, and the malleoli hyper- trophied in all dimensions to such an extent that the lowxr part of the leg is thicker than the middle. In ad- dition, all the long bones of the limbs are thickened, though miore markedly in the leg and forearm than in the thigh and arm. The joints are involved in these changes; their enlargement inter- feres with ease of motion, both active and passive. Furthermore, kyphosis is not constantly present, and when it is present is confined to the lower dorsal or lumbar regions. In the face, the su- perior maxillary bone is alone thick- ened, the mandible remaining normal. Pulmonary osteoarthropathy may give rise to some little difficulty in diagnosis, principally owing to its rarity. It is most likely to be confounded with acro- megaly, but in the latter disease there is no alteration of the nails, nor are the finger-ends nor the carpus and meta- carpus much thickened. The chief characteristics of the disease are great enlargement of the hands, wrists, feet, and ankles, associated with, and second- ary to, some chronic pulmonary affec- tion, such as phthisis, chronic bronchitis, ACROMEGALY (LAUNOIS AND CESBRON). 313 and empyema. In the joints the changes arc effusion with enlargements and ulceration of the cartilages and articular ends of the bones. Marie is of the opinion that these changes are due to toxic poisoning, but Thorburn looks on them as tuberculous. The evidence either way is slight and in- definite. G. A. Banna.tyne (Lancet, Feb. 23, 1901). In syringomyelia of the psendoacro- mcgalic type, the hypertrophic process is confined to the upper limbs and some- times to a single extremity. It does not involve equally all the fingers of a hand. The parts involved are deformed and exhibit more or less marked trophic changes. The symptoms resulting from the spinal. cord lesion are easily recog- nized. As for certain localised hypertrophic manifestations (macrodactylia, macro- podia, hypertrophy of a limb, or of one side of the body), described by Virchow under the name of partial acromegaly, they are congenital in most instances and bear no relationship to true acro- megaty. PATHOLOGY.— The dystrophic process in acromegaly shows a special predilection for the supporting tissues derived from the mesoderm (connect- ive tissue, cartilage, and bone), to what- ever degree of differentiation they may have attained. The thickening of the integument is due to marked proliferation of its con- nective-tissue elements; the prolifera- tion takes place in each of its various layers. Hyperplasia in the superficial stratum brings about hypertrophy of the papillae, causing them to appear as pronounced ridges. Similar connective- tissue proliferation takes place in the walls of the sebaceous and sweat glands, in the sheaths of the hair-follicles, in the adventitia of the superficial blood- vessels, and in the nerve-sheaths. These vascular and nervous changes are not without influence on the trophic state and functions of the skin. They like- wise interfere with the nutrition of the cutaneous appendages. The epidermis develops many new layers, especially in the zone of the stratum corneum; the several varieties of hair become thick- ened and kinked, and the nails develop longitudinal striations. Hypertrophy of the teeth has occasionally been noticed (Henrot). The connective-tissue cells of the sub- cutaneous panniculus adiposus in some cases become overloaded with fatty ma- terial. To this superficial adipose de- posit is added, in the syndrome identi- fied by Frohlich, a deep-seated adipose accumulation, especially marked in the neighborhood of the peritoneal reflec- tions. Macroglossia is due not only to thick- ening of the mucous covering layer of the tongue, but also to abnormal growth of the interstitial connective tissue. The nasal, pharyngeal, laryngeal, and tra- cheal mucous membranes are likewise the seat of marked proliferation of the connective-tissue elements. The alterations occurring in the fleshy portions of the muscles must also be attributed to changes of this kind. Thickening of their sheaths and of the I septa dividing them into bundles brings ' about a marked increase in their size. Microscopically, proliferation of the nu- clei and atrophy of the contractile sub- stance are observed. The hypertrophic process extends to the tendons, of which the inserting surfaces become broader, and to the aponeurotic expansions. Among all the changes which the sup- porting tissues undergo, the most char- acteristic, as well as the most marked, are those involving the skeleton; they 314 ACROMEGALY (LAUNOIS AND CESBRON). are the result of a disturbance in the process of periosteal bone formation. They are met with in the bones hav- ing marrow cavities, and are confined to those of the extremities and those of cancellous structure. They are also found in those membranous bones (cranial bones, inferior maxillary bone) which develop directly from the con- nective tissues, without being preceded by cartilage. Whereas in adult life the periosteum ordinarily ceases to be productive ex- cept under certain experimental or trau- matic conditions, of which a detailed analysis was made by Oilier, in acro- megaly it is seen to proliferate and pro- duce increased thickness of the bones by laying down new osseous layers. Pierre Marie and Marinesco (Archives de Med. Exper. et d'Anat., p. 539, 1891), Renaut and Duchesneau, have made studies of the histological changes occurring in this abnormal type of os- teogenesis. The process is described as "a slow growth of certain bones, taking place at the expense of the periosteal bone, which is reduced to thin layers, while the bony tissue of medullary origin gains in prominence, continues to develop with, so to speak, mathemat- ical regularity, and comes to occupy a predominant position in the structure of the bone. On transverse section the en- tire area is occupied by red bone-mar- row, containing more or less numerous fat-cells. The vessel supplying each medullary space is located exactly in Its center and appears in cross-section. , . . At the periphery of the bone- marrow, in the neighborhood of the open areas corresponding to the giant Haversian spaces of cancellous bone- tissue, the rows of osteoblasts and mul- tinuclear cells which are seen in rachitic bones are here conspicuously absent." Summarizing the above, we may state that, whereas new layers are being added at the periphery of the bone, the central portion is undergoing actual re- sorption by the osteoclasts, the marrow proliferating to take its place. Recently Presbeanu (These de Paris, 1909) had the opportunity, in a case of acromegaly that died as the result of a fall causing multiple fractures, to note the existence of marked demineralization of the bones ; the proportion of ash, which nor- mally ranges between 50 and 80 per cent., had been reduced to 36 per cent. These chemical changes may well ac- count for the weakened condition of the skeleton in this disease. In infantile giants undergoing transi- tion into acromegaly, the changes in the bones coexist with an altogether abnor- mal persistence of the cartilages uniting the epiphyses of long bones to their di- aphyses. In these cases the bones, while growing in thickness, also increase in length, at least for a certain period. The articulating surfaces of the bones become broader, and the cartilaginous tissues covering them spread out with- out losing in depth. They may undergo some slight alterations in structure, re- calling those seen in the early stages of certain arthropathies. As for the changes occurring in the cardiovascular system, though less plainly evident than those already dis- cussed, they are, nevertheless, well marked. The thickening of the vessel walls and cardiac hypertrophy are due to hyperplasia of the connective-tissue elements they contain. The cardiac muscular fibers may be more or less al- tered. Enlargement of the heart, either simple or associated with a myocar- ditis, is the condition usually found in acromegaly. Sclerosis of the ar- teries and degenerative lesions affect- Molds of the Upper Extremities of a Case of Acromegaly. (P. E. Launois.) ACROMEGALY (LAUNOIS AND CESBRON). 315 ing the walls of the veins, with dila- tation and subsequent obliteration of their lumen, are constantly present. These changes in the heart and ves- sels should be considered as much a part of the clinical picture as the changes in the bones, and they are probably due to the prolonged hyper- tension of the vessels, the result of hypersecretion of the pituitary body. Phillips (Med. Rec, Feb. 20, 1909). The spleen and lymph-nodes some- times appear sclerosed, so greatly has their connective-iissue netw^ork become thickened. In a few cases a more or less general- ized condition of splanchnomegaly has been reported, constituting a genuine gigantism of the viscera. [In this connection the observations of Linsmayer, of Bourneville and Regnault (Bull, de la Soc. Anat. de Paris, July 31, 1896), and of Chauffard and Ravaut (Bull, de la Soc. Med. des Hop. de Paris, Mar. 23, 1900) have yielded valuable informa- tion. Launois and Cesbron.] The kidneys, spleen, and pancreas had, in a few^ of these cases, doubled or even tripled in size. Atrophy of certain viscera, e.g., of the kidney, has been recorded in a few cases ; the appearance of the renal cor- tex recalled that commonly found in in- terstitial nephritis. In the nervous system the connective- tissue proliferation already manifested in the finer peripheral divisions then ex- tends to the deeper branches of the nerves, which present the appearance of thick cords. The sympathetic nerve branches, and more especially the in- ferior cervical ganglion, have been found enlarged and sclerosed. In a case studied by Duchesneau, the peripheral nerves showed changes due to pressure exerted on the spinal roots at the intervertebral foramina. In that of Sainton and State there was bony in- filtration of the dura, with the forma- tion of calcareous deposits on its inner surface, transforming it, in the dorsal and lumbar regions, into a veritable tube of lime. The spinal cord has occasionally been found the seat of connective-tissue pro- liferation and localized or more or less widespread sclerosis. In the brain, the neuroglia, which is also one of the group of supporting tissues, may proliferate more or less actively. The Hypophysis. — Among the changes taking place in the intracranial structures, the most interesting, as well as the most important, are those involv- ing the hypophysis. Connected by a partially hollow stalk with the base of the brain, molded into the sella turcica, which it almost com- pletely fills, held in position by a dia- phragm of dura mater centrally perfo- rated, arid weighing on the average 0.5 gram [7^ grains] in adults, the hy- pophysis has long been considered an ancestral remnant, a rudimentary organ of no importance. [Modern histological researches, in par- ticular those of Comte (These de Lau- sanne, 1898), of Caselli, of Benda (Berliner klin. Wochenschr., No. 52, 1900; Neurol. Centralbl., p. 140, 1901, and p. 223, 1902; Archiv f. Psych., xxxv, p. 272, 1901), of Launois (These de la Faculte des Sciences de Paris, 1904), of Thaon (These de Paris, 1908), of Gentes (Bull, de la Station biolog- ique d'Arcachon, 1907), of Joris ("Contri- bution a I'etude de I'hypophyse," Memoire couronne public par I'Academie royale de Bruxelles, xix), etc., have furnished an insight into the structure of its two con- stituent parts— the epithelial lobe and the neural lobe. Launois and Cesbron.] According to one of us, the anterior or epithelial lobe of the hypophysis is a gland of branched tubular type. The epithelial tubes or cords of which it is 316 ACROMEGALY (LAUNOIS AND CESBRON). composed undergo anastomosis. In the spaces between them run very broad capillary blood-vessels, with very thin endothelial walls, which must be con- sidered as the excretory ducts. The glandular cords are made up of epithe- lial cells loaded with granulations. In view of the different staining affinities shown by the latter, the cellular ele- ments containing them may be divided into three classes: 1, acidophile cells, which may be eosinophiles, fuchsino- X-ray of base of an acromeg'alic cranium, showingr enlargement of sella turcica. ( Ch. Jnfroit.) philes, or aurantiophiles ; 2, basophile cells, sometimes called cyanophiles ; 3, chromophobe cells. The protoplasm of these cells is always acidophile. It con- tains, except in the case of the young acidophilic forms and the chromo- phobes, zymogenic granulations, which infiltrate the epithelial elements of the glands. In addition to their acidophilic property, the intracellular granulations possess in common the property known as siderophilia. The primordial cell of the pituitary gland, from the morphological as well as the embryological standpoint, is a small eosinophilic cell with compact nu- cleus and small protoplasmic body, de- void of granulations. This cell develops along two different lines and produces either an acidophilic and siderophilic se- cretion or a basophilic secretion. Two distinct series of cells, therefore, exist in the hypophysis : an eosinophilic se- ries, which becomes siderophilic, and an eosinophilic series, which becomes baso- philic. The products elaborated by them having been eliminated by a semi- holocrine process, the cells of both series become chromophobic cells, which are capable of undergoing regeneration and of renewing their functional activity. The secretory product of the hypophy- sis is a colloid substance, giving reac- tions sometimes acidophilic, at other times basophilic, and which presents analogous features with the material contained in the alveoli of the thyroid gland. We have thought it proper to introduce a summary of this cytologic study, based on our own researches, be- lieving that it may serve as a basis for pathological studies, the results of which thus far have been indefinite and inconstant. On the basis of facts discovered on the autopsy table, which today usually receive confirmation from radiographic studies of the skull during life, we are able to assert, as we have already shown, that hypertrophy of the hypophysis is the rule in acromegaly. [We need but call to mind the statistics of Woods Hutchinson, based on a series of 48 cases. In 44 of these the autopsy revealed a more or less marked enlarge- ment of the gland and a corresponding in- crease in the size of the sella turcica. Of the 4 cases in which no enlargement was found, 3 could hardly be considered as cases of true acromegaly (those of Scarbo, of Friedreich, and of Arnold). In the fourth, that recorded by Bonardi, the gland seemed morphologically normal. Similarly, Modena, out of 70 cases with autopsies recorded, found hypertrophy of the hypophysis in 65. In but 5 cases did ACROMEGx\LY (LAUNOIS AND CESBRON). 317 Cyanophile Series. acidosiderophile Series. Slightlt/ granii In r cyanophile cell. Markedly granular cyanophile cell con- taining fat. Cyanophile cell con- taining cyanophilic colloid secretion. Primordial eosinophile cell without granula- tions. \ Gramilar eosinophile cell. ^k*\Siderophile cell con' »'-*' taining fat. Siderophile cell containing siderophilic colloid secre- tion. Residual chromophobe cell destined to undergo regen- eration. The two series of secreting cells found in the hypophysis, according to the researches of P. E. Launois. 318 ACROMEGALY (LAUNOIS AND CESBRON). the organ appear to be of normal size, and in only 1 [Labadie-Lagrave and Deguy (Archives gen. de Med., Feb., 1896)] did it seem likewise normal in histological struc- ture. Gaussade and Laubry (Archives de Med. exper. et d'Anat. pathol., p. 172, Mar., 1909) have more recently collected the informa- tion scattered in literature concerning cases in which a tumor of the hypophysis was not accompanied by acromegaly or osseous hypertrophy. Schiister, in 62 cases Tumor of the pituitary from the giant Santos. (Dana.) of tumor of the hypophysis accompanied by mental disturbances, reports having found acromegaly but 12 times. Launois AND Gesbron.] We desire to call attention to the fact that in a number of these negative cases the tumor did not originate in the hy- pophysis itself ; that this gland was simply compressed or destroyed, and that in a few cases the histological de- scriptions were decidedly lacking in completeness. We must admit, never- theless, that certain of the facts at hand leave room for doubt; which will have to be dispelled by future observations. The gross features of tumors of the hypophysis vary. The size ranges from that of a cherry up to a hen's egg or mandarin. The sella turcica varies sim- ilarly in its dimensions ; its clinoid proc- esses recede from one another, become blunted, and, where an infiltrating neo- plasm is present, sometimes disappear entirely, together with the bony parti- tions they surmount. The tumor not infrequently projects beyond the limits of the bony fossa, not- withstanding the increased size of the latter; it bulges toward and indents the lower surface of the cerebrum, and may even infiltrate it to a considerable depth. In color the growth is usually gray- ish, sometimes yellowish ; its external surface, often granular in appearance, may be dotted with small, reddish areas, representing dilated vessels or even true hemorrhagic foci. In consistency it is soft and more or less friable. On com- plete transverse section more or less extensive pockets of colloid material having a gelatinous appearance may be revealed. These general features, which belong more particularly to tumors of epithe- lial origin, may be variously modified according to the type of neoplasm pres- ent, which may be sarcomatous, angio- matous, etc. The minute structure of tumors of the hypophysis has been variously in- terpreted. The diversity of the descrip- tions given of it results chiefly, if not entirely, from the uncertainty which prevailed until within the last few years as to the normal structure of the gland. It seems to have been shown, how- ever, that, in a number of the cases re- ported, the tumor was epithelial in origin. From the 57 cases collected by him, Parona has obtained the following percentages : — ACROMEGALY (LAUNOIS AND CESBRON). 319 Adenosarcoma 45 per cent. tary which, while normal in macro- Adenoma 26 " " scopic appearance, contained numerous Sarcoma 19.4" " , , .... ,, Angioma 3.4 " " '^'"^"^ chromophilic cells. These figures, together with similar [Similarly, Gilbert Ballet and'Laignel- statistics already published, should be Lavastine (Nouv. Iconogr. de la Salpe- taken with some reserve, and we must *"^'';. P" ^'^\ ^^°^^ ^^^^ "°*"^ '" ^<=''°- .. -TT ,1 ,• megalics at the outset a glandular hyper- recognize, with Hanau, that the condi- pj^^^^ j^ ^^^^^^ ^f development. L.^unois tion of diffuse hypertrophy of the pitui- and Cesbron.] Tumor of the pituitary body extendinginto the right lateral ventricle, (P. E. Launois.) tary bears a marked resemblance to sar- coma. A few of the descriptions, however, embody cytological details sufficiently definite to be of value. Among them may be mentioned the observations of Benda, who found, in three instances, that the hypertrophy was due to pro- liferation of the chromophile cells, i.e., the functionally active elements of the gland. In a fourth case, the neoplasm was undergoing regression. Hyperpla- sia of the same cells has hkewise been observed three times by Vassale. Lewis, in an acromegalic case which succumbed to cerebral hemorrhage soon after the onset of the dystrophy, found a pitui- Case of acromegaly of ten years* duration. No enlargement of the hy- pophysis was found at autopsy, but, in- stead, a tumor composed of tissue identical with the chromophile cells of the anterior lobe of the hypophysis, and occupying the body of the sphenoid bone, immediately beneath the sella turcica. Supports theory of Tamburini and Benda that acromegaly is caused by a hypersecretion of the hypophysis. Erdheim (Ziegler's Beitrage, Bd. Ixiv, S. 233, 1909). Enlargement of the hypophysis may also result from exaggerated growth of its connective-tissue network. Under such conditions the stage of hyperplasia of the organ, associated with expansion of the sella turcica, may be followed by 320 ACROMEGALY (LAUNOIS AND CESBRON). a stage of sclerotic atrophy. The en- larged bony cavity does not resume its former size and appears too capacious for the gland inclosed in it. This condi- tion was found in a case of Huchard, in which the autopsy was performed by one of us. Instead of being generalized through- out the glandular parenchyma, the neo- to us appears premature, cannot, at present, be unreservedly accepted, for a few cases have been seen in which the hypophyseal lesion was not accompa- nied by any dystrophic disturbance. In acromegalic gigantism tumors of the hypophysis are more constantly present than in simple acromegaly. We have already stated, indeed, that in the Celliilar characteristics of a tumor of the pituitary. (P. E. Launois. ) plastic process may be localized and ap- pear in the form of more or less volum- inous masses (partial adenomas, cysts), reaching a variable size [Widal, Roy, and Froin (Revue de Med., Apr. 10, 1906)]. From a general review of the facts yielded by recent investigations, the tend- ency has arisen to accept the conclu- sion that the hyperplastic condition of the hypophysis observed in acromegaly is dependent upon an increase in the number and size and an exaggerated functional activity of the chromophilic cells. This assertion, however, which former condition they have never been found wanting. As for their histolog- ical structure, the same uncertainty pre- vails. To complete this study, we shall men- tion the alterations which the other ductless glands may undergo in acro- megaly : — With reference to the thyroid, Hins- dale, in a series of .36 cases collected from the literature, found h)^pertrophy 13 times, atrophy 11 times, while in 12 cases the gland appeared to be normal. [According to Furnivall (Pathol. Soc. of London, Nov. 2, 1897), the thyroid seemed ACROMEGALY (LAUNOIS AND CESBRON). 321 normal in only 5 out of 24 cases of acro- megaly. Wc lia\ c mirselves seen the dys- trophy coexisting with simple goiter; Lan- cercaux and Murray (Edin. Med. Jour., 1897), with exophthalmic goiter. Launois AND CeSBRON.] Klebs, Massalongo, and Mosse have reported hypertrophy or regeneration of the thymus gland. Most observers have failed to inquire into the condition of the adrenals. Their study might prove fruitful, in view of the opinion of Sa- jous that these organs take an active part in the morbid process. PATHOGENESIS.— According to Klebs, who had witnessed persistence of the thymus in a case of acromegaly, the affection is due to an unusual state of de- velopment of the vascular system, and results from an angiomatous condition of the thymus. According to this view, the thymus produces endothelial ele- ments which, swarming through the ves- sels, assume the role of formative cells in the production of fresh vessels. Thus there would result an increase in the number of vascular channels, and, in consequence, hypernutrition and aug- mentation in size of the terminal por- tions of the body, i.e., of those regions of the organism in which the flow of blood slackens its speed. This power to form new vessels, however, which he attributes to the thymus, is as yet lacking in proof. Massalongo has taken up Klebs's the- ory and modified it. He believes acro- megaly to be due to persistence of the functions of the thymus and the hypoph- ysis — organs which play an impor- tant part during fetal life. Normally, these glands undergo retrogression, he states, at the age when growth ceases, i.e., between the 20th and 25th years. If their functions continue after that age has been passed, acromegaly results. Freund and Verstraeten attribute the dystrophy to a reversal in the normal order of events occurring in sexual de- velopment. "In a certain number of individuals," writes Freund, ''the ordi- nary mode of development is disturbed. Either it lags behind the norm, or else it advances beyond the norm, both in time and in space [i.e., morphologic- ally] ; the malformations which result go hand-in-hand with the disturbance in the development of puberty, and later, too, of the sexual functions." It is certain that the development of the genital apparatus is not without influ- ence on that of the osseous system, and one of us, in a series of communica- tions, has described the alterations pro- duced in the bones by congenital atro- phy of the testicles, of the ovaries, and by castration before puberty. Now, the frequency with which disturbances of the genital .functions are associated with acromegaly has long been noticed. But how is the influence they may exert on the growth of the skeleton to be ex- plained ? Perhaps by their suppression, diminution, or modification of a secre- tory product having as its purpose, a'' suggested by Sajous, to activate the oxidation of phosphorus-containing substances. [Schiff, Ruttle, and Duchesneau have re- ported an increased elimination of phos- phorus; but Moraczewski (Zeitschr. f. klin. Med., xliii, Nos. 3 and 4, 1901), Tansk and Vas, and Parhon ("Contributiuni la studiul schimburilor nutritive in acromeg- alie," Bucuresti, 1903; Revista Stiintelor Medicale, No. 2, 1905), on the other hand, have found it to be retained in the organ- ism. Launois and Cesbron.] In short, the development of the geni- tal functions having some influence on that of the skeleton in general, disturb- ances in these functions may be factors in the production of acromegaly, but 1—21 322 ACROMEGALY (LAUNOIS AND CESBRON). they do not appear to be sufficient to bring on the dystrophy of themselves. In the opinion of Reckhnghausen and Holschewnikow, acromegaly is merely a trophoneurotic affection, dependent upon changes in the central and pe- ripheral nervous system. Disturbances involving the vasomotor nerves would, according to this view, lead to over- nutrition and hypertrophy of the ex- tremities. There is nothing to indicate, however, that the nervous changes in this dystrophy are primary. The case on which these two observers based their opinion was one of syringomyelia. Pierre Marie looks upon acromegaly as "a kind of systematized dystrophy, occupying in the nosological scale a po- sition about corresponding with that of myxedema, and bearing to an organ of trophic function (the hypophysis) as yet unknown relations similar to those which unite myxedema and cachexia strumipriva to certain lesions and re- moval of the thyroid gland." As this quotation shows, it was the sponsor of acromegaly himself who was the first to suspect the functional role of the hypophysis, "that enigmatic or- gan," as Van Gehuchten termed it not so many years ago. In the preceding pages we have suffi- ciently dwelt upon the frequency, and even constancy, with which hypertrophy of the hypophysis, especially of epithe- hal origin (adenoma), is present in acromegaly. We pointed out, likewise, a condition which is daily receiving con- firmation from X-ray studies, viz. : that, whatever be the mode of progression of the dystrophy, whether it take expres- sion in its sthenic phase as the pure acromegalic type of Pierre Marie, or the lipomatous type of FrohHch, there is present in most cases enlargement of the sella turcica, which serves to indi- cate hypertrophy of the pituitary body. In view of these facts, while recognizing to their full value the negative cases so far recorded, we are completely in favor of the hypophyseal theory. Having reached this conclusion, we still have to solve two other phases of the problem, viz. : to ascertain the na- ture and mode of action of the disor- ders affecting the function of the hy- pophysis, and to find out whether these disorders are sufficient in themselves, or whether it is not necessary to invoke the synergistic functions of the other ductless glands as participating in the disturbance. The experiments of physiologists, an excellent analysis of which has been given by Paulesco (L'hypophyse ducer- veau, Paris, 1908), have yielded, it must be said, no definite results. Practised upon young or old animals, removal of the hypophysis produced no skeletal dis- orders nor acromegalic manifestations. This dearth of results is not surprising when we consider, on the one hand, the comparatively short period of survival of the experimental animals, and, on the other, the serious traumatism to which they had been subjected in the operations. Of greater weight, as we have already emphasized, are the data afforded by the clinicopathological method. It is on the basis of these data that investigators have sought to ascer- tain the functions of the hypophysis, and, in particular, its trophic role. Some authors, among them Tansk and Vas, and Parhon, consider acro- megaly to be the result of excessive functionation on the part of the pitui- tary — a genuine hyperhypophysia. Ac- cording to others, the functional role of the gland is to destroy substances toxic to the nervous system. The accumula- tion of these substances, in the presence ACROMEGALY (LAUNOIS AND CESBRON). 323 of functional disturbance of the hy- pophysis, would produce, because of spe- cial predisposition, a continual state of irritation, resulting in hyperplastic changes in the bony and other support- ing tissues, primarily and chiefly notice- able in the extremities. The acromeg- alic deformities would be an expression of functional insufficiency of the organ, or Jiypohypophysia. The above hypotheses were those most generally accepted when Hochen- egg published the results of his opera- tions of hypophysectomy, which will be described below. The progressive re- trogression of the manifestations of acromegaly witnessed after excision of hypophyseal tumors affords an argu- ment of the first importance in favor of the theory of glandular hypersecretion. Future observations will soon bring fur- ther confirmatory evidence. The facts recorded by Hochenegg have also lent considerable support to the doctrine of the synergistic func- tional relationship existing between the ductless glands. In one of his cases, menstruation, which had long since been arrested, returned and was main- tained at regular intervals. In 2 cases removal of the hypophysis was followed by hypertrophy of the thyroid. We have already stated that at the autopsy of acromegalics hyperplasia of one or more ductless glands is frequently found. Furthermore, it is well known that the sexual glands exert a distinct influence on the osteogenetic activities of the connecting cartilages, and that thy- roid extract is possessed of an analo- gous action. Caselli has expressed his belief in the identity of the functions of the hypophysis and thyroid, basing his opinion on the experimental observation that removal of the hypophysis acts on tetany parathyreopriva in the same manner as does removal of the thyroid. This functional identity, as Souques (" Acromegalic" in "Traite deMedccine" of Charcot and Uouchard, 2d ed., vol. x, p. 490) terms it, or, better, this func- tional analogy, would furnish an ex- planation for the power of mutual sub- stitution of function exhibited by these glands under pathological conditions. It was through surgery, practised for curative purposes, that the functions of the thyroid were revealed to us ; it is through surgery that today the role of the hypophysis is being disclosed. It is to surgery, again, that we shall in the future be indebted for the acquisition of positive data which will enable us to solve the absorbing problem concerning the synergistic functional relationship of the ductless glands. The craniopharyngeal canal, which passes down from the floor of the sella turcica through the basisphenoid into the nasal pharynx, normally becomes obliterated in the fetus at the begin- ning of the third month. In 4829 skulls it was noted by le Double to be per- sisting in only 10, about 0.2 per cent. Schlaginhaufen observed it, on the other hand, in 40 per cent, of apes' skulls examined. The interesting fact now comes to light that Dr. Ettore Levi, of Florence, has found it persisting in the skulls of two acromegalics which he has had the opportunity of observ- ing, and he describes the condition in the Revue neurologique for May 15th. In one, situated mesially and at the junction of the anterior and middle third of the floor of the sella turcica, was a round depression 6 mm. in diameter and 6j/^ mm. deep ; at the bottom of this was a small, round open- ing which communicated by a canal 9 mm. long through the basisphenoid with the nasal pharynx, entering the latter at a point 5 mm. from the posterior margin of the left wing of the vomer, and allowing the passage of a seeker 1 mm. in diameter. In the second case a canal in almost exactly the same 324 ACROMEGALY (LAUNOIS AND CESBRON). site and with the same course was found. In this connection it is instruct- ive that in the skull of the Irish giant Magrath, described by Professor Cun- ningham, an elliptical perforation was is called for, as it is quite conceivable that an abnormality of this nature has escaped observation. The light which it may throw on the hypophyseal theory of acromegaly may be considerable. Re- Vertical rhinotomy by means of bilateral osteotomy; Ollier's method. {R. Proust.) noted in the floor of the sella turcica communicating directly with the nasal pharynx, the lower end of it being partly covered by the enlarged wing of the vomer. A re-examination of acro- megalic crania in view of these facts cent researches have conclusively shown the existence of pituitary tissue in the vault of the nasal pharynx, deep in the soft tissues lining the vault, an acces- sory pharyngeal hypophysis identical in structure with the glandular part of the ACROMEGALY (LAUNOIS AND CESBRON). 325 cranial hypophysis and of normal and constant occnrrence. Its pathology is vmknown, and what relation it may bear to those cases of acromegaly without obvious lesions of the pituitary gland, TREATMENT.— The treatment of acromegaly necessarily remained, for a long time, purely symptomatic, and was limited to combating the most distress- Openingr of the frontal sinus after deflecting thie nose. (R. Proust.) and those other cases of lesion of the pituitary without acromegalic symp- toms, is equally unknown. Data such as these suggest an interesting line of research for subsequent investigators. Editorial (Lancet, June 5, 1909). ing manifestations, such as pain and in- somnia. Agents modifying general nu- trition, such as iodine and arsenic (Campbell), were then brought into use. Iron in large doses and hot baths 326 ACROMEGALY (LAUNOIS AND CESBRON). were said to have given distinct relief in a case under the care of Brissaud. Schwartz claimed to have obtained tried thyroid treatment without suc- cess, though Lyman Greene claimed good results with it. Napier admin- Approach to the sphenoid after resecting the ethmoid and clearing the nasal passages. (B. Proust.) beneficial effects from the use of ergot. As a corollary to the discoveries of Brown-Sequard, opotherapic medica- tion was resorted to, Warda and Pirie istered powdered ovary to an acrome- galic woman without benefit. Kuh, using pituitary substance, and Favor- sky, using Poehl's opohypophysine, noted distinct improvement in the ACROMEGALY (LAUNOIS AND CESBRON). 327 subjective, and even the objective, have been led to the conclusion that they symptoms. The latter ol)server was are entirely ineffective. able to continue the administration In view of these unsuccessful efforts of hypophysine in daily doses of 0.05 on the part of medicine, the surgeons, Opening the sphenoidal sinus, of which the median cell is visible. {R. Proust.) to 0.06 Gm. (^4 to 1 grain) for fifteen months, without untoward effects. For our part, we have utilized the various animal preparations in a systematic manner and for extended periods, and emboldened by the increasing safety at- tending their operations, were not afraid to attempt the removal of the hy- pophysis. The anatomical situation of the sfland seemed to make the access 328 ACROMEGALY (LAUNOIS AND CESBRON). to it well-nigh impossible. Never- theless, encouraged by the results obtained by physiologists, and hav- ing gained additional information and on November 16, 1907, Schlosser performed the operation of removing a tumor of the hypophysis from a living person. rrephining the posterior wall of the sinus. The pituitary, marked with a white cross, can be seen in its dorsal sheath. (R, Proust.) through researches on the cadaver, the operators ascertained the avenues of entrance which would permit of their reaching the pituitary gland, In theory, the hypophysis may be reached, according to Toupet, either by an intracranial or by an extracranial route. Those who favor the intracranial ACROMEGALY (LAUNOIS AND CESBRON). 329 method advance as their chief argument the less danger of infection to which the I^atient is subjected, and propose either the frontal route (Krause, KiHani) or the temporal route, already employed in their experiments by Caselli and Hors- ley (Brit. Med. Jour., Aug. 25, 1906). The supporters of the extracranial route " are the more numerous at the present time. Against the former method they .raise the objections of operative dififi- culty, severity of operative interference, and the great ease with which a com- munication may accidentally be estab- lished between the cavity of the sella turcica and the sphenoid sinus, of which the thin and fissured walls, in the pres- ence of tumor of the hypophysis, may yield to the slightest touch. According to these observers, the possibility of such a commmiication would greatly re- duce the chances of performing an asep- tic operation by the intracranial route. Moreover, the extracranial operation in- duces but a minimal degree of shock, and is comparatively easy in technique ; it does not, however, exclude the chances of infection. The intracranial method is danger- ous, uncertain, and difficult, while the oral route gives but a limited operative field and is almost sure to be fol- lowed by infection owing to connection with mouth. Hecht (Jour, of Nerv. and Ment. Dis., Nov., 1909). We cannot here enter into detail con- cerning all the proposed technical meth- ods of reaching the sella turcica through the sphenoid sinus. According to their respective temperaments, surgeons have planned either sweeping and broadly mutilating operative procedures or else more economical methods. These pro- cedures may, in their main features, be reduced to four, as follows: 1. The simple nasal route, practically the only one which has been employed in man. 2. The nasal route combined with more or less extensive resections of the su- perior maxilla and the inner wall of the orbit, even to sacrificing completely an eye already functionally lost (Schlos- ser). 3, The buccal route of Gussen- baum, with resection of the hard palate, advocated by Konig (Berliner klin. Wochenschr., No. 46, p. 1040, 1900). 4. Transverse and median suprahyoid pharyngotomy, proposed by Loewe (ibid., Feb. 17, p. 378, and Feb. 24, p. 422, 1908). ^ Of all these methods, the simple nasal route is the one which has been used almost exclusively, with slight varia- tions in technique, on the living subject. Horsley and McArthur alone seem to have employed the temporal intracranial route. With the omission of a few details, the operative technique may be sum- marized as follows : Temporary resec- tion of the nose, which is reflected later- ally above and below; resection, osteo- plastic if desired, of the anterior wall of the frontal sinus; excision of the vomer and of the nasal septum to its insertion posteriorly, which is preserved as a landmark, showing the median line ; removal of all the ethmoid air-cells and of the turbinated bones, to permit of seeing and opening into the sphenoid sinus. The sinus having been entered, the next step is to make an opening at the bottom of the sella turcica, the an- terior wall of which bulges forward. The dura mater is then incised. The tumor is removed piecemeal by means of the curette. (The tumors hitherto removed have generally been very soft, sometimes cystic, as inEiselsberg's case, and their excision presented no difii- culty.) The cavity of the sella turcica is then drained by means of a rubber 330 ACROMEGALY (LAUNOIS AND CESBRON). tube which passes out through the nasal f ossffi ; the latter are packed, and, as a final step, the nose, temporarily drawn aside, is put back in place. This operation is accompanied by marked bloody oozing, which yields rap- idly, however, to packing with adrenalin solution in 1 : 1000 strength, and gen- Ohiasm. and whose history was later reported in extenso by Stumm, was a young lady, 31 years of age, in whom the initial dys- trophic manifestations had appeared at about the 25th year and soon become fully developed. The operation was in- dicated because of the severity of her headache and visual disturbances. It Optic nervi. Olfactory bulb. Inferior wall of sphenoidal sinus. Pituitary body. Relations of pituitary body, as exhibited in the nasal route of operative access, with additional removal of bony floor of anterior cerebral fossa. (Proust.) erally ceases at the end of fifteen min- utes. Successful cases of hypophysectomy are of interest aiot only from the stand- point of the treatment of acromegaly, but also from that of its pathogenesis. With .respect to the latter, they possess the ■ same value as true experimental studies, and it will be worth while here to give a resume of the first two cases operated by Hochenegg. The first patient, presented before the German Congress of Surgery in 1908, was carried out by the nasal route. No untoward after-effects appeared, and immediate results were obtained. Upon awakening the subject was already re- lieved of the intolerable headaches which had made her life miserable. Vision rapidly improved. A more re- markable event was further witnessed in that, on the fifth day, the symptoms of acromegaly began to disappear. The patient regained the ability to close her mouth completely, which she had been unable to do before. Her tongue and ACROMEGALY (LAUNOIS AND CESBRON). 331 nose soon after began to decrease in size. A similar change was observed in her feet aiul hands : their thminntion in bulk was so marked that, on leaving the hospital, she was obliged to wear three pairs of stockings in order to make use of her shoes, and that her fingers and wrists literally floated around in the gloves she had worn before the opera- tion. The change in her appearance was such that her family had difficulty in recognizing her. We may add that her menstruation, long since arrested, re- sumed its usual regular course, and that in August, 1908, a parenchymatous goiter appeared in her neck. The second case operated by Hoch- enegg appeared as though modeled after the first. The patient was a woman of 34, in whom the disease, dating back ten years, had produced the most typ- ical dystrophic changes, and was asso- ciated with amenorrhea, headache, and disordered vision. Excessive hairy growth and alterations in her voice gave her a peculiar masculinity. The opera- tion w^as carried out with the same tech- nique as before and was likewise crowned with success. At the end of a week the headache had almost com- pletely disappeared. The extremities diminished in size to such an extent that three months after the operation, when Exner presented the patient before the Medical Society of Vienna, the third toe measured ^ cm. less in circumfer- ence, and the middle finger }^ cm. While the menstrual periods did not re- appear, the hairy appendages resumed their normal state, and, as in the first patient, the thyroid gland increased in volume ; a growth the size of a walnut developed from the isthmus. Different measures should be adopted under different circumstances: (1) "comparatively small tumors in the sella turcica covered with a tent of dura mater can be removed completely by the nasal route ; (2) growths growing endocranially, but filling the sella tur- cica, can be removed in part to relieve the pressure symptoms, though not the acromegaly; (3) endocranial growths, removal of which can only prove harm- ful. Hochenegg (Deut. Zeit. f. Chir., Bd. c, S. 317, 1909). Confirmation of Paulesco's observa- tion that simple division of the stalk of the pituitary is as fatal a procedure as removal of the latter organ also, and also of the view that the latter procedure in animals is invariably fol- lowed by death within a few days. This fatal result is evidently due to re- moval of anterior or epithelial lobe, since removal of the posterior or neural lobe is followed by no characteristic symptom. Cushing and Redford (Johns Hopkins Hosp. Bull., April, 1909). Removal of part of the pituitary for the relief of acromegaly by the trans- sphenoidal route. The patient was a typical "case of acromegaly, with partial blindness and epileptic crises. A tumor of the hypophysis was diagnosticated, and operation was done by opening the nose, passing through ethmoidal and sphenoidal cells into the sella turcica, and the removal of a considerable amount of tissue from the hypophysis. The patient lived some six weeks after the operation, the external wounds en- tirely healed, but he died suddenly. An examination of the skull and brain after death showed that the tumor of the hypophysis was an epithelioma with several prolongations into other parts of the skull and around the cavernous sinus. It was entirely unencapsulated, and could not have been removed by the route taken or any other. Lecene (La Presse medicale, Oct. 23, 1909). The writer performed the following operation on the cadaver : An incision is made from the frenulum of the upper lip to the last tooth through the mucous membrane and periosteum down upon the facial wall of the antrum of Highmore, which is laid bare and then removed. The mucous membrane of 332 ACROMEGALY (LAUNOIS AND CESBRON). the antrum is then removed, a portion of the medial wall chiseled away, the sphenoidal sinus entered anil removed as thoroughly as possible with chisel, forceps, and sharp spoon. The poste- rior part of the septum is then removed with a few blows of the chisel, the sphenoidal rostrum cut through, and the septum between the cavities re- moved. This leaves the bone beneath the hypophysis exposed and ready to be cut through with the chisel. Fein (Wiener klin. Woch., July 14, 1910). McArthur has operated by a lateral route, advancing to the middle along the roof of the orbit and in the one in- stance was able to remove about two- thirds of the growth. The author be- lieves that the nasal route is the best, despite the resulting deformity. He reports on 6 cases of tumor of the pituitary. Case I was diagnosed from the menstrual history, double temporal hemianopsia, optic atrophy, and the X-ray picture, but no operation was performed. Case II, a boy of 14, had no evidence of acromegaly. Headache came on at intervals since the third year, with vomiting, frequently ter- minating in nosebleed, with apparent relief. Double optic atrophy with hemianopsia showed a pituitary cyst with calcareous plates. This case was operated by Horsley, and a pituitary cyst containing chocolate-like fluid was evacuated. The convalescence was sat- isfactory, but the boy died eighteen months after the operation. Case III, a woman of 25 years, ceased to men- struate at 22, had headaches, bilateral nasal atrophy, and diminution of the eye-grounds. An X-ray showed a much enlarged sella turcica. At operation, going over the orbital plates, a cyst of the pituitary was reached and evac- uated, but the frontal lobe was lacerated in the procedure, and the patient died in eighteen hours. Case IV, a man of 36 years, had for five months noticed the eyesight of left eye failing, and he had intense left-sided headaches, which became less in the last two months. The field of vision showed a sharply defined, right-sided, temporal hemian- opsia. The patient had been impotent for a year. An X-ray showed an en- larged sella turcica. He was operated by von Eiselsberg by the nasal route, and recovered. The tumor was a malignant epithelioma. Case V, a boy aged 14, for one year had noticed his vision getting bad, and later there were temporal headaches; later hemianopsia was found and atrophy of the disk. The X-ray showed an enlarged sella. Though operation was refused, the boy lived over four years after the symp- toms of tumor were felt. Case VI, a man of 33, had for six years noticed failing vision in one eye, and later of the other, the outer half of the field going first ; marked atrophy of the disk on one side. The X-ray showed a large sella turcica. No operation was performed, because the patient was in such excellent good health, with no other symptoms than those of the eyes. Church (Jour. Amer. Med. Assoc, July 10, 1909; Interstate Med. Jour., Feb., 1910). The author is inclined to think that cases of the Marie type, with hyper- plasia or the adenomatous condition, represent hyperpituitarism, and that cases of the Frohlich group represent hypopituitarism in consequence of in- vasion of compression of the gland by a tumor or cyst. The case reported was one of acro- megaly in a man of 38. Constant head- ache and photophobia were prominent symptoms, and these were practically cured by partial hypophysectomy — which was followed, also, by marked reduction in the thickening of the fingers, tongue, and jaw. For this operation temporary tra- cheotomy was first performed. In Rose's position an omega flap was made over the frontal sinuses, continued down on each side of the nose to the base of the nasal bones. An osteoplas- tic flap was then turned down. An opening was made in each frontal sinus, and these were joined by a Gigli saw; with forceps the lateral incisions of the proposed frontonasal flap were carried down through the nasal bones; the median septa were divided with chisel. The ethmoidal cells were rongeured ACTINOMYCOSIS (LAPLACE). 333 away to provide a channel 2 cm. wide, below the ethmoidal roof, to the poste- rior part of the nasal fossa. The sphenoidal cells were then broken into, the projecting sella turcica exposed and chiseled away. The dura enveloping the pituitary glr.nd was thus exposed. It was incised, and about one-half of the exposed portion of the gland was removed, piecemeal, by curette. Two cigarette drains were introduced into the sphenoidal cells, one emerging from each nostril. The frontonasal flap was then sutured in place. Primary union. In addition to tracheotomy, plug- ging of the posterior nares and swab- bing the nares with adrenalin preceded the operation. Urotropin administered for twenty-four hours before operation. Anesthesia by warmed ether vapor. In dogs the hypophysis is easily ex- posed by the lateral cranial route, bi- lateral craniectomy being performed to allow dislocation of the brain (Paul- esco). In man the exposure by this route is hazardous, if not impossible, and Horsley's approach (temporal in- tracranial) seems to be eligible only for a growth lying well above the sella tur- cica. The transsphenoidal operations are those of choice for growths within the sella turcica, as first advocated by Schlofifer, and of these the writer re- gards as best a direct median approach through the nose (extracranial). Har- vey Cushing (Annals of Surg., Dec, 1909; Amer. Jour, of Surg., March, 1910). From this brief discussion of the sur- gical aspect of acromegaly we may con- clude that hypophysectomy is practi- cable in the human subject by the nasal route, and that it represents a relatively safe operation. Surgical intervention has yielded results which could not have been hoped for from any mode of treat- ment previously employed. • P. E. Launois AND M. H. Cesbron, Paris. ACTINOMYCOSIS .— D E FI NI- TION. — A parasitic, infectious, and inoculable disease due to the develop- ment of the actinomyces, or ray fungus. First described in 1877 in cattle by Bol- linger and in man by James Israel ; it can no longer be considered a rare dis- ease. From its frequent development in the lungs it has often been confused with tuberculosis. SYMPTOMS.— The symptoms vary according to the locality of the disease. The affection is chronic and exception- ally rapid. The granulation tissue is abundant and the mass resembles a tumor. Previous to suppuration it is quite firm, and, if progressing rapidly, is surrounded by diffuse edema. Pain and tenderness hardly ever exist. When suppuration occurs the mass increases rapidly in size. Actinomycosis may develop in almost any part of the body, but Poncet and Berard showed, after an investigation of 500 reported cases, that the sites of predilection were relatively as follows : Head and neck, 55 per cent. ; thorax and lungs, 20 per cent. ; abdomen, 20 per cent. ; other parts, 5 per cent. In France the face and neck were affected in 85 per cent, of the 66 cases reported. 1. Cutaneous Surface. — Usually, a lesion of the skin is secondary to the evolution of an underlying actinomy- cotic tumor, which, by its growth, bursts through the skin. A sanguineous or purulent liquid, containing the charac- teristic grains, issues from the ulcera- tions so formed. The grains are small, opaque, yellowish-white, or yellowish masses about as large as a pinhead, which are composed of smaller grains, measuring about %o t^^^'^- These smaller grains are formed by a central mass, of interwoven or straight fibers, whence ex- tend toward the periphery spoke-like 334 ACTINOMYCOSIS (LAPLACE). prolongations, with club-like termina- tions. Rarely the affection may develop primarily on the fingers, hand, nose, or face. It forms a small, round, ligneous mass, which may soften in a few weeks, burst through the skin, and give a gran- ulous and varied pus, containing actino- mycotic granulations. The border of the granulation is uneven, violet-hued, and undermined. Around the original mass there arise secondary masses ; so that the entire lesion forms a violet-red, in- durated patch, deeply adherent, and somewhat resembling scrofuloderma. In cutaneous actinomycosis the lym- phatic ganglia are usually not enlarged. Pain is, in some cases, intense ; in other cases it is awakened only by pressure. The pathognomonic spots, which are more or less deep in color, according as the general color of the lesion is more or less pronounced. If the general color is pale, the spots are bluish red or violet ; if the tint of the mass is deeper, the spots present a blackish or slate color. These spots vary in size from that of a pea to that of a pin's head. They ap- pear to correspond to the points at which the wall of the abscess is thinnest, and it is here alone that fistulse form. In some instances, as in the case re- ported by Pringle and illustrated in the annexed colored plate, the lesions may assume the appearance of large sarco- matous-looking growths, ulcerating at various points, situated upon hard, brawny, and deeply undermined skin and from the ulcerative points of which pus exudes, mixed with characteristic yellow granules, actinomycosis. 2. Alimentary Canal. — Teeth. — The fungus has been found in carious teeth (Israel), often side by side with lepto- thrix (Senn), or almost pure culture with no manifestation of disease except chronic periodontitis (Partsch). Cari- ous teeth have increasingly been shown to be the origin of the affection. Tongxie and Tonsils. — In man three cases of this affection have been found on the tongue, one of which was of pri- mary development ; the other two are believed to have found origin in a ca- rious tooth. The tonsils may also be affected and be the seat of white projec- tions resembling masses of moss, which seemed to grow in the crypts. The pharyngeal wall also shows these white masses, as a rule. Lingual actinomycosis in cattle ap- pears as a nodular tumor, with prolon- gations into the parenchyma, of ligneous hardness. Jaws. — The lower jaw is the, most frequently affected. At first the disease resembles periosteal sarcoma, until the loose tissues of the neck are reached, when it often rapidly extends downward along the subcutaneous connective tis- sues and intermuscular septa. Accord- ing to Poncet, an early sign of actino- mycosis in this location, in some cases, is a marked difficulty in opening the mouth, long before the presence of the disease can be determined microscopic- ally. Eight cases tending to show that a proportion of the cases ranking as alveolar abscesses may be due to the specific organism of actinomycosis. Few cases enter hospital with ad- vanced actinomycosis of the jaw, and many recover after simple incision and after rupture. Certain cases of generalized disease in the lungs, in- testinal tract, liver, etc., occur in which the organism gained entrance through the food, or was swallowed, and therefore the surgeon should aim at making external drainage. C. A. Porter (Boston Med. and Surg. Jour., Sept. 13, 1900). The upper jaw is rarely primarily affected. It then tends to attack rapidly ^^.a"^' \y y -' -- n > CO O o 3 o' •<: D o o CO l-b 55" ? o (/I ACTINOMYCOSIS (LAPLACE). 335 the adjacent parts, and even the base of the skull and brain. Autopsy indicating that actinomy- cosis of the middle ear may arise from blood-infection from a primary focus elsewhere in the body, or from a neighboring actinomycotic process in the mouth, pharynx, tonsil, or from carious teeth; that the fungus may enter the middle ear through the Eustachian tube or through the ex- ternal auditory canal. J. C. Beek . (Prager med. Woch., Mar. 29, 1900). In three cases the predominant sign was a sharply defined local mov- able mass, which is always strongly indicative of the disease. Hofmeister (Beit. z. klin. Chir., B. 26, H. 2, 1900). In the case of a butcher the first signs were in the floor of the mouth, in the form of a pseudoranula; after- ward swelling of the cheek showed characteristic yellowish discharge and granules. Lenoir and Claisse (Jour, des Praticiens, July 14, 1900). 3. Intestinal Canal. — The disease be- gins with a sharp, lancinating pain in the abdomen and follows the course of chronic peritonitis. Swellings forming abscesses are found on the anterior ab- dominal wall, which sometimes commu- nicate with the intestine. It may also start from the vermiform appendix. There have also been cases of primary actinomycosis of the colon with meta- static deposits in the liver. Actinomycosis of the vermiform ap- pendix was first recognized by Barth in 1890, and was first recognized in England in 1892 by Ransom. It has become evident, however, that a num- ber of cases really originate in the cecum, and an identical clinical pic- ture may result after perforation. Hence a preferable title would be "actinomycotic perit3rphlitis." Three cases observed by the writer in one year, and he describes three more from the annals of the Bristol Royal Infirmary. Grill mentions 11 cases of actinomycotic perityphlitis as re- corded up to 1895. It is proI)able that the total number up to 1904 is about 150, of which 27 are English. The proportion as to the sexes is about 5 males to 2 females. It is more frequently seen between 20 and 30 years of age. A large number of sufferers are connected in some way with farm life, or deal with corn. Short (Lancet, Sept. 14, 1907). 4. Genitourinary Tract. — The uterus may also become invaded by the disease, the first manifestation being the dis- charge of a turbid, fetid fluid contain- ing the characteristic shreds and masses. Case of a peasant woman in which the labium majus was swollen and covered with orifices of fistute dis- charging pus. The tracts were slit up freely and scraped; the actinomy- ces was detected by aid of the micro- scope. Three-quarters of a year later no signs of recurrence could be detected. Only two similar cases have been recorded, one by the writer himself, and one b}'- Lieblein, of Prague. ' Bongartz (Monats. f. Geb. u. Gyn., Nov., 1902). Up to the present only one case (von Israel) of the primary renal ac- tinomycosis has been published. The writer reports a second case, which oc- curred in a hoy, aged \?>/^ years, who, like von Israel's patient, was oper- ated on Avith successful result. Ku- nith (Deut. Zeit. f. Chir, Bd. xcii, S. 181, 1908). The gross macroscopic and micro- scopic picture resembles that of tu- berculosis in many cases. Bollinger's desideratum for the diagnosis of actinomycosis, namely, that corpora flava must be present, is untenable at the present time. Repeated bac- teriological examinations, and some- times long and tedious ones, of the same specimens must be made to insure a correct interpretation of sus- picious pathological material. Inocu- lation with pure cultures into the ani- mal is not attended with success. Only the injection of pus with actino- mycosis, or the ingestion of material 336 ACTINOMYCOSIS (LAPLACE). upon which actinomycosis is grown, will prove successful in the production of actinomycosis in the animal. Actino- mycosis does not travel by the lym- phatics, and probably not by the blood route. The prognosis is favorable in circumscribed cases, which is most likely the condition in which we find the uterine appendages. The treatment consists in radical extirpation and free drainage, the appli- cation of tribromphenolbismuth, or irrigation of the fistula with copper sulphate. The internal administration of large doses of iodide of potash up to 75 grains a day, which exerts a posi- tive healing effect. Carl Wagner (Surg., Gynec. and Obstet, Feb., 1910). 5. Respiratory Tract. — Inbronchitic actinomycosis the affection is less severe in winter than in summer, which is the contrary of what is observed in ordi- nary bronchitis. It can be classified in three groups: (1) lesions of chronic bronchitis; (2) miliary actinomycosis, and (3) cases with bronchopneumonia and abscesses. The lower lobe is at- tacked more frequently than the upper ; the opposite is the case in tuberculosis. Review of 14 recorded cases of ac- tinomycosis of the lung. The only 2 which recovered were those in which radical operations, with resection of four or five ribs, and cauterization of the diseased cavity in the lung were carried out. All those that were simply incised and drained ended fatally. The infection of the lung may be secondary to either cervico- facial or pharyngoesophageal actino- mycosis, or it may be primary, either through the bronchi or from an ex- ternal wound. There are three forms clinically: (1) the pulmonary, with insidious onset, going on to induration of a large area of lung, generally in the subclavicular or posterolateral re- gions, the apices being usually free; (2) the bronchial, with a diffuse catarrh and fetid mucopurulent expectoration, containing the fungus; (3) the pleural, with effusion; the coexistence of pleural eft'usion with retraction of some part of the thoracic parietes — due to fibrous changes in the lung — is pa- thognomonic. Another pathognomonic symptom is the presence of a swelling in the wall of the thorax where it has been invaded by the fungus, along with shrinking of the lung, causing retrac- tion of the thoracic walls ; later on this softens and becomes subfluctuating without the formation of large ab- scesses. Puncture obtains a fluid con- taining fragments of fungus. Death may occur after months or years, ac- cording to the varying invasion of other organs by the disease ; in one case of rapid diffusion of the fungus death occurred in twenty- four days. Parascandolo (Brit. Med. Jour., from Clinica Mod., Nov. 7, 1900). Mammary actinomycosis may occur in two ways: primary and secondary. In the former infection occurs either from propagation of the actinomy- cotic grains in the milk-ducts or from their penetration into the tissues through a continuity of the skin. Four cases of the primary form wit- nessed. The secondary form spreads to the mammae from the lung (most frequently) or some other organ. The disease is not easy of diagnosis, and is liable to be confused with tu- bercle, cancer, interstitial inflamma- tion, or syphilitic disease, and re- peated microscopical examination of discharges or pieces of tissue should be made. The prognosis in the pri- mary form is good, but in the second- ary form unfavorable. Mileff (Gaz. d. Hop., Jan. 1, 1901). The diagnosis of "primary pul- monary actinomycosis," even in the absence of all abdominal symptoms, must remain doubtful without a post- mortem examination. In abdominal, as well as in pulmonary, actinomycosis the patient should be closely ques- tioned regarding any previous more or less indistinct symptoms of ap- pendicitis and sores at the anus. Fecal concrements found in the ap- pendix in cases of actinomycosis should be microscopically examined. In actinomycosis following typhoid- ACTINOMYCOSIS (LAPLACE). 337 like symptoms, a Widal test should be made. At the post-mortem special attention must be paid to intestinal scars, which may easily avoid de- tection. Experiments and clinical observation indicate that the fungus cannot enter ' the human or animal body without a wounded surface. Must the wounded body also be the carrier of the infectious material, or can infection take place secondarily through a granulating accidental wound or the chronic ulcers de- scribed? Human actinomycosis of the skin, or actinomycosis of the jaw in pasturing cattle, may offer a suit- able object for investigation in re- gard to the latter point. Fritz Maas (Annals of Surg., Aug., 1903). Case of intralaryngeal actinomyco- sis. The patient, aged 19, first noticed a slight hoarseness, which gradually increased until he could speak only in a whisper; it was for this symptom alone that he sought relief. There was at times a slight "stinging" in the throat, which had never been more than disagreeable. There had been a slight cough and some dysp- nea on exertion. In the region of both true cords and completely cov- ering and concealing them were ir- regular masses of dirty-white tissue, more than half occluding the chink of the glottis. The same sort of tis- sue lined the trachea as far down as the writer could see, which was but a short distance, by reason of the encroachment on its lumen by this adventitious material. The man was given vigorous antisyphilitic treat- ment for a month, without improve- ment. After he had been under ob- servation for about three months, several portions of the laryngeal mass were removed and examined micro- scopically. The diagnosis of actino- mycosis was then made. The patient was put on increasing doses of potas- sium iodide without apparent improve- ment, although there soon was no evidence of actinomj'-cosis in the sputum. There were present occa- sional tubercle bacilli, streptococci, and groups of staphylococci. This condition gradually became worse. Physical signs of consolidation were discoverable in the right upper lobe. There were some cough, emaciation, irregularity of temperature, anorexia, and digestive derangement. At the last examination there was an area in the vault of the pharynx which pre- sented an appearance identical with that in the larynx — previously there had been absolutely no lesion discoverable elsewhere than within the larynx. The physical signs then present were the classical ones of early pulmonary tuber- culosis. Arrowsmith (Laryngoscope, Oct., 1910). Actinomycosis of the lungs is found in 20 to 30 per cent, of all cases of actinomycosis. It probably originates in the mouth, and usually takes the form of bronchitis or broncho- pneumonia. The diagnosis is made by finding the "sulphur granules" in the sputum, and the streptothrix un- der the microscope. J. O. Alksne (Deut. Aerzte Zeit., Mar. 15, 1910). 6. Brain. — Here, tumor-like symp- toms exist during life, with headache, paralysis of the abducens, congestion of the optic papilla, and attacks of uncon- sciousness. In a case reported by Ran- son the autopsy indicated the probable mode of infection of the orbit and brain. A sinus was found leading from the orbit to the gum of the upper jaw; the ray fungus had probably lodged in or near a tooth, as it has so often been found to do. The fungus was probably carried into the system on an ear of corn chewed at harvesttime. Having reached the orbit, it crept along its outer wall and in the wall of the right cavern- ous sinus to the base of the brain, ulti- mately setting up meningitis and small abscesses, and burrowing through the pituitary body and sella turcica to the cavernous sinus of the left side. The orbit is very seldom the seat of actinomycosis. A case is reported from von Brun's clinic, and 9 cases 338 ACTINOMYCOSIS (LAPLACE). are cited in detail from the literature. The author's case was the first to be operated upon by temporary resec- tion of the upper part of the cheek- bone, a procedure which is consid- ered superior to Kronlein's resection of the lateral portion of the orbit. The chief symptoms were exophthal- mos and failure of vision in the af- fected eye. There was also lack of mobility of the eyeball. These symp- toms are, however, not pathognomo- nic of actinomycosis, it being essential to an exact diagnosis that the ray fungus be found in the pus. As soon as a diagnosis is made, or there is a well-grounded suspicion of this dis- ease, steps should be taken to radi- cally remove the focus of infection. Miiller (Beitriige z. klin. Chir., Bd. 68, H. 1, 1910). DIAGNOSIS. — When the process is very rapid, actinomycosis may stimulate acute phlegmonous inflammation and os- teomyelitis, or, when widespread, syph- ilis. A study of all cases reported showed that the clinical characteristics vary greatly with the region of the body involved. In the cervicofacial and cutaneous, as well as in many of the thoracic and abdominal, cases the first symptoms noticed were pain and swelling, though the pain was not often severe and may be absent en- tirely. Fever above 101° F. is rare, and examination of the blood shows a leucocytosis, averaging 17,000. In- jections of tuberculin failed to give a febrile reaction. Cervicofacial cases are often mistaken at first for tooth- ache; in thoracic forms the first symp- toms are those of bronchitis or pleurisy, and abdominal cases often resemble appendicitis. The diagnosis should never be positive without finding of the organisms which occur in the sulphur granules of the abscess contents. Al- though the progress of the disease is sluggish, extension is prone to follow by direct involvement of the contiguous tissues or by metastases. W. G. Erving (Bull. Johns Hopkins Hosp., Nov., 1902). Sarcoma. — This form of neoplasm does not suppurate or break down so early. In the jaws it is to be differentiated from dental affections : epulis. Tuberculosis. — In this disease the lymphatic glands are infected, and the apices are usually the first involved. Carcinoma. — The skin or mucous membrane involved is in close connec- tion with the tumor; in actinomycosis the skin will be found broken on micro- scopical examination. Case of a farmer suffering from actinomycosis of the jaw. After the disease existed for upward of a year, a surgeon diagnosed it as cancer, and advised removal of the right half of the lower maxilla. Three months later this patient was exposed to the X-ray treatment for three months, twenty-five applications of the light being made in that time. The treat- ment was perfectly futile. After three months' rest the patient consulted a second X-ray specialist, who gave twenty applications in nine weeks with negative results. Iodine treat- ment, begun two years from the be- ginning of his trouble, was, however, followed by a marked improvement. Heidingsfeld (Cincinnati Lancet- Clinic, Mar. 28, 1903). Many actinomycotic tumors have been removed surgically under the impression that they were due to can- cer, and a cure of the latter hailed in consequence of their non-recurrence. Mercury and the iodides will cure ac- tinomycosis, which is thus often mis- taken for syphilis to the normal det- riment of the patient; the iodide treatment, however, is counseled in all doubtful cases. Poncet and Ber- ard (Lyon Med., Mar. 27, 1904). Syphilis. — A gumma will, in two or three weeks, be sensibly affected by large doses of potassium iodide, which does not act so rapidly in actinomycosis. The undoubted influence exercised by iodide of potassium countenances ACTINOMYCOSIS (LAPLACE). 339 the suspicion that many patients sup- posed to be syphilitic have really been actinomycotic. ■ Poncet (Glas- gow Med. Jour., April, 1S9S). Lupus, — The diagnosis depends, in thhs condition, upon microscopical ex- amination. Ten cases which simulated actino- mycosis, but in which the causal agent was either the Cladothrix lique- faciens or the bacillus described by Sawtschenko. Radical removal of the focus is the only treatment. G. Kle- seritzky and L. Bornhaupt (Archiv f. klin. Chir., Bd. Ixxvi, Nu. 4, 1905). Case of actinomycosis of the big toe, in which there was marked re- semblance of the pathological and microscopical picture to Madura foot. The patient had had inflammation of the big toe, with suppuration of the matrix of the nail, followed some months after its complete subsidence by another thickening of the toe, but without any pain or other disturb- ance. Two years after the shedding of the nail the toe rapidly increased to the triple circumference of the op- posite toe, A^esicles appearing on the skin and undergoing- suppuration. The toe was amputated, and the ex- amination showed the presence of actinomycosis. Kulbs (Wiener klin. Woch., Nu. 2, 1907). The writer was able to differen- tiate actinomycosis by the seroreac- tion in 8 cases, the only negative reaction being in a case in which the cure had been complete for over four years. The specific reaction is both by agglutination and by fixation of complement by means of the spores of the sporotrichum. Actinomyces cultures cannot be used for the tests, but the generic reaction with sporo- thrix spores is constant and lively. It is specific for actinomycosis, sporo- trichosis, and thrush, but these can be readily distinguished. Widal (Bull, de I'Acad. de Med., May 10, 1910). ETIOLOGY. — Both men and ani- mals are probably infected from vege- tables or water (Israel), from eating ears of barley, or rye, when the fungus penetrates through the wound or abra- sion thus provoked, or in many cases through carious teeth. Intestinal acti- nomycosis is due to taking contaminated food or water, when the fungus be- comes implanted upon an already dis- eased tissue, multiplies, and causes ac- tive proliferation of the submucous tis- sue. It may be transmitted by kissing, as in a case reported by Baracz. Farm- ers should be warned against the habit, so common among them, in chewing bits of straw, wheat, oat-chass, etc., the most prolific cause of the disease. Ac- tinomycosis is frequently met with in shoemakers. This is due to their habit of placing their needles in their mouths (Ullmann). Actinomycosis of the lower jaw ac- quired by a toothbrush-maker in the following manner: Hogs' bristles were washed, then held in mouth be- fore sticking into the handle-holes in bundles. Guinard (Bull, et Mem. de la Soc. de Chir. de Paris, T. 26, No. 6, 1900). Total of 72 cases of actinomycosis from American sources collected. Six personal cases, 2 of which had not been previously reported. In one, al- veolar abscess followed chewing wheat-grains with a carious tooth. In a second case a quantity of pus collected in the right iliac fossa. The patient died of malnutrition, having recurred after evacuation. J. Riihrah (Annals of Surg., Feb., 1900). All the reported cases of actinomy- cosis in man carefully studied. The cases are scattered widely through- out the country, though most are re- ported from large medical centers. Less than 20 per cent, come from the Southern States. Males were affected about three times as often as females. The youngest case reported was a child 6 years old; t'.e oldest a man of 70; most are in middle life. Con- 340 ACTINOMYCOSIS (LAPLACE). cerning occupation, there is a wide range, but 36 per cent, had much to do with live stock and grain. The chronic character of the disease was well shown by the fact that in 62 per cent, it lasted over six months. W. G. Erving (Bull. Johns Hopkins Hosp., Nov., 1902). Large number of cases collected in which actinomycosis which had re- mained latent throughout pregnancy suddenly took on a very rapid de- velopment as soon as this was ended. The curative action of iodine on the disease and the frequent disturbance of iodine metabolism in pregnancy and the puerperium may have some- thing to do with this relation. Theve- not (Revue de Chir., No. 9, 1906). Primary invasion of the skin and subcutaneous tissues by Actinomyces bovis is of rare occurrence. The cases number less than 20. Even some of these may have been due to secondary rather than primary in- vasion of the skin. Personal case of actinomycosis of the skin of the foot. Leser was the first to arouse interest in this particular localization by the publication of 3 cases. Leo Buerger (Amer. Jour. Med. Sci., Nov., 1907). In the case reported a scrap of a head of barley was found sticking in the tissue of the sublingual gland, the outer end in one of its excretory ducts. Soderlund (Upsal a Lakare, Forhandlingar, vol. xiv, Nos. 3-4, 1909). Only 6 cases for actinomycosis of the ovary are on record, and none of these are primary. Case of the latter kind in a patient who had lived in London for 16 years, but in 1903 and 1904 was brought into contact with hay, straw, and corn, the usual sources of actinomycosis, and it is noteworthy that the symptoms date from 1904. As there was no evidence of disease in any adjacent organ, the streptothrix must have reached the ovary by way of the blood-stream, the mode of entry into the body be- ing, the authors suggest, some cryto- genic focus — e.g., the tonsil, through which, it is well known, micro-organ- isms may pass into the blood-stream without producing any local lesion. Taylor and Fisher (Lancet., Mar. 13, 1909). The writer has observed a number of cases in which latent actinomy- cosis was roused to active prolifera- tion by some intercurrent trauma. He has also found similar instances in the literature. There may be an interval of j^ears between the trauma and the manifest actinomycotic proc- ess; in one case seventeen and in an- other ten years had elapsed, and intervals of five and ten years are by no means uncommon. Noesske (Med. Klinik, Mar. 27, 1910). PATHOLOGY.— The actinomyco- ses -were formerly thought to be mold fungi (hyphomycetes), but Bostroem, in 1885, proved by cultivating them that they were a variety of cladothrix, be- longing to the schizomycetes. Comprehensive study on the biol- ogy of the branching filamentous micro-organisms isolated in pure cul- ture from 13 cases in man and 2 in cattle of actinomycosis. The writer considers the organisms to be all of one species, essentially an anaerobe, growing well only in agar and bouil- lon and in the incubator. He found that the filaments took on the "club" appearance only when grown in im- mediate contact with animal fluids or Avithin the animal bod3^ Experi- mental inoculation caused the forma- tion of tumor masses of small sizes, which showed but little progressive tendency. The organism could be re- gained, but there was little evidence that multiplication had taken place within the animal. The writer considers Actinomycosis bovis to be the proper name for the organism. He does not accept the prevalent belief, based on the work of Bostroem, Gasperini, and others, that the specific infectious agent of actinomycosis is to be found among certain branching micro-organisms widely disseminated in the outer ACTINOMYCOSIS (LAPLACE). 341 world, which diflfer profoundly from Aciinoiiiycosis boz'is in having spore- like reproductive elements. On ac- count of the fact that the organism he describes docs not grow on all culture media, and practically not at all at room temperature, he does not believe that it has its usual habitat outside of the bod}-. The organism is a normal inhabitant of the secre- tions of the buccal cavity and of the gastrointestinal tract. The part played by foreign bodies is in the formation of a nidus where the actinomycoses de- velop to form actinomycosis, and he does not think that straw and like foreign bodies so frequently found in actinomycotic lesions are the carriers of the micro-organism. The "club'' formation about the filaments is a protective function. The bacteria so frequently found ac- companying the disease are important in the spread and continuance of the infection, forming new sinuses, to be reinfected with Actinomycosis bovis from the alimentary canal. J. H. Wright (Jour, of Med. Research, vol.. xiii, p. 349, 1905). The mass is made up of granulation tissue, which, except for the presence of the ray fungus, would be mistaken for a round-celled sarcoma. Epithelioid ele- ments and giant cells are also seen. In the granular mass, or in the pus coming from a case of actinomycosis, the fun- gus itself appears under the form of small, yellow, brown, or even green masses, about a pinhead in size, which, on microscopical examination, are found to be composed of a central interwoven mass of threads, from which radiate club-shape-ended rays ; in some speci- mens certain rays project far beyond the others. In man the clubbed bodies are frequently absent (Senn). The his- tological lesions are alike in the actino- mycotic nodule and in the tuberculous . follicle; only the foreign body differs. Water or a weak solution of sodium chloride causes the rays to swell enor- mously and lose their shape ; ether and chloroform have no action upon them. The yellow grains are not always to be found in fistulas, etc., unless they are carefullj^ sought in scrap- ings, etc. An early diagnosis is es- sential, since later the disease may be beyond the resources of therapy. A. Poncet and L. Berard (Le Bull. Med., Mar. 28, 1900). Case in which microscopically there was no appearance of the ray fungus in the fresh pus, and yet mi- croscopical examination showed the presence of fungus at once. The ab- sence of the typical grouping of the micro-organisms is not sufficient to exclude the diagnosis of actinomy- cosis, as the micro-organisms tend to arrange themselves in different ways at different times. W. Silber- schmidt (Deutsche med. Woch., Nov. 21,1901). At a certain stage there are in every colony three elements, viz. : — 1. Club-shaped formations. 2. A centrally placed network of fungous filaments of varying shape and size. 3. Fine coccus-like bodies (spores), which originate from the fungous fila- ments, and grow into long rods and branching twigs. Two types, the typical and atypical, should be recognized, according to Ber- estneff. Typical actinomycosis is the disease in which occur the charac- teristic mycelial masses, having club- shaped radiations. Atypical actinomy- cosis includes such diseases as Nocard's farcin de bccuf, and infections which clinically and anatomically resemble ac- tinomycosis, and are caused by branch- ing mycelial organisms which corre- spond quite closely to the cultural pecu- liarities of the streptothrix actinomyces, but fail to form the characteristic grains in the tissues and pus. 342 ACTINOMYCOSIS (LAPLACE). Case of streptothricosis, a disease of man or animal due to one of the various forms of streptothrix. The manifestations of the disease probably differ in accordance with the forms of causative organism. If organisms of thread form are present the surgeon can be reasonably sure of the diagnosis. If the threads are branched he can be certain of it. The ray fungus is sel- dom found in humans, and is not in- variably found in bovine streptothricosis. The appearance of the disease varies with the stage in which it is seen. A description of the surface appearance ■jrM&Mm^smm a, Ray-fungus or masses, showing central myce- lium of actinomycosis. 6, White blood-corpuscles, showing their relative size. (Poneet and Bc'rard.) of an early stage would by no means fit a well-developed or an advanced case. The appearance is greatly changed by mixed infection with pyogenic bac- teria. A severe secondary pyogenic infection may obliterate all appearances suggestive of streptothricosis, and in such a case it may be impossible to demonstrate the streptothrix. Certain persistent abscesses, particularly ab- scesses connected with the alimentary tract, are due to streptothrix infection and secondary infection with pyogenic bacteria. J. Chalmers Da Costa (An- nals of Surg., July, 1911). Staining, — The following stains have been used : — Wedl's orseille (Weigert). Eosin (Marchand). Cochineal — red (Dunker and Mag- nussen). Hematoxylin alum (Moosbrugger). Gram's method — section staining (Partsch). Safranin in aniline oil, followed by K. L (Babes). Solution of orcein in acetic acid (Is- rael). Picrocarmin — fungus, yellow; other parts, red (Baranski). The actinomyces in a section are best shown by Gram's method, first with methyl violet, then with Bismarck brown (Tillmann). Cultivation. — It is quite difficult to cultivate in coagulated blood-serum (O. Israel), coagulated blood-serum and agar-agar (Bostrom), and coagulated egg-albumin and agar-agar (Wolff and J. Israel). INOCULATION.— It has been suc- cessfully carried out by James Israel and Ponfick, from tissue and from pure cul- tures. Opinions differ as to its power of producing pus, a secondary infection by the pus-germs being thought the true cause of the pus sometimes found with actinomycosis. Dissemination by the lymphatic system never occurs. Glan- dular enlargement indicates secondary infection. L Cutaneous Surface. — Around the primary lesion are small secondary le- sions. Two forms are described: (a) The anthracoid, which pursues a rapid course, with fever, and sometimes sep- ticemic in character. It is characterized by flat tumefaction, with multitudes of small openings with yellow granula- tions, from which thick pus exudes. (b) The ulcerofungous, which pursues a subacute course, with tendency to chronicity. In the face it tends to form ACTINOMYCOSIS (LAt»LACE). m burrowing abscesses instead of recog- nizable tumors. 2. Bronchial Tubes and Lungs.— Some observers believe that the peri- bronchial lymphatic vessels and glands disseminate the fungus or its spores in the lungs ; when the fungus reaches the lung-tissue proper, granulation tissue is formed, which, through secondary in- fection, suppurates. Amyloid degenera- tion of other organs may occur, or 6 00 Q a O m^ Actinomycotic growths in the liver in man, according to Crookshank, have a characteristic naked-eye appearance, from their peculiar honeycombed struc- ture. The cases between the fibrous tra- beculc-e are full of caseous matter, in which the more or less spheroidal masses of the fungus are imbedded. In museum specimens, which have been for some time preserved in spirit, the con- tents of the loculi may have fallen out, H m' Ray fungus {c.c.c), club-shaped bodies {d pus of actinomycosis. metastasis of the disease, in case a pul- monary vein has been pierced. At times the pericardium or peritoneum becomes affected (Strlimpell). 3. Alimentary Canal. — In the jaws the mass usually resembles a sarcoma, but, if incised before secondary infec- tion and suppuration has occurred, the reddish surface will be seen to be inter- mingled with yellowish spots, which are collections of actinomyces. In the intestines the fungus causes proliferation of the submucous tissue, and whitish patches. External fistulse are commonly found. ,d.d), and spores (a, a, a) found in the (Poncet and Berard, ) and the honeycombed appearance is then much more marked than in recent speci- mens. The writer having noted the fre- quency of the organisms in sputum, their faihire to grow at other than body temperature, and the lack of convincing evidence that the disease was contagious, these facts suggested that the infection arose within the individual. The prevailing location of the diseases about the jaw or neck pointed to the mouth as the source of infection. In addition, the history of much trouble with the teeth, pre- ceding the infection, was conspicuous in two of the author's cases of acti- 344 ACTINOMYCOSIS (LAPLACE). nomycosis. Following this line of thought, he made careful micro- scopic, cultural, and biological exam- inations of the contents of carious teeth removed in 16 examined cases. In all 11 cases by cover-slip prepara- tions, Gram-staining filaments mixed with other bacteria were found. Se- rial sections studied in 5 cases were positive. The organisms were pres- ent in such numbers as to suggest that they play a fundamental part in dental caries. Lord (Boston Med. and Surg. Jour., July 21, 1910). PROGNOSIS.— The prognosis is se- rious in proportion to the rapidity with which suppuration occurs. Actinomy- cosis of the upper jaw is more serious than actinomycosis of the lower jaw, as it has a greater tendency to invade the deep structures. Internal actinomycosis is almost always fatal, owing to its in- accessibility. External actinomycosis may cause death from pyemia, septice- mia, and exhaustion. When so placed as to be easily removed and treated early the prognosis is favorable. A per- manent recovery usually follows a com- plete removal of the primary focus, as metastasis is rare (Senn). Actinomycosis has a pronounced tend- ency to spontaneous recovery except in internal organs (Schlange). From an analysis of 60 cases the fol- lowing conclusions are reached : When the disease involves the head and neck, except in a few cases when the base of the skull is invaded, the course is favor- able, recovery taking place in from three to nine months. It is exceptional for the fistula to persist or to form anew after the lapse of a year. Pulmonary actinomycosis may terminate in recov- ery. The prognosis of actinomycosis is the more favorable, as the anterior ab- dominal walls are involved and the posterior escape. Death usually results from amyloid degeneration and wasting. If actinomycosis presents pyemic mani- festations, a fatal termination is to be expected, as a number of vital organs are likely to be involved. Actinomy- cosis may pursue a chronic course, continuing thirteen years or longer, if functionally important organs be not involved, as when the process confines itself to the connective tissue about the spinal column. The prognosis, as shown by a study of all cases reported, depends largely upon the location of the disease, the pulmonary cases showing the highest mortality, the cervicofacial the low- est. W. G. Erving (Bull. Johns Hop- kins Hosp., Nov., 1902). The prognosis is now much better than formerly, some cases recovering spontaneously. If surgical treatment is not possible the prognosis is grave, but not always hopeless. If the dis- eased tissue can' be reached it should be incised, scraped, cauterized with nitrate of silver stick, the cavity packed with iodoform gauze, and io- dide of potassium given internally in large doses. The X-ray should sub- sequently be used. Bevan (Annals of Surg., May, 1905). TREATMENT.— 1. General.— Po- tassium iodide was found useful in animals by Thomassen and Nocard. In man it should be thoroughly tried before surgical intervention is resorted to, es- pecially when the disease is so extensive as to prevent complete removal by surg- ery. The results obtained from iodide of potassium have been remarkable in some cases and negative in others. This divergence of views, according to Fer- net, depends on the variation in the vir- ulence of the disease, in its evolution in different individuals, in the difference existing in the receptivity of the tissues, and on the influence of secondary in- fective processes. In recent and purely actinomycotic lesions the results may be ACTINOMYCOSIS (LArLACE). 345 excellent ; in old-standing cases, and ■where the ray fungns is associated with streptococci, staphylococci, and the bac- terium coli cominune, the drug treat- ment is less successful. According to Berard, in two-thirds of the cases of chronic actinomycosis of the face and neck the results of iodide, treatment are /;//. In three-fourths of the recent cases recovery has been ob- tained by it, combined with surgical treatment, and in one-fourth by iodide treatment alone. Potassium iodide can- not be regarded as specific in actinomy- cosis in man. If, at the end of some weeks, improvement is slight only, oper- ative interference should be carried out at once. The drugs which are the most suc- cessful in pulmonary actinomycosis, in the opinion of Sabrazes and Cabannes, are potassium iodide and eucalyptus. If there is any involvement of chest wall, surgical treatment should be undertaken. Four cases, in one of which the tumor was situated below the angle of the scapula. All the patients were given iodide of potassium, and the wounds were treated with peroxide, tincture of iodine in full strength or solution, and packed in iodoform gauze until all evidence of presence of the fungus had disappeared. J. C. Munro (Boston Med. and Surg. Jour., Sept. 13, 1900). The injection of a 5 per cent, solution of permanganate of potassium into the cysts has been of advantage. Case of actinomycosis of the face which was cured by hot compresses (temperature, 63° C, or 145° F.) and carbolic acid injections. The first dose of the latter was 12 c.c. of a 3 per cent, solution. The compresses were continuously applied day and night, being changed every ten min- utes. A. Strubell (Miinch. med. Woch., May 8, 1900). Wiiilc potassium iodide in connec- tion with the X-ray exerts a curative effect in superficial actinomycosis, this treatment is, to a great extent, without avail in pulmonary and ab- dominal involvement. Hence copper sulphate, which is used to destroy the fungi of grain and other vegetable parasites, tried in doses of i/^ to 1 grain three times a day. Good results obtained both in blastomycosis of the skin, where the copper is given internally and used as a wash of 1 per cent, strength for the lesions, and in actinomycosis, where it is also given by mouth, and a 1 per cent, so- lution is employed in irrigation of sinuses. A mixed treatment of cop- per and iodine salts may prove most effective in certain cases. A. D. Bevan (Jour. Amer. Med. Assoc, May 20, 1905). Great difference of opinion exists as to the value of iodide of potassium in the treatment of actinomycosis. The important point is to use the drug at a time when there is a chance of eradicating the disease. Cases in the advanced stages of the disease may be benefited by its use, but the possibility of a cure is an extremely remote one. Whether the simple treatment of opening the abscess and draining it would be sufficient for a cure, it is impossible to say, but in this case the fact remains that the patient did not begin to improve until she was thoroughly under the influence of the drug. The action of the iodide in this disease is unknown; , possibly by promoting absorption of) inflammatory products as they are formed it may check the spread of the disease. So far as known, it can have no specific action on the organ- ism of actinomycosis. Iodides are largely used in the treatment of this disease in veterinary practice, and many cures have resulted. Knox (Lancet, Nov. 3, 1906). Actinomycosis of the appendix is usually chronic and may last for years. If possible, the cecum and neighboring bowel should be sacri- ficed for a thorough removal of the 346 ACTINOMYCOSIS (LAPLACE). disease. Usually all that can be done is to open abscesses as they point, and to give internal remedies, as po- tassium iodide, etc. Short (Lancet, Sept. 14, 1907). Six cases of actinomycosis appar- ently cured by injections of sodium cacodylate. The infection originated always from the cavity of the mouth, with localization of the abscesses and infiltration on the tongue ; the neck, with perilaryngeal spreading; in the regio temporalis, with spreading to the base of the skull, and of the lower jaw, with spreading to the submaxil- lary glands. On the first day a 10 per cent, watery solution (^ of a Pravaz syringeful) was injected intramus- cularly in the nates, increasing each day J4 syringeful until a full syringeful is given during one week, and then decreasing the quantity to the Y^ syringeful, and then commencing over. The local measures are con- fined to puncture or little incisions for abscesses. More extensive opera- tions are avoided. Foederl (Zen- tralbl. f. Chin, Bd. xxxv, p. 45, 1908). Experience in 56 cases in which treatment was by iodide alone, with 34 cures; 94 with operation alone, with 75 cures; 109 with excision plus iodide, wnth 60 cures, and 30 in which treatment was by other measures, with 25 cures. All but 46 of the cured patients have been re-examined re- cently. The writer calls attention to the fact that the deaths during the years since were, in many cases, re- ported as having been due to tuber- culosis, while there is a possibility that the supposed tuberculosis may have been merely a metastasis in the lung from the old actinomycotic in- j^fection in some of these cases. His conclusions from a review of nearly 300 cases are that actinomycosis, when circumscribed, should be re- sected like any other tumor. If this is not possible, or if the afifection is diffuse, he advocates administration of sodium iodide internally, with partial resection. His experience in one case encourages further trials of tuberculin in actinomycosis, as the cure in this case can be ascribed, he thinks, only to the course of tuber- culin treatment. The iodide does not require such large dosage as some ad- vocate; his preference is for 1 Gm. the first day, 2 Gm. the second, 3 Gm. the third (from 15 to 45 grs.), repeat- ing the same succession after suspen- sion for three days. Sometimes he gave from 2 to 5 Gm. a day in pow- ders, supplemented by local applica- tions of a 10 per cent, solution of sodium iodide. Maier (Beitrage z. klin. Chir., June, 1909). 2. Surgical.— Local measures which do not completely remove the infected tissues do harm, as they frequently give rise to secondary infection, rapid exten- sion, and death. Cauterization with solid silver nitrate in actinomycosis of skin and soft parts in which suppuration and fistulous tracts have occurred possesses a specific action on the actinomycosis (Kottnitz). 3. Electrotechnical. — Two platinum needles, attached to the two poles of a constant-current battery, are to be in- serted into the tumor. Through the two needles a current of 50 milliam- peres is to be passed, while every min- ute some drops of a 10 per cent, iodide of potassium solution are to be injected into the mass. The solution is decom- posed into nascent iodine and potas- sium. This is repeated every eight days, each session lasting twenty minutes, un- der an anesthetic (Gautier). Before suppuration all diseased tis- sues, glands, etc., should be removed and the parts, when possible, cauterized with the thermocautery. After suppuration the parts should be treated as if they were tuberculous, curetting and packing with iodoform gauze. Ernest Laplace, Philadelphia. ACTOL. ACUPUNCTURE. ACUTE RHINITIS (SCARLETT). 347 ACTINOTHERAPY. Sec Light. ACTIVE HYPEREMIA. See Ihi'EREMiA, Bier's Treatment by. ACTOL or silver lactate, occurs in the form of a white powder, odorless and almost tasteless, which is soluble in 15 parts of water. Its color is changed when ex- posed to the light. Applied to the tissues, it causes coagulation of the proteids, in com- mon with the nitrate of silver. THERAPEUTICS.— Actol has marked antiseptic and disinfectant properties, ac- cording to the strength of solution used. In solutions of 1 in 500 to 200 it is used as an antiseptic for wounds. For infected wounds it may be employed as a disinfectant in stronger or even saturated solutions. But little discomfort is caused when the powdered silver lactate is applied to open surfaces. It is claimed to have a deep-seated effect "by penetration to the subjacent tissues, though known to be decomposed into other com- pounds when in contact with the superficial cells. Actol has also been used' internally as an antiseptic. It has been found effective in diminishing intestinal putrefaction, at the same time causing a tendency to constipation. Some have even employed it internally and hypodermically for a general antiseptic action- throughout the organism. Sixteen grains (1 Gm.) have been injected subcutaneously without serious results. S. ACUPUNCTURE.— This proced- ure is principally used for the relief of tension in edematous or congested tissues. It is especially useful in edema of the scro- tum, labia, and extremities when the tissues are sufficiently distended to threaten slough- ing. Acupuncture is also employed for the relief of pain in neuritis and muscular rheu- matism, especially in sciatica and lumbago ; the benefit afforded, when such is obtained, is due mainly to reflex contraction of the blood-vessels "t)f the area, thus reducing the congestion of the nervi nervorum and the sensory terminals to which the pain is due. In edema, the benefit is the direct result of the abstraction of considerable blood-serum imprisoned in the tissues. TECHNIQUE. — The instruments em- ployed are a very small narrow-bladed bis- toury and surgeons' needles. The part should be carefully sterilized by first washing it with soap and water and then bathing it with alco- hol or a 1 : 2000 solution of mercury. The operator's hands and instruments should like- wise be carefully sterilized. These pre- cautions are very important in view of the fact that edematous tissues are readily in- fected. If the patient is very sensitive to pain, the part may be anesthetized with ethyl chloride. For edematous tissues the small bistoury is the better instrument, one or two stabs, or, in large areas, many such, being practised, avoiding blood-vessels. A compress dipped in a warm 5 per cent, solution of boric acid is then applied to encourage escape of the serum. These must be frequently changed and the tissues kept very clean, as otherwise fetor soon appears. For muscular rheumatism, especially lum- bago, a number of round needles are thrust into the painful area from 1 to 2 inches, according to the fat overlying the part, and left in situ from five to ten minutes. The pain often ceases at once. Great care should be taken, on withdrawing the needles, not to break them, lest fragments remain in the tissues. ' In neuritis, sciatica, etc., the needles, several of them are thrust into the nerve sheath at intervals (not a difficult pro- cedure in large nerves) and ^eft in situ about five minutes. A fine hypodermic needle may be used, among the ordinary needles, with advantage, in the same way, and increase the efficiency of the treatment by being used to inject a little sterile water, which acts as an analgesic, or, if the pain be very severe, morphine. This treatment is efficacious in most instances where other measures have failed. S. ACUTE RHINITIS, OR ACUTE CORYZA— DEFINI- TION. — An acute inflammatory condi- tion of the nasal mucous membrane, in which repeated attacks predispose to the extension of the inflammation to the neighboring cavities, as the pharynx ; the larynx ; the lower air passages ; and to a lesser degree, to the accessory sinuses of the nose. SYMPTOMATOLOGY.— The ear- liest manifestation of an acute rhinitis 348 ACUTE RHINITIS (SCARLETT). is a sensation of dryness or irritation in tlie nose, which later becomes of an itching, tickhng, or stinging character. \"ery often the attack is ushered in by a preliminary chill or "z creepy feeling." Sneezing is an early symptom, and is soon followed by a sensation of fullness in the nose, with subsequent obstruction to nasal breathing, and a dull throbbing headache over the site of the accessory cavities. A general feeling of illness, with aching in the limbs and back, fre- quently prevails. The sense of smell and taste are interfered with. Hearing is often markedly impaired, owing to the involvement of the mucous mem- brane at the orifice of the Eustachian tube, or the extension of the inflamma- tion through the tube into the middle ear. The voice is also altered and assumes a nasal intonation. There is a noticeable loss of resonance v/hich characterizes the normal voice, and the sounds of w and 11 cannot be readily produced. The skin is dry and at times becomes hot from the presence of fever. Thirst and anorexia are also asso- ciated symptoms. The urine is scant and high colored. The existing consti- pation is usually responsible for the presence of the furred tongue. The eyelids are more or less swollen from the existing congestion, and a profuse lachrymation is not infrequently present from the extension of the inflammation through the nasolachrymal duct. The membrane of the nose is red, swollen, dry, and glazed, and is unduly sensitive. The nasal passages are practically oc- cluded by the swelling of the membrane and the erectile tissue of the turbinates to the capacity of the fossae, thereby greatly interfering with the normal physiological functions of the nose, as well as with that of deglutition. Owing to this existing obstruction, nursing infants at times manifest considerable difficulty in obtaining sufficient nourish- ment. The nasal discharge at first is scant, or it may be entirely absent, but it soon becomes copious, is clear, and, owing to the presence of an excessive amount of salines in its composition, it becomes very irritating to the skin of the upper lip and the nasal alse; in fact, the irri- tation not infrequently becomes so marked as to cause excoriation, or even cracking, of the bordering cutaneous surfaces. This condition, no doubt, is often very much aggravated by the frequent use of the handkerchief. As the disease progresses, the dis- charge becomes opaque, mucopurulent in character, thick and tenacious, and of a greenish-yellow color. A micro- scopic examination of the discharge shows a marked increase in the corpus- cular elements. No sharp line of demarcation exists between the second and the terminal stages of this disease. In three or four days the discharge gradually becomes thicker and scantier; the swelling of the membrane subsides; the constitu- tional manifestations gradually lessen and finally disappear; the special senses assume their normal activity, and in the course of a week or ten days all traces of the disease disappear. A significant feature of acute rhinitis is the possibility of the antrum of High- more, the frontal sinus, the ethmoid or the sphenoid cells, the Eustachian tube, or the middle ear becoming the seat of disease as the result of the extension of the inflammatory process. The naso- pharynx and the pharynx invariably become involved, partly through the extension of the inflammation by con- tinuity* and partly from the interference with the normal function of the nose. ACUTE RHINITIS (SCARLETT). 349 DIAGNOSIS. — The recognition of this condition, as a rule, is seldom fraught with many difficulties, and the diagnosis in most cases is usually made with considerable ease. It is important, however, to guard against the possibil- ity of a mistake by making careful in- quiry into the history of the attack, and also by making a cautious examination of the nasal cavities in order to distin- guish between a simple acute catarrh and a rhinitis as the result of measles, influenza, nasal diphtheria, hereditary syphilis, a foreign body, a tumor, and iodism. Cases of measles and in- fluenza will invariably show a higher temperature and greater constitutional disturbances, and in the former case the appearance of the rash will elimi- nate all doubt of the cause of the exist- ing nasal condition. Nasal diphtheria can be recognized by the existence of the characteristic grayish membrane in the anterior nares and in the throat, associated with the usual constitutional symptoms. In the absence of the mem- brane, strong evidence of the condition continues to exist in the blood-tinged discharge, but a positive diagnosis can be obtained only by culture. The "snuffles" of hereditary syphilis is usu- ally found in very young children, with concomitant symptoms of this infec- tion, i.e., malnutrition, glandular en- largement, and in older children the characteristic Hutchinson's teeth. A foreign body or a tumor can be detected on examination, and in cases of iodism a careful history will elicit the fact that a considerable quantity of the drug has been taken. Cases of acute rhinitis are occasion- ally encountered in which the causative agent is some chemical irritant. The diagnosis should not be difficult, as con- stitutional symptoms are rarely resent ; the duration of the attack is seldom, if ever, as long as the ordinary cases ; and with the withdrawal of the cause the condition invariably subsides. The patient seldom seeks treatment for acute rhinitis much before the end of the first or the beginning of the second stage of the disease, and then gives a history of exposure, quickly followed by the nasal discomfort and the rapid development of the disease. This history, in conjunction with the more or less characteristic appearance of the conditions within the nasal chambers, will usually be sufficient evidence for a positive diagnosis. ETIOLOGY.— Predisposing Causes. — If careful observation were made in each case of acute rhinitis, it would, no doubt, frequently be seen that the at- tack occurs when the resisting powers of the body are below par. Under normal conditions a certain equilibrium is maintained for the production and the elimination of the waste products of the body; but, when, for some reason, the normal function of this apparatus is interfered with and there occurs a faulty elimination of the waste products or an overproduction of the same, body resistance is lowered and susceptibility to disease becomes more marked. This condition is undoubtedly often en- couraged by indiscreet action of the patient in regard to diet, causing digest- ive disturbances, torpid liver, and con- stipation, in which the consumption of food is out of proportion to the com- bustion, thus causing an autotoxemia, in which there is sometimes a marked evidence of uric acid. It is at this time that a coryza may be considered the nasal signal of systemic poisoning, for the blood will be found tainted with the products of faulty oxidation. Strong evidence of this condition will also be 350 ACUTE RHINITIS (SCARLETT). found in the examination of the urine, in which uric acid or mixed urates will be present. With such lowered resistance, one becomes easily affected by conditions such as prolonged confinement in an ill- ventilated room, extreme physical ex- haustion following overwork, or a se- vere mental strain. A lowered nerv- ous tone; interference with the normal activity of the sudoriferous glands, and the absence of a natural coverinsr for the head, as in baldness, are oft- times important predisposing factors. Acute coryza is the result of a triple pathogenetic alliance — a chronic rhinitis, a chronic intestinal toxemia, and an exposure to an accidental stress of some kind, not necessarily thermo- metric or hydrometric, for just as effective as these are others of an emotional, dietetic, dynamic, or micro- bic nature. Although in all cases the general principles of treatment will be the same, considerable discrimination in the matter of detail must be exer- cised in the individual case, because of the varying nature of the exciting cause. Grayson (Therap. Gaz., May, 1909). It is not uncommon to find in some patients showing a disposition to fre- quent colds some underlying patholog- ical condition within the nose, such as deviation of the septum, a stenosis, or a hypertrophic rhinitis, thus causing the current of air to be misdirected in such a way as to act as an irritant upon a more or less sensitive membrane, which is usually below par as the result of recurrent attacks. When frequent and persistent attacks occur in childhood, a careful examina- tion of the nasopharynx will sometimes show the causal agent to be the exist- ence of adenoids. Acute rhinitis is not in- frequently found in infants under three months and those who are sufferinsf from malnutrition, as in rachitis. It is also thought by a noted pediatrist to be a complication of dentition. In suscep- tible children, the cause is often very trivial. A curious fact exists in that this affection is seldom found in old people. An hereditary tendency seems quite apparent in some cases, notably in chil- dren. In the majority of cases, how- ever, the direct cause can be traced to an improper mode of living. The child gets very little fresh air; is confined in a room which is improperly venti- lated, usually overheated; the windows of the bedroom are kept carefully closed at night for fear the child may catch cold; the clothing is very often in excess of what is really needed, thus making it impossible for the individual to indulge in any active play with- out producing a profuse perspiratiom Under these conditions the mucous membrane, especially of the nose and throat, soon becomes very sensitive and the child is a frequent sufferer of colds. Evidence sometimes point to such chronic conditions as asthma, hay fever, rheumatism, tuberculosis, and syphilis as being factors in the production of acute rhinitis. Attacks in some persons can be attributed only to their idiosyn- crasy. Excessive sexual indulgence often shows a predisposition to pro- voke an attack, as do gastric and in- testinal diseases, and a neurotic tend- ency. Thermic and climatic condi- tions are sometimes to be considered. Exciting Causes. — Although certain depraved conditions of the body may be said to predispose to attacks of acute rhinitis, usually there are certain causes to which the attack may be definitely attributed. Exposure to cold and wet when the body is overheated ; exposure to sudden or extreme changes in the atmosphere; the wetting of the feet ACUTE RHINITIS. (SCARLETT). 351 when the system is debihtated from other diseases; or the chihing of the body from any cause, especially as the result of sitting in such a position as to allow a draft of air to strike the back of the neck or head. This seems to support the theory advanced by some that the impression of cold on certain parts of the body produces an inhibi- tory effect upon the vasomotor nerves controlling the blood supply of the nasal mucous membrane. The inhalation of certain irritating chemical fumes, such as those of iodine, chlorine, bromine and hydrochloric acid may result in a coryza. Sometimes the mere inhalation of irritating dust may produce an attack. Foreign bodies in the nose ; or certain drugs, as ipecac and the iodides, may produce the same effect. Wagner is of the opinion that the inflammation is not infrequently the result of migration of bacteria from diseased tonsils. The examination of the nasal secretion often shows the "presence of a variety of micro-organ- isms, chief among which are the Micro- coccus catarrhalis, the Bacillus septus, the Bacillus Friedldnder, and the Bacil- lus segmcntosus of Cautley. There are several kinds of organisms capable of causing a cold. This term does not, therefore, answer to one specific malady, but connotes several distinct maladies which it is convenient to group together under a generic name. Among the more common "cold" organ- isms are the following : Friedlander's bacillus ; the Bacillus septicus; the bacillus of influenza; the Micrococcus catarrhalis. These organisms give rise in the susceptible to specific febrile dis- orders; but, unlike the exanthemata, these disorders do not confer immunity for more than a very limited period, sometimes for not more than a few weeks. Campbell (Practitioner, Oct., 1909). The evidence seems indicative that the diphtheroids, particularly Bacillus segmcntosus of Cautley, are concerned in the production of so-called common cold in its typical manifestations in the nose, and there is much evidence that it occurs in epidemic form. The Micro- coccus catarrhalis is much more general in its manifestation, and is, probably, also epidemic and prodiictive of a rather more severe inflammation, though mild epidemics occur. It seems likely that the symbiosis of these two organisms increase the virulence. The pneumo- bacillus of Friedlander is much more concerned in chronic conditions and is probably identical with the ozena bacil- lus. The pneumococcus of Frankel flourishes in any part of the upper re- spiratory tract and, when virulent, has been found in pure culture. Clinically, the segmcntosus infection is most likely to be in the nose, seldom in the trachea, but may cause otitis media ; Micro- coccus catarrhalis is most apt of all to invade the larynx and trachea, but may occur, in the ear or nose and with variable virulence. The pneumobacil- lus is mostly confined to the nose and sinuses. Influenza is conspicuous by its absence. Pyogenic cocci are non-patho- genic locally, except as secondary in- vaders, and the probability is that only a limited number of strains are con- cerned in causation of acute infections of the mucosa, and these are not gen- uine coryza. The bacterial flora of the nose in America probably do not differ materially from those of other coun- tries, but must of necessity be governed largely by environment, occupation, social position, and epidemics as to the ratios of finding. W. Walter (Jour. Amer. Med. Assoc, Sept. 24, 1910). Whenever the disease is at all preva- lent, suspicion arises as to the pos- sibility of it being contagious or pro- duced by some infectious material in the air. It not infrequently ushers in an attack of bronchitis, laryngitis, or one of the acute infections, such as influenza, measles, t3^phoid fever, small- pox, or whooping-cough. 352 ACUTE RHINITIS (SCARLETT). PATHOLOGY.— An acute rhinitis is characterized by the same patho- logical changes which take place in in- flammation of the mucous membrane elsewhere in the body, and may be con- sidered in three stages. Stage of Engorgement. — During this stage the mucous membrane is swollen and rather dark in color. The normal secretion at first is decreased, or even entirely arrested, and there occurs a proliferation of the epithelium. If the microscope could be used at this time, the blood-vessels would be seen to be markedly dilated and there would be more or less stasis of the blood-stream, permitting the adhesions of leucocytes to the blood-vessel walls. Their final penetration into the surrounding tissue is the beginning of the next stage. Stage of Exudation.— With the mi- gration of the leucocytes into the interstitial tissue, there is also a tran- sudation of altered blood-serum and a forcing out of erythrocytes. The dis- charge that follows is usually profuse ; at first it is a mixture of mucus and serum, but this soon becomes of a mucopurulent type and finally purulent. Stage of Resolution. — This is char- acterized by the restoration of the normal function of the mucous glands, the secretion from which causes the dis- charge to become thicker and more opaque. The exudate within the mu- cosa is gradually absorbed, the lost epithelium in time is replaced by new cells, and the membrane is slowly re- duced to its normal size. PROGNOSIS.— This depends upon the severity of the attack and the extent to which the tissues are involved. The simple cases usually recover in the course of a few days to a week without any detrimental results. In some few cases, however, certain changes may take place in the tissues and increase their tendency to recurrent attacks. The prognosis becomes less favorable for an early recovery if the inflamma- tion should extend into any one of the accessory cavities of the nose and cause a suppurative process, or if there should occur an involvement of the middle ear by extension through the Eustachian tube. TREATMENT.— The treatment of acute rhinitis may be prophylactic, abortive, or curative, depending upon the cause of the attack. Persons who show a predisposition to recurrent at- tacks of coryza should guard the body against such conditions as favor their onset. The protective agencies of the body should be strengthened by regular and systematic exercise, especially in the open air, and should be of the nature of horseback riding, golf, ten- nis, or something as vigorous. Gray- son recommends, instead of medicine, good vigorous exercise several times a day, claiming that "the quickened capillary circulation and vigorous action of the sweat glands that accompany hard exercise are incomparably more beneficial than the merely passive leak- age that follows the use of diaphoretic drugs. If in addition to this an abun- dance of water is drunk and the supply of food is greatly reduced — almost stopped in fact — we may look for an amelioration of all the coryza symp- toms in a much shorter time than if our main reliance is vested in quinine, bella- donna, and opium combinations, that have had too long a vogue." Proper discretion in diet should be practised, particularly by those who are victims of uric acid diathesis. Cold bathing, gradual at first, is an effi- cient stimulant to the relaxed vascular system. Proper selection of underwear ACUTE RHINITIS (SCARLETT). 353 and clothing, especially for outdoor service, should be made. If the patient is seen in the early- stages, in the first few hours, the attack may be abbreviated, or the duration, at least lessened, if the proper treatment is immediately instituted. The patient should be given a mustard foot-bath, 4 grains of quinine, 10 grains of Dover's powder, a hot lemonade, and then put to bed with a liberal covering of bedclothes to encourage free per- spiration. This should be followed by active catharsis. The above treatment will usually necessitate the keeping of the patient in the house at least the following day. Recent investigations lead to the be- lief that the isolation of the predomi- nating organism from the nasal secre- tion and the injection into the patient of a vaccine product from the same will frequently abort an attack, and even establish a certain degree of im- munity for a short period of time. The earlier the injection, the more decided will be the result. By means of vaccine therapy, not only are we able to cut short an acute cold, but also to confer considerable im- munit}'- against future attacks. By this method we can, further, often suc- cessfully treat colds which have be- come chronic, e.g., chronic rhinitis, laryngitis, bronchitis, etc. In but few cases of common cold can a stock vaccine be employed with much hope of success; except in the case of the Bacillus septus we are not likely to do good by any vaccine other than that prepared from the patient's own person. Having secured the specimen it is forwarded to an expert, and the vaccine can be prepared ready for use within forty-eight hours of its receipt. The best time for the injection is the evening, and the best spot the flank slightly above and internal to the an- terior superior spine. If the reaction is pronounced it may be necessary to keep the patient in bed for twenty-four hours. Campbell (Practitioner, Oct., 1909). Early convalescence and the return of the normal vigor will be augmented by the administration of tonics, strych- nine and quinine being, two of the favorite remedies. After two or three days this treatment is not sufficiently efficacious and curative measures will have to be resorted to. The usual run of cases can be cured without confining the patient to the house, unless the weather is severe. In children, however, an attack which may be considered mild in an adult may be severe enough to confine the young patient to bed. On the first visit of a case of acute rhinitis, especially if early in the disease, the nasal discharge will be found thin and acid, and the mucous membrane markedly swollen. Reduc- tion in the size of the turbinal bodies can be obtained by the application of a 1 per cent, solution of cocaine and a 1 : 10,000 solution of the suprarenal extract. A solution of 2 per cent, cocaine and 2^4 per cent, antipyrin often acts to greater advantage in these cases, as the latter remedy prevents a violent reaction and frequently prolongs the contraction. In patients who are sufferers from gout, the cocaine will invariably fail to produce the desired reduction of the mucous membrane, but relief may be obtained by the free administration of colchicum. Cocaine should be used with the greatest care in infants, as they are particularly susceptible to its detri- mental effects. Weak solutions are permissible, however, when the symp- toms are severe and the infant is pre- 1—23 354 ACUTE RHINITIS (SCARLETT). vented from nursing. Powders contain- On the other hand, Weitlauer, of ing cocaine are often prescribed for Innsbruck, commends the internal use adults; but it has caused cocaino- of sodium salicylate, combined with mania in so many cases that it should Dover's powder, which, it is said, will only be applied by the physician him- afford relief one hour after beginning self with an insufflator to cause con- treatment: — traction of the mucosa and the effect IJ Sodium salicylate Sj (30 Gm.). kept by means of a powder containing Dover's powder gr. xlv (3 Gm.). no cocaine which the patient can use ^^'''[ '/ P'PP'rmint... luJ (0.06 c.c). pt; '^niiff '^° ^^ divided into 20 powders, 1 of which is to be taken in a little water every three or For use by the physician the follow- fom- hours. ing is efficient :— Aromatic spirit of ammonia and IJ, Cocaine hydrochloride, s^ee^ spirit of niter are recommended Camphor aa gr. j (0.065 Gm.). n ^ ^ ^ u ■, j_„ i, n , . , ^-wor- ^ as excellent agents to abort a cold Pulverised sugar 3ij (8(jm.). s' Morphine hydro- by Beverley Robinson. chloride gr. j (0.065 Gm.). One or two doses of 1 Gm. (15 Pulverised acacia, grains) each of acetylsalicylic acid. Bismuth subnitrate .aa. 5j (4Gm.). taken at the first indication of an on- Pulverised mallow... Siss (6Gm.). coming cold in the head, will arrest it. _ 1 ,. ^ 1 . The drug is especially effectual when Enousfh to cover a dime to be in- ., ^ , ,• , ,• • ,, ,. . • r i, ^ _ the first tickhng m the throat is felt sufflated in each nostril. toward evening, and the drug is taken Ointments may also be used con- then and again in the morning. This veniently by the physician, by means permits him to go about his surgical of a flat probe. Lemoine recommends f'^f ^^^er breakfast without any ^ . further symptoms of coryza. If acute the following formula :— rhinitis has developed or the coryza IJ Cocaine hydrochloride, relapses, two or three further doses Salol aa gr. % (0.021 Gm.). always cured it completely. The drug Menthol gr. ss (0.032 Gm.). probably does not act on the bacteria, Boric acid 5ss(2Gm.). but it seems to enhance the resisting Petrolatum B] (30 Gm.). powers of the tissues. Sick (Miinch. ..,,.., . med. Woch., July 16, 1912). A piece the size of a large pea is applied with the probe to the swollen 'At home the patient should be in- mucosa in each nostril. structed to use one of the well-known Insufflations may be made with :— cleansing sprays, such as Dobell's solu- U. Calomel, tion, glycothymoline, or a solution Morphine hydro- made from Seiler's tablets. chloride aa gr. % (0.01 Gm.). A very useful and economical solu- Bismuth subnitrate .. Siiss (10 Gm.). ^^^^ jg prepared by dissolving a tea- To sustain the effect Rudaux, spoonful of salt in a pint of water— Grosse and le Lorier recommend the practically a normal salt solution— and instillation into each nostril, night and using it freely in the nose, morning, of several drops of the fol- I" using any cleansing solution, great lowing solution :— ^^^^ s^°^^^ ^^ exercised m blowing the _.„,,, ^r /AAcr^ N nose directly afterward, for when it is ^. Eucalyptol gr. % (0.05 Gm.). . , i, r ^ , ^• Sterilised liquid ^one too harshly some of the solution vaselin Bj (30 c.c). mixed with the nasal secretion may be ACUTE RHINITIS (SCARLETT). 355 blown into the middle ear through the Eustachian tulje and set up an inflam- mation with the formation of an abscess. Following the cleansing, the inflamed mucous membrane may be protected by an oily solution composed of : — B Menthol, Camphor aa gr. v (0.3 Gm.). Liq. albolcne fSij (60c.c.)- •This is to be sprayed in the nose, or several drops may be placed in each nostril, and snuffed up, several times a day. If it is found impossible to drop the solution in the nose of a child, the application may have to be made by a brush. Another useful combination is : — B Menthol gr. viiss (0.5 Gm.) . Phenylsalicylate 3ss (2.0 Gm). Boric acid Sij (8.0 Gm.). M. fiat pulvis. Since the swelling of the mucous membranes renders the snuffing up of the powder difficult, the patient will find it advantageous to use a piece of rubber tubing about 20 cm. long; the powder is placed in it at one end, and air blown through from the other end by the mouth. An excellent agent to keep the swelling of the mucosa down is the adrenalin ointment 1 : 1000, a piece as large as a pea being applied in each nostril. During the early stage of the disease, when the nasal discharge is watery, one of the coryza tablets on the market can be used to good advantage to dry up the excessive secretion. This is particu- larly advantageous to those who are compelled to appear in public, A very satisfactory comibination is the one devised and recommended by Dr. S. MacCuen Smith, which is made up as follows : — I^ Atropine sul- phate gr. %oo (0.0001 Gm.) . Strychnine sulphate, Arsenous acid. iia gr. 1/^40 (0.00027 Gm.). Morpliine sul- phate gr. i/ioo (0.0006 Gm.) . Quinine sulphate, gr. Yio (0.006 Gm.). Powd. camphor. gT.% (0.016 Gm.). By the time six of these are taken, at half-hour intervals, a dryness in the throat will be noticed. Only half of one should be given to a child of five years. Notwithstanding their known value among the laity, the indiscrimi- nate use of these tablets should not be encouraged, for their administration at a time when the nasal discharge has become inspissated renders the patient much more uncomfortable and the dis- charge more difficult of expulsion. In the third stage, when the mem- brane is relaxed and the epithelium is being shed more rapidly than it should, a spray composed of 20 to 60 minims of the distilled extract of hamamelis to the ounce of water may be used to good advantage. It seems almost needless to state that the diet in all cases of acute rhinitis should be restricted at the beginning of the attack, but as convalescence takes place it can gradually be increased and finally restored to its normal status. In those cases, and especially is this true in children, where there is a tend- ency to excoriation of the upper lip and the nostril, these exposed cutaneous surfaces should be protected from the irritating effect of the discharge by the application of vaselin or some simple ointment. A mixture of menthol and chloro- form, equal parts, is very efficacious. A few drops of the mixture are placed upon a handkerchief and inhaled through the nostril. It causes the ob- struction in the nose to immediately disappear, A few drops may also be 356 ADDISON'S DISEASE (LANGLOIS). placed in a cupful of hot water and the vapor inhaled. (Les Nouveaux Reme- des, March 24, 1910). Sodium salicylate causes a cold to abort if taken within twenty-four to thirty-six hours. Single dose of 7>^ grams (0.5 dram) often suffices. Taken later, it relieves symptoms and shortens attack. It is also valuable in the chronic coryza of gouty subjects. Should be taken after eating and pref- erably in small doses, dissolved in half a glassful of water. Courtade (Revue de therap., Jan. 1. 1910). RuFus B. Scarlett, Philadelphia. ADDISON'S DISEASE— In 1855, Addison pointed out in a historic mon- ograph ("On the Constitutional and Local Effects of Disease of the Supra- renal Capsules") the relations between a disease known as "bronzed skin" or "bronzed cachexia" and lesions of the adrenal bodies. The interest excited by this work at once called forth nu- merous observations on the subject, and, while a certain number of the papers lent support to the idea of close relationship between the lesion of the adrenals and the syndrome which Addi- son described, in others a contrary opinion was expressed. In the year succeeding the publication of his first monograph, Addison brought out a paper in which he described a lesion of the semilunar ganglia unaccompanied by changes in the adrenals. We can thus state that it was Addi- son himself who originated the two theories which are still brought into requisition to explain the manifesta- tions of the bronzed disease : the theory of adrenal insufficiency and the nervous theory. Before discussing these hypotheses, a study of the dis- ease itself from the clinical aspect must first be made. SYMPTOMS. — When Trousseau proposed that the term "Addison's dis- ease" be applied to the affection de- scribed by the Scotch physician under the name "bronzed skin," he specifically designated "a singular cachexia espe- cially characterized by the bronzed hue assumed by the integument." We therefore feel justified in including under the term Addison's disease only those affections which are of the "bronzed disease" types, and not the aggregate of all the conditions resulting from functional disturbances of the ad- renals, i.e., "without melanodermia, no Addison's disease." The disease, even thus limited, still presents a number of clinical forms showing rather well- marked special characteristics. Asthenia. — The patient is generally unable to state the exact period of on- set of the affection. In typical cases the pathological state is almost always one of adrenal tuberculosis which has invaded these organs secondarily, the patient is already in the wasting stage of tuberculosis, and it is difficult to recognize the new symptoms. Where there is primary adrenal tuberculosis, however, the symptomatology is more characteristic. Asthenia dominates the whole picture. The least physical effort is followed by extreme lassitude. At first the patient is still capable of ener- getic and rapid muscular activity, but he is not equal to sustained work ; fatigue at once appears ; later, as the process advances, lassitude becomes constant and the patient thinks of but one thing — avoiding the slightest exer- tion and remaining in bed in the dorsal decubitus. The mere ingestion of food requires an effort beyond the patient's strength, and the administration of solid food becomes difficult. The earliest writers had been struck ADDISON'S DISEASE (LANGLOIS). 357 by the asthenia of Addison's (hscase, and Jaccoud gave an excellent descrip- tion of it. lUit the exact conditions under \vhicli this fatigue occurs were learned through the labors of Langlois, Charrin, and Abelous, who explained it on the basis of a new conception of its pathogenesis. The study of muscular fatigue with the ergograph of IMosso permits of differentiating the resistance in an ordinary case of tuberculosis from that in one of Addisonian phthisis. The simple tuberculous subject will continue lifting the weight of the ergo- graph for two minutes, performing total work equal to 1150 grammeters ; the Addisonian subject, after having lifted the weight just as energetically during the earlier contractions, becomes fatigued very soon and stops exhausted before the second minute, having per- formed work equal to only 750 gram- meters. If the weight to be lifted is placed at 2 kg., fatigue already ap- pears at the fifth contraction and the sum of work done is practically nil. Mclanodcrmia, or bronzing, from wdiich symptom the disease received its earliest appellation, often does not de- velop until after the asthenia. It ap- pears most frequently in the form of small, browmish macules scattered over the entire skin-surface, though most marked at certain points of election. The scrotum and labia majora, which are normally pig- mented, very frequently present a characteristic color. The mucous membranes are very often affected before the skin. The internal sur- taces of the cheeks, the labial com- missures, as well as the genital mucous membranes, should, always be examined in asthenic subjects. The melanodermia may remain local- ized, and this is, indeed, more usually the case, but ir may also become gen- eralized through confluence of the pri- mary patches and involve the whole of the integument, making the patient's skin appear truly like that of a mulatto, though never like that of a full-blooded negro. Erault points out that the palms and soles are not involved, but these areas are imperfectly or not at all pig- mented in negroes, and even in the anthropoid apes the soles of the feet remains of a pink color. Case of Addison's disease in a woman, aged 37, who complained of cough with expectoration and gen- eral weakness. The first sign was a very striking pigmentation of the skin. The color was yellowish brown, and affected chiefly the forehead, neck, hypochondriac and abdominal regions in front, and tl.e infra- scapular and lumbar regions be- hmd. The arms were uniformly pig- mented from the shoulder to the metacarpophalangeal joints. There was an entire absence of pigment over the clavicular and mammary re- gions in front, and the suprascapular region behind. Scattered here and there through the pigmented areas are patches varying in size from a lentil to a walnut, of clear, pearly skin. The pigmented areas were not raised above the surface, nor were they affected by scraping with the nail or sharp instrument. The thighs and legs were free from pigment. The pigment was more marked over the areolae and axillary regions. There was evidence of consolidation over the left apex, where there were relative dullness to percussion, diminution of respiratory murmur, some tubularity, and a few dry and moist rales. The lungs were otherwise normal. The symptoms in their order of develop- ment were pigmentation of the skin, great weakness accompanied by breathlessness, cough with expectora- tion, anemia, and, lastly, a tendency to diarrhea. McKendrick (Glasgow Med. Jour., June, 1909). 358 ADDISON'S DISEASE (LANGLOIS). Case of Addison's disease in a male, aged 31, in whom exposure to the sun darkened the pigmentation, which involved the axillae, elbows, nipples, breast, the pubis, gums, lips, tongue. Of late the nails have be- come a dark brown. A. F. Chace (Post-Graduate, Feb., 1911). Traumatism of the skin is a predis- posing cause to pigmentation. The earliest melanodermic patches are often noted to appear over old cica- trices, especially over the healed areas of former blisters, and even the appli- cation of a blister or merely of a poultice on an asthenic subject is often sufficient to cause a sudden outburst of pigmentation and permit a positive diagnosis of Addison's disease. Gastrointestinal disturbances are fre- quent, but very variable in nature. At the outset, constipation is the rule, and is accompanied by anorexia, which may be accounted for both by the intestinal paresis and by the general lassitude to which we have already alluded. The constipation may be succeeded, par- ticularly in the acute forms, by atonic diarrhea. But the most characteristic symptom is, without doubt, vomiting. Preliminary nausea is very seldom present; the vomiting comes on sud- denly, and generally in the morning upon awaking. At first the patient's stomach is evacuated but once a day ; then, as the disease progresses, the vomiting becomes more frequent and occurs at intervals during the day. The act takes place with but little muscular effort, of which the subject is, indeed, incapable. The vomitus is' colorless, thin, and consists of mucus. Circulatory disturbances are of great importance. The earlier observers had already pointed out a special weakness of the pulse, together with all the symptoms of cerebral anemia. There- searches of Schafer and Oliver and of Langlois and the later investigations of the action of adrenalin served to direct the attention of clinicians to these disorders, at the same time dis- closing their pathogenesis. The Addisonian subject is in a state of hypotonicity. By reason of the ab- sence or insufficiency of the adrenal secretion, the normal tonus of the ves- sels is no longer maintained. Even at the outset of the affection, along with the first signs of asthenia, lowered arterial tension is to be found. The sphygmomanometer shows 100 to 120 mm. of mercury. The fall in pres- sure is accentuated as the disease advances; in the last stages, a tension as low as 50 mm. may be noted. Bernard and Sergent have brought out a clinical phenomenon which they claim to be useful in diagnosis without the aid of instruments of precision, viz., the "adrenal white line" — as op- posed to the red line of meningitis. To cause it to appear, the skin of the abdomen is lightly rubbed with the pulp of a finger, without scratching; after a few moments a rather broad white streak appears, which becomes more and more marked, remains stationary for three to four minutes, then grad- ually fades off. Pain and Nervous Disturbances. — Lumbar and abdominal pains of great severity may be present at the outset of the disease. They frequently become localized in the epigastric and hypo- chondriac regions, and Martineau has described a pathognomonic seat of pain at the anterior extremity of the eleventh rib. These pains, however, almost characteristic when they are sudden in onset, are sometimes entirely wanting throughout the course of the disease. ADDISON'S DISEASE (LANGLOIS). 359 When considering the pathogenesis of the affection, we shall find it easy to understand how the variations ob- served in the painful phenomena may be explained according to the extent and the seat of lesions surrounding the adrenals. We have already mentioned the as- thenic manifestations, which, according to us, are referable rather to the mus- cular system than to the nervous sys- tem proper, or at least to the structure which unites the nerve with the mus- cle — the terminal plate (as formerly designated) or the receptive substance of Langley. True paralyses are rare and in no sense characteristic. Cere- bral disturbances, such as the pros- tration, the tinnitus aurium, the hal- lucinations, and especially the en- cephalopath)^ of Addison's disease, may be due to two causes : cere- bral anemia resulting from vascular hypotonicity, and intoxication either through suppression of the antitoxic activity of the adrenals or through the formation of toxic products owing to functional deficiencies — asthenia, hy- potonicity, etc. Case of Addison's disease with ter- minal mental symptoms in a woman of 47 years of age, who had been suf- fering two years from Addison's dis- ease. She became fretful, discour- aged, showed diminution of volitional impulses, incapacity for mental effort, and mental defect. She also had ideas apparently dependent upon par- esthesia of the skin, i.e., that animals were crawling upon her, that a dog had bitten her upon the arm, that a searchlight was being played upon her back, etc. The patient dying af- ter a sojourn of eighteen days in the hospital, the author was able to make a complete autopsy with microscop- ical examination. There was healed tuberculosis in the lungs, and the ad- renals showed advanced tuberculous degeneration, bacilli being found in the debris. H. W. Miller (Amer. Jour, of Insanity, Jan., 1907). General Disturbances. — The muscu- lar and vascular weakness are neces- sarily followed by disorders of a gen- eral nature. The chemical interchanges are reduced, the phenomena of assimi- lation greatly retarded, whence result marked wasting of the tissues and a strongly manifested sensation of cold generally accompanied by hypothermia. According to the view of Sajous, who considers Addison's disease as char- acterized by deficient oxidation and lowered metabolism, a study of the temperature should enable us to judge of the degree of adrenal insufficiency. The blood in cases of Addison's dis- ease presents nothing peculiar. The search for pigment in the blood-plasma has always proved negative. Gener- ally the blood-cells show diminution, but observations on this subject have been contradictory. While Laignel- Lavastine described diminutions of the corpuscles to three millions, Loeper and Crouzon found a polycy- themia. Langlois, in a comparative study of two tuberculous cases pre- senting similar pulmonary lesions, but one of whom showed distinct Addison's disease, observed no dif- ference either in the hemoglobin percentage, the number of cells or the proportion of leucocytes. The two patients gave identical results. The secretion of urine is diminished because of the lowered tonicity. Cola- santi and Bellati, who made a study of the urine of an Addisonian patient for eighteen days, found its toxicity above that of norrhal urine. Langlois did not find this abnormal toxicity in the two subjects of which he made a compara- tive study. 360 ADDISON'S DISEASE (LANGLOIS). Course and Termination. — Addison's disease always terminates fatally, but its course may be more or less rapid. Sometimes the destruction of the adre- nals is so quickly produced that the morbid phenomena show very rapid progression. Asthenia is present al- most from the outset, the circulatory disturbances at once become very, marked, and, lastly, the gastrointes- tinal disorders, which do not appear to be closely related to the adrenal insufficiency, may become of such severity, with intractable vomiting- and diarrhea, that cachexia and death supervene before the melanodermia has had time to declare itself. In the cases having a slow course, the disease may remain stationary for a long time, and it is in such cases that are sometim.es observed temporary pe- riods of improvement not only with regard to the digestive tract, but also in the symptoms of melanodermia : asthenia and arterial tension. The cause of such periods of improvement it is difficult to state. We shall lay no stress on the mode of death by progressive cachexia, which presents nothing peculiar, but must dwell with some emphasis upon the form of death which takes place rapidly or even suddenly. The rapid fatal termination in Addi- son's disease takes on the features of an acute intoxication. The abdominal pains show marked exacerbation; diar- rhea becomes profuse and vomiting continuous, the blood-pressure at the same time showing progressive reduc- tion. In some cases hypothermia is ob- served, with a tendency to collapse ; in others, on the contrary, there occurs hyperthermia accompanied by delir- ium and convulsions. Case of acute Addison's disease in which the duration of the disease was seventeen days. The onset was marked by severe abdominal pain and vomiting. There was, at times. watery diarrhea. Ten days later red- dish discoloration of the skin ap- peared over various points of pres- sure. These later assumed a more brown color. There was no pigmen- tation of the mucous membranes. The blood-pressure remained 105 mm, Hg., until the day of the death, when it fell to 99 mm. The clinical diagnosis was malignant tumor of the lungs, pyloric stenosis, and tumor in the right lumbar region. The symptoms, pigmentation, asthenia, psychical disturbance, and sudden death, also suggested Addison's dis- ease. Autopsy showed scirrhous car- cinoma of the pylorus with multiple metastases. Both adrenal glands were involved, but only to a very moderate degree. The most striking lesion of the adrenals was a general venous thrombosis, the apparent age of which corresponded well with the duration of the symptoms. The writer believes that the obstruction to venous outflow was the etiological factor in the case. Straub (Deut. Archiv f. klin. Med., Bd. xcvii, S. 67, 1909). To explain this sudden aggravation in the course of the affection, several hypotheses have been put forth. That one which appears to us the most ad- missible among them is based on a sud- den diminution, sometimes even on al- most complete suppression, of the func- tion or rather the functions of the adrenals. Almost always, indeed, such an unfavorable turn in the disease suc- ceeds upon an intercurrent infection. Now, since the researches of Charrin and Langlois, • followed by those of Loeper and others, it has been known that certain infections, such as diph- theria and scarlatina, exert a selective action on the adrenal glands, causing ADDISON'S DISEASE (LANGLOIS). 36i in them a more or less marked func- tional tleliciency. It is thus plain that if in a gland already the seat of tuber- culosis, but which, nevertheless, suffices to insure the adrenal function, a fresh lesion appears to destroy the surviving cellular elements the symptoms of ad- renal insufficiency will show a sudden outburst and be seen in all their inten- sity. Boinet has also laid stress on the appearance of serious accidents after excessive fatigue. Such occurrences confirm the investigations of Abelous and Langlois and of Albanese upon the influence of fatigue on experimentally decapsulated animals. Another theory accounts for the ag- gravating effect of intercurrent infec- tions from the fact that, the antitoxic action of the adrenals against certain toxins no longer being exerted, the accidents due to intoxication are more severely manifested. It is evident that this hypothesis explains better than the former the phenomena of excitation, viz., delirium, convulsions, fever. ■Sadden death, or at any rate death taking place within a few minutes, is not rare in the bronzed disease, and Addison had already referred to such a termination in his monograph. In 1896 Ihler was able to collect 18 cases, and since that time numerous instances have been noted. Certain cases of sud- den death in apparently healthy persons have defied explanation until the au- topsy disclosed a tuberculous or can- cerous process of the adrenals. The advent of death may be truly fulminating; a patient previously ex- hibiting no signs of aggravation in his condition may drop dead while getting out of bed or on attempting to lift a chair. The patient of Dupaigne- Beclere, who was among the first to be treated with relative success by opo- therapy, died suddenly in bed during her convalescence. In some cases the end is marked by symptoms of a more striking character, such as a sudden attack of severe vomiting, convulsions, etc. The pulse becomes frequent and thready ; the face cyanosed ; dyspnea develops, and death occurs. Accidental syncope, nervous shock, acute intoxication, and sudden adrenal insufficiency have all been advanced as hypotheses in explanation of such oc- currences. It is difficult to believe, in this connection, that adrenal insuffi- ciency can produce so rapid an effect, since it is well known that completely decapsulated animals survive for fifteen to eighteen hours and show progress- ively increasing intensity before death. It appears to us more reasonable to attribute the termination to nervous shock originating in the adrenal or peri- adrenal sympathetic nerves, and react- ing on the general organism with its cardiac and vascular inefficiency result- ing from decreased tonic activity on the part of the adrenals. Case of Addison's disease in a ne- gress, aged 55 years. The face and backs of the hands and fingers were intensely black — much blacker in hue than other parts of the body. The palms of the hands were also abnor- mally pigmented, but to a lesser de- gree than the face. There were nu- merous irregularly defined areas of pigmentation on the mucous mem- brane of the cheek, gums, and tongue. Her pulse was frequent, small, and regular. At the necropsy the vagina showed evidence of chronic inflammation of its mucous membrane and presented patches of pigmentation similar in character to those present in the mouth. On the vulva were a few small leucodermic areas. Both supra- renals were enlarged and exhibited caseous masses in their substance. 362 ADDISON'S DISEASE (LANGLOIS). apparently affecting the cortex. Their capsules were much thickened and adherent to the surrounding parts. They contained caseating masses, at the margin of which were giant cells, in the cortex. The condition was tubercular, with marked tendency to caseation. R. Seheult (Lancet, Aug. 3, 1907). Three cases of Addisonism occur- ring in the same family, in sisters, aged 9, 6, and 314 years, respectively. The father, mother, and an elder sis- ter, aged 19 years, were all healthy. The case of the girl aged 9 years was one of true Addison's disease, with prostration, asthenia, typical pigmen- tation, low blood-pressure, and occa- sional vomiting. The other two cases showed only the typical pigmentation and low blood-pressure. Addison's disease is very rare in children under 13 years of age. Croom (Lancet, , Feb. 27, 1909). Clinical Varieties. — Several forms of Addison's disease have been described according to the relative prominence of certain symptoms. These include the gastrointestinal form, painful form, melanodermic form, and as- thenic form. These divisions are worthy of acceptance because they correspond in each case to a develop- ment and pathogenesis dififering from the others. It seems probable, indeed, that in the melanodermic as well as in the painful form sympathetic changes predominate from the outset, while, in the asthenic form, adrenal insufficiency is the primary cause. Addison's disease in infancy is not rare, occurring in sucklings as well as in later months. Most cases are due to tuberculosis of the adrenals, although some cases have been asso- ciated with the perfectly normal glands. The most important symp- tom is pigmentation of the skin, al- though pigmentation may be brought about by a long-continued diarrhea in infants. Other symptoms are gen- eral depression and extreme weak- ness, diarrhea and vomiting, and convulsions. The pulse is v/eak and irregular. The disease is always fatal, dissolution being due to weakness, or to some intercurrent disease, espe- cially tuberculosis. S. Finkelstein (These de Paris, 1900). Addison's disease in children. Be- fore puberty, i.e., under 13 years, it presents considerable differences from that above this age, and is extremely rare. Analysis of 25 cases, including a personal one. As to relative fre- quency, Monti found among 200 cases 6 in children below 13, while Green- how in 330 found it four times; in other words, 1 to 62. Etiology. — The main etiological factor is tuberculosis, though the patient of Anglade and Jaciuin showed no such lesion in the adrenal glands, although extensive tuberculosis in the lungs and spinal cord was present. Age: Twelve cases occurred between the ages of 10 and 13 years, 4 cases between 5 and 10, while 9 occurred below the age of 5. The youngest case on record is that of Belyayeff, of a child 7 days old. Contrary to what textbooks state, that the disease oc- curs far more frequently in boys than girls, the occurrence in males and females is about equal. Family History. — Tuberculosis occur- red as a family taint in 4 cases; in one instance a rheumatic history; in one instance the mother and four children had had the disease. Previous History. — In 13 cases in which this was obtained there was tuberculosis of other organs in 3, measles in 2, scarlet fever in 2, ton- sillitis and chorea in 1. Felberbaum and Fruchthandler (N. Y. Med. Jour., Aug. 10, 1907). Hypoglycemia should be included among the symptoms of Addison's disease, as a corollary to the arterial subtension. Bernstein (Berl. klin. Woch., Oct. 2, 1911). PATHOGENESIS. — The patho- genesis of Addison's disease cannot be explained except by referring to ADDISON'S DISEASE (LANGLOIS). 363 the data of physiolog-y, and, while Addison was deserving- of higli credit for pointing- out the relation of the bronzed disease to changes in the adrenals, the pathogenesis none the less remained obscure because the functions themselves of the adrenals were still unknown. Two important theories have been advanced, which, moreover, do not refer exclusively to lesions of the adrenals, but to which recourse is also had to explain the morbid syn- dromes related to lesions of all duct- less glands, including the thyroid gland, the pancreas, etc. These are : 1. The nervous theory, which at- tempts to explain all the phenomena by an action of the nervous system through its adrenal connections. 2. The glandular theory, which attrib- utes the disturbances to functional alterations in the adrenals. Ncrz'ous TJicory. — The nervous theory had already been clearly stated in Addison's second paper, which pointed out the close relations exist- ing between the solar plexus, with the semilunar ganglia, and the adrenals. In France, Jaccoud became a strong partisan and defender of this theory. After him and after Addison, Haber- shon, Barlow, Schmidt, ]\Iattei, and Alartineau attributed the nervous disturbances observed to lesions of the solar plexus and semilunar gan- glia. Following Jaccoud, this view is still held by Greenhow, Jurgens, von Kahlden, Lancereaux, Raymond, and Brault. These authors offer as argu- ments, on the one hand, changes in the adrenals in cases where during life the subject had exhibited none of the symptoms referable to Addison's disease and, on the other hand, the normal condition of the adrenals in individuals declared to have Addi- son's disease before the autopsy. Jaccoud supported the theory on the basis of three orders of facts : the symptoms observed, the lesions found post mortem, and the structure of the adrenal glands. Among the symptoms observed, leaving the mel- anodermia out of consideration at once, the nervous disturbances are of two kinds : increasing asthenia and the gastric or nervous manifestations. Prof. Jaccoud, after referring to these symptoms, adds: 'Tf we now bear in mind that in the uncomplicated cases these symptoms show progressive development in the absence of any important visceral lesion, without anemia, without albuminuria, without hemorrhage, and without diarrhea, they will without doubt appear to us as the direct and immediate result of a disturbance of the nervous S3^stem." \\& shall see later that these asthenic phenomena cannot be brought forth as arguments in favor of the nervous theory, and that the capsular theory, as conceived by Abelous and Lan- glois, itself finds strong support in the asthenia of Addison's disease, de- scribed by Jaccoud. The autopsy in a case of Addison's disease in a child of 10 years showed tubercular infiltration of the lungs and enlargement of the bronchial glands. The suprarenal capsules were congested, but macroscopically they presented no lesions. A microscopic examination revealed no change in the histological structure. The cap- sule was of normal thickness, and the gland, as a whole, was not enlarged. The nuclei of the cells were distinct and there was no fattj^ degeneration. The semilunar plexus was somewhat altered and congested. The mesen- teric glands were large, but not case- ous. Upon examination the Bacillus tuberculosis was absent. Richon (Arch. 364 ADDISON'S DISEASE (LANGLOIS). de med. des enfants, tome vi, No. 6, p. 350, 1903). In every case of true Addison's dis- ease there is a gray degeneration of the nerve-fibers of the splanchnics. This may be either protopathic, when one finds simple atrophy of the ad- renals without other inflammatory appearances in these or other organs, or (more commonly) deuteropathic, in consequence of primary disease of the adrenals or pancreas. Withing- ton (Med. News, Sept. 24, 1904). The attacks of vomiting- and the epigastric and lumbar pains are, in- deed, in favor of nervous lesions, and it can readily be understood how the close proximity of the sympathetic nervous structures may explain the motor and sensory disturbances ob- served in cases of bronzed disease. As for the structure of the adrenals, it does not permit of our forming any definite opinion. While it is quite true that these glands receive a large number of nerve-fibers from the sympathetic, as shown by the researches of Nagel, Bergmann, Kolliker, and Henle, there exist in the cortical layer ganglionic cells which may constitute reflex centers (Moers, Joesten, Holm) ; and while it is true that excitation of the adrenals tends to inhibit the in- testinal movements (Jacob), yet the role of the adrenal bodies cannot be denied, even on the ground of their texture alone. The main argument against the pathogenetic role of the adrenals is based on the following double series of observed facts : Mel- anodermia may exist without lesions of the adrenals; marked lesions of the adrenals may exist without melanodermia. Glandular Theory. — The researches of Brown-Sequard, which followed the monograph of Addison at an interval of but a few months, were steeped in the idea which then pre- vailed as to the "predominance of melanodermic disturbances in the bronzed disease." Furthermore, while unable to observe pigmentation of the skin in animals deprived of their adrenals, he pointed out the presence of numerous pigmentary granulations in the blood. The most prominent result of his researches, however, lay in the discovery of the functional importance of the adrenals, of which the role had until then escaped physi- ologists. "Death resulting from changes in these organs," wrote this author, "is preceded by a gradually developing weakness, going on to paralysis of the posterior extremities, then of the anterior, and finally of the respiratory muscles. Among the disorders noted may also be men- tioned anorexia, failure of digestion, rather frequently delirium, epilepti- form disturbances, and a gradual lowering of the temperature." Brown- Sequard concluded that destruction of the adrenals was followed by ac- cumulation in the blood of a toxic substance ha^dng the property of becoming transformed into pigment. Since 1855 the investigations on the adrenals have been numerous. The conclusions of Brown-Sequard have been vigorously attacked. Philip- peaux, Gratiolet, Harley, Berutti, and Martin-Magron combated the vital role of the adrenals, asserting, con- trary to the belief of Brown-Sequard, that destruction of these organs did not necessarily result in death. Tizzoni, in numerous researches carried out between the years 1884 and 1889, likewise recognizes the pos- sibility of survival after destruction of both adrenals ; but he points out at ADDISON'S DISEASE (LANGLOIS). 365 the same time the possibility of regen- eration of these organs when not totally destroyed; finally he referred to medullary disorders succeeding upon destruction of one adrenal. Stirling showed that in a certain number of cases survival after de- struction of both adrenals is explained by the presence of accessory adrenals. Alezais and Arnaud ascribed the fatal ending to ascending degeneration reaching the cord by way of the splanchnics. Clinical and autopsy findings in 3 cases: The morbid changes in the suprarenals were accompanied by corresponding changes in the other glands with an internal secretion, the thyroid, hypophysis, and spleen — all of these were hypertrophied, with evidence of hyperfunctioning. The writer does not regard Addison's dis- ease as due to a single gland, but to several participating in the process. The first symptom in one patient was tremor of the arms, probably the re- sult of professional exposure to elec- tric currents, the man's work being done under an electric light of be- tween 15,000 and 20,000 candlepower. The effect of the Roentgen rays on glandular organs suggests that the light here may have affected the cer- vical sympathetic, the thyroid, and the hypophysis. Later the process seems to have extended to the abdominal sympathetic and suprarenals. In an- other case atrophy of the ovaries fol- lowed a pregnancy with premature menopause. Calcareous degeneration of the thyroid followed, with tuber- culous infection later and fulminating suprarenal symptoms. The diseased suprarenals could not obtain help from the ovaries and thyroid, and there was merely slight hyperfunc- tioning of the hypophysis as a de- fensive reaction. In the 3 cases patients in the last stages of Addi- son's disease recovered their energy and the bronzing subsided under thy- roid treatment. The thyroid was al- ready modified and was inadequate to supplant the diseased suprarenals, but it only required slight additional aid from without to be able to counteract temporarily the destructive process in the suprarenals. The disease, the course, the outcome, the histologic findings, the research in the experi- mental field, all sustain the assump- tion that Addison's disease, in its com- plete form, is a general affection of the entire great sympathetic system. Leonardi (Policlinico, Aug., 1909; Jour. Amer. Med. Assoc, Oct. 2, 1909). In 1891, Abelous and Langlois published their first researches on the functions of the adrenals in frogs; these were followed by a series of papers on the functions of the glands in other animals. They showed that, in all animals subjected to double adrenalectomy, death promptly and inevitably occurs, but that a portion of an organ if left behind is sufficient to cause survival. Muscular weak- ness and asthenia are all the more intense if the animal be forced to per- form muscular movements, whence their first conclusion "that the ad- renals possess the function of neu- tralizing or destroying toxic sub- stances evolved during muscular labor." This conception of the role of the adrenals explains a portion of the symptoms observed in Addison's disease, including the most charac- teristic symptoms : asthenia and the disastrous effects of fatigue. The discovery of the vasoconstrict- ing action of suprarenal extract by Oliver and Schafer, on the one hand, and Cybulski, on the other, that of the presence of the active substance in the blood of the capsular vein (Cy- bulski and Langlois), that of the rapid destruction of this substance in the organism (Langlois), and finally )66 ADDISON'S DISEASE (LANGLOIS). the isolation of adrenalin by Taka- mine also threw new light on the symptoms observed. The lowered vascular tension and the cerebral disorders can henceforth be inter- preted as resulting- from diminution of the tonic influence of the adrenals. The syndrome of adrenal insufficiency in its entirety can henceforth be ex- plained through the data of experi- mental physiology. Study of the nitrogen and sulphur metabolism in a patient who had Ad- dison's disease and who was on a purin-free diet. The desamidating capacity of the patient (capacity to reduce amid nitrogen) and his capac- ity to transform the sulphur of the cystin group into sulphuric acid were absolutely comparable to that of nor- mal individuals. A considerable de- gree of acidosis was observed, which is not accounted for by any factor which was found in this examination. The endogenous metabolism of the patient, as represented by the kreati- nin and uric acid outputs, was below that of normal subjects. Wolf and Thacher (Arch, of Int. Med., June, 1909). The writer, who had previously ob- served a striking hypoglycemia after removal of the adrenals, now reports the effect upon the glycogen content of the liver and muscles of the same procedure. Seven dogs were killed at intervals of four and one-half to eight hours after removal of the ad- renals. At this time all showed great muscular weakness. Their livers con- tained an average of 0.722 per cent, glycogen. If one animal be excluded, the average of the other six was 0.222 per cent. Schondorff found 18.69 to 1 .2> per cent, of glycogen in the livers of normal dogs on a similar diet. The muscle content of glycogen was 0.653 per cent., compared with Schondorfif's average of 4 per cent. In three dogs dying spontaneously after operation, the livers contained no glycogen what- ever, the muscles an average of 0.187 per cent. The lack of glycogen is the cause of the hypoglycemia. The mus- cular weakness is, in all probability, due to lack of sufficient sugar and sugar-producing material, for muscle glycogen is well known to be far less readily available for the body than is the liver glycogen. Porges (Zeit. f. klin. med., Bd. Ixx, S. 243, 1910). Adrenalin glycosuria is due to the conversion of liver glycogen into su- gar. In animals rendered glycogen- free by starvation and strychnine poi- soning, adrenalin injections cause a new formation of glycogen and sugar. Pollack (Arch. f. exper. Path. u. Phar- mak., Bd. Ixi, S. 149, 1909). Even the insufficiency or complete failure of adrenal opotherapy finds its explanation in the instability of suprarenal extracts. (We retain this vague term to convey the fact that adrenalin is but one of the principles now isolated which are elaborated by the adrenals). But while physiology can explain and experimentally reproduce most of the symptoms of Addison's disease — those which Bernard and Sergent classify in the syndrome of pure adrenal insufficiency — she has shown herself entirely powerless to repro- duce and explain the pigmentation which is so characteristic of this affection. Excepting in one observation by Boinet, no experimenter has been able to produce pigmentation experi- mentally, either by destroying the adrenals or by setting up local irrita- tion. Following Loeper we shall refer into four groups the theories which have been advanced to explain mel- anodermia : adrenal origin, cachectic origin, nervous origin, and mixed glandular and sympathetic origin. A. Adrenal Origin. — The elabora- tion of a pigment by the secretion of ADDISON'S DISEASE (LANGLOIS). 367 the adrenals, thought of by Brown- Sequard and Pfandler, and which would be caused by lesions of the org-an itself, is not supported by any evidence of value. The hemolytic function of the g-land and the accumu- lation in the blood of pigment derived from hemoglobin when the glandular function is weakened arc likewise too hypothetical. B. Cachectic Origin (Gubler, Teis- sier, Debove). — It is certainly true that any cachexia may provoke, along with general nutritional disorders, pigmentary phenomena. But the bronzed disease is frequently mani- fest previous to the establishment of cachexia, and presenting features which give it a specific character which does not bear well with the general processes of the cachexia. C. Nervous Origin. — The intimate connections existing between the adrenals and the sympathetic system are such as to warrant a belief in functional changes in this system during Addison's disease. Addison had already thought of the possible role of the nervous system. Jaccoud, Lancereaux, and Raymond defended this. theory. The clinical observations of Sem- mola and of Brault, who noted mel- anoderma in conjunction with sim- ple compression of the semilunar ganglia and solar plexus, and the cases of Addison's disease with lesions of but one adrenal (Green- how) are cited as favoring the view of nervous origin. Irritation of the sympathetic would presumably bring about an overproduction of pigments, either in the blood itself (von Kahl- den, Nothnagel), in the chromoblasts (Raymond) or in the cells of the epidermis (Behier, Chatelin). D. Mixed Origin. — Attractive as the nervous theory may be, it does not suffice in all cases, and especially is in complete disagreement with ex- perimental facts, since all excitations of the sympathetic, whether extra- or intra- capsular, have proven without efifect in producing melanodermia. A number of physicians are at present adopting the opinion of Loeper, that melanodermia is the result of changes both in the adrenals and the nervous network surrounding them. Accord- ing to Loeper, the adrenal secretion is the normal and necessary exciting agent of the nervous system in its function of regulating pigmentation. Sajous (1903) and Laignel-Lavastine hold an opposite view : the sympa- thetic is not the regulator of pigmen- togenesis, but of the adrenal gland itself, on which the formation of pigment .depends. Addison's disease is not infre- quentlj^ accompanied by enlaro^ement of the lymphatic glands, and hyper- plasia of the spleen and thymus. The writer saw, in one year, three cases of this disease with very marked status lymphaticus. Examinations of the autopsy records of the Berne and Basle Pathological Institutes showed that the latter condition frequently is associated with Addison's disease. The hyperplasia of the lymphatic sys- tem in these cases must be due to Ad- dison's disease. By special stains he found that the chromaffin cells of the adrenal gland, including the para- ganglion, were greatly reduced. The change or the defective anlage of the chromaffin cells is the common cause for Addison's disease and of status lymphaticus. Hedinger (Zeit. f. Pa- thol.; Charlotte Med. Jour., Aug., 1908).. Two cases, pronounced hypoplasia of the chromaffin system, accom- panied the typical Addison's disease, while the lymph-glands were enlarged. 368 ADDISON'S DISEASE (LANGLOIS). V. Werdt (Berl. klin. Woch., Dec. 26, 1910). Case of chronic Addison's disease in a youth with the thymolymphatic temperament. The suprarenals had been totally destroyed by a primary tuberculous process, as also in a simi- lar case in a man of 41 with the status lymphaticus. Analysis of these cases and of similar ones in the literature seems to demonstrate a mutual stim- ulating action between the thyroid and the suprarenals and between the thyroid and the thymus, while there is mutual inhibiting action between the suprarenals and the thymus. Kahn (Virchow's Archiv, June, 1910). DIAGNOSIS.— The various symp- toms encountered in Addison's dis- ease may be divided into two groups: A. Symptoms of adrenal insufficiency. Cardiovascular disturbances ; — Lowered arterial tension. Tachy- cardia. White line on abdomen. Cerebral anemia. Syncope. Disturbances of metabolism : — Lowered temperature and sensation of cold. Progressive asthenia. Wasting. Pros- tration. Encephalopathy and various nervous disorders. Vomiting and diarrhea. B. Symptoms of irritation of the adrenal sympathetic. Melanodermia. Radiating pains. Vomiting and diarrhea. Where the Addisonian syndrome is complete and the course rapid, the diagnosis is easily made. It becomes more difficult when melanodermia is absent or doubtful. A study of the resistance to fatigue, either by means of the ergograph or by simply caus- ing the patient to perform a definite piece of work, combined with the use of the sphygmomanometer, may be of value in facilitating diagnosis, but very often in the hospital, in cachectic tuberculous subjects, the involvement of the adrenals is not discovered till the autopsy. In fact, the question of diagnosis is generally raised when it becomes necessary to attribute the melano- dermic patches to Addison's disease or, on the other hand, to some other affection producing pigmentary changes, such as the pigmentation of cachectic tuberculous cases, pigmen- tation of hepatic origin, the melano- dermias of malaria, arsenic poisoning, lead poisoning, and phthiriasis. The most common fallacy is to mis- take Addison's disease for pernicious anemia; the peculiar lemon tint of the skin in the latter condition, however, is different from that of the charac- teristic case of Addison's disease; but in slight cases confusion often arises. Fortunately, modern means of exam- ination of the blood, which in Addi- son's disease is but little abnormal, enable the recognition of the marked blood characteristics of pernicious anemia. The writer, however, cau- . tions against being content with negativing a diagnosis of pernicious anemia because a single blood exam- ination fails to show characteristic changes. The blood in pernicious anemia varies from day to day and from hour to hour. Another pos.sible source of confusion is the discolora- tion consequent on prolonged admin- istration of arsenic. By inquiry of many persons of considerable experi- ence in arsenical poisoning the writer finds that the occurrence of pigmentation in the mouth is in favor of the case being Addison's disease. In malignant disease the wasting is apt to be much more marked, and local evidence of malignancy can usually be found. Other conditions sometimes confounded with Addison's disease, but which ought to be easily distinguishable, are the filthy, dirty patients, infested with lice, sometimes seen in hospital out-patient depart- ments; phthisical and syphilitic pig- ADDISON'S DISEASE (LANGLOIS). , 369 mentation; Hanot's cirrhosis of the liver, and bronzed diabetes. Any condition that destroys the functional activity of the medullary part of the suprarenals may cause Ad- dison's disease, by far the most com- mon being tuberculous degeneration. Calmette's reaction helps in this mat- ter. The comparative frequency of malignant disease as a cause, the au- thor considers due to the necessity of having both suprarenals affected, and, perhaps, to the fact that in malignant disease death will be occasioned be- fore the evolution of characteristic phenomena. The proportion of cases in which clinically characteristic Ad- dison's disease has failed to show dis- ease of the suprarenals is so small, about 12 per cent., as to be within the margin of allowable error due to erroneous diagnosis, inefficient post- mortem examination, or the possibil- ity of functional disturbance of the suprarenals. Further, other glands, e.g.,- the internal carotid and the coc- cygeal, have cells functionally resem- bling those of the suprarenals, and it is conceivable that very rarely disease of these glands may cause Addison's disease and lead to death before the suprarenals are affected. On the other hand, when the suprarenals have been found to be diseased, and yet no Ad- dison's disease has been present, it may be that the vicarious activity of these other glands may have formed sufficient internal secretion to prevent the patient having Addison's disease. W. H. White (Clinical Journal, Mar. 18, 1908). The melanodermia of phthisical patients is all the more likely to lead one astray because of the fact that the cases of Addison's disease are almost all tuberculous. For some authors, moreover, the majority of melanodermic tuberculous cases are cases of Addison's disease in which the adrenal changes are just begin- ning-, not yet showing the signs of glandular insufficiency, but having pericapsular lesions which cause a precocious melanodermia. In pig- mented tulDcrculous subjects without Addison's disease the pigmentation is said to be of a lighter grade and especially the mucous membranes to be unaffected. Three cases of tuberculosis of the suprarenals in which there was no pigmentation. The diagnosis was made in two from the remarkable'^ weakness of the patients in strong contrast to their well-nourished as- pect. Another sign is the low blood- pressure, not to be explained to any disturbances on the part of the heart. Gastrointestinal disturbances without traceable cause are further corrobora- tive testimony. These findings differ- entiate Addison's disease even with- out pigmentation of skin or mucosae. Stursberg (Miinch. med. Woch., Bd. liv, Nu. 16, 1907). Cases of liver cirrhosis and even a few incipient hepatic cases without appreciable change in the size of the liver present either disseminated he- patic patches of discoloration or a diffuse melanodermia of the same color as in Addison's disease. Here again the mucosae are but slightly or not at all involved, and the hepatic disorders place one on the right track. Arsenical pigmentation is a rare occurrence ; the same is true of sat- urnine pigmentation. In the latter the blue line on the gums is generalh^ sufficient to permit diagnosis. In pigmentation due to arsenic, the color is more slaty in hue, and a dark mot- tling is also present, which is rather characteristic. Finally the signs of arsenical intoxication, together with the absence of those of adrenal in- sufficiency, serve to establish the diagnosis. In malarial subjects the pigmenta- tion again does not involve the mu- 1—24 370 ADDISON'S DISEASE (LANGLOIS). cous membranes, it Is more diffuse and uniform, and the special indica- tions of malaria are present. The melanodermias of phthiriasic origin (pediculosis) seen among- vaga- bonds in a state of physiological de- bility, and who are bearers of para- sites, are accompanied by itching and cutaneous excoriations. The causa- tive agent may be discovered. On the whole, it should be borne in mind that the melanodermia of Addi- son's disease differs from other forms of pigmentation in that it shows marked preference for mucous mem- branes, although this characteristic should not be put down as absolutely distinctive. Early diagnosis is all important, though often very difficult. The dis- ease gives rise to definite signs and symptoms, and usually to marked le- sions of the medulla of the suprarenal gland. The solar plexus is frequently diseased, owing to the influence of the secretion of the gland in stimulat- ing the sympathetic system. Pathog- nomonic signs are asthenia, pigmen- tation, voiniting, and attacks of faint- ness. If these symptoms are well marked the diagnosis is not difiicult, but when they have become evident the chances of successful treatment are not good. Grunbaum (Practi- tioner, Aug., 1907). Two personal cases which empha- size the resemblance existing between Addison's disease and tabes dorsalis. Both patients presented an almost identical pigmentation, and both had muscular atrophy. One was a typical case of Addison's disease, while the presence of tabes was undoubted in the other. It is not necessary to as- sume a combination of tabes dorsalis with Addison's disease, however, since other symptoms of the last-named affection were lacking. The pigmen- tation should rather be referred to tabetic changes of the nervous sys- tem. Possibly the pigmentation in Addison's disease is likewise the ex- pression of disease on the part of the nervous system. In this particular instance atrophy of the shoulder mus- cles was said to have been present ever since birth, and atrophy of the thigh muscles was claimed to have followed later, in connection with traumatism. Wagner (Berl. klin. Woch., Nu. IS, 1908). TREATMENT. — Addison's dis- ease of pure type or manifested in the syndrome of adrenal insufficiency without melanodermia is largely caused by tuberculosis of the ad- renals. The general treatment of tuberculosis, or rather that form of treatment which is in vogue in a given locality at the time, is indi- cated. Syphilis of the adrenals is rarely diagnosticated during life; at the autopsy may be found either ex- tensive gummata, a miliary syphilo- sis or, especially in the young, a sclerosis resulting in atrophy of the gland. In doubtful cases the effect of specific treatment may be tried. Certain cases seem to have been bene- fited by the iodides, with or without the addition of mercury (Schwytzer, A. Andrews). Cases of bona fide acute adrenitis with or without hemorrhage, which are almost always frankly infec- tious in origin (small-pox, diph- theria, etc.), generally run a very rapid course and do not possess any special line of treatment. As for the morbid growths — sarcoma, epithe- lioma, carcinoma, etc. — which it is almost impossible to diagnosticate during life, unless perhaps it be when persistent edema is noted in com- bination with the usual syndrome, surgical intervention is indicated, though the results obtained by Israel, Mayo, Kelly, Lecenne, and Hart- ADDISON'S DISEASE (LANGLOIS). 371 mann have afforded but little en- couragement. Physiological data naturally led to the trial of adrenal opotherapy. This treatment was first instituted by Abelous, Charrin, and Langlois in the form of a glycerin extract of the adrenals of guinea-pigs, dogs, and horses. The patients were in such a state of cachexia that no results were obtained, but in two less advanced cases, employing injections each rep- resenting Gm. 0.10 of the dried ex- tract, Langlois obtained better results and in particular a notable diminution of the asthenia. Since that time numerous trials have been made and the treatment mark- edly altered. Among the methods that have been tried are: 1. Hypo- dermic injections of the extract. 2. Ingestion of fresh or dried glandular substance. 3. Injection of adrenalin solution. 4. Grafting of adrenal tissue. 1. The injections of extract of the suprarenals were early abandoned because of the great pain they occa- sioned and the fact that they failed to give satisfactory results in a large number of cases. 2. The ingestion of fresh or dried gland has furnished a few unhoped- for results, together with numerous failures. Beclere and Anderodias re- port cases of cure, or, perhaps better, disappearance and long-continued ab- sence of the symptoms of adrenal insufficiency. It is advised to use the adrenals of calves and start with doses of Gm. 1.5 to 2.0, which are gradually increased to Gm. 6.0. Sajous employs the dried gland (the glandulse suprarenales siccse of the U. S. P.). The dried extract may be given in capsules in the dose of Gm. 0.25 to 0.35 daily for ten successive days; it is left off for four days, then resumed for six to eight days, etc. Systematic testing with the sphygmo- manometer should be used as a guide in the treatment. Improvement in the arterial tone is to be considered the sign of efficiency in the treatment, while any indication of hypertonicity demands immediate stoppage of the administration of adrenal. Adams's paper in the Practitioner for October, 1903, includes an analysis of 97 cases treated with a preparation of the suprarenal glands. Of these, 7 were distinctly made worse by the treatment, 43 derived no benefit, 31 showed marked improvement, and 16 were cured. The methods of treat- ment in these cases may be divided into five heads: 1. Suprarenal grafts. Three patients were treated by this method and all died. 2. Nine pa- tients were treated by fresh glands given- by the mouth; of these, 1 be- came worse, 1 was not benefited, 6 were improved, and 1 permanently re- lieved. 3. Eleven patients were treated by hj^podermic and intramus- cular injection. One became worse, 6 derived no benefit, 3 were improved, and 1 permanently benefited. 4. Sixty-one cases were treated with the fluid or solid extract of the suprarenal gland by the mouth. Of these, 2 were made worse, 32 derived no benefit, 17 were markedl}- improved, and 10 were permanently relieved. 5. Fi^^e pa- tients were treated by mixed meth- ods; 3 were improved and 2 cured. The cases most likely to derive bene- fit from the specific treatment are those in which the process is a chronic sclerosis and in which the other or- gans are fairly sound. D. Symmers (Med. News, Sept. 10, 1904). Case of Addison's disease which im- proved .remarkably under the open-air treatment and the simultaneous admin- istration of suprarenal extract. The patient, a man, aged 36, had been ill for eighteen months. He applied for 372 ADDISON'S DISEASE (LAXGLOIS). treatment early in November, the weather at the time being cold, wet, and stormy. The man was placed on the balcony outside the hospital ward and stood the exposure well. The su- prarenal extract was administered in 5- grain doses three times daily. All the symptoms disappeared rapidly and the patient was discharged as cured five and one-half months after the begin- ning of the treatment. Death occurred suddenly two years afterward, due to asthenia and failure of the heart action. Bramwell (Brit. Med. Jour., Oct. 28, 1905). Case in a male, aged 18, which fol- lowed a very rapid course, i.e., less than four months, although suprarenal gland was given up to 15 grains thrice daily. At the autopsy chronic adrenal tuber- culosis was evident, with secondary in- flammation of the neighboring SA-m- pathetic plexuses. Second case in a female, aged 32, who had been ill two years. Adrenal gland caused so much improvement that she stood pregnancy parturition ■ easily, and bore a healthy child. She was given 5 grains, which were rapidly increased to 20 grains thrice daily. If she vomited the ad- renal extract for a few days her symp- toms began to return. A. G. Gullan (Lancet, Aug. 19, 1905). Case reported in a boy 18 years of age, who was brought to- the hospital in a fainting condition. He was gasp- ing for breath and sank exhausted into a chair. A walk of half a mile pre- ceding his admission was accomplished with the greatest difficult}', and only after repeated rests. The pulse was uncountable; respiration was rapid. The symptoms had existed for three months. It was stated by the mother of the patient that the boy's father had died of the same disease after some years of illness. The skin was gen- erally pigmented, with well-marked patches on the forehead. The patient only complained of extreme fatigue. After a few days extract of suprarenal was administered in the form of tab- lets, beginning with 1 three times a day, which soon increased to 2 three times a day. Under the treatment im- provement was rapid. In two weeks there was a gain of 6 pounds in weight and the pulse had decreased to 110, and he was able to move about the room with less difficulty. The pigmentation was less marked. The treatment was continued until 500 tablets were taken. The patient gained 56 pounds in weight, the pigmentation entirely disappeared, and he was able to resume work as an active farm laborer. R. E. Weigall (Austral. Med. Gaz., Oct. 20, 1905). The writer takes the blood-pressure at least three times in all suspected cases, and if it is found low adminis- ters suprarenal extract bj' the mouth, 3 grains three times a day, for three days. If there is a rise of more than 10 per cent, in the pressure, the probability that the patient suffers from adrenal insufficiency approaches a certainty. In regard to the blood, the opsonic index of- the serum for the tubercle bacillus may be taken, as tuberculosis is the commonest cause of the destruction of the capsule. Griinbaum (Practitioner, Aug., 1907). Case of Addison's disease which ex- hibited all the typical symptoms of this affection. When the patient was first seen the adynamia was so marked that an unfavorable prognosis was made. Owing to the secretory and motor in- sufficiency of the stomach, gastric la- vage with salt solution was practised. Nutrient enemas were given and hy- drochloric acid, but nothing else in the way of remedial agents. The patient slowly gained in strength and weight and eventually was dismissed in a very much improved condition. The skin pigmentation also lessened, but not so much but that a military surgeon was able to diagnose Addison's disease when the applicant was examined for the service. Since 1903 the patient had improved steadily, and the author be- lieves that the man may be considered as cured. In another instance, to which reference is made, this treatment pro- duced similar good results. The im- portance of gastric lavage is empha- sized in these and other cases for the purpose of removing from the gastro- intestinal canal toxins which it may ADDISON'S DISEASE (LANGLOIS). 373 contain. Grawitz (Dent. mcd. Woch., July 4, 1907). Our experience with Addison's dis- ease justifies the belief that one-sixth of the cases can be cured by the timely and persistent use of suprarenal ex- tract, while a considerable larger pro- portion, perhaps 25 per cent, more, can be substantially benefited. It does not appear that surgery can help us here, because in so far as the adrenals are involved it is the loss of secretion, as it is of the thyroid in myxedema, which lies at the bottom of the syndrome. G. W. McCaskey (Jour. Indiana State Med. Assoc, Jan. 15, 1908). Case of well-defined Addison's dis- ease in which the extreme languor, asthenia, and emaciation indicated a rapidly fatal outcome, but under or- ganotherapy the symptoms subsided and the patient, a man of 34, has been in good health during the ten j^ears since. The gland substance was eaten fresh and a glycerin extract was injected two or three times a week. There are still traces of pigmentation, confirming, the writer thinks, the assumption of the nervous origin of this symptom. Be- clere has reported a similar case of per- manent recovery under organotherapy. The suprarenal treatment evidently acts by stimulating to hypertrophy the parts of the suprarenal capsules which are still intact, thiis i.isuring adequate functioning. The writer cites 5 other cases that have been reported in France with marked improvement imder or- ganotherapy- and adds 3 from his own experience, all the symptoms, except the pigmentation, showing great benefit from the suprarenal treatment. E. Boinet (Bull, de I'Acad. de Med., Oct. 5, 1909). Series of 120 cases collected from literature, including 97 previously col- lected by E. W. Adams, in all of which adrenal preparations had been used in some form, gave the following results : 1. Cases in which death ran be as- cribed to grafting or adrenal preparations 8 2. Cases in which the benefit was slight or 7iil 51 3. Cases in which marked improve- ment occurred 36 4. Cases in which permanent bene- fit was obtained 25 120 Analysis of these cases shows that far better results could be obtained by . a careful adjustment of the dosage to the actual needs of each individual case. Addison's disease being due, from the writer's viewpoint, to inadequate oxy- genation and metabolic activity, the re- sult in turn of a deficient production of the adrenal secretion, it follows that tlie temperature and blood-pressure in- dicate the degree to which the adrenals are still performing their functions. It is plain, therefore, that our aim should be to supply only just enough adrenal extractive to compensate for the defi- ciency of adrenal secretion produced. The 25 cases of Addison's disease in which, out of the 120 referred to above, permanent benefit occurred include one, treated by Bate, in which but M^ grain (0.005 Gm.) of adrenal extract three times daily caused very great and last- ing improvement with marked lessening of the bronzing. When the remedy could not be obtained temporarily, which occurred twice, the case relapsed. On the other hand, Suckling began with 10 grains daily and gradually increased until 175 grains were given each day, and also obtained favorable results. That in Bate's case the adrenals were still able almost to carry on their func- tion is self-evident, while in Suckling's the remedy practically compensated for the adrenals (while the local morbid process in them was still active, and such as to paralyze their functions — a fact well shown by the severity of the case when the use of the extract was begun). The average dose is probably that used by Weigall in a very severe case — 5 grains, increased to 10 grains, of the extract three times a day. The patient increased 6 pounds in two weeks, and after about three months 56 pounds. In other words, in the 25 cases of permanent benefit, although the remedy was used empirically, it so happened in all probability that the 374 ADENITIS (WITHERSTINE). doses employed coincided with the needs 1. Cases in which death can be ascribed of the organism. In the 51 cases in to grafting or adrenal preparations . 8 which no benefit was obtained several 2. Cases in which benefit was sHght or occur in which failure was evidently nil 51 due to inadequate dosage or to too early 3. Cases in which marked improvement cessation of the treatment, while in occurred 36 others excessive doses — practically in 4. Cases in which permanent benefit was every instance a too rapid or excessive obtained 25 increase of the dose — as clearly pre- vented a successful issue. Sajous 120 (Monthly Cyclo., April, 1909). -piius, adrenal opotherapy, while it 3. The injection of adrenahn rec- I'^mains the rational mode of treat- ommended by Netter and Sergent ap- "'^^^ ^" Addison's disease, requires pears to us best suited for the cases ^^""^ ^^^^ subject be kept constantly showing low arterial tension, whether ""^^^ supervision. It cannot, there- of adrenal orig-in or not. ^°^^' ^^ considered a harmless form 4. Grafting of adrenal tissue. The °^ medication. only rational treatment for adrenal J' ^- Langlois, insufficiency is grafting of the gland. Experimentation shows, indeed, that ADENITIS. — DEFINITION. the substances secreted by the gland Inflammation of a gland, are very quickly destroyed in the VARIETIES. — Adenitis may be organism, and that either the inges- acute, due almost invariably to infection tion or injection of the extract can, from an attack of angioleucitis and oc- therefore, produce but very evanes- casionally to injury or strains; or cent effects, which, besides, cannot chronic, resulting from either of the completely replace the activities as preceding, especially in strumous or yet unknown having their seat in the cachectic persons, and from slight glandular cells themselves. Unfor- sources of irritation, and not uncom- tunately, success in adrenal grafting monly resulting in permanent enlarge- is not easily obtained, and in cases ment and induration or in tuberculous where the vitality of the grafted degeneration. Adenitis of specific gland has manifested itself accidents origin wih be described under Syphilis of so grave a nature have been noted and Urinary System. that grafting has been considered an ACUTE ADENITIS. impracticable method. Courmont re- SYMPTOMS.— The general symp- ports 3 cases of the grafting of dogs' toms depend upon the extent and adrenals in man and states that in severity of the infection. Rigors may all of them the results were disas- occur when pus forms. The tempera- trous. His personal case developed ture is frequently elevated. If the in- a formidable hyperthermia and car- fection is severe, symptoms of profound diac collapse. septicemia appear. Sajous has collected from the gen- The local symptoms are, by far, the eral literature 120 cases of Addison's most prominent in the majority of cases, disease treated by opotherapy in its and consist of pain, heat, and swelling, various forms and presents the fol- The suffering varies from a slight sore- lowing table : — ness only to intense pain according to Adenitis (witherstine). 375 the position of the gland, its relations with the surrounding tissues, and the density of the tissue in which it is im- bedded. The heat may vary according to the degree of the congestion present. The swelling may either be great or slight. If the lesion be confined to the gland, it will be well defined; if peri- adenitis is present, the swelling will be more or less dift'use. Glands in any re- gion of the body may be affected, but those of the neck, axilla, and groin more than the others ; this is due to the fact that infection generally enters the system through the mouth, throat, genital organs, and the extremities. In the congestive, or exudative, stage, pain and swelling are present in the region of the glands ; if the glands are superficial the swelling is ovoid, with the long axis coinciding with the direc- tion of the afferent lymphatics, and pal- pation reveals several movable, hard, elastic, and tender rounded masses. When the glands are deep, as in the axilla, abdomen, or even the neck, the results of palpation are less definite and unsatisfactory. In the suppurative stage the pain in- creases and becomes sharp and catch- ing, the skin reddens, and the periglan- dular tissue swells. If the gland alone suppurates, the skin remains normal, while under it may be felt the softened and enlarged gland. This latter opens outwardly or into the neighboring cellular tissue on from the sixth to the fifteenth day of the affection. When the gland opens outwardly, the cicatrix is much smaller than when it ruptures into the cellular tissue, as in the latter case it gives rise to an abscess. If the cellular tissue around the gland suppurates, the skin becomes quite hot, swollen, and painful, and fluctua- tion may be felt. Two foci of suppu- ration are thus established. The skin is occasionally undermined by the pus. Recovery is possible, however, without suppuration of the gland. Both the gland and the cellular tissue around it may suppurate, either simul- taneously, or suppuration of the cellular tissue may precede that of the glands, or the latter may suppurate and rupture into the surrounding cellular tissue and form an abscess. Pus is usually pro- duced in considerable quantity, and the affection is of long duration. Suppurative adenitis may result in cicatrization after several weeks. This cicatrix may reopen to allow the exit of pus from a suppurated gland. On the other hand, a fistula may result, which may give exit to seropus or to lymph (Despres). A lymphatic gland or vessel will then be found at the bottom of the abscess cavity, below the crater- like opening. As the suppuration usually starts in more than one focus in the gland, the first sensation to the touch will be one of bogginess, which periglandular con- gestion may render obscure. Well- defined fluctuation is found only when considerable tissue is destroyed. The writer reports the case of a child that had been referred to him with the diagnosis of hypertrophy of the thymus gland, the chief symptoms being dyspnea and retrosternal dull- ness. On operating with the inten- tion of removing the thymus this or- gan was found too small to account for the symptoms, but deeply behind the sternum, between the innominate artery and the trachea, the author came upon a grayish mass, which proved to be a suppurating lymph- gland.- This and another large node situated at the side of the trachea were removed. The result was satis- factory, the suffocative attacks being relieved. The lesson drawn from this 376 ADENITIS (WITHERSTINE). case by the author is that predomi- nance of abdominal recession during inspiration, as against almost com- plete absence of suprasternal and sub- clavicular recession, as had been pre- viously noted in this case, is a point of considerable importance in the dif- ferentiation of mediastinal periade- nitis from thymus enlargement. Veau (Bulletin med.. Mar. 1, 1911). DIAGNOSIS.— The diagnosis of ordinary superficial acute adenitis is usually easy; it is more difficult when the neighboring cellular tissue is also inflamed; it may be impossible in cases of deep-seated or visceral adenitis. In adenitis of the inguinocrural re- gion the swelling is found in the ex- ternal portion of the region if due to a lesion of the gluteal tissues, and in the inner portion of the region if due to a lesion of the anus, perineum, or external genitals. In both conditions the tumor will have its long axis directed more or less horizontally. The swelling will be found in the lower portion of the inguinocrural re- gion, with the long axis directed more or less vertically, if the lesion causing it is situated on the foot, leg, or lower part of the thigh. This disposition is due to the anatomical relations of the lymphatic vessels and glands, and should be borne in mind. Operation for strangulated crural (femoral) hernia has been performed for an adenophlegmon of the crural canal. Supraclavicular adenitis, while fre- quent in phthisis, is not present in every case. Yet it is of great diagnostic value when present. There may be a few or a great number of slightly enlarged glands, and they are frequently bilat- eral. The cervical glands may also be enlarged. There is no pain, nor does the swelling increase, remaining just the same for years. They rarely ac- company apical tuberculosis, but are generally found with peripheral, sub- pleural lesions. The writer considers that the presence of enlarged supra- clavicular glands confirms the diagnosis of doubtful phthisis. C. Sabourin (Jour, des praticiens, Dec. 27, 1902). New sign described, based on aus- cultation at level of seventh cervical or first dorsal vertebra. When the child speaks in a low voice the voice sound is accompanied by an added whispering sound, localized to one or two vertebras, or extending even to fourth or fifth dorsal vertebra. It is present long before dullness appears. The bronchial quality of respiration over this area is also significant, but it only appears when the glands are considerably enlarged. The absence of abnormal breath sounds and apical rales afifords corroborative evidence. D'Espine (Brit. Med. Jour., Oct. 15, 1910). ETIOLOGY.— The lymphatic glands serve as reservoirs on the course of the lymphatic vessels, through which any irritants or infection must pass. Cold and overexertion act as local depressants, and thus may indirectly favor the development of adenitis. Gen- eral debihty has the same effect. The following varieties of adenitis, etiolog- ically regarded, are recognized : — 1. Adenitis by contiguity, resulting from the propagation, by contact, of a neighboring inflammation. 2. Adenitis by continuity or follow- ing lymphangitis. 3. Adenitis by embolism, due to the transportation of septic or irritating matter, produced in the system or com- ing from the outside. Adenitis of the mesenteric glands may be due to dysentery or to the inflammation of Peyer's patches in typhoid fever. Adenitis occurs in carbuncle, furun- cle, vaccination, erysipelas, and eruptive or infectious fevers. Attention has been called by many ADENITIS (WITHERSTINE). Z77 observers to the frequent association of enlargement of the cervical glands and diseased tonsils. So often has this been found that every patient suffering from cervical adenitis should have the tonsils examined, with a view to their removal if diseased. The contents of the ton- sillar crypts should be examined mi- croscopically, and the identity of the bacterial growths therein ascertained. It is wase to submit the tonsillar mass to bactericidal measures — iodine in glycerin, for example — sometime be- fore removing them. The ordinary operation of tonsillec- tomy removes only the protruding por- tion of the tonsil. The submerged tonsil, which frequently extends a dis- tance of one-half to three-fourths of an inch into the tissues of the neck, is the one that gives the most trouble, and is the one that is the most difficult to remove. No single instrument can be relied upon for the removal of this tis- sue. If the tonsil is situated so that it can be drawn out by forceps, the old guillotine can be used, but this only applies to a limited number of cases. Usually the tonsil must be grasped with forceps and carefully cut loose from its capsular sheath, after which it is removed by the wire snare or guillo- tine. A tonsillar curette is valuable for removing the masses at the bottom of the cavities which have been left after the snare or punch forceps. The tonsil may be drawn from its bed by a thread, which is found often more useful than the forceps, as it does not need read- justing in cases of bleeding or vomit- ing. As a rule the operation can be done without general anesthesia. In every case of enlargement of the lymph- glands the tonsils should be thoroughly removed. R. C. Myles (Jour. Amer. Med. Assoc, Oct. 29, 1904). The writer made histological ex- aminations of 65 whole tonsils re- moved from children; 57 tonsils of patients not clinically tuberculous showed no tuberculous lesions. Of eight patients with tuberculous cervi- cal adenitis the tonsils were found tu- berculous in five. In two of the cases there was evidence of other than ton- sillar source for the tuberculous in- fection. F. S. Matthews (Annals of Surg., Dec, 1910). PATHOLOGY. — If suppuration does not occur, resolution may take place, or chronic enlargement of the gland may follow hyperplasia of the connective-tissue stroma of the gland. If suppuration does occur the sur- rounding connective tissue may, and usually does, suppurate; then the more or less disintegrated gland lies in a sup- purating cavity formed by the circum- jacent connective tissue. There are two forms of acute ade- nitis, depending upon the degree of inflammation present : — 1. Exudative adenitis. In this form the gland is swollen, and it feels hard and elastic. On section it appears red- dish brown, like the spleen, with small foci of hemorrhage, all of which indi- cate excessive dilatation of the capil- laries. The lymphatic stream is arrested by the dilatation of the cortical lymph- sinuses and their obstruction by fibrin, granular material, and portions of altered white corpuscles. The lymph- follicles are filled with fibrin and accu- mulated lymph-cells. The stroma of the gland is swollen and infiltrated with cells. If the section of the gland is scraped, a milky liquid will be obtained, which contains white corpuscles and epithelial cells, the latter showing several nuclei. 2. Suppurative adenitis. In this va- riety the gland softens, its tissues become more brittle, hemorrhagic infil- tration centers form that soon change into yellow, purulent foci. These, at first distinctly separate, soon unite, forming an abscess within the fibrous capsule of the gland. Sometimes the 378 ADENITIS (WITHERSTINE). periglandular tissue suppurates, while the gland does not. The glandular abscess and the peri- glandular abscess may open externally, each one separately or both simulta- neously. The suppurating gland may rupture into the cellular tissue. Occa- sionally the gland is hard and elastic ; it may be difficult to separate it from its fibrous capsule. The afferent lym- phatics are enlarged and thickened. The lymph-cells and cortical follicles are few in number and have under- gone granulofatty degeneration. PROGNOSIS.— The prognosis is usually favorable ; it may be unfavor- able, however, when extensive abscesses form in the neighborhood of important organs. Deep-seated suppurative adenitis may give rise to dangerous complications, especially in certain regions, like the neck and mediastinum, on account of the purulent extensions (through bur- rowing) and the difficulty of evacuating the pus. Ulceration of the great vessels of the neck giving rise to grave hemorrhages may also occur. TREATMENT.— The first indica- tion in acute adenitis is to remove any source of irritation or infection. Any wound, abrasion, opening, or any natural cavity with which either of these may connect should be so treated as to bring about absolute local asepsis. Enlarged glands of the neck are not, primarily, tubercular, and bear the sHghtest relation, if any, to general or pulmonary tuberculosis. The}'- are due to a mixed infection of pus-producing bacilli, and will quickly resolve if the source of the infection is removed be- fore the glandular tissue becomes dis- organized. If disorganization takes place, the gland should be poulticed until it is practically liquefied. It should then be opened by a stab puncture, emp- tied and drained by a Briggs cannula. Cases seen late with a large mass of partially calcified and partially disor- ganized glands present call for a thor- ough and extensive dissection. Treat- ment, other than local, should be food, fresh air, and proper clothing. F. D. Donoghue (Boston Med. and Surg. Jour., Mar. 28, 1907). The region in which the affected gland is situated should be kept at rest and, if possible, elevated. In this man- ner the afferent arterial current is diminished, while the efferent venous and lymphatic currents are increased. To prevent suppuration, gray mer- curial ointment, very gently rubbed in, is useful. The injections of from 5 to 10 minims of a 3 per cent, carbolic acid solution into an inflamed gland have also proven satisfactory. If it is desired to hasten suppuration, warm antiseptic fomentations are to be used in preference to poultices. The compound resin cerate of the pharma- copoeia is effective for this purpose, and is antiseptic as well. When pus has formed, the gland should be opened by a generous inci- sion, sinuses, if present, being opened throughout their entire length to facili- tate treatment. The contents are then carefully removed, and the infiltrated •wall scraped with a sharp curette. The cavity should then be packed with iodo- form gauze, or gauze impregnated with camphorated naphthol or salol. The dressing may be removed on the third day. Sufficient attention has not been paid to the subject of wholly avoiding or at at least minimizing the scar in the sur- gical treatment of cervical adenitis. Many cases of cervical adenitis occur in which this is of great importance, and in which radical operative meas- ures are not demanded. In such cases aspiration, or the use of a seton, or both, while not infallible, may prove ADENITIS (WITHERSTINE). 379 successful. When the tuherculous glands do not subside under medical treatment, excision, done with extreme care and reasonably early, is the method of choice. Neither aspiration nor the use of a seton should be resorted to in cases involving the deep cervical glands. Bulkley (Amer. Med., Feb. 27, 1904). In addition to climatic and general tonic treatment, the writer advised the evacuation by puncture of suppurative adenitis and the injection of a mixture of iodoform, 1 part; ether, 10 parts; oil of sweet almonds, 100 parts; creo- sote, 2 parts. In chronic cases cure may be obtained in two or three months after about twenty punctures. Robin (Tribune med., xli, 249, 1908). Balsam of Peru is a valuable curative agent, as it is not only antiseptic, but is a stimulant to healthy granulation. It is applied directly to the open, cleansed wound, and then covered with gauze and ^retaining bandage. In the treatment of cases of simple chronic adenitis, applications of iodine, compression, and local blistering have given the best results. Blisters, nitrate of silver, or iodine tincture should be applied around, but not over, the inflamed gland. Excision may be performed if the mass be large or disfiguring. In cervical adenitis due to tonsillar infection some authors have strongly advised the thorough removal of the diseased tonsil before attempting the external operation upon the glands, especially in those cases in which the lymph-glands have not broken down. The extension of the infection through the lymphatics from the tonsils is thus checked. In cervical adenitis due to tonsillar infection, the writer removes the dis- eased tonsil itself before attempting the external operation, in cases where the lymph-glands have not broken down. The cervical glands receive their lym- phatics from the tonsils, arfd the exten- sion of the infection, a conuuon occur- rence, is thus checked. Five cases re- ported in which the neck swelling dis- appeared after removal of the diseased tonsillar tissue. Some of these cases had advanced to a considerable involve- ment of the cervical glands. A. E. Rogars (Med. Rec. Nov. 28, 1903). Electricity, preferably the constant current, is highly recommended by some authors. Daily sittings of ten minutes each, using 5 to 15 milliamperes, are required. Codliver oil, the iodides, and iron are indicated in all cases when the digestive organs do not rebel against their use. Arsenic and strychnine are the agents next in order, and sometimes I)rove very eft'ective. Out-of-door life and plentiful nourishment are of pri- mary importance. CHRONIC ADENITIS. SYMPTOMS.— The symptoms vary according to the period of development in which the diseased gland is found at the time of examination. Three periods of development are commonly recognized in tuberculous adenitis : the period of induration, or indolence; the period of inflammation, and the period of suppuration. 1. Period of Induration, or Indo- lence. — This period may last for years, and resolution may even take place, though the gland always remains some- what enlarged and indurated. The glands are felt as hard, elastic, enlarged bodies, rolling under the finger, with more or less distinctness as they are situated superficially or deep. No heat, pain, or redness of the skin is perceived. 2. Period of Inflammation. — In this period we have pain, redness of the skin, and tenderness on pressure. The gland, if solitary, may adhere to the skin. Fluctuation may be present. 380 ADENITIS (WITHERSTINE). 3. Period of Suppuration. — In this period we notice much more softening of the contents of the gland than a real suppuration. The skin may ulcerate through almost without inflammatory symptoms, and the contents — consisting of caseous matter half-dissolved in a whitish watery fluid — may be evacuated. When periadenitis occurs, true pus may be present. If chains of glands are tuberculous, the latter inflame alternately and dis- charge their contents in the same order, a series of abscesses being thus formed. When the contents of the gland are discharged, the skin may become ulcer- ated in the neighborhood, form fistula, and after heahng leave a depressed, adherent, violet-colored cicatrix. In some cases a fistula may form and last for years; the skin may be under- mined, and disfiguring cicatricds may be formed. Cretaceous transformation occurs at times in the deeper glands, but rarely in the superficial ones. Some caseous glands undergo a process which trans- forms them into a cyst-like cavity con- taining a serous liquid. In chronic adenitis the glands may become painful by the compression of small nerves, or of neighboring organs ; when they are inflamed a small, hard mass usually appears, either alone or united with others, which may become enlarged and suppurate, or persist with practically no change for years, or finally disappear if the cause of irrita- tion be removed. Chronic adenitis may assume various forms. 1. General Tuberculous Adenitis. — This presents itself especially in ne- groes. Organs other than the glands are but little affected, and continuous fever exists. The retroperitoneal, bron- chial, and mesenteric glands are the most enlarged. It resembles in many ways an acute attack of Hodgkin's disease. The majority of children presenting symptoms of tuberculosis also have general adenitis, the swollen glands being felt everywhere ; they never change in size or consistence. Sud- denly a bronchitis develops, followed by a bronchopneumonia, from v/hich the child dies. Microscopical examina- tion reveals caseous spots and the pres- ence of tubercle bacilli throughout the affected glands. The name of "gener- alized peripheral adenitis" is suggested for this condition. Grancher and Mari- nescu (L'Union Med., Dec. 2, 1890). 2. Local Tuberculous Adenitis. — (a) Cervical. This form is usually met with in children, and begins in the submaxillary glands, wdiich are gener- ally more enlarged on one side. (b) Bronchial. This form is thought to be always secondary to a focus in the lungs, by some authors, but this opinion is contested by many others. Osier among them. Local lung infection, pericardial infection, and general infec- tion are to be feared, however. (c) Peribronchial. In this form we must realize the importance of lesions resulting from caseation. There is a softening of the lymphatic glands situ- ated around the lower end of the trachea and main bronchi. Evidence from percussion is of doubtful value ; alterations in breath-sounds are much more important, especially when uni- lateral; divided respiration, with pro- longed expiration, is found unaccom- panied by any adventitious sounds. In cases in which the enlarged glands ulcerate through the air-tubes, the breath has a very offensive odor, and coexistence of fetor with hemoptysis and evidence of pulmonary consolida- tion is suggestive. When vomiting of ADENITIS (WITHERSTINE). 381 blood and its passage by ll)o bowel arc added, tbc diagnosis of glands ruptur- ing into tbc bronchus and esophagus is the nuvst likely one. General tuberculous adenitis is likely to occur in such cases unless prompt remedial measures are insti- tuted. (d) Mesenteric. This form may be primary, and is thus very common in children, or secondary to local intestinal tuberculosis. The sufferers are usually weak and wasted; the abdomen is en- larged and tympanitic, and diarrhea is a common symptom. Some fever is usually present. This form may exist in adults. Sims Woodhead found tuberculous mesenteric glands in 78.7 per cent. o£ necropsies on tuberculous children, and in 11 per cent, the mesenteric was the only lesion present. Colman found them in 66 per cent, of the necropsies; Walter Carr in 54 per cent. ; W. P. S. Branson in 22 per cent. When this con- dition is present in adults, it is found to affect most frequently the glands of the appendix, or of the ileocecal region, because, according to Corner : — 1. The cecum is like the stomach, a resting place for the bowel contents in its passage. 2. The bowel contents contains a maximum number of organisms in the cecum. 3. The lymphoid tissue has its great- est development in the ileum, the cecum, and especially the appendix. Louis Rassieur (Jour. Missouri State Med. Assoc, Feb., 1909). DIAGNOSIS. — Chronic adenitis is generally limited to one or two glands ; when the glands are tuberculous, chronic adenitis is apt to affect an entire mass. The former is often asso- ciated with an external simple lesion; the tuberculous form is apt to be more frequent in children, young soldiers, and negroes. A fragment of the suspected tissue may l)e implanted into the subcutaneous connective tissue of the groin of a guinea-pig, and if the specimen is tuber- culous a miliary tuberculosis will de- velop in from five to six weeks. The use of the tuberculin test in the diagnosis of tuberculous adenitis is reliable and harmless. The tubercuhn used is a 1 per cent, solution of Koch's original product, from 1 to 5 mg. con- stituting a usual dose. If in from six to twenty-four hours after the injection of tuberculin solu- tion there occur weakness, sensations of heat and cold, general malaise, nausea, anorexia, severe headache, pain in the back and limbs, and if these symptoms are sharply defined in both their beginning and ending, reaction is considered to have oc- curred. Supraclavicular adenitis, while fre- quent in phthisis, is not present in every case. It is, however, of great diagnostic value when present. There may be few or many slightly enlarged glands, and they are frequently bilateral. Lymphadenoma. — This variety of tumor is usually more voluminous and is not suppurative. The diagnosis, how- ever, is exceedingly difficult. Simple Adenitis.— This is an acute affection usually ending in a few days in suppuration. Syphilitic Adenitis.— When a pri- mary sore is present, numerous, small, hard, indolent glands can be felt if the region is supplied with a chain of lym- phatics. When in secondary syphilis there is glandular enlargement, a large number of external lymphatics take part in the process. Carcinoma. — The enlarged glands are small and hard, and can generally be distinctly traced to the growth. Lymphosarcoma. — This persists 382 ADENITIS (WITHERSTINE). longer and is much larger before de- generation occurs. Chronic adenitis is frequently a com- plication of malignant tumors. Supra- clavicular adenitis appearing during the course of visceral cancer is usually situ- ated on the left side (found 27 times on that side by one author). It may be solitary or accompanied by adenitis in other regions ; it usually appears late and develops rather rapidly. When occurring early it may be very useful for diagnostic purposes. From a clinical point of view this adenitis may be known by its ligneous hardness, its painlessness, its freedom from adhesions, and by the union into one solid mass of all the glands forming it. ETIOLOGY.— This form of adeni- tis frequently follows some neighboring superficial lesion, such as eczema, impetigo, conjunctivitis, or the exan- themata. Catarrhal inflammation of the mucous membranes predisposes to tuberculosis of the glands. The resist- ance of the lymph-tissue is weakened. This explains the frequent development of tuberculous bronchial adenitis after whooping-cough and measles, and of mesenteric adenitis in children with intestinal disturbances. Cervical adenitis is not a manifesta- tion of an already generalized tuber- culosis ; the bacillus penetrates, by solu- tion of continuity of the mucous mem- branes or the skin, to the ganglion, which becomes a seat of infection (Duhamel). Enlarged glands of the neck are not, primarily, tubercular, and bear the slightest relation, if any, to general or pulmonary tuberculosis. They are due to a mixed infection of pus-producing bacilli, and will quickly resolve if the source of the infection is removed before the glandular tissue becomes disorganized. A distinction should be made between hereditary (congenital) and acquired tuberculosis. In the latter case the author's views seem rational and cor- rect, being comparable with and analo- gous to the phenomena observed in carcinoma and syphilis. When the in- fection is acquired there is, at first, a local seat, or focus, of infection in which the disease germs develop and from which, after proliferation, they spread tmtil the disease becomes more or less generalized, — the germs being transmitted through the lymphatic sys- tem to the lungs and thence in the blood-stream to the various organs of the body; the various glands along the course or path of transmission become affected and in turn become additional possible foci of infection. On the other hand, when the trouble is hereditary the glandular manifestation is an indi- cation of an already generalized tuber- culosis. Youth predisposes to caseous adenitis on account of the predominance at that period of the lymphatic system. Crowding, humidity, and bad or insuffi- cient food are also predisposing factors. Tuberculous adenitis is frequently ob- served in temperate regions. Negroes brought to such climates are especially prone to become sufferers. The absorbent power of the lym- phatic system is so great that the mor- bific principle of tuberculosis may be transported to the glands without visible external lesion of the skin or mucous membrane. Axillary adenitis is frequently sec- ondary to chronic tubercular lesions of the lungs (Lepine). The cervical glands are occasionally found affected in phthisical patients. ADENITIS (WITHERSTINE). 383 Observations by Mitcbell, of Johns Hopkins Hospital, ni)on 170 cases of tuberculous cervical adenitis show the disease to be more prevalent among negroes than among whites, males pre- ponderating over females in the pro- portion of 3 to 2, the majority being between 10 and 30 years of age. A family history of tuberculosis was pres- ent in about half the cases, though only 4 per cent, showed positive evidence of the disease in the lungs. The condition is regarded as a local manifestation of infection through the tonsils, adenoids, or carious teeth. PATHOLOGY.— Usually an entire group of glands is atTected. The glands are isolated when the irritation and rapidity of growth are not great; this usually occurs in secondary visceral adenitis. In other cases — especially when the glands are superficial, where the adenitis is primary — the glands are united into a large lobulated and irregu- lar mass, the size of which may vary from that of a small nut to that of an orange. If the adenitis follows a visceral tuberculosis the afferent lymphatics show, in some cases, signs of tubercu- losis, as is the case in pulmonary and mesenteric tuberculous meningitis. Two varieties of lesions are to be noted: 1. Lesions of chronic adenitis affecting the stroma and the elements of the gland, which becomes hyper- trophied. 2. Specific lesions of tuber- culosis,, consisting in miliary granula- tion at first, ending in caseation. As one or the other of these two processes is the more prominent, so will the lesion vary in appearance. Deep adenitis is never so sclerous as the superficial variety, the latter being characterized by a more vigorous reaction. On section of a gland in the early stage of tuberculous infection we find it redder than usual, though at times gray and somewhat translucent. The tuberculous granules may be perceived by a glass. They are formed from the vascular and lymphatic vessels found in the cortical and medullary portions, and resemble ordinary follicles, but contain many small cells. Caseation rapidly occurs in them, beginning at the center of the cells, where giant-cells are first formed, proceeding to coagulation necrosis and caseation. A number of these granulations united form the small, yellowish masses, which may be seen by the unaided eye. Caseation is due to vascular obliteration. The small, yellowish masses, softened at their centers, are surrounded by fibrous tissue due to sclerosis of the stroma of the gland. When this tissue gives way, several masses form a large collection of yellowish, softened material resembling putty. Calcification may occur when the process is very slow. The specific lymphadenitis blocks the lymph-spaces and thus, for a time at least, mechanically prevents the bacilli from penetrating into the general circu- lation. Glands not in the stream become infected, this probably being due to the transportation by migrating cells of the motionless bacillus. However, infec- tion usually takes place in the direction of the lymph-current. As the lymph- spaces are obstructed by inflammation products, and entrance of fresh bacilli into the gland is thus prevented, it is the multiplication of those already entered into the gland which gives rise to the tuberculosis. When caseation occurs, nearly all the bacilli have dis- appeared, but the spores remain, and are capable of reproducing the disease. Suppuration is due to a secondary in- fection by pyogenic micro-organisms. 384 ADENITIS (WITHERSTINE). The virus of tubercular adenitis is less potent, for the caseous material of a lymph-gland kills guinea-pigs, while rabbits escape, the latter being less sus- ceptible to tuberculous infection. Taken as a whole, tuberculous adeni- tis (a) is a local disease which may fre- quently undergo (b) spontaneous reso- lution, but which (c) frequently tends to suppuration, the pus being nearly always sterile. It is, however, a con- stant danger to the system. Chronic adenitis may, in some cases, be due to continued irritation; ulcers; chronic lesions of the skin or mucous membrane of the bones ; periosteum ; articulations ; chronic inflammation of the viscera, and certain new growths where the adenitis is purely irritative and not yet specific. PROGNOSIS.— A chronic adenitis may end in resolution, suppuration — caseation (see Pathology), cretaceous formation, or cyst formation. If all the tuberculous matter can be elimi- nated, either by nature or art, a re- covery may be obtained. The deeper glands are more dangerous than the superficial, as they are extirpated with more difficulty. The great danger of local tuberculous adenitis is that it may give rise to other tuberculous lesions, either local (pulmonary phthisis, tuber- culous osteitis, white swellings, or ab- scesses) or general (generalized tuber- culosis, with rapid death). Acute miliary tuberculosis may be caused in two ways : either by convey- ance through the lymphatic system until the venous system is reached or by the perforation of a vein and the entrance of tuberculous material (Weigert). TREATMENT.— The general treat- ment should, in all cases of adenitis, receive considerable attention. Good food, country air, and sea bathing are of the greatest value. In peribronchial adenitis the same general methods are to be resorted to. When due to tuberculosis and kindred diatheses and uncomplicated by fever or involvement of lung-tissue, the sea- shore or the country is indicated. At the seaside children should not bathe in the sea, and should be as quiet as is consistent with life in the open air. Brisk frictions, milk, a nutritious diet, and iodotannic syrup (2 to 4 teaspoon- fuls per day) are effectual measures. After three to four weeks, emulsion of calcium lactophosphate and codliver oil should be given. Counterirritation between the shoulder-blades favors the curative action of the other remedies (Marfan). AppHcations of tincture of iodine between the shoulders, or in some cases blisters or, even better, ignipuncture, will fulfill the latter indi- cations. The syrup of the iodide of iron, tincture of iodine, potassium io- dide, or large doses of codliver oil, already mentioned, either alone or with cinchona wine, arsenic, or ar- seniate of sodium, are the standard remedies usually recommended in these conditions. Not much is to be expected from them, however, unless outdoor life is insisted upon. Extirpation is indicated when internal medication has failed; when glands involve the face and produce deformity ; when they are isolated and few in numbers ; when they have undergone fibrous degeneration; when they are not freely suppurating. It is con- traindicated when there is impaired general health and tubercular deposits in the lungs and joints; when ramifica- tions of the chain of glands are very extensive. The possibility of giving rise to a ADENITIS (WITHERSTINE). 385 tuberculous process elsewhere by facili- tating absorption through exposed tis- sues should be borne in mind. One thousand cases of extirpation of tuberculous glands, without a single case of pyemia or septicemia and with only 2 cases of erysipelas, in both of which the infection was traced to a nurse. One of the best criterions of the success is the ever-increasing num- ber of patients who present themselves for operation, and who nearly all enter the hospital asking for the removal of their enlarged glands. Milton (St. Thomas's Hospital Reports, vol. viii). Out of 335 children treated, the tuber- culous glands were removed in 102. The operated cases gave a percentage of 83.34 cured, and the non-operated 68.77 per cent., that is, 14.56 per cent, in favor of the operation. Generaliza- tion of the disease could be found only in 1 per cent, of the cases. Cazin (Lyon Med., Jan. 11, 1890). Five hundred and six cases: 286 operated; 220 medically treated. Of the operated cases 149 were carefully followed during three years ; 93 (62.4 per cent.) have not shown the least sign of return of the affection. In the remaining 56 cases there was a return. Of the 149 non-operated cases, 28 died in sixteen years (18 per cent.) from general tuberculosis, and 14 are still alive, but have developed pulmonary tuberculosis. Von Noorden (Schmidt's Jahrbucher, July, 1890). In the cases of tubercular adenitis which are not yet suppurating, extirpa- tion through a small incision is indi- cated at once, with medical after-treat- ment to prevent recurrence. When one hard, caseous nodule exists, it should at once be extirpated, unless the result- ing scar will cause marked deformity. When these are multiple, immediate extirpation is the treatment to be fol- lowed. Should the adenitis become purulent, extirpation is only indicated after all other methods of treatment have failed. Local injections are ad- vised, with a long sojourn at the sea- shore, especially should fistulae occur. Clean dressings must be applied to the fistute to prevent secondary infection. When extirpation is done, it should be complete. A. Broca (Jour, des Prati- ciens, Oct. 26, 1901). Senn states that early operative in- terference is as necessary in the treat- ment of tubercular adenitis as in the treatment of malignant tumors, and holds out more encouragement, so far as a permanent cure is concerned. Tillmann argues that glandular tuber- culosis should be operated as soon as possible, in order to prevent general Sigmoid incision for the removal of cervical glands. (Senn.) miliary tuberculosis by the passage of the bacilli into the system. After incision, thorough curetting followed by iodoformization and clos- ure should be performed. The wound should be drained. The operator should not only feel, but see, every gland he removes. In cervical adenitis an S-shaped incision gives more room and a better cicatrix. In other regions the incision should be made so as to bring its axis parallel with the cutaneous folds. Local recur- rence should be treated in the same way. Three or four operations in as many years have been performed by Senn on the same patient, with final successful result. 1—25 386 ADENITIS (WITHERSTINE). Mitchell, of Johns Hopkins Hospital, uses a T-shaped incision when making a radical operation for removing all the glands and surrounding fat. The long arm of this incision is made to curve forward over the sternomastoid muscle and starting from the mastoid process joins the short arm along the clavicle, the dissection being carried from below upward and outward from the mesial line, the external jugular vein being tied with two ligatures and divided be- tween them. The omohyoid muscle is then divided, and by using it as . a retractor the internal jugular vein is exposed and the sternomastoid muscles pulled aside. In dissecting out the mass of glands the greatest difficulty is experienced with the chain connecting the anterior and posterior triangles behind the sternomastoid muscle, as the spinal accessory nerve passes through the mass and is generally very adherent. It is only when there is very extensive mischief that it becomes necessary to divide the sternomastoid muscle or spinal accessory nerve, or even to tie and divide the internal jugular vein, and these steps should only be resorted to when the advantages of free ex- posure outweigh other considerations. The wound is closed with a subcu- taneous silver suture and drained at its most dependent part. The resulting scar is usually sHght. When many glands are involved and suppuration has occurred, or when peri- adenitis is present, excision is not to be recommended, as extensive connective- tissue infiltration renders it impossible to remove all the infected tissue. Subcutaneous extirpation may be resorted to, but the method allows of l)Ut imperfect evacuation of the glan- dular contents and can hardly be recommended. Drainage of the abscess is a measure which may be recommended for many reasons. A small incision is sufficient for all purposes, and there is practically no scar left. Mesenteric tuberculous glands should be removed if possible. They are usu- ally discernible as persistent movable tumors beneath the abdominal wall, with anorexia, loss of weight and strength, occasional fever, colicky pains, and possibly mucus in tl:e stools with a tendency to diarrhea. Case in a female, aged 25 years, clerk, who had been complaining for one and one-half years of malaise, slight acceleration of pulse, and rise cf temperature. She had a movable tu- mor the size of a hen's egg, one and one-half inches below the umbilicus, in the middle line. The mass was re- moved. Intestine was resected. No drainage. Patient made a complete recovery. Collins (Interstate Med. Jour., vol. xi, p. 366, 1904). Case of a man, aged 41 years, who had been ill for six months. He com- plained of urethral pain before, and pain in the groins after, urination. The tip of the sacrum was so sensitive that he could not sit. Careful examination was negative. Several months later an X-ray picture showed a shadow op- posite the third lumbar vertebra, which might suggest renal calculus. Explora- tory laparotomy revealed a thin, atrophic appendix, and in the mesentery opposite the third lumbar vertebra was found a caseous and cretified gland the size of a large walnut. Appendix was re- moved. The gland was incised, cu- retted, and obliterated with sutures. No drainage and no gut was resected. Patient made a good recovery. He had no family or other history of tubercu- losis. E. M. Corner (Lancet, Dec. 23, 1905). Less radical measures sometimes bring about a cure. A transformation of the tuberculous tissues into a scle- rotic mass may be obtained. A solution Adenitis (wiTHERSXiNfi). 387 of chloride of zinc injected about the tul^erculons foci excites a growth of new fibrous tissue, which encapsulates the diseased portion. Solutions of iodoform and ether (iodoform, 1 part; ether, 5 parts; dis- tilled water, 5 parts. Injection not to be repeated while iodoform is being excreted in the urine), after A^erneuil, in cases where operative procedures are incHcated, give a lasting cure, without a cicatrix. These injections seem to exert a beneficial action not only on the tuberculous glands treated, but also on those at a distance from the seat of the injection. Robin uses an injection, iodoform, 1 part ; ether, 10 parts ; oil of sweet almonds, 100 parts ; creosote, 2 parts. The connection between inflammatory conditions of the nasopharyngeal space and acute infections of the glands at the angle of the jaw should be borne in mind. If promptly after the lighting up of the primary inflammation of the gland as evidenced by its enlargement, further absorption of infectious mat- ter from the nasopharynx can be pre- vented, the gland will cope successfully with the initial invasion and resolution occur, but if fresh invasions are allowed to take place resistance will be over- come and the gland will break down. Attention should therefore at once be directed to the problem of limiting sep- tic absorption from the nasopharynx by measures which keep the mucous mem- brane clean and also restore it as soon as possible to a normal condition. Chlorate of potash has an almost specific action in limiting the pharyn- geal inflammations of childhood, there- fore : — ^ Potassii chloratis gr. j-ij. Sig. : Every two hours for twenty- four hours, then every three hours, and later every four hours. To cleanse and soothe the naso- pharynx some mild alkaline wash is necessary. Of value in this connec- tion are: — IJ Tablets alkaline antiseptic {Seller'), Sig.: Dissolve one in a half-glassful of water and pour a little with a tea- spoon into each nostril every three hours. The results obtained from this line of treatment were immediately most gratifying. T. S. South worth (Jour. Amer. Med. Assoc, May 30, 1903). The following plan is recommended : A salve composed of equal parts of ichthyol and official ointments of io- dine, mercury, and belladonna, to be well rubbed in daily, and the bubo covered with gauze dressing, upon which the same salve has been spread thickly. It should be held tightly against the area by spica bandage. If the swelling then breaks down, infil- trate the softest and most prominent part of the swelling with 1 per cent. cocaine; incise, empty out the pus from the cavity by pressure, wash out two or three times with hydro- gen peroxide, diluted one-half with sterile water, then flush with sterile water alone, using an ordinary glass syringe. Melt some 10 per cent, iodo- form ointment and inject into cavity with some force, to fill it completely. Cover with cold bichloride gauze com- press, retained by spica. After five days remove dressing and squeeze out excess of ointment, or reinject if any pus remains. Royster (Medical Record, Feb. 25, 1911). Camphor-naphthol has proved valu- able in some cases. It is prepared as follows : — IJ Betanaphthol, Camphor aa 10 parts. Alcohol (60 per cent.) 40 parts. A few drops are to be injected, with antiseptic precautions, here and there throughout the mass of indurated glands, as suggested by Courtin, of Bordeaux. It is claimed in favor of camphor- naphthol that there is no danger of intoxication and that the treatment is, almost painless. Menard and Calot„ 388 AGENITIS (WITHERSTINE). however, have reported cases of intoxi- cation following injection of camphor- naphthol into abscess cavities. The patient suffered from frequent, rapid pulse, loss of consciousness, and epilep- tiform attacks. The quantity of the drug injected was about 6 drams. This patient recovered. In another case, 8 years of age, 1^ ounces of the solution were injected. In the third case, aged 12, 5 drams. In the last 2 cases life was saved by freely opening the cavity and washing it out on the first appear- ance of toxic symptoms. Camphorated guaiacol injected, 4 minims into the center of each gland, causes a rapid diminution of size, and ultimate atrophy. Glands which are beginning to soften should not be treated after this manner. Absolute success obtained in forty-six glands. ( Simon (Jour, de med., No. SO, 1904). Interstitial injections of iodine, fre- quently recommended, usually fail or cause suppuration, owing to the fact that the tincture of iodine is employed. Metallic iodine, however, gives good results; the abscess is filled with the crystalline iodine, 8 or 10 applications usually insuring a cure. Barjou, of Lyons, commends the use of the X-ray in the treatment of tuber- cular adenitis. The principal effect of this treatment is upon the general in- filtration which so often accompanies scrofula, uniting the lymph-glands in a solid mass. The glands become sep- arated soon after beginning the appli- cations, and later disappear. If there is any tendency to softening, the rays hasten this, so that the abscess may be opened earlier. The rays continue to have a good effect upon the suppurat- ing tissues. Untoward effects or tend- ency to cause metastasis are rarely noted. The Roentgen-ray treatment is the most effective method for the treat- ment of tuberculous adenitis in all its varieties. It afifords also the best cos- metic, as well as permanent, results. If treated early the scars are com- pletely avoided — an important consid- eration, especially in young women, who are often subject to the disease. The treatment is harmless and pain- less, but must be adapted to the indi- vidual. If too weak there will be no progress, and if pushed too far it may be hurtful. It seems also to raise the opsonic index and to pro- duce autogenous vaccines or anti- bodies, which pass through the pa- tient's system and effect tuberculous lesions at a distance and produce an immunity. The treatment is not con- fined to the earlier stages, though it is in these that the best cosmetic re- sults are obtained. C. L. Leonard (Jour. Amer. Med. Assoc, May 14, 1910). Koch's tuberculin and the simultane- ous use of the Bier method have been used with success in tuberculous adenitis. After treatment of tuberculous ade- nitis and other non-pulmonary tuber- culous lesions by the injection of Koch's old tuberculin, the glands were reduced in size, discharging sinuses healed, and there was neither spread nor recurrence of the disease. The writer reports 10 cases of adenitis, 4 of tuberculous otitis media, 3 of deposits in the phar- ynx, 4 of tuberculosis of the bladder, 3 of joint tuberculosis, and 1 of tuber- culous testicle. In the joint cases Bier's hyperemia was added to the tuberculin treatment. Tuberculin stimulates the production of tuberculo-opsonins, and causes a hyperemia around the tuber- culous area, thus aiding in the process of inoculation. G. R. Pogue (Med. Rec, Aug. 29, 1908). C Sumner Witherstine, Philadelphia. ADENOID VEGETATIONS (KNIGHT). 389 ADENOID VEGETATIONS — DEFINITION.— A definition of ade- noid vegetations, or adenoids, must be somewhat elastic. The name tonsil is often appHecl, and we hear pharyngeal tonsil, third tonsil, Luschka's tonsil, or bursa, used indiscriminately. It would be well to restrict the term tonsil to the lymphoid aggregation between the pil- lars of the fauces, where it was fiirst employed. The word adenoid seems to have been proposed nearly two thous- and years ago (Wright, "The Nose and Throat in the History of Medicine"), is therefore sanctified by time and us- age, and will doubtless be permanently retained. Lymphoid tissue is a normal con- stituent of mucous membranes, but the question : When does it become patho- logical? is not easy to answer. On the one hand we are told that it is abnormal "when visible to the naked eye," and on the other "when it causes subjective symptoms." Many insignificant hyper- plasise cause a good deal of disturb- ance, and on the contrary in a stolid, phlegmatic child or in a pharynx of large dimensions very considerable hypertrophies often seem to interfere but little with comfort or health. An accurate definition is desirable, but in view of the fact that lymphoid tissue is a recognized avenue for invasion of the system by pathogenic germs it is most important to determine in what condition of this tissue, healthy or dis- eased, the process of invasion is favored. Clinically it is clear that, when diseased, it is no longer capable of performing its physiological function and is a detriment to health quite apart from effects due merely to mechanical obstruction. The general symptoms present can hardly be explained on the latter ground alone, A species of toxemia must be also concerned. Dis- tended crypts provide an excellent bed for the cultivation of germs, which find ready access to the circulation in the absence of efifecti resistance. Lym- phoid tissue may be a portal of entry without itself showing marked patho- logical change, while it is probable that a dense fibrous adenoid, as met with in older subjects, may ofTer a firm barrier to bacterial assaults. SYMPTOMS AND DIAGNOSIS. ■ — It is not safe to rely upon the so- called "adenoid facies" as a diagnostic sign. A very similar appearance is sometimes seen in a subject of intra- nasal obstruction, while the postnasal space is quite free. A typical case of adenoid hypertrophy in the vault of the pharynx usually wears a dull, Hstless expression. The nostrils are narrow and pinched ; the bridge of the nose by contrast seems widened. The upper lip is retracted, exposing the teeth of the upper jaw, which project and overlap those of the lower. The upper jaw is compressed laterally, so that the roof of the mouth is converted into a Gothic or V-shaped arch. Deflection of the nasal septum may be a result. The nasolabial folds are effaced, and the transverse vein at the root of the nose is unusually conspicuous (Scanes Spicer). The child has a pasty, sallow complexion, and the cervical glands are prominent. The nutrition of a nursing infant suffers in consequence of fre- quent interruptions due to need of get- ting air through the mouth. For a similar reason older children "bolt" their food, which being defectively in- salivated causes gastric derangement. The latter is further aggravated by catarrhal secretion, always in excess in these cases, finding its way into the stomach. Loss of appetite and 390 ADENOID VEGETATIONS (KNIGHT). malassimilation are natural sequels. In severe cases deformity of the chest, pigeon-breast (Dupuytren), re- sults from the bad constitutional state, the labored breathing, or from both combined. The mental dullness shown by these children is referred to inter- ference with the lymphatic drainage of the brain and to impaired hearing. Investigations in 1573 German school children. Of this number 315, or about 18 per cent., were found to have a suf- ficient degree of impairment of hearing to make a professional examination advisable, although in the majority of them the impairment had not been no- ticed, either by the patients themselves or by the teachers. In 153 cases the impairment of hearing was directly referable to the presence of adenoids, and in 12 additional cases it was refer- able to the consecutive changes induced by adenoids which had spontaneously resolved. The number of cases in which adenoid vegetations could be re- garded as the causative factor in the impairment of hearing in all the cases considered amounted therefore to about 52 per cent., and the author lays stress upon the importance of a preliminary examination of all school children, both objectively and by hearing tests, at their entrance upon school life, as well as at later stated intervals, and gives the Bezold estimate of 2 meters, for the whispered voice, as the lowest accept- able standard. Cohn (Zeit. f. Ohren- heilkunde, Bd. Hi, S. 246, 1906). An investigation of the occurrence of adenoids in three London elemen- tary schools, with an attendance of 2315, showed that, on the average, about 37 per cent, of the children in elementary schools have adenoids, and that between 72 and Id per cent, of these have enlarged tonsils as well. On the average, 31.2 per cent, of ade- noid cases are mouth-breathers, com- plete or partial, and hypertrophy of the faucial tonsils may give rise to mouth-breathing in the absence of adenoids. Sex appears to have no in- fluence upon the incidence of ade- noids. Adenoids are more common about the age of 8 years, and are next most frequent at about 12 years. True aprosexia is often confused with ap- parent dullness, due to defective hear- ing, and it occurs in only about 4.7 per cent, of adenoid cases, is more fre- quent in girls, and, when present, is associated with a marked degree of adenoids. Macleod Yearsley (Brit. Jour. Child. Dis., Feb., Mar., 1910). During the last year there have appeared at the Eye and Ear Infirm- ary in Newark 471 cases of adenoids, all but 166 of which were associated with operations on the tonsils. The writer draws the following conclu- sions: 1. The condition of inatten- tion and lack of power of concentra- tion is frequently seen in juvenile mouth-breathers, and they are uni- formly helped by operation. The ef- fect is immediate and striking. 2. In those young children having the lymphatic tendency and bearing stig- mata of degeneracy, the enucleation of the tonsils and the removal of ade- noids are followed by most brilliant results. 3. The conditions called choreal, due, as they frequently are, to peripheral irritation, are not only greatly helped, but frequently perma- nently cured by the removal of the peripheral irritation. 4. In the con- genital defects of mental development the mental deficiency is bettered by the removal of the handicap to the general development. 5. He has seen a typical case of mental defi- ciency of the Mongolian type which showed a marked improvement fol- lowing the operation for the removal of adenoids. W. P. Eagleton (Medi- cal Record, July 30, 1910). The term aprosexia has been given to lack of ability to concentrate (Guye). Mouth-breathing is a source of much discomfort and even danger. The membranes of the whole respiratory tract suffer from inhalation of improp- erly prepared air. Two facts are beyond dispute : The peculiar susceptibility in childhood to ADENOID VEGETATIONS (KNIGHT). 391 infectious diseases, and the mode of in- vasion is by the upper respiratory tract. As corollary to these, the following conclusions are submitted : The pha- ryngeal tonsil possesses a distinct func- tion or functions. This function is of the nature of a defense against the entrance of bacteria, and consists in a certain irrigation of the tonsil surface by a lymph-stream loaded with lympho- cytes. This protection function carries with it the inherent qualities of the tonsil to enlarge on the slightest irri- tation for the affording of further power of defense. This inherent tend- ency of the tonsil to enlarge is fur- ther seen in the frequent recurrence of the tonsil after removal. Strictly speaking, then, in the great majority of cases such enlargements are not a pathological, but a physiological, process. Harris (American Medicine, Jan. 2, p. 20, 1904). Snuffling and noisy breathing by day and snoring at night are often distress- ing. Sleep is much disturbed thereby as well as by bad dreams, "night ter- rors" {pavor nocturnus) resulting from deranged cerebral circulation. The ef- fect upon the voice is characteristic. Its non-resonant, "dead" quality always suggests adenoids, at least in young sub- jects. The ability to precisely locate an obstruction from the sound of the voice, claimed by some, seems to be hardly warranted. In addition to special difficulty with the nasal con- sonants speech in general is thick and unpleasing. Actual stammering and stuttering have been ascribed to ade- noids, and a long list of reflex neuroses affecting the eyes, the ears, and more remote organs has been compiled. Among them may be mentioned laryn- geal spasm, hiccough, asthma, hernia, prolapse of the rectum, nocturnal enuresis, chorea, and epilepsy, some of which no doubt have their origin in the imagination of the observer. The rela- tion of laryngeal neoplasms to adenoids is a question of much interest. Even if we decline to accept a theory of "ver- rucous diathesis," or special predisposi- tion to neoplastic development, it is reasonable to assume that habitual mouth-breathing must irritate the laryn- geal mucosa. It has also been sug- gested that secretions find their way from above into the vestibule of the larynx, and, again, that the extraordi- nary labor imposed upon the larynx during phonation under these circum- stances favors the formation of new growths. In spite of what might be expected, some excellent observers maintain that neoplasms of the larynx are not especially common in adenoid • cases. Frequent attacks of earache, of nosebleed, and a tendency to catch cold, are generally included in the list of symptoms. Headache and asthenopia are complained of, the senses of smell and of taste are impaired, and fre- quently an ichorous discharge excoriates the nostrils and upper lip. The eyes are often found to be af- fected in cases of adenoids, the dis- eases of the eye usually found being : 1. Phlyctenular conjunctivitis (by far the most common). 2. So-called weak ulcer of the cornea, the non-inflamma- tory tilcer which looks as if a small piece of- the corneal surface had been gouged out ; sometimes difficult to see unless fuchsin is used. 3. Eczematous keratitis, often called phlyctenular kera- ' toconjunctivitis. 4. A peculiar irrita- bility or hypersensitiveness of the ret- ina, leading to difficulty in opening the eyes in a bright light. There can be no reasonable doubt that these oph- thalmic conditions are secondary to the nasopharyngeal : (a) By the marked lowering of the general health pro- duced. .(&) By the actual extension of the inflammatory process up the nasal duct to the eye. Hern (Brit. Med. Jour., Aug. 26, p. 437, 1905). The writer agrees with Bamberger, Moebius, and other authors in believ- 392 ADENOID VEGETATIONS (KNIGHT). ing that exophthalmos alone, if not due to mechanical causes, is sufficient ground for making the diagnosis of Basedow's disease. He describes two cases of exophthalmos which were com- pletely relieved by removal of adenoid vegetations. The first case was that of a boy of seven years, with well- marked exophthalmos, accompanied by both Graefe's and Stellwag's signs, and ophthalmos, but a week later the ade- noids were removed, and in the course of the next two weeks the exophthal- mos disappeared completely. The au- thor is of the opinion that Basedow's disease represents an intoxication of the central nervous system through abnormal internal secretions, and that adenoid vegetations are capable of evoking the malady. Epilepsy and Posterior rhinoscopic view. (After Grunwald.) who further presented the clinical pic- ture typical of adenoids. Ten days after removal of the pharyngeal tonsil the exophthalmos had completely dis- appeared. Two years later the patient reappeared with a return of all his symptoms, as a recurrence of the ade- noids was again accompanied by bilat- eral exophthalmos. Radical extirpation of the vegetations was followed by per- manent cure of the ocular protrusion. The second patient was also a boy of the same age, who, in addition to ade- noids and exophthalmos, suffered from hypertrophy of the tonsils. Amputa- tion of the latter structures was not followed by improvement in the ex- chorea probably have some etiological similarity to Basedow's disease, and the author thinks that they also may be produced by the presence of adenoids. An illustrative case is cited in which clearing of the nasopharyngeal space in a boy of 7 years was followed by the cure of a well-marked chorea minor. It therefore appears advisable to look for adenoids in all cases of these three diseases, and to remove them, even if there is no respiratory obstruction. B. Holz (Berl. klin. Woch., Jan. 23, p. 91, 1905). In a large number of school chil- dren who suffered with blurring vi- sion and fatigue on reading, the author ADENOID VEGETATIONS (KNIGHT). 393 found nasopharyngeal hj-pertrophy to be the real cause of the symptoms. Removal of the adenoids and correc- tion of faulty nasal passages resulted in cure in cases where, ordinarily, glasses would be thought necessary. W. M. Killen (Brit. Med. Jour., Sept. 25, 1909). The picttire in the rhinoscopic mirror is unmistakable, Lobulated or fissured masses of various sizes are seen hang- ing from the vault of the pharynx, obscuring the arches of the choanse, and often filling the fossae of Rosen- miiller and covering the orifices of the Eustachian tubes. They have been likened in appearance to a "cock's comb" (Czermak, 1860), and they are spoken of by Voltolini (1865) as "stalactite-like growths," a term adopted by Morell Mackenzie. They are often visible by anterior rhinoscopy when the intranasal structures have been shrunken by atrophy or retracted by cocaine. Sometimes the vegetations are distributed down the posterior wall of the pharynx, below the plane of the velum, or they may push forward into the nasal chambers. The view may be masked by viscid or in- spissated secretion, and, being fore- shortened in the mirror, does not give an adequate idea of the volume of the growth. In some cases, generally in older subjects, the mass is more uni- form and cushion-like in appearance, or is bilobed, being divided by an anteroposterior median furrow {reces- sus pharyngeus niedhis), and is less vascular looking. In adults remnants of adenoids are often seen in the form of bands between the Eustachian cushion and the pharyngeal wall, which doubtless bear some relation to various subjective aural disturbances. Applications of cocaine and the use of a palate retractor are to be recom- mended only in older children and when a rhinoscopic examination is iniperative. By the exercise of tact and patience it is often possible to get a view, even in a very unpromising case. In some it is out of the question and the only resource is a digital examina- tion. The process is disagreeable to the patient and dangerous for the examiner in children, unless one's finger is pro- tected in some way. A finger shield of metal or rubber may be used, or a mouth-gag may be applied. Better Adenoids seen through anterior nares. (After GriXnwald.) Still, the child being firmly held by an assistant, the examiner standing on the left presses the right cheek of the patient between the separated jaws with his right middle finger while he quickly passes his left forefinger into the open mouth and up behind the velum. The mouth cannot be closed and thus the finger is safe. The anatomical landmarks to be sought are the posterior margin of the vomer in the middle line and the Eu- stachian eminences at the sides. A novice might mistake a prominent Eustachian cushion, a papillated pos- terior end of an inferior turbinate, or even the contracted velum (F. H. Hooper) for an adenoid mass, but the 394 ADENOID VEGETATIONS (KNIGHT). last is higher in the fornix of the pharynx and more posterior and has a distinctly lobulated, elastic, and pulpy feeling, compared to that of a bunch of earthworms. On withdrawal the fin- ger is smeared with blood, which is not the case when a healthy pharynx is ex- plored, unless excessive force has been exercised. In those who object to the finger some idea of the extent and con- sistence of a postnasal growth may be gained by palpation with a stifif probe or the edge of a rhinoscopic mirror. In some cases a very beautiful view of the vault of the pharynx is given by the ingenious electric pharyngoscope de- vised by Hays. The end of the instru- ment having been passed into the oro- pharynx the patient is instructed to close the lips and breathe quietly through the nose. The palatal muscles relax and permit the light to flood the cavity of the rhinopharynx. With a little patience and care a complete picture may be obtained, even in very sensitive throats. Nasal polypi, retro- pharyngeal abscesses, syphiloma, and neoplasms, benign or malignant, may occur in this region, but usually present features or give a history which serve to distinguish them. Benign nasopharyngeal polypi, stud- ied in 22 cases. They are usually uni- lateral and solitary, and have a peculiar pear-shaped form, the broad end lying in the nasopharynx, while the stalk ex- tends into the nose. They may attain considerable size, and are subject to in- flammatory changes which may end in partial or total gangrene. The treat- ment is very favorable, as they are easily laid hold of, and readily torn out on account of their slender stalk. In the majority of cases the polypi do not recur. There is usually a profuse dis- charge of serous fluid after the extrac- tion, and examination of the antrum shows a slight chronic inflammation. Choanal polypi originate within the antrum of Highmore, and are due to inflammation of the antral mucous membrane. Killian (Lancet, July 14, p. 81, 1906). It is hard to believe that a simple pendulous polypus of the nasopharynx could be mistaken for a bunch of ade- noids. Yet the risk is evidently present in the minds of some observers. In a recent paper by W. A. Wells (Laryn- goscope, July, 1911) the fact is noted that it is usually taken for granted that postnasal obstruction in a child under 15 years is due to adenoids. He describes 3 cases of fibrous pol3'pus, which he makes the basis of a plea for intranasal removal with the cold-wire snare rather than by' a "mutilating" external operation generally employed in growths of this kind. He enumer- ates three theories of etiology: (1) cranial, propounded by Nelaton; (2) choanal, that is, springing from the ethmoid, sphenoid, or vomeral region, and (3) sinusal, as adopted by Killian in the paper above quoted. While it is well to bear them in mind, fibrous polypi of the pharynx are so rare and their symptoms are so different from those of adenoids, except in the single feature of obstruction, that the chance of confusion is rather remote. Rugae or folds of thickened mucous membrane in the floor of the nose, and the so-called "lateral bands" of red and thickened membrane on the walls of the pharynx behind the posterior pillars {pharyngitis lateralis hypertropica) are regarded by some as pathogno- monic, but each is often found without adenoids. Fluid injected into one nos- tril is expected to escape by the other if the nasopharynx is free; by the mouth if adenoids are present (Semon, quoted by Schech). A similar test with oil spray is regarded as "almost abso- AbENOID VEGETATIONS (KNIGHT). 395 hitely diagnostic" (Bosworth). Each of these experiments must be invaH- dated by a unilateral nasal stenosis and should not be relied upon. Adenoids may exist without enlarged f aucial tonsils : the reverse is seldom true. Hence it is important to examine the pharyngeal vault in all who mani- fest the latter condition. The occur- rence of adenoids, as well as of tur- binate hypertrophy, in victims of cleft palate has often been remarked, whether as an effort of nature to stop the gap or as a consequence of the same diathesis that caused the palatal deformity is hard to decide. Such cases afford unusual opportunity for study of these anomalies. ETIOLOGY. — A constitutional state allied to struma, termed lymphatism (Potain), predisposes to lymphoid hy- perplasia. From observation of 1995 cases Sendziak concludes that "scrof- ula" plays an important part in etiology, a view shared by Lennox Browne. The exanthemata, syphilis, tuberculosis, are similarly accused. Poor sanitation, bad hygiene, and improper diet are undoubted factors, yet not infrequently cases occur in which none of the fore- going elements is concerned and we are at a loss to discover the cause of the condition. The importance of nasal stenosis, resulting perhaps from some injury in early life, is generally admitted. Be- hind an obstruction the air is so rarefied on inspiration that congestion of the mucous membrane results with conse- quent tendency to hyperplasia. The bearing of this fact with reference to treatment should be appreciated. The habitual breathing of impure air, or of air too hot or dry, often prevailing in our homes and sleeping rooms, no doubt has a bad effect on the mucous membranes. The same is true of cer- tain occupations that involve the inhala- tion of irritating vapors or floating matter in the air. The condition occurs with equal frequency in the two sexes. It seems reasonable to admit an in- herited proclivity. Those who deny the existence of heredity find it difficult to explain the exhibition of almost iden- tical local conditions in several suc- cessive generations. The effect of a rigorous climate is not necessarily bad, but extremes and sudden changes of temperature and humidity are no doubt harmful. Adenoid growths are essentially a disease of early life, of the formative period, when the lymphoid tissues are especially active. A few congenital cases are on record. Among 437 chil- dren in the first three years of life examined by W. F. Chappell not a single example of lymphoid hypertrophy under the age of three months was found. Some instances of adenoid vegeta- tions in infancy appear to be truly- congenital, symptoms referable to the condition being present at birth. A considerable number of infants suffer from slight degree of adenoid vegeta- tions, as evidenced by mild symptoms of nasal obstruction and catarrh. But there are also not a few cases in which more severe and even grave symptoms may be present. These will materially interfere with the health of the infant, and do not tend- to im- prove with ordinary medical treatment. There are several forms of the affec- tion : the first, in which there are marked nasal obstruction and catarrh, with or without epistaxis ; the second, in which reflex phenomena are the principal manifestations of the trouble, without any real nasal obstruction (such signs may be convulsions, laryn- geal stridor, and vomiting) ; the third, those in which secondary septic affec- tions predominate, these being chiefly 396 ADEXOID VEGETATIOXS (KXIGHT). septic adenitis and otitis media, and, lastly, those cases in which nasal ob- struction is present and is associated with nervous and septic conditions. In by far the larger number of cases of adenoids in infanc}', the S3'mptoms are slight and do not call for active opera- tive treatment, but, on the other hand, there are certainly some cases, com- paratively few in number, in which the signs and symptoms are such as to de- mand removal of the adenoid growth. In these the improvement that follows operation tends to confirm the fact that the various phenomena that the infant presents are, in reality, due to the lesion in the nasopharynx. R. C. Dun (Lancet, August 15, p. 474, 1903). Adenoid vegetations are present in nursing children more frequently than is usually supposed. The symptoms are difficult and noisy nasal respiration, and there is usually some nasal secretion. In advanced cases there is marked dyspnea, laryngeal spasms, disturbed sleep, and restlessness during waking hours. The nutrition is diminished, the skin pale, and the cries are weak and changed in their timbre. The first de- velopment of these cases is hard to establish because it is exceptional that a specialist is consulted, and frequently the little patient succumbs to a pro- gressive inanition; if it survives, it grows with the characteristics of ade- noidism. If, on the other hand, the proper treatment is followed, the trans- formation is complete ; the mechanical difficulty of respiration ceases, the nu- trition improves, the child gains rapidly in weight, and recovers its normal quietness and sleep. F. Massei (Revue Hebd. de Laryn., etc., Oct. 22, p. 499, 1904). Very little consideration is usually given to the presence of adenoids in the infant, although they are common and their evil results even greater than in childhood. The anatomical construction of the pharynx and post- nasal space in infants makes a small amount of adenoid tissue a marked im- pediment to respiration. They are directly responsible for the attacks of otitis media so often seen in infants. J. L. Morse (Jour. Amer. Med. Assoc, Xov. 9, p. 1589, 1907). The writer criticises the neglect of adenoids in early infancy, as they in- terfere with the proper development of the child by reflex action, by the irritation they produce and the ob- struction they cause. The postnasal pharynx at birth is a space only one- quarter inch high by one-third inch wide, so that a very slight adenoid hypertrophy at this period will cause obstruction. At the end of the first year it is nearly doubled in size. It often produces symptoms in the first days of life, and the mistake is some- times made of diagnosing specific dis- ease. The snuffles are specially marked while the child is nursing and result from an adenoid which pro- duces irritation, and, if large enough to obstruct the pharynx, there is mouth-breathing. Other causes may produce mouth-breathing, but ade- noids do so most frequently during the first year of life. A third indica- tion of the condition is the appear- ance of recurrent colds, which, during the first year, are usually caused by adenoids. Another most characteristic sign is a persistent cough, sometimes simulating w^hooping-cough, without any other indication in the pharjmx or bronchi to account for it. A fifth and most dangerous condition is oti- tis media. It is not always easy in a very young infant to determine the presence of adenoids, but it can be done by rapid manipulation. The right index finger being rapidly passed into the mouth while the jaw is held open by the ends of the fingers of the left hand pressing on the teeth, the rough surface of the adenoid can be detected by the skilled physician and sometimes so quickly that the baby does not even cry. R. G. Free- man (Jour. Amer. Med. Assoc, Aug. 21, 1909). From a study of 32 cases Erdely con- cludes that adenoids are congenital and should be removed in children after the sixth month if symptoms are present. (Jahrb. der Kinderh., May, 1911.) ADENOID VEGETATIONS (KNIGHT). 397 Rare instances have been noted in the aged, but the tendency is toward atrophy after puberty. Several cases in elderly people have been observed by Bryson Delavan, who holds the behef that the condition may develop in mid- dle life and is not necessarily a legacy from childhood. One was discovered by J. Solis-Cohen in a woman of 70, and a number of authentic cases after the age of 60 have been reported (P. G. Frank), but at this time of hfe a malignant element is always to be sus- pected. The curious observation has been made by Gelle that these structures sometimes show renewed activity at the menopause. Series of 57 cases found in literature in which a considerable amount of tis- sue was found in the pharyngeal vault of adults. In most cases it was possi- ble to make the diagnosis by posterior rhinoscopy, but sometimes it was nec- essary to use the finger. The growths varied in size and distribution, but were always of considerable size, and usually sprang from the angle between the roof and posterior wall of the pharyngeal vault. They were usually soft, pulpy, and friable, particularly so in the older subjects. Thirty of these cases were between 20 and 30 years of age, 15 be- tween 30 and 40, and 12 over 40 years of age. Thirty-six had throat symp- toms, 25 ear symptoms, 10 tuberculosis, 1 cervical adenitis, and 1 ethmoiditis. The sexes were nearly equally divided. The improvement following operation was much better in the decade between 20 and 30 years of age than in patients over 40. D. M. Barstow (N. Y. Med. Jour., May 6, p. 899, 1905). PATHOLOGY. — Lymphoid cells embedded in a reticulum of connective tissue containing small blood-vessels and nerves, the retiform adenoid tissue of His, and enclosed in a mucous mem- brane covered by columnar ciliated epithelium, constitute adenoid vegeta- tions. The relative proportion of these elements varies with the age of the patient, the duration of the disease, and the frequency and intensity of acute inflammatory attacks, to which this tis- sue is very liable. In young subjects cells predominate and the tissue is soft, friable, and vascular ; in older ones con- nective tissue is in excess and the mass is more dense and hard. As a matter of clinical convenience adenoids are sometimes divided into soft and hard, Avhich are, of course, merely grades of the same pathological process. In very young children, also, a temporary intumescence takes place in consequence of gastrointestinal dis- turbance or other cause, when many of the subjective symptoms of ade- noids are presented. This condition, naturally, calls for different treatment than an organized hyperplasia. Morbid changes . are not confined to the epi- pharynx, but involve adjacent lymphoid structures. Cystic transformation and other disorders of the pharyngeal bursa have been particularly described by Tornwaldt. A cyst of the bursa may reach extreme dimensions and occa- sionally small cysts are met with in the adenoid tissue, but the importance of these conditions has been somewhat exaggerated. The idea once expressed by Woakes that adenoid vegetations are papillomatous in structure is not sustained by modern views. PROGNOSIS.— Under present-day methods of attacking the disease the prognosis is good, both as to arrest of the morbid process and reHef of asso- ciated symptoms. Only in case the con- dition has been extreme in degree or duration organic changes may have been estabhshed, for example in the ears, which are irremediable. Chronic otor- rhea due to adenoids cannot be cured 398 ADENOID VEGETATIONS (KNIGHT). while the latter are allowed to persist. Likewise impaired hearing and tinnitus due to occlusion of the Eustachian tube from pressure or congestion must be reached through removal of an adenoid m_ass. Recurrence of adenoids may take place in certain cases of pronounced lymphatism (status lymphaticus), in which predisposing factors cannot be wholly eliminated, or when an opera- tion for removal has been done very early in life. The suspicion remains, however, that some alleged relapses are realty examples of incomplete removal. These partial operations are explained in. a measure by A. A. Bliss on the ground that the lymphoid tissue pene- trates the fissures of the vomerosphe- noidal articulation (canales basis vomeri of Harrison Allen), where it is more or less inaccessible. Extreme vascularity of the region and the fact that the adenoid is often made up of separate and distinct bundles also contribute to the possibility of apparent recurrence, which is really a growth of tissue that has evaded the knife. It is safe to say that no operation in the upper air tract confers more grati- fying and positive benefits than an adenectomy properly done. There has been much controversy as to the thor- oughness with which morbid tissue should be removed, one side advocating extirpation of every vestige and the other averring that such a course is ultraradical. When we reflect upon the wide distribution of lymphoid tissue in the so-called ring of Waldeyer, or lymphoid triangle, the conclusion is forced upon us that absolute eradica- tion is impracticable, even if desired. What we accomplish in a given case is extraction of the most salient and dis- eased portions : the consequent im- provement in air supply and in other respects enables nature to do the rest. This statement is not to be taken as a defense of superficial operating, or as a suggestion that we may trust nature to supply defects involved in our own negligence. Postoperative shrinkage of any considerable remnants is not to be expected, yet there are limits of safety beyond which we may not pass and anatomical conditions which are insuperable. Certainly erasion of the mucous membrane through its whole thickness, so as to replace glandular secreting tissue by scar tissue, is to be strongly deprecated. Case of a child of 7 years, who had been operated upon three years ear- lier for adenoid vegetations without accident, but without benefit. A sec- ond operation was performed two years later, after which, on returning home, the patient passed a great deal of blood by vomit and by stool. A third operation for enlarged tonsils was also performed without special incident. Nevertheless, the child never breathed freely by the nose, and con- tinually kept the mouth open. The writer found an incomplete adhesion between the soft palate and the phar- ynx consecutive, in all probability, to the second intervention. The pharyn- geal orifice behind the uvula was too small to permit the passage of an adenoid curette. On being enlarged the opening offered ample space for respiration. Courtade (Annales des mal. de I'oreille, du lar., du nez, et du pharynx, Aug., 1910). Case of a young woman suffering from nasal insufficiency, due to the presence of large adenoids, removal of which was followed at once by commencing atresia. The case being referred to the writer, he advised op- eration, but this was declined. The closure soon became complete, and in May, 1909, she consented to opera- tion. An incision was made through the adhesion, and a strip of gauze was passed through • the nose into the mouth, and the ends attached over ADENOID VEGETATIOx\S (KNIGHT). 399 the lips. This was left for three days, when sloughing commenced, and, fear- ing extensive destruction of tissue, the gauze was removed. Subsequent treatment consisted of dilatation twice a day with the probe or finger. When reported, six months later, the phar- ynx was perfectly free and the pa- tient's voice was normal. Wolf? Fru- denthal (Laryngoscope, May, 1910). Adenoid tissue is present in the vault of the pharynx in 1 out of every 4 recruits. The fact of its presence should be noted on the rec- ord of the physical examination in order that due weight may be given to it as a factor in producing defective hearing when cases of this sort come up for discharge for disability or pen- sion. All large adenoids should be excised on entry into the service, and smaller masses if associated with pathological changes in the middle ears. Refusal to consent to operation should disqualify applicants for en- listment in the artillery branch of the service or transfer to that branch. Every 2 out of 3 recruits who have adenoids have visible changes in the middle ears. Fifty per cent, of the cases who do not have adenoids, but who do have hypertrophied ton- sils, have changes in the middle ears. Changes in the middle ears without the presence of either adenoid or ton- sillar hypertrophy are unusual, and occur in only 1 case out of 12, and in the case in which it occurs it is usually associated with hypertro- phic rhinitis. In other words, in 11 cases out of 12 which show changes in the middle ears, ade- noid or tonsillar hypertrophy will be found. One out of every 3 cases with adenoids will also have hyper- trophied tonsils. Two out of every 3 cases with hypertrophied ton- sils will also have adenoids. Recruits with marked hypertrophy of the ton- sils should have the glands excised, whether they have had repeated at- tacks of acute tonsillitis or not. Ade- noids do not undergo spontaneous atrophy in young adults. Le Wald (Military Surgeon, May, 1910). In a small proportion of cases breath- ing b}^ the natm-al channels is not at once resumed. This is due simply to the habit of mouth-breathing, or to im- perfect development of the air tract from prolonged disuse. In the former case the habit is soon corrected by some device for binding up the chin and keeping the mouth closed during sleep. In the latter the difficulty is greater and it may be a long time before the normal respiratory current is restored. These cases, fortunately rare, are most dis- appointing to operator and parents and yield, if at all, only to careful attention to hygiene and to measures tending to promote development. The co-opera- tion of the dentist is enlisted for cor- rection of the oral deformity, widening the dental arch and thus depressing the floor of the nose and increasing t':-: diameters of the nasal passages. It is best -not to delay this beyond the sixth or seventh year (E. A. Bogue), although surprising results may be achieved much later. Two other causes of continued diffi- culty in breathing after adenectomy have been described : one is extraor- dinary prominence of the bodies of the cervical vertebrae (J. E. Newcomb), and the other is a paresis of the sus- pensory apparatus of the hyoid bone and the tongue, so that, Avhen the mus- cles are relaxed in sleep, the tongue falls back and occludes the glottis (Harrison Allen). In the experience of Payson Clark mouth-breathing persisted in 35 out of 75 cases whose subsequent history could be learned. Over 500 others were not traced and it is fair to assume that the above percentage might be greatly reduced. Faulty habits of speech are to be re- formed by careful exercises under com- 400 ADENOID VEGETATIONS (KNIGHT). petent supervision. The palatal muscles having been long curbed in their action need to be properly educated. TREATMENT. — Until Wilhelm Meyer, in 1868, gave to the world the results of his careful studies, but little had been done in diagnosis or treatment of adenoids. A few scattered refer- ences are found in literature many years before his day, and the valuable researches of Luschka and others in the anatomy of this region are well known, but no serious attempts were made to remove from the postnasal region cer- tain obstructions, and their exact nature was not fully understood until Meyer began his investigations. In the hope of escaping surgery various local astringent applications and methods of treatment have been ad- vised, all of which are more or less futile, except in the vascular or "cyanotic" adenoid of some writers. In these cases instillations of adrena- lin chloride, 1 to 5000, followed by fine sprays or vapors of mentholized albo- lene are of service. Glycerite of tan- nin and other astringents can have little or no permanent effect while the underlying cause remains. Anemia, gastrointestinal derangements, or other disorders must be corrected by proper hygiene, diet, and general medication as indicated. Internal medication offers but little. With anemic or chlorotic children one is often inclined to temporize and try to build up the system by means of iron and other tonics, but the speedy improvement in general condition following surgical intervention is conclusive proof that the main cause of the constitutional depression lies in the local disorder, upon which medication alone has little or no effect. Experience with opotherapy is still too limited to justify a final verdict. Some authorities assert that under its use reduction in volume of lymphoid hypertrophy is so rapid as to eliminate the necessity of surgical intervention. In this connection attention is drawn to the danger of too thorough eradica- tion lest neighboring glands be stimu- lated to excessive functional activity and increased growth. The internal and local use of iodine for its sorbefacient effect has not had pronounced success. The Bier suction hyperemia treatment, for which very temperate claims are made in hyper- trophy of the faucial tonsils, does not seem to have been applied to adenoids. The tubes figured by Meyer-Schmieden for aspirating the nasal chambers and the sinuses would make but little im- pression in the postnasal space, al- though good results in atrophy of the nasopharynx are mentioned. At one time certain "breathing exer- cises" were loudly vaunted as a cure for adenoids. The shallow character of respiration practised by most people and the health-giving value of deep breathing are generally comprehended in these days, especially in connection with the class of cases under considera- tion. Meyer appreciated the fact that a dense hyperplasia cannot be dissipated by breathing exercises, or by measures tending to promote the general health, or designed to exert a contractile effect upon the morbid growth. His early essays at removal were made with a small "ring knife" passed through the anterior naris and guided by a finger inserted behind the velum. It was soon found possible to operate more easily and expeditiously through the mouth, and in consequence today the instru- ment shops are flooded with forceps. ADENOID VEGETATIONS (KNIGHT). 401 guillotines, and curettes designed to facilitate this procedure. In adopting a plan of operation the principles of thoroughness, gentleness, and celerity are to be observed. By the first is meant not a clean sweep of all t!ie soft parts down to the bone, but a removal of projecting tabs that can be detected by the examining finger. The second is insured by selection of instru- ments that include in their bite generous segments of tissue. Thus the need of frequent reintroductions is obviated and the parts are spared unnecessary vio- lence and contusion. Finally, while undue haste is to be avoided, it is well to abbreviate as much as possible the period of narcosis. We are prone to underestimate the importance of this detail. As a matter of fact, a large proportion of accidents, both immediate and secondary, can be traced to excess- ive crowding of the anesthetic at the hands of one who is not expert in its management. General anesthesia should always be in charge of one trained for the duty, who knows how to get satisfactory relaxation with a mini- mum of anesthetic. Preparation of the Patient. — While adenectomy may not be properly con- sidered a major operation, yet it is by all means to be postponed in the pres- ence of any acute local disturbance, or of concurrent general disorder, or when an epidemic of any contagious disease is prevailing. The advice once given by Lennox Browne to operate during an attack of diphtheria, with a view of averting the necessity of a tracheotomy, is refuted by the modern mode of treat- ment in that disease. Locally an at- tempt to secure an aseptic operative field by the use of antiseptics is hope- less. The parts should be cleansed of seeretion by douching with warm nor mal salt solution, but anything be- yond that is superfluous. Nasal ste- nosis from overgrowth or deformity should be corrected at the same time, or' by a preliminary operation if very extensive. Large faucial tonsils which dnterfere with manipulations should first be excised. Bleeders should be avoided, or pre- pared by a few doses of calcium chlo- ride or lactate. The strange conflict of opinion, both in the laboratory and in the clinic, as to the effect of calcium upon the coagulability of the blood tends to weaken confidence, but pos- sibly should rather teach us to use it in larger doses than has hitherto been the custom. The weight of evidence is strongly in favor of calcium lactate, some authorities asserting that the chlo- ride is practically inert (W. K. Simp- son). The former is more agreeable to take, and' thus far no unpleasant con- sequences from larger doses have been experienced. Clinical experience shows that cal- cium lactate has a controlling influ- ence in hastening the coagulation of the blood. Its efiicacy is more marked in hemophilic cases where the coagulation is delayed than in cases of normal coagulation time. Before operation, especially on ton- sils and adenoids, careful inquiry should be made relative to any hemo- philic heredity or tendency. In sus- picious cases the coagulation period should be determined before opera- tion. It is questionable, if not posi- tively contraindicated, whether such operations should be undertaken in hemophilic cases other than under the most extreme urgency. In all cases of operation for the removal of ton- sils and adenoids, calcium lactate should be given for a period prior to and after the operation, both for its possible effect in diminishing the im- mediate hemorrhage and in prevent- ing secondary surface hemorrhage. 1-26 402 ADENOID VEGETATIONS (KNIGHT). Of the calcium salts, the lactate is more positive in its results, is more agreeable to administer, and is less irritating to the stomach. Simpson (Medical Record, Sept. 25, 1909). The bowels should be evacuated by a saline laxative and no solid food and no milk given for at least six hours beforehand. Position of the Patient. — The erect position is advocated by some, because it is that to which we are accustomed in routine work, the loss of blood is less, and debris and blood tend to escape forward rather than backward toward the glottis. Moreover it is thought that the ears are in less danger as a result of freedom from accumulations at the openings of the Eustachian tubes. The position on the side is favored by others on account of the tendency of blood and secretions to gravitate to the de- pendent side and drain off through the nose and mouth. After all has been said, the recumbent position seems to be the most convenient for all concerned and is free from risk, provided the anesthesia be not profound and the reflexes are preserved. In such case foreign material approaching the larynx is promptly ejected, and what finds its way into the stomach is thrown up before complete recovery from the anesthetic. WitL attention to this point, the so-called Rose's position, the head being dependent, is not essential. In adults and under local anesthesia the upright position is preferable. When the operator selects the recum- bent position, the body should be hori- zontally on the back, the head being neither flexed nor extended. With the head extended the cervical curve of the spinal column is increased. Ln this position the operator is liable to cut deeply into the structures of the poste- rior pharyngeal wall, which will be stripped down by the curette. A lat- eral position favors the drainage of blood from the pharynx and in no way inconveniences the surgeon in remov- ing the tonsils. For the latter purpose a small guillotine is better than a large one, and is not so liable to slip. F. C. Carle (Lancet, May 13, p. 1265, 1905). Anesthesia. — In children under one year the adenoid growth is so soft and friable that it can be readily broken down with the fingernail and no anes- thetic is necessary. An artificial nail adjusted to the fingertip (Creswell- Baber, Motais) has no advantage over a curette, and rather hampers freedom of manipulation. Local anesthesia with cocaine, stovaine, or alypin is re- served for adults and for children old enough to be manageable. Method of anesthetizing the pharyn- geal tonsil by infiltration, the needle being passed through the nostril. First of all, a camel's hair brush is soaked in a 10 to 20 per cent, solution of cocaine, passed through one nostril, slightly up- ward toward the upper border of the posterior nares, and left there for a few minutes. The process is repeated on the other side. The deeper parts are caused to shrink, so that the upper border of the posterior nares and the adenoid tissue behind becomes visible by anterior rhinoscopy. The camel's hair brush is then gently rubbed over these parts until they are superficially completely anesthetic. To anesthetize the pharyngeal tonsil proper, the most satisfactory drug is B-eucaine in a warm 5 per cent, solu- tion with 0.8 per cent, of NaCl. Co- caine is unsuitable, as more concen- trated solutions are required than are necessary for ordinary infiltration an- esthesia. Novocaine is unreliable. The eucaine solution can be sterilized by boiling, is but slightly toxic, and is not followed, as are the vasoconstrictors, 'by secondary paresis and hemorrhages. Its action is increased by the addition of 5 drops of adrenalin to each syringeful. The capacity of the syringe employed by the writer is ADENOID VEGETATIONS (KNIGHT). 403 slightly more than 2 c.c. (about 34 minims). The needle is passed into one nostril backward and slightly up- ward toward the upper margin of the orifice of the posterior naris, where it impinges on the mucous membrane of the anterior part of the roof of the pharynx, and the insertion of the pharyngeal tonsil a short distance external to the septum. This should be done under the guidance of the eye. Considerable pressure is required to force the fluid into the tissues, and an easy flow indicates that the needle has not traveled sufficiently upward to the pharyngeal roof. The process is re- peated through the opposite nostril, half a syringeful being injected on either side. After waiting a short time the adenoids can be removed, in the great majority of cases entirely, painlessly. F. Hutter (Wien. med. Woch., Oct. 10, p. 2263, 1908). Although certain statistics, hke those given by C. A. Parker, from Golden Square and St. Bartholomew's Hos- pitals, are partial to chloroform, it is the general belief that this agent is especially dangerous in lymphatism and should never be used (F. W. Hinkel). The danger is said to be less when it is joined with oxygen. Nitrous oxide gas is universally admitted to carry the least risk, but it is too transient for any but the simplest case. Com- bined with oxygen, its effect is slightly more prolonged and in other respects it is satisfactory (W. E. Casselberry). When used as a pre- liminary to ether in what is known as the gas-ether sequence, with a Ben- nett inhaler, the process of narcosis is rendered as agreeable, rapid, and safe as possible. By this method a much smaller quantity of ether is needed with proportionate reduction in stimulation of mucous secretion and less of unpleasant after-effect, two of the chief objections to ether. Braden Kyle quotes Royer to the effect that secretion is lessened by adding to the ether a few drops of oil of Hungarian pine. The disagreeable odor of ether may be partially prevented by first pouring a little cologne water in the mask, and thus the confidence of a timid patient may be secured. By many operators the "drop" method of giving ether is preferred, especially in young children, and thereby the strain upon the chest walls incident to the use of a closed inhaler is avoided. By some the use of morphine, atropine, or chlore- tone to reduce mucus secretion is ad- vised. A clear operative field may be procured with the ingenious suction apparatus advocated by Alexander and Gwathmey (N. Y. Med. Jour., March 11, 1911). Those who oppose general anesthesia refuse to- admit the fact that the shock without it, especially in a nervous child, overbalances any risk incurred when the plan just outlined is pursued. It is almost indispensable when, as often happens, the palatal tonsils must be re- moved or other instrumentation done at the same time. Ethyl bromide and ethyl chloride, the latter said to be the less objec- tionable, have no supreme advantage and are not proved to be free from risk. According to Lermoyez, the ■difficulty in regulating the dose of ethyl chloride, owing to its great volatility, is overcome by giving it with a suitable mask, whereby the quantity inhaled is precisely known. The Apperson inhaler is highly recom- mended, from 3 to 5 grams of the anes- thetic being required for a short opera- tion. The drug is so rapidly eliminated that after-effects are few or absent. Other good features claimed for it by 404 ADENOID VEGETATIONS (KNIGHT). those experienced are ease of adminis- tration and rapidity of action. It may be given prior to other anesthetics, or alone continuously for an indefinite time without regard to the position of the patient, upright or prone (G. F. Hawley). At the Royal Infirmary of Edin- burgh, the experience of T. D. Luke has been so gratifying that he rec- ommends ethyl chloride as a matter of routine for short operations. On the other hand Z. Mennell, at St. Thomas's, London, notes the frequent occurrence of pulmonary embolism at that institu- tion since the introduction of ethyl chloride. He attributes it to increased coagulability of the blood caused by the drug, and on this account has abandoned its use. Those who advocate ethyl bromide ascribe disasters with it to the use of an impure product, or to the mistake of having substituted for it ethylene bromide. In addition we are enjoined to give it en masse, ad- mitting no air, and to continue the administration no longer than one minute (A. R. Solenberger). Most operators will find sixty seconds too short a time for thorough work. The Schleich inhalation mixture (E. Mayer) and the A. C. E. mixture are urged by some, but have no spe- cial attraction. If the operation is to be done in the upright position, it is customary to give the anesthetic to the patient lying down and to slowly elevate the body when all is ready. Special operating chairs have been devised for this purpose (T. R. French). The question of safety being of the first importance, too much stress cannot be laid upon the necessity of choosing a reliable anesthetic and a trustworthy anesthetist. It would be strange if in this psycho- therapeutic era an escape from the an- noyance and risks of general anesthesia were not sought in the line of sugges- tion. Accordingly we find proposed "mental suggestion as a substitute for anesthetics in the removal of ton- sils and adenoids from children" (F. D. Gulliver). The number of children amenable and of operators capable of exercising the requisite psychic influ- ence must be extremely small. Yet the method is said to be in successful op- eration in one of our large metropolitan clinics. Insufflation anesthesia, or the forc- ing of ether vapor tO' the lungs through a tracheal tube (Jackson direct laryngoscope), is pronounced by C. A. Elsberg, of A'lount Sinai Hospital, who introduced the method and devised an excellent apparatus for the purpose, "ideal" in operations in the upper air tract, as regards pre- vention of aspiration of blood and mucus and as to rapidity and safety of narcosis. This view is confirmed by C. H. Peck from experience with a number of cases at Roosevelt Hos- pital. The numerous experiments by S. J. Meltzer at the Rockefeller In- stitute justify his opinion that it is the "safest and most effective way" of ad- ministering ether. He finds chloro- form far less safe, but it may be given for short operations with confidence under proper supervision. Recovery is said to be prompt and free from the usual discomforts. In using this method the anesthetist avoids inter- fering with the operator. Another great advantage is that it permits giving a supply of air to the lungs without the action of the respiratory muscles, if, perchance, artificial respi- ration becomes necessary. ADENOID VEGETATIONS (KNIGHT). 405 Instruments and Methods. — Chem- ical caustics and the electric cautery have been generally superseded by in- struments for extracting the morbid tissue instead of destroying it and allowing" it to slough away. Caustics are available, if ever, only in tractal)le patients and under guid- ance of the rhinoscopic mirror, the palate being held forward with a re- tractor (White) or by means of elastic ligatures (flexible catheters) passed through the nares and out of the mouth, the nasal and buccal ends being tied or clamped together. Under cocaine the process is not extremely painful. Silver nitrate and chromic acid have been used in tliis way. Without* the ut- most care and the use of a guarded applicator there is danger of excessive damage and violent reaction. The electric cautery point or loop is more precise and manageable, but at best these methods are tedious and un- satisfactory. They are reserved for hematophiliacs and those who refuse to be cut. In other cases the cold-wire snare, the guillotine, forceps, and the curette provide a wide choice of cutting instruments. A straight snare (Jarvis) White's palate retractor. may be passed through the naris, or a curved one behind the velum (Bos- worth). It is successful only when the lymphoid tissue is so bunched in the vault that the wire can readily encircle its base. It is apt to slip and include only superficial portions. The guillotine or adenotome of Schuetz, modified by Cradle, works admirably in the vault, but not on the lateral walls. We have finallv a great variety of forceps and curettes adapted to any age or situation. It is Schuetz-Gradle adenotome. well to have several sizes, large for the main operation and small for the fossae of Rosenmiiller and the choanas. The majority of forceps cut laterally; those of Schuetz cut anteroposteriorly. The edges not crossing like scissors, the operation is practically a combination of avulsion and cutting. The small forceps of Hooper cross slightly, and the large fenestrated blades of Cradle's forceps have a defined scissors action. The writer advocates operating with- out systemic anesthesia whenever feasi- ble, since he notes that the statistics show a disproportionately large number of deaths when chloroform is used. With proper skill the operation can be done as effectively in the wide-awake child as in the anesthetized subject. Nor in his own practice has he noted any unpleasant sequels of operation. He uses for ordinary adenoid opera- tions no instrument but the guillotine- shaped adenotome of Schuetz of his own modification. This brings out the whole tonsil intact. When the adenoids are extensive the instrument is pressed firmly toward one Rosenmueller fossa, 406 ADENOID VEGETATIONS (KNIGHT). and after its action is reinserted toward the other side. The work is done quicker, with less hemorrhage, and as efficiently as with any other instrument. He abolishes actual pain almost com- pletely by injections of 20 per cent. cocaine solution, supplemented bj^ adrenalin applied to the pharynx up to its roof. Gradle (Chicago Med. Record, Nov., p. 634, 1907). tonsillotome (Alackenzie^ ^lathieu), or punch (Alyles, Roberts), and the pa- tient is quickly turned on the side to allow blood and secretion to drain. Bleeding having subsided, the patient is replaced on the back. A little more anesthetic may now be required. The nasopharynx is explored with the finger to determine the extent and distribution of the growths. Den hard's mouth gag. The early instruments for scraping ere the sharp spoons of Justi and of Trautmann. Curettes are now made larger and of different sizes and shapes, and some are provided with forks to catch the resected fragments. Such The soft palate being dragged for- ward with the left forefinger, a forceps with large blades is passed into the vault, opened to full width, and while the left index finger presses the blades firmly upward the instrument is tightly Brandegee's adenoid forceps. complicating attachments are a disad- vantage rather than otherwise. The simpler the instrument, the easier it is to handle and keep aseptic. While the anesthetic is being given, the patient lies flat on the back. After the muscles are somewhat relaxed, a Denhard mouth-gag is inserted on the left side. The operator stands on the patient's right. If the palatal ton- sils are enlarged, they are first re- moved with snare (Farlow, Moseley), closed. The forceps of Brandegee, or the author's, is preferred. Then by a slight twisting movement the pendulous masses which have been seized are torn from their attach- ments. Again the patient is turned on the side. After a few moments the pharynx is explored for rem- nants which need to be removed with small forceps (Gleitsmann, Loewen- berg) or curette under guidance of the finger. By many operators a curette ADENOID VEGETATIONS (KNiGHT). 407 of the Gottstein or Beckmaun pal- tern is used for the whole operation. A curette of proper shape and size, and correctly used, certainly sweeps off the tissue most effectually. The blade, al- ways quite sharp, is slipped behind the velum and crowded from below upward close to the posterior margin of the vomer, and then by a quick movement pushed backward and slightly down- .ward through the base of the growth. The blades are directed by the finger passed behind the velum, and in any case it is a useful instrument for clear- ing out the postnasal arches, where fragments are sometimes missed and afterward give trouble. Even when the postnasal adenoids have been completely extirpated, the part is apt to remain vulnerable for some time, often highly sensitive to atmospheric changes, so that the at- 'Knight's adenoid forceps. A clean complete removal is thus en- sured at least as to the vault itself, when the conformation of the region is normal. Unless the blade is passed close to the posterior surface of the velum and is made to hug the vomer in its upward movement, pendent masses are apt to be crowded into the choange. By giving the shaft of the curette a curved or bayonet shape it is possible tacks may not altogether cease until steps have been taken to brace up the relaxed mucous membrane and re- duce its susceptibility to chills. It is, therefore, advisable to remove the patients, soon after the operation, to the seaside, choosing a situation which is moderately bracing, but not bleak. He should be taught to breathe as much as possible through the nose, and should pass the greater part of his time in the open air. There are Gottstein' s adenoid curette. to avoid the obstacle offered by the in- cisor teeth or by the palate and thus reach farther forward in the vault (J. Fein). Other curettes are made heart-shaped, so as to actually enter the nares on either side of the septum (C. E. Hunger). The nasal route for reaching adenoids has been revived by Freer, who recom- mends for the purpose a modification of Ingal's straight nasal cutting forceps two applications which are very ser- viceable in these cases. Tvi^ice a day a solution of resorcin in normal sa- line (5 or 10 grains to the ounce, with the addition of half a dram of tincture of hamamelis) should be in- stilled into the nostrils as the child lies on his back with his head sup- ported by a pillow. Five or six drops may be used to each nostril with a "dropper," allowing the fluid to trickle down into the pharynx. After using these drops for a week we can begin 408 ADENOID VEGETATIONS (KNIGHT). to paint the pharynx. The best ap- plication for this purpose is a solution of IS grains of potassium iodide and 12 of iodine in an ounce of water, well sweetened with glycerin. This should be applied twice a day to the pharynx with a brush, taking care to sweep the brush round with a turn of the wrist before withdrawing it, so as to reach as high up as possible behind the soft palate. This application not only checks morbid oversecretion by curing the nasopharyngeal catarrh, but also puts an end to laryngeal irri- tation and favorably influences the glandular enlargement. In fact, this is the very best method of treatment for acutely swollen cervical glands, and as long as the latter remain of elastic softness, varying in size from time to time according to the amount of laryngeal worry, we may expect them to be dissipated by this means. Smith (Practitioner, Jan., 1910). Accidents and Complications. — The most serious accident is hemorrhage, whicli may be first shown by pallor and rapid, flickering pulse. Small children should be closely watched and not allowed to sleep continuously for sev- eral hours after operation. The con- trast between the quiet and the pre- viously noisy breathing often creates enough anxiety to enforce this caution. Bleeding usually ceases spontaneously in a very few minutes. The total loss of blbod is difficult to estimate ; accord- ing to C. G. Coakley, from 2 to 8 ounces is the ordinary quantity. If in excess or too long continued, measures to check it must be adopted. An interesting and a rather promis- ing hemostatic agent, suggested by Ba- telli in 1910 (thrombokinase), has re- cently been prepared by L. W. Strong in the laboratory of the Manhattan Eye, Ear and Throat Hospital. His method differs slightly from the original, and he believes he has obtained a "ferment body" fairly stable and effective in all situations where a local application is possible. It occurs in the form of crys- tals or scales, of which a very small quantity will promptly induce coagula- tion. It does not afifect the caliber of the blood-vessels and is not adapted to internal use. Several members of the staflf of the hospital have resorted to it in various conditions with satisfaction. As yet it does not appear to have been subjected to such a crucial test as would be ofifered by a case of hematophilia. Its field of usefulness is, therefore, still undetermined. It is important that the surface to which it is to be applied should be made as dry as practicable by pressure with a cotton tampon. In this particular a difficulty might be met with in the case of very free hemor- rhage. In March, 1902, the writer removed the tonsils and adenoid vegetation, at the same sitting, from a child of 11 years. The adenotomy was done with the curette of Kirstein, and the hem- orrhage was not more than usual. An hour afterward it was reported that the child was losing considerable blood. A postnasal tampon was inserted ; during the night a new hemorrhage developed, followed by death. The boy was suf- fering from leukemia of a lymphatic form. Six months later a boy applied to B;urger to have the three tonsils re- moved. The pharyngeal tonsil was pale, and of a cyanotic appearance, with several hemorrhagic points. Cautioned by the above accident, he first had an examination of the blood made. Leu- kemia was found pronounced (35 leu- cocytes to 400 chromocytes), and the child was placed in the medical clinic. Some weeks after, the child died, . and the autopsy confirmed the first diag- nosis. The danger of fatal hemorrhage is very rare ; with the exception of two or three cases of hemophilia, there are only 3 cases of fatal adenotomy re- ported. Burger made 2200 in the space ADENOID VEGETATIONS (KNIGHT). 409 of nine years without the least aecident. M. Burger (Revue Heb. de Laryn., d'Otol. et de Rhin., Jan. 30, 1904). Operations upon the pharyngeal ton- sils are generally considered without danger, yet wound infection and hem- orrhage, although comparatively rare, do occur frequently enough to warrant careful attention. Hemorrhages may be divided into two types: those ap- pearing at the time of operation, and those occurring some time afterward. In the first instance the causes lie in a constitutional or a local condition, the most important of which is hemo- philia. This is shown by family and personal history. If there exists abso- lute proof of a hemophilia, naturally the operation would be denied. But in such cases as appear relatively doubt- ful the operation should be given the benefit of the doubt. An unrecognized leukemia can be the cause of excessive hemorrhage. Characteristic is the livid bleached color of the tonsils. Opera- tion in such cases can produce the same untoward results as in hemophilia. Among other diseases which impose the danger of severe postoperative hemor- rhage are nephritis, heart lesions, etc., which, however^ appear so rarely in cases needing adenoidectomy that they can be neglected. Many authors have associated severe postoperative hemorrhage with the co- incidence of the operation and men- struation. About 1 per cent, of cases have postoperative hemorrhage. Injury to neighboring parts, and especially the leaving of partly removed tissue shreds, are the important factors. The former more often leads to hemorrhage im- mediately following the operation, and only to after-bleeding when the blood- clot covering the lesion is accidentally removed. Mucous membrane shreds hanging from the wound are found in over 50 per cent, of after-hemorrhages. Hemorrhages occurring after several days generally follow sudden muscular exertion, such as sneezing, blowing the nose, etc., and are due to dislocation of the exudate covering the wounded surface. Healing had progressed so far after a week's time that bleeding is no longer to be feared. Haymann (Archiv f. Laryngologie, Bd. xxi, S. 15, 1908- 1909). Reference has already been made to the internal use of calcium chloride or lactate in hemophilia, as well as to local applications of the new "fer- ment," thrombokinase. Locally, in- stillations of adrenalin chloride, 1 to 1000, are sometimes effective. Direct pressure by means of a gauze tampon crowded up into the vault in the grasp of a postnasal forceps is usually successful. The gauze may be soaked in a saturated solution of tannogallic acid (1 part gallic, 3 parts tannic), one of the cleanest and most active hemostatics. Signs of collapse are to be combated by saline injections, stimulants, constricting the extremi- ties, and similar expedients. Even after extreme exsanguination the re- pair of waste is generally rapid, but may need to be encouraged by the use of ferruginous tonics or other medica- tion. Such being the case, the proposal of Iglauer to transform adenectomy into an "almost bloodless" operation by packing the postnasal space with a tampon of rubber sponge the moment the adenoid mass has been removed is of doubtful utility. The plan suggested is like that followed in plugging the posterior nares for epistaxis. The tam- pon is ready before the operation is begun, and the tape attached to it is used as a palate retractor during instrumentation. The handle of the forceps cutting laterally should not be too much de- pressed lest the margin of the vomer be nipped between the blades. Care should be taken to keep the blade of a cutting instrument in the middle line of the vault: if tilted to one side,, there is 410 ADENOID VEGETATIONS (KNIGHT). danger of harm to the Eustachian cushion. A rare and interesting compHcation, torticolHs, has been described by several writers and is probably "due to sepsis or to excessive energy in the use of instru- ments. It disappears spontaneously in a few days and is worthy of note only because of the unnecessary alarm to which it may give rise. Laceration of the velum would seem to be inexcusable, but has been known to occur with rough handling of an ex- cessively large instrument, or from at- tempting to make use of a cutting edge in a struggling child, or before one is quite sure that the instrument has passed beyond the plane of the velum and is well within the cavity of the nasopharynx. Finally, the mucous membrane may be stripped up over an excessive area, if too dull an instrument be used, or if it be forced too deeply into the tissues. With the exception of the first-mentioned, hemorrhage, these accidents are obviously all results of faulty manipulation. Attention has been called by Wyatt Wingrave and others to a peculiar transitory rash resembling that of scar- latina at times following removal of adenoids or tonsils. It merits notice only for the danger that it might be confounded with a more serious infec- tious exanthema. No precise theory of the phenomenon is propounded, whether septic or nervous, although marked leucocytosis is demonstrable for a week or ten days after. Several cases of alleged sepsis have been recorded, but in many the histories are by no means conclusive. A case of fatal meningitis, believed to be septic, has been reported by Shurly; two similar cases have been noted by Putnam, who expresses the opinion that such sequelse are not un- common. An interesting case of cav- ernous sinus thrombosis in which the surface of the basilar process of the occipital bone had been shaved off together with an adenoid mass with a Beckmann curette is a graphic warning against the use of extraordinary force (A. E. Wales). Cases of pharyngeal abscess, inflammation of the cervical glands, endocarditis, and acute rheuma- tism have been met with by various observers after adenectomy. Several instances of lighting up of latent tuberculosis by adenectomy have been reported (Lermoyez, Chappell). It is perhaps more correct to say that tubercle bacilli lying in the operative field have ready admission to the cir- culation through the divided lymph- channels, whence general infection fol- lows. In the majority of cases the adenoid tuberculosis is undoubtedly secondary to a focus in the lung or else- where which is excited to activity by the surgical shock of operation. In a primary case the results of removal are favorable (E. H. White), but there must always be difficulty in deciding this question of priority. The hyperplastic pharyngeal tonsil often contains micro-organisms, and these are mainly pyococcal forms. The bacteria for the most part lie near the surface, and the infection usually oc- curs from the surface, with or without demonstrable lesion of the epithelium. Primary tuberculosis of adenoids is probably more common than most pre- vious studies show. Sixteen per cent, of the series contained tubercle bacilli, 10 per cent, with characteristic lesions of tuberculosis. The tubercle bacilli were present in small numbers. The lesions in primary tuberculosis of the adenoid are generally close to the epi- thelial surface and focal in character. Occasionally they may be found in the deeper parts of the pharyngeal lym- phoid "tissue. The pharyngeal tonsil ADENOID VEGETATIONS (KNIGHT). 411 may be a portal of entry for the tuber- cle bacillus and other micro-organisms in localized or general infections. A. J. Lartigau and M. Nicoll, Jr. (Amer. Jour. Med. Sci., June, p. 1031, 1902). Examination of 35 specimens of ade- noids from children ; in 1 case, a boy aged 3 years, suffering from caseat- ing tuberculous glands behind the left sternomastoid the pharyngeal tonsil showed numerous tubercles. In cases of tuberculosis of the cervical glands where no other source of infection can be found the pharyngeal tonsil must be regarded with suspicion. Ivens (Lan- cet, Sept. 16, p. 817, 1905). Primary tuberculosis occurs in a cer- tain proportion of all cases of adenoids. From the figures of other observers and the author's this seems to be about 5 per cent. This is regarded as a con- servative estimate. In determining the presence of adenoid tuberculosis the histological method is the most satis- factory. Tuberculosis does not appear to be an important factor in the pro- duction of adenoid hypertrophy. Ade- noids and tonsils are the important channels of infection in tuberculosis of the cervical glands. In the development of pulmonary tu- berculosis adenoids may sometimes be direct channels of infection, but their importance is probably more often in- direct by predisposing to catarrhal in- flammations of the upper respiratory tract. E. Hamilton White (Amer. Jour. Med. Sci., Aug., p. 228, 1907). The writer found evidences of tu- berculosis in the growths in only 1 of 27 cases of adenoid vegetation, and in this case it was evidently second- ary. Wikner (Hygieia, April, 1910). An interesting case is mentioned by J. L. Morse, in which "adenoids were removed from an infant of five months during the early stage of tuberculous meningitis, tubercle bacilli being found in the adenoid tissue." The possibility of infection by this route is looked upon as a strong reason for operating in the early months of life, even with the certainty that a repetition will be called for at a later period. Spasm of the glottis requiring tra- cheotomy, as ini cases of his own, is believed by Holger Alygind to be not infrequent in adenectomy without an- esthesia in rachitic children, and one should be prepared for such an emer- gency. The writer has twice witnessed seri- ous disturbance of respiration (laryn- gospasm with stridulous inspiration and marked cyanosis of the lips) as a result of adenotomy without use of chloro- form. Both cases were children under 2 years having symptoms of rachi- tis. In the third case, in a boy of 2 years, wath rachitic deformities, there was sudden collapse accompanied wnth suspension of respiration and cyanosis consequent to adenotomy, which re- quired tracheotomy. The child's mother later declared that the child was subject to fits of suspension of respiration wath cj^anosis. On two occasions he had such attacks in the presence of the family doctor, and artificial respiration had to be em- ployed. Holger Mygind (Hospital- stidende, Nov. 18, p. 1173, 1903). Case in which a very large adenoid removed from a child aged 6 years gave rise to asphyxia on spasmodic closure of the jaw just as the child was appar- ently under complete ether anesthesia. The writer had to resort to artificial respiration, hypodermic injections, forcible opening of the jaw, and traction of the tongue in order to re- suscitate his patient. G. L. Richards (Laryngoscope, Feb., p. 289, 1905). After-treatment. — The control of hemorrhage, and that in very excep- tional cases, is practically the only indication for interference during con- valescence. If catarrhal secretion is overabundant, it is sometimes desirable to keep the parts clean with a douche or coarse spray of warm normal salt solution. Drainage from this region is so good that sepsis is almost unknown, 412 ADIPOSIS DOLOROSA (DERCUM). and it is well to abstain from the use of antiseptics, either in solution or powder. In order to prevent the formation of adhesions, the passage of the finger into the vault for a few days after operation has been recommended. Al- though no statistics on this point are available, it is believed that adventitious bands met with in adult life are due not to operative interference, but to at- trition and erosion of lymphoid masses in childhood which have been neglected and have finally undergone spontaneous shrinkage. No procedure in the upper air tract has added so much to the vigor of the race as removal of adenoid vege- tations, and the fact must be admit- ted that they are often a source of disease, even when their volume is not sufficient to cause obstructive symptoms. Not all lymphoid nodules demand extraction : only those which are clearly causing disturbance, or inviting infection. Removal of adenoid vegetation has brought about, in the writer's hands, recovery of 2 cases of exophthal- mic goiter, 1 of glaucoma due to lesion of the fifth pair and not re- lieved by iridectomy, and of 1 case of Addison's disease. The persistence of the craniopharyngeal canal, the vascular communication between the pituitary cavity and the pharyngeal miucous membrane, the presence of an accessory pituitary gland encoun- tered sometimes in the pharynx, might cause an alteration in the se- cretory function of the pituitary gland, and, indirectly, by intermedia- tion of the grand sympathetic nerve and of the spinal marrow, of the other glands of internal secretion. Popp (Annales des mal. de I'oreille, du larynx, du nez, et du pharynx, Oct., 1909). Charles H. Knight, New York. ADIPOSIS. See Obesity. ADIPOSIS DOLOROSA; DER- CUM'S DISEASE. [The term "Dercum's disease" is that by which adiposis dolorosa is generally known in Europe. Hence its introduction here by the Editors.] DEFINITION.— Adiposis dolorosa derives its name from its two principal features, namely, fat and pain. [Objection may naturally be made to the form of the word "adiposis," as it is of mixed origin, being made up of a Latin root joined to a Greek termination. It has, how- ever, the sanction of generations of use among English-speaking writers, and, be- sides, is paralleled by other mongrel words in common use, such as terminology, which no one any longer questions. The correct Latin form of the word would, of course, be "adipositas," the word used by German writers. However, adipositas is equally a coined word, a word artificially made, for it is not used by any Latin writer. The real Latin word is "obesitas," which, as purists, we ought to use. F. X. Dercum.] In 1888, the writer described the symptoms which constitute this affec- tion in reporting a case under the title of a subcutaneous connective-tissue dystrophy. Later, in 1892, he grouped this case, a second described by F. P. Henry, and a third discovered in the wards of the Philadelphia General Hos- pital under the name "adiposis dolo- rosa," by which the affection has since become generally known. Within the next few years cases were published by Collins, Peterson, Ewald, Eshner, Spil- ler, Fere, and others. In 1901, Louis Vitaut (These de Lyon, 1901, "Maladie de Dercum") published a special treat- ise on the subject. His description of the affection was so full and accurate that at the present date it needs but lit- tle modification and but few additions ; the latter mainly bear upon the pathol- ogy of the affection. Up to the present ADIPOSIS DOLOROSA (DERCUM). 413 time between 50 and 60 cases have been recorded. [Among the more important recent papers upon the subject are those of Frankenheimer (Jour. Amer. Med. Ass'n, 1908, i, p. 1012), of Price (Amer. Jour. Med. Sci., May, 1909), and the thesis of Poirier, Montpeher, 1910.] SYMPTOMS AND COURSE.— The development of the disease is usu- ally slow and insidious. A woman who, up to the period of onset, has been well and occupied with her usual occu- pation notices a slight pain or tender- ness in this or that portion of the body. This early symptom of pain is very variable in character and in intensity. Most often it is a sensation of smarting or stinging more or less annoying be- cause of its persistence. Sometimes the pain, even in the beginning, is severe, though this is unusual. At other times the onset of symptoms is preceded by a sensation of cold in regions in which pain subsequently makes its appearance. As a rule, the pains at first are not very pronounced and the patient is for some time able to follow her ordinary occu- pation. Furthermore, the pains are not persistent, but recur at intervals, the patient being comfortable for hours and sometimes for days at a time. Little by little the pains become more pro- nounced, they increase in intensity and are then also accompanied by distinct local changes. The patient naturally examines the part which is painful and may note these changes herself. Some- times there is a little flushing of the skin and sooner or later a swelling is noted. At first it is hardly appre- ciable, but gradually becomes more pro- nounced. The swelling may give a sensation to the finger of a rather firm localized edema. As a rule, it is in the beginning a small nodule, — smaller than a walnut, rarely larger. Sometimes a number of such swellings are noted at the same time. The affection continues to evolve, usually slowly; the pains be- come more intense and more frequent, and gradually the tumefactions change their character and finally become veri- table tumors or great tumor masses. In rare cases the fatty deposit appears to make its appearance without either previous or concomitant pain, the pain making its appearance only after the enlargements or swellings have existed for some time. This, as already stated, is unusual, the most common history by far being that just outlined. The pain is quite commonly paroxys- mal, though in long-established cases it may be continuous. In the intervals the tumefactions are usually tender or pain- ful to pressure. When the disease is well established, we may distinguish, as pointed out by Vitaut, 4 cardinal symptoms, namely, tumor formations, pain, asthenia, and psychic symptoms. The sweUings may present themselves under three different aspects. Some- times they are small, of variable dimen- sions, distinct from one another, and readily isolated. Under these circum- stances they present what Vitaut has termed the nodular form of the disease. Sometimes they form extensive masses, invading an entire limb or the segment of a limb. To this condition Vitaut has given the name of "localized diffuse form." Finally, a tumor, properly speaking, may not be present, but the entire body may be augmented in vol- ume in consequence of a hyperplasia of the fatty subconnective tissue. This con- dition Vitaut has called "the general- ized diffuse form." The Nodular Form. — The nodular form manifests itself at first by pains. 414 ADIPOSIS DOLOROSA (DERCUM). variable in character, stinging, itching, smarting, shooting, soon followed by a slight redness of the skin and a slight induration scarcely appreciable to the finger. If we examine the painful area, we feel a tumefaction, usually of small changes, so that it no longer has the appearance of a simple tumefaction, biit that of an actual tumor. Each increase of swelling is preceded or attended by characteristic pains. The latter are sometimes so sudden in their onset and Author's first case [Dercum.) size, at first yielding and later a little more resistant. The sensation is that of a firm edema, which is not well differ- entiated from the surrounding tissue. The tumefaction appears to develop slowly in keeping with successive at- tacks or crises of pain. Gradually it becomes somewhat better defined, its volume increases, and its consistence so severe as to cause the patient to cry out. During the height of the paroxysm, the tumor may resemble very closely, in the sensation which it gives to the fingers, a "caking breast." The painful crisis having passed, it is found that the dimensions of the swell- ing have distinctly increased. It has become permanently larger, as well ADIPOSIS DOLOROSA (DERCUM). 415 as more resistant and better defined. After repeated paroxysms, the swelling resembles a distinct tumor more and more closely. In certain portions, the mass may appear finely lobulated, while in other parts it gives to the fingers the capsulated. Sometimes after a crisis we discover around the tumor a well- defined edematous zone, which in sub- sequent crises undergoes a transforma- tion such as the original mass itself had undergone. In this way the mass may Case of adiposis dolorosa in a male. (Dercum.) sensation of a bag of worms beneath the skin. Each painful crisis leaves be- hind it very appreciable changes. In an area where nothing existed pre- viously, we find after a crisis a diffuse edematous tumefaction ; if the tume- faction has existed previous to the crisis, we find it transformed into a lobulated tumor more or less well en- eventually attain great size. The vari- ous stages of the evolution of these masses can be followed very closely by palpation. One and the same patient, besides, usually presents in various regions tumors in various stages of development. Painful crises supervene usually with- out appreciable cause ; at times they are 416 ADIPOSIS DOLOROSA (DERCUM). provoked by trauma and at others they ensue upon unusual exertion. The pa- tient is frequently very positive in stating that slight contusions of the surface or that excessive fatigue pro- vokes the painful crises. The tumors are, of course, variable in size. Some of the very smallest may be no larger than a pea, though so small a mass is the exception. More frequently the mass is of the size of a walnut or a small orange. Much larger sizes are met with. The larger masses are of course evident to ordi- nary visual inspection ; the smaller ones require to be sought for by palpation. If we examine the patient attentively in a good light, we are struck by the changes in the skin in certain areas. In places, indeed, it presents a bluish tint due to a slight superficial veining, and if we examine such a region by the feel we frequently discover a small subjacent tumor. Small as the tumor may be, it may betray its existence by this bluish tint in the skin which covers it. It happens sometimes that these small tumors become confluent and finally form a single large mass. Such a mass gives rise to a sensation like that of a varicocele or of a bag of worms. The masses do not appear to have a special localization; they are sometimes symmetrical in the beginning, but soon group themselves without any apparent order. They develop by preference over the limbs or in the segments of a limb. In some patients it is limited to the arms and thighs, or forearms and legs in others. Sometimes we find them on the thorax, abdomen, and lumbo- sacral region. 'The face, hands, and feet are never involved. The relations of these neoplasms to the surrounding tissue- vary according to the degree of their development. In the state of edematous swelling, they pass without exact limitation into the surrounding tissue. The skin is but slightly movable over them. Later, when they form distinct tumors, more or less encapsulated, they are mobile in all directions and the skin which covers them may be folded above them. How- ever, they are slightly adherent to the latter, so that if one tries to displace the superjacent skin the movement is trans- mitted to the underlying tumor. Fi- nally it may be noted that these masses are painful not only during the crises, but are very tender to pressure, and this tenderness, as already pointed out, may persist in the intervals between the paroxysms. The Localized Diffuse Form. — The localized diffuse form may present it- self primarily or it may develop out of the nodular form. When it develops from the nodular form^ it is because the nodules multiply so rapidly that they unite and become confluent. In this way a more or less voluminous mass may develop, which involves a portion of a limb or it may be a segment of a limb or even an entire limb. However, this is not the usual method of origin of the localized diffuse form. In the nodular form the separate masses are generally so small and the evolution so slow that the patient has usually been under observation for some time before the masses become confluent. More frequently the localized diffuse form originates spontaneously and rapidly in an entire limb or a segment of a limb. In such a case the pains are felt over a correspondingly extensive region. At first the entire region presents an edematous swelling easily observable by the eye. Subsequently the evolution of the mass is substantially the same as in the nodular form. Painful crises are ADIPOSIS DOLOROSA (DERCUM). 417 here again present antl the swelhng in- creases in size with each successive attack. Finally, a mass is formed which is resistant and painful to pressure. It may be c|uite smooth or it may be finely lobulated, or separate, apparently en- capsulated tumors may be found im- bedded in the general lipomatous mass. Naturally, in the localized dififuse form it is difficult to make out the limitations as clearly as in the nodular form. The masses involve more espe- cially the limbs, excluding save in the rarest instances the hands, the feet, and the face; not rarely they are found on the thighs and on the back. The tume- faction may be excessively painful and may present during a crisis the sensa- tion given by a breast distended by milk or, to repeat a term already used, a "caked breast." The Generalized Diffuse Form. — The generalized diffuse form is much less characteristic than the nodular or the localized diffuse form. The origin and course of the affection is, however, the same. The edema may appear rapidly, even suddenly, over the greater part of the surface of the body and limbs, exclusive again of the face, hands, and feet. It increases progress- ively and produces a general lipoma- tosis. More frequently it begins in a certain part, such as the abdomen, some- times upon one side, and then diffuses itself gradually over neighboring por- tions of the trunk and limbs. Other masses may make their appearance at the same time or subsequently, and, be- coming confluent with the original mass and each other, a diffuse lipomatosis results. The regions affected are ordi- narily the arms, the chest, the abdomen, the hips, and the thighs. Contrary to the case in the nodular and localized diffuse forms, the hands and feet are not always in this form absolutely free. At an advanced stage of the disease, it is not unusual to see small masses of lipomatous tissue over the thenar and hypothenar eminences and even on the soles of the feet. In one case the writer observed even a slight invasion of the face. Only the back of the hands and the backs of the feet escape invariably the lipomatous invasion. In consistence the swelling is resistant, but much less so than in the nodular form. The mass is spontaneously painful and tender to pressure. Sometimes the suffering owing to the universal tender- ness is very great. Occasionally it is such as to prevent movement on the part of the patient and to immobilize him in his bed. Of the three forms the most common is the nodular. It presents a special physiognomy, which makes its recogni- tion easy. The localized diffuse form resembles certain forms of ordinary lipomatosis, but it is, notwithstanding, differentiated by the pain and other characteristics still to be considered. The pains are never absent. They are present either spontaneously or are readily elicited by pressure. Usually they manifest themselves in both of these ways. Most often they pre- cede the appearance of the edematous swelling. Sometimes they come on at the same time as the swelling; more rarely they are not noted until after the swelling has made its appearance. Slightly marked and intermittent, they become more violent when the disease is established. The pains are described by the patients as stinging, burning, pinching, darting, or even lancinating. Most commonly they are darting and radiate or diffuse in and about the nodules. They do not follow the large nerve trunks or indeed any nerves. 1—27 418 ADIPOSIS DOLOROSA (DERCUM). The patient describes them as though they were situated in the thickness of the masses. The muscles, the bones, and joints are not painful. The pains are exaggerated or brought on by pres- sure or handhng. If the fatty accumu- lation is considerable, movement and effort may increase the pain to such an extent that the patient may be obliged to remain perfectly quiet during the paroxysm or indeed continuously. There is one characteristic which one finds in all cases, namely, the parox- ysmal exacerbations already described. Suddenly and without cause or follow- ing an effort or trauma the patient again feels active pain. At the same time the new formations increase in volume ; if it concerns a nodule the latter is surrounded by an edematous zone more or less extended; if it is a case of diffuse swelling the skin in this region becomes more tense and the cir- cumference of the mass increases. As the pain subsides, the swelling recedes, but never to its former dimensions. After each crisis, the volume of the new formation is increased. All or almost all of the patients pre- sent the symptoms of a general asthe- nia. The patient is very readily ex- hausted. Even in cases in which the muscular development is good, this fact is early noted. In cases which are ad- vanced the asthenia is very pronounced. Sometimes this is so marked that the patient is unable to leave the bed. Sometimes she is unable to change even her position in bed largely because of her weakness, but also because of the pain and the enormous increase in the size and the weight of the limbs and body generally. The psychic symptoms are not con- stant. However, they are very fre- quently present. A cerebral asthenia or ready cerebral exhaustion is rarely absent. Many patients present in addi- tion great irritability; this is at times so great as to be attended by a change in character and disposition. The least opposition may enrage the patient and not infrequently she will quarrel with her neighbors in the wards to such an extent that isolation becomes impera- tive. Sometimes she thinks that the other patients and the nurses are against her. The sleep is usually broken and disturbed by distressing dreams and nightmares. One of Eshner's pa- tients was disturbed mentally to such extent as to necessitate her commit- ment to an asylum. Hale White's case had two attacks of mental dis- turbance. Giudiceandrea has noted delusions of persecution and a true dementia. In several cases lessened sensibility to touch, pain, and temperature have been noted. In the writer's first case there were found areas of anesthesia, while in other areas the sensibility was diminished. The same patient com- plained of velvety sensations in the finger tips and in the soles of the feet. The case reported by Henry pre- sented marked disturbances of sensa- tion. Touch, pain, and temperature were sometimes not perceived ; at other times confused. In Giudiceandrea's case the sensibility to pain, on the other hand, was much increased, especially in the regions corresponding to the adi- posed masses. The thermal sensibility, again, was particularly exquisite in the regions in which there was no trace of the neoplasms. Hyperalgesia was noted by Achard and Laubry. Patients have also complained of sudden sensa- tions of cold or heat, of formication, or of cramps in various parts of the body. Headache is not rare. At)iPOSiS DOLOROSA (DERCUM). 419 Disturbances of the special senses are quite frequent. In some observa- tions there was noted a narrowing" of the visual fields ; in others various subjective sensations, such as phos- phenes, muscte voHtantes; in one case amaurosis was noted, which began to disappear from the day that thyroid treatment was instituted, and in a case of the writer there was present a circinate retinitis, — a mass of partly fibrinous and hemorrhagic exudate in the center of the retina, surrounded by crescents of fatty degeneration in Mueller's fibers. Diminution of auditory perception has been noted several times. In some cases tinnitus more or less marked has been recorded. Smell and taste were impaired in one of the writer's cases. Vasomotor disturbances have been very frequently noted. The skin over a nodule may present no changes whatever; on the other hand, it may be noted to be somewhat injected during a crisis of pain, or much veined and slightly bluish. Occasionally the face is much flushed, — the malar re- gions, the frontal regions — or it may be the neck, although no actual indura- tion or swelling accompanies the change in color. In some cases cyanosis of the ex- tremities and transitory edema have been noted. Frequently also the patient notices that his flesh bruises very readily, and it is not uncommon to note small ecchymoses on various portions of the limbs and trunk, and at times these evidently make their appearance spontaneously and inde- pendently of trauma. Perhaps, in keeping with this fact is the history, not infrequently obtained, of excessive menstruation or even of metror- rhagia. At times also epistaxis and, in one of the writer's cases, even hematemesis are noted. Trophic changes in the form of ulcerations, blebs, and bullae have been observed. It is important also to add that there is quite commonly a marked dryness of the skin. Patients them- selves comment upon this and ex- amination confirms it. Adiposis dolorosa with involvement of the joints. (Dercum.) Among unusual complications noted in adiposis dolorosa are changes in the joints. Attention was first directed to this by Renon and Heitz, who in 1901 presented a case of "adiposis dolo- rosa with multiple arthropathies," be- fore the Neurological Society of Paris. In addition to the usual symptoms of the affection there were present marked pain, creaking, and limitation of move- ment in numerous joints. A skiagraph of the left knee failed to reveal any alteration of the articular surface. The knee-cap, however, was a little thick- ened, and its structure offered a some- what mottled appearance. The syno- vial membranes gave rise to a slightly opaque shadow, which was especially evident at the cul-de-sac under the 420 Adiposis dolorosa (dercum). quadriceps tendon. This shadow, In- froit, who made the skiagraph, re- garded as due to fatty thickening of the synovial membrane. In 1902 the writer placed on record (Philadelphia Medical Journal, Decem- ber 20th) a second case of adi- posis dolorosa with involvement of the joints. Skiagraphs revealed no changes whatever in the bones, but some thickening of the tissues about the joints, especially about the knee- joints. The conclusion was justified that there was present a marked thickening of the synovial membranes land possibly of other structures in the neighborhood of the joints. There w^as a marked tendency to the forma- tion of fringes and rice bodies. The joints appeared, as the patient ex- pressed it, to be "loose," and motion was attended by considerable pain. That the changes observed were due, in part at least, to fatty infiltration, and that this fat was painful, just as was the fat in the tumor masses on the surface of the body, afforded the most reasonable explanation of the condition. It was possible also that an actual synovitis was present. Rheumatism could not offer an ade- quate explanation of the conditions found, while rheumatoid arthritis was excluded by the absence of changes in the bones and cartilages. More recently Price has made studies in the joints of two other cases con- firming these findings. A most interesting case of adiposis dolorosa in which bony changes were noted in the dorsal vertebrje and in the ribs has been placed on record by Price and Hudson (Journal Nervous and Mental Diseases, April 19, 1909). Kyphoses with corresponding de- formity and reduction in size of the vertebrae were noted in the dorsal region and confirmed by the skia- graph. Similar changes were noted in the ribs. The authors call atten- tion to the possible significance of these findings when the frequency of pituitary changes in adiposis dolorosa is borne in mind. The course of adiposis dolorosa is essentially chronic. Its progress is slow, the patient being worse or better by turns in accordance with occurrence of paroxysms of pain. In well-established cases the suffering is continuous, subject always to more or less marked exacerbations. In the majority of cases the patients become extremely obese, the weight often running from 200 to 300 pounds ; in others again, in the nodular form, the weight may undergo only a moderate if any increase. The symptoms may be briefly sum- marized as follows : fatty deposit, pain, general asthenia, and psychic symptoms. The deposits are present either in the nodular, a localized dif- fused or a generalized diffused form. The distinction between these forms is of course not absolute, as combina- tions of the various forms — or transi- tional states — may be found in one and the same patient. The deposits are found most commonly over the trunk, shoulders, arms, and thighs ; the forearms and legs being less fre- quently affected and the hands and face almost never. Pain and tender- ness upon manipulation of the swell- ings are present; spontaneous pain, pain occurring in paroxysms, is also present unless it happens that the patient is observed during an interval between paroxysms. Involve- ment of the nerve trunks is rare, though it has been a few times observed, not- ADIPOSIS DOLOROSA (DERCUM). 421 ably in a case of Bergerson's. Anes- thesias are rare, hypesthesias not un- common, paresthesias are frequent ; the latter consist, as already pointed out, of sensations of numbness, cold, burning, tingling, crawling. The general asthenia and the mental phenomena have been already sufficiently considered. The tendon reflexes may be normal or increased, but are usually dimin- ished and sometimes abolished. In one case, that of Delecq, the skin reflexes were lost. Coincident gross nervous disease has been noted several times. Hemiplegia and apha- sia were noted in one case ; in another, a case of the writer, a sclerosis of the columns of Goll was revealed at the autopsy, and in still another there was involvement of the lateral tracts. ETIOLOGY. — It is occasionally noted that the patient presents a neuro- pathic heredity; not infrequently grave nervous disorders are noted among the ancestors or collateral relatives. Now and then it is noted that other members of the family are unusually stout, e.g., in 1 of Eshner's cases the mother was obese. In a few instances adiposis dolorosa has been observed in members of the same family. Thus, Cheevers reported the case of a man whose father and sister both had the dis- ease, while Hammond reported 2 cases occurring among sisters. The striking fact in the etiology is the predominance of the female sex ; the ratio is about 6 women to 1 man. The age at which the disease makes its appearance is exceedingly variable. The youngest re- corded case, that of Hale White, began at 12 years of age; the oldest case recorded was 78 years of age. Ac- cording to Frankenheimer, the major- ity of cases in men occur between 30 and 40 years of age, and in women between 30 and 50 years. The disease was originally believed to occur exclusively in women and about the climacteric period ; although this was the rule in the writer's experi- ence, he has known it to begin as early as 12, and has seen 3 cases in males. He describes in detail 5 cases of the affection, 4 in women whose ages range from 20 to 42, and 1 in a man aged 47. These cases all presented the char- acteristic symptoms of the disease. The panniculus adiposus was invariably thickened, sometimes to a marked ex- tent. The skin was red and in depend- ent parts has a bluish, livid appearance. It was painful, sometimes with a feel- ing of burning, at other times as if it were being pierced by a needle. The skin of the legs especially, but occasion- ally that of the trunk and arms also, was thick and infiltrated, generally in patches, but in some cases in large areas involving the whole lower extremity except the feet. The latter condition is described by the writer as "elephan- tiasic edema." Actual edema was not present, the skin did not pit on pressure, and no fluid was obtained on punctur- ing with a needle. Charcot observed this condition in connection with indi- viduals suffering from functional dis- turbances of the nervous system, and named it "oedeme hysterique." Strub- ing (Archiv f. Dermat. u. Syphil., Feb., 1902). Case of adiposis dolorosa, or Der- cum's disease, believed to be unique, in a newborn infant. The writer was called in consultation to see the child on the day after its birth. It was then 5 weeks old, and, in addition to the characteristic irregular symmetrical de- posits of fat, which were situated on the upper half of the body (the lower extremities being normal), there were two cystic formations of considerable size, one on the left posterior aspect of the neck and the other on the left breast. While lying undisturbed the child appeared to be entirely comfort- able, but the slightest movement was attended with pain. W. C. Walser 422 ADIPOSIS DOLOROSA (DERCUM). (Boston Med. and Surg. Jour., June 30, 1910). Occasionally the patient presents a history of antecedent alcoholism or of syphilis. As Price says, the toxic ef- fects of alcoholism and syphilis are well known and the fact that they frequently cause degenerative changes in the duct- less glands has been emphasized by Lorand, This is suggestive when we learn of the role which the ductless glands appear to play in adiposis dolo- rosa. In a case described by E. W. Taylor, the disease developed while the patient was convalescing from an acute alcoholic neuritis. In quite a number of cases excessive menstrual flow and even uterine hemorrhages have been noted. In one case, that of Spiller, the adiposis dolorosa followed pregnancy, while in another, that of Schlesinger, it followed an abortion. Quite a number of cases finally have developed after the menopause. Occasionally trauma is noted in the history, and the importance of this fact has been especially insisted upon by Guidiceandrea. In a case of the writer's and in one of Eshner's, trauma seemed to be the direct exciting cause. Emo- tional shock has also preceded the onset, as in the case of. Achard and Laubry. In Vitaut's case there ap- peared to be a mild infection of the digestive tract; in other cases exposure to cold and dampness, rheumatism, appeared to play a role. Occasionally also some other neurosis exists side by side with the affection, as in the woman reported by Henry and in a man re- ported by the writer, both of whom sufifered from epilepsy. In other cases again, undoubted mental disease has been noted ; sometimes indeed, as in one of Eshner's cases, commitment to an institution becomes necessary. Heredity seems to play some role, the ancestors frequently having been obese, gouty, asthmatic, or subject to migraine; in other words, the victims of nutritional disturbances. The signs of premature senility are frequently present. M. Gilbert Ballet (Presse med., April 8, 1903). Case of adiposis dolorosa in a woman aged 80, the mother of 5 children, who had fallen fifteen years before, after which accident an operation was per- formed upon her hip, some bloody fluid being evacuated. Since that time her legs have been weak. For three years after- ward, and off and on since, to her 65th year, irregular metrorrhagia existed. Pain appeared in the left hip and lum- bar region, always along the nerves. It is made worse by pressure. She grew stouter very gradually, weighing now 163 pounds, while she is under 5 feet high. The fat is in large masses about the malleoli, hips, calves, buttocks, ab- domen, forearms, and backs of the arms especially. This fat is only found in certain regions, and is not universally or equally distributed. Debove (Presse med., July 17, 1901). Case in a woman, aged 61 years, who, with an apparently unimportant family history, dates her troubles from a fall from a chair many years before the disease became manifest. The left eye became blind, and the left side of the nose developed a tumor. The adiposis appeared in her thirtieth year in the right leg first, and then in the left. The arms were next attacked. Pain accompanied all the early symptoms. When examined, the patient's neck and the subclavicular region, as well as the abdomen, besides the limbs, were loaded with fat. An enormous fatty tumor was also present on the internal aspect of the left thigh. The buttocks were immense. The pores of the skin were enlarged. Pain, lasting two or three days, in the fatty region was not un- common. Sensation and temperature were normal ; the corneal reflex was absent, as well as the patellar and Achilles. Mentality was apparently normal, but there was great asthenia, increasing with age. In view of the ADIPOSIS D(3LOROSA (DERCUM). 423 eye trouble and the nasal tumor, the writers are inclined to attribute the etiology of the disease to some affection of the pituitary body. Delucq and Alaux (Presse med., Sept. 17, 1904). PATHOLOGY.— Up to the time of writing, eight autopsies have been held. These indicate that in adiposis dolorosa there is some disturbance of the internal secretions, excessive forma- tion of fatty tissue, and an interstitial neuritis of the nerve-fibers contained in the deposits. [Price has summarized the results of the various autopsies as follows : — Cases I and II. — Dcrcum : Macroscopic disease of the thyroid, the glands being en- larged and the seat of calcareous infiltration. Case III. — Dercum : Irregular atrophy of the thyroid, extensive interstitial neuritis of peripheral nerves in fatty deposits, degenera- tion in the columns of Coll. Case IV. — Burr : Glioma of the pituitary body; colloid degeneration, with atrophy and absence of secreting cells in many acini of the thyroid gland; interstitial neuritis of terminal filaments; sclerotic ovaries. Case V. — Dercum and McCarthy : Adeno- carcinoma of pituitary body, thyroid nor- mal, right suprarenal gland hypertrophied, hemolymph-glands, interstitial neuritis, un- developed testicles. Case VI. — Guillain and Alquier: Hypoph- ysis doubled in size, with marked increase of connective tissue in the glandular portion and changes suggesting an alveolar carci- noma ; thyroid hypertrophied, with increase in connective-tissue stroma. Case VII. — Price : Inflammatory changes in thyroid, with marked increase in the inter- stitial connective tissue, one whole lobe being especially infiltrated, the other showing compensatory hypertrophy. Inflammatory changes in hypophysis, with presence of a condition suggesting alveolar or glandular carcinoma, interstitial and parenchymatous neuritis, sclerotic ovaries. Case VIII. — Price : Marked nicrease in the connective tissue of the thyroid gland, dilatation of the acini, with infoldings of the cuboidal epithelial lining. The same changes in the hypophysis as were found in Cases VI and VII, but less marked. No abnormalities of the adipose tissue. F. X. Dercum.] Delecq thinks that disease of the thyroid, testicle, ovary, and pituitary body may -be causes of adiposis dolorosa. Von Schroeter concludes that adiposis dolorosa is due to a dysthyroidismus. Pineles regards the disease as a result of the disturb- ance of function in numerous blood- glands and that there are present hypothyroidism, genital atrophy, and changes in the hypophysis. The thyroid gland, it will be noted, showed unmistakable changes in 7 of the 8 autopsies. These changes are very interesting and are well illus- trated by the findings in the third autopsy of the writer, in which the gland was submitted to microscopic examination. A study of the sections reveals the gland to be made up of three or four different kinds of secret- ing tissue. In the first place, there are large acini distended by colloid material. These large acini vary in size, and their contents vary also in density. The larger acini are globu- lar in shape, while some of the smaller ones are elongated or angular in form. The limits of these acini are clearly indicated by blood-vessels which occupy their walls. The epi- thelium is a single layer, which covers uniformly the peripheries of the acini. Contrasted with these there is another kind of secreting tissue, which is very solid, and in which the acini are made out with great diffi- culty. They consist of cells filling interspaces of the stroma, and the blood-vessels supplying these acini can only be made out in exceptional instances. The lumina of these acini when they can be made out are usually very small. There is he-re a 424 ADIPOSIS DOLOROSA (DERCUM). complete absence of colloid material. In other portions acini are observed which are a transition between the more solid nests of cells and the large vesicles which contain the colloid material. In addition, there is a third form of acinus, which is of peculiar interest in that the acini present plica- tions or papillary outgrowths of the walls. These plications ., or out- growths project into the lumina of the affected acini, which contain, as a rule, colloid material of lighter staining qualities than the larger vesicles, although not lighter than is contained in some of the smaller vesicles. The epithelium of these last-mentioned acini appears at times to be slightly higher than the normal cubical epithelium of the other vesi- cles. Finally,-^ in some areas, solid masses of cells resembling lymphoid cells are seen, but these are probably young solid acini, like the small acini described above, though the limits of these acini are irregular, because of the absence of preserved blood in the surrounding vessels and of the absence of definite interstitial frame- work. The changes observed are indica- tive in part of hypertrophy. Certainly this seems to be the only interpreta- tion which can be placed on the numerous small acini which appear to be in process of development. Whether the large acini, distended with more deeply staining colloid material, are to be considered old acini, containing old or altered colloid material, it is, of course, impossible to say, but such an interpretation does not seem improbable. The pli- cations and papillary outgrowths observed in some of the acini are also worthy of comment, in that they evidently represent an attempt to in- crease the secreting surface of the acini and are again expressive of h3^pertrophy. These findings are very surprising, and it is difficult, of course, to frame an explanation. It is not impossible that we have here a hypertrophy which is the direct outcome of a general atrophy of the gland; in other words, a com- pensatory hypertrophy such as Hal- stead obtained in the dog after partial extirpation. The gland was small, per- haps sufficiently so to determine com- pensatory hypertrophy. It is probable, however, that other factors, e.g., quali- tative changes of function, also played a role in the peculiar symptoms from, which this patient suffered. It is not inconceivable that as a result of de- ranged thyroid action some substance was thrown into the circulation, which at one and the same time prevented the proper oxidation of the hydrocarbons of the food and tissues, and also acted as a cause of neuritis and nerve degen- eration. Whatever the explanation, it is interesting to recall the diminished sweating and the occasional slowness of speech and mental irritability. The in- terpretation is somewhat difficult ; the obesity and the dryness of skin suggest thyroid deficiency, while the flushing of the face, the occasional tachycardia, and the psychic symptoms would point rather to thyroid excess, and it is safer perhaps with Pineles to regard the con- dition as one of dysthyroidismus. Among the most significant findings, however, are the changes noted in the pituitary body. In 5 of the 6 cases in which the pituitary was examined, it was found diseased. Thus Burr de- scribed a glioma of the pituitary, Der- cum and McCarthy adenocarcinoma, Guillain and Alquier changes suggest- ADIPOSIS DOLOROSA (DERCUM). 425 ing an alveolar carcinoma and Price changes likewise suggesting alveolar or glandular carcinoma in 2 cases. The detailed findings in the case of Dercum and McCarthy are ver}^ interesting. The pituitary bod}^ was closely ad- herent to the dural lining of the sella turcica, and an attempt at removal of the gland revealed a calcareous layer from 1 to 3 mm. in thickness, be- tween the dura and the gland sub- stance. When this was removed, what appeared to be the normal portion of the gland occupied the left quarter of the mass ; the remaining three-fourths consisted of a tumor mass. It was of the same consistence as the gland struc- ture, roughened on the surface where the calcareous plate had been removed, and attached at its farthest end to the internal carotid artery. The calcareous plate under the microscope showed a true bone reticu- lum infiltrated with the eosinophilic cells comprising the tumor mass. Sec- tions were made transversely through the gland and tumor. The tumor mass was composed almost entirely of the eosinophilic type of cells, arranged irregularly, with a minimal amount of interstitial tissue. Around the pe- riphery of the tumor mass the cells w^ere arranged in parallel rows, much after the type of cell arrangement seen in endotheliomata. The tumor mass had, on account of the arrangement of the cells in rows at its periphery, an appearance as if it were encapsulated and separated from the normal gland tissue. A careful study of the cells of the tumor revealed no trace of a regu- lar arrangement of the cells, such as is seen in the acini of the normal gland. The individual cells were round, stained a pinkish red with eosin, and contained a small, deeply staining nucleus. The nucleus in some of the larger cells was very large and irregular in shape, such as is frequently seen in proliferating cells. The cells varied greatly in size : some were twice the size of the normal gland cells; others one-third to one- fourth that size. Between these cells, and at times in the capillary vessels of the tumor mass, small areas of colloid material were seen. The area of normal gland tissue — i.e., arranged according to the normal gland structure — is about one-third the size of the normal adult gland, and is situated between the tumor mass and the protuberance, consisting of cerebral tissue. The larger portion of the glandular acini is perfectly normal. At the junction of the latter with the nerve tissue, and extending into the latter area, are large groups of cells, following an alveolar arrangement and differing "from the rest of the section by the deep staining properties of the cells with nuclear stains. The posterior portion of the gland, composed of reticular nerve tissue, is permeated by the small, round, deeply staining nuclei in such a way as to give the impression that the infiltrating process followed definite lymph-channels. At the pe- riphery of the acinous portion of the gland, masses of colloid material, of sufficient size to be visible to the naked eye as minute dots, are inclosed in areas lined by rounded cells. The tumor mass, composed as it is of the same type of cells as make up the acinous portion of the gland, must necessarily belong to the carcinomata. The infiltrating tumor formation, begin- ning in the acinous portion of the gland and involving the cerebral portion of the gland, follows the cell arrangement of an adenocarcinoma. The arrangement of the eosinophile cells of the tumor mass 426 ADIPOSIS DOLOROSA (DERCUM). around the periphery of the tumor resembles an endothelioma, but the type of cell points strongly to a diagnosis of carcinoma. In commenting upon the involvement of the pituitary in the above instance, the writers pointed out, that bearing in mind the interrelation which exists between the thyroid gland and the pituitary body, the pituitary body is thus brought into relation, though per- haps indirectly, with a fat-producing or fat-destroying function — a relation which, up to that time, had not been considered. In the light of recent observations this subject assumes a new importance. Froelich has shown that, instead of the symptom-complex termed acromegaly, lesions of the 'hy- pophysis may be associated with an adipositas universalis and genital atro- phy. In other words, hypopituitarism, other things equal, leads to adipositas. Further curious and remarkable inter- relations of function — seemingly anti- thetical — appear to exist between the pituitary and the pineal gland, — the pineal gland appearing to have a fat- producing and a fat-destroying func- tion inversely to the pituitary. For a detailed presentation of the subject, which here would lead us too far afield, the reader is referred to Otto Mar- burg's interestmg paper on "Adipositas Cerebralis,' a Contribution to our Knowledge of the Pathology of the Pineal Gland," Deutsche Zeitschrift f iir Nervenheilkunde, 1908, Bd. 36, p. 114. In his discussion of the pathology of adiposis dolorosa. Price points out that sufficient attention has not been given the pituitary, which, he suggests, is etiologically of almost as much im- portance as the thyroid. It would ap- pear, indeed, from the above considera- tions that the pituitary must be seriously considered, and he asks the question whether the symptom of adiposis dolo- rosa may not result from primary dis- ease of either the pituitary or the thyroid gland. It is well known that a close interrelation exists between these two glands; experimental extirpation of the thyroid in animals has been found to be followed by pituitary en- largement and it would seem that dis- ease of one gland means sooner or later disease of the other. Poirier also di- rects especial attention to the hypophy- sis, which he evidently regards as the most important structure concerned in adiposis dolorosa. An examination of the fatty deposits reveals not only the structure of fatty tissue, but also the signs of great nutri- tional activity. Fragments removed during life by the Duchenne trocar in the writer's first case and submitted to microscopical examination presented the appearance of a connective tissue em- bryonal in type. The cells were volum- inous, fusiform and containing large nuclei, while the intercellular spaces were filled by a transparent substance apparently without structure. On the whole the appearance was that of a lymphoid tissue. In some fragments fat cells were numerous and among these were cells which evidently had not undergone complete fatty transforma- tion. In some of them the nuclei were still very apparent, while osmic acid revealed fat drops suspended in the cell contents. In the autopsy recorded by Dercum and McCarthy, the fatty nodules were submitted to microscopical examination with the following result. Each of the larger nodules was composed of cap- sules inclosing large numbers of small, oval, fatty bodies connected with each other and with the capsule by delicate ADIPOSIS DOLOROSA (DERCUM). 427 fibrous bands. Tbese delicate trabecnloi united and joined tbick, jelly-like bands attacbed to the capsule. Sections made tbrougb the connective-tissue capsule and the fatty bodies in situ gave the following structure : The capsule was composed of several layers of well- developed connective tissue. Within this capsule a looser areolar tissue is met. This tissue is highly vascular, and between the vessels is a reticular tissue, denser in some areas than others and inclosing a large number of mono- nuclear cells, a few polynuclear cells, and large numbers of cells staining a tawny color by the Van Gieson stain. Scattered through the granular, tawny masses many of the mononuclear type of cells may be found. In other areas granules of blood-pigment in clumps may be seen. Wherever the connective- tissue trabeculse penetrate into the con- gested fat nodule, this same fine, reticu- lar structure, holdin'g in its meshes rich plexuses of blood-vessels, and between these a fine reticulum of connective tissue filled with a light-yellow granular material, with nucleated yellow cells, small mononuclear cells, polynuclear reagents, as do nucleated red blood- cells, and numbers of degenerating red blood-cells, may be seen. Some of these cells react to many of the staining corpuscles, but to the Biondi-Ehrlich triple stain they appear more as mono- nuclear leucocytes. This tissue is iden- tical in structure with the hemolymph- glands found in the immediate neigh- borhood of the large, congested nodules of subcutaneous fat. Lying loose in the yellow fat, several small, firm bodies, the size of a split pea and of a yellowish-brown color, \vere found. These proved on micro- scopic examination to be hemolymph- glands. They were composed of a cap- sule of connective tissue, from which trabecul?e of connective tissue spread in many dififerent directions throughout the body. Within this trabecular net- work a rich plexus of capillaries was found. Between the capillaries a fine meshwork of fibers contains large num- bers of lymphoid cells, with here and there groups of red blood-corpuscles. Free blood-pigment giving the iron re- action was found in small quantities free in the trabecular network. The Fatty nodtile dissected from subcutaneous fat; shows the encapsulation of the fat, with nerve- fibers branching over it. (Dercum and McCarthy.) Opinion of Dr. Simon Flexner that these structures are new-formed hemo- tymph-glands was confirmed by that of Dr. A. S. Warthin, of Ann Arbor, who has written on the subject. An examination of the nerves found in the fat has shown the presence of an interstitial neuritis. There is a diminu- tion of nerve-fibers, together with a marked proliferation of the perineu- rium and endoneurium, (See illustra- tion, next page.) The chemistry of the subcutaneous fat was investigated by Edsall, who especially sought for an increase in the fatty acids as this might have had to do with the pain and tenderness. 428 ADIPOSIS DOLOROSA (DERCUM). However, marked free acidity was not present. Its amount was rather low, lowest of all in the tumor fat, and decidedly below that of normal fat. The significance of this fact is not evident. Case in which there concurred adipo- sis dolorosa with well-marked myxe- dematous manifestations. In view of the frequency of myxedematous symp- Section of nerve in subcutaneous fat nodule showing intersititial neuritis. A distinct over- growth of connective tissue is present between the nerve-fibers. The number of blood-vessels is also increased over normal nerve-tissue. {Der- cum and McCarthy.) toms in adiposis dolorosa, we are justi- fied in accepting a kindred cause of both syndromes. That thyroid insuffi- ciency stands at the foundation of myxedema there can be little doubt; again, some thyroid alteration was found in 4 out of 5 cases of adiposis dolorosa which came to autopsy. While the seat of the externally visible pa- thognomonic symptoms of myxedema is in the subcutaneous tissues, that of adiposis dolorosa is situated in the fatty structures. Moreover, the improvement of case reported following the administration of thyroid extract seems to evince with certainty that perverse thyroid function was, to say the least, an antecedent. The yielding of both symptom-com- plexes to the same medication again points to their interrelation or their springing from a kindred cause. Thy- roid therapy cannot, therefore, be util- ized as a test of differentiation between myxedema and adiposis dolorosa, as some authors maintain, because both syndromes may vanish under its in- fluence, and, as in the present instance, even at the same time. In so far as the pains disappeared in the ratio of shrinkage of the fat bunches, we are justified in concluding that the irrita- tion of the nerve terminals was either due to mechanical insults on the part of the overgrowth of fat-tissue or to cer- tain fatty acids or products of catab- olism exciting the nerve trunks in the vicinity of the fat deposits and stimu- lating the fat-tissue to further prolifer- ation. In view of the fact that myxe- dema occurs without pains in the swell- ings, it appears that thyroid insufficiency cannot be held directly responsible for the aches and paroxysms in adiposis dolorosa. Heinrich Stern (Amer. Jour. Med. Sci., March, 1910). DIAGNOSIS.— The diagnosis is based upon the presence of the fatty masses, presenting the feature of pain, spontaneous, paroxysmal, or elicited by manipulation, and having in addition the physical peculiarities already described. The disease is readily differentiated from myxedema because of non-involvement of the face and hands and because of the absence of pain in myxedema. When the tumor masses are numerous and small, they might suggest neurofi- bromatosis, but the peculiar charac- ter of the swellings, the fact that they appear Icbulated under palpa- tion, that they are spontaneously painful and almost never occur upon ADIPOSIS DOLOROSA (DERCUM). 429 the face or hands would serve to make the differentiation. In neurofibromatosis, again, there are two kinds of tumors, some of them cutaneous, not rarely on the face, and others on the mucous sur- faces. They are of soft, yielding con- sistence and very slightly painful. Others, those of nervous origin, are small, very hard, and often grouped along the course of the nerve trunks like a string of beads. They are only laterally mobile, while the adi- pose tumors are mobile in all direc- tions and are irregularly distributed. Again, anomalies of pigmentation are rare in adiposis dolorosa, but are frequent and sometimes very pro- nounced in neurofibromatosis. On the whole, it is hardly probable that an error could be made. In simple obesity, the fat is dis- tributed throughout all the tissues and does not heap itself up in separate lipomatous masses, such as is the case in adiposis dolorosa, — even in the so- called diffuse form. Besides, ordinary obesity is painless and is a matter of gradual development, while the fatty deposit in adiposis dolorosa is painful and occurs as the result of successive crises. PROGNOSIS.— Adiposis dolorosa is an affection which is essentially chronic. Most cases live for many years and it does not appear to imme- diately threaten life. However, in cases of long standing, a bed-ridden period eventually ensues ; general exhaustion becomes more and more marked; degeneration and failure of the heart muscle, pulmonary conges- tion, or a renal complication may terminate the picture. The resistance to infection also appears to be greatly diminished, for one of the writer's cases died very rapidly of an attack of erysipelas. Cases in a relatively early stage of development — more particularly cases with small nodular or localized and limited deposits — offer a dis- tinctly better prognosis and are dis- tinctly amenable to improvement. Advanced cases, cases with very ex- tensive deposits, marked asthenia, and especially with the tendency to sub- cutaneous hemorrhages and hemor- rhages from the mucous membranes are very unpromising. TREATMENT.— In the treatment of adiposis dolorosa one remedy has in a few cases proved of value and that is thyroid substance. This should be given in doses of from 2)^ to 5 grains three times daily, for a very long time. The* salicylates, notably aspirin, are of decided value in relieving the pain. The best plan of procedure, as a matter of course, is to place the patient in bed, and to institute a systematic course of treat- ment. The rest should be absolute and should extend over several months of time. Typical case with symptoms of myxe- dema in which the treatment consisted of an antiobesity diet, thyroid medica- tion, and physical therapeutics, especially vibratory massage and exercise. Nine months later the patient presented her- self to show the beneficial effects of the treatment. Excepting the pallor, which, she said, had always caused her much annoyance since her early youth, she looked very well. She felt strong, and was able t- walk from five to eight miles a day; she experienced no short- ness of breath on ordinary exercise, but perspired mildly when she walked briskly. ■ The fat Lrnches had disap- peared almost entirely ; the neuralgic pains had ceased about four months earlier ; there was no tenderness on pressure on the location of the former 430 ADIPOSIS DOLOROSA (DERCUM). fat masses. The skin in the supraclavic- ular regions and in the face had been quite tender. She evinced not the slightest mental depression and apathy, but, on the contrary, displayed a healthy optimism. Her weight had been re- duced to 161 pounds. Heinrich Stern (Amer. Jour. Med. Sci., March, 1910). The patient should be weighed when treatment is begun and thyroid substance given at first in small and then in somewhat larger doses. At the same time a diet should be insti- tuted that is largely free from carbo- hydrates and fats. It should be remembered, however, that a diet, no matter how rigid, will of itself make no impression in adiposis dolorosa ; it will fail absolutely. It is of course wise to institute a careful diet, but patients do better when the diet is not too strict. Inasmuch as the affec- tion is attended by a marked asthenia, the diet should be nutritious. It should consist of the red meats in moderation, the white meats freely, the succulent vegetables, eggs, and skimmed milk. The latter can be used between meals and if necessary also at mealtimes. The pains are not infrequently controlled or at least made better by aspirin or salophen in full doses, 10 or 15 grains three times daily after meals. Sometimes the tenderness and soreness are better borne when the limb or part affected is gently supported by a flannel roller; if the tenderness be extreme a layer of cotton-wool may first be applied. Just as soon as the tenderness permits, gentle massage should be in- stituted; sometimes this can never be employed ; in other cases again it can be instituted comparatively early and there can be no doubt that in a measure it favors the diminution of the swellings, especially if the patient can bear deep kneading. Bathing between blankets as in ordinary rest treatment should also be carried out, but of themselves baths accomplish nothing in adiposis dolorosa ; indeed the ph3'^sical exertion and manipula- tion attendant upon the application of ordinary hydrotherapeutic meas- ures in these cases exhausts the patient. It is a good plan to keep a record of the pulse and temperature during the thyroid administration, although the writer has never observed any fluctuations of moment in these cases, even when the thyroid was pushed. The patient should, of course, be weighed from time to time and the dose of thyroid modified according to the impression made. In some cases no impression whatever can be made; in other cases again the impression is decided. In 3 cases of the writer, the result was most satisfactory ; 2 of these were treated systematically by rest in bed; the third could not for certain reasons be put to bed. In all 3 the improvement in the size of the swellings and in the lessening of pain was very great. Treatment was car- ried out six months to a year. In 1 case the affection recurred at the end of two years, but was again con- trolled. In the second, improvement and practically good health has per- sisted for four years. The third was greatly improved and has disappeared from observation. The experience of the writer with cases in the hospital wards and out- patient departments has been very unsatisfactory partly because many of the cases were greatly advanced, the deposits being enormous and the asthenia grave, and partly because ADONIS VERNALIS (SAJOUS). 431 the cases could not be kept system- atically under treatment for a suffi- ciently long period. General tonics, iron, arsenic, strych- nine may be given, but they do not help appreciably. Electricity is useless. Finally, it would in the judgment of the writer be perfectly justiliable to attempt the surgical enucleation of a specially painful mass ; this procedure has not yet been attempted. We should bear in mind, of course, that these patients have but a feeble resistance to shock and often pre- sent, even to superficial examination, marked cardiac weakness. F. X. Dercum, Philadelphia. ADIPOSITAS CEREBRALIS. See Obesity, Frohlich's Disease. ADNEPHRIN. See Animal Ex- tracts : Adrenals. ADONIS VERNALIS.— Adonis is a ranunculaceous plant, closely related to the anemone, growing wild in Europe, Asia, and Africa. Several species of adonis are employed, — Adonis vernalis, A. (cstivalis, A. capensis, A. cupaniana, and A. amiirensis, — but all seem to possess the same properties, although the several varieties are variously em- ployed in the different countries in which they grow. In Russia, for in- stance, it has long been employed in cardiac diseases, and in Africa as a substitute for cantharides, the bruised leaves, when fresh, possessing vesicat- ing properties. DOSE. — An infusion of 4 to 8 parts of the plant in 200 of water may be given in tablespoonful doses three or four times a day (Huchard). The tincture may be administered in doses of ^ to 1 dram (2 to 4 c.c). The lluidextract has also been used in doses of 1 to 2 minims (0.06 to 0.12 c.c). Cervello isolated a glucosid from .Idoiiis 7'cnialis, — adonidin, — a yellow, liygroscopic powder having a bitter taste, obtained from the leaves. It is soluble in water and alcohol, ])ut in- sc)lul)le in ether or chloroform. Adonidin is administered in doses varying from Yiq to ^ grain (0.004 to 0.017 Gm.). It acts more promptly than digitalis. Inoko also obtained a glucosid — adonin — from the Japanese plant, Adonis amurcnsis. This substance is free from nitrogen, amorphous, color- less, of a bitter taste, and soluble in water, alcohol, and chloroform. The effects observed on the heart of a frog were precisely those seen when digitalin is used. It is about twenty times weaker than the adonidin ob- tained from the European Adonis vernalis. PHYSIOLOGICAL ACTION.— Adonis resembles digitalis in its action upon the heart when given in therapeutic doses. It increases car- diac energy and raises the arterial tension. The increased contractions eventually diminish and a period of quiet follows, varying in duration with the dose administered. The prevailing knowledge of the mode of action of adonis is based on experiments with the glucosid adoni- din. The results have, on the whole, been contradictory. While Cervello and Lesage found that it arrested the heart in systole, Huchard and Flare ascertained repeatedly that this organ was arrested in diastole and Guirlet found the left ventricle in systole and the other cavities in diastole. There has been greater concordance in 432 ADONIS VERNALIS (SAJOUS). respect to its effects on the blood- pressure, all observers having found that there was first a rise, then a fall. While the primary slowing is at- tributed to the inhibitory action of the vagus, since its section prevented it, Hare found that the diastolic arrest was not due to this nerve, since it occurred after the latter was divided, while galvanization of the nerve later on also failed to inhibit the heart. He concludes, therefore, that adonidin tends secondarily to paralyze the vagus — Kakowski, in fact, found that it caused dilatation of the coronaries instead of contrac- tion of these arteries. Hare's experi- ments indicate that it may also cause primary stimulation and secondary paralysis of the vasomotor system. Adonis has been credited with diuretic properties by Bubnow, Alt- mann, and Michaelis, though their observations have failed to be con- firmed by certain others. Whatever diuretic power it may have is prob- ably the result of activation of the renal circulation (Wood). [Viewed from my standpoint, the evident confusion which attends prevailing knowl- edge concerning the action of adonidin is due to the fact that all these experiments, which are of many years standing, do not take into account facts I have since pointed out (see "Internal Secretions," vol. ii, 1907) : (1) That the inhibition of the heart is due not to true vagal fibers, but to vasomotor fibers which the vagus contains and trans- mits to the coronaries ; (2) that the caHber of the cardiac arterioles is governed by sympathetic fibers, and (3) that the secre- tion of the adrenals takes part in cardiac dynamism. If now adonidin is considered as a stiiiiu- larit of the adrenal and sympathetic centers, instead of as a depressant of any center, the action of the drug becomes plain : by excit- ing the adrenal center it increases the pro- duction of adrenal secretion, and thus causes the preliminary rise of blood-pressure while strengthening cardiac action. A larger dose excites, besides, the sympathetic center,^ as this center governs the caliber of the cardiac arterioles, the heart muscle receives less blood and its contractions weaken then cease, with failure of the circulation as a normal result — all irrespective of the vagus, v>'hich does not contain sympathetic fibers. This enables us to explain, also, why some experimenters observed that the heart was arrested in systole, while others found it stopped in diastole. These results are con- tradictory simply because the preparations differed chemically. Those which produced arrest in systole, the better drugs, excited more actively the adrenals, and the excess of adrenal secretion caused such violent con- tractions of the heart muscle that the organ finally failed to dilate (the tetanic or cramped heart) ; on the other hand, the poorer drugs excited more actively the sympathetic center, and, the cardiac arterioles being unduly con- stricted, the heart muscle failed to receive enough blood to sustain its contraction and the heart remained dilated, i.e., in diastole. S.] INCOMPATIBILITIES. — The glucosid adonidin in solution is de- composed by free acids or alkalies. It is incompatible with tannic acid, corrosive sublimate, and silver nitrate. The physiological incompatibilities of adonis include aconite, amyl nitrite, muscarin, veratrum viride. CONTRAINDICATIONS. — Ado- nis is contraindicated in arterioscle- rosis, in affections attended by a high vascular tension (as in the earlier stages of interstitial nephri- tis), and in hypertrophy and other disorders of the heart in which digi- talis, its physiological homologue, is harmful. THERAPEUTICS.— Adonis is use- ful in cases of valvular heart disease with loss of compensation and in which evidences of grave circulatory disorder, such as cardiac asthma, are present. It ADONIS VERNALIS (SAJOUS). 433 lias been specifically recommended in aortic and mitral regurgitation. The diuretic powers of the drui^" cause it to be of value in cases of dropsy and cardiac degeneration. It is also valuable in palpitation dependent upon irregular inhibition. As it does not seem to possess cumulative tend- encies, it may be administered with more freedom than digitalis. Accord- ing to Dujardin-Beaumetz, however, large doses cause gastric disorders and vomiting. Borgiotti found adonis valuable in different cardiac disorders. One dram to 1 ounce of the infusion daily constitutes an excellent cardiac tonic. In fatty degeneration of the heart it increases diuresis and regulates the circulation. The writer found the drug very useful in many conditions as a substi- tute for digitalis, though its action is weaker; but it has the advantage over digitalis of being free from disagree- able by-effects, especially effects of a cumulative character. It is, therefore, appropriate for long-continued use, when, for some reason, the adminis- tration of digitalis is undesirable or inadvisable. A satisfactory form of employment is a 1.5 to 2 per cent, in- fusion, which may be prepared by the patient himself, and the dose of which is a tablespoonful every two hours. Mutterer (Therapie d. Gegenw., Oct., 1904). Adonidin is credited with proper- ties superior to digitalis, in that it acts more promptly and with less tendency to cumulation. As Dujar- din-Beaumetz had observed in the case of the infusion of adonis, how- ever, Lublinski and Durahd have found adonidin to produce violent gastrointestinal disorders with diar- rhea and vomiting. According to Dujardin-Beaumetz, the dose should never exceed % grain (0.02 Gm.) ; Iluchard gives yi2 grain (0.005 Gm.) three or four times daily in adults. [The therapeutic value of adonis or adon- idin would be unquestionable and in reality exceed that of digitalis were we able to ob- tain a reliable product. This is especially true in view of the fact that the so-called ''cumulative" action of digitalis is due, from my viewpoint, to its tendency to excite the sympathetic center, while a good preparation of adonis or adonidin does not possess this defect. S.] As a remedy for the reduction of obesity, adonis aestivalis has proved of value. Owing to the fact that it does not possess a tendency to cumu- lation, it may be continued for a long time. It is claimed to have been eft'ective in relieving the heart from an excessive covering of fatty tissue. The tincture of this species may be given in doses of 10 minims (0.6 c.c.) three times daily. Case in which the patient weighed 342 pounds and suffered severely from dyspnea when the administration of adonis was begun. After taking 10 drops of the tincture three times daily for twelve days there was a loss in weight of 17 pounds, the respiration had become easier, and there was gen- eral euphoria. R. Kessler (Amer. Med- ico-Surg. Bull., Aug. 15, 1894). To reduce the active cerebral hyperemia present during a paroxysm of epilepsy adonis has been recom- mended, owing to its power of stimu- lating- the vasoconstrictors. It may be advantageously combined with the bromides. [There is good ground for the belief that adonis is a valuable remedy. By exciting the adrenal center it enhances general metab- olism, and simultaneously the conversion of the spasmogenic wastes into eliminable prod- ucts, thus preventing the fits. It was used with success by Bechterew and others. S.] C. E. DE M. Sajous AND L. T. DE M. Sajous, Philadelphia. 1—28 434 ADRENALS, DISEASES OF (SAJOUS). ADRENALIN. TRACTS : Adrenals, See Animal Ex- ADRENALS, DISEASES OF THE. — Although it is the purpose of this Cyclopedia to present the prevail- ing or current views upon the subjects treated, the writer does not feel that he can conscientiously observe this rule in the present instance. Hav- ing probably devoted more time to the study of the ductless glands and to a comparative analysis of the work done by others than any other investigator in this comprehensive field, he does not hesitate to state that the physiological role authors in general now attribute to the adrenals, though correct as far as it goes, represents only a part of the func- tions these organs actually carry on in the body. To be more explicit, he can- not admit that the functions of the ad- renals are, as stated even in recently published textbooks, merely to raise the blood-pressure and give tone to the muscular elements of the heart and blood-vessels ; he maintains that, besides these well-known properties, the adre- nals sustain tissue oxidation and metab- olism by contributing an oxidizing fer- ment to the hemoglobin, and that they also take an active part in the auto- protective process known as "immu- nity," the active agents of which, not- withstanding the great amount of work devoted to the subject, have never been traced to their original source. [It is impossible within the limits of an encyclopedic article to review at length the physiological evidence upon which these four correlated functions are based. It may be recalled, however, that the action of the ad- renal secretion on the heart and blood-ves- sels was first pointed out by Oliver and Schafer in 1894, while their role in oxidation, general immunity and fever was pointed out by myself in 1903 in my work on "The In- ternal Secretions and the Principles of Medicine," the fourth edition of which has recently (1911) appeared. The conclusions of Oliver and Schafer based on relatively simple experiments have become classic, while mine, which required experimental in- vestigations from many directions, physio- logical, biochemical, clinical, etc., by a cor- respondingly large number of investigators, may be said to have been steadily gaining ground. The action of the adrenal secretion on the blood-pressure and cardiovascular system discovered by Oliver and Schafer being fa- miliar to every one, I will submit only a sum- mary of the fundamental features which sus- tain my own view concerning their additional influence upon general oxidation, including metabolism, immunity, and fever : — The Adrenal Secretion in Pulmonary and Tissue Oxidation. — The prevailing dif- fusion doctrine as to the absorption of oxygen from the pulmonary air and the elimination of carbonic acid, having been shown by Paul Bert, Miiller, Setschenow and Holmgren, Bohr and other authorities to be defective, Bohr concluded in 1891 that some internal secretion capable of taking up the oxygen from the air in the lungs was neces- sary to explain the process. A comprehen- sive study of the question led me to the conclusion that it was the internal secretion of the adrenals which carried on this all- important function. The following are but a few of the main factors in support of this opinion : — 1. Ihe marked affinity of the adrenal secre- tion for oxygen, sustained by the experi- mental observations of Vulpian, Cybulski, Langlois, Battelli, Abel, Takamine and others^ including the writer. 2. The presence of the adrenal secretion in the venous blood between the adrenals and the pulmonary air cells, sustained by the experimental observations of Gottschau, Manasse, Aulde, Stilling, Pfaundler, Cybul- ski and Scymonowicz, Biedl, Langlois, Dreyer, Salvioli and Pizzolini and personal ana- tomical researches. 3. Tlie marked reducing pozver of the blood coursing in the walls of the air-cells, shown by the experiments of Robin, Verdeil, Garnier, and Miiller. 4. The presence in the hemoglobin, of a constituent whose physic o chemical properties are those of the adrenal secretion, sustained ADRENALS, DISEASES OF (SAJOUS). 435 by the observations, first, of Vulpian, Gaut- ier, Moore, Moore and Purinton, and Cybul- ski as to the properties c f the adrenal prin- ciple ; those of Battelli, Dixon and Young as to the presence of the adrenal principle in the blood; of Mulon as to its presence in the red corpuscles; of Schmiedeberg, Jaquet, Abelous and Biarnes, and Salkowski, and my own as to the presence of an oxidizing fer- ment in the blood; of Jolles an J Poehl as to the catalytic and oxidizing properties of the adrenal components of the blood. 5. The presence of the hemoglobin con- taming the adrenal principle in all parts of the body, including the skin, sustained by the presence of melanins everywhere and their identity as hemoglobin derivative and as the adrenal principle based on the investigations of Leonard "Hill, Hirschfeld, Chittenden and Albro as to melanin being an hemoglobin derivative; those of Boinet, Miihlmann, and myself as to the identity of melanin (the bronze pigment of Addison's disease) as a product of the. adrenals. 6. The marked influence of the adrenal secretion and preparations upon the tem- perature, general oxidation, and metabolism, sustained by the observations of Reichert, Morel, Lepine, Israel, and others, including myself, as to their ability to cause a rise of temperature ; those of Brown-Sequard and many others, as to the steady decline of tem- perature following removal of the adrenals, or occlusion of the adrenal veins ; the hypo- thermia of Addison's disease; the observa- tions of Byelaventy, loteyko, Dcssy and Grandis, and others, including myself, as to the increased gaseous interchanges and cellu- lar metabolism, and the increase in the elimination of waste products caused by the adrenal principle. The Adrenal Secretion in Immunity. — The adrenal secretion in this connection is, from my viewpoint, but one of the antibodies which carry on this process, being what has been termed by Bordet the "fixative" or "specific immunizing body" and by Ehrlich "amboceptor." Referring to "Internal Se- cretions" for details which cannot be em- bodied here, upon this phase of the question, I will limit myself to the direct relationship of the adrenals with the autoprotective functions : — The adrenals are known to carry on anti- toxic functions. Sustained by the observa- tions of Albanese (1872), which showed that removal of the adrenals reduced the resist- ance to poisoning by neurine ; those of Abel- ous and Langlois (1892-1898), which showed that the adrenals neutralized poisonous sub- stances derived from muscular activity and bacteria! products, and also by the investiga- tions of Mosse. Additional testimony is afforded by the marked evidences of over- activity shown by the adrenals under the influence of certain waste products and tox- ins, as noted by Langlois and Charrin, Petit, Stilling, Auld, Wybaux, and others, and also by the protection afforded by adrenalin in- jections against strychnine injections ob- served by Oppenheim, Meltzer and Auer and various toxemias and infections as observed by Hoddick, Netter, Marran and Dare, Moizard, Kirchheimer, and many other clinicians. The relationship between the adrenals and general oxidation, shown above, also estab- lishes a connection with the production of fever, which, in the light of modern work is also considered, up to a certain limit, as a defensive process. C. E. de M. S.] To disregard functions of such im- portance would make it impossible to -account for many phenomena aw^ak- ened by disorders of the adrenals, and correspondingly limit our usefulness in the practical field. This entails, how- ever, the necessity of granting to the adrenals a position in pathology equal to any of the major organs. Indeed, the functions I have attributed to them, in addition to those with which they are already credited, entitle them to rank pathogenically with the heart and blood- vessels in so far as the general vascular pressure is concerned, and the lungs in respect to respiration and tissue oxida- tion. When, moreover, their role in the autodefensive or immunizing proc- esses of the body is also taken into ac- count, their importance may almost be said to exceed that of other organs; since they thus not only serve to sustain life through tissue oxidation, but also to 436 ADRENALS, DISEASES OF (SAJOUS). protect . life through their role in im- munity. CLASSIFICATION.— Impairment of these functions to any extent, through factors which either inhibit or exaggerate the secretory activity of the adrenals, must necessarily awaken symptoms which indicate the functional disorders present. In Addison's disease (treated by Prof. Langlois, of Paris, on pp. 356-374 of this volume), for example, where destruction of the ad- renals or of their secretory nerves by a local lesion correspondingly compro- mises their functions, we have as main phenomena not only the vascular hypo- tension and cardiac weakness which the well-known action of the adrenal secre- tion on the blood-pressure explains, but also the low temperature, the general coldness, the dyspnea and the gradual emaciation which deficient oxidation alone accounts for. Now if, from any cause, the functions of the adrenals are inhibited, we have a reproduction, more or less marked according to the degree of inhibition, of these morbid phenom- ena. They form the symptom-complex of the condition which appears to me best designated by the term "hypoad- renia." [This term was selected owing to its greater exactness and brevity than "hypoad- renalism," and owing to the fact that the latter suggests the presence of a habit such as "alcoholism." It is obviously less cum- bersome than "insufhciency of the adrenals" or "adrenal insufficiency," and corresponds with terms in current use such as "anemia," "asthenia," etc. In 1899 Sergent and Bernard (Archives Generales de Medecine, July) were the first to advance the view that adrenal insufficiency was a syndrome due to destruction of the adrenals, but standing apart from Addison's disease, which they ascribed mainly to lesions of the abdominal sympathetic. My own re- searches ("Internal Secretions," vol. i, 1903. and ii, 1907) sustained the opinion of many other observers, however, to the efifect that the elimination of Addison's disease was not warranted, and that this disease presented the most comprehensive external picture of grad- ual destruction of the adrenals or of the periadrenal sympathetic structures, or of these structures and the adrenals jointly, i.e., of adrenal insufficiency. Again, Sergent and Bernard ascribe the syndrome of adrenal insufficiency as a whole to a general intoxication which they divide into fulminant (sudden death), acute (rapid autointoxication), and subacute (slow auto- intoxication). From my viewpoint, however, all the symptoms excepting the convulsions are due to the inhibition of functions which are primarily dependent upon the adrenals : viz., general oxygenation, metabolism, and nutrition. The only intoxication phenomena, the convulsions witnessed in these cases, I ascribe to the accumulation of toxic wastes (shown by Abelous and Langlois to be an- tagonized by the adrenal secretion) which are not broken down with sufficient rapidity when the oxidation processes sustained by the adrenals are inhibited. C. E. de M. S.] Of the various forms of hypoadrenia is one which is practically unrecognized, though frequently a cause of death, mainly among children, viz. : — TERMINAL HYPOADRENIA. DEFINITION.— Terminal hypoad- renia is a form of marked asthenia which occurs late in the course of an acute febrile disease as a result of ex- hausting secretory activity of the ad- renals — acting as defensive organs — in the course of that disease. [The term "terminal" is ' serted here be- cause it is important to differentiate this form of hypoadrenia from that which occurs early in the course of a toxemia and known as adrenal hemorrhage, treated farther on in this article. C. E. de M. S.] PATHOGENESIS AND SYMP- TOMATOLOGY.— The adrenals be- ing admittedly concerned in the protec- tion of the organism during infections and intoxications, by contributing an excess of their secretion during the ADRENALS, DISEASES OF (SAJOUS). A%7 febrile stage of the disease (sometimes considerably prolonged), it follows that, after this stage is over, the adrenals should lapse into a condition of more or less temporary insufficiency through fatigue or exhaustion. That other or- gans concerned in the immunizing pro- cess are influenced in the same way must doubtless be the case, but the fact remains that it is the symptomatology ■of hypoadrenia that is uppermost. In lobar pneumonia and broncho- pneumonia, for instance, resolution may be considerably delayed and convales- cence likewise. There is, late in the case, extreme adynamia and a low blood-pressure, the temperature is below normal, the pulse weak and more or less rapid, and death from heart-failure is not infrequent. In typhoid fever, hypo- adrenia is commonly observed. The disease assumes what is now known as the cardiac type, with, late in the case, extreme prostration, a rapid, weak and sometimes irregular pulse, hypothermia, and a marked tendency to vertigo, faint- ing, and cardiac failure. [Sicard (Bull, de la soc. med., July 21, 1904) reported the case of a young woman in whom the foregoing symptoms appeared on the ninth day of a bronchopneumonia. Extreme muscular weakness, marked hypo- thermia and low blood-pressure, diarrhea, and Sergent's white line, which denotes marked adrenal insufficiency, were present. On the fifteenth day the blood-pressure fell to 70 or 80 (7 or 8 per cent, potain) and death followed three days later. At the autopsy the adrenals were found hemor- rhagic. This suggests that adrenal lesions may be present in all such cases. Yet, Ribadeau-Dumas and Bing (Bull, de la soc. anat., June 3, 1904) have witnessed the sam.e symptoms in cases of measles which recovered, while Bossuet (Gaz. hebd. des sci. med. de Bordeaux, Oct. 30, 1904) refers to 8 cases in various febrile disorders in which typical symptoms of adrenal insuffi- ciency, asthenia, low blood-pressure, etc., developed suddenly and disappeared spon- taneously, aided perhaps by adrenal extract which had been administered. As stated recently by Morichau-Beauchant (Le progres medical, Oct. 9, 1909), the ad- renals seem to show a special predilection for certain infections. Diphtheria easily leads them all in this connection. So seri- ously do these organs suffer in these cases that Sevestre and Marfan have termed the type "secondary syndrome of malignant diphtheria." Hutinel ascribes the fulminat- ing cases of scarlatina to this cause. Tet- anus, erysipelas, mumps, certain forms of tonsillitis, and certain streptococcic infec- tions may also present the typical syndrome of hypoadrenia. Goldzicher (Wiener klin. Woch., June 10, 1910) was led by his re- searches to conclude that in the various forms of septicemia the appearance of lower blood-pressure was to be ascribed to in- sufficiency of the adrenals. C. E. de M. S.] When, at the end of an infectious disease, the case, instead of proceeding to convalescence, remains in a condition of asthenia, with low blood-pressure and temperature, there is good ground for the conclusion that terminal hypo- adrenia has occurred. Exhaustion of the adrenals during the acute process having inhibited the secretory activity of these organs, the above symptoms result from inadequate oxidation of, and metabolic activity in, the tissues. Sergent's white line, brought about by gently rubbing a narrow streak over , any part of the abdomen with the finger, may be obtained in the majority of these cases. After a short period the area becomes whitish and remains so a short time. The writer announced in 1903 that he had occasion to observe a condi- tion simulating meningitis in a young girl, but autopsy revealed complete cheesy, degeneration of both supra- renal capsules, while the meninges were intact. A white line appeared when the fingernail was drawn across the abdomen of the patient, and lasted for two to five minutes. He 438 ADRENALS, DISEASES OF (SAJOUS). has since noted this white line in a number of other cases in which the suprarenals were primarily or second- arily affected, and others have con- firmed his observation. The writer has never observed it with an arterial pressure above 13 (Potain — 130 mm. Hg). It disappears on administra- tion of adrenalin, and is evidently due to reflex spasm of the capillaries dur- ing low arterial tension, with more or less dilatation of the vessels. The subject was discussed at the meetings of the Paris Societe Med. des Hop., in February, at which some cases of the suprarenal pseudomeningitis were reported, as also two cases of insola- tion in which the white line, or a par- tially red line, was noticed. In both these cases lumbar puncture, with re- moval of 20c.c. of fluid, had a marked beneficial effect, especially on the headache. The fluid was compara- tively normal, but under considerable tension. Sergent (Jour. Amer. Med. Assoc, Apr. 20, 1907). The writer has critically examined the significance of Sergent's sign in 79 cases, taking the blood-pressure in all of them with Potain's sphygmoma- nometer. The white line was present in 31 patients, absent in 41, and in- termittent in 7. In 2 patients with definite lesions of the suprarenals, as proved by autopsy, the sign was ab- sent. In the 31 cases in which the sign was positive the blood-pressure was low in 8, normal in 7, high in 11, and variable in S; in the 41 cases in which the sign was negative the blood-pressure was high in 22, nor- inal in 8, low in 8, and variable in 3. He concludes that this white line is not a sign of suprarenal insufficiency and is not dependent on low blood- pressure. L. Bernard (Bull, et mem. Soc. Med. d'Hop., Paris, vol. xxiv, p. 866, 1907). The writers found the white line present in 145 out of 228 cases; 65 of these had hypotension and 80 a nor- mal or hypertension. The 83 cases which did not give the test included 30 with hypotension and 53 with nor- mal or hypertension. The 80 cases with the white line without hypoten- sion and 30 with hypotension with- out the white line make a total of 110, or one-half of the 228 cases tested, which do not conform to the rule. They conclude that the white line cannot, therefore, constitute a sign of either adrenal insufficiency or hypotension. Lautier and Gregoire (Soc. de biol., vol. Ixvii, p. 690, 1910), The patient complains of chilliness; the surface is pale, owing to the poverty of the blood in cellular elements and hemoglobin, and to recession of the blood-mass from the surface to the deeper vascular trunks. The vascular tension being low, the pulse is rapid and the heart-beat weak. Anorexia, due to deficient metabolism and diminished de- mand for food, nausea, the result of re- laxation of the gastric muscular coat, and diarrhea, due to a similar condition of the muscular coat of the already pas- sively engorged intestine, and more or less frequent fainting spells, are all con- comitant symptoms that may be wit- nessed in such cases, which are always greatly exposed to relapse or to sudden death from heart-failure. The writer published with Bernard a description of this syndrome in 1899. He now reports 2 more cases with necropsy which corroborate the existence of a pseudomeningitis orig- inating in suprarenal insufficiency. There had evidently been a chronic affection of the adrenals in each case, clinically latent, until fanned into a flame which proved rapidly fatal. One patient was a young woman, the other a man of 32. The symptoms suggested intoxication from the sud- den suppression of the suprarenal functions. The syndrome may simu- late, also, acute dyspepsia, poisoning, peritonitis, or cholera. The combina- tion of pains in the epigastrium, ano- rexia, vomiting, extreme prostration and progressive emaciation, arterial hypotension and tachycardia indi- cated the suprarenal origin, but other ADRENALS, DISEASES OF (SAJOUS). 439 signs such as instability of the pu- pils, photophobia, pain on pressure of photophobia, and pain on pressure of the ej'eballs, cutaneous hyperesthe- sia, a plaintive cry and tardy head- ache, indicated meningitis, notwith- standing the absence of contractures, of Kernig's sign, and of the menin- gitis stripe, with the retention of con- sciousness. The necropsy disclosed that there was no meningitis, but merely a pseudomeningeal reaction, a suprarenal encephalopathy. Ser- gent (Presse med., ii, No. 94; Jour. Amer. Med. Assoc, Jan. 2, 1904). The author has observed nine cases of acute suprarenal insufficiency or variable intensity, ending in recovery. The symptoms develop very rapidly, and, besides, they can disappear spon- taneously, at the same time with the illness which they accompany, for this acute adrenal insufficiency is due to an infection or an intoxication. The writer has always noted that the insufficiency occurs in the course of a toxic or infec- tious malady, medical or surgical. The longest duration of this acute suprarenal insufficiency that the writer has observed was one month and a half, in a woman who was suf- fering from an outbreak of syphilis. This affection has yielded to the em- ployment of adrenal extract. The patients treated by the author recov- ered from the suprarenal insufficiency in a few days. In eight of the nine patients the cure appears to be defi- nite, for the symptoms, which disap- peared with the causal illness, have not returned after an interval of sev- eral months. In one case of recur- rent bronchitis, however, with every attack, the patient became asthenic and the skin became dark. But when the attack of bronchitis passed, so did the insufficiency. It would be very difficult to say to what lesion of the capsule the syndrome corresponds. The fact that this insufficiency is secondary to an intoxication or in- fection is the characteristic which gives it a true clinical importance. G. Bossuet (Gaz. hebd. des Sci. Med. de Bordeaux, Oct. 30, 1904). Case of acute insufficiency of the adrenals in an apparently healthy farmer who had been doing some hard work, exposed to the sun for several hours, when suddenly he col- lapsed with intense abdominal pain and headache, with great prostration. On the presumptive diagnosis of sun- stroke, he was treated with cold to the head and purgatives, but the symptoms persisted, soon accompa- nied by vomiting and hiccough; the prostration increased, with a ten- dency to stupor; there were intense headache and delirium, respiration was superficial, the pupils were di- lated and did not react to stimuli, the heart-sounds became faint and death occurred at the end of the week. The only pathological findings at autopsy were atrophy of the adrenals from a sclerotic process in the veins, and compression from a hematoma from rupture of one of the veins in the adipose tissue surrounding the left suprarenal capsule. The writer at- tributes the acute insufficiency in his case to excessive exposure to the heat of the sun. Sotti (Policlinico, Jan. XV, Med. Sec. No. 1, 1908). Symptoms arising in the course of scarlatina which are very suggestive of insufficiency of the suprarenals. The symptoms are asthenia, depres- sion, failure of the heart-power, hypo- tension of the arteries, tendency to syncope, abdominal pains, and a brown coloration of the skin. The use of small doses of adrenalin had a remarkable effect in the cases cited, the patient recovering after being in an apparently desperate condition. V. Hutinel (Le bull, med.; Med. Record, Sept. 18, 1909). Complications of various kinds may- occur. The immunizing processes be- ing greatly weakened through the defi- ciency of adrenal secretion, one of its important factors, septic infection, ab- scesses, bone lesions, tuberculosis of a rapid type, and other infections may more or less rapidly develop. Disorders of nutrition, cholelithiasis, and occa- 440 ADRENALS, DISEASES OF (SAJOUS). sionally Addison's disease may also appear. In acute pulmonary infections, pneumonia, for example, organs in the neighborhood of the focus of infection, the pleura, the mediastinal glands, etc., being inadequately protected by the blood or its phagocytic cells, become the prey of specific bacteria. Briefly, the body is rendered vulnerable to the attacks of almost any pathogenic organism. PATHOLOGY. — In the special type in question no adrenal lesion may be discernible. In the majority of in- stances, however, the organs are en- larged and congested and may show, here and there, a limited hemorrhagic area. Their appearance suggests not only the functional torpor incident upon functional exhaustion, but the presence of a passive congestion resulting from loss of resiliency of their sinusoidal ves- sels, thus impeding the circulation through them. Occasionally they are the seat of suppuration, a complica- tion which is apt to be observed when the causative disease is, or includes, a streptococcic infection, pneumonia, or meningitis. , The functional disturbance in the adrenals during disease estimated by the lesser pressure-raising power of the extract in various animals. It showed that the adrenals are not materially affected by various patho- logical conditions, starvation, fever, etc., but that others, such as uremia, phosphorus poisoning, diphtheria, and various infectious processes, appar- ently arrested the suprarenal func- tions. The extract of the organs under these conditions failed to dis- play the normal pressure-raising prop- erty. F. Luksch (Wiener klin. Woch., Bd. xvii, Nu. 14, 1905). The pathological picture of the more severe form of adrenal complications, i.e.j intercurrent hyperadrenia, shows far more distinct lesions of the adrenal parenchyma. Hence the typical lethal phenomena that attend many of these cases. Case of infarction of the right ad- renal which would appear to be al- most unique, as no mention of such a condition is made in the literature referred to by RoUeston in his lec- tures on the suprarenal bodies. Spe- cimen obtained from the .body of a female child, aged 11 months, who died from some throat trouble, pos- sibly diphtheria. On opening the ab- dominal cavity a mass of the size of a goose-egg, and resembling a hema- toma, was found in the right renal region. It was found that the right adrenal was imbedded in this mass; it was enlarged and firm, but very dark, almost black, in appearance, as from hemorrhage. On section the lines of the cortex and medulla could be seen with difficulty, and the entire substance of the gland was of prac- tically the same consistency and dark color. In the medullary portion, and corresponding to the site of the cen- tral vein, was a large, round, whitish mass, in size about that of an ordi- nary match, which had all the ap- pearance of a thrombus. This could be followed throughout the length of the organ. The left adrenal showed some hemorrhagic spots, both in the medulla and cortex, but otherwise was healthy. Woolley (Jour, of Med. Research, Mar., 1902). Mott and Halliburton have found already that in cases of death from exhausting diseases the adrenalin present in the adrenals was dimin- ished or absent. The writers have extended these observations; they have examined the adrenals in the cases of 50 adults dying from various diseases. The glands were placed in Cohn's fluid for twenty-four hours and afterward stained with Schar- lach or Sudan III; by this method the chromafifinic substance and the fat were demonstrated. They relied upon this demonstration of the amount of chromafifinic granules in ADRENALS, DISEASES OF (SAJOUS). 441 the cells of the medulla, and did not carry out the physiological test. No appreciable Ios3 of the substance oc- curred during twenty-four hours fol- lowing death, as told by control ex- periments in animals. Adrenalin was always being given ofif, especially if the splanchnics were stimulated. The conclusions drawn from their work were that in cases of acute infection and rapid death adrenalin was absent in the medulla; this applied also to cases of death from shock and from peritonitis when, in short, the blood- pressure was low. On the contrary, in chronic diseases, such as phthisis, adrenalin was to be found in the me- dulla. In cases of high blood-pressure adrenalin was present and distinctly increased. F. A. Bainbridge and P. R. Parkinson (Brit. Med. Jour., Mar. 11, 1907). In 25 experiments on guinea-pigs and hedgehogs, the writer found that in only three was the microscopic condi- tion of the adrenals approximately nor- mal, while in the remaining 22 very characteristic changes were present, which in 18 were of serious degree, con- sisting of hemorrhages and necroses, alone or combined, after poisoning with the diphtheria toxin. Strubell (Berl. klin. Woch., March 21, 1910). TREATMENT.— In these particu- lar cases the use of adrenal gland, or of pituitary body, which acts very simi- larly but with less violence and more lasting effects, sometimes gives surpris- ing results. The adrenal product — which, from my viewpoint, is also the main active agent in the neural lobe of the pituitary, as shown by the chromaf- fin test — supplies precisely what the body needs, e.g., the resumption of all oxidation processes (thus restoring gen- eral metabolism and nutrition), and a rise of blood-pressure, which causes the blood to circulate normally in all organs, including the skin and the adrenals themselves. Indirect effects are also obtained : its action on the heart in- creases the contractile power of this organ, which is thus rendered capable of projecting the blood with more vigor through the lungs, and causes oxygena- tion of the blood to become more per- fect. Recovery is also materially aided by the rise of blood-pressure that the adrenal product insures, causing, as it does, arterial blood to be driven from the splanchnic area toward the periph- eral organs, including the lungs and the brain. From these features alone considerable benefit is derived. If we recall, moreover, the participa- tion of the adrenal secretion (which the adrenal preparation administered repre- sents) in the immunizing process, we have the added factors of ridding the blood of any intermediate — and there- fore toxic — wastes, bacterial toxins, etc., it may contain, and of increasing phagocytic activity, thus antagonizing efficiently any pathogenic organism that may remain to compromise the issue. Thus explained, we can understand the phrase, "little short of marvelous," applied to the results obtained by some clinicians. We can also understand the marked reduction in the mortality ob- tained by Hoddick (Zentralbl. f. Chir., Oct. 12, 1907) in cases of peritonitis following appendicitis accompanied by uncontrollable decline of the blood- pressure, cyanosis, and other evidences of collapse, and also in puerperal toxe- mias, by the slow intravenous use of ad- renalin in saline solution. Hoddick as- cribes the lowering of the blood-press- ure to paralysis of the vasomotor cen- ter; but as the toxemia is the cause of this condition, an agent capable of coun- teracting both cause and effect is neces- sary. This is met by the adrenal prin- ciple. Josue (Soc. Med. des Hopitaux, May 21, 1909), in typhoid fever, like- wise relieved threatening symptoms by 442 ADRENALS, DISEASES OF (SAJOUS). injecting 15 minims (1 c.c.) of adrena- lin (1:1000 sol.) in 1/2 to 1 pint (250 to 500 c.c.) of physiological saline solu- tion subcutanously. The influence of -the saline solution in these cases must not be overlooked, however. Eight years ago I urged that death was often due, in infectious and septic diseases, to the fact that the osmotic properties of the blood became deficient, and advised the use of saline solution from the onset of th'2 disease. The reduction in the mortality of pneumonia in the practice of men who have carried out this sug- gestion has demonstrated its value. [Several clinicians have employed much larger doses of the adrenal active prin- ciple with profit. Marran and Darre (Jour, des praticiens, May 15, 1909) found it of great value in the collapse of diphtheria with marked asthenia, low blood-pressure, and subnormal temperature. Moizard (Re- vue de therap., Jan. 1, 1910) recommends ad- renal organotherapy as soon as asthenia and low blood-pressure occur in any infection. He gives daily two sheep's fresh adrenals, finely divided and mixed with powdered sugar, or administers the active principle, 10 to 20 drops daily divided in five or six doses. Kirchheimer (Mijnch. med. Woch., Dec. 20, 1910) has found large doses, 10 to 24 min- ims, safe hypodermically in the collapse of pneumonia, diphtheria, and scarlet fever. Letulle has found it of great value in the latter disease. The better plan, from my viewpoint, is to inject it with saline solution (at 108° F.), intravenously, the needle of the syringe containing the adrenalin being in- serted into the rubber tube of the saline solution apparatus. C. E. deINI. S.] Adrenal organotherapy is useful both for differentiation and cure, and the writer has witnessed the entire sub- sidence of the Addison syndrome, in- cluding the disappearance of the "white line" under the influence of suprarenal medication. Fresh glands from young calves may be used, the patient ingest- ing from 1.5 to 2 Gm. a day up to 5 Gm., or the dry extract can be taken. This is kept up for ten or twelve days. then suspended for two or three, and then recommenced. As a rule, he pre- fers the extract of the whole gland, but he sometimes uses adrenalin. He has found this particularly tiseful in infec- tious disease when he suspected supra- renal involvement. Signs of cardio- vascular weakness subside under the in- fluence of the adrenalin, and the white line vanishes and reappears parallel with the fluctuations of the pulse, which he regards as substantial proof of its pathognomonic character. The usual dose is 0.001 Gm. a day, but up to 0.006 may be given fractioned in six doses, and this may be kept up for two months. E. Sergent (Presse med., July 10, 1909). Case of adrenal insufficiency due to typhoid fever in a woman of 46 years. The symptoms : low blood-pressure, tachycardia, a persistent feeling of cold- ness, marked asthenia and lassitude, tendency to syncope, vomiting, stub- born constipation, marked anemia, and emaciation, lumbar pains radiating throughout the abdomen, continued five months. Adrenal organotherapy, of all the remedies tried, was alone of value, the symptoms recurring as soon as it was stopped, to again disappear when the use of adrenal medication was resumed. After five days the patient was able to rise ; the convalescence pro- ceeded regularly under the influence of the remedy. Fortineau (Gaz. med. de Nantes, Feb. 28, 1910). [In this case, the adrenals had probably become the seat of organic lesions in the course of the febrile process which had re- duced their functional efficiency to a marked degree, the adrenal secretion produced being inadequate to raise general oxidation and metabolism to the needs of convalescence. Hence the almost immediate efifect (noted the next day) produced by addition of the adrenal principle to the blood through or- ganotherapy. C. E. DE M. S.] Collapse of obscure origin sometimes occurs in the course of infectious dis- eases. This accident, which not infre- quently ends fatally, is explainable by lesions of the adrenals. The success obtained with glandular extracts in such ADRENALS, DISEASES OF (SAJOUS). 443 cases affords evidence in favor of this view. The adrenals, v^hen active, exert an angiotonic and antitoxic action, and suppression of their functions results in phenomena akin to those of fatigue. In infections complicated by adrenal insufficiency hemorrhages into these organs have often been noted. If severe and bilateral, such hemorrhages result in death. In the slowly progress- ing forms of adrenal failure, treatment by glandular extracts is also of great value. Such treatment is indicated as soon as asthenia and lowered blood- pressure appear. The author recom- mends the daily administration of two capsules of fresh suprarenal substance from sheep, finely divided and mixed with powdered sugar, or, better, the use of adrenalin solution (1:1000) or of cachets containing glandular extract. In children 10 to 20 drops of the 1 :1000 solution may be given daily, divided into five or six doses. Moizard (Revue de therap., Jan. 1, 1910). If adrenal insuflficiency arises during the progress of diphtheria, the writer advises combining suprarenal opother- apy with serotherapy. If syphilis is also present, suprarenal opotherapy may be associated with mercurial treatment. In the other infectious diseases, where no specific medication exists, opotherapy should be begun from the beginning of the symptoms of suprarenal insuffi- ciency. Adrenalin may be given by the mouth, or, if the hypodermic method is used, 1 c.c. of a 1:1000 solution is added to SO grams of normal salt solu- tion and injected into the subcutaneou-s tissue. As this medication is inoffen- sive, it can be continued daily until the accidents of suprarenal insufficiency have disappeared. Comby (Archives de med. des enfants, Jan., 1911). These measures are only indicated in emergency cases, however. In the average case the glandulae suprarenales siccas of the United States Pharmaco- peia, administered by the mouth, is fully as effective if a good preparation is obtained as soon as asthenia and low blood-pressure appear. The powder in 3-grain (0.2 Gm.) doses, three times daily, in capsules, gradually increased until 5 grains are given at each dose, usually suffices. When the cardiac adynamia disappears, a small dose of thyroid, the desiccated gland, y> grain (0.03 Gm.) ; strychnine, %o grain (0.001 Gm.), and Blaud's pill, 1 grain (0.06 Gm.), added to each capsule, greatly hasten convalescence. The iron and the adrenal product serve jointly to build up the hemoglobin molecule, a slow process when left to itself. For our knowledge of the action of the use of pituitary extracts in infectious diseases we are mainly indebted to L. Renon and Delille (Bull, de therapeu- tique, Feb. 8, 1907), who began their use in 1907. In a recent work in which the clinical observations of both ob- servers are recorded, Delille ("L'Hypo- physe et la medication hypophysaire," 1909), referring to grave cases of ty- phoid fever, states that they showed "arterial hypotension, irregularity of the pulse (especially the grave forms), oliguria, insomnia; while convalescents showed asthenia, hypotension, or at least 'effort hypotension' (Oddo and M. Achard), paroxysmal or continuous ta- chycardia" — all, we have seen, symptoms of hypoadrenia or adrenal insufficiency. They found 1^ grains of pituitary ex- tract (of both lobes) at noon daily ex- tremely efficient ; it counteracted at once the depressed arterial tension, produced diuresis, counteracted insomnia, and greatly improved the general condition. Similar effects were observed in diph- theria and erysipelas. The results in pneumonia do not appear to me to war- rant the use of any adrenal or pituitary preparations early in the case, the first few days of the disease, when the blood-pressure and the fever are high. They should be used only when a low 444 ADRENALS, DISEASES OF (SAJOUS). blood-pressure and other symptoms of hypoadrenia are present. The results reported by Delille strengthen this opinion. In advanced tuberculosis no beneficial effect was observed. ACUTE HYPERADRENIA AND ADRENAL HEMORRHAGE.— This condition, which may lead to fatal hypoadrenia by arresting the functions of the adrenals, is generally known un- der the term of "adrenal hemorrhage." The association with hyperadrenia, i.e., excessive functional activity of the ad- renals, introduced here, is important in that it calls attention to the cause of the lethal hemorrhage, viz., abnormally high temperature and blood-pressure. [Just as /zjz/'oadrenia appears to me to re- place advantageously "hypoadrenalism" and "adrenal insufficiency," so does "hyperadre- nia" seem to convey more exactly excessive adrenal activity than "hyperadrenalism," which suggests habitual overactivity, besides being less cumbersome than the phase "ex- cessive secretory activity" and others in gen- eral use. C. E. deM. S.] This disorder is, briefly, the result of undue activity of the adrenals. Hyper- emia of these organs occurs normally, i.e., physiologically (owing to their par- ticipation in the autodefensive func- tions of the body), in the course of all febrile infections or intoxications. When these toxemias are severe this adrenal congestion is increased in pro- portion — sufficiently so in some in- stances to cause rupture of the adrenal vascular elements, and hemorrhage within the organs. An additional cause of congestion in the latter is the abnor- mal rise of blood-pressure which the unusual production of adrenal secretion entails ; all the vessels of the body being unduly contracted, the adrenal capilla- ries, which are deprived of muscular elements, are overladen with blood and prone, therefore, to rupture. These few facts are necessary to elucidate the definition of the disorder. DEFINITION.— Acute hyperadre- nia is that condition of the adrenals characterized by intense congestion of their vessels, which occurs in the course of severe febrile infections and certain intoxications, and manifested by a high blood-pressure, and in infections, also, by a high temperature. When this congestion exceeds the resistance of the adrenal vessels adrenal hemorrhage oc- curs, causing death when both adrenals are hemorrhagic, in a large proportion of cases, especially infancy and child- hood. [The limitation "certain intoxications" is introduced, because active congestion of the adrenals is produced only by poisons virhich cause a marked rise of the blood-pressure, strychnine and quinine, for example. As shoum m "Internal Secretions" (vol. i, pages 19 to 55, 4th edition, 1911), the use of such remedies in the course of infections and in- toxications may do harm by increasing the congestion of the adrenals and therefore the chances of hemorrhage. C. E. deM. S.] SYMPTOMATOLOGY AND PATHOGENESIS.— This disorder is relatively common in children, especially in infants; death occurs, from adrenal hemorrhage, without premonitory symp- toms, except, perhaps, a hemorrhagic rash or purpura — denoting excessive vascular tension — over the body, and a high temperature. The toxemia here has promptly destroyed the adrenals. As a rule, however, more or less marked phenomena, besides those due to the dis- ease from which the child may be suf- fering, and varying considerably with each case, initiate this acute phase of the process, the adrenals being on the border-line of hemorrhage. These may include vomiting and diarrhea, melena, very acute abdominal pain, hemateme- sis, icterus, fever, with hyperpyrexia ADRENALS, DISEASES OF (SAJOUS). 445 sometimes immediately before the ad- renal rupture. W'lien tlie lieniDrrhage occurs there is more or less sudden col- lapse, a very feeble and rapid pulse, shallow respiratitm and, perhaps, some bronchial rhonchi, the face being more or less dusky, cyanosed, or even livid, and the temperature subnormal. These pl^enomena are typical of adrenal insuf- ficiency or failure, the adrenal secretion sustaining, we have seen, general oxy- genation and metabolism and cardio- vascular contractility. Still (Pathol. Soc. Reports, 1898), who collected the cases recorded up to 1S9S, divided them into three groups: — 1. Those in which death occurred within a few hours or days of hirth (never later than the sixth day), i.e., cases of congestion or hemorrhage in the suprarenals in the newborn. 2. Those in which death occurred later, and the suprarenal lesion was a complication of some disease, usu- ally of the respiratory tract. 3. Tliose in which, after an acute illness lasting only two or three days, usually with a purpuric or bulbous eruption, death occurs, and the supra- renal lesion appears to be part of the fatal disease. To this latter group belongs a case recorded by Voelcker (Registrar's Reports, Middlesex Hospital, 1894), in which an infant, aged 2 years, died with acute illness and purpura, and was found to have hemorrhage in both suprarenal capsules. This asso- ciation of suprarenal hemorrhage with acute illness and purpura is seen also in the cases recorded by Garrod and Drysdale and Andrewes (Pathol. Soc. Reports, 1898), and in a recent case at the Royal Free Hospital (Post-mortem Reports, 1900). An- drewes considers that we have clearly to do with an infective, process, and inasmuch as several cases have oc- curred in unvaccinated children, the question of variola deserves consider- ation. Probably, however, the asso- ciation IS merely an accident owing to the occurrence of death in infancy. Talbot's cases were both infants with a hi'story of sudden onset of vomit- ing, abdominal pain, convulsions, a temperature of 100° or 101°, and nothing discoverable to account for the symptoms; purpura, however, was not present. In the Royal Free Hos- pital cases there was some evidence of acute bronchial inflammation. Still considers that the association with a respiratory disease, producing severe dyspnea and cyanosis, sug- gests an asphyxial origin for some of the cases that occur in later infancy. Talbot (St. Bartholomew's Hospital Report, 1900). Symptomatology of adrenal hemor- rhage as observed in 80 cases: (1) In 46 out of 79 cases there were no appre- ciable signs. (2) In 5 cases there was a voluminous hematoma or abdominal tumor that could he perceived by pal- pation. The diagnosis was made in 1 case only during life. (3) There were peritoneal symptoms in 6 cases, all accompanied by tearing of the cap- sule with hemorrhage. (4) There were symptoms of capsular insufficiency in 8 cases. (5) In 15 cases there was sud- den death, or death after three days at the most, sometimes accompanied by delirium, convulsions, contractures, coma, hypothermia, and syncope. In more than half of the cases, therefore, the hemorrhages remain latent and apparently without effect upon the organism. F. Arnaud (Archives gen. de med., May, 1900). Series of four cases of hemorrhage into the skin and suprarenal capsules, the interesting features of which were the sudden onset, rapid course and fatal termination. Not one of the patients was over a year old. The history throws absolutely no light on the causation of the disease; neither does the question of food ap- pear to bear any relation to it. The presence of hemorrhage in the skin and suprarenal capsules would seem to make it more probable that the disease is some form of toxemia. In two cases the blood from the un- 446 ADRENALS, DISEASES OF (SAJOUS). opened heart was examined bacterio- logically with negative results. In its extremely rapid and fatal termination the disease somewhat resembled the epidemic diarrhea . and vomiting of infants. The general condition of the patients was different. They did not present the sunken eyes and the in- elastic skin which is frequently met with in the epidemic diarrhea, and the cyanosis present in these cases is very rarely, if ever, seen in the skin and suprarenal capsules; the fact that Peyer's patches were much swollen is interesting. The authors believe that these symptoms are the mani- festations of a special disease, and that the cause of this disease is a blood poisoning of some form, at present unknown. P. S. Blaker and B. E. G. Bailey (Brit. Med. Jour., July 13, 1901). Three cases of sudden death in in- fants, due to hemorrhage into the suprarenal capsules. The train of symptoms is very definite. A child, previously well, is suddenly seized with acute abdominal pain and vom- iting, the temperature rises, and one of the exanthemata is suspected. Xo characteristic rash appears, however, though sometimes there is purpura. Convulsions supervene, the patient becomes moribund, and death occurs in a few hours. If the condition is in infection presumably, it is a spe- cial infection of unknown origin. Bac- teriological examination has proved negative in almost every case. Lang- mead (Lancet, May 28, 1904). The writer was in attendance at birth of a full-term male child born after a normal labor. The umbilical cord, a thick one, was tied three times in suc- cession on account of bleeding at the seat of ligation. This was finally checked and the child did well till the ninth day, when it became weak and jaundiced. In a few days more red patches appeared on the chin and later on various bodily areas. Fever and slight convulsions came on, and the child died on the twentieth day. Autopsy revealed a dark, slate-colored left adrenal. Opened in situ, it col- lapsed at once and emptied its fluid contents into the abdomen. On exam- ination it appeared to be converted into a blood-sac, was very soft, and partly torn in removal. There were no signs of inflammation spreading up from the umbilicus, and the umbilical cord in- side the abdomen was small, pale, and evidently not diseased. The brain was not examined. The microscopic report was as fol- lows : The right suprarenal showed no abnormal appearances. The left supra- renal was much broken up, but there were the remains of hemorrhage in its medullary substance, both in the form of extravasated corpuscles and as gran- ules of pigment. B. G. Morrison (Lan- cet, June 6, 1908). Case of a man 35 years old who suc- cumbed in five days to adrenal hemor- rhage. The disturbance was sudden in its onset, with symptoms resembling those of intestinal obstruction : violent abdominal pains, which morphine was powerless to relieve, continued vomit- ing, and absolute retention of gas and feces. Laparotomy was performed and showed the intestinal tract, including the appendix, to be entirely normal. The pain was in no way modified, by operation. The temperature rose to 39° C. (102.2° F.), the pulse became extremely feeble, the respiration slow and shallow, and death took place on the fourth day after operation. The autopsjr showed bilateral lesions of the adrenajs, without other dangers of any kind. The left adrenal gave evidence of a recent and of a former hemor- rhage (the patient had experienced a similar, though less severe, attack a few years before). The condition of the abdomen, slow- ing of the pulse, with temperature re- maining normal, should draw the atten- tion from the intestinal tract to the adrenals. The case also indicates that this syndrome may not be fatal, and, if not fatal, may recur. Brodnitz (Miinch. med. Woch., July 26, 1910). In adults, most frequently subjects between 20 and 30 years of age, the at- tack may also be sudden, or preceded by ADRENALS, DISEASES OF (SAJOUS). AM a period of great lassitude or asthenia. In most instances, however, the symp- toms are such as to suggest acute in- toxication or infection, with very severe pain, either in the epigastrium, the ab- domen or below the costal margin, as the pre-eminent symptom. Then follow, in rapid succession, incoercible vomiting and, perhaps, diarrhea, and the signs of adrenal hemorrhage : great weakness of the pulse and rapid decline of the blood- pressure, hypothermia, cold sweats, cold- ness of the extremities, coma and death. This, may, however, be preceded by a typhoid-like state, delirium, convulsions and various perversions of the cuta- neous pigmentation, varying from yel- low to light-brown. In a series of 79 cases collected by Arnaud (1900) death occurred within a period ranging from a few hours to three days. The hemor- rhage may be due to the rupture of a hemorrhagic cyst of the adrenals (treated under the next heading) and be preceded, therefore, by the symptoms peculiar to this condition. The types of acute insufficiency of the suprarenals are classed by the writer as follows: (1) those of sud- den onset; (2) the asthenic type; (3) the nervous type; (4) sudden death where nothing but a destructive le- sion is found; and (5) cases which occur in hemorrhagic diseases. These types often overlap each other. In the asthenic type there is only ex- treme asthenia, followed in a few days by death. The nervous type in- cludes those showing convulsions, coma, delirium, or typhoid states. In instances of convulsions the convulsion might well be the cause of the adrenal le- sion. The first type is of particular interest because of its striking simi- larity to acute pancreatitis. The on- set is sudden, "with epigastric pain and tenderness, vomiting, extreme prostra- tion, feebleness and rapidity of pulse, coldness of extremities, lumbar ten- derness, and, at times, diarrhea and abdominal distention, followed within a few days by death." The shock is more profound, the lumbar tender- ness more acute, and the epigastric pain and vomiting less pronounced in adrenalitis than is usually the case in acute hemorrhagic pancreatitis. Attention should be paid to the rela- tive frequency of the condition in the purpuras of childhood and during or shortly after the acute infections; and due consideration must be paid to the apparent insufficiency and in- flammations in the neighborhood of the suprarenals, s irf ace burns, chronic heart or pulmonary disease, and any phenomenon tending to a great in- crease in internal blood-pressure. Lavenson (Archives of Intern. Med., Aug. 15, 1908). ETIOLOGY.— That we are deal- ing with a relatively common morbid process is shown by the fact that Mattel, Rolleston and Le Conte, in 230 autop- sies in the newborn, found adrenal hem- orrhage iri over 100 instances, or 45 per cent., while the proportion in adults is about 1 per cent. To explain the marked predilection of infants to this disorder many theories have been advanced: Weakness of the intra-adrenal vessels, either congenital or due to general dis- orders, such as syphilis, scorbutus, or, again, to lesions of the vascular walls, such as fatty degeneration, aneurism, etc. ; lack of firmness of the medullary portion of the organ, the usual seat of the hemorrhage; compression by the uterus during labor of the inferior vena cava, thus offering resistance to the blood-streams from the adrenals which enter this great venous channel ;. ligation or prolapse of the funis, and other me- chanical factors capable of causing pass- ive congestion of all organs, including the friable and extremely vascular ad- renals. Case in a boy, aged 18, following operation for a left inguinal hernia, 448 ADRENALS, DISEASES OF (SAJOUS). though before the patient had been in perfect health. On the first day, Jan- uary 28th, after the operation the pulse ranged from 100 to 140; it was normal on the second day, but from the third day, January 30th, until February 10th, it ranged from 100 to 140; after Feb- ruary 10th it was normal in rate but irregular until death, February 15th. The pulse was feeble all this time. The temperature was normal until the third day after the operation, when it gradually rose to 102° F., where it re- mained for two days, gradually going down to normal during the next five days. The day before death the tem- perature was subnormal. The urine at no time showed anything abnormal. Immediately after the operation the patient complained of pain a little to the left of the median line under the costal margin and later of the same kind of a pain under the right costal margin. This pain persisted with some tenderness until death. On the fifth day the liver reached three fingers be- low the costal margin and was then quite tender, but on the ninth day it seemed to have returned to its normal size; the tenderness, however, persisted. Some food was taken every day and there were no disturbances of the bowels, but the patient vomited at different times after the fifth day, grad- ually losing weight. The wound healed by primary intention. On February 9th the mind seemed somewhat clouded and gradually became more so until death occurred, February ISth. Both suprarenal bodies were much larger than normal, firmly adherent to the surrounding structures, and densely and uniformly infiltrated with blood so that their appearance was like that of a hemorrhagic infarct. In places there was some infiltration of blood into the tissues about the suprarenal, but the main hemorrhage was wholly within this organ. On the cut surface it was quite smooth and red. The hemor- rhagic infiltration was most intense in the medullary part and appeared to be of about the same age everywhere, and microscopically the tissue was uniformly necrotic, no nuclei being demonstrable in the adrenal cells; some of the vessels in the central part were plugged with clots and the mouth of the suprarenal vein was closed by a firm, adherent and yellow thrombus which projected into the vena cava as a small, smooth, oblong body about 1 cm. in the longest dimen- sion. L. Hektoen (Jour. Amer. Med. Assoc, June 12, 1909). Series of 124 infants in whom death occurred within eight days of birth. In 8 of these cases the necropsy revealed macroscopic hemorrhages in one or other adrenals. Two of these 8 cases were delivered spontaneously, 3 by ver- sion, 2 were foot presentations, and 1 was delivered by Cesarean section. The labors in most of the cases were difficult. Three had asphyxia, and the Schultze method of swinging was em- ployed. In all but 2 cases the infants died within eight hours of birth. The autopsy in these cases showed usually anemia and icterus, and in every case hemorrhage with free bleeding in one or both adrenals. George Magnus (Berl. klin. Woch., Bd. xlviii, S. 1119, 1911). While all these agencies probably cause hemorrhage in a certain propor- tion of cases, the majority are due, as stated above, to some form of intoxica- tion, either toxins or endotoxins of in- fectious origin, or autogenous poisons, such as toxic waste products or auto- toxins of intestinal origin. Some ob- servers have ascribed the morbid pro- cess to a single hypothetical organism, but it has been clearly shown that dif- ferent germs could produce it, including the Staphylococcus aureus and alhus (Riesman), the pneumococcus (Hamill and Dudgeon), the pneumobacillus of triedlander (Litzenberg and White), and others. In adults it occurs also, as a rule, as a complication of various dis- eases, some of which, such as septicemia, erysipelas and tuberculosis, are clearly of bacterial origin. Epilepsy, on the other hand, illustrates the class of cases ADRENALS, DISEASES OF (SAJOUS). 449 in which adrenal licmorrhagc may be caused by autogenous poisons. In the adult, as shown under the next heading, several of these morbid processes may give rise to hemorrhagic cysts, which mav eventually rupture into the abdom- inal cavity. [That a general toxemia is an active factor in adrenal hemorrhage has been demon- strated experimentally. Roger (Le bull, med., Jan. 21, 1894) found that inoculation of the guinea-pig by a pure culture of the pneumobacillus of Friedlander is followed by abundant hemorrhage of the suprarenal capsules, the blood bursting through the great capsular vein and causing necrosis of the elements by mechanical compression. These hemorrhages do not occur in the rab- bit. Langlois (Le bull, med., Feb. 7, 1894) saw hemorrhages produced by the pyo- cyaneus bacillus. Pilliet (Le bull, med., Feb. 7, 1894) has also observed such hemorrhage after intoxication by essence and nitrate of uranium. C. E. de M. S.] The adrenals are exceedingly vas- cular, and at times are subject to emporary passive engorgement. An- other cause of hemorrhage is unques- tionably bacterial invasion, and sev- eral hemorrhages of considerable size have been reported as due to this cause. The hemorrhage may be also due to toxemia from irritating chem- ical poisons. In animals who have been injected for experimental pur- poses, with sera or antitoxins, as, for example, that of diphtheria, severe congestions and, occasionally, hemor- rhages have occurred. A. J. M'Cosh (Annals of Surg., June, 1907). Instance in an epileptic who died during an attack of enteritis, and in whom the autopsy revealed recent extensive hemorrhage in both ad- renals. This seems to be a rare cause of death in adults, though not so uncommon in children. The reported case is one of Arnaud's asthenic type, probably due to circulatory failure from sudden removal of the tonus, producing secretion of the supra- renals. J. F. Munson (Jour. Amer. Med. Assoc, July 6, 1907). Case of adrenal hemorrhage and acute edema of the lungs in the course of convalescence from acute nephritis due to erysipelas. The patient, a woman of 35 years, died suddenly on the fourth day of the nephritis, which had been brought on by exposure to cold. The autopsy showed, besides the evidences of pulmonary edema and intense acute nephritis, great distention of the adrenals by hemor- rhage into them, with compleite de- struction of the medullary substance. Loederich (Le bull, med., July 8, 1908). From an extensive experience in autopsy work in the newly born, the writer believes that hemorrhage into the suprarenals is very common, and that the evidence is sometimes micro- scopic instead of macroscopic. He has found some degree of hemor- rhage in infections due to the strep- tococcus, staphylococcus, pneumococ- cus. Bacillus pyocyaneus, the colon bacillus and a micrococcus he was unable to classify. We may have in- fections with the pneumococcus with- out any evidence of pneumonia. S. M. Hamill (Jour. Amer. Med. Assoc, Dec. 5, 1908). Hyperplasia of the adrenal is an al- most constant lesion in arteriosclerosis associated with chronic interstitial ne- phritis and left-sided hypertrophy, and it occurs with almost equal fre- quency in arteriosclerosis with chronic nephritis of the parenchymatous type ; it is also a frequent lesion of arterio- sclerosis without nephritis and of ne- phritis without arteriosclerosis. Adre- nal hyperplasia is, consequently, prob- ably the result of some factor active in a period of life in which these affections are most frequent. The adrenal lesion consists of increase of connective tis- sue, round-cell infiltration, increase in the thickness of the vascular wall a«d hyperplasia of the adrenal cells proper. Pearce (Jour, of Exper. Med., Nov., 1908). ■ PATHOLOGY. — An important function of the adrenals is to destroy products of metabolism. This was first 1—29 450 ADRENALS, DISEASES OF (SAJOUS). shown by Abelous and Langlois, whose views have been confirmed by many ob- servers. Subsequently this function was found to apply to bacterial toxins. The prevailing view as to the pathogenesis of adrenal apoplexy is that, as a result of the active congestion of the adrenals incident upon infection and excessive functional activity and the high blood- pressure resulting therefrom, or passive congestion due to factors which prevent the free passage of blood out of the or- gans, such as pressure upon the adrenal veins, the inferior vena cava, etc., the capillaries become engorged and yield, thus causing a more or less diffuse inter- stitial hemorrhage. In some instances the entire adrenal parenchyma is de- stroyed, and the organ is more or less dilated by the blood accumulated in it, and may thus form a brownish or red- dish-blue mass, varying in size from that of a small walnut to that of the under- lying kidney. In other cases the organ ruptures, the blood flowing into the peri- toneum or the abdominal cavity. Both adrenals are involved in the morbid pro- cess in most instances. Other organs, the lungs, the pleura, and skin in par- ticular, may also be the seat of hemor- rhage, the purpura witnessed in a large proportion of cases being naught else than a punctiform hemorrhage into the cutaneous tissues, due to excessive vas- cular tension. Death may be due to these hemorrhages or to the annihilation of the functions of the adrenals. Small ecchymoses into the adrenals occur frequently in the various infec- tious diseases and are to be considered toxic in origin. Hemorrhagic infarc- tion of both adrenals often leads to peritonitis and collapse and may result in death. It may, however, occur with- out any of these sequences. Large hem- atomata may be found in the adrenals. Hemorrhage into these glands may also occur under the following circum- stances : traumatic influences (under this class is found the form seen in the newborn) ; hemorrhagic diathesis ; thrombosis of the suprarenal veins, which is the most common cause ; and bacterial capillary embolism, which oc- cupies the second rank. The thrombi can affect the trunk or the tributaries of the suprarenal veins; they can occur in both or only in the right organ; they are to be regarded as marantic thrombi, occurring, as a rule, only in individuals suffering from some form of chronic disease. The peculiar anatomical dis- position of the vessels favors their formation. A primary suprarenal dis- ease does not precede these cases. Under the cases of bacterial capillary emboli are included those in which neither clinically nor anatomically can septic disease be observed. Bleeding into the adrenals may lead to atrophy of the organ. M. Simmonds (Vir- chow's Archiv, Nov. 3, 1902; Med. News, Dec. 27, 1902). Acute hyperadrenia and adrenal hem- orrhage in the infant may also be due to toxemia. While the fetus is in utero its waste products are transferred to the maternal blood and converted therein into eliminable products. When its birth occurs it is left to its own resources, and if it is unable fully to break down its waste products these accumulate in its blood. Its waste products — and this ap- plies as well to certain toxins, including those enumerated above — excite power- fully both the adrenal system and the vasomotor center (hence the flushing following a copious meal). If the adre- nal system can thus be made to prevail, the wastes (or toxins) will be gradually destroyed, and the vasomotor center will not be abnormally excited. If it is not, the wastes accumulate, and the vaso- motor center being powerfully stimu- lated, the vascular tension and the blood- pressure become intense ; this being fur- ther enhanced by the excess of adrenal ADRENALS, DISEASES OF (SAJOUS). 451 secretion produced, the pressure be- comes such that the adrenal tissues, al- ready overburdened with blood as a feature of their overactivity, yield — along with many cutaneous capillaries, as witnessed by the hemorrhagic pur- pura. Case of a child who had been brought to the Bellevue Hospital with no fur- ther history than that it had been blue since birth. It had died very suddenly a few minutes after entering. At the autopsy, the abdominal cavity was found filled with blood, and the intes- tines all matted together by very firm adhesions. On the superior surface of the adrenals, represented by a more or less organized blood-clot of a consider- able size, was an opening two inches in diameter, through which the blood had escaped into the abdominal cavity. On examining the foramen ovale it had been found nearly closed. The ductus arteriosus as it entered the aorta pre- sented a funnel-shaped opening. Hem- atomata of the suprarenals are rarely as large as the one presented. This is the second case of the kind that the writer has met with. He has been able to find only one or two instances re- ported in the literature in which rupture had taken place into the peritoneal cavity. One observer reported 26 cases in which there have been small hemor- rhages into the suprarenal in a series of over 100 autopsies on stillborn infants. In 2 of the cases the hemorrhage had started in the cortex. Charles Norris (Med. Record, June 9, 1900). Examination of the adrenals in 16 cases of diphtheria, 10 of variola, 23 of lobar- and broncho- pneumonia, 5 of typhoid fever, 1 of tetanus and 4 of streptococcus infection. The glandular cells v/ere profoundly altered. There was also hemorrhagic extravasation into the stroma, in which the polynuclear neutrophilic leucocytes are especially abundant. True abscess formation, oc- curs chiefly in the prolonged infections of variola and typhoid fever. No pecu- liar alterations were observed as the result of special infections and the changes in general were common to all the cases examined. A pericapsular sclerosis, cortical and central, was pres- ent in most cases. This chronic lesion is not due to the acute process, but is to be regarded as the result of previous repeated or continued infections. The writers regard the adrenals as possess- ing an important function in the re- sistance of the organism to infection. Oppenheim and Loeper (Archives de med. exper., Sept., 1901). Case of a male infant, four days old, who was born after a normal labor. On the fourth day after birth the infant ceased to pass urine and after total suppression for twenty-four hours it died. At the autopsy the chief interest centered in the suprarenal bodies ; the left one was replaced by a tumor the size of a hen's egg and the right one presented a tumor as large as a cherry at its apex. The structure of both tumors was identical, both showing a hypoplasia of the fascicular zone fol- lowed by marked fatty changes and necrosis. In the case of the growth in the left suprarenal body, liquefaction of the necrosed central portions gave rise to a cyst which was filled with cell debris. Both growths were considered to belong to the group of adenoma. A. S. Warthin (Archives of Pediatrics, Nov., 1901). Results obtained by inoculating rab- bits and guinea-pigs with cultures of various micro-organisms. The micro- organisms used were diplococci, typhoid bacilli, bacterivun coli, Staphylococcus aureus, streptococci, anthrax bacilli, and diphtheritic bacilli. In the ex- periments with active ctiltures there was always great hyperemia of the suprarenal bodies and in the more active cases there were hemorrhages. E. Frederic! (Lo Sperimentale, Iviii, Fasc. 3, 1904). Common pathological changes found in the suprarenals are hemorrhage, which converts the medulla of the organ into a pulpy mass, and embolism of the suprarenal artery, whereby the entire organ is destroyed. Occasionally, one or both organs will be converted into 452 ADRENALS, DISEASES OF '(SAJOUS). the large bluish tumors, whose contents are fluid blood. This is especially com- mon in the newly born, and many be- lieve that the motions necessary for artificial respiration are the real cause. In a number of cases observed by the author, however, artificial respiration was not resorted to, and it is likely that severe labor, particularly if the child is in the breech position, will furnish the necessary trauma to rupture the friable suprarenal tissue and thus give rise to a hematoma. If both organs are af- fected the symptoms are those of Addi- son's disease, and death rapidly sets in. S. Oberndorfer (Wiener klin. therap. Woch., June 18, 1905). It has been demonstrated that the ad- renals have the function of neutralizing or destroying poisonous products result- ing from muscular work; also those of uremic poisoning, and of poisons in- troduced from without. The author found as a result of experiments in rabbrts, that they also neutralize the poisons circulating in the blood as a result of burns. In the case of animals dying within a few hours after the burns, he noted only a marked dilata- tion of the vessels of the suprarenal capsules ; after a longer period a marked hyperemia resulted ; after three to five days the capsule was increased in vol- ume, and there was hyperplasia of the glandular epithelium, testifying to an increased activity of the organ and a proliferation of the cells. Augusto Moschini (Gaz. Med. Lombarda; Med. Record, March 25, 1905). Conclusions based on a study of 119 cases including 2 personal cases : 1. Hemorrhage of the suprarenal capsules is more common than hemorrhage in the other viscera. 2. This is due pri- marily to the close relation of the adrenals to the vena cava, making congestion easy, and to the peculiar anatomical construction which favors hemorrhage. 3. A weakness of the ves- sel walls, either normal delicacy or pathological alteration favors the rup- ture. 4. The place of election of the hemorrhage is visually in the internal cortical zone because of its vascularity and the anatomical arrangement of the vessel. 5. The bleeding always follows active or passive congestion. 6. Pas- sive congestion may be caused by diffi- cult labors, obstetric operations, throm- bosis, or, in short, anything that would favor venous stasis. 7. Active conges- tion is induced by infection or any toxemia which incites hyperemia by a superactivity of the gland. 8. The find- ings of the pneumobacillus of Fried- lander in the 2 cases personally reported and other bacteria in 5 additional cases prove beyond question that infection is a cause of adrenal hemorrhage. 9. Death results either from loss of blood or an interference with the physio- logical function of the gland. J. C. Litzenberg and S. Marx White (Jour. Amer. Med. Assoc, Dec. 5, 1908). TREATMENT.— The literature of the subject is suggestively silent on the prevention and treatment of this condi- tion. The foregoing conception of its pathogenesis, however, opens a greater field in this connection. As to prophylaxis, it must be borne in mind that acute hyperadrenia is present when the blood-pressure and the febrile process are abnormally high. Antipy- retics are worse than useless, since they further increase the blood-pressure and through this fact the danger of adrenal congestion, which may lead to hemor- rhages. The physiological saline solu- tion offers, on the other hand, all desir- able qualities. It does not, as argued theoretically by some authors, increase the vascular tension, even if injected intravenously, as shown by the experi- ments of Sollmann (Archiv f. exper. Path. u. Pharm., Bd. xlvi, S. i, 1901), Briggs (Johns Hopkins Hosp. Bull., Feb., 1903), and others, any excess of fluid leaves the vessels at once. By re- ducing the viscidity of the blood, saline solution tends to relax the blood-ves- sels ; by increasing its osmotic proper- ties it facilitates greatly the penetration of the plasma into the lymphatic chan- ADRENALS, DISEASES OF (SAJOUS). 453 nels, thus further rcchiciug the vascular tension. The hactericidal and antitoxic properties of the blood are not reduced in the least by this procedure ; there is considerable evidence available to show, in fact, that they are enhanced (see "In- ternal Secretions," 4th ed., vol. ii, p. 1367, 1911). Saline solution, therefore, should be used intravenously in emerg- ency cases ; subcutaneously in threaten- ing cases, and per rectum in all cases in which there is any likelihood Avhatever that adrenal hemorrhage might occur. If employed from the onset of all infec- tions, as I suggested in 1903, the blood- pressure would probably never be raised sufficiently to endanger the adrenals. As to drugs, we have several at our disposal which lower the blood-pressure. In emergency cases nitrite of amyl by inhalation, with nitroglycerin (or, in children, the sv^eet spirit of niter) to sustain the effect, appears indicated. Chloral hydrate has been used advan- tageously by J. C. Wilson in certain ex- anthemata, to subdue the cutaneous dis- comfort and as a sedative ; as it is also a vasomotor depressor, it might also serve advantageously in all but infants in whom the respiratory mechanism is de- fective. Veratrum viride suggests itself as another useful agent of this class. Of all measures, however, the saline so- lution is much to be preferred. When the hemorrhage has occurred the lethal phenomena are of such short duration in most cases as to have sug- gested, we have seen, the term "adrenal apoplexy." In a fair proportion of cases, however, the hemorrhage causes sudden hypoadrenia. The treatment of this condition is that indicated in the emergency cases of terminal hypoadre- nia (see page 441). If the hemorrhage has not been too extensive the chances of recovery will be greatly increased by the use of adrenal or pituitary prep- arations, the latter owing its properties, in my opinion, to the adrenal chromaf- fin substance the pituitary contains. These agents will help to sustain oxida- tion and metabolism while the adrenal lesion is undergoing resolution. HEMORRHAGIC PSEUDO- CYSTS OF THE ADRENALS.— In most instances hemorrhagic blood- cysts are the results of acute hyperad- renia in the course of some infection or intoxication in which the adrenal hem- orrhage has been limited to a small area, which eventually develops into such a cyst. SYMPTOMS.— These growths may give rise to no symptom, other, perhaps, than a sensation of weight, until quite large, when pain supervenes. This is at first indefinite, though most marked in the region of the tumor, in the right or left loin, or in the upper portion of the abdomen and loin. The neuralgia-like pain becomes increasingly severe, and radiates in various directions, especially toward the hip and thigh of the corr.e- _sponding side, and is subject to exacer- bations, which may be very severe, es- pecially after meals. Epigastric pain and vomiting — which affords relief — oc- cur in some cases, especially during these exacerbations of suffering. The tumor may manifest itself at first merely by enlargement of the abdomen. The bulging then becomes more clearly defined on one side or the other (this variety of growth being almost invari- ably unilateral), under the lower ribs, which may be pushed outward if the growth is sufficiently large, or below their free border, i.e., between them and the superior spine of the ilium. If the tumor, which grows downward and for- ward, is sufficiently below the ribs to be palpated, it is usually found globular, or 454 ADRENALS, DISEASES OF (SAJOUS). oval, smooth and tense, though elastic, to the touch. Fluctuation may also be elicited. In some cases it is immovable under palpation, though it may, at first, follow the respiratory movements. Nor can it be grasped as is sometimes possi- ble in renal tumors ; if small, the tumor is movable, either upward or downward, but this mobility gradually decreases as the tumor develops. The growth is sometimes sensitive under pressure. At first, several years, perhaps, the patient may appear normal in every other respect, be well nourished, ruddy, etc. With comparative suddenness, how- ever, he begins to fail, losing flesh rap- idly, all the other symptoms mentioned, to which dyspnea and a sense of con- striction about the chest is added, be- coming more severe. If the cyst does not rupture, polyuria, hematuria, and even slight bronzing may appear. It is probable, however, that this train of phenomena is witnessed only in a very small proportion of cases, rupture and hemorrhage constituting the "adrenal hemorrhage" in adults treated under the preceding heading, being the outcome in practically every instance. Adrenal hemorrhage in the newborn is probably not uncommon, but in the great majority of cases there are no Symptoms to indicate the occurrence of such a lesion, and the hematoma is quickly absorbed. It is equally difficult to understand why in adults these hemorrhages should occur. The deep situation of the adrenal bodies would seem to be sufficient protection from in- jury, except that of the severest char- acter, and yet in a certain proportion of these cases the cause has aparently been a trauma. A. J. M'Cosh (Annals of Surg., June, 1907). [This abstract indicates the drift of the prevailing conception of the pathogenesis of these growths. While local lesions are as- cribed to the concomitant disorder, the ad- renals, being supposedly affected directly by the toxin or poison that may be present, are thought to explain some cases, others require, it is believed, some form of traumatism. It is to the excessive blood-pressure pro- duced by the toxin that the vascular rup- tures to which the hemorrhage is due should be ascribed. C. E. de M. S.] DIAGNOSIS.— The symptomatol- ogy of adrenal cyst, apart from the loca- tion of the tumor, does not present, as just shown, very characteristic features. The location of the pain sometimes sug- gests intercostal neuralgia; but inas- much as pain occurs only when the growth is large, percussion and palpa- tion will reveal the presence of a tumor. In neuralgia the pain is also apt to be localized, thus distinguishing it from the radiating pain of adrenal cyst. The sud- den onset of severe pain may be taken for acute pancreatitis. The location of pain and tenderness in the upper left ab- dominal quadrant, the subnormal tem- perature and the early lethal trend — death occurring sometimes within three days — clearly point to the latter dis- ease. Pancreatic cyst is also differen- tiated by its location and its association with glycosuria, stearrhea, and imper- fect digestion of fats and albuminoids. Hydatid cyst of the liver, another source of confusion, is attended by the presence of biliary pigments in the urine, the ap- pearance of cysts in the stools and vom- ited matter, and with obstruction phe- nomena. Cancer of the spleen may be recognized by the more nocftilar outline of the growth and the cachectic phe- nomena. Hydatid cyst of the spleen is usually associated with hydatid cysts elsewhere, and may be accompanied by the presence of booklets in the excre- tions. Puncture of the growth should be carefully avoided when there is any suspicion whatever that an adrenal blood-cyst is present. Renal cysts are ADRENALS, DISEASES OF (SAJOUS). 455 more easily palpatetl bimanually, and arc usually freely movable. Only nine cases of large serous cysts of the adrenals are on record. Case personally observed', in which a serous cyst, probably of lymphatic origin, had developed in the left su- prarenal capsule. As the other supra- renal was sound, there were no signs of Addison's disease. Tumors of this kind have a very slow development, but gradually push up the diaphragm, distending the lower part of the tho- racic cavity and finally protruding in front below the costal arch. The neighboring organs are displaced to a remarkable extent, and com- pression of the abdominal sympa- thetic is liable to cause severe pains. Terrier and Lecene (Revue de Chir., vol. xxvi, No. 9, 1906). ETIOLOGY.— Adrenal blood-cyst has been ascribed to many morbid condi- tions. Acute intoxications, especially diphtheria, typhoid fever, burns, osteo- myelitis, hepatic abscess and tuberculo- sis, have been regarded as initial factors of these growths, a small cyst formed during the active stages of these dis- eases, or, as a complication thereof, gradually increasing in size until the foregoing phenomena or adrenal hem- orrhage occur. In the light of the data submitted in the foregoing pages, they are merely after-effects or complica- tions, in other words, of the damage done to the adrenals during an acute febrile toxemia. Atheroma of the adrenal arteries is also regarded, and doubtless justly, as a source of initial lesions, but it is prob- able that cerebral lesions of the same kind and apoplexy, which have been considered by some authors as etiolog- ical factors, are merely concomitant lesions due to general arteriosclerosis. Thrombosis of the adrenal vein by blocking the efferent circulation has also been incriminated, while traumatism is known to have started the morbid proc- ess in at least two instances. PATHOLOGY.— While older in- vestigators, including Klebs, Virchow and Heuschen, considered these growths as retention cysts, similar to those formed in the thyroid, and thus termed them "struma adrenalis," the prevail- ing view at the present time is that a small hematoma or an acute congestive process — though erroneously, in my opinion, ascribed to local intoxication — initiates the growth. As the latter in- creases in size the adrenal structure is gradually destroyed and the content is no longer — unless a recent hemorrhage has occurred — merely blood, but a more or less fluid magma of detritus, broken- down blood- and tissue- cells, flakes or fibrin, cholesterin crystals, etc., which may be dirty yellow, greenish or brownish *in color. Microscopically, the walls of the cyst, which vary from Y^q to % inch in thickness, are composed of fibrin tissue; the inner aspect shows shreds or remnants of the adrenal cortex. Certain thickened portions of the capsule and what semiorganized clots the cyst may contain may be found to include small cysts, chalky deposits. These growths sometimes become very large — as large as an adult head in a case of Chiari's — and contain several' pints of blood or liquefied blood and tis- sue elements. PROGNOSIS.— The fact that this growth is practically always unilateral, and that the loss of one adrenal does not compromise life, as does removal of both organs, make it possible to remove the growth with safety. The frequent instances of severe collapse and shock that have followed these operations sug- gest that the operative prognosis can- 456 ADRENALS, DISEASES OF (SAJOUS). not but be improved by resorting to those surgical procedures which will en- tail the least possible handling of the intraperitoneal organs and of the sym- pathetic ganglia, all of which are well known to produce shock readily by re- flex action. TREATMENT.— The treatment is, of course, entirely surgical. The cyst may be removed through either an ab- dominal or lumbar incision. In accord with M'Cosh's advice, which a review of the operative results recorded fully sustains, preference should be given to the lumbar incision. The approach is more -direct; it avoids the handling of the intraperitoneal organs, which must necessarily take place if the tumor be reached through the abdominal incision, and it affords the most direct route for drainage. In the average case, an ob- lique incision from behind downward and forward below the last rib, which has been found most convenient for ex- tirpation of the kidney and ureter, is as applicable here. If much space is needed, it is safer to remove the last rib than, as some European surgeons have advised, to resort to the abdominal incision, which, as previously stated, entails con- siderable shock. The tumor is some- times found so firmly adherent to the kidney that removal of this organ be- comes necessary. Personal case in which the growth was successfully removed through a lumbar incision. The main dangers of the operation are hemorrhage from the pancreas or the larger veins, and injury to the descending colon or to the sym- pathetic plexus. These cysts are usually very adherent and considerable time is consumed, and blood lost in enucleation of the sac. The adhesions toward the vertebral column and abdominal aorta are especially troublesome, and in some of the cases subjected to operation have prevented complete removal of the cyst. Severe collapse has followed many of the operations. This may be due to blood lost, time of exposure, shock due to peeling the tumor from the dia- phragm or sympathetic nerves. A. J. M'Cosh (Annals of Surg., June, 1907). In the case of large serous cysts complete extirpation should be prac- tised if possible; but if the sac can- not be readily and gently detached from the surrounding parts, the sur- geon should rest content with partial resection of the wall of the cyst, and with the method of marsupialization, in which the margins of the sac are attached to the external wound and the cavity is packed and drained. The results of the operative treatment of large suprarenal cyst have not, up to the present time, been satisfactory. Five cases only have been thus dealt with, of which three were fatal. Ter- rier and Lecene (Revue de Chir., vol. xxvi, No. 9, 1906). FUNCTIONAL HYPOADRE- NIA. DEFINITION.— Functional hypo- adrenia is the symptom complex of de- ficient activity of the adrenals, due to inadequate development, exhaustion by fatigue, senile degeneration, or any other factor which, without provoking organic lesions in the organs or their nerve- paths, is capable of reducing their secre- tory activity. Asthenia, sensitiveness to cold, and cold extremities, hypotension, weak cardiac action and pulse, anorexia, anemia, slow metabolism, constipation, and psychasthenia are the main symp- toms of this condition. SYMPTOMATOLOGY AND PATHOGENESIS.— The process of development in the child and the influ- ence of senility on the adrenals make it necessary to discriminate between the main stages of life, infancy, childhood, adult and old age, in describing this con- dition. Infancy. — Although the adrenals are relatively large in the infant (one- ADRENALS, DISEASES OF (SAJOUS). 457 third the size of the kidney at birth), their functions are Hmited to the carry- ing on of the vital process, at least dur- ing the first year of life, the mother's milk supplying the antitoxic products capable of protecting it against the de- structive action of poisons of endogen- ous and exogenous origin. This pro- tective influence of maternal milk is clearly defined in the following quota- tion from Professor William Welch's Harvey Lecture: "It is an important function of the mother to transfer to the suckling, through her milk, immu- nizing bodies, and the infant's stomach has the capacity, which is afterward lost, of absorbing these substances in active state. The relative richness of the suck- ling's blood in protective antibodies, as contrasted with the artificially fed in- fant, explains the greater freedom of the former from infectious diseases." Striking proof of this is afforded by the fact that during the siege of Paris, in 1870-71, according to J. E. Winters ("Practical Infant Feeding," p. 6), "while the general mortality was dou- bled, that of infants was lowered 40 per cent, owing to mothers being driven to suckle their infants." Childhood. — The predilection of children to certain infectious diseases obviously indicates that it is not only in infancy that vulnerability to these dis- orders exists ; it exposes life during the first decade, and more, of the child's ex- istence. If, then, in the infant the ma- ternal milk, as Welch says, protects the suckling against such diseases, at least to a considerable extent, we must con- clude that the same underlying cause of vulnerability persists several years, i.e., until itdias in some way been overcome. The adrenals acquire, with other or- gans, the power to supplant the mother in contributing antitoxic bodies to the blood ; they supply internal secretions which fulfill this role. These facts point to the adrenals as at least prominent organs among those whose inadequate development explain the special vulnerability of children to certain infections, the "children's dis- eases." It becomes a question now whether there are degrees of this hypo- adrenia which render the child more or less liable to infection. That degrees of hypoadrenia exist in children is, in reality, a famifiar fact to every physician when the signs of this condition are placed before him. The ruddy, warm, hard-muscled, heavy, out- of-door, romping child with keen appe- tite and normal functions, is one in whom the adrenals are as active as the development commensurate with its age will permit. He is ruddy and warm be- cause oxidation and metabolism are per- fect and -the blood-pressure sufficiently high to keep the peripheral tissues well filled with blood; his muscles, skeletal, cardiac and vascular, are strong because, in addition to being well nourished, they are exercised and well supplied with the adrenal secretion, which, as shown by Oliver and Schafer, sustains muscular tone. As normal outcome of this state, we have constant stimulation of the functional activity of the adrenals. The muscular exercise and maximum food- intake involve a demand for increased metabolism and oxidation, and the re- sulting greater output of wastes imposes upon the adrenals, as participants in the oxidation and autoprotective processes, greater work, more active growth and development, with increase of defensive efficiency as normal result. The pale', emaciated, or pasty child, with cold hands and feet, flabby mus- cles, whose appetite is capricious or de- ficient — the pampered house-plant so 458 ADRENALS, DISEASES OF (SAJOUS). often met among the rich — represents the converse of the healthful child de- scribed, just as does the ill-fed, perhaps overworked, child of the slums. The emaciation, the cold extremities, indi- cate deficient oxidation, metabolism and nutrition owing to the torpor of the ad- renal functions ; the pallor is mainly due to a deficiency of the adrenal principle in the blood and to the resulting low blood-pressure, which entails retroces- sion of the blood from the surface. This child is not ill, but the hypoadrenia which prevails normally, owing to the undeveloped state of its adrenals, is ab- normally low, and it is vulnerable to infection. That all conditions which in the adult tend to produce functional hypoadrenia affect the child at least to the same ex- tent, is self-evident. Adult Age.' — As in the child, the ad- renals may be inherently weak. Such subjects do not, as in hypothyroidia, show signs of myxedema ; but their cir- culation and heart action are feeble, they tend to adiposis, and show other signs of hypoadrenia. I have witnessed sug- gestive bronze spots in such cases. As a rule, however, the development of the adrenals in adults is an accomplished fact — as also that of their coworkers in the immunizing process, the thyroid and pituitary, we shall see. The adrenals, fully capable of sustaining oxidation and metabolism, are able to defend the organism adequately ; indeed, they do more : by sustaining oxidation and met- abolism up to its highest standard in all organs, they also preserve the efficiency of all other defensive resources, includ- ing phagocytosis, with which the body is endowed to their highest level. On the whole, the normal adult zvhose adrenals functionate normally is relatively resist- ant to infection. The infrequency with which we are infected, notwithstanding daily exposure in our professional work, attests to this fact. Functional hypoadrenia appears, how- ever, when, irrespective of any disease, and as a result of the vicissitudes of our existence, the adrenals are subjected to abnormal secretory activity. Fatigue is a prominent factor in this connection. Mosso's ergograph shows clearly the functional efficiency of the forearm. If by means of this instru- ment we compare the muscular power of a case of Addison's disease with that of any other kind of sufferer, whose muscles are organically normal, a strik- ing difference will be noticed : signs of fatigue appear very soon, and muscular impotence asserts itself where an ad- vanced case of tuberculosis, for exam- ple, will be able to show appreciable strength. Intense asthenia is, in fact, a symptom of Addison's disease almost as characteristic as the bronze spots. It is as pre-eminent after experimental re- moval of both adrenals. This harmo- nizes with Oliver and Schafer's demon- stration of the influence of the adrenal secretion over muscular tone. Many other proofs could be adduced to show that there is a close relationship between fatigue and the functions of the ad- renals. The pale and drawn face of an exhausted man, the readiness with which he suffers from the effects of cold and exposure, especially in the intestines, are familiar features of daily life. The unusual prevalence of disease among soldiers in the field is, of course, partly due to the defective sanitation that a campaign entails ; but fatigue — particularly that due to heavy march- ing, carrying heavy accoutrements — is, in my opinion, an important predispos- ing cause, through its influence upon the adrenals. Not only are these organs ADRENALS, DISEASES OF (SAJOUS). 459 called upon to sustain general oxidation and metabolism at a rate exceeding by- far that which amply suffices for normal avocations, but the fact that, as shown by Abelous and Langlois {loc. cit.), they also serve to destroy the toxic products of muscular activity, constitute another cause of drain upon their secretory re- sources. "Fatigue," write Morat and Doyon (Traite de Physiologic," Art. "Secretions Internes," p. 441, 1904), re- ferring to experimental fatigue in ani- mals deprived of their adrenals, "has an aggravating influence, as first indicated by Abelous and Langlois, and confirmed by Albanese and all authors. Hultgren and Andersson have even observed sudden death as a result of powerful movements of the body." Debility from any source, starvation, loss of blood, etc., as efficiently renders the body vulnerable to disease : "Com- bine toxin and antitoxin, and inject the mixture," writes Professor Charrin ("Les Defenses Naturelles de I'Organ- isme," p. 63, Paris, 1898); "no harm will follow. But weaken the animal by starvation or slight bleeding and admin- ister the same injection; death will fol- low wath all the signs of poisoning by the toxin, with congested adrenals." , , , "That relations exist between the adrenals and infection," urges the same authority, "is today an incontro- vertible fact." It follows, therefore, that hypoadrenia from any source should render the body vulnerable to disease. Deficient food, excessive work, that of the sweat-shops for example, ac- count for much of the predilection of our slums as foci of disease, their filth nurturing the appropriate germs. Masturbation and excessive venery are important morbid factors in this connection. The pallor and asthenia witnessed in these cases, so far unex- plained, can rea(Hly be accounted for if, as I believe, the liquid portion of the semen is rich in adrenal principle. This is suggested by the fact that spermin, the purest of testicular preparations, gives the same tests and acts precisely as does the adrenal principle. The latter is an oxidizing body acting cata lytically; it resists all temperatures up to and even boiling; it is insoluble in ether and practically insoluble in abso- lute alcohol, and gives the guaiac, Flor- ence, and other hemin tests. Now, sper- min not only raises the blood-pressure, slows the heart and produces all other physiological effects peculiar to the ad- renal principles, but its solubilities are the same ; it gives the samie tests ; it re- sists boiling. Moreover, it is regarded in Europe as a powerful "oxidizing tonic," and has been found equally use- ful in disorders in which adrenal prepa- rations had given good results. The in- ference that spermin consists mainly of the adrenal product suggests that it should not be regarded as specific to the testes, but, instead, a constituent of the blood at large; not only did this prove to be the case, but it was found in the blood of females as well as in that of males. Old Age.— Perpetual life would doubt- less be ours were it not that all living organic matter is subjected, after more or less precarious periods of growth and adult existence, to one of decline and final disintegration. This applies par- ticularly to the adrenals, if their func- tions are, as I hold, to sustain oxidation and metabolism, the fundamental pro- cesses of the living state. Indeed, the senile state may be said to be as evident in these organs as it is in the features of the aged. Series of corrosion preparations, of the veins of the left adrenal in different 460 ADRENALS, DISEASES OF (SAJOUS). people, aged, respectively, 22, 30, 80, and 82, using the same inject- ing substance and technique. They showed conclusively that the vascular system of the adrenals becomes steadily smaller as adult age wanes, being greatly shrunken in old people. Landau (St. Petersb. med. Woch., June 14, 1908). According to Landau (St. Petersb. med. Woch., June 14, 1908), Ecker, Henie, and von Kolliker found that fat occurred in increasing quantities in the adrenal cortex \s age advanced, while Hultgren and Andersson found fibrous tissue between the cortex and medulla in very old animals. Minervini (Jour. d'anat. et de physiol., pp. 449 and 639, 1904) found a similar condition in the medulla of aged individuals. Dostojew- ski, moreover, observed a marked — oc- casionally very great — reduction in the size of the adrenals in the aged. Rolles- ton (Lancet, Mar. 23, 1895) has also called attention to this fact. Landau studied the influence of age on the vessels, large and small, of the adrenals, adopting for the pur- pose a process introduced by Rauber and applied by many others, including Bezold, Hyrtl, and Lieberkiihn, to the study of other organs, viz., injection of the vessels with some hardening sub- stance, and the subsequent use of a cor- rosion method to destroy the paren- chyma. The adrenals receiving their blood through a number of small arte- ries, the adrenal vein, which contains no valves, was used for the injection. The annexed plate shows the result. The vessels, and therefore the adrenals, are well developed and in full bloom, as it were, in the adrenals of the three young adults, while those of the aged are shrunken and correspondingly deficient as blood-channels — a certain index of the lowered activity of the adrenal func- tions, and, through these, of the vita! process they sustain. The asthenia of old age thus finds a normal explanation in the defective sup- ply of adrenal secretion — precisely as it does in Addison's disease. In fact, Rol- leston states that atrophy of the glands in the young may produce this disease. Lorand ("Old Age Deferred," Am. ed., p. Ill, 1910), in h-is recently published book on old age, urges, in fact, that "old age is caused by degeneration of the ductless glands, and that there exists a condition of autointoxication in old age" quite in keeping, I may add, with a de- cline of the antitoxic power shown by the adrenals. Lorand, who has ante- dated others in showing the influence of the ductless glands upon old age, has found his views confiremed by Camp- bell (Lancet, July, 1905), Pineles, Sir Herman Weber, and also — though he denies a relationship between old age and myxedema — Metcnnikoff. In his closing remarks on the causa- tion of old age, Lorand remarks : "It is evident from the above considerations that all hygienic errors, be they errors of diet or any kind of excess, will bring about their own punishment, and that premature old age, or a shortened life, will be the result. In fact, it is mainly our fault if we become senile at 60 or 70, and die before 90 or 100." Hence the motto of his title page : — "Man does not die. He kills himself." — Seneca. In the light of the data I have sub- mitted, however, it is clear that the le- sions to which the adrenals are subjected during infections and autointoxication, from birth to the last day of life, do greatly shorten it by limiting the func- tional area of the organs through the local fibrosis they entail. It is quite ADRENALS, DISEASES OF (SAJOUS). 461 probable, in fact, that centenarians owe their prolonged longevity mainly to in- tegrity of their adrenals. Hygiene, and particularly those of its divisions which bear directly upon the prevention of infectious diseases, thus asserts itself as one of the most useful of our sciences in another direction, viz., that of preserving the organism against those diseases which, seemingly benign because they are recovered from, mea- sles for example, in the end shorten our existence by compromising the integrity of the organs which sustain the vital process itself. Prophylaxis and Treatment. — Though we are dealing with depraved states of a physiological condition, we cannot but regard them as abnormal m the sense that we deem adynamia abnor- mal, and, therefore, susceptible to reme- dial measures. Indeed, there is much that can be done in each of the three forms of functional hypoadrenia de- scribed. In the infant we should, by every pos- sible means, prevent infection or intoxi- cation to preserve the integrity of their adrenals and other autoprotective or- gans. The key of the whole situation lies in the fact that, as Ruhrah states, "nearly all the cases and nearly all the deaths are in bottle-fed babies." Physi- cians are, as a rule, entirely too ready to yield to the demands of social and other claims put forth by mothers who do not wish to nurse their offsprings. The re- sponsibility assumed by both mother and physician under these circumstances is overlooked. I cannot but hope that if this continues, and the sacrifice of count- less infants proceeds, laws may be en- acted -to prevent it by imposing upon the physician the duty of submitting to the State authorities a certificate in 'which sound reasons shall alone account for his consent to a departure from nature's methods which entails deaths untold. J. Lewis Smith states that the death rate among foundlings in New York City reached almost 100 per cent, until wet- nurses were provided. Men such as Jacobi, Winters, and many French au- thorities have written forcibly upon this subject, but seemingly to no avail. The holocaust continues. Experimental research in the same direction has only served to emphasize the all-important prophylactic value of maternal milk. As L. T. de M. Sajous (Univ. of Penna. Med. Bull., June, 1909) states: "That milk is capable of conveying antitoxic substances after these have been injected into the mother has been known for a number of years. In 1892 Ehrlich and Brieger demon- strated this fact in their experiments on mice. The offspring of non-immune mice werfe suckled by other mice which had been immunized against the actions of certain poisons. It was found that the young were thereby rendered im- mune to the poisons employed, viz., ricin, abrin, and tetanus toxin. This im- munity steadily increased during the period of lactation, persisted for some time after, and then gradually disap- peared. Ehrlich thus showed that a passive immunity was created in the young by the absorption of milk from an immune adult, and even went so far as to assert that all so-called heredity immunity was, in reality, of the passive variety, being transmitted during lacta- tion and not inherent in the offspring itself. "This transmitted immunity has been shown to occur in various other animals. Thus, in 1893, Popoff showed that im- munity against cholera could be trans- mitted through cows' milk. He injected bouillon cultures into the peritoneal cav- 462 ADRENALS, DISEASES OF (SAJOUS). ity of a cow, and later injected into guinea-pigs from 2 to 10 c.c. of the cow's milk. The guinea-pigs become immune against cholera. The same ob- server noted also that, when the milk was boiled before injecting it, no immu- nity was produced. Kraus showed that the milk of goats immunized by injec- tions of 'typhus-coli bacilli' and cholera organisms had protective and aggluti- nating properties. He also ascertained that the relative proportion of aggluti- nating substance present in milk to that contained in the serum was as 1 to 10. Taking up the subject from the stand- point of tuberculosis, Figari showed, in 1905, that the agglutinins and antitoxins of this disease appeared in the milk of cows and goats that had been actively immunized against it. In another series of experiments he fed the milk of im- mune cows to a number of rabbits, and in others injected it subcutaneously. In both cases these animals, thus passively immunized, were found to transmit to their young, by their milk, the aggluti- nins and antitoxins of tuberculosis. "Evidence is not lacking of the trans- mission of antitoxic substances through human milk. It has long been known that infants below one year of age were but slightly susceptible to certain infec- tious diseases, and in particular scarlet fever, diphtheria, measles, and mumps. In fact, it was an attempt to throw some light on this subject that Ehrlich per- formed his classic experiments on mice in 1892. Four years later Schmid and Pflanz performed some interesting ex- periments on guinea-pigs. Into some of the animals they injected blood-serum derived from human blood which was taken, at the time of delivery of her child, from a woman to whom had been administered diphtheria antitoxin. Into other guinea-pigs they injected milk from the same woman. The animals were then given injections of the ordi- narily fatal dose of diphtheria toxin. From the results obtained the investiga- tors concluded (1) that antitoxin sub- stances found in the blood of parturient women exist also in the milk; (2) that the quantity of antitoxic substances ex- creted with the milk is much less than that found in the blood. Similarly, in 1905, la Torre injected diphtheria anti- toxin in several wet-nurses, and noted the antitoxic power resulting in the blood of the nurslings by injecting meas- ured amounts of this blood mixed with diphtheria toxin into guinea-pigs. He was able to satisfy himself that a pass- age of the antibodies occurred in small amounts into the blood of the infants. "These experiments show, then, that antibodies injected into the mother are transmitted to the offspring. This being the case, it is but reasonable to expect that some of the protective substances ordinarily present in the normal moth- er's blood should likewise reach the child through the milk. Experiments have shown this also to occur. Moro found that the bactericidal power of the blood-serum in breast-fed children was distinctly greater than in those arti- ficially fed. Further confirmation was afforded by the fact that this difference rapidly disappeared when the bottle-fed infants were put back to the breast." The prevention of disease in the in- fant is raised to its highest standard by maternal lactation. The organisms of its gastrointestinal canal are kept under control; the barriers to infection that the respiratory tract and pulmonary al- veoli offer are well armed with antitoxic bodies ; the blood itself is destructive to pathogenic organisms, and the infant is thus protected against those diseases which, even if recovered from, we have ADRENALS, DISEASES OF (SAJOUS). 463 seen, leave enfeebling lesions, fatty and fibrous degeneration, in those organs upon which his health in after years and the duration of his life depend. In the child beyond the nursing pe- riod the problem is more difficult. The fatal "second summer" recalls the sins of the milkman, the filth of the cowshed, and of the vessels in which the milk is transported and kept amply long enough to favor the growth of the oft-present Shiga bacillus, the virulent Bacillus coll, and even at times the streptococcus. The correction of these and many other factors replete with danger to the child, and which surround it on all sides, of- fers the only resources to diminish not only the mortality of children's diseases, but their occurrence, besides safeguard- ing health and longevity in after years. The good already done by our profes- sion in this direction is incalculable. Briefly, public, home, and school hy- giene, in the light of the facts I have submitted, not only serves to protect life for the moment when the child is con- cerned, but its entire career as a health- ful individual, while enhancing greatly his chances for a long life. It now becomes a question whether our resources are such as to enable us to raise, where functional hypoadrenia exists, the autoprotective resources of the child, sufficiently, perhaps, to enable it to resist infection successfully. The influence of many toxins and drugs on the adrenals points clearly to overactiv- ity under their influence. In 1903 ("In- ternal Secretions," vol. i) I referred to mercury as occupying "a high position among the stimulants of the adrenal sys- tem." Now, C. R. Illingworth ("The Abortive Treatment of Specific Febrile Disorders," etc., London, 1888) and others have found the biniodide of mercury extremely efficient in aborting scarlatina, diphtheria, measles, variola, varicella, pertussis, parotitis, and many other infections. The great vogue of calomel among the physicians of the past generation may have found its raisoii d'etre precisely in just such an action — which I have myself observed. Arsenic is a familiar agent in the abort- ive treatment of malaria in Africa, and, as Surgeon-General Boudin states, in many other diseases. The remarkable results of Petresco with large doses of infusion of digitalis in pneumonia have only been tentatively explained. But if we realize that division of the path to the adrenals arrests and prevents the effects of digitalis, as is now well known, there is good ground for the be- lief that the prevailing conception of the action of this drug is erroneous, and that it is by stimulating the adrenals that it acts, at least in part. In view of the im- munizing action of the adrenals, there- fore, we can realize how digitalis could be of use in this infectious disease, and how it might prove useful in aborting any pulmonary disorder due to patho- genic organisms. Very remarkable in this connection is the action of thyroid gland 1 grain (0.06 Gm.), adrenal gland 2 grains (0.12 Gm.), and Blaud's pill 1 grain (0.06 Gm.) in a capsule three times daily, previously referred to. Given during meals to a debilitated child of 10 or 12 years, it seems promptly to start the vital machinery on a new lease of life — where, of course, the demands of hy- giene are adequately met. Meat is of value here, while milk, the fluid portion of which gives the test for oxidases, and which, as I have shown elsewhere, depends upon the adrenal secretion for its ferment (adrenoxidase) is also of great value. Digitalin or strychnine in small doses is added if the heart 464 ADRENALS, DISEASES OF (SAJOUS). is weak or to increase the oxygen in- take. All these agents tend, by keeping up a slight hyperemia of the adrenals (and of the other organs acting in con- junction with it), to augment the effi- ciency of the child's defensive resources. In the adult functional hypoadrenia may have persisted from childhood. Here the measures just suggested for children apply as well not only as pre- ventives where infection threatens, or as abortive treatment, but also to raise the efficiency of the adrenals and the general health of the individual to the normal plane. It is probable that most tonics exert their beneficial influence through the adrenals. That "tonic" doses of mercury, i.e.^ minute doses, are efficient is well known; we have seen that it is a powerful adrenal stimulant. In toxic doses, in fact, as observed by Moline (Bull. gen. de therap., Apr. 8, 1906), it causes intense congestion and even hemorrhage of the adrenals. While there is no doubt that meat in excess is harmful, it is undoubtedly true that, as Lorand (he. cit., p. 313) states, undernutrition through lack of the necessary proteids in the diet in- creases the habiHty to infection, as I several years ago pointed out, Lorand refers to personal cases of tubercu- losis arising from a purely vegeta- rian diet. On the other hand, Richet and Hericourt (Lancet, Jan. 7, 1911) obtained remarkable effects from a diet of raw meat in enabling animals to re- sist tubercle infection by inoculation, and ravv^ meat has become an important factor in the treatment of this disease. Grawitz (Klinische Pathologic des Blutes, 3d ed., 1906) also found that a purely vegetarian diet predisposed to anemia. We have seen that the ad- renals supply the blood its albuminous hemoglobin, a deficiency of which is an important feature of anemia. Did we live where pathogenic bacteria do not flourish, we might safely undertake to adopt vegetarian principles; but a rea- sonable amount of meat, by keeping our autoprotective organs, and particularly the adrenals, active, serves a very useful purpose. The influence of excessive fatigue on the adrenals, we have seen, is such as to weaken greatly their functional ac- tivity and, therefore, the oxygenizing and immunizing functions of the blood. The main harmful feature in this con- nection is the relative deficiency of rest, which means, from my viewpoint, the inadequate opportunity afforded the ad- renals to recuperate. This, of course, should be proportionate to the amount of strain imposed upon these organs, and the resistance of which they are capa- ble. It is probably owing to lack of this that apparently strong men are often the first to "give out" in forced marches. The physical examination being based mainly upon the status presens, and the adrenals being necessarily (for we are now dealing with a new line of thought) overlooked as factors, there is marked inequality in the resistance of the men to strain. This applies as well to the pathogenesis of chronic disorders. In a personal analysis of 40 cases of hay fever, for instance, the severity of the disease corresponded to a considerable degree with the number of children's diseases the patient had had, the worst cases having had six of these diseases in comparatively quick succession. This suggests the need of ascertain- ing the number and severity of chil- dren's and other diseases to which the recruit has been subjected and to add this factor to others in deciding upon his admission to the service or the arm to which he is to be assigned. The ADRENALS, DISEASES OF (SAJOUS). 465 mounted man suffers less from actual fatigue than the infantryman, who must carry his accoutrements, arms, car- tridges, etc., aggregating in some armies as much as 70 pounds. When, besides, defective or poor food, impure water, exposure, etc., and other frequent ac- companiments of a campaign are taken into account, one need not wonder that disease is a far greater factor as causes of debility and death than wounds. Briefly, fatigue should be considered, owing to its inhibiting influence on the adrenals and the immunizing process in which they take part, as an important predisposing cause of disease. The pe- riods of rest should be so adjusted, therefore, as to counteract this by far the most destructive factor of active warfare. In civil life, such hardships are seldom endured, but here, likewise, much could be done to prevent infection by means calculated to insure the func- tional integrity of the adrenals. To stimulate the adrenal functions when marked fatigue prevails would, of course, only aggravate, the hypoadrenia after, perhaps, a period of temporary betterment. The powdered adrenal sub- stance should, on the other hand, judg- ing from the effects of injections of ad- renal extracts in experimentally fatigued animals, serve a useful purpose. In old age the ductless glands assume such importance that a valuable work has been written by Lorand ("Old Age Deferred," F. A. Davis Co., Phila., 1910) to indicate how the functional ac- tivity of these organs could be preserved in order to retard the ravages of age beyond the fifth decade, while prolong- ing life. The reader is therefore re- ferred to Dr. Lorand's volume for a mass of information which cannot be considered here. The adrenals, as shown by the plate opposite page 460, are deficient in circu- latory activity, and, therefore, unable to sustain functional activity of all organs up to its former standard. It becomes a question whether, realizing this fact, we should by artificial means excite the adrenals to greater activity. That such a step might shorten life instead of pro- longing it, is probable. In the first place, the frequent presence of arteriosclerosis in the aged counsels prudence ; in the second place, to activate the adrenals would only hasten their degeneration by imposing a greater wear and tear upon them. Drugs capable of enhancing ad- renal activity had, therefore, better be avoided in the aged. Far better is it to compensate for the loss of efficiency of the adrenals by sup- plying to the blood, through a suitable diet, substances which contain the ad- renal principle. If my opinion that sper- min owes its virtues to the adrenal prin- ciple it contains is warranted, we can understand why Brown-Sequard reju- venated himself by means of testicular juice injections (I saw him at the time and can testify to its wonderful effects upon him), since he enriched his blood with the pabulum of oxidation, met- abolism and general nutrition, without impairing his adrenals. With advanced knowledge we need not follow his ex- ample. We have seen that milk con- tains the adrenal principle, and that all animal tissues owe their functional ac- tivity to its presence. In milk, butter- milk especially (since it is almost pure plasma), we have a ready and inexpen- sive means to compensate for deficient adrenal activity. If debility and other signs of functional hypoadrenia prevail, I advocate the daily addition to the plain, though varied, diet to which elderly peo- ple should restrict themselves of the ex- pressed juice (uncooked) of one pound 1-30 466 ADRENALS, DISEASES OF (SAJOUS). of fresh beef daily, taken in soup, if dis- tasteful otherwise, and salted to taste. This is a powerful agent for good which is well borne by the stomach, and which more than compensates for the weak- ened adrenals, since it rapidly restores strength and vigor — provided, of course, harmful influences in other directions are avoided, and. a hygienic mode of life, with reasonable out-of-door exercise, prevails. In matters sexual, aged men should be extremely reserved, since the waste of seminal fluid to them means w'aste of life substance, replaced with difficulty and never in abundance. Case of total absence of the adrenals in a woman, aged 52, who, in Septem- ber, 1902, noticed that her hands fre- quently became cold and discolored. In January, 1903, the joints of fingers and wrists became stiff and swollen ; during April she suffered frcn pleurisy, and one month later noticed that the skin of the entire body was becoming darker (Addison's disease), the abdomen en- larged, and she discovered a slight dis- charge from the umbilicus. The skin grew darker and darker (scleroderma). The joints of the fingers and wrists became almost immovable and several of the finger-joints ulcerated, attended with a purulent discharge (Raynaud's disease). She suffered intensely with the pain, cold and stiffness in all the joints of the extremities. She became emaciated and the whole integument be- came dry, hard, and cold. Under treatment with desiccated ad- renal immediate improvement was no- ticed. The ulcerated joints healed, pain in them ceased, and they became more limber. The skin softened and grew lighter. Improvement continued for about one year when the patient complained that the po der disturbed her stomach and refused to continue the drug. From this time she grew gradually worse and the previous ul- cerated, stiff, cold, and painful condi- tion of the joints returned, associated with the increased pigmentation and hardness of the skin. She died sud- denly, December 14, 1906. At the autopsy no trace of the adrenals could be found. C. R. Love (N. Y. Med. Jour., Jan. 29, 1910; Jour. Amer. Med. Assoc, Feb. 12, 1910). PROGRESSIVE HYPOADRE- NIA. — In this condition, local lesions, tubercular, syphilitic, sclerous, etc., pro- gressively inhibit the functions of the adrenals until they fail, destroying life. Addison s disease, treated separately on page 356 of this volume, by Professor J. P. Langlois, of Paris, to whose labors I have repeatedly referred in the fore- going pages, is the most important syn- drome of this group. In addition is the group of malignant tumors which, though presenting the chief phenomena of the former and, therefore, those of hypoadrenia, include various symptoms peculiar to malignant neoplasms which warrant the recognition of an autono- mous syndrome complex. CANCER OF THE ADRENALS. — Primary malignant tumors of the ad- renals are generally regarded as very rare, but it is probable that when the symptomatology of these growths will be known by the profession at large, a certain proportion of deaths now attrib- uted to Addison's disease in adults and to asthenic disorders in children w"ill be found to be due to this class of growths. Addison, in fact, included these neo- plasms among the etiological factors of the disease which bears his name, but it is now plain that the two syndromes differ in many respects, and that the treatments indicated — medical in the one and surgical in the other — imposes the need of recognizing malignant neo- plasms of the adrenals as distinct mor- bid entities. VARIETIES.— Primary malignant tumors of the adrenals are of the va- rious forms of sarcoma, those most fre- ADRENALS, DISEASES OF (SAJOUS). 467 quently met with and which occur, in the majority of instances, in infancy, childhood and adolescence; carcinoma, which occurs, as a rule, in adults or aged subjects. Among the rarer varie- ties may be mentioned the malignant hypcrncpJiroma and a class of tumors termed by Prudden hcmorrliagic ade- noma. The sexes are affected about equally, but they appear much earlier in females than in males. Carcinoma may develop from hypernephroma. [Sixty-seven collected by Ramsay from literature, including 30 of sarcoma and 37 of carcinoma. This would tend to suggest that the two forms occur about evenly. C. E. DE M. S.] Primary tumors of the adrenals are very infrequent. In the statistics of the Pathological Institute of Geneva, out of 7249 autopsies performed from Oct. 1, 1876, to Oct. 1, 1903, the pro- portion was 0.6 of 1 per cent. Dupraz (Revue med. de la Suisse Romande, Mar. 20, 1906). Study of the collection of kidney tumors in the Jewish Hospital at Berlin, 103 in all. No less than 69 . belong to the group of hypernephro- mas. In two the writer found unmis- takable evidence that true carcinoma had developed out of a hyperne- phroma. Displaced suprarenal ger- minal matter had lodged in the kid- ney in early embryonic existence, a hypernephroma had developed from this, and the carcinoma from the parenchyma of the hypernephroma. The writer does not maintain that embryonal displacement of germinal matter is the only cause of these can- cers, but in these cases it was evi- dently the first embryologic cause, without which these carcinomas would never have developed. The same applies also to some cases of sarcoma developing in a hyperne- phroma which are in the collection. The sarcoma had developed from the stroma. Neuhauser (Archiv f. klin. Med., Bd. Ixxix, Nu. 2, 1906). SYMPTOMS.— As a rule, the gen- eral phenomena develop insidiously, the adrenal lesion being well advanced when they begin to appear. The strength wanes more or less rapidly ; the weight graually decreases; the pulse and car- diac action become increasingly weaker and more rapid ; the temperature shows exacerbation of a couple of degrees at times, but in the advanced cases is us- ually subnormal ; the appetite decreases ; digestive disturbances, such as nausea, vomiting, flatulence and diarrhea, are commonly observed. Anemia is some- times manifest, the hemoglobin being often reduced to 50 per cent., and the red corpuscles to 3,000,000 or less. Cough, with bronchial rales, localized dullness and hemoptysis are occasional complications, while dyspnea and in- crease of the number of respirations are apt to occur in advanced cases. The skin may refnain normal, but various de- grees of pigmentation, ranging from slight icterus to actual bronzing, are ob- served in the majority of cases. The typical fpcies may alone be present in cases of primary carcinoma. [This symptomatology is based on a per- sonal analysis of 60 reported cases of pri- mary malignant tumors of the adrenals. The phenomena are clearly explained by the functions I attribute to the adrenals. Being the purveyors of the secretion which — as the albuminous constituent of hemoglobin— sustains oxygenation and metabolism and, therefore, nutrition, in- creasing emaciation, weakness, hypother- mia, the decrease of hemoglobin, etc., are but normal results, all the other phenom- ena being secondary thereto. The cases in which no pigmentation of the skin oc- curs are usually those in which but one adrenal is involved. C. E. de M. S.] Case of primary sarcoma of the adrenal glands which did not show symptoms of Addison's disease. The existence of the tumor was not sus- pected until after the death of the 468 ADRENALS, DISEASES OF (SAJOUS). patient. The symptoms present sug- gested carcinoma of the stomach, though the more characteristic symptoms were absent. Both ad- renal glands were sarcomatous. Blackburn (Amer. Jour. Med. Sci., Aug., 1906). Case of myxosarcoma of the supra- renals, in which the patient had been suffering from gastrointestinal dis- turbances, a sense of weight in the abdomen after meals, and later from a pain at the base of the chest on the same side. This pain resembled that of muscular rheumatism, and was especially severe at night. These symptoms gradually increased, fol- lowed by intestinal hemorrhage, and edemas at the ankles. The urine had always been normal, and there had been no -i-^omiting. The tumor could be distinctly felt on the right side, was firm in consistence, and reached from the iliac crest to the costal arch; the right lobe of the liver was found pushed upward. The diagnosis of a renal tumor was made and the opera- tion revealed a large bilobed growth, partly softened in the center, which occupied the suprarenal gland and did not involve the kidney. On fur- ther examination the tumor proved to be a myxosarcoma. Sicuriani (Ri- forma Medica, Nov. 4, 1905). All these phenomena are seldom wit- nessed in a single case. As a rule, after a period of progressive emaciation and adynamia, a tumor can be detected by palpation posteriorly below the costal margin, close to the vertebral column. The mass at first follows the respira- tory movements and recedes under pressure, but it eventually becomes fixed and immovable. In some cases, especially in infants, the tumor cannot be detected in this manner, but the abdomen gradually enlarges with a steady increase of the line of dullness, though, perhaps, no other symptom be discernible. When the outline of the growth can be clearly followed with the fingers, its border is nodular, as in hepatic cancer, but smooth. Pain is sometimes complained of ; it may be located in the region of the tu- mor ; or, radiating upward or across the back, it may extend to the shoulders. [The pain has been attributed to the "phrenic nerve, but a clearer explanation is the effect of the traction by the tumor, upon the sympathetic ganglia and through the greater splanchnic, upon the sympa- thetic chain, which is merged in with the mass of nerves, including the brachial plexus, in the tissues of the shoulders. C. E. DE M. S.] Pressure symptoms are apt to compli- cate a case of long duration. Ascites, general edema, or edema of the ankles or legs are commonly observed in such cases, due notably, in most instances, to pressure upon the inferior vena cava. Gangrene of the feet has also been observed. In carcinoma metastasis is most common in the liver and lungs ; in sarcoma it is not quite as frequent and occurs in most cases in the liver and kidney. Death may occur suddenly, preceded, by very few of the above symptoms, es- pecially the sarcomata of infants. In. the majority, however, especially in adults, the morbid symptoms gradually develop and the asthenia increases until unconsciousness, labored breathing and coma terminate in death. Infants may also suffer from a con- genital type of adrenal tumor which simultaneously invades the liver. It is encountered as a congenital tumor dur- ing the first week of life. The abdomen becomes increasingly distended ; there is moderate emaciation, but no jaundice, pigmentation, ascites, or even pain, the child nursing almost up to the time of death. Series of six cases, including a per- sonal case, showing that congenital ADRENALS, DISEASES OF (SAJOUS). 469 sarcoma of the adrenals and liver constitutes a special type of malig- nant disease with its own peculiar symptoms and pathological findings : Swelling of the abdomen occurred within a period ranging from birth to five weeks, thus indicating the con- genital nature. The infants lived from one to sixteen weeks, thus showing great malignancy. The increase of growth could be discerned from day to day, thus illustrating rapid devel- opment. All were females. The en- tire normal liver structure was prac- tically destroyed in all. The supra- renal growth exhibited the peculiar- ity of being very hemorrhagic. No other part of the body was involved by the new growth. William Pepper (Amer. Jour. Med. Sci., Mar., 1901). Case of a female child, aged 7 weeks, who presented a swelling of the belly.. On examination of the ab- domen the superficial veins were found distended, and the epigastric and both hypochondriac regions were greatly enlarged and prominent. The surface of this enlargement was per- fectly smooth and uniform, presented no irregularity, and no pulsation was visible. Careful palpation revealed the presence of a solid mass which was movable during respiration, and which was evidently an enlarged liver. A second enlargement occupied the left half of the abdomen. It was also movable during respiration. The two swellings appeared to be quite dis- tinct from each other. The blood was frequently examined, and at first showed decided leucocytosis, which, however, disappeared. The patient steadily lost strength and emaciation began, and then slight edema of the lower limbs appeared. The abdomen became increased in girth, and grad- ually the two areas of enlargement and dullness descended into the right and left iliac fossa respectively. A provisional diagnosis of splenic ane- mia with coincident hepatic enlarge- ment was made. The post-mortem examination revealed the fact that the enlargement of the liver was due to the presence of numerous sarco- matous nodules. The primary growth was discovered in the right adrenal. John Orr (Edinburgh Med. Jour., Sept., 1900). Case of primary malignant tumor of the adrenal occurring in a child 2 months old. The parents first no- ticed a slight swelling of the abdo- men, which increased rapidly. On examination the writer found distinct enlargement, some edema of the abdominal walls, and the superficial veins much distended. On palpation a hard, smooth mass was felt, chiefly in the right side of the abdomen, ex- tending from the costal margin down to the right inguinal region, passing deeply into the right flank and filling up the whole space between the ribs and the iliac crest. In the right in- guinal region a firm edge was felt, which could be traced from Poupart's ligament toward the navel, passing below the navel and then gradually ascending. To the left of the navel a notch could indistinctly be felt, but it was not possible to distinguish two separate masses. The length of the tumor mass in the median line was 16 cm., the distance from the inter- clavicular notch to the umbilicus was 21.5 cm., and the greatest circumfer- ence of the abdomen was 46 cm. The uniform tumor apparently repre- sented the liver. The red blood-cor- puscles numbered 2,800,000; the white 11,000, of which 79 per cent, were polymorphonuclears, 18.5 per cent, small mononuclears, 2.3 per cent, large mononuclears and transitionals, and 0.2 per cent, eosinophiles. The child died in convulsions six days after it was seen the first time. The autopsy disclosed a tumor of the left adrenal gland and a very much en- larged liver. The liver was cirrhotic and fatty, and contained numerous masses of cells, the same as those in the adrenal tumor. Amberg (Arch- ives of Pediatrics, Aug., 1904). DIAGNOSIS.— The diagnosis of malignant tumor is not difficult when the tumor is sufficiently large to be dis- covered by palpation, especially when 470 ADRENALS, DISEASES OF (SAJOUS). paresthesia over the kidney is present. This and the asthenic phenomena point clearly to the adrenals, especially if jaundice or any pigmentation of the skin be present. Unfortunately, the morbid process is far advanced, as a rule, when these signs appear. The tumor has been mistaken for psoitis and abscess. From hepatic cancer it differs in that the sur- face of the tumor is smooth instead of lobulated. Of course, the possibility of metastasis in the liver, its most frequent seat, must be borne in mind. Hydatid cyst may be suggested, but the absence of the hydatid thrill and other typical symptoms will avoid error. A project- ing and enlarged gall-bladder is some- times simulated by an adrenal tumor capable of displacing the intestines an- teriorly; but the latter are much less tense than such a gall-bladder. Ab- dominal aneurism may be suggested,but the absence of aneurismal bruit and the absence of all other signs of adrenal growth eliminate this source of error. In renal cancer or renal hypernephroma hematuria and other evidences of renal disorder are usually present, while they are more likely to be absent in malig- nant growths of the adrenals. Pain oc- curs earHer than in renal tumors, while febrile disturbance is rare in the latter. Two symptoms point to involve- ment of the suprarenal gland: (a) paroxysms of pain and paresthesias in the absence of a palpable tumor, and (b) a febrile course. The pain- ful paroxysms in renal as well as suprarenal tumors are due to the ex- tension of the neoplasm to the roots of the lumbar plexus. In suprarenal tumor this may occur quite early, owing to the immediate vicinity of these structures. On the other hand, in renal tumors the invasion of the capsule usually takes place at a late period, when the growth has reached so considerable a size as to become palpable. The fact that fever occurs in cases of suprarenal tumors has hitherto been unknown. The writer observed it in 57 per cent, of his cases, while in renal tumors it was present only in 1 to 2 per cent. Another apparently characteristic fact in differentiating from renal tu- mor is that the adrenal growth tends to approach more nearly the median line — in the region from the seventh to the ninth costal cartilages; while the primary tumor of the kidney ap- pears first in the region from the ninth to the eleventh. Tumor of the adrenal at the time of its presenta- tion beneath the margin of the ribs appears broader than does that of tumor of the kidney, and the lower contour of the tumor of the adrenal is much less rounded than is that of the kidney. J. Israel (Deut. med. Woch., Nu. 44, 1905). [The emphasis laid by Israel on the presence of fever in adrenal malignant neoplasms affords striking proof of the correctness of my contention that the ad- renals, through the role of its secretion in oxidation and metabolism, was the active organ in fever — a process which patholo- gists have totally failed to explain. C. E. deM. S.] Lencocythemia is sometimes simu- lated, but the absence of myelocytes and other characteristics soon eliminate this disease. Ecchymosis of the orbit of unaccount- able origin in infants and young chil- dren, or tumor of the orbit should cause careful search for other manifestations of malignant hypernephroma of the ad- renals. TREATMENT.— Removal is the only resource, but, as a rule, the result is unsatisfactory, owing to the fact that the presence of the growth is recognized only through metastasis ; or when it has developed to a marked extent, and pro- duced either through metastasis, press- ure, etc., disorders in other parts of the organism which cannot be reached. ADRENALS, DISEASES OF (SAJOUS). 471 Three cases of adrenal tumor treated by removal. One was in a woman, aged 47, on whom the writer operated in 1891, who died of recur- rence of sarcoma and exhaustion sev- eral months after the operation. The suprarenal growth was so firmly fixed to the top of the kidney that that organ had to be removed as well. The second case was that of a woman, aged 62, on whom he op- erated in 1897, and who is still living and well, the tumor removed having been a struma lipomatosa suprare- nalis, as described by Virchow. In this case only a wedge-shaped piece from the top of the kidney was re- moved with the tumor, a procedure followed by no morbid symptom. The third operation, by his colleague, Mr. Ward, was for a sarcoma of the adrenal in a child, aged 12 months. The child died from shock within a few hours. Of 9 cases, including his own, 5 recovered from the operation and 4 died. The true secret of success lies in operating at an early stage of the growth, as in the writer's second case. Mayo Robson (Med. Press and Circular, Aug. 23, 1899). Removal of an adrenal myxosar- coma from a man of SO. The tumor weighed about seven pounds when removed. There was no cachexia, mononuclear leucocytosis or other symptoms pointing to the suprarenals. The sound suprarenal must have acted vicariously for the affected or- gan. The patient had recovered when last seen, two months after a two- hour operation. F. Sicuriani (Riforma Medica, vol. xxi, No. 44, 1905). Cases in which the tumor involves one adrenal only, as suggested by the absence of symptoms of adrenal insuffi- ciency, marked asthenia^emaciation, hy- pothermia, etc., and the presence of a tumor and hyperesthesia on one side only, ofifer a better chance of success, since they indicate that the other ad- renal will probably be able to subserve alone the needs of the organism. The chief difficulties encountered in the course of the operation are a marked tendency to hemorrhage, owing to the friability of the morbid tissues. HYPERNEPHROMA.— This name has been given to tumors formerly considered as lipomata, adenomata or myxomata, but shown by Grawitz in 1883 to be developed from adrenal tis- sue, either within the adrenals them- selves or in the kidneys, the walls of blood-vessels or other structures in which "adrenal rests" (fragments of misplaced adrenal tissue) or "aberrant adrenals" occur. From my viewpoint, these so-called "adrenal rests" — found in 90 per cent, of all autopsies by Bayard Holmes, at least once a week by Grawitz in his au- topsies, etc. — are not misplaced frag- ments of adrenal tissue; they belong normally to the kidney. [I have shown (Monthly Cyclo., June and July, 1909) that what has been termed the internal secretion of the kidney is a product the properties of which correspond with those of the adrenals, and (see "In- ternal Secretions," 3d ed., p. 289, 1908) that the kidney and the adrenals were governed by the same nervous structures, being thus closely linked functionally. Under the in- fluence of centric impulses the sorcalled adrtnal rests and t'le adrenals are both caused to increase their secretory activit}'- and to enhance the intrinsic metabolism of the tissues they supply. On the whole the "adrenal rests" are but local aggregates of the chromaffin substance found in all sym- pathetic structures. C. E. de M. S.] Study based upon 48 hypernephro- mata. Thirty-four of the tumors were removed at operations in the Mayo Clinic, and 14 were unreported cases gathered from outside sources. The following general conclusions are drawn from this study: 1. Most, if not all, so-called "adrenal rests" are probably of Wolffian origin. 2. There is almost no evidence, embryological or histolog- ical, in support of Grawitz's hypothesis 472 ADRENALS, DISEASES OF (SAJOUS). that the so-called hypernephromata have their origin in adrenal rests. 3. There is much evidence that the so-called hypernephromata do arise (according to Stoerk's hypothesis) from prolifera- tions of the adult secreting epithelium of the convoluted tubules. 4. There is much evidence that the so-called hyper- nephromata do arise from islands of nephrogenic tissue (primitive renal blastema). Such tissue is sometimes present in the adult kidney and appears capable of forming tumors of non-infil- trating mixed .cordon, tubular, papilli- form, and sarcoma type characteristic of the so-called hypernephromata. L. B. Wilson (Jour, of Med. Research, Jan., 1911). Hypernephromas are relatively com- mon in the kidney, constituting, as shown by Albarran and Joubert, 17 per cent, of all renal tumors ; they are much less frequently found in the adrenals proper, or in other organs, such as the uterus, ovary, the broad ligament. Mi- croscopically they present the typical characters of the adrenal cortex, and closely, as a rule, infest vascular chan- nels. These vessels and adjacent tissues usually contain a colloid material simi- lar to that found in the thyroid, or se- creted by the adrenals. They are be- nign at first and become troublesome — sometimes after many years — mainly on account of their size, which sometimes reaches that of a child's head, but the pressure they exert on surrounding structures, their tendency, even when benign, to metastasize in the lungs, bones, brain, give them their malig- nancy. Case of hypernephroma encroaching upon the heart. The earlier symptoms were cardiac with great weakness, one and one-half years before urinary phenomena occurred. Then followed hematuria, and a tumor was discovered in the left kidney ; it proved on removal to be a hypernephroma from an aber- rant suprarenal tissue proliferating into the ascending vena cava with a tumor thrombus up in the right auricle. Skip- ■ping the right ventricle, it had prolifer- ated into the pulmonary artery. Kirsch- ner (Berl. klin. Woch., Sept. 25, 1911). SYMPTOMATOLOGY.— Before the local symptoms of the tumor appear — when any are clearly discernible — it evokes phenomena which are diametri- cally opposed to those of Addison's dis- ease, and which correspond with in- creased nutrition and a stimulation of growth such as that produced by thy- roid preparations in cretinism. [This action on growth and its resem- blance to that brought about by thyroid overactivity has imposed itself upon in- vestigators quite independently of my own view — advanced in 1903 ("Internal Secre- tions," vol. i, pp. 146-152), that it was in great part through the adrenals, i.e., through incidental stimulation of the ad- renal center by the thyroid secretion, that the benefit of thyroid in cretinism was produced. The confirmatory evidence it affords is self-evident. The excess of ad- renal tissue which constitutes hyperneph- roma brings about the general phenomena of overnutrition merely because it awak- ens excessive metabolism precisely as if the thyroid overactivity had done so by exciting the adrenal center. C. E. de M. S.] The symptomatology varies consider- ably in different cases and suggests that several types exist which our present knowledge does not enable us to dis- criminate. Some of these exhibit such malignancy that they have been grouped in a separate class. Beginning with hy- pernephromas of the adrenals proper, we will first review this class of cases. MALIGNANT HYPERNEPH- ROMA OF THE ADRENALS.— This growth occurs, as a rule, between the first and eighth year, especially in girls of the latter age, and causes pre- mature development so marked, in some instances, that the child appears, as to s''-- - Appearances of kidney and tumor on section through the long axis of the organ and its pelvis. (Annals of Surgery, Dec. 1906.) Hypernephroma. Showing the external appearance of the kidney and tumor about one-third smaller than at the time of operation. (Annals of Surgery, Dec, 1906.) ADRENy\LS, DISEASES OF (SAJOUS). 473 size and development, twice or three times its true age. The face, genitaha, and pnhis are covered with abundant growth of hair, the external genitalia being as fully developed as in the adult. The body is obese, the appetite and thirst excessive, although gastric dis- orders, including stubborn vomiting, are common. The skin may be swarthy or dark-hued, as in a brunette, but not bronzed as in Addison's disease. Such children are usually cross and sullen, unlike obese children, in whom the obes- ity is due to deficient fat catabolism. These primary growths of the adrenals, which are usually observed in girls, are of slow development, and years usually elapse before metastasis and press- ure phenomena — those which give the growth its malignancy — appear. The abnormal growth of the child may suggest gigantism or acromegaly, due to some disorder of the pituitary body, but the characteristic growth of the extremities, the absence of obesity in these disorders do not occur in hyper- nephroma. An elevated temperature is often observed in these cases. Removal of 14 cases of malignant hypernephroma. Fever was a promi- nent symptom, unaccounted for by any complication. This reaction may be early, intercurrent, or late. It some- times is the first clinical evidence of the malady, or it may accompany the evolution of the disease; or it may be a terminal symptom. The type may be hectic, recurrent, or one associated with hematuiia; or the fever .may be atypical. The reaction cannot be con- nected with liberation of bacterial toxins or absorption from necrobi- otic tissues. It doubtless accompan- ied the evolution of all malignant growths, but the rationale is not clear. Israel (Deut. med. Woch., Jan. 12, 1911). [The occurrence of fever in these cases is clearly accounted for by my views. As shown in "Internal Secretions" (vol. ii, p. 1907), the pituitary body contains the sym- pathetic center besides the adrenal center. During the first or erethic stage, therefore, the adrenals, the secretion of which sus- tains oxidation and metabolism, and which alone cause overgrowth in malignant hy- pernephroma, are not alone overactive, but the arterioles, which the sympathetic gov- erns, also. The blood is not only abnor- mally rich in oxygenizing properties, there- fore, in this disease as it is in malignant hypernephroma, but it is also driven with excessive energy into the tissues, particu- larly in the long capillary loops of the ex- tremities. Hence the difference between the phenomena of overgrowth in the two diseases and the elevated temperature. C. E. DE M. S.] Turhor of the orbit in infants and young children should arouse the sus- picion of metastases from an adrenal growth. If an abdominal tumor be found, it is almost certainly of ad- renal origin, and this would be still further corroborated by enlargement of the preauricular glands, which ren- ders the diagnosis of sarcoma of the orbit unlikely. Chloroma presents almost identical growths, being as- sociated with tumors of the orbit in two-thirds of the cases, with exoph- thalmos usually as the first symptom, but this may be excluded in the ab- sence of leukemic changes in the blood. Myeloma may cause bony growths about the skull, but is ex- ceedingly rare in childhood; the pres- ence of the Bence-Jones body in the urine would render the diagnosis of myeloma certain, while its absence is not conclusive. The authors state that abdominal tumor associated with precocious maturity is practically certain to be of adrenal origin, if tu- mors of the ovaries or a retained tes- tis can be excluded. Other adrenal tumors cannot be distinguished from tumors of the adjacent tissues, es- pecially of the kidneys. Tileston and Walbach' (Amer. Jour. Med. Sci., June, 1908). Case of tumor of the adrenal gland with metastasis in and about the orbit. The following are the char- 474 ADRENALS, DISEASES OF (SAJOUS). acteristic symptoms usually found in infants or young children: Ecchy- mosis of the eyelids, accompanied by exophthalmos, suddenly appears; it may be followed by growths about the orbit. It is usually confined to one side. The glands throughout the body are apt to be enlarged. Exam- ination of the abdomen may reveal a tumor in the region of the kidney, or a mass may be felt in other parts of the abdomen. The blood shows secondary anemia. The urine is usu- ually free from blood and albumin. Most of the reported cases have been under 4 years of age. The course of the disease is rapid, death result- ing from cachexia and anemia. The author also calls attention to the following: 1. Tumors of the or- bit in young children, especially if accompanied with ecchymosis of the lid, should arouse suspicion of metas- tasis from an adrenal growth. 2. The microscopic examination of speci- mens shows a characteristic rosette formation of cells. 3. This form of tumor arises from embryonic nerve- cells of the adrenal gland. Quacken- bos (Arch. Ophthal., Sept., 1910). Case of malignant hypernephroma in a boy of 9 years, who had always been pale and weak. Six weeks after an acute pericarditis the symptoms of the malignant disease became ap- parent and the tumor soon penetrated into the thorax. Three other cases are on record in which a malignant hypernephroma developed in a child. The other children were between 2 and 5 years old; in one the tumor had developed on a horseshoe kidney. All were distinguished by extreme malignancy, but no hematuria was observed. In the 222 cases of hyper- nephroma the writer has found on record a traumatic factor was evident in only eight instances. Franck (Beitrage z. klin. Chir., Jan., 1910). Infants and young children are also subject to a form of primary malignant tumor of the adrenals, described by Hutchinson, in which, even before the neoplasm^ which grows with great ra- pidity, can be felt in the renal region, there appears a spontaneous — some- times traumatic — ecchymosis of one or both eyelids, soon followed by (usually unilateral) exophthalmos and metasta- sis in the skull, and often in other bones, especially the ribs. The preauricular lymph-nodes, and those behind the angle of the jaw, are enlarged, and the whole temporal region eventually becomes the seat of a malignant growth. Pain in this location and optic neuritis with amblyopia may complicate the case. Death occurs early from anemia and cachexia. Out of 196 cases of kidney tumor 146 were hypernephromata — that is, almost exactly 75 per cent. The re- maining 25 per cent, are made up mostly of sarcomata, to a much less extent of squamous epitheliomata of the pelvis, while a true carcinoma of the kidney, apart from hyperne- phroma, is a very great rarity, or, possibly, does not exist. The kidney tumors of children are practically all sarcomata; there is but one case on record of a true hypernephroma in an infant, and, as was long ago pointed out by Kiister, malignant disease of the kidney is a disease of earliest childhood and middle age, affecting but little young adults and the aged. Hence, we may lay it down definitely that hypernephroma is the common kidney tumor of adults, and, con- versely, that any given kidney tumor in an adult is much more likely to be one of this type than anything else. This is the only etiological fact bear- ing on the disease which we can re- gard as absolutely definite. Trotter (Lancet, June 5, 1909). Adrenal carcinoma shows two en- tirely distinct syndromes and path- ological states, according to which adre- nal is the seat of the primary tumor. On the left side secondary deposits occur in the liver, ribs, cranial bones, and in the thoracic duct and some of its tributaries. On the right side the pri- mary growth generally attains a larger ADRENALS, DISEASES OF (SAJOUS). 475 size, and oftener remains localized to the abdomen. It tends to involve the kidneys by direct extension into their pelves, stretching out the kidney sub- stance over it, but, as a rule, being easily separated. Secondary deposits occur on the upper surface of the liver, in both lungs, occasionally in the cranial bones, and also in the right lymphatic duct and some of its branches. The lym- phatics of the right suprarenal are trib- utaries of the right lymphatic duct, and do not, as is usually stated, follow a course similar to that of the lymphatics of the left adrenal, viz., join the lumbar glands. Deposits in the cranial bones often cause exophthalmos, this usually occurring first on the same side as the primary growth. Ecchymoses into the eyelids may occur and lead to confusion of the disease with chloroma and in- fantile scurvy. The tumor in these cases involves the medulla of the adre- nal, and there are reasons for believing that it is of carcinomatous nature. No pigmentation or evidence of a prema- ture sexual development, such as have been described as occurring in cases of carcinoma of the cortex of the supra- renal, were found in any of the cases studied. R. S. Frew. (Quarterly Jour, of Med., Jan., 1911). HYPERNEPHROMA OF THE KIDNEY. — It is to renal growths de- veloped from the so-called "adrenal rests" that Grawitz, in 1883, gave the name "hypernephroma." They occur not only more frequently in the kidnevs than elsewhere in the body, but consti- tute a large proportion of all renal tu- mors, i.e., 17 per cent. S Y M P T OMATOLOGY.— Hema- turia is often the first and the most fre- quently observed symptom of renal hy- pernephroma, having been noted in 90 per cent, of all cases. The hemorrhages are usually severe and occur intermit- tently, weeks and even months elapsing between them. Worm-like clots — thus shaped during their passage through the ureters — are often passed. During the intervals the urine is either clear or it may contain red corpuscles. The hema- turia is increased by exercise and by manipulation of the region overlying the growths if the latter is sufficiently large to be felt. It may be the only symptom of the growth or precede the detection of the latter by palpation as much as ten years. As a rule, however, the tumor (which occurs in 80 per cent, of all cases) is sufficiently large to be detected inuch earlier, and som.etimes immediately after an attack of hema- turia. It is located in the loin, often on the right side, and two or three fmger- breadths below the costal margin. It is at first small — about the half of a wal- nut — and is movable in about one-half of the cases. As a rule, palpation cattses no pain at first, though it may prove ten- der when directly pressed upon. Dull pain in the lumbar region, sug- gesting lumbago, may be the initial symptom. This pain gradually increases and, after being centered in the region of the growth, with a sensation of weight, increasingly radiates in various directions, the back, the abdomen and the testicles. It may come on suddenly and last three or four hours, then be followed by hematuria and frequent urination, followed by a period of rest, during which the urine is slightly albu- minous. The urine sometimes contains a few casts, oxalate of lime and a few corpuscles. During this period of rest a certain stiffness may be experienced en the side of the tumor. Varicocele is frequently observed in these cases, on the same side as the focus of pain ; it may develop simultaneously with the latter and disappear when the patient assumes the recumbent position. While periodical hematuria, a tumor and pain in the locations mentioned are typical signs of renal hypernephroma, 476 ADRENALS, DISEASES OF (SAJOUS). other phenomena may appear gradually as the morbid process advances. Most important among these are the metasta- ses, which occasionally occur as first signs of the disease. This is especially the case in bone metastasis, which may appear in the vertebrae, the ribs and other long bones, the skull, scapula, etc., i.e., practically any portion of the skele- ton. Metastasis may also occur in va- rious viscera, particularly the lungs, the consolidation in the latter suggesting the corresponding stage of phthisis. Case in which the symptoms and the local findings were so obscure that it was impossible to make a cor- rect diagnosis. The abdomen was opened on the left border of the left rectus muscle. The capsule of the tumor was carefully incised and the peritoneum thus liberated was sewed to the parietal peritoneum of the lapa- rotomy wound, thus shutting off com- pletely the peritoneal cavity from the field of operation. The tumor and the kidney, to which it was attached, were delivered through the incision and the tumor carefully enucleated. No large blood-vessels were severed, but the oozing from the cut surface of the cortex of the kidney could only be arrested by bringing the capsule on one side against the capsule on the other by three mattress stitches. The kidney was allowed to fall back into its normal position. With the exception of the development of a periappendicular abscess in an old ap- pendicitis scar, the patient made an uneventful and rapid recovery. A microscopic examination of the tumor showed that it was a typical adrenal growth. Bayard Holmes (Med. Stand- ard, Nov., 1904). Series of 27 cases in which a single bone metastasis was the first symp- tom of the disease. Two were au- topsy cases. In one case the metas- tasis to the scapula was excised, and • the patient has remained well so far, eighteen months after operation. In another instance the metastatic area in the occipital bone showed ossifica- tion. This so-called osteoplastic car- cinosis has been described by von Recklinghausen in metastatic bone foci from carcinoma. Albrecht (Zen- tralbl. f. Chir., Bd. xxxii, S. 112, 1905). Case of renal hypernephroma in which the first evidence was a metas- tasis in the upper part of the hu- merus, the only sign of the primary growth being an enlargement of the left kidney. Fifteen cases from liter- ature suggested the following deduc- tions in this connection: 1. A bone metastasis may be the first sign of hypernephroma. 2. A bone tumor in a middle-aged or elderly person should suggest a metastatic hyper- nephroma, for a primary bone tumor in elderly people is uncommon. 3. The bone metastasis from a hyper- nephroma may be the only metasta- sis. 4. A hypernephroma may exist for a considerable period without symptoms. 5. The kidney region should be palpated with great care in every case of bone tumor. C. L. Scudder (Annals of Surg., Dec, 1906). The arteries may be thickened and show clearly defined signs of arterio- sclerosis, quite in contrast, sometimes, with the relative youth of the patient, and the blood-pressure be quite high. The skin is. not bronzed in these cases, but yellowish, and sometimes swarthy or smoky, this being replaced by pallor when the end is near. The temperature may be raised, but this rarely exceeds 1° or 2° F. [An important feature in this connec- tion is that bronzing is a characteristic of insufficiency of the adrenals, as in Addison's disease, whether due to degeneration, tu- berculosis, or malignant tumor of these organs or of their nerve supply. In hyper- nephroma, on the contrary, we have an addition of adrenal substance to the cir- culation through the secretory activity of the adrenal rests, as shown by the familiar results of adrenal overactivity enumerated ADRENALS, DISEASES OF (SAJOUS). 477 — liigli blood-prcssurc and arteriosclerosis. The icterus or swarthiness here is due, from my viewpoint, to the continuously high blood-pressure which causes the cu- taneous capillaries to become hj^peremic and to expose an increased quantity of the adrenal principle — the component of melanin (see "Internal Secretions," vol. ii, p. 835) to oxidation. The stage of bronz- ing is not reached because the pigment is not deposited in the cutaneous tissues, as it is in Addison's disease, but merely sup- plied to them in excess. C. E. de M. S.] The duration of the disease varies from fifteen weeks to eight years. The patient gradually loses flesh and grows weaker, all the symptoms become aggra- vated, hematuria becoming prominent, causing marked secondary anemia ; moderate edema of the lower limbs may appear mainly as a result of pressure on some large venous trunk, and delirium sometimes precedes the terminal coma. DIAGNOSIS.— The pain in the re- gion of the affected kidney, the hema- turia accompanied by frequent urina- tion and the localized tumor, are the chief diagnostic points among those pre- viously enumerated, but other features may serve to facilitate the diagnosis. Gelle pointed out that fragments of the tumor, which is very friable and often dissociated during hemorrhages, could be found in the clots passed with the urine. The cells preserve their charac- ters and staining properties. As to diagnosis of the tumor itself after removal, Croftan found (1) that a watery extract of fresh hypernephroma, in keeping with adrenalin and adrenal extracts, provoked glycosuria when in- jected in the rabbit; (2) that a pure starch solution, to which the watery ex- tract of hypernephroma was added, con- tained an appreciable quantity of dex- trose; and (3) that the watery extract also possesses the power to decolorize an iodine starch solution. These simple tests make it possiljle to differentiate hypernei)hronia from other tumors of the kidney. This is important, since the post-operative prognosis of hyperne- phroma is much more favorable than that of any other malignant tumor of the kidney. A high blood-pressure tends greatly to insure the diagnosis. Hypernephroma can be recognized by the histological structure of the organ, the presence of oil globules in the cells, and the peculiar staining reaction discovered by Lubarsch. Case of a man of 29 years, who died with symptoms of brain tumor, and in whom masses of adrenal tissue were found in the kidney and liver. A careful study of the literature showed that hypernephroma is more common than is usually supposed. Radasch (Amer. Jour. Med. Sci., Aug., 1902). There are no pathognomonic signs of renal hypernephroma. A diagno- sis, ^specially in the early stages, must be made by a process of exclu- sion. Two personal cases, one of which was a boy of 14, showed ex- tensive arteriosclerosis. This sug- gests again the importance of blood- pressure determinations in all cases where a suspected kidney lesion ex- ists. Hematuria is the most impor- tant early sign. Metastasis occurred in three instances as late manifesta- tions. Only two of the eight cases were operated tipon. They have re- mained well seven and fifteen months respectively. H. C. Moffitt (Boston Med. and Surg. Jour., Oct. 8, 1908). A question in regard to these cases which has never been thoroughly in- vestigated is that of increased arterial tension. It is logical to suppose that, with an increase of adrenal tissue, we may have an excess of adrenal secre- tion, which would result in a rise of blood-pressure — certain writers have noted that this was true; but observa- tions upon this point sufficient to set- tle the question have not j^et been made. Every case of hypernephroma should be thoroughly investigated in 478 ADRENALS, DISEASES OF (SAJOUS). this regard, and we may find that a study of the blood-pressure furnishes us a valuable aid in diagnosis. George E. Beilby (Albany Med. Annals, Jan., 1909). Various disorders may be suggested by hypernephroma, prominent among which is urinary calculus. In this con- nection the pain is coincident with the hemorrhage, while in hypernephroma the pain continues after the latter, though greatly relieved. The vermicu- lar and cylindrical shape of the clots in hypernephroma is also suggestive. Cys- toscopic examination at this time often reveals these clots projecting from the ureter of the diseased kidney, whose tumor can also, in some instances, be discerned under X-ray examination. Pregnancy is sometimes suggested when the growth projects anteriorly, espe- cially in view of the fact that amenor- rhea sometimes precedes the abdominal enlargement. Hypernephroma may be mistaken for enlarged spleen. The latter is usually nearer the surface and its mobility on inspiration more marked. It is located on the left side, whereas hyperne- phroma, in most instances, occurs on the right side. Catheterization of the ureters may serve to indicate, between the periods of hematuria, which of the two kidneys is most impaired function- ally. The blood count affords little, if any, information, any diminution of red corpuscles — sometimes to an extreme degree — being readily accounted for by hematuria. Moderate leucocytosis oc- curs in some cases, but not with sufifi- cient frequency to give this sign any diagnostic importance. In some cases the symptoms and phys- ical signs, other than hematuria, afford but little help to establish the identity of the tumor, either anteriorly or pos- teriorly. In that case the absence of pregnancy being clearly established, an exploratory incision followed imme- diately, if hypernephroma be present, by its radical removal, is indicated. PATHOLOGY. — Hypernephroma is usually located in the upper pole of the kidney, immediately, therefore, un- der the adrenals. When found early in life at autopsies hypernephromata may be no larger than lentils, or even smaller, but they may attain the size of a child's head, growing outwardly, or, in some cases, inwardly, at the expense of the renal tissues. They reproduce more or less perfectly, the adrenal tissue, the smaller growths being made up, as a rule, of the cortex, and the larger of both the cortical and the medullary sub- stance. They are firm when small, but when they attain a certain size their ten- dency is to become lobulated, the pro- jecting masses becoming softer and cyst-like. They are lobulated owing to the fibrous bands derived from the renal capsule, and the lobules, when opened, may be yellowish, grayish red, or brown or blackish, and contain hemorrhagic areas — the source of the blood which causes hematuria. [The various colors mentioned correspond suggestively with the cutaneous pigments I have ascribed to the adrenal principle in icterus bronzing, etc., and this, in turn, fur- ther confirms the fact that the melanins are mainly composed of this principle ("Internal Secretions," vol. ii, p. 835). Hence the asso- ciation of hypernephroma with melanotic sar- coma by various pathologists. C. E. de M. S.] The larger growths are those which tend to become malignant and to pro- duce metastases. These occur through the blood-vessels, both the arteries and veins ; the bones and lungs, as previously stated, are the structures most fre- quently invaded, though, occasionally, extension occurs by the lymphatics, in- cluding the retroperitoneal glands. ADRENALS, DISEASES OF (SAJOUS). 479 ]\Iicroscopically they usually contain a scanty stroma composed of vascular- ized connective tissue in columns and a parenchyma formed of endothelial polygonal or columnar, translucent nu- cleated cells, which differ entirely from those of the renal epithelium. The cyto- plasm is granular and contains, besides detritus and giant cells, numerous fat- laden vacuoles. It is the presence of considerable fat which first caused these tumors to be regarded as lipomata. The fat contains lecithin. Glycogen is also present, sometimes in relatively large quantities. Prior to 1883 many forms of renal growths were grouped under the head of lipomata. Some authors had pre- viously, and others since that time, described these neoplasms as adenomata arising from the renal tissue itself. Grawitz was the first to bring order out of chaos when he maintained that these growths formerly described as lipomata in reality had their origin in suprarenal tissue misplaced within the kidney. His reasons for believing these tumors to be of adrenal origin were: (1) the subcapsular position in which aberrant adrenal tissue is likely to occur; (2) the cells were quite different in form from the renal cells, and contained fat- globules in large drops like fatty in- filtrated liver-cells; (3) the capsule and the arrangement of the tumor-cells in rows, like the supiarenal cortex, the preponderance of cells over stroma; (4) amyloid degeneration of blood-ves- sels present in his case only in the adrenals. Others, like Chiari, Lubarsch, and many others, supported Grawitz's views and added the following criteria : (1) the similarity between tumors of the adrenal body itself and these growths ; (2) the presence of glycogen. The frequency with which portions of the suprarenal tissue are found under the true renal capsule and imbedded in the renal cortex was shown to be as- tonishingly great by Grawitz. L. L. McArthur and D. N. Eisendrath (Phila. Med. Jour., April 29, 1899). ' Four personal cases illustrating the stages of transition from the smallest benign neoplasm, a pure aberrant ad- renal germ to the large growth which assumes the characteristics of a cancer. Gradually as the malignant growth is approached, the adrenal germs or "rests" lose their normal characters to assume the vague embryonic cellular types. These correspond in every way with the renal cancers containing trans- lucent cells which certain classic writers still consider as renal cancers, but which in reality are hypernephromata. E. Gelle (L'Echo med. du Nord, Aug. 2, 1908). PROGNOSIS.— As a rule, hyper- nephromata grow slowly at first, months, and even years, elapsing before they metastasize or show other signs of malignancy. They may then progress very rapidly, and, the hematuria becom- ing continuous, death occurs from exhaustion. A case was reported by Hausemann in a woitian 60 years of age, in whom the tumor had been present fifteen years without evidence of rapid growth. Suddenly the tumor began to grow rapidly and the hematuria which until then had been periodical and not pro- fuse, became continuous. The patient died of exhaustion within a few months. Kusmik (Beitrage zur klin. Chin, Bd. xlv, S. 185, 1905). They show a tendency to recur, though years may elapse before recur- rence occurs. If recognized early, how- ever, removal affords a greater chance of permanent recovery. Out of 4 cases, 1 of the patients al- ready reported was known to be well seven months after operation ; another has remained well fifteen months, but the presence of a varicocele on the sound side renders his future doubt- ful. Dr. Levison operated on a second case that remained well for some years. Out of 24 cases with operation recorded by Albrecht, 8 died from the immediate results of the procedure and 9 soon 480 ADRENALS, DISEASES OF (SAJOUS). afterward from local recurrence or metastases ; 1 died of pneumonia two yea/s after operation, and autopsy gave no evidence of recurrence. Only 4 pa- tients remained well after three years, and of these 1 developed metastasis in the occipital bone at the end of four years ; a second, metastasis in the scap- ula after four years and three months; a third, metastasis in the spine after seven years. Only 1 patient out of the 24 remains well after four years. The danger of metastases years after operation renders prognosis most un- certain. Claimont has recorded a case of recurrence in the bronchial glands ten years after removal of a renal hypernephroma. It must be re- membered, however, that Albrecht has shown that there may be but one me- tastasis, and removal of this may lead to a permanent cure. The dishearten- ing results of operations in the past should spur on the clinician to try all methods that may lead to early recog- nition of the growths. H. C. Moffitt (Boston Med. and Surg. Jour., Oct. 8, 1908). TREATMENT. — An exploratory incision is warranted, as previously stated, when an abnormal growth in the abdomen or in the region of the kidney occurs coincidently with hemorrhage, even when other symptoms of hyper- nephroma are not present. The ma- jority of authorities consider this pro- cedure advisable even when hemorrhage into the bladder cannot be accounted for. In some cases discomfort or ten- sion over one kidney, and deep compara- tive palpation, on both sides may suggest which side should be explored first ; but if this unilateral examination fails to in- dicate the presence of a growth, ex- ploration of the other kidney is justifi- able. In some instances the organ is merely enlarged, especially toward the upper pole, or at the hilum. Removal of the growth may be performed extra- peritoneally through a lumbar incision. The fatty capsule should, according to Kuzmik, be removed along with the growth, as it may be infiltrated and thus lead to recurrence. Case in a woma,n aged 37, married, who had an abdominal swelling the size of a fetal head at term. It was very mobile and fluctuant, and could not be pushed down into the pelvis. A diagnosis of cyst of the kidney or ovarian cyst with a long pedicle was made. On opening the abdomen the tumor was found to be retroperito- neal and crossed by the descending colon. The peritoneum was divided and the cyst enucleated. There was no pedicle. The cyst lay immediately in front of the left kidney, which was normal. The patient made a rapid recovery. On section the tumor con- tained blood and clots. The cyst- wall showed fibrous septa inclosing polyhedral granular nucleated cells, closely resembling the "zona glome- rulosa" of the normal suprarenal cap- sule. Archibald Donald (Brit. Med. Jour., Dec. 9, 1899). Two cases of hypernephroma, both of which were absolutely well one year after operation, a nephrectomy having been done at that time. Keen, Pfahler and EUis (Amer. Med., Dec. 17, 1904). An extraperitoneal operation can be done even for the removal of a very large tumor, although it is possible only when the tumor has slowly grown into the tissues of the mesocolon, and the ventral or right peritoneal surface of the colon has become greatly hyper- trophied or enlarged, and the blood- vessels of 'the colon so distorted that a long incision would not, in any way, vitiate the blood-supply of this large duct. The. results of a personal opera- tion also showed the necessity of taking advantage of every opportunity to com- pletely remove a neoplasm, no matter how grave the prognosis may be at the time of operation. Bayard Holmes (Med. Standard, Nov., 1904). Case of hypernephroma of the left kidney in which the following proved successful : the patient having been AGAR-AGAR. AGARICIN. 481 perfectly well fifteen months before the present report. A Morris incision on the left side began about 2 cm. outside the quadratus lumborum and extended forward and downward to the level of the anterior superior spine. This neces- sitated division of the external oblique muscle. The peritoneum was pushed forward and the kidney tumor removed after much difficult dissection. The tumor and kidney measured 18 x 10 x 8 cm., and was densely adherent at the upper border. The vessels were ligated high up, and on account of the high position of the tumor the tips of the tenth and eleventh ribs were divided subperiosteally and the diaphragm raised with retractors. Most of the capsule was removed and the ureter was stripped downward, almost to the blad- der, and cut short after carbolizing the end. The vessels were large, but not occluded by the tumor mass, and were ligated by Pagenstecher. The peri- toneum was opened at the upper end of the incision, but was easily closed with continuous catgut sutures. The hemor- rhage was fairly severe from the cap- sule, but was readily controlled. The remnant of the capsule was stitched with catgut and a cigarette drain in- serted in the space. Muscles sutured with chromicized gut, skin with silk- worm gut and continuous plain catgut. Sterile gauze dressing. H. C. Moffitt Boston Med. and Surg. Jour., Oct. 8, 1908). C. E. DE M. Sajous, Philadelphia. ADRIN. See Animal Extracts : Adrenals. AGALACTIA. Gland. See Mammary AGAR-AGAR is the East Indian name of a substance extracted from various seaweeds, which is available in the shops in the form of long, transparent strips resembling goose-quill pith, and also in quadrangular cakes weighing about 150 grains (10 Gm.) each. It consists chiefly of gelose, and is soluble in hot water, though insoluble in cold water. It has been extensively used as a culture medium and as a demulcent, combined with glyc- erin for chapped hands and lips. Recently, however, it has been used for constipation in doses ranging from V/z drams (6 Gm.) to Yz ounce (8 Gm.), coarsely comminuted and mixed with food. It becomes a jelly in the stomach and in- testines by absorbing water and, being in- digestible, gives considerable bulk to the feces, thus promoting defecation mechan- ically. A. Schmidt gives agar-agar cut up in small pieces, adding 25 per cent, of an aqueous extract of cascara sagrada. One teaspoonful to a tablespoonful in mashed potatoes or any other soft food is given daily in chronic constipation. S. AGARICIN is obtained from the white agaric {Boletus laricis), a fungus growing on the trunk of the European larch. The activity of agaricin is due to agaricic, agaricinic, or agaric acid. The pure acid occurs as a white, silky powder made up of minute prismatic or lamellar crystals, and having a bitter taste. It is soluble in alcohol, and in hot water, and but slightly so in cold water, ether, and acetic acid. It forms soluble salts with the alkali metals. Agaricic acid is the preparation from agraric generally used in therapeutics under the name of agaricin. The commercial agaricin, on the other hand, is an impure resinous product ob- tained by extraction from the crude drug, and is much weaker in its effects than the acid. DOSE. — The dose of agaricic acid is M.5 to y2 grain (0.004 to 0.03 Gm.). It is usually given in pill form, but may also be administered hypodermically, when the dose should be one-half smaller. The resinous agaricin is sometimes used, the dose being from 1 to 5 grains (0.065 to 0.3 Gm.). The doses given should at first be small; they can then gradually be in- creased as the patient becomes partially tolerant to the effects of the drug. PHYSIOLOGICAL ACTION.— Agar- icic acid in therapeutic doses decreases markedly the activity of the sweat-glands. It probably acts on the secretory nerve- endings to these glands (Hofmeister), thus resembling atropine in its action. It ex- erts, however, no inhibiting- influence on -31 482 AGGLUTINATION TEST. the other secretions of the body, including the salivary secretion, and does not aflfect the pupils. In larger doses it causes purg- ing and sometimes vomiting by an irri- tating effect on the gastrointestinal tract. No serious constitutional results are ever produced by it when used internally be- cause of the slowness with which it is absorbed. It has no cumulative action. Toxic effects from it may be observed, however, upon its intravenous injection in large doses into animals, and less readily upon subcutaneous injection. It excites primarily, and secondarily causes, pro- gressive paralysis of the bulbar centers, in- cluding the vagal and vasomotor centers. The animal shows marked weakness, be- comes dyspneic, has convulsions, and dies as a result of paralysis of the respiratory center. Subcutaneous injections of agar- icic acid produce inflammation of the sur- rounding tissues, sometimes followed by abscess formation. When applied to abraded areas or to mucous membranes it acts as a local irritant. THERAPEUTICS.— Agaricin (agaricic acid) is of great value in the treatment of the night-sweats of pulmonary tuber- culosis. Doses of Yq to 3^ grain (0.01 to 0.03 Gm.) are generally effective; accord- ing to Conkling, Yio grain (0.005 Gm.) will often suffice. Where the gastric diges- tion is good, it is well tolerated, and often causes diminution or even complete dis- appearance of the sweats (Andral, Leguu- geux), especially in the second and third stages of the disease (Combemale). The action begins two. hours or more after administration, and reaches its height three hours later. Taken before retiring, agaricin will sometimes prevent the oc- currence of a night-sweat, thereby re- lieving the patient from the consequent exhaustion. While not as certain a remedy as atro- pine, it is advantageous in not causing the other unpleasant effects of the latter, such as drying of the mouth and fauces, nausea, and dilated pupils. It may be given in combination with aromatic sulphuric acid, which has a similar action in reducing sweats. Where agaricin is found to cause gastrointestinal irritation and a tendency to diarrhea, it is sometimes prescribed with small amounts of some preparation of opium, — Dover's powder, for example. Agaricin is used to counteract excessive sweating from other causes than phthisis, including various infections and intoxica- tion by certain drugs (coal-tar antipy-. retics, salicylates). It has also been em- ployed to arrest the secretion of milk. Its action can be kept up, if desired, by giv- ing small doses repeatedly. S. AGGLUTINATION TEST. — This test, also known as the Widal re- action or the Gruber-Widal reaction, is used to establish the presence of typhoid fever. It is based upon the fact that in this disease the specific bacteria in free dilution "agglutinate," that is to say, ad- here to one another and lose their motile power, thus forming clumps or masses in the solution examined. The essential feature of this test is that, while normal serum, i.e., the serum of a normal individual, when diluted up to a certain limit, will agglutinate many bac- teria besides the typhoid bacillus, the lat- ter organism causes the production of so great a quantity of the substance "agglu- tinin," which provokes the phenomenon, that, even when a drop of serum from a typhoid patient is diluted SO times or more with saline solution, agglutination of typhoid bacteria, obtained from a recent culture of these germs, will occur. The reaction is only reliable, in fact, when the degree of dilution is not below 1 to 50. The microscopic reaction requires a slide with a concave depression in the middle of one of its surfaces. A small quantity of the patient's serum is obtained by prick- ing the ear or the finger. This quantity is diluted in fifty times its volume of saline solution. A drop of this is then placed on a cover-glass, with a drop or loopful of fresh bouillon of genuine typhoid bacilli. The cover-glass is then inverted and placed over the concavity of the slide in such a way as to cause the mixture to hang downward. Hence the term "hanging drop" method. The edges of the cover-glass being then sealed with paraffin or vaselin, the slide is examined under the microscope, using the one- twelfth oil-immersion lens, and the clamp- ing and loss of motility of the typhoid bacilli ascertained. If more than 4 bac- AGURIN. AINHUM. 483 tenia are permanently ac^sUitinatcd, the test is positive. This method is only applicable, however, in hospitals, where a clinical microscope is available, unless the physician carries his microscope to the patient's home. This inconvenience can be readily obviated, however, by dipping a piece of absorbent paper in the patient's blood. When dried this paper can be used for the test by placing it in forty to fifty times the quan- tity of saline solution that the paper con- tains of serum. The latter \n\\ then dis- solve in the saline solution, and a drop of the mixture with the drop of typhoid bacilli culture can then be used as de- scribed above. Or again, "3 drops of blood are taken from the well-washed aseptic finger-tip or lobe of the ear, and each lies by itself on a sterile slide, passed through a flame and cooled just before use; this slide may be wrapped in cotton and transported for examination at the laboratory. Here one drop is mixed with a large drop of sterile water to redissolve it. A drop from the summit of this is then mixed w^ith 6 drops of fresh broth culture of the bacillus (not over twenty-four hours old) on a sterile slide. From this a small drop of mingled culture and blood is placed in the middle of a sterile cover-glass, and this is in- verted over a sterile hollow ground slide and examined. A positive reaction is ob- tained when all the bacilli present gather in one or two masses or clumps and cease their rapid movement inside of twenty minutes" (Green-Hughes). The test may also be carried out without the aid of a microscope; this is the mac- roscopic reaction. Several bouillon cultures being available, 5 c.c. of each culture are placed in as many test-tubes as there are cultures. To each test-tube is then added sufficient serum of the suspected case to obtain a solution of 1 to SO. The test- tubes are then kept at blood or room tem- perature from three to seven hours. Their contents will then have become clearer, the bacilli having been precipitated to the bottom of each test-tube if the reaction is positive. It is obvious, how- ever, that the microscopic reaction is pref- erable and less liable to mislead. That the value of the Widal reaction is very great is now generally recognized. Kncass and Stengel in statistics based on over 2000 cases give 95.2 per cent, as the proportion in which true cases of typhoid fever had given a positive reaction, while no reaction occurred in 98 per cent, of the cases which eventually did not prove to be typhoid. Abbott, in statistics based on 4154 cases for which the Widal reaction was taken in the municipal laboratories of Philadelphia, places at only 2.8 per cent, the possibility of error. S. AGORAPHOBIA. See Index. AGURIN, a diuretic, is a double salt of theobromine sodium and sodium acetate, which contains 60 per cent, of theobromine. It occurs in the form of a fine crystalline powder, which is freely soluble in water, and but slightly so in cold alcohol. MODES OF ADMINISTRATION.— Agurin is hydroscopic and, in aqueous solu- tion, readily splits into its components. Hence, the advisability of prescribing it in capsules or in tablets, 5-grain tablets being available in, the shops. The dose is from 5 to 10 grains (0.3 to 0.6 Gm.) three to five times a day. It is also absorbed from the rectum when given in an enema of plain water. THERAPEUTICS.— Agurin is especially efficacious as a diuretic in cardiac dropsy and acts well in combinatioi with digitalis. It acts like theobromine (q. v.) and is, unlike diuretin, well borne by the stomach. It also gives good results in interstitial nephritis, especially when combined with the milk diet. This applies also to hepatic cirrhosis, though to a less marked degree. Agurin presents the advantage of promoting diuresis without increasing the blood-pressure, a property which renders it particularly useful in cases of dropsy of cardiac, renal, or hepatic origin in which arteriosclerosis renders diuretics which raise the blood-pressure dangerous. S. AINHUM. — African word meaning "to saw off." DEFINITION.— Ainhum is a disease occurring exclusively in negroes and con- sisting in the spontaneous amputation of the little toe by an adventitious fibrous, band. 484 AINHUM. SYMPTOMS.— The first indication of the disease is a furrow on the lower sur- face of the little toe, and occasionally other toes, at the proximal interphalangeal joint. This furrow, the result of the cir- cumferential pressure exerted by a fibrous ring, gradually deepens until the bone is reached, this process taking several years, sometimes as many as ten. The distal portion of the toe becomes greatly liyper- trophied, then finally drops off, the stump healing without further complications in the great majority of cases. It does not give rise to much suffering, owing to its very gradual progress. It is sometimes mistaken for leprosy. It has been ob- served in the white race also. Though rare in the United States, ainhuni is so common in India that Crawford found a case in every two thousand surgical patients in Indian hospitals. The absence of pain or inconvenience in many cases also probably prevents their being re- ported. The ultimate result of the disease, which begins as a crack or fissure, is the spontaneous amputa- tion of one or more fingers or toes by a gradiial circular strangulation. In the writer's case, complete ampu- tation of one toe and partial amputa- tion of another had occurred before the patient sought medical assistance or appreciated his condition. It is rare in females, and is almost ex- clusively confined to the dark-skinned races, only 4 cases having been re- ported in whites. It is probably a trophoneurosis of unknown origin. N. D. Brayton (Jour. Amer. Med. Assoc, July 8, 1905). Case of ainhum in a white girl in Florida. The case is of interest be- cause of the appearance of ainhum in the Southern States and heretofore reported in the negro race only. When ulceration takes place the ulcer assumes a resemblance of a necrotic ulcer with a distinct nauseous color. As advanced by Unna, the condition is a sclerodermic callosity, with ring formation, producing a stagnating necrosis. The tumefaction indicates a stagnation, resulting in degenera- tion, retraction, and finally disappear- ance of the phalanges. The disease sometimes covers a period of several years. Eskridge (Med. Rec, Sept. 17, 1910). Two cases of ainhum that the writer has cared for-at Garfield Hos- pital Dispensary. He watched the progress of the case for two years, and showed photographs and skia- graphs of them, taken at the begin- ning and end of observation. One case, in a negress, a native of Mary- land, was of sixteen years' duration, but only slightly advanced. The pain in the crack was, however, sufficient to indvice her to have the toe ampu- tated. The specimen showed the groove in the soft tissues and the slight atrophy of bone. The other case, also in a negress, a native of Georgia who had lived fifteen years in the District of Colum- bia, was of about twenty-five j^ears' duration and much more marked than the other case; the groove around the toe was deepest on the plantar and inner margins of the toe and had penetrated almost to the toe-nail. The middle phalanx was practically gone; only the nail-bearing part of the ungual phalanx remained; the basal phalanx was atrophied about one-half. The advance of absorption of bone was quite plain in the skia- graphs. The skin of the feet and hands showed a scaly condition. As the toe had given but little pain, the patient declined to have it amputated, and was therefore presented herself. Truman Abbe (Washington Med. Annals, Nov., 1910). ETIOLOGY.— Ainhum is always ob- served in negroes, especially of the west- ern coasts of Africa and South America. A number of cases have also been reported in the United States by Bringier. Hin- doos are said to also suffer from the dis- ease. Self-mutilation has been suggested by some observers, but the likelihood of this cause is very slight. Heredity does not seem to play any role in its production. PATHOLOGY.— The lesions observed have been hypertrophic thickening and AIROL. 485 retraction of the derma, with consequent atrophy of the underlying hone (ITerniann, Weber, Wuchcrer, SchiippeO. It has been confounded with congenital amputation, but, as stated, ainhum is never congenital. That the disease bears some connection with leprosy is insisted upon by. some authorities. According to Zambaco Pacha, undoubted symptoms of leprosy are pres- ent in all cases of true ainhum. It should be looked upon as an attenuated form of the latter disease. Its relations to sclero- derma are explained by the fact that this latter affection is a special form of leprosy. It has also been attributed to syphilis, larvas, and atavism. The writer agrees with Matas in terming ainhum a trophoneurosis. Personal case in a negress of 65 years whose right little toe was affected in the characteristic way. The toe was disarticulated at the metatarsophalangeal joint under co- caine anesthesia, and the cicatrix has since remained in healthy condition. H. N. Blum (Med. Record, Oct. 22, 1904). No definite and undisputed cause for the lesion has yet been proved, but the writer thinks that there is most to be said in favor of de Silva Lima's view that it is due to traumatism. The splay-footed negro is especially liable to such, and the groove around the toe in this disease, both macro- scopically and histologically, is a cicatrix. The later fatty and atrophic conditions in the amputated toe are not yet fully explained, but may de- pend on local cicatricial formations or may be of trophic origin. Well- man (Jour. Amer. Med. Assoc, March 3, 1906). TREATMENT. — Surgical measures alone prove of value in these cases. Early section of the fibrous ring is sometimes sufficient to arrest the progress of the dis- ease, or division of the skin down to the periosteum on the opposite side of the seat of the disease may be resorted to. Murray successfully treated a case by dividing the skin and all the tissues down to the periosteum, on the side opposite to -the seat of the disease. S. AIROL or bismuth oxyiodogallate [Coll:., (0H)3. COO. BilOH], is a compound of gallic acid and bismuth subiodide. It occurs in the form of a bulky, grayish-green powder, devoid of odor or taste. It is in- soluble in water, alcohol, chloroform, and ether, but is slightly soluble in glycerin and is dissolved in alkaline solutions and dilute mineral acids. When exposed to moisture, including wound secretions, it is gradually changed into a reddish powder, due to the liberation of a portion of its iodine : this change occurs with great rapidity when boil- ing water is applied to airol. MODES OF ADMINISTRATION.— Internally airol has sometimes been given in doses of 2 to 5 grains (0.13 to 0.32 Gm.). Externally it is used principally in the powder form, which is dusted over the sur- face involved after it has been washed with hydrogen peroxide or other cleansing agent. It may also be applied in an ointtpent con- taining about 2 to 4 drams of airol to the ounce of petrolatum, or in a 10 per cent, glycerin emulsion containing equal parts of glycerin and water. The latter preparation may be injected in septic areas. In the treatment of skin lesions it has been applied as a paste containing 2 parts each of glyc- erin and mucilage to 1 part of airol, mixed with a sufficient amount of refined clay or kaolin (Brun's paste). Airol has also been used as a vaginal suppository. An airolated gauze (20 per cent.), similar to iodoform gauze, is frequently employed. The fact that this substance is decomposed by free contact with water should always be kept in mind. PHYSIOLOGICAL ACTION. — When used internally or by injection in large amounts, airol has been known to cause symptoms similar to those of bismuth poison- ing. Thus Semmer witnessed a case in which 55 grains of airol az a 10 per cent, solution in olive oil injected into an abscess, resulted within three days in softening of the gums, darkening of the buccal mucous membrane, foul breath, headache, nausea, and prostration. Marked irritative effects have also been observed (Zelemsky, Gold- farb), though a total amount of 15 grains taken within three days was found by Haegler to cause no unpleasant effects. THERAPEUTICS.— Airol is valuable ex- ternally as an antiseptic, astringent, desic- 486 ALBARGIX. ALBUMINURIA (LEVISOX AND ERLAXDSEX). cant, and protective. Its germicidal proper- ties are mainly due to the liberation of iodine upon exposure to moisture. Haegler considers airol the equal of iodo- form in disinfecting power, and it has the added advantage of being without odor. It is frequently used as an antiseptic dressing for open wounds, including surgical wounds, and generally causes no pain when applied. It has been applied to infected ulcers of different kinds, varicose ulcers (Fahm), burns of the second degree, and to the lesions of various skin diseases, such as intertrigo (de Sanctis), etc. It has proven useful when injected with glycerin in ab- scesses of pyogenic or primarily tuberculous origin. In ulcerations of the cornea, airol has been applied in powder form with success (Gallemaerts, Bonivento). Airol has been used for the treatment of uterine and vaginal inflammations. It may be incorporated in the usual cocoa-butter suppositories for vaginal use, or introduced into the uterus and vagina on gauze moist- ened with a liquid mixture. Delbert dips a wick of aseptic gauze in a 1 to 4 emulsion of airol in glycerin and inserts it through the previously dilated cervix into the uterine cavity; he then packs the vagina with tampons of absorbent cotton dipped in a 1 to 20 emulsion, and does not remove it for forty-eight hours (Manquat). Airol may be given where an astringent effect on the intestinal tract is desired. Fahm has recommended its use in tuber- culous enteritis. S. ALBARGIN, or gelatose silver, an antiseptic and germicide, is a compound of silver nitrate 15 parts and gelatose 85 parts. It occurs as a light, browaiish-3^el- low, shining powder, w^hich is freely solu- ble in equal parts of both cold and hot water, making a permanent solution if not exposed to light. It is incompatible with ferric and ferrous chlorides, tannin, opium, resins, and the essential oils. THERAPEUTICS.— Albargin is mainly used as a substitute for silver nitrate in the treatment of gonorrhea. Its aqueous solutions being neutral, it may be used as injections in strengths from ^ to 2 per cent. Its molecule being smaller than that of albuminous preparations of silver, it is thought to penetrate more thoroughly and promptly the diseased tissue and destroy the gonococci therein. Albargin has also been found efficacious in the treatment of chancroids. Its use is painless, and it does riot irritate mucous membranes; it may safely be used, therefore, in the treatment of gonorrheal ophthalmia. S. ALBUMINURIA. — D E F I N I - TION. — The presence of albumin in the urine, a condition now known to occur under many circumstances without necessarily indicating- the presence of serious morbid changes in the kidney. Albuminuria may be true — when the albumin is dissolved in the urine — or spuvious, when caused by admixture of semen, pus, or blood in the urine. Spurious albuminuria is easily dis- tinguished from the true form by the aid of the microscope. Both kinds of albuminuria may occur simultaneously. Domenico Cotugno discovered, in 1770, that urine may contain albumin; by boiling a sample of urine he found that pure albumin was precipitated. It was long maintained by all authors that albuminuria was always a symp- tom of disease, but of late many authorities have admitted that albu- minuria may be compatible with per- fect health. Posner maintains that albumin is always found in the urine, but normally in too small quantity to be revealed by the ordinary reagents. To demonstrate the presence of albu- min in normal urine Posner evapo- rated large quantities of urine at low temperature and tried the different reagents in the concentrated urine. His experiences were repeated and his views supported by Senator and by Leube, who, however, did not ALBUMINURIA (LEVISON AND ERLANDSEN). 487 find all)umin in all cases. Von Noor- den, Winternitz, Lecorche, Talamon, and other authors do not admit that albumin is a constituent of the normal urine; but this was recently denied by Morner, who found that it inva- riably containetl at least 22.78 mg. (about 3.5 of a minim) per liter. Different kinds of albumin may be present in the urine; generally the proteids contained in the blood-serum are to be found, — viz.: (1) the serum- albumin, and (2) the globulin, or paraglobulin ; in most cases both these proteids are present, but in varying proportions. In some cases there may also be found (3) hemial- bumose, or propeptone, a mixture of different albumoses which are not precipitated by boiling; (4) nucleo- albumin, which has also erroneously been called "mucin," and (5) peptone. Joachim found pseudoglobulin in every case of albuminuria, while eu- globulin was often absent. The. albumin content mostly exceeds that of the globulin. The writer carefully estimated the amount of serum-albumin, of euglobulin, and of pseudoglobulin in various forms of albuminuria, by means of fractional precipitation with sulphate of ammonia, and subsequent determination of nitro- gen by Kjeldahl's method. Euglobulin • was never found in febrile albuminuria. The globulinic index cannot be accepted as a guide in the discrimination of various kinds of albuminuria, a.s it varies in such wide limits in cases which are closely akin to each other. No reliance can be placed on the albu- minoid index as a prognostic criterion, for, although sometimes it was higher in cases where the kidneys were com- paratively free from disease, the re- verse was the case at other times. The author did not find a marked increase in globulin in acute nephritis, febrile albuminuria, orthostatic albuminuria, and the albuminuria of pregnancy. Balocco (Gazz. deg. Ospcd., Jan. 28, 1906). The urine may, of course, also contain albumin in connection with hematuria and hemoglobinuria, but such cases cannot be classed as true albuminuria. PHYSIOLOGICAL ALBUMI- NURIA. — Regarding the origin of the albumin in the urine only guesses can be made ; two theories are pos- sible : (1) the albumin may come from the glomeruli; (2) from the tubular epithelial cells. Formerly the opinion predominated that the fluid which escaped from the glomeruli was albuminous, but that the albumin was absorbed during the pas- sage through the healthy renal tubules, diseased tubular epithelium being unable to absorb the albumin. This has not been proved, however, and most modern authors believe that albumin is not contained in the urine coming from the glomeruli, except when these are diseased or when the pressure of blood in the glomeruli is abnormally great. Runeberg, on the contrary, is of the opinion that albuminuria is caused by low pressure of blood, and supports this opinion by experiments with animal membranes, but experiences with dead membranes cannot be regarded as con-, elusive for the action of the living' kidney. Von Noorden and other authors re- gard the tubular epithelium as the unique source of albuminuria. These epithelial cells are subject to successive disintegration: when this is minimal, and successive traces, only, of albumin are found in the urine, the albuminuria is physiological; when the disintegra- tion of the tubular epithelial cells is augmented and hastened by disease, a morbid albuminuria takes place. In 488 ALBUMINURIA (LEVISON AND ERLANDSEN). his opinion, this theory is supported by the fact that nucleoalbumin, of which the protoplasm of the cells undoubtedly is the source, is always found in nor- mal urine. Senator considers physiological al- buminuria in the same light as physio- logical glycosuria, and, among the causes that give rise to it in susceptible individuals, he mentions : severe exer- tion of the lower extremities, eating and digestion of hearty meals, men- struation, cold baths, psychical excite- ment, etc. He deems albuminuria pathological only when it does not disappear promptly on the cessation of the particular stimulus that caused it. Physiological and allied forms of albuminuria are attributed to con- genital predisposition of the individ- ual to disease of any organ which directly or indirectly may influence the elimination of albumin. The occurrence of albuminuria is to be regarded as pathological only when it does not take place under unusual conditions alone, and does not dis- appear promptly on the cessation of the particular stimulus that caused it. Orthostatic albuminuria is distinctly pathological, and most cases of this or cyclical albuminuria are caused by a slight irritation or inflammatory state of the kidneys, which may go on to recovery or may develop into a chronic diffuse nephritis. Physiological and allied forms of albuminuria are based upon congenital or acquired predispo- sition of the individual, which consists in an abnormality of various organs, such as the kidneys, the digestive tract, the blood-vessels, or the body fluids. Senator (Deut. med. Woch., Dec. 8, 1904). Study of the albumin in the urine of normal children. In each specimen of urine, the writers determined the color, the appearance, the specific gravity, the reaction (in twenty-four-hour speci- mens, the total acidity), the presence or absence of albumin, sugar, acetone, diacetic acid, indican, urobilinogen, and phenol ; and microscopically, the pres- ence or absence of cells, casts, cylin- droids, and crystals. Four hundred and forty-five specimens of urine were ex- amined. These were obtained from 124 children, ran£ing in age from 18 months to 14 years. During the period of examination the usual routine of life was followed, except that the children were kept from school. There was no relationship between the specific gravity and thf^ form or amount of albumin. The reaction had no influence on the production of albumin. Sugar, acetone, and diacetic acid were never found. They may, therefore, be con- sidered as having no bearing on the production of albumin. Indican, phe- nol, and urobilinogen, when present, were usually associated with albumin, but albumin was soinetimes absent when they were all present, and the amount was never greater when associated with them than it was in the cases in which they were absent. Crystals, when pres- ent in amounts, such as are occasionally found in normal children, are in no way responsible for the associated albumin. The mild disturbances of the intestinal digestion, as shown by the examination of the stools, were not sufficient to account for the occurrence of albumin. The blood-pressure was within the normal range in all cases and, there- fore, did not influence the albumin out- put. The albumin elimination was the same on mixed and exclusive milk diets. They found no children in whom the albumin excretion corresponded to the requirements f6r postural or orthostatic albuminuria, a rather surprising result in view of the frequency with which this condition is supposed to occur. Thirty-two and one-half per cent, of the children showed occasional hyaline casts and cylindroids in the urine. The authors do not consider their "occa- sional presence" as indicative of a lesion of the kidneys, but rather as suggesting a temporary overtaxation of the kid- neys resulting from variations in the habits of life of the individuals, which are too slight to be recognized. Eighty- ALBUMlNURfA (LEVISON AND ERLANDSEN). 489 ciglit and scvcn-tcnths per cent, of the urini.' of these 124 chilch-cn showed al- bumin, 27.4 per cent, showed serum- albumin alone and in combination, and 85.4 per cent., an albuminous body precipitated by acetic acid in the cold. These two albumins were nearly always present in very slight traces, occasion- ally in slight traces, and rarely in traces. In 38 children the twenty-four-hour specimens showed nucleoalbumin in all but 1, and in this case samples examined over prolonged periods of time showed nucleoalbumin frequently. In these 38 children, the percentage of serum-albumin was very much larger (42.1 per cent.) than in the total number of cases examined. The authors believe, therefore, that it is possible to demonstrate in the urine of every presumably h^^lthy child traces of an albuminous body precipitated by acetic acid. Consequently, this sub- stance must be regarded as an exceed- ingly common, if not constant manifes- tation in the urine of children under 14 years of age, and as of no clinical significance. The writers do not believe that serum-albumin in the amounts in which it appears in these children indi- cates a diseased condition of the kid- neys any more than does the presence of occasional hyaline casts and cylin- droids, and that its etiology may be considered the same as that given for these former elements. Hamill and Blackfan (Amer. Jour, of Dis. of Children, Feb., 1911; Jour. Amer. Med. Assoc, Mar. 4, 1911). From a pathological point of view the causes of albuminuria may be divided into three groups: 1. Disturbances of circulation. 2. Changes of the tubular epithelial cells or of the walls of the blood-vessels o" the kidney. 3. Changes in the composition of the blood. 1. All disorders of circulation capa- ble of causing a venous renal congestion will increase the blood-pressure in the capillaries of the kidney, and thus give rise to a transudation of albuminous liquid; when the congestion is very great the urinary tubules may even be compressed and the escape of the urine rendered difficult. When this is the case and when, also, the supply of. arterial blood is diminished, the tubular epithelium will be damaged, and the first result of all this is albuminuria. It is very improbable that arterial con- gestion ever produces albuminuria, al- though the experiments of Munk and Senator tend to prove the contrary. Leube found in the early stages of aortic insufficiency, not accompanied by cyanosis, edema, etc., a slight albumi- nuria. Pathological examination of the kidneys showed the walls of arteries and capillaries much thickened. He makes these changes and their conse- quences responsible for the malnutri- tion of the kidney and its result : albuminuria. A complicating parenchymatous ne- phritis-may exist, as where the endo- carditis is caused by diphtheria. The nephritis is generally amenable to treat- ment, while endocarditis persists. There may be a general atheroma, which also involves the renal vessels, leading to arteriosclerotic kidney. This is espe- cially common with aortic insufficiency. When the energy of the heart sinks and the cardiac muscle undergoes fatty de- generation, stasis, followed by cyanotic induration, is found in all the organs. This occurs only in the later stages of aortic insufficiency. Besides this there is, however, another form of albumi- nuria, characteristic for the early stages of aortic insufficiency and not accom- panied by cyanosis, edema, etc. The urine is not diminished in amount, the specific gravity is relatively low, and the amount of albumin, hyaline and granular casts very slight. Patholog- ical examination of a few kidneys of this kind shows that the marked varia- tions in pressure are responsible for certain anatomical changes. The walls of the arteries and capillaries are found much thickened ; so that the amount of blood carried to the kidneys must nee- 490 ALBUMINURIA (LEVISON AND ERLANDSEN). essarily be less than normal. The liver and spleen show similar lesions, but never the lungs. V. Leube (Miinch. med. Woch., July 28, 1903). 2. Changes of the 'tubular epitheha and the walls of blood-vessels of the kidneys may, as already stated, be due to disorders of circulation, but they may also be caused by different poisons and toxins. When albuminuria is chiefly caused by degeneration of the tubular epithelia, their protoplasm dissolves in the urine, and nucleoalbumin in great quantity is contained in it, combined with serum-albumin and globulin. Menge and Schreiber noted albumi- nuria in several cases in which the kidney had been palpated bimanually, as a result of the circulatory changes produced during the examination. This procedure has been used by Schreiber in the diagnosis of doubtful cases of floating kidney. Albuminuria follow^ing renal palpa- tion. Renal hematuria with albuminu- ria noted in several cases in which the kidney had been examined bimanually and in which no albumin had been pres- ent in the urine before examination. The pressure to which the kidney is exposed causes circulatory changes which permit of the transudation of serum from the renal capillaries. C. Menge (Miinch. med. Woch., June 5, 1900). If a floating kidney be palpated in the usual manner, albumin will almost always appear in the urine, even where only a small portion of the kidney can be grasped between the fingers. The color of the urine voided after palpa- tion is generally somewhat paler, and microscopical examination shows an abundance of epithelial cells from the pelvis, ureter, and bladder, cylindroids, red and white blood-cells, but hardly ever casts. The albuminuria is very probably caused by the passage of serum from the capillaries into the tubules. Prob- ably some lymph also reaches the latter, since there frequently is no rela- tion between the degree of pressure exerted and the amount of albumin. The observation is of great clinical value, since a doubtful organ in the abdomen may be safely diagnosed as kidney, if albuminuria follows after palpation. J. Schreiber (Zeit. f. klin. Med., Bd. Iv). Albuminuria may be discovered at one examination and not at the next, even the following day, i.e., "fugal al- buminuria," and may lead to errors in diagnosis. It is evidently the result of some interference with the circulation and may be encountered as a direct consequence of palpation of the abdo- men. It occurs only when the epigas- trium and mesogastrium are palpated, thus showing that the aorta above the renal arteries feels the effect of the palpating fingers. J. Schreiber (Med. Klinik, Apr. 4, 1909). 3. When the composition of the blood is altered, the urine often becomes albuminous. This can be proved ex- perimentally by injecting egg-albumin, soluble casein, hemoglobin, etc., into the veins of animals; the quantity of albumin excreted after the injection will generally exceed the quantity in- jected. Similar results may be obtained by the injection of peptone and propep- tone, whereas the albuminates are gen- erally inoffensive. Ingestion of a very large quantity of egg-albumin is liable to provoke albuminuria. Semmola has tried to prove that albu- minuria is always caused by changes of the blood characterized by abnormal diffusibility of its proteids, and, in his opinion, the pathological changes in the kidneys are consecutive to the albumi- nuria. Though his theory is not gener- ally accepted, Rosenbach has adopted it for the albuminuria which is not caused by nephritis, and regards it in such cases as a salutary and regulating process. In most clinical cases different causes ALBUMINURIA (LEVISON AND ERLANDSEN). 491 are simultaneously active, and it is generally very difficult to determine which is the preponderating etiological factor. L, Williams ascribes the ma- jority of cases of albuminuria either to altered blood states or to failure in the normal vasomotor mechanism. The majority of the cases arc due to either altered blood states or to failure in the normal vasomotor mechanism. This failure may' manifest itself in one or two directions. In the first, chiefly by some means so far undiscovered, the blood-pressure in the splanchnic area arises and is maintained at a suffi- ciently high level to induce a renal plethora and consequent albuminuria. Of such are the cases of hyperpiesis, as in the instance quoted. In the sec- ond place, owing to a local or general vasodilatation, the blood-pressure in the splanchnic area falls to the point at which a renal stasis is induced. Of such are the cases of cyclical, postural, and athletic albuminuria, of which also instances are cited, cases which, for the most part, occur in young adults in whom the vasomotor response is either undeveloped or for some reason is in- adequate. Having regard' to these facts, the writer ventures once more to insist not only that, of itself, albumi- nuria affords no evidence of renal dis- ease, but that, of itself, it does not present even a reasonable suspicion of the existence of such disease any more than, of itself, dyspnea presents a rea- sonable suspicion of cardiac disease. L. Williams (Clin. Jour., Apr, 1908). It is, nevertheless, true that traces of albumin, and even a rather considerable amount of it, may be found in the urine of persons otherwise healthy and pre- senting no symptoms of disease of the kidneys or of the organs of circulation. Many clinicians, therefore, admit that albuminuria may be regarded, in some cases, as physiological ; this is, however, contested by many. Case in which for over twenty years the patient had been passing large quantities of albumin in the urine, 3 grams per liter. Microscopic examina- tion revealed no casts or corpuscles, and there was nothing to suggest renal trouble. The heart was normal in size, the sounds were normal, blood-pressure was in the limits of the normal, and there was little or no arterial thicken- ing. The patient has maintained his usual high standard of health, and, al- though he had always been thin and spare, he is very tough. The most re- markable feature of the case, however, is that all the members of the patient's family exhibit the same peculiarity. They are all perfectly well, and, con- sidering the age the parents have at- tained (87 and 78 respectively), such a case as this should have an important bearing on the question of rejection or "loading" of candidates for life insur- ance. Fergusson (Brit. Med. Jour., Mar. 19, 1910). Virchow described a physiological albuminuria in infants, occurring in the first days of life, and explained it by the sudden changes of circula- tion taking place immediately after delivery. Flensburg and Sjoquist have shown that albuminuria regularly occurs in the first days of life, and that the urine also contains an extraordinary quantity of uric acid crystals ; prob- ably the albuminuria is then due to the irritation of the kidneys caused by these crystals. Ebstein and Nicolaier have shown experimentally that when the kidneys are forced to excrete a surplus of uric acid which cannot be dissolved, but goes to the bottorn in the form of crystals, the urine commonly contains albumin and sometimes even blood. Gull found a certain -form, of ph3^sio- logical albuminuria in adolescents about the age of puberty, especially in weak and pale individuals. Other authors, among whom is Ouain, have 492 ALBUMINURIA (LEVISOX AXD ERLAXDSEN). noticed that this condition is quite frequently associated with masturba- tion. Lommel found that 19 per cent, of young men (14 to 18 years oldj suf- fered from albuminuria. without hav- ing nephritis. The albuminuria had an intermittent character and w'as orthostatic in type. A large percentage of boys from 14 to 18 years of age suffer from albu- minuria without having nephritis. Re- peated examination of over 500 young employes of a large factory showed albumin in no less than 19 per cent. In most cases only traces could be detected, though in a few the amount exceeded 1 pro mille. The greater part of the albumin seemed to consist of lobulin, as in acute nephritis, indicating the presence of wide meshes in the filter- ing apparatus of the kidney. The cause of the albuminuria, which generally had an intermittent character and was ortho- static in type, was to be found in an impoverished condition of the blood, together with a mild degree of cardiac insufficiency and tendency to stasis, such as is liable to occur during puberty where the rapid growth of the body is out of proportion to the functional powers of the internal organs. In ac- cord with this, dilatation of the heart, tension of the arteries, and accentuation of the second aortic sound were fre- quently noted. F. Lommel (Deut. Archiv f. klin. Med., Bd. Ixxviii, Nu. 5 u. 6, 1903 J. Dunhall and Patterson and Collier found albuminuria (0.2 to 15 per cent.j after severe exercise (such as rowing and running in races j also in healthy subjects. Several instances in healthy subjects in which albumin was found in varying amounts after severe exercise (0.02 to 0.15 per cent.). The writers also dis- covered incidentally that in different urines the sensitiveness of boiling and ferrocyanide of potassium with acetic acid, as tests for proteid, varied consid- erably. S. P. Dunhall and S. W. Pat- terson (Inter. Med. Jour., July 20, 1902;. As examiner of students at Oxford University, the writer has, during the past, been in the habit of advising all m.en whose urine showed the presence of albumin after exercise to give up all competitions involving great muscu- lar strain, such as rowing and running in races. He found that if albumin was present during the student's first year at the university it continued throughout his career there. During 1906, however, he made systematic ex- aminations of the various men in train- ing for boat-racing, and found that, without exception, every man who rowed over the full course passed albu- min in his urine, and at least one-half passed a considerable quantity. The same thing was true of the running men. So that just as evidence of hyper- trophy of the left ventricle of the heart, and emphysema of the lungs may be expected in men indulging in violent athletics, so may the presence of a definite amount of albumin in the urine for a few hours after such exercises be looked for. The writer, therefore, no longer holds that such men should be advised to give up all hard athletic competitions, nor should insurance com- panies continue to refuse to consider the acceptance of the lives of such men. Collier (Brit. Med. Jour., Jan. 5, 1907). PHYSIOLOGICAL CYCLICAL, ORTHOSTATIC,AND ORTHOTIC ALBUMINURIA.— The question of physiological albuminuria in adults has been much discussed during the past few years and has particularly engaged the interest of the medical men employed in insurance work. It is characteristic of physiological albuminuria that the quantity of albu- min is generally small and that the excretion is, in most cases, intermit- tent, or cyclical. Leube, Pa\'y, Fiir- bringer, Klemperer, and many other authors have studied this condition. Pavy introduced the denomination "cyclical albuminuria" for the cases ALBUMINURIA (LEVISON AND ERLANDSEN). 493 in which the allniniinuria ceases and returns at regular intervals. Stirling ascribes cyclical albumi- nuria to a sudden shock from the blood-pressure upon assuming the upright position on arising, but Rudolph showed that albumin also appeared in the urine when the up- right position was assumed very slowly. . Pavy likewise insists upon posture as the invariable cause of cyclical, or in- termittent, albuminuria, the excretion ceasing when the subject is in the re- cumbent position and going on only when he is walking or standing. The cycles are commonh- completed within the day, but in a case narrated by Klem- perer there were two cycles^ the maxi- mum of albuminuria taking place in the forenoon and afternoon. Hauser concludes that these cases can always be traced back to an uncured nephritis or to some acute infection (notably scarlatina), and puts no cre- dence in a functional disorder. In other words, he always considers cyclical al- buminuria as the expression of some pathological factor. The writer records a prolonged study of 14 cases of cyclical albuminuria, and concludes that these cases can invari- ably be traced to an uncured nephritis, or to some of the acute infectious dis- eases, especially scarlatina. The author does not believe that a functional disor- der exists in these cases, but refers the appearance of albumin to excessive muscular use which affects the epithe- lium of the vessels of the glomeruli by an increase in toxins or in metabolic products. Hauser (Berl. klin. Woch., Dec. 14, 1903). Case of a young man, 21 j^ears of age, who had suffered for eight j^ears from intermittent albuminuria that ap- peared as a sequela to an attack of nephritis caused by scarlet fever. Eich- horst (Med. Klinik, April 18, 1909). Oswald attributes all forms of albu- minuria of adolescence to irritation of the renal epithelium. There is no difference between the albuminuria of puberty and the so- called physiological albuminuria of adult "life: between orthostatic albu- minuria in a man and the puberal albu- minuria of a bo3^ The writer considers that both are due to irritation of the renal epithelium. A. Oswald (Miinch. med. Woch., 1904). Aloritz ascribes cyclical albuminuria to some insufBciency of the circulatory apparatus, having observed that the in- creased blood-pressure which normally occurs after moderate exercise is fol- lowed by abnormally low pressure in individuals that are subject to C3xlical albuminuria. Cyclical albuminuria is due to some insufliciency of the circulatory appa- ratus, for the writer noticed that the increased blood-pressure which nor- mally occurs after exercise of a mod- erate degree was followed by abnor- mally low pressure in those persons who were inclined to display a tendency toward c\-clical albuminuria. He made some practical tests in two patients of this type bj- requiring them to lie down and then artificialh- inducing a disturb- ance of respiration by calling on them for straining efforts for ten or fifteen minutes, similar to those at stool. This was invariably followed by the appear- ance of albumin in the urine, although none had been present before. P. Moritz (Deut. med. Woch., Nu. Zl, 1903). The diagnosis of physiological albu- minuria ought not to be made except in cases when persons presenting"^ no other symptom of disease excrete, constantly or intermittently, a urine containing a scanty quantity of albumin, but no morphotic elements and especially no casts. The centrifugal apparatus, now in general use, will certainly contribute to restrain the number of these cases. 494 ALBUMINURIA (LEVISOxN AND ERLANDSEN). The urine should be obtained by catheterism in all doubtful cases. The prognosis is generally considered good (Broadbent, Beck, Dukes, Ties- sier, Posner). Nevertheless it is still justifiable for life-insurance examiners to be cautious in accepting persons suffering from albuminuria. Orthostatic albuminuria is one of the functional albuminurias, and requires the erect posture for its appearance. It appears in young persons who are otherwise healthy, is not influenced by fatigue, habit to milk diet, and is not accompanied by any of the functional conditions associated with Bright's dis- ease. The discovery is purely acci- dental, and depends upon methodical examination of the urine. Standing immobile will cause it to appear, and lying down to disappear. The albumin may persist while the patient is walk- ing, but walking alone does not produce it. No functional disturbances in the other organs can explain this form of albuminuria. Orthostatic albuminuria occurs equally in both sexes, in neuro- pathic and slightly anemic adolescents, presenting a nervous or diathetic hered- ity, and is always associated . with an appreciable disturbance of the vaso- motor system. It seems to be due to fluctuating congestion of the kidney, a vasomotor disturbance of the renal cir- culation comparable to cyanosis of the extremities produced by the same cause. H. G. Beck (Amer. Jour. Med. Sci., Sept., 1903). There is an affection which may be called postural albuminuria. Its char- acteristic feature is albuminuria on ris- ing from bed in the morning, usually passing off in the course of the day. It is most common in boys and young men, especially those who are studying hard. It is not due to food, does not appear if the patient remains in bed to breakfast, and disappears quickly on lying flown. It is obviously in relation with the erect posture after a night's rest in bed, and with imperfect cardio- vascular adjustment to the changed hydrostatic conditions. The amount of albumin may be very small, but it is usually very considerable. Its recog- nition is important, as the treatment re- quired is the exact reverse of the usual milk diet and protection from cold and fatigue. The most common antecedent is a neurotic family history and cardio- vascular instability. The pulse varies greatly in frequency and is greatly influenced by changes of position. The violent cardiac impulse is due to for- cible action of the right ventricle, the apex beat being weak, and the second sound is reduplicated on lying down. The prognosis is favorable, all the treat- ment usually required being good, simple food ; fresh air, and vigorous exercise. Tonics may be useful and constipation should be corrected. If these cases are treated for renal disease they usually go from bad to worse, and become con- firmed nervous valetudinarians. Broad- bent (Brit. Med. Jour., Jan. 2, 1904). When the albuminuria of adolescents is recognized and treated, there is lit- tle likelihood of its proving the precur- sor of organic disease of the kidneys, even when its duration has been many years. The general treatment resolves itself into so reasonable a regulation of life as to insure the highest state of vitality during adolescence : Work, while it may be ample, must not be excessive ; and work is always excess- ive during the years of growth, when sleep is insufficient. The hours of both must be determined according to age. Exercise should be recreation rather than physical drill, which, by the pleas- urable sensations, increases the tone of the whole nervous and vascular sys- tem, and such exercise should be daily. Food should be sufficient for the pro- vision of growth, as well as the re- moval of wear and tear, bearing in mind that the adolescent requires more food than the adult, and the girl more than the boy on account of her greater rapidity of growth. The duties of the scavengers of the body should be so disciplined as to be brought under the habitual control of the will. Natural action should not be replaced by the perpetual stimulus of aperients, for this ALBUMINURIA (LEVISON AND ERLyVNDSEN). 495 vicarious duty obviously confirms the intestines in sluggishness of work, and tends to convert a temporary inactivity into a permanent abandonment of func- tion. Clement Dukes (Brit. Med. Jour., Oct. 7, 1905). It is a mistake to diagnose a nephri- tis in every case where traces of albu- min are excreted. With delicate tests albumin may be detected in almost every urine, but larger quantities often occur in the so-called essential albu- minuria, and merely signify that the renal filter has become less dense with- out, however, altering the appearance or function to such an extent that a nephritis may be assumed. If the his- tory of such cases be studied in detail, an infectious disease will often be dis- covered as cause, but even after years the amount, appearance, and specific gravity of the urine will remain normal and casts are uncommon or absent alto- gether. The treatment consists in proper diet and mode of living, since the kidneys undoubtedly form a locus minoris resistentice, and a nephritis may follow after the use of much alcohol, etc. C. Posner (Zeit. f. klin. Med., vol. liii, 1904). It is no longer justifiable for life in- surance and other such examiners to take the serious view hitherto accepted by most clinicians of physiological albu- minuria. When it is found that the excretory function is being properly performed ; that the substances nor- mally gotten rid of through the kidneys are not being retained in the organism, and that the albumin in the urine may be diminished by lessening the hydro- static pressure upon the renal capil- laries by increasing the coagulability of the blood, there is every reason to con- clude that the kidneys are free from organic disease, that life is not in the least endangered. Instances reported in which excellent results have been achieved by the administration of cal- cium chloride in doses of 20 grains three times a day. Calcium lactate in the same dosage is also useful. Both increase the coagulability of the blood. A. E. Wright and G. W. Ross (Lancet, Oct. 21, 1905). Very small proportions of albumin should not be taken into account in rela- tion to life insurance, and consequently the writer does not regard as of much moment the efforts to produce more and more delicate tests for albuminuria. The so-called physiological slight albu- minuria after excessive exertion, sports, etc., may also be disregarded. The majority of cases of orthostatic albu- minuria are also comparatively harm- less; it is exceptional for nephritis to develop later in these cases. In ex- amining it is important to note the absence of the higher blood-pressure characteristic of contracted kidney; also that the urine is free from albu- min during reclining. Fiirbringer (Deut. med. Woch., Nov. 25, 1909). Teissier distinguishes three groups of orthostatic albuminuria : The true or- thostatic albuminuria, where the albu- min appears very soon after assuming the erect posture. It disappears in the recumbent posture. The mixed ortho- static albuminuria, which, more slow in its development (usually not before ten and twelve in the morning), is found in persons with an earlier acute infec- tion and believed to be due to actual organic changes in the kidney. The associated orthostatic albuminuria is also slower in making its appearance after assuming the erect posture and is associated with abnormal conditions of other organs (dilated stomach, ente- roptosis, movable kidney, etc.). As nephritis can be excluded in the greatest majority of cases of orthotic albuminuria in children, a milk diet is contraindicated and a strengthening general diet indicated. In addition, there should be physical treatment to increase the general strength, with special attention to muscles of the lum- bar region. Jehle (Miinch. med. Woch., Jan. 7, 1908). Examination of 150 girls between the ages of 9 and 14 to determine the in- fluence of curvature of the spine on orthostatic albuminuria. It showed 496 ALBUMINURIA (LEVISON AND ERLANDSEN). that curvature of the spine is not the exclusive cause of orthostatic albumi- nuria, although it is an important factor in many cases by its interference with the circulation in the kidneys. Vas (Deut. med. Woch., Aug. 26, 1909). Albuminuria in 4 girls between 12 and 16, nervous and anemic, but the albuminuria disappeared when the girls remained in bed. There was nothing but the albumin to indicate anything wrong in the kidney or circulation. The albuminuria could be induced at will by inducing lordosis. During the years of most active growth the verte- brae are not supported so firmly as later in life, and the physiologic curve of the spine becomes exaggerated by the laxness of the ligaments, etc. Tur- rettini (Revue de med., Sept., 1909). There are two indications to be fol- lowed : an avoidance of lumbar lordosis while standing or walking, and eflforts to strengthen the muscles of the loins and abdomen in order to correct as quickly as possible the incorrect and harmful position. Fischel (Med. Klin., May 1, 1910). Examination of 346 children between the ages of 5 and 13 for albuminuria showed that 14.5 per cent, 189 girls and 157 boys, gave signs of orthostatic albuminuria. There did not seem to be any more pronounced tendency to neuropathies among these children than among their mates, although enlarged tonsils or chronic pharyngitis were more frequent among them. There was no trace of pathological lordosis among a large number of the children, while true lordosis was quite frequent among children free from any tendency to albuminuria. F. Gotzky (Jahrbuch , f. Kinderheilk, April, 1910). Even when no casts can be found, albuminuria ought never be regarded as absolutely inoffensive. Although a cyclical albuminuria continuing years may be compatible with perfect health, many authors (Johnson, Greenfield, Bull, etc.) are of the opinion that it sig- nifies the first stage of the evolution of granular atrophy of the kidneys. On the other hand, casts may be found in normal urine and do not mean nephritis. Tuttle, for example, beheves that ne- phritis may exist without albuminuria. The mass of evidence which has come to us of late from the autopsy table shows conclusively that chronic nephri- tis exists and is an unrecognized cause of death in a proportion of cases far beyond ordinary belief, and the com- parison of carefully kept records of cases before death with autopsy find- ings shows that little reliance can be placed on the mere urinary examina- tion, either positive or negative, as a means of absolute diagnosis or prog- nosis of Bright's disease. The writer's own experience leads him to believe that (1) Bright's disease may exist without the ordinary urinary manifes- tations — viz., albumin or casts ; (2) albumin and casts may be found in the normal urine and do not necessarily mean Bright's disease ; (3) given a case of chronic Bright's disease with albuminuria, the fact of its presence, its constancy, or its amount has absolutely no prognostic significance. C. A. Tuttle (Jour. Amer. Med. Assoc, Mar. 31, 1900). Series of experiments show that the albumin present in nephritic urine is derived from the blood and is different from the specific kidney albumins. L. Aschoff (Lancet, Sept. 6, 1902). The albuminuria often found in par- turient women (Aufrecht saw it in 56 per cent, of all cases) must be regarded as physiological. Albuminuria occurring during labor is a reasonable accompaniment of par- turition ; the quantity is greater than can be considered normal, and is often the greatest seen in any except a permanent pathological condition. The condition requires no especial and sep- arate treatment, and cannot be con- sidered a permanent pathological lesion. The albuminuria of labor is differen- tiated from the other by the presence of labor and by the fact that it ceases ALBUMINURIA (LEVISON AND ERLANDSEN). 497 after parturition. The more abundant the albumin, the more gradual is its dis- appearance. The albuminuria of the puerperal period is the continuation of that of labor, and is never a separate condition. The Ibuminuria of labor is most pronounced toward the end of parturition, especially in cases of diffi- cult or complicated labor. Circum- stances which do not tend to make par- turition especially difficult have no in- fluence upon its albuminuria. The sedi- ment of urine taken during labor shows organized material, including cylin- droids, so often seen in cases of abun- dant albuminuria. These cylindroids are not abundant, and are to be dis- tinguished from others by the fact that they contain superficial kidney epithe- lium in abundance, but not the elements which come from the deeper kidney structures. Jageroos (Archiv f. Gyn., Bd. xci, Hft. 1, 1910; Amer. Jour. Med. Sci., Nov., 1910). PATHOLOGICAL ALBUMINU- RIA. — Pathological albuminuria is found in pathological changes of the blood — as anemia, leukemia, pseudo- leukemia, scurvy, icterus, and diabetes — even when the kidneys do not present pathological changes. It is also found in many disorders of the nervous system, as epilepsy, migraine, psychosis apoplexy, neuras- thenia, and Basedow's disease, etc. Delirium tremens has also been men- tioned as a nervous disease often com- plicated with albuminuria. H. H. Schroeder regards excessive eating, overindulgence in alcoholic drinks and possibly tobacco as the most frequent causes of albuminuria. Transient albuminurias are not of serious import unless they occur too frequently. Persistent and even cyclic albuminurias should cause anxiety on the part of the attending physician, who should endeavor to ascertain the cause, and, if possible, remove it. A careful examination of these cases means a study of the twenty-four-hour speci- men of urine. The daily quantity as well as specific gravity and amount of urea should be noted, and there should be an examination for albumin and casts. The blood-vessels should receive attention. Such observations might have to extend over months or even years. The most frequent causes of albuminuria are excessive eating, overindulgence in alcoholic drinks and possibly tobacco, and the gouty diathesis. H. H. Schroeder (Med. Rec, July 18, 1903). Although the kidneys are theoretically believed to be healthy in the diseases mentioned above, there is no doubt that albuminuria, in many cases of this class, is caused by pathological changes of the kidneys. In all febrile and especially in all in- fectious diseases albuminuria is a very frequent symptom. It has been noticed in enteric fever, diphtheria, variola, after vaccination, in erysipelas, influ- enza, rheumatic fever, pneumonia, etc. In these cases the albuminuria is caused by changes in the composition of the blood, increase of blood-pressure, rise of temperature, and finally by changes in the structure of the kidneys, espe- cially of the tubular epithelial cells caused by the toxic substances excreted. The presence of albuminuria in pregnancy, as stated above, is com- mon (56 per cent.). Casts are only found in about 50 per cent, of these cases of simple albuminuria. The so- called kidney of pregnancy is to be regarded as a specific toxic nephritis which tends to recur in subsequent pregnancies. The prognosis of it, if properly treated, is good. Albuminuria has been observed in diseases of the intestines, dilatation of the stomach, ileus, ruptures, etc., and in renal venous congestion caused com- monly by disease of the heart or the great vessels. ' 1—32 498 ALBUMINURIA (LEVISON AND ERLAXDSEX). It is present in all diseases of the kidneys. Acute, as well as chronic, albuminuria is generally found in the diffuse forms of nephri- tis, as well as in circumscribed renal diseases — such as infarcts, abscesses, or tumors. After retention of urine the portion of urine first passed is fre- quently albuminous. A large amount of albumin, without blood or pus, may generally be taken to indicate chronic tubal nephritis, and this can be confirmed by a high specific gravity, by microscopic examination, and by the appearance of the patient. A very small trace in an elderly or middle-aged man will probably indicate chronic interstitial nephritis; confirma- tory evidence can be found in the aspect, the history, the pulse tension and tracing, the outward displacement of the cardiac impulse, the accentua- tion of the systolic apical sound, and the accentuation and reduplication of the second sound at the base of the heart. These indications may be fur- ther supported in some cases by the pale color and low specific gravity of the urine; less frequently information may be gathered from the presence of casts and from their predominant characteris- tics. The absence of casts is not, how- ever, to be regarded as an indication that the case is not one of chronic inter- stitial nephritis. In a young man a mere trace of albumin may be the only evidence of a functional albuminuria, and the diagnosis must then rest upon negative evidence to a large extent, one of the most important factors be- ing the relatively high specific gravity, unless this has been influenced by nervousness or by the recent consump- tion of a large quantity of liquid. With the same limitations the deep color of the urine will lend confirmatory evi- dence. There are so many causes for great variations in the condition of the urine that stress cannot be laid upon the amount of albumin without paying due regard to most of the changes which have been touched upon by the writer. After all, albumin is merely an indi- cation of an abnormal condition ; it is not a disease. Therefore, as with every other symptom, by itself, it affords no reasonable ground for a diagnosis. Numerous other signs and symptoms must be carefully weighed, perhaps at short intervals, before it is justifiable to express more than a provisional diagnosis. Nestor Tirard (Lancet, Oct. 9, 1909). Albumin is found in many diseases of the ureter, the bladder, the pros- tate and urethra. Ballenger speaks of prostatic albuminuria as a name for an albuminous secretion from an hyperemic or inflamed prostate. This prostatorrhea is constant by chronic prostatitis and often increases regu- larly every ten to thirty days. It should not be taken for a true albu- minuria. In making insurance examinations as well as in the diagnosis of obscure forms of albuminuria, this possibility should be eliminated with the other sources of contamination before reach- ing a positive conclusion as to the sig- nificance of albumin. The periodic in- crease in the prostatic discharge, along with the striking similarity between the symptoms of intermittent, postural, orthostatic, and cyclical albuminuria and prostatorrhea, makes the possibility of . mistakes in the diagnosis extremely likely when this fluid flows back into the bladder, and does not appear at the meatus. This regular increase every ten to thirty days and the anal- ogy between the uterus and the pros- tate suggest a relation between the causes of this condition and menstrua- tion. E. G. Ballenger (N. Y. Med. Jour., Feb. 24, 1906). The writer means by alimentary al- buminuria the passage of native food albumin, as such, unchanged from the alimentary tract into the urine. One should learn to recognize the existence of a distinct and well-characterized form of albummuria of rather favorable prognosis that is not due to a nephritis ALBUMINURIA (LEVISON AND ERLANDSEN). 499 of toxic or infectious origin, to cir- culatory disturbances in the kidneys, to general cardiorenal disease (Rright's disease in the modern sense), but is due primarily to digestive disorders of a certain type. We are dealing here with an exclusively enterogenous al- buminuria in the interpretation of which the renal idea proper should be largely relegated to the background and in which treatment should not, as in Bright's disease, be directed chiefly against disturbances about the general metabolism and the cardiovascular ap- paratus, but against a well-characterized perversion of the gastrointestinal and hepatic ductions. Croftan (Archives of Diagnosis, Oct., 1908). Merk found that many affections of the skin, eczema, pruritus, urti- caria, erythema, and furunculosis, are intimately associated with albumi- nuria. Gunzberger noted albumi- nuria during a severe attack of acute urticaria. Nicolas and Jambon and Boas hold that albuminuria is a fre- quent accompaniment of scabies, but it is not satisfactorily settled how it produces this phenomenon. Albuminuria is a frequent accom- paniment of scabies. The connection between scabies and albuminuria is not merely that of coincidence; it is not to be explained by the assumption that the subjects were already affected with renal disease and the itch was simply a casual acquisition, though persons who have been subjected to the ordi- nary causes of nephritis are more likely than others to be attacked with it in the course of scabies. The cutaneous irritation may of itself give rise to the kidney trouble through the mediation of the nervous system, but the manner in which scabies gives rise to albuminuria is by no means satisfactorily settled. J. Nicolas and A. Jambon (Annales de dermat. et de syphil., Feb., 1908). Lancereaux observed frequently al- buminuria in his cases of gouty, her- petic diabetes, but never noted it in his 40 cases of pancreatic diabetes. Glycosuria alone does not entail al- buminuria. When it occurs it may •be connected with arteriosclerosis, with subsequent lesions of the kid- neys and heart, or be due to some intercurrent affection, tuberculosis in particular. Certain remedies may also give rise to albuminuria. The prognosis and treatment of albuminuria, therefore, depend en- tirely on the origin and causes of it, and the reader is referred to the various diseases in which it occurs as a symptom. Investigations showing the existence in many cases of a direct relationship between the acid content of the urine and the amount of albumin and tube casts present. In the first case of al- buminuria, the administration of phos- phoric acid was found to cause an im- mediate increase in the albuminuria. In other words, with an increased acidity of the urine, there was a corre- sponding increase in the amount of al- bumin. On the administration, how- ever, of alkalies in place of the acid, the albumin and tube casts diminished and finally disappeared. All the cases which were examined showed that, with increased acidity, there was increased albuminuria, and, corresponding with a diminution in acid, there is a diminution in the albuminurii. At the same time, in all cases of advanced grave kidney trouble, and especially in uremic pa- tients, the relationship to acidity cannot always be demonstrated. The writer goes on to show that not only is the albuminuria lessened by alkali adminis- tration, but the functioning of the kid- ney is greatly improved and the very important excretion of chlorides is ac- celerated. The best mode of adminis- tration of the alkali is in the form of the ordinary sod. bicarb., which must sometimes be given in large doses. V. Hoesslin (Miinch. med. Woch., Aug. 17, 1909). 500 ALBUMINURIA (LEVISON AND ERLANDSEN). TESTS. — By means of the tests commonly employed the presence of albumin in the urine is revealed, but no attempt is made to discern be- tween the different proteids ; the dif- ferential diagnosis between the serum- albumin, globulin, etc., will be given later on. The sample of urine to be examined must be very limpid without deposits of any kind ; if this be not the case, the urine should be filtered previous to the examination, because a slight cloud of coagulated albumin will only be discernible when the fluid is very clear before the reagent has been added. When the urine contains many bacteria, even repeated filtra- tion will be insufficient to make it clear; this can then be done, however, by addition of a solution of sulphate of magnesia and of carbonate of soda. By shaking the mixture a precipitate of carbonate of magnesia is formed, and when this is removed by filtra- tion the filtrate will be perfectly clear. In many cases a few drops of caustic soda will clear the urine, but urine treated in this manner will not give a precipitate of albumin by boil- ing, while the test of Heller is practi- cable also in this case. Test by Boiling. — A few c.c. of urine are heated to the boiling point and some (5 to 10) drops of nitric acid added. When the urine is acid the albumin will ordinarily coagulate by boiling alone and precipitate as a whitish powder or in small flakes. The nitric acid is nevertheless in all cases to be added, as well in order to complete the precipitation of albu- min as to avoid mistakes caused by the presence of a precipitate of phos- phates or carbonates, — which will immediately dissolve when nitric acid is added. This test is very delicate and will reveal 0.01 to 0.005 per cent, of albumin. Instead of nitric acid, acetic acid can be employed, but, while the nitric acid is to be added after boiling and in a quan- tity of 5 to 10 drops, acetic acid is added before the boiling, and only a sufficient quantity (1 to 2 drops) should be employed as to make the urine but slightly acid. This is espe- cially necessary when the urine is alkaline, because the alkaline albumi- nates with a surplus of acetic acid give a compound which is not coagu- lated by boiling. Tretrop heats the urine nearly to a boiling point and adds a few drops of a 40 per cent, solution of formalin. The albumin coagulates like white of egg. After pouring off the fluid, the proportion of albumin can be deter- mined by weighing the coagulum left. Bj^chowski describes the following simple method to detect the presence of albumin, even if only a few drops of urine can be obtained: One or 2 drops of urine are put in a test-tube of hot water. After shaking, a whitish cloud is formed, if albumin is present. The test is very distinctive and is still more apparent when the test-tube is held against a black back- ground. Of course, phosphates give the same reaction, but the cloud dis- appears on the addition of a drop of acetic acid. Test for albumin in the urine in which the extra work of having a con- trol or the filtering of the urine or the modification of its reaction has been eliminated. Material needed for the test : Satu- rated salt solution, acetic acid, test- tube, pipette. On heating urine three substances may be thrown down : albumin, nucleo- ALBUMINURIA (LEVISON AND ERLANDSEN). 501 protcid, and phosphates. About 5 to 10 c.c. of saturated salt solution, slightly- acidulated with acetic acid, is heated to boiling in a test-tube. The urine to be tested is carefully allowed to run on top of the hot salt solution by means of the pipette. In order to make a good picture, the quantity of urine used ought to equal that of the salt solution. By means of the heat in the sat- urated acidulated ' salt solution the above-mentioned substances are likely to be precipitated, but, owing to the contact, the saturated salt will not let the nucleoproteids appear, while the phosphates are also held in sus- pension by the acid ; hence nothing can appear at the point of contact of the hot saturated salt with the urine except albumin. Depending on the quantity of albumin present the reaction will be marked or only a film will appear overlying the clear, crystal-like salt solution. It is in urine with a trace of albumin in which this test shows extreme delicacy. The clear, crystal-like salt solution and the control-column of urine above with the surface of contact contrast quite decisively in distinguishing a delicate cloud. Different pictures are produced in the great variety of urines by means of this technique : — 1. In clear urine which contains no albumin the delicate point of contact where the urine rides the hot salt solu- tion is better brought out by setting the solution in motion by gently shak- ing the tube to and fro. 2. In clear urine sometimes a cloud appears some distance above the point of contact. This is due to the heat, which, traveling farther and faster than the acid of the salt solution, throws down a phosphate cloud. 3. Cloudy urine due to phosphates or urates is cleared at the point of contact because the acid and the heat dissolve these, respectively. 4. In cloudy urine due to bacteria no change is seen in the urine at the point of contact, and here, at times, only a close scrutiny of the urine above the crystal-like salt solution below in com- parison with the zone of contact will give us the correct reading. 5. In urine containing albumin clouded by urates or phosphates, the albumin cloud at the contact dififers in density from the remainder of the urine. Often the film of coagulated albumin is so delicate that the clearing of urates or phosphates is again seen above that of the contact zone. 6. In albuminous urine clouded by bacteria the coagulated albumin at the point of contact accentuates its pres- ence by its difference in density. It is in cloudy urine that the control of a clear, crystal-like liquid below the urine above emphasizes the beauty of the reaction in the zone of contact. This test is a modification of the saturated salt, or brine, test, yet it adds to this old method the new qualities of diminished labor, simplicity, and ac- curacy. H. L. Ulrich (Jour. Minn. State Med. Assoc, Feb. 15, 1909). Method of employing the acetic acid test for the detection of albumin which has long been used in France: 20 c.c. of urine, about three-fourths of a test-tube 1.5 cm. in diameter, are treated with 5 drops of 20 per cent, acetic acid, mixed, and one-half poured into a second test-tube. The contents of one tube are boiled, the other serving as a control. Albumin produces a cloud or precipitate in the boiled tube. Before testing, the urine must, of course, be perfectly clear; if necessary, it is shaken with Kieselguhr and filtered. If the acetic acid causes a cloud in the cold (nucleoalbumin), it is cleared by filtration before boiling. An alkaline urine should be acidulated slightly to prevent the precipitation of the phos- phates, or, if a precipitate of phos- phates appears when the urine has been treated with acetic acid and boiled, a few more drops of the dilute (20 per cent.) acid may be added to dissolve it. This will not redissolve even a slight albuminous cloud, pro- vided the urine is not boiled again. Glaesgen (Miinch. med. Woch., Bd. Iviii, S. 1123, 1911). 502 ALBUMINURIA (LEVISON AND ERLANDSEN). Heller's Test. — Three to 4 c.c. of nitric acid are poured in a test-tube and a few c.c. of urine are cautiously filtered down along the sides of the tube without shaking the latter. The nitric acid rests on the bottom of the test-tube, and where the fluids are in contact a distinctly limited disk of grayish-white precipitate will appear. When only traces of albumin are pres- ent the precipitate will only take place after some minutes. The more or less distinct violet coloring which also ap- pears at the point of contact of the two fluids is due to oxidation of indican or other chromogens. This test is very delicate and reliable; 0.003 per cent, of albumin is revealed by it. Fallacies. — By the addition of nitric acid the urates or urea are also pre- cipitated ; these wnll not form a limited disk, but render the urine turbid. Resinous acids (copaiba, etc.) are precipitated by nitric acid, but are dissolved by the addition of concentrated alcohol. This error can be avoided by diluting the urine or by moderately warming the nitric acid before the test. Very often also a fine disk or ring will appear above the point of contact. This precipita- .tion is due (Morner) to the presence of nucleoalbumins (mucin, chondrolin, sulphuric acid, etc.) and is more dis- tinct after dilating the urine. Test by Acetic Acid and Potassic Ferrocyanide. — The urine is rendered acid by acetic acid, and some drops of a solution of potassic ferrocyanide are added. This reagent, the serum-albu- min, the globulin, and the albumoses are precipitated, while none of the normal constituents of the urine are (Huppert). Heynsius's Test. — A still more deli- cate test than Heller's is that of Heyn- sius, by acetic acid and sulphate of soda. The urine is rendered acid by acetic acid, and an equal vplume of a saturated solution of sulphate of soda (or of common salt) is added. The mixture is boiled, and all kinds of albumin will then be precipitated in white flakes. The Magnesium-nitric Test (Rob- erts's). — One c.c. of nitric acid is mixed with 5 c.c. of a saturated solu- tion of sulphate of magnesium, and a small quantity of this mixture is • added to the urine. The albumin will be precipitated as a distinct ring. Metaphosphoric Acid (Hinden- lang's) also precipitates albumin in the same manner as nitric acid ; but this test is not as delicate as that of Heller. The solution of metaphosphoric acid must be freshly prepared for use, as the solution easily changes to orthophos- phoric acid upon standing, which does not precipitate albumin. Picric Acid Test (Johnson's). — A few drops of a saturated solution of picric acid will cause a white precipitate when albumin is present; this test is only indicative of the presence of albu- min, however, when the precipitate appears immediately. The urine must be acid. After some time the uric acid and the creatinine will also be pre- cipitated (Jaffe). Fallacies. — By addition of picric acid and peptones, the resinous acids, — such as those of copaiba, — and alkaloids — such as morphine — are precipitated. Perchloride-of-niercury or Spiegler Test. — A solution of 8 grams of mer- cury, 4 grams of tartaric acid, 20 grams of glycerin in 200 grams of water pro- duces a precipitate of albumin. The test is carried out in the same manner as Heller's test. It is very delicate (it reveals 0.0002 per cent, of albumin), but is not reliable when the urine is poor in chlorides (Jolles). ALBUMINURIA (LEVISON AND ERLANDSEN). 503 Millon's Test. — A solution of nitrate of mercury is added to the urine and the mixture heated to boihng. Nitrate of potash is then added; the albumin presents as a precipitate of red flakes. This test is disturbed by the sodium chloride of the urine and will be much better if tried upon the precipitate after boiling the urine. Tanret's Test. — The reagent of Tanret is composed of perchloride of mercury, 135 grams ; iodide of potash, Z.Z2 grams ; glacial acetic acid, 20 c.c. ; distilled water, sufficient to make 100 c.c. Some drops of this mixture are added to the urine, when it will coagulate the albumin. It will also, however, pre- cipitate the urates. Tognetti described a "tannohydro- chloric" test which reveals albumin, even in a proportion of 1 to 2,000,000. An equal amount of 1.5 per cent, alco- holic solution of tannin is added to the urine. After heating, an equal amount of 33 per cent, hydrochloric acid is added. A yellowish-white precipitate is gradually thrown down. The advantages of tannic acid as a reagent for albumin have long been known, but it could not be used in urine, as other ingredients of the urine also give a positive response. This difficulty- has been removed by the adoption of the following technique, which, the writer says, renders the test reliable, instruc- tive, and extremely sensitive. An equal amount of an alcoholic solution of tan- nin (1.5 Gm. of tannin in 100 c.c. of 90 per cent, alcohol) is added to the urine. The whole is then heated and an equal quantity of a 33 per cent, aqueous solution of hydrochloric acid is added — equal to the quantity of urine. In the presence of albumin, the fluid becomes opaque and the albumin is gradually thrown down in a yellowish- white precipitate. In case of icterus, the bile pigments must first be removed by the Grocco technique, that is, by add- ing glacial acetic acid in the proportion of one-thirtieth or one-fiftieth of the amount of urine. With the exception of this precaution, which is necessary with other tests for albumin, the tanno- hydrochloric test, he declares, can be regarded as free from causes of error. The combination of tannic acid, hydro- chloric acid, alcohol, and heat elimi- nates the usual drawbacks of tests for albumin. A. Tognetti (Gaz. degli Ospedali, vol. xxvii. No. 60, 1906). Colquhoun recommends a solution of carbolic acid in absolute alcohol; this gives a white, milky precipitation of albumin. The test is said to show 0.002 per cent, albumin. A solution of carbolic acid in abso- lute alcohol is a very delicaie test for albumin in the urine, comparing very ■favorably with nitric acid. The urine should first be diluted until the specific gravity is about 1.010; a few c.c. of carbolic acid are then poured on top of this, and a white ring is immediately formed, from which milky drops fall to the bottom of the tube, and adher- ing to this are the flakes of albumin. The test is sufficiently delicate to show 0.000012 gram in 1 c.c. of urine. W. Colquhoun (Lancet, May 6, 1900). Many other reagents have been recommended, which cannot be men- tioned in detail. The boiling test. Hel- ler's test, the potassic ferrocyanide test, and the picric acid test are the most practicable and quite sufficient in gen- eral work. Xanthoprotein Test. — Albuminous urine heated with a surplus of con- centrated nitric acid will take a yellow color, and some of the albumin coagu- lates in yellow flakes, which are soluble in alkalies with an orange-red color. Very minute quantities of albumin may be detected in the urine b}^ means of the deviation-of-complement test. For antigen the writer has used the serum of rabbits which had been im- munized against human blood-serum. 504 ALBUMINURIA (LEV150N AND ERLANDSEN). When albuminous urines were diluted to such a point that they no longer gave a reaction with heat and acetic acid or with nitric acid, they still yielded positive results by the comple- ment-deviation test, while in many instances albumin could be detected by this method in diluted urine when it could not be demonstrated by the ordi- nary chemical tests. The deviating power of the urine is not affected either by filtration through a Berkefeld filter or by dialysis. The antibody of the urine was, moreover, found to reside entirely in the serum albumin and serum globulin, and after the removal of the substances from the urine the remaining fluid no longer had the property of an antibody. C. H. Wilson (Jour. Path, and Bact, vol. xiii, p. 484, 1909). Following are two new qualitative tests for albumin in urine, which are apparently specific as well as simple. The first test is with tincture of iodine and sodium bisulphate : A few c.c. (5 to 6) of the urine — which must, of course, be clear — are placed in a test- tube and acidified with a few drops of dilute acetic acid. About % volume of tincture of iodine (10 per cent.) is now added, and the whole is well shaken. A dirty, dark-brown precipitate results. A saturated solution (watery) of sodium bisulphate is next added drop by drop, shaking constantly, until the brownish fluid is decolorized. If the urine contains albumin, one sees a permanent whitish cloud or flocculent precipitate. If no albumin is present, the fluid remains clear after the addi- tion of the sodium bisulphate, and shows only the original urinary color. With minimal quantities of albumin, the reaction becomes more evident on standing a few minutes. The second is with decolorized tincture of iodine : One decolorizes tincture of iodine with saturated watery solution of sodium bisulphate and filters. The filtrate is a clear, rather yellowish fluid, which keeps well. On standing for some time, small, yellow crystals may be precipi- tated, without injury to the reagent. The urine, as in the first test, is acidi- fied with dilute acetic acid. About Ys volume of the reagent is added and the whole well shaken. If albumin is present, a cloud or a flocculent white precipitate forms. With traces of al- bumin the reaction may be delayed a few minutes. Normal urine never shows a cloud with these tests. Oguro (Zeit. f. exper. Path. u. Therap., Bd. vii, S. 349, 1909; Amer. Jour. Med. Sci., Jan., 1910). Aufrecht's method is to be preferred. It consists of centrifugating the urine, mixing with 4 c.c. of urine 3 c.c. of an aqueous solution of l.S per cent, picric acid and 3 per cent, citric acid. The results are reliable, while the method is simple, rapid, and practical, and can be applied to any organic fluids, and also for determination of propeptones in urine after filtering out the albumin, cooling and centrifugating anew. Kop- pang (Norsk Mag. f. Laegevidenska- ben, Sept., 1910). Transportable Reagents for Albu- min. — Hoffmann and Aazette employ strips of test-paper previously placed in a solution of the double iodide of potas- sium and mercury until saturated, then removed and dried. Geissler's albumin- test paper is previously placed in a solu- tion of citric acid. The urine which is to be tested should be clear and ren- dered acid by means of a few drops of acetic acid. If there be albumin pres- ent, upon immersion of a slip of paper in the urine a distinct precipitate will appear. Pavy recommends test-pellets con- taining ferrocyanide of soda and picric acid; when albuminous urine is well shaken with a parcel of the pellet, albu- min will be precipitated. Stiitz and Fiirbringer employ oapsuloids of gela- tin filled with perchloride of mer- cury, sodium chloride, and citric acid. The relative delicacy of the tests most frequently employed is graphically rep- resented by Unger-Vetlesen^ in the ALBUMINURIA (LEVISON AND ERLANDSEN). 505 diagram shown below. The longest columns indicate the most delicate tests. Quantitative Tests. — The only method which gives fully reliable re- sults is the gravimetric method. One hundred c.c. of urine are boiled upon a water-bath half an hour ; if precipi- tation does not take place a few drops of a weak solution of acetic acid are added; the liquid is now brought on a ■ weighed filter and the precipitate Ferrocyanide of potassium and acetic acid Solution of picric acid Test-paper Solution of sulphate of soda and acetic acid Heller's test Picric acid in cr\'Stals Magnesium-nitric test (Roberts) . Trichloracetic acid Metaphosphoric acid Boilinsr and nitric acid repeatedly washed with hot water. The filtrate must once more be acidu- lated with acetic acid and boiled ag?.in, in order to ascertain whether the precipitation has been quantita- tive. AMien the water has been removed from the filter by strong alcohol, and the" alcohol with pure ether, the filter is dried at a tempera- ture of 110° to 120° C, and the per- centage of albumin determined by Aveighing. For clinical use several approxi- mate methods have been invented. Esbach employs an albuminimeter, i.e., a graduated glass tube ; this tube is filled to one mark {U) with the urine and then to the mark R with the test-solution consisting of picric acid, 10 grams; citric acid, 20 grams; water, 1 liter. The tube is then closed with a rubber stopper and the contents cautiously mixed (not shaken). The mixture is allowed to stand undisturbed for twenty-four 12 24 35 48 60 ■J72 84 96 \6% W/MMM> i-'v/w^y^/^ii^/ • f^^ ^i l» hours and the quantity of precipitated albumin then read off. The reading indicates in grams the amount of albumin per liter. The urine must be acid, the specific weight should not be more than 1006 to 1008, and the temperature of the room approxi- mately constant (15° C). Resinous acids must be extracted with ether. The yellow crystals often found on the side of the glass are crystals of uric acid. Christensen recommends another method : the albumin contained in 5 506 ALBUMINURIA (LEVISON AND ERLANDSEN). c.c. of urine is precipitated by 10 c.c. of a watery solution of tannic acid (1 per cent.). The albumin having been precipitated, 1 c.c. of an ordinary gum-arabic mucilage is added, the volume brought up to 50 c.c. with water, and the whole con- verted to an emulsion by agitation. Upon a piece of white paper, ruled with black lines 0.5 mm. wide and at equal intervals, is placed a cylin- drical glass measuring 4 cm. in diameter. This is half-filled with water, and as much of the emulsion run in as possible without obscuring the black and white lines beneath the vessel. From the number of cubic centimeters required, reference to a table of calculations arranged by Christensen furnishes the proportion of albumin present in the emulsion. When the urine is alkaline it should be faintly acidified with acetic acid before the precipitation of albumin. This test can be made as well by daylight as by the light of a good lamp, and requires only ten or fifteen minutes; but is not applicable to urine containing a small amount of albumin, the variations amounting to two-thousandths. The polariscope is sometimes em- ployed to estimate the quantity of albumin, but this test is not reliable. It is true that albumin is levorota- tory, but this is also the case with normal urine, and sometimes the color of the urine is too dark to allow the use of the polariscope. Goodman and Stern have pointed out (1908) a quantitative method which gives results in a few minutes. It is based on the precipitation of albumin by phosphotungstic acid in the presence of a mineral acid. One gram of crystallized egg-albumin is dissolved in 100 c.c. of distilled water (solution A) ; 1 c.c. of this solution is diluted with 9 c.c. of distilled water (solution B), Drop in a test-tube 5 c.c. of the following solution : — 5 Phosphotungstic acid 1.5 Gm. Hydrochl. acid (cone.) 5 c.c. Alcohol (95 per cent.) . .q. s. ad 100 c.c. Now it takes 0.1 cm. (added with a pipette graduated in 0.1 c.c.) of solution B to cause a cloudy pre- cipitate, i.e., 0.0001 Gm. of albumin. The diluted urine is tested in the same manner. Miscellaneous. — By the tests above mentioned, as well qualitative as quantitative, the different coagulable proteids contained in the urine are precipitated ; it is rarely of any use to differentiate them one from another. Pure globulinuria without the simultaneous presence of serum- albumin does not occur. In order to precipitate the globulin alone the urine is rendered alkaline with solu- tion of ammonia, after some time filtered, and the filtrate mixed with an equal volume of a saturated solu- tion of sulphate of ammonia. If glob- ulin be present a flaky precipitate will appear. - [The same result can be obtained by using a solution of sulphate of magnesia, which does not precipitate the other proteids of urine, or by diluting the urine until it reaches a specific gravity of 1002 and leading a slow current of carbonic acid through it for two or four hours. After twenty-four to twenty- eight hours the globulin will be precipitated. Levison.] The albumoses often found in the urine seem to be a mixture of deu- teroalbumoses and protalbumoses. F. Levison AND A. Erlandsen, Copenhagen. ALCOHOL (SAJOUS). 507 ALCOHOL.— Alcohol is one of a group of hydrocarbon compounds which have as their base a radical desig- nated as ethyl, chemically represented by the formula C2H5. Alcohol is a hy- drate or hydroxide of ethyl — C0H5OH. To distinguish it from other more toxic members of the series of alcohols, par- ticularly fusel oil (chiefly amyl alcohol) and wood spirit (methyl alcohol), the spirit used in medicine is called ethyl alcohol. It is obtained by distillation and subsequent purification from a fer- mented mash of potatoes or grain, from fermented sugar, or from wine, and is known in the British Pharmacopeia as rectified spirit. Absolute alcohol, i.e., alcohol at least 99 per cent, pure, occurs as a volatile, inflammable, colorless liquid, with a characteristic pungent odor and burn- ing taste. Its boiling point is 172° F. (77.7° C). It has a marked affinity for water, which it abstracts from whatever substances it may be in contact with, including the air and the human tissues. It is miscible in all proportions with water, glycerin, ether and chloroform. When absolute alcohol is mixed with water the resulting volume of fluid is slightly less than the sum of the two components before their admixture. Alcohol is a solvent for resins, volatile oils, fats, and alkaloids, and is very extensively employed as such in preparations containing remedies of these classes, most of which are insoluble in water. It forms the mens- truum in the official tinctures, spirits, elixirs, and all but two of the fluid- extracts. PREPARATIONS AND DOSE. Alcohol contains 94.9 per cent, by volume (92.3 per cent, by weight of pure ethyl alcohol to 5.1 per cent, of water). Specific gravity, 0.816. Rarely used internally in doses of 1 to 4 drams, diluted with water. Alcohol Absolutum (Absolute Al- cohol) contains not more than 1 per cent, by weight of water. Specific gravity, 0.797. Alcohol Dilutum (Diluted Alco- hol). — A mixture of alcohol and dis- tilled water, containing 48.9 per cent, by volume (about 41.5 per cent, by weight) of pure ethyl alcohol to 51.1 per cent, of water. Specific gravity about 0.937. Spiritus Frumenti (Whisky) . — 44 to 55 per cent, by volume of absolute alcohol. Spiritus Vini Gallic! (Brandy). — 46 to 55 per cent, by volume of absolute alcohol. Vinum Album (White Wine). — 8.5 to 15 per cent, by volume of absolute alcohol. Vinum Rubrum (Red Wine). — 8.5 to 15 per cent, by volume of absolute alcohol. Whisky is produced by the distillation of fermented grain (rye, corn, or bar- ley), and brandy by the distillation of fermented grapes. Inasmuch as the toxic amylic alcohol is likely to be pres- ent in freshly distilled spirits, the Phar- macopeia specifies that these products shall have been kept in storage for a certain period before use (whisky, two years; brandy, four years), the amylic alcohol becoming oxidized into harmless ethers. White wine results from the fermentation of the juice of fresh grapes, from which the skins, seeds and stems have been removed, while red wine is produced from purple-colored grapes with the skins included. The latter contains more tannin, but less tar- taric acid than white wine. Dose. — The ordinary dosage of whisky or brandy in adults unaccus- tomed to their use may be said to range 508 ALCOHOL (SAJOUS). from 1 dram (4 c.c.) to 2 ounces (60 c.c). In regulating the dose the capac- ity of the individual to oxidize the alco- hol is to be taken into account, the object being, if alcohol is to be given repeat- edly, to limit the amount to that which can be destroyed in or eliminated from the organism in the interval between successive doses. According to Bartho- low, the quantity which a healthy adult is able to oxidize in twenty-four hours is from 1 to 1>4 ounces of absolute al- cohol. Where this is exceeded, an accu- mulation of the drug in the system is likely to occur, and the following symp- toms may be expected to appear. Flush- ing of the face, dryness of the skin and mucous mebranes, bounding pulse, and the odor of alcohol on the breath. Such signs indicate, in any given case, that the useful amount of alcohol, whether employed for general or merely for di- gestive stimulation, is being exceeded. In persons habitually taking alcoholic beverages the ability to oxidize alcohol is augmented, finding its expression in increased tolerance ; hence in these indi- viduals, if alcohol is given for the pur- pose of obtaining therapeutic effects, the dose will have to be increased, and even, in many cases, doubled or tripled. In febrile states large amounts have often been administered without caus- ing signs of intoxication, the oxidizing power evidently being heightened dur- ing the febrile process ; notwithstanding this fact, it is now generally considered that small doses of alcohol — if, indeed, it be used at all in these cases other than during periods of dangerous circulatory depression — will give as good results as large amounts. In children, as well as in the aged, alcohol is well borne. To the former it can be administered in doses proportion- ally larger than are suitable for adults, while in the latter the dose need not be reduced from that given to the middle- aged. MODES OF ADMINISTRATION. — Alcohol, as used in therapeutics, is usually exhibited in dilute form in one of the various spirituous beverages, the majority of which are non-official. They may conveniently be grouped according to the percentage of alcohol contained. The so-called "spirits" include whisky, brandy, gin, rum, and arrack, and all contain about 50 per cent, of alcohol. A liquor having this percentage is said to be "proof spirit," implying that it con- tains just sufficient alcohol to be inflam- mable. Gin ("spiritus Genevse") is made by adding oil of juniper berries to rectified alcohol or whisky. The offi- cial spiritus juniperi compositus, with 4 per cent, of juniper oil as well as other flavoring substances, is a preparation similar to gin, but is stronger in alcohol, containing 70 per cent. ; the average dose is 2 drams. Rum ("spiritus Jamai- censis") is obtained by distilling fer- mented molasses or sugar. Like gin, it is not official. Arrack results from the distillation of fermented rice. Spirits contain a large number of other volatile bodies besides the main component, ethyl alcohol. These include higher members of the same group of alco- hols as ethyl alcohol, as well as alco- hols of other series and a group of bodies the composition of which re- mains obscure, known as the oenanthic ethers, and which, though present in small amounts, give to the various liquors their characteristic flavors. Spir- its differ radically from wines in that they are free of non-volatile compounds, which are left behind in the process of distillation. The heavy wines contain about 20 per cent, of alcohol, being made from grapes ALCOHOL (SAJOUS). 509 having a large proportion of sugar. They inchule port, sherry, Madeira, Marsala, Malaga, and others. Port (formerly official as "vinum portense") is a sweet, red wine, containing 15 to 22 per cent, of alcohol ; its sweetness is due to arrest of the process of fermentation while still incomplete. Sherry ("vinum Xerici") is a white wine, containing 15 to 18 per cent, of alcohol. Port and sherry of American production are usu- ally lighter, the percentages ranging from 10 to 18. Madeira is a dark-col- ored white wine with 18 to 22 per cent, of alcohol. Marsala is a wine similar to Madeira, but of Sicilian production. Malaga is a sweet wine, having 17 per cent, of alcohol. The heavy wines are, in general, too sweet for the use of sick persons; when obtained "dry" (free, or nearly free, from sugar), however, they are frequently of benefit to convales- cents and to the debilitated. The light wines contain from 5 to 15 per cent, of alcohol. Ordinary claret ranges from 6 to 12 per cent. This group also includes Burgundy, the Rhine wines. Moselle, Tokay, champagne, and hock, in all of which the percentage of alcohol is usually between 9 and 14. Champagne, though it contains only about 10 per cent, of alcohol, has a pro- nounced stimulating effect on the gastric mucous membrane because of the large amount of carbon dioxide it liberates. Wines are more slowly absorbed than alcohol, and the physiological effects of the alcohol they contain are correspond- ingly less marked. In addition, wines possess distinct nutritive value, by vir- tue of the numerous substances, both organic and mineral, which they em- body. These include, according to an analysis of red wine by Gautier, albu- minoid, fatty, and carbohydrate constit- uents, glycerin, potassium tartrate^ suc- cinic acid, acetic, citric, malic and carbonic acids, and salts such as the chlorides, bromides, iodides, fluorides, and phosphates of potassium, sodium, calcium and magnesium oxide of iron, etc. Wine also contains a number of volatile bodies, such as are present in brandy in larger amount. Light wines are useful wherever prostration is or has been a marked feature of the case, e.g., in typhus, intermittent fever, scurvy, and cholera among the more acute diseases ; also in many chronic af- fections, excluding, however, cases of Bright's disease, chronic digestive dis- orders, neurasthenia, anemia, and dia- betes. Wines are peculiarly liable to undergo acetic fermentation in the stomach (Hayem), and hence are not well borne in certain gastric dis- turbances. It has been found in vitro that wines uniformly interfere with peptic digestion. Red wines very usually disagree where there is gastric hyperacidity. In these cases white wines are generally service- able. White wines have a diuretic ef- fect beyond that possessed by the red wines. When very acid, however, they are in themselves capable of causing gastric disorders, and should be avoided wherever diarrhea exists! Many of the Rhine wines are not suited to those having a tendency to the formation of oxalic deposits, owing to the oxalic acid which they contain. Malt liquors (beer, ale, brown stout, porter) contain less alcohol but have greater nutritive value than any other of the alcoholic beverages. They are produced by causing an extract of malt (sprouted barley grains) and hops to undergo fermentation by the yeast- plant. The malt is previously allowed to germinate, in order that the starch it contains shall be transformed into the 510 ALCOHOL (SAJOUS). more easily fermentable sugar. The diastase which effects this conversion is formed by the grain itself during germi- nation. The yeast then ferments the sugar with the production of alcohol. The final product contains about 3 to 7 per cent, of alcohol and a large percent- age of solid constituents available for nutrition, including mainly dextrin, sugar; albuminoid, fatty and gummy substances ; succinic!^ lactic and acetic acids; aromatic and bitter principles derived from the hops, carbon dioxide to the extent of 6 to 8 times the volume of the liquor, and a number of salts re- sembling those found in the ashes of meat extract, principally phosphates and salts of potassium and calcium (Man- quat). Beers also contain diastase, which aids in the digestion of carbohy- drate foods and tends to produce obesity. Ale differs from beer in that its fermentation is carried on at a high temperature instead of a low one; it usually has a higher percentage of alcohol, ranging from 4 to 8 or 9 per cent., while beer has 2 to 6 per cent. (4 per cent, on the average). Porter and brown stout are fermented at a still higher temperature ; some of the sugar is converted to caramel, giving these beverages their darker color. They contain 4 to 6 per cent, of alcohol. When the digestive powers are but little impaired, beer is valuable as a tonic and nutritive. The hops and the carbon dioxide probably both stimulate functionally the gastric mucosa. Where the digestion is weak, the large dextrin and sugar content of beer may undergo fermentation in the stomach. The ab- sorption of beer is, in any case, slower than that of other liquors. Beer diluted with water is said to be better borne than wines where there is hyperchlor- hydria. The low percentage of alcohol contained in beer renders it useful where the patient appears specially sensitive to the action of alcohol on the cerebrum. A syrupy extract of malt is official in the United States Pharma- copeia as extractum malti; it contains large proportions of dextrin, sugar, phosphates and nitrogenous bodies, and but 2 per cent, of alcohol. Less important medically are the wines of other fruits than the grape, and the liqueurs. Among the former may be mentioned cider, which results from the fermentation of apples and contains 2 to 5 per cent, of alcohol, and perry, a similar product made from pears. Cider is useful where diuretic and slightly laxative effects are desired. Liqueurs comprise a large class of alcoholic products differing widely in composition. They are generally made by the addition of essential oils ; they frequently contain a large amount of sugar, and are of but little value in therapeutics. In acute diseases alcohol is usually given internally in the form of whisky or brandy. CONTRAINDICATIONS.— Al- cohol is contraindicated in nephritis and inflammatory conditions of the urinary passages, in conditions associated with marked gastric or intestinal irritation, and in persons likely to acquire the alcoholic habit, — especially young adult or middle-aged neurotics, and persons who have been subjected to traumatism of nervous structures. In prolonged cardiac depression alcohol is likely to do more harm than good. Sweet wines and beer are contraindicated in diabetes mellitus and in eczema. In the diar- rheas of children alcohol should not be administered unless the stomach and bowels have already been freed from putrefying material. ALCOHOL (SAJOUS). 511 Protest against alcoliol in any form in ptosis of the stomach or intestines, as this is not a local affection, but is associated with nervous and other disturbances. The physical and nerv- ous disturljances which forbid the use of alcohol in cases of enteroptosis in many cases do not develop until the age of 25 to 28. Concussion of the brain contraindicates alcohol; many physicians refuse to treat traumatic nervous affections unless the patients go to a hospital where abstention from alcohol will be enforced. Trau- matic nervous affections tend to in- duce hysteria, and the necessity for abstention from alcohol in hysteria and neurasthenia and conditions of dread and compulsion can never be too often emphasized. The patient is chained to his crutch and soon is unable to do without it if alcohol is given to relieve him. A psychic trauma of any kind should contraindi- cate alcohol, as it is particularly liable to act abnormally in abnormal psy- chic conditions. This includes the period before and after an operation. Abstention from alcohol is an impor- tant factor in the warding ofif of the after-affection of gonorrhea and syph- ilis. The worst forms of tabes occur among those who take alcohol, and the lesser consumption of alcohol is one reason why women have the milder form. Among the injurious influences of syphilis must be counted, besides the virus, the emotional dis- tress, the knowledge of the disease, the psychic depression and the neces- sity for secrecy, all of which render alcohol particularly injurious for syphilitics. Roder (Med. Klinik, Nov. 8, 1908). Syphilis is always badly affected by alcohol, and the latter is responsible for many of the evil results often seen in this disease, both in the skin and in the nervous system. The syphilitic should be an abstainer from alcohol from the moment of his infec- tion. Acne constantly shows the effect of drinks containing alcohol, the condition varying more or less according to the character of the beverage. The acne rosacea of tip- plers is well known, and this is often followed by a permanent dilatation of the capillaries of the face and hyper- trophy of the nose, resulting even in rhinophyma. In beer and ale drink- ers the eruption is of a more pustular character, often with large • lesions. Eczema is often profoundly affected by alcoholic beverages, which might render the disease incurable when they are persisted in, even in mod- eration. Psoriasis is greatly aggra- vated by the indulgence in alcoholics and is caused to itch by such indul- gences; the use of alcohol can also induce a fresh attack after a long period of freedom from the eruption. In cases of even moderate drinkers the disease yields much more quickly under total abstinence. L. Duncan Bulkley (Med. Rec, Jan. 29, 1910). PHYSIOLOGICAL ACTION.— The effects of alcohol, when it is taken internally, vary according to the size of the dose. The action here to be de- scribed is that of therapeutic or some- what larger doses. Digestive Tract. — In the mouth and pharynx, alcohol has a slightly astringent action upon the mucous membranes. For a brief period it also causes an increased flow of saliva, and when in no greater concentration than 5 per cent., has been found by Storck to favor the digestion of starchy foods by ptyaHn. The action of ptyalin is, on the contrary, unfavorably influenced by alcohol in 10 per cent, strength and, more particularly, by the acids con- tained in malt beverages and wines. On reaching the stomach, alcohol produces a sense of warmth, which is promptly followed, as absorption takes place, by a general feeling of well-being and restfulness. When present in the stomach in small amount only, alcohol has no marked effect on peptic diges- tion, and often distinctly augments the 512 ALCOHOL (SAJOUS). secretion of gastric juice, itself becom- ing thereby progressively more dilute. It acts both by stimulating directly the gastric circulation and the secreting cells to greater activity, and probably also by a special secretory influence of the alcohol after its absorption. Since Spiro, Frouin and Moulinier observed that alcohol administered per rectum caused in the stomach a marked flow of abnormally acid gastric juice. Chitten- den and Mendel showed, moreover, that the relative amounts of pepsin and hydrochloric acid in the gastric juice were both increased. Thus alcohol in small quantities tends to hasten gastric digestion. Fatty substances being dis- solved by it, their absorption is facili- tated. The appetite, when poor, is improved. When 5 to 10 per cent, of alcohol is present, peptic digestion takes place less rapidly than normal, the degree of interference varying with the kind of food to be acted upon. According to Klemperer and Battelli, however, gastric motility is hastened by moderate amounts of alcohol, while Bandl, Scan- zoni and others have shown that liquids containing alcohol are much more rapidly absorbed from the stomach than liquids free of it. It thus happens in many cases that the interference of the alcohol with peptic digestion is more than counterbalanced by the hastened absorption as well as by the increased amount of gastric juice. Gluzinsky's experiments indicate that alcohol slows gastric digestion only during the period before its absorption; it then causes in- creased rapidity of digestion because of the special stimulating effect on secret- ing structures already mentioned. Ac- cording to this author 60 Gm. (about 2 fluidounces) of cognac, taken during or before a meal, slows the digestion of carbohydrates and hastens that of meats, but when taken after the meal hinders both. It has been noticed that spirits are much less potent in hamper- ing peptic activity than are wines and especially malt liquors. Series of experiments to determine the influence of alcohol upon the se- cretion of the gastric juice: upon a case of gastroptosis, one of hysteria, one of atony of the stomach, after gastro-enterostomy, and one of gas- tro-enteritis. The alcohol was admin- istered per rectum, and the patient took no nourishment by the mouth. It was found that the enema caused an active secretion of gastric juice provided the amount of alcohol was not less than 7 to 10 c.c. The acidity reached its maximum about an hour after the injections, and then grad- ually decreased. In two cases of achylia due to carcinoma of the stom- ach no effect was observed. R. Spiro (Miinch. med. Woch., No. 47, 1901). Alcohol passes quickly from the stomach into the intestines. Here also it is absorbed, and exerts, when in small amount, an effect similar to that produced on the stomach, viz., stimu- lates the mucous and other glands to increased activity. Relaxation of the bowels and meteorism are frequently influenced by it. In vitro alcohol in 3 per cent, strength, "however, slows the digestion of proteids by the pancreatic juice (Chittenden and Mendel). Nervous System. — When the ac- tion of alcohol has been exerted long enough, it acts as a depressant to the nervous system. The effects seen at first suggest primary cerebral stimula- tion, but it is a question whether these phenomena are not really the result of impaired inhibition, in which case alco- hol might be said to act as a depressant from the beginning. Small amounts of alcohol do, indeed, produce effects sug- ALCOHOL (SAJOUS). 513 gesting loss of inhibitory control over cerebral activities, though it must be admitted that the actual physiological existence of such a controlling function has not yet been definitely proved. In the primary stage of apparent excita- tion, the subject exhibits loss of con- trol, as manifested by loose speech, laughter upon slight provocation, out- bursts of the passions and exaggerated movements. The subject becomes self- ish, irresponsible, and lacks will-power. Bunge, Schmiedeberg and others be- lieve that these phenomena occur be- cause the normal inhibitory influence on the cortical centers has been reduced. As an argument against the theory of primary stimulation it is pointed out that a primary stage of excitement is usually not seen when the subject re- mains in quiet and dark surroundings after taking alcohol, while certain indi- viduals show no evidences of stimula- tion under any circumstances, but soon pass into a state of cerebral depression. Other observers believe that the physi- cal excitement and the unusual flow of ideas and powers of speech often ob- served under the influence of alcohol indicate a primary stimulating effect on the same centers. The ability to per- form muscular work has usually been found in experiments to be increased for a brief period by alcohol in small amounts, especially where fatigue ex- ists, but this is very promptly followed by a distinct decrease ; further, it is not proven that the preliminary increase is due to excitation of the motor areas, since the nerves or muscles themselves may instead have been affected. Krae- pelin concluded from his experiments that motor activities were heightened by alcohol in small amounts and de- pressed by larger quantities, but that the mental activities were lowered for a period of twelve to twenty-four hours by it even in small doses. Alco- hol acts also on certain sensory centers, reducing pain. After taking small amounts of alco- hol there is an apparent temporary in- crease of brain-activity, which is but an evidence of the paralyzing and deleterious effect of alcohol. It de- stroys the special function of the cerebellum, and produces tremor and weakness of the lower limbs. In chronic alcoholism the dendrites oi the pyramidal nerve-cells show swell- ings and shrinkages, and there is wide- spread pigmentation in the nerve- cells. Even small doses of alcohol at meals have a deleterious influence, and total abstinence must be the course of those who wish to follow the plain teaching of truth. Victor Horsley (Lancet, May 5, 1900). With our present knowledge it may be said that alcohol furnishes energy for muscular work in the same man- ner as fats and carbohydrates. There is no reason for believing that the muscle-cells cannot burn alcohol as they do other foodstuffs. However, from the standpoint of ability to do strenuous muscular work, there is evi- dence that a man cannot do as much work in the long run with alcohol as with carbohydrates. Mountain-climb- ers and athletes cannot do their best work when alcohol forms a part of their diet. This effect is explained by the drug action of alcohol upon the nervous system. Scarbrough (Yale Med. Jour., Feb., 1910). Tests carried out on himself by the author through a number of months to determine the influence of a small amount of liquor on the power of concentrating the attention on and remembering twenty-five lines of a translation of the Odyssey, the blank verse being especially adapted for such tests. The alcohol had an un- mistakable influence in reducing the powers of perception, and this efifect was twice as marked on a fasting stomach. Vogt (Norsk Mag. f. Lae- gevidenskaben, June, 1910). 1—33 514 ALCOHOL (SAJOUS). After the initial stage of apparent stimulation, the actual depressant action of alcohol on the nervous system is no longer in doubt. Soldiers have been found to march better and remain stronger without alcohol than when supplied with it in moderate amounts. Large single doses produce signs of dis- tinct brain depression, passing from muscular inco-ordination, with imper- fect speech, impaired sensibility, and somnolence, to a state of unconscious- ness similar to that of ether and chloro- form anesthesia. The spinal cord is depressed by alcohol even before the unmistakable signs of cerebral depres- sion occur, as shown by the early muscular inco-ordination (apart from disturbances of equilibrium) and dimin- ished reflex irritability. The functions of the bulbar centers, however, are not markedly affected until late. On the peripheral nerves alcohol in large doses was found by Dogiel to exert a pro- nounced depressing effect in dogs. Motor nerves are believed to withstand this effect longer than sensory nerves. In the frog the response of the motor nerves to stimuli is at first increased when the vapor of alcohol is brought in contact with it, but the usual depressant action soon follows. Circulation. — Although the pulse- rate is commonly increased after the use of alcohol in considerable amount, Jacquet believes that where the subject can be kept free from external exciting influences, no such change in the heart- action is produced. The results of ex- periments intended to develop the action of alcohol on the heart have been con- tradictory. It is thought by many that the mammalian heart is slightly stimu- lated by alcohol unless given in large amounts, when it is depressed (Dixon and Bachmann, Wood and Hoyt, Loeb, Bachen). Alcohol in 2 per cent. strength passed through the coronaries of a cat's heart does not cause ari-est of cardiac activity (Loeb). Other experimenters conclude that alcohol causes no increase in the work per- formed by the heart. According to Cushny the preliminary action of alco- hol is to weaken the heartbeats. As for the blood-pressure, moderate doses have usually not been found to alter it. The advocates of primary cardiac stimulation by alcohol account for this by the dilatation of the peripheral blood-channels, which is often manifest in the flushed face, injected conjunc- tivje, and heated skin surfaces observed after the use of alcohol. The speed with which the blood courses through the vessels is thereby increased (Hem- meter, Wood and Hoyt). Whether the vascular dilatation is due to an action on the vasomotor centers or on the vessels themselves has not as yet been determined. The results include dis- turbances in the cerebral circulation; the brain may be the seat either of marked hyperemia or of anemia (Claude Bernard). Certain experi- menters have at times observed in- creased blood-pressure due to alcohol; thus Kochmann noted in man a rise in the pressure upon the exhibition of 5 to 10 c.c. (1^ to 2y2 drams) of abso- lute alcohol. Such an elevation of pressure might be due either to a direct stimulating effect on the vasomotor centers, or, as many believe, to a reflex effect on these centers due to irritation of the gastrointestinal mucous mem- branes. The contact of strong alcohol with the mucous membranes of the mouth, esophagus, and stomach acts reflexly through the medulla to cause vaso- constriction, which raises the blood- pressure, and hence stimulates the ALCOHOL (SAJOUS). 515 heart. After alcohol is absorbed (it circulates as alcohol) it causes vaso- dilation and a fall in blood-pressure. It is certain that overdoses of alcohol after absorption are depressant to the heart-muscle, to the muscle-fibers of the blood-vessel walls, and to the vasomotor center in the medulla. On these considerations the author bases his advice on the use of alcohol in derangenients and affections of the heart. With regard to the utility of alcohol in combating poisons circulat- ing in the blood, clinical experience is not conclusive. Laboratory experi- ments should be undertaken in order to settle this point. O. T. Osborne (Jour. Amer. Med. Assoc, Dec. 5, 1903). Experiments performed in rabbits, supporting the belief that the accel- eration of the heart after the use of alcohol is a gastric reflex from irrita- tion, and that when the reflexes have been abolished as a result of the an- esthesia, the quickening of the heart and the subsequent rise in pressure from alcohol do not occur. A simi- lar effect upon the circulatory system can be produced by other gastric ir- ritants, such as ammonia, ether, and capsicum. McNider (Charlotte Med. Jour., Aug., 1909). Report concerning a series of mano- metric blood-pressure tracings show- ing the effect of alcohol on dogs not under the influence of any. anesthetic. The primary action of alcohol was found to vary according to the mode of administration: By mouth it caused a marked rise in blood-press- ure, with increased amplitude and a constant, or slightly slowed rhythm of heartbeat. This rise gradually passed off in five or ten minutes. In some instances, at the time of pour- ing the alcohol into the dog's throat, and just preceding the rise mentioned, there was a sudden drop and almost immediate recovery of blood-pressure. When given intravenously alcohol caused a sharp drop in blood-pressure, during which the heart was greatly slowed or almost stopped; but very soon, unless the dose was too large. there followed a rapid recovery. Upon administration of alcohol by gastric fistula there was no specific primary action. By whatever method admin- istered, alcohol, when circulating in the blood-stream, causes a gradual, pfogressive lowering of blood-press- ure with decrease in amplitude, but increase in rate of heartbeat. Clyde Brooks (Jour. Amer. Med. Assoc, July 30, 1910). Excessive amounts of alcohol cause a pronounced fall in the bloocl-pressure, since they depress both the heart and the vasomotor center. They have also been observed in animals to slow the heart action, and even produce cardiac arrest, in much the same manner as does chloroform. According to Pou- chet, the secondary fall of blood-press- ure is due largely to stimulation of the inhibitory pneumogastric centers ; the pressure may, indeed, at a certain stage of the poisoning be brought almost back to normal by section of the vagi. Retardation of the pulse is brought about by an irritation of the vagus centers, and of the peripheral ends of the vagi, in part due to a direct car- diac action. The fall in blood-press- ure is due to a direct injurious influ- ence upon the heart-muscle. Ladislas Ilaskovec (Wiener med. Blatter, Oct. 11,1900). Experiments to determine whether alcohol, coming in direct contact with the heart muscle, would act as a stimulant to the action of that mus- cle or not. The author feels justified in concluding that alcohol is not a stimulant to heart muscle, but rather a depressant and a poison. A. W. Downs (Monthly Cyclo. and Med. Bull., March, 1911). Blood. — Large amounts of alcohol must be present to cause perceptible changes in the blood in a short space of time. Foguet claimed to have ascer- tained that intoxicating doses, taken daily, were without efifect. Pouchet 516 ALCOHOL (SAJOUS). states, however, that tinder small, re- peated doses, the blood gradually under- goes fatty changes, owing to the fact that the emulsified fats entering the blood with the chyle are not consumed as normally. At the same time the alkalinity of the blood is lowered, the coagulabihty rises, and a process of dehydration goes on, as shown by diure- sis and increased secretions generally, whereby the blood becomes relatively more concentrated, the erythrocyte count and hemoglobin percentage ris- ing. Schmiedeberg found that blood containing alcohol loses in part its oxygenating power, — a fact of con- siderable practical significance. In vitro, alcohol added to blood darkens its color, coagulates it, and causes hemo- globin to leave the erythrocytes. Such effects can only be obtained in the animal organism by the intravenous in- jection of alcohol in large doses. Under these conditions the red cells undergo marked changes in shape and color (Hayem). The fats a-nd lecithin are dissolved, and the hemoglobin becomes dissociated from .the stroma and pre- cipitated in reddish, refractile droplets. Bordet and Massart showed alcohol to have a strong negative chemotactic in- fluence on the white blood-cehs, even when greatly diluted. Microscopic changes in the tissues as a result of alcohol, taken from ob- servations on animals: L The most marked effects are produced on the blood-vessels. 2. The cells which line the vessels are swollen and broken, and there are serious retro- grade changes in all of the tissues. The white blood-cells become swol- len and necrotic. 3. The lymph- spaces become choked with broken- down white blood-cells, and the small blood-vessels are also completely blocked by plugs in detritus and dead tissue. 4. In the veins the blocking is often so severe that the vessels burst from the backing up of blood in them. The changes are always more marked in the vessels of the brain than elsewhere because they do not possess the special nerves which con- trol their caliber, as do the vessels of other parts of the body. H. J. Berkley (Johns Hopkins Hosp. Bull.; Amer. Jour, of Physiol. Therap., May, 1910). Respiration. — Volumetric estima- tions made before and after the inges- tion of alcohol have shown fairly con- clusively that, even in the absence of motor excitement, the drug causes an increase in the amount of air breathed. Usually the augmentation is more pro- nounced in fatigued or exhausted individuals. Considerable experimenta- tion has been indulged in for the pur- pose of ascertaining whether the drug stimulates directly the respiratory cen- ters in the medulla or whether the effect is of indirect origin, viz., through irritation of the gastric mucosa. Thus Loewy conducted experiments in which the irritability of the centers of respira- tion before and after the use of alcohol was ascertained through its response to an increase of carbon dioxide in the blood. The results of these and other researches have not been entirely con- clusive, but, in a general way, they tend to show that alcohol exerts, in man at least, little if any direct central stimula- tion, and therefore, that the improve- ment in respiration observed under the influence of therapeutic doses of alco- hol is probably due to a reflex effect on the centers. An additional argument in favor of the latter view is in the fact that respiratory depression occurs only under exceedingly large doses of alco- hol and at a late stage in the poisoning, tending to show that the effect of this drug on the respiratory centers is, under ordinary circumstances, not a very ALCOHOL (SAJOUS). 517 marked one. Yet it is well known that in the final stage of acute alcoholic poisoning the breathing becomes more and more shallow and infrequent, com- plete arrest ultimately occurring. In fever, both the respiration and the heart-rate are slowed by alcohol. This seems reasonably accounted for by a lessening of general bodily excitement through the narcotic action of alcohol, without implicating a direct depressing action of moderate doses of it upon both the respiratory centers and heart. Secretions. — A^Eany of the secre- tions are to a certain extent activated by alcohol. The saliva and digestive secretions are increased reflexly by the local action of alcohol on the mucous membranes, as well as, probably, after its absorption, through direct contact of alcohol with the gland-cells as the drug circulates with the blood-stream. The sweat secretion is increased owing to the peripheral vasodilatation. The urine is also augmented. The question whether a direct exciting action on the renal epithelium is exerted or not has not yet been settled, though the fact that albuminuria may result from excessive doses would seem to point to an irrita- tive effect on the kidney cells. - Temperature. — Alcohol in ordinary doses causes a slight fall in the body temperature (}4° to 1° C, according to Cushny), owing to the dilatation of the superficial blood-vessels, which exposes a larger amount of blood to the cooling influence of the surrounding air. At the same time a sensation of warmth is experienced, and the temperature of the skin may rise considerably owing to its flushed condition. If a large amount of alcohol be taken the fall of mternal temperature may be exaggerated owing to the complete motor inactivity. The §ame will occur under a moderate dose of alcohol if the subject be subsequently exposed to cold. Metabolism. — Alcohol causes but little change in the oxygen intake and carbon dioxide output, which, after its ingestion, show no modification beyond that to be expected from any other sub- stance yielding energy to the system by oxidation. Of course, if alcohol be taken in amounts sufficient to produce sleep, the respiratory gaseous inter- changes will be lowered because of the muscular inactivity. Where the drug is taken repeatedly in moderation, how- ever, a gradual increase in the oxidizing power of the blood occurs, apparently corresponding in amount to the degree to which tolerance of alcohol has been developed in the individual. This fact was well illustrated in the experiments of Hunt on the toxicity of methyl cyanide, a compound whose poisonous effect is proportional to the extent to which it is oxidized to hydrocyanic acid in the system. Animals given repeated small doses of alcohol, insufficient in themselves to elicit signs of intoxication, showed an increased susceptibility to methyl cyanide, demonstrating that the oxidizing power of the blood had be- come greater. In addition, the administration of alcohol, which is almost entirely de- stroyed in the system by oxidation, naturally tends to preserve from com- bustion other oxidizable substances present — fats in particular. This ac- counts for the well-known fattening tendency of alcoholic beverages, when habitually taken in any but very moder- ate amounts (see section on Alcohol in Nutrition). Immunity. — As to the influence of alcohol on the powers of resistance of the individual to disease, it is well known that alcoholics are less 518 ALCOHOL (SAJOUS). resistant to acute infections and more susceptible to dangerous shock from bodily injury than are the temperate. Likewise, animals given alcohol and subsequently inoculated with pathogenic organisms or in- jected with disease toxins have al- ways shown a low degree of resistance as compared to normal animals. Del- earde and Laitinen in their experiments found it "almost impossible to confer immunity against rabies, tetanus, and anthrax on alcoholized animals." The question, however, whether alcohol in the amounts in which it has been used in the treatment of acute febrile dis- eases in non-alcoholics has a similar prejudicial effect has not been definitely settled. [Inasmuch as the defensive power of the body fluctuates with its vital activity, beverages rich in alcohol, besides inhibit- ing the life process itself, place it at the mercy of disease-breeding germs, and thus actually help to destroy life through de- oxidizing or reducing action on the blood. This is further emphasized by the in- fluence of alcohol on the ductless glands themselves. While small doses or weak solutions, as stated by Lorand, stimulate these organs, large quantities of beverages strong in alcohol cause their degeneration, as shown by numerous autopsies. My work on the "Internal Secretions" contains a microphotograph showing a pituitary body in which alcohol produced sclerosis. Hertoghe and de Quervain have found alcohol harmful to the thyroid — an organ which, as is well shown by cretinism and the marvelous effects of thyroid prepara- tions in this disease, has much to do with the development of the body. The defen- sive functions of the body, if carried on, as I hold, by the ductless glands, are thus directly hampered by the use o'f alcohol in any but very weak solutions. This coin- cides with the recent observations of Parkinson, who studied the influence of alcohol on the autoprotective functions of the body. While his experiments showed that small quantities temporarily enhanced the production of antibodies, as soon as they were replaced by large doses the opsonic index fell; and if their use was continued, it remained low permanently, which meant that the immunizing func- tions were paralyzed. This confirmed the earlier experiments of Miiller, Wirgin, and others referred to below. It is because of this fact that drunkards in general fare so badly in infectious dis- eases; their autoprotective mechanism is powerless to defend them. Quite in accord with these teachings of experience, Par- kinson found that the reaction to vaccines was much less effective in alcoholized rab- bits than in normal rabbits, and that the difference was still more marked when living micro-organisms were used. Many experiments by competent observers afford evidence 'in the same direction. Again, I have shown that the immunizing process of the body is closely linked and runs on parallel lines with oxidation; since alcohol in anything but small doses reduces oxida- tion, it inhibits in proportion our power to fight disease during the active or de- fensive phase of the morbid process, espe- cially in febrile infections and toxemias. If alcohol is used at all, therefore, in the acute infections and toxemias, it should only be given in small quantities and freely diluted. But better agents to enhance the defensive process are now available. C. E. de M. S.] Friedberger, Muller, Wirgin, and other observers found that, in rabbits, the administration of alcohol for some days in amounts sufficient to pro- duce a mild degree of intoxication interferes with the formation of antibodies in the blood. The greater the time allowed to elapse, how- ever, between the injection of the antigen and the giving of alcohol, the less the restraining effect of the lat- ter on the development of protective substances. Experiments conducted by Laitinen, in which animals were given for some time doses of alcohol so small as to correspond with the amounts taken dietetically by moderate users of ALCOHOL (SAJOUS). 519 alcohol, did not reveal any pronounced disadvantage in the habitual use of small quantities of alcohol as regards susceptibility to disease, the mortality being but slightly greater than among the animals not given alcohol. Alcohol in small quantities has no action on the phagocytic activity, nor has it any action on the phagocytic activity until it is present in 12.5 per cent, strength. Small quantities of alcohol injected into rabbits may stimulate the production of antibodies temporarily. A large dose lowers the opsonic index for twenty-four hours. Continuous moderate doses cause a permanent lowering of the opsonic index. The reacting mechanism to vaccines is mvich less effective in alco- holized rabbits than in normal rab- bits; the difference is still more marked when living micro-organisms are used. P. R. Parkinson (Lancet, Nov. 27, 1909). Ingestion of alcohol is quickly ac- companied by a lowered opsonic in- dex, but the index as quickly returns to the normal with cessation of the alcohol. The amount of alcohol needed to bring about this result had no in- fluence on the resistance of the animal to infection. Abbott and Gildersleeve (Univ. of Penna. Med. Bull., June, 1910). Study of protein metabolism and utilization, and especially the parti- tion of nitrogen in the urine, under the influence of alcohol, carried out on man and dogs under fixed and comparable conditions of diet. There is no pronounced disturbance in the alimentary utilization of the food- stuffs. Moderate doses exert a pro- tein-sparing action, which is suc- ceeded by loss of nitrogen when larger quantities of alcohol are ad- ministered. The partition of urinary nitrogen remains remarkably unal- tered, with the exception of an in- creased elimination of ammonia nitro- gen and a higher output of purins. The most significant impression af- forded was the absence of pronounced alterations indicative of markedly dis- turbed protein metabolism, even when comparatively large doses were con- tinued for days and weeks. Mendel and Hilditch (Amcr. Jour, of Physiol., Nov., 1910). [As is the case with all food accessories, coffee, tea, pepper, common salt, etc., al- cohol becomes toxic when used immod- erately, and when insufficiently diluted. Light wines, beer, and other beverages that contain a very small proportion of alcohol, when taken in moderation, tend to activate the functions of the ductless glands, and, therefore, the autoprotective functions of the body. The harmful in- fluence of alcohol begins as soon as the proportion of absolute alcohol in a bever- age exceeds 5 per cent, to any marked degree, the toxic effects being due mainly to its property of becoming oxidized at the expense of the blood and other body fluids and cellular elements. When the proportion exceeds 10 per cent, and ap- proximates that of brandy, whisky, and many patent or proprietary nostrums, al- cohol becomes an active toxic; it tends to paralyze the functions of the ductless glands, and, therefore, the autoprotective functions, thus giving free sway to patho- genic germs, their toxins and other toxics, venoms, toxic wastes, etc., that may be present in the blood, thus defeating in- directly and insidiously the efforts of the physician. C. E. de M. S.] Absorption and Elimination. — The absorption of alcohol is very rapid, unless it be so concentrated as to coagu- late the albumins with v^hich it comes in contact. Roughly, 20 per cent, of alcohol ingested is absorbed from the stomach, and the remaining 80 per cent, from the intestine. Proceeding to the liver with the portal blood, it is in part arrested in this organ, the other portion passing through to enter the general blood-stream. Eventually much of the latter portion leaves the capillaries by exosmosis and is absorbed by the various tissues. The liver and brain have a special affinity for alcohol, the 520 ALCOHOL (SAJOUS). former fixing four times and the latter twice as much as is present in the blood (Pouchet). More than 98 per cent, of .the whole amount ingested is oxidized in the tissues (Atwater). The re- mainder passes out with the urine un- altered, though traces may still remain in the blood after the first twent}'-four hours. The aroma of the breath of alcohol users is due rather to higher alcohols and by-products eliminated in this manner than to ethyl alcohol (Cushny). According to Brauer, some alcohol is excreted with the bile, then reabsorbed from the intestinal tract. An insignificant amount may leave the body with the sweat and milk. The products of the oxidation of alcohol in the system are believed to be acetic acid, carbon dioxide, and water. According to the researches of Dujardin-Beaumetz and Jaillet, it is oxidized in the red cells themselves, with the formation first of acetates of the alkali metals, then of carbonates. When the oxidizing ca- pacity of the blood-cells is exhausted alcohol begins to be eliminated in large amount with the emunctories and to accumulate in the tissues. Role of Alcohol in Nutrition. — The painstaking experiments of Neumann, of Atwater and Benedict, and of Rose- mann have shown alcohol to be capable of sparing the fats and carbohydrates of the body through its combustion in their stead, i.e., where the amounts of fat and carbohydrates ingested are in- sufficient for the needs of the body alco- hol will, to a certain extent, act as a substitute, and prevent the remaining reserve of these substances in the system from being exhausted. The combus- tion of alcohol, however, yields but a comparatively small amount of heat, the body temperature being, therefore, seldom raised by it, but rather lowered, owing to the peripheral vasodilatation it also produces, with the consequent in- crease in heat loss. Neumann con- cluded from his experiments that alco- hol could take the place of a chemically equivalent quantity of fat in the diet, and also that alcohol given in combina- tion with a diet in itself sufficient would bring about an economy of proteins — as measured by the nitrogen excretion in the urine — in the same way that an extra amount of fat would. When moderate amounts of alcohol are taken, the first result is an increase in the amount of nitrogen excreted, which persists, as in the case of any other change in the non-nitrogenous constit- uents of the food, until the organism has become used to the new diet, i.e., through a period of three or four days. After this the protein-saving property of alcohol asserts itself, the amount of urea and uric acid, as well as of sul- phates and phosphates, eliminated with the urine showing a decrease. Accord- ing to Pouchet, however, the proteins are spared by alcohol only if the subject is receiving in the diet an amount of protein in excess of the needs' of the body at the time. If not, or in any case if the administration of alcohol be long enough cont^inued, the amount of nitrogenous wastes will soon show an increase until the utilization of the body proteins becomes greater than normally — a condition of affairs un- favorable to the nutrition of the body. The same result will obtain at once where excessive, instead of moderate, doses of alcohol are used, the drug acting as a spur to the breaking down of the albumins. It is possible to prolong the life of starving rabbits by the subcutaneous injection of suitable doses of alcohol, but larger quantities of alcohol hasten ALCOHOL (SAJOUS). 521 the death of the animals. The favor- able action of the alcohol is to be ascribed in part to its saving effect on albumin and the better preserva- tion of the watery constituents of the organism. The acceleration of death under the influence of larger quanti- ties is to be explained naturally by the increased destruction of albumin. A diuretic action is produced only by the administration of larger quanti- ties of alcohol, smaller quantities having- an opposite effect. Kochmann (Miinch. med. Woch., Mar. 16, 1909). The advantages of alcohol as a source of body energy may be said to lie in its ready absorption, the fact that no diges- tion of it is required, and that it is easily oxidized. In fever or conditions of central nervous exhaustion, with result- ing temporary digestive failure, alcohol is, therefore, available for cautious use as a food. Roughly speaking, 4 min- ims of alcohol will yield the same amount of energy as 7 grains of sug-ar, starch, or protein or 3 grains of fat (Committee of Fifty, 1893). The disadvantages of alcohol are that it has toxic side effects, that it leads to obesity, and, probably, that, even in the temperate, it tends to lower the resist- ing power of the body to disease. M. Duclaux recently declared, on the strength of a number of experi- ments made on themselves by two American investigators (Atwater and Benedict), that alcohol, so far from being a poison, has, in moderate doses, a distinct dietetic value. This profession of faith, made, as it was, just at the time when the Academic de Medecine was, at the request of the Minister of the Interior, drawing up a list of toxic essences employed in the manufacture of liquors, and when the Prefect of the Seine had placarded the walls of Paris with warnings as to the deadliness of alco- hol, caused no little scandal among the antialcohol party, who, with the charity characteristic of "antis" of every hue, even hinted that the opin- ion of the distinguished successor of Pasteur was not altogether disinter- ested. This ignoble imputation is mentioned only to show the degree of malevolence and mendacity to which the minds of well-meaning per- sons can be inflamed by prejudice. In La Revue, M. Duclaux states that no definite practical consequences can yet be drawn from the experiments of Atwater and Benedict. He is anx- ious that the question should be fully discussed, but he awaits the coming of adversaries who will consent to read and reflect before rushing into print. In the mean time he will agree to a truce, accepting as an average one liter of wine a day, an amount which has been shown by the Ameri- can investigators to be harmless and even useful. The wine must be well diluted with water, and its consump- tion spread over a day. Roux, also of the Pasteur Institute, holds that, even if Atwater and Bene- dict's experiments be accepted, the fight against alcohol must still be con- tinued. He thinks that habitual drinkers will never submit to the restricted allow- ance which Atwater and Benedict im- posed on themselves. In regard to wine, Roux admits that the experi- ence of centuries as seen in whole nations shows that moderate drinking does no harm. Metchnikoff holds that alcohol in any form is a poison. He confesses, however, that he has not made a special study of the question, and his conclusion is based on his personal experience. He never drinks alcohol himself, as he has found that even a small quantity makes him giddy. Berthelot is clear that alcohol is not a food. In very small doses it may be useful as a medicine. He thinks alcoholism is a factor in the present decadence of most European nations, and that their only hope of salvation lies in vigorous legislation against the evil. Brouardel gives the guarded reply that from the chemical constitution of a body no conclusion can be drawn as to its alimentary value; experience alone can decide 522 ALCOHOL (SAJOUS). the question. Charles Richet says there is no doubt that alcohol is a food, and that in very small doses, when pure, it is almost harmless. This fact, however, does not warrant the inference that it is a good food. He thinks that men must be angels before alcohol ceases to be a great danger. It is a mischievous delusion to think that alcohol is consumed as a food; it is rather its poisonous ef- fects that are sought by unfortunates anxious to forget their misery. Pro- fessor Bernheim, of Nancy, does not think that the use of alcohol should be proscribed. He even holds that many abstainers from "the generous wine of France" are actuated by snobisme. Wine, he says, is, like other medicines, poisonous only in large doses. It would be as reasonable to forbid its use on that account as to condemn the eating of meat because it contains ptomaines, or eggs because phosphorus enters into their compo- sition. Like everything that we take, wine suits some and not others. Lancereaux also holds that wine is dangerous only if taken in too great quantity — for instance, in a daily quantity of 3 liters. Alcohol in every form, however, if taken to excess, brings on premature senility and tends directly to tuberculosis and death. Hericourt holds that, to the question, Is alcohol food? no absolute answer can be given. Every food is toxic in cer- tain amounts, and, although the con- sumption of a liter of wine a day may have been a direct cause of the death of anyone, it may be so indirectly, as by diminishing the power of resistance to disease. Dr. Landouzy is of the opinion that natural wine taken in doses suitable to age, constitution, and mode of life does not deserve the uncompromising condemnation of intemperate advo- cates of temperance; he looks upon spirits and liqueurs, however, as, gen- erally speaking, pernicious. Magnan thinks that, whatever chemistry or ex- perimental physiology may appear to show, alcohol can never be recom- mended as a food. Garnier, speak- ing from a large prison experience, says that alcohol is responsible for 70 per cent, of all the crimes com- mitted in France. Bourneville is not hostile to wine; he holds, with Du- claux, that, from the hygienic point of view, it is distinctly useful in mod- erate doses. On the whole, then, the weight of opinion among leading scientific men in France is in favor of the dietetic value of wine. But the wine must be pure and it must be taken in moderate amount. Those who, like Cassio and Metchnikoff, have very poor and un- happy brains for drinking ought, by all means, to avoid looking upon the wine when it is red. They have no right, however, to make this personal idiosyncrasy the measure of other people's tolerance, still less to found upon it a universal law for the gov- ernance of mankind. As to the deadly effects of the abuse of alcohol we are all agreed, and prob- ably all will also agree that its use should be carefully regulated in ac- cordance with individual constitution. The experience of men differs. Glad- stone, who had an "open mind" in most directions, tested the matter for himself. He found that wine helped him when he had to make an ex- traordinary oratorical effort, and the want of it made the effort more labori- ous and less successful. On the other hand, some find that wine paralyzes their faculties. In regard to alcohol, it may be said with truth that what is one man's meat is another man's poison, and that homely proverb seems to us to sum up the teachings of science and philosophy on the ques- tion. Editorial (Brit. Med. Jour., Mar. 14, 1903). The following comparative table represents demonstrable facts and the teachings of laboratory work :^ Food. Alcohol. 1. A certain quan- 1. A certain quan- tity will produce a tity will produce a certain effect at first; certain effect at first, the same quantity but it requires more will always produce and more to produce the same effect in the same effect when the healthy body. the drug is used habitually. ALCOHOL (SAJOUS). 523 Food {Oontinued). 2. The habitual use of food never in- duces an uncontrol- lable desire for it in ever-increasing- amounts. 3. After its habit- ual use a sudden to- tal abstinence never causes any derange- ments of the central nervous system. 4. Foods are oxi- dized slowly in the body. 5. Foods, being useful, are stored in the body. 6. Foods are the products of con- structive activity, activity of proto- plasm in the pres- ence of abundant oxygen. 7. Foods (except meats) are formed in nature for the nour- ishment of living or- ganisms, and are, therefore, inherently wholesome. 8. The regular in- gestion of food is beneficial to the healthy body, but may be deleterious to the sick. 9. The use of foods is followed by no re- action. 10. The use of food is followed by an in- crease in activity of the muscle-cells and brain-cells. 11. The use of food is followed by an in- crease in the excre- tion of carbonic oxide. 12. The use of food may be followed by accumulation of fat, notwithstanding in- creased activity. 13. The use of food is followed by a rise in body temperature. 14. The use of food strengthens and Steadies the muscles. Alcohol {Continued}. 2. When used ha- bitually it is likely to induce an uncon- trollable desire for more, in ever-in- creasing amounts. 3. After its habit- ual use a sudden to- tal abstinence is likely to cause a se- rious derangement of the central nervous system. 4. Alcohol is oxi- dized rapidly in the body. 5. Alcohol, not be- ing useful, is not stored in the body. 6. Alcohol is a product of decompo- sition of food in the presence of abundant oxygen. 7. Alcohol is formed in nature only as an excretion. It is, therefore, in common with all excretions, inherently poisonous. 8. The regular in- gestion of alcohol is deleterious to the healthy body, but may be beneficial '■o the sick (through its drug action). 9. The use of al- cohol, in common with narcotics in general, is followed by a reaction. 10. The use of al- cohol is followed by a decrease in the ac- tivity of the muscle- cells and brain-cells. 11. The use of al- cohol is followed by a decrease in the ex- cretion of carbonic oxide. 12. The use of al- cohol is usually fol- lowed by an accumu- lation of fat through decreased activity. 13. The use of al- cohol may . be fol- lowed by a fall in body temperature. 14. The use of al- cohol weakens and unsteadies the mus- cles. Food (Concluded). 15. The use of food makes the brain more active and ac- curate. Alcohol {Concluded). 15. The use of al- cohol makes the brain less active and accurate. [Alcohol is considered as a food-sparing agent by some observers, its value corre- sponding with its dynamic equivalent of pure food hydrocarbon. This presupposes, however, that alcohol is utilized by the tissues in the same manner as these hy- drocarbons — merely because its oxidation liberates energy in the form of heat. But this is a fallacious conception; alcohol only simulates normal oxidations; far from being the product of cellular ex- changes which constitute the vital process, the heat it liberates is at the expense of the tissue, since by becoming oxidized itself, especially in the liver — whereby the body is protected against its toxic effects — it utilizes oxygen intended to sustain tissue metabolism. If alcohol were a food, large doses would prove more profitable to the organism than small ones; but the reverse is the case; large doses inhibit all activities tha,t would be enhanced by a ^ liberal use of food. The debilitating action of alcohol on the nervous system, for example, has been demonstrated by Bunge, Schmiedeberg, Ach and Krepelin, and others, while Dogiel found that it de- pressed markedly both motor and sensory nerve-centers. It does this not only with nervous tissue, but with all tissues. A depressing agent cannot logically be re- garded as a food. C. E. de M. S.] In healthy persons alcohol unques- tionably plays the same role as a food, e.g., a carbohydrate or a fat. In con- trast to fats and carbohydrates, alco- hol spares the proteids only in those cases in which the organism has be- come accustomed to the action of the stimulant, which usually takes sev- eral days. In disease alcohol appar- ently acts upon metabolism in the same way as in health. It is particu- larly useful as a food in diabetes mel- litus; by taking the place of fats in the food it lessens the production of the acetone bodies. Hare showed that alcohol raises the power of the blood to destroy bacteria. Fried- berger found that under the influence 524 ALCOHOL (SAJOUS). of alcohol the blood acquired an in- creased resistance against the cholera vibrio. Mircoli found that under the influence of alcohol the body acquired the power to resist the tubercle bacil- lus. A. K. Sievert (Roussky Vratch, Oct. 24, 1909; N. Y. Med. Jour., Jan. 1, 1910). [The protective influence of alcohol re- ferred to here applies to small quantities only. Everyone knows and hospital ex- perience has amply and conclusively shown that alcoholism greatly weakens the power of the body to resist disease. C. E. de M. S.] External Action. — Applied to the skin and allowed to evaporate, alcohol reduces the local temperature because of its marked volatility. It may also exert an anesthetic effect. If evapora- tion be prevented, however, and the contact maintained for some time, alco- hol acts as an irritant. Owing to its rather high diffusion power, it pene- trates through the cuticle to the un- derlying tissues, and induces a sen- sation of heat, often preceded by itching and accompanied by red- dening of the skin surface. It may thus be employed as a counter- irritant. For such effects a concentra- tion of about 60 per cent, or over is re- quired, more dilute solutions not giving rise to distinctly irritative phenomena. When applied to ulcers and other open surfaces, alcohol may, through its irri- tant properties, hasten tissue repair. The prominent local effects of concen- trated alcohol include the abstraction of water from the tissues, and the coagula- tion of albumin. It is because of these effects, and also by dissolving out the fat, that alcohol hardens the skin when repeatedly applied. It is sometimes used to cover sores or wounds with a thin, protective, air-excluding layer of coagulated albumin, which facilitates healing. Alcohol may also act as an astringent, a property not infrequently availed of in such condition as saliva- tion, pharyngeal relaxation, scurvy, etc., alcoholic preparations being employed as mouth-washes and gargles. The irri- tant and astringent powers of alcohol are naturally more pronounced upon the mucous membranes and upon wound surfaces than upon the skin, and dilute preparations can, therefore, be used on the former to procure effects such as only concentrated ones would produce on the skin. Inhalation of the vapors of alcohol is capable of causing tempo- rary spasm of the laryngeal muscles through reflex irritation. Alcohol has noteworthy antiseptic and germicidal properties, which may be utilized in the disinfection of wounds. According to Harrington and Walker, 60 and 70 per cent, alcoholic solutions, applied to wounded surfaces for at least five, minutes, are the most efficient in de- stroying bacteria. In these percentages alcohol corresponds in strength to about 3 per cent, phenol (Cushny). Dry bacteria may not be destroyed by a day's exposure to absolute alcohol. Against dry bacteria, absolute alco- hol and ordinary commercial alcohol are wholly devoid of bactericidal power, even with twenty-four hours' direct contact, and other preparations of alcohol containing more than 70 per cent., by volume, are weak in this regard, according to their content of alcohol, — the stronger in alcohol, the weaker in action. Against the com- moner, non-sporing, pathogenic bac- teria in a moist condition, any strength of alcohol above 40 per cent., by vol- ume, is effective within five minutes, and certain preparations within one minute. Alcohol of less than 40 per cent, strength is too slow in action or too uncertain in results against pathogenic bacteria, whether moist or dry. The most effective dilutions of alcohol against the strongly resist- ALCOHOL (SAJOUS). 525 ant (non-sporing) bacteria, such as the pus organisms, in the dry state, are those containing from 60 to 70 per cent., by volume, which strengths are equally efficient against the same organisms in a moist condition. Un- less the bacterial envelope contains a certain amount of moisture, it is im- pervious to strong alcohol; but dried • bacteria, when brought into contact with diluted alcohol containing from 30 to 60 per cent, of water by volume, will absorb the necessary amount of water therefrom very quickly, and then the alcohol itself can reach the cell protoplasm and destroy it. The stronger preparations of alcohol pos- sess no advantage over 60 to 70 per cent, preparations, even when the bac- teria are moist; therefore, and since they are inert against dry bacteria, they should not be employed at all as a means of securing an aseptic con- dition of the skin. Provided the skin bacteria in the deeper parts can be brought into contact with disinfect- ants, alcohol of from 60 to 70 per cent, strength may be depended upon usually, but not always, to destroy them within five minutes. Charles Harrington and Harold Walker (Bos- ton Med. and Surg. Jour., May 21, 1903). THERAPEUTICS.— As a "Stim- ulant." — The opinion of the medical profession in regard to the value of alcohol as a stimulant is divided, and the extent to which the drug is em- ployed in the treatment of disease (ex- ception being made of its external uses) is on the decline. The more recent studies have brought out the importance of the vasodilator influence of alcohol, and cast a shadow on its effectiveness as a true stimulant. By many it is believed that a part, if not all, of the stimulating effect of alcohol results from the local irritation produced by it in the stomach, the centers in the medulla oblongata being thereby excited reflexly. [Buchner, Chittenden, Mendel, Jackson, and many other authorities have shown that beverages which contain a small pro- portion, about 5 per cent., of absolute alcohol, such as light wines, beer, etc., increased the production of gastric juice and the activity of the digestive process. Being entirely oxidized in the stomach and promptly eliminated by the lungs and kid- neys, this small percentage, unless taken in large quantities, does not influence morbidly either the blood or its oxidizing body. Such is not the case, however, when the proportion of absolute alcohol exceeds 5 per cent, to any marked degree. A beverage containing 10 per cent., for ex- ample, retards digestion manifestly, and if stronger, as is the case with brandy, Avhisky, etc., it tends besides, as first shown by Claude Bernard, to cause coagu- lation of the gastric secretion and its fer- ments. Under these conditions, the func- tions of the digestive tract are not alone interfered with, but considerable alcohol is absorbed into the blood. It is this absorbed alcohol which does incalculable harm. Being oxidized at the expense of the blood's oxidizing body — of adrenal origin — it robs the tissues of that which sustains their life. C. E. de M. S.] Partly because of the fact that it is often the only remedial agent imme- diately available, it is still largely admin- istered, especially by the laity, in all varieties of emergencies. Its effect, though of short duration, is exerted promptly. As a cardiac and respiratory stimu- lant alcohol is made use of in imme- diately dangerous conditions, such as syncope, shock, collapse, severe hem- orrhage, asphyxia, and poisoning by depressant drugs, as well as, in many instances, in the course of acute in- fectious diseases, such as typhoid fever, typhus, pneumonia, diphtheria, small-pox, scarlatina, septicemia, ery- sipelas, tetanus, yellow fever, cholera, dysentery, influenza, etc. The con- sensus of present opinion is that alcohol should never be administered 526 ALCOHOL (SAJOUS). continuously, even in severe infec- tions, but should be reserved for periods of unusual depression, when special stimulation is necessary to tide the patient over a dangerous crisis. In selecting the dose to be used, the vaso- dilator influence of alcohol must always be remembered, excessive doses tending to lower markedly the tone of the blood- vessels, — the importance of which tone in the maintenance of cardiac activity is well recognized. According to many, indeed, the use of alcohol in shock is to be avoided, as this is a condition of paretic vasodilation, and the vaso- dilator effect of alcohol exerted after its absorption is likely to prove more harmful than its primary reflex stimu- lating effect on the heart and respiration will have done good. Similarly in severe hemorrhage, alcohol has been said to be contraindicated, owing to its vasodilator property. While alcohol may stimulate the heart and raise arterial pressure mo- mentarily, its secondary effect is that of a cardiac depressant and a vaso- dilator. The only time when alcohol is a stimulant is in acute cardiac fail- ure, and then it is stimulant to the heart only before its absorption, re- flexly from the irritation, when taken in concentrated solution, of the mu- cous membrane of the mouth, phar- ynx, esophagus, and stomach, the rec- tum, if it is administered as an enema, and the tissues, if it is given hypo- dermically. To obtain such stimula- tion the alcohol must be in strong preparation — either brandy, whisky, gin, rum, or champagne. This reflex irritation through the vasomotor cen- ter temporarily raises the blood- pressure, and perhaps, through the accelerator nei'ves, stimulates the heart. To keep up this stimulation another dose must soon be given, in from fifteen minutes to half an hour or an hour, depending on the pro- longation of the heart weakness. The dose of alcohol for such stimulation should be small in order that the re- sults from the subsequent absorption will be the minimum, as the vaso- dilator effects are not desired. If the alcohol is administered too frequently it accumulates in the system before the previous doses can be burned or eliminated, and then to obtain stimu- lation it will be necessary to give a larger, concentrated dose to cause sufficient irritation and stimulation to overcome the depression of the pre- vious doses. Soon the vasodilation is increased, the heart is depressed. the nervous system more or less par- alyzed, and depression is added to depression. Consequently, the only excuse for using alcohol in any form as a cardiac or circulatory stimulant is when the depression or syncope is short-lived, or, perhaps, as a primary stimulant in acute collapse. (Jour. Amer. Med. Assoc, Nov. 6, 1909.) Observations on the remarkable stimulant effect on the heart and cir- culatory system produced by the in- halation of oxygen containing alcohol vapor. There are the good effects of the oxygen plus an additional marked stimulant effect on the circulation caused by the contained alcohol va- por. Oxygen which had been bub- bled through absolute alcohol con- tained in an ordinary wash-bottle was administered in several cases of ill- ness in which cardiac failure was a prominent symptom, and it was found that the mixture produced a marked stimulant effect on the heart and cir- culation, decidedly greater than that produced by oxygen alone. In some of these cases the administration ap- peared to have been the cause of pro- longation and saving of life. In cases of pneumonia with cardiac failure the mixture of oxygen and alcohol vapor was found to be a valuable remedy. Willcox and Collingwood (Brit. Med. Jour., Nov. 5, 1910). In emergency conditions, large doses of alcohol, e.g., 1 or 2 ounces (30 to 60 c.c.) of whisky or brandy, are not in- frequently administered. Where, owing ALCOHOL (SAJOUS). 527 to unconsciousness or profound adyna- mia, the spirits cannot be swallowed, they may be injected subcutaneously. By this method absorption of the drug is more rapid, and its general effect cor- respondingly hastened. Alcohol may also be given by rectum, preferably in the form of brandy. In the treatment of wounds inflicted by venomous snakes and poisonous fishes, the internal use of alcohol has long been considered an effective measure, though the idea that the drug exerts a specific antidotal effect in these cases appears to be based on pure assumption. Large doses are customa- rily given in these cases, but this should certainly not be pushed to the point of adding an acute alcoholic intoxication to the difficulties with which the system already has to contend. In the prostration attending cases of meat poisoning or ergotism, the ad- miinistration of alcohol also often proves valuable. As a Vasodilator. — The value of alcohol in feverish or frankly febrile conditions depends in reality on not a single, but a group, of effects, which have been enumerated by Sollmann as follows: 1. Dilatation of the cutaneous vessels. 2. Counteraction of the nerv- ous phenomena of fever, through nar- cotic action. 3. The furnishing of a readily absorbable food. 4. Diuresis. Among these effects peripheral vaso- dilation ranks as the most important. AVhen the pulse becomes of the high- tension variety, owing to excitation of the contractile vascular walls by dis- ease toxins, and the superficial circula- tion becomes sluggish, for the same reason, alcohol is likely to prove bene- ficial by dilating the vessels, lowering the tension, facilitating the work of the heart, and prornpting perspiration. It will act thus pre-eminently as a restorer of the circulatory ecjuilibrium. Certain particular indications for the use of alcohol in fevers have been formulated, viz., where in addition to a frequent, small, or irregular pulse or respiratory depression there are present dryness of the tongue and skin, together with rest- lessness and delirium or, on the other hand, indifference and hebetude, and perhaps subsultus tendinum, — phenom- ena commonly grouped under the term "typhoid state." While, in a general way, the validity of these indications for alcohol seems to be established upon the basis of past experience, it cannot be said that the drug will invariably be productive of benefit where the indica- tions are present. If, alcohol having been administered, the pulse and res- piration are improved, the mouth and skin rendered moist, and the mental condition corrected, the propriety of employing it in the individual case will become apparent. As a vasodilator in chronic high arte- rial tension alcohol should ordinarily not be used. This indication is present in arteriosclerosis and gout, and is a symptom and sign in late middle life or old age. If the condition requires treatment it is much better managed by nitroglycerin, thyroid extract, potassium iodide, or small doses of chloral. If arteriosclerosis is present and the pa- tient is well along in life and is accus- tomed and has been accustomed to take alcohol regularly in doses that do not intoxicate, it may be unwise to stop the vasodilating effects of the alcohol until it has been ascertained that some other treatment will be as conducive to his well-being. In other words, the physio- logical relief from high tension which he has been accustomed to acquire by tak- ing alcohol cannot be abruptly stopped without due consideration of the con- sequences of withdrawing the drug. (Jour. Amer. Med. Assoc, Nov. 6, 1909.) 528 ALCOHOL (SAJOUS). The dose of alcohol given in the feb- rile diseases has usually been that rep- resented by ^ to 1 ounce (15 to 30 c.c.) of whisky or brandy, diluted with water, this amount being repeated every two to four hours. AMiile it has been a mat- ter of common observation that very large doses of alcohol may be given in fever without eliciting the ordinary signs of intoxication, this fact should not be interpreted as giving the physi- cian license to introduce alcohol into the systems of patients without due consideration of the dosage. It should be kept in mind that alcohol, though set- ting free energy in the form of heat through its oxidation, in doing so draws upon the supply of oxygen present in the tissues, and if caused to accumulate in the system through injudicious dosage is hkely seriously to interfere with other oxidative processes essential to the welfare of the economy. Hence the tendency recently has been, if alco- hol is used at all in fever, to limit strictly the amount given to what is necessary for amelioration of the symptoms. According to Osborne, a dose larger than 1 to 3 teaspoonfuls, once every three hours, is probably never indicated in febrile conditions ; if this dosage be exceeded, the harmful effects resulting when alcohol is given in amounts that overtax the oxidizing powers of the tissues and lead to accumulation of the drug in the system will be avoided. Butler counsels that, even in cases where alcohol proves beneficial, it should rarely be given throughout the twenty-four hours, but reserved for periods when the heart action grows especially weak, usually in the interval between midnight and 7a.m. One fluid- ounce (30 c.c.) of whisky may be given before midnight and repeated every three hours. In lieu of pure whisky or brandy, diluted alcohol may also be ad- vantageously given in the form of milk punch or eggnog. In infectious diseases alcohol should never be given unless the patient is near collapse. Even in small doses it weakens the resistance, and so favors the action of the invading microbe. It is a cause of stillborn infants, with more or less widespread fatty degen- eration. Gruber (Wiener klin.Woch., May 9, 1901). The effect of alcohol on the circula- tion in the sick, and its effect on the power of man's blood to resist infec- tion, studied experimentally. Only the results of study of the first of these two problems are now reported. The following facts, regarding the action of alcohol, the author considers as already established by the investi- gations of many observers : (a) In health alcohol can replace the fats and carbohydrates. Whether it can replace the proteids is not yet set- tled. Alcohol is both a food and a poison. (&) In the stomach alcohol disturbs the digestive process to a greater or less degree. After absorp- tion it exerts through the nervous system a temporary increase both in the secretion and in the motility of the stomach. On intestinal absorp- tion, so far as known, alcohol exerts little or no influence, (c) In healthy people and in persons with cardiac and renal diseases alcohol has no con- siderable diuretic power. In healthy people it rather decreases than in- creases diaphoresis, (d) The labor of respiration is increased by alcohol, yet there is no increase in the amount of O absorbed, nor in the quantity of CO9 given off. To the above facts regarding the action of alcohol the writer adds the following, ascertained experimentally: 1. The action of alco- hol upon the circulation is nil. Neither the maximum nor minimum blood- pressure showed any variation that could reasonably be attributed to the action of alcohol. 2. From the study of 309 patients suffering from a great ALCOHOL (SAJOUS). 529 variety of diseases it would seem that alcohol, in therapeutic doses, has no effect on the temperature, pulse rate, respiration rate, appetite, delirium, and secretions. These observations should not, however, be interpreted as prov- ing that alcohol is useless or useful in disease. R. C. Cabot (Boston Med. and Surg. Jour., July 23, 1903). Rabbits injected with diphtheria toxin or other infectious products, followed by injection of alcohol, the results confirming the clinical obser- vations of Dennig, Hindelang, and Griinbaum in respect to the injurious action of alcohol on the circulation during febrile conditions. The alco- hol improves the respiration, but this favorable effect is outbalanced by its unfavorable action on the circulation, the blood-pressure dropping and the amplitude growing smaller, although the pulse rate may remain the same. It is necessary to restrict the use of alcohol in febrile states, weighing in each individual case whether the eu- phoria that follows the use of alcohol outbalances the inevitable somatic injury. Alexandroff (Corresp.-Blatt ■f. schweizer Aerzte, May 20, 1910). Impairment of the vascular regulat- ing mechanism is more apparent than active disturbance of the heart in the circulatory derangements of the acute infections. Treatment should, there- fore, be directed to the prevention or correction of these vasomotor dis- turbances, and, while alcohol in small doses sometimes acts as a cardiovas- cular stimulant, its mode of action is not quite clear. In larger amounts, in individuals not accustomed to its use, it invariably acts as a depressant, paralyzing the vasomotor center. The border line between doses that act as a stimulant and those which act as a depressant is very uncertain. Some investigators have been unable to de- tect a rise in blood-pressure, even with very moderate doses, and this uncertainty renders it an undesirable therapeutic agent. Even in small doses it may, and in large doses al- ways, depress the circulation, and Other drugs more constant in their action are advisable, being less likely to affect the patient unfavorably. J. L. Miller (Jour. Amer. Med. Assoc, Dec. 10, 1910). Alcohol is frequently used to in- crease the warmth of the body surface in the presence of chilly sensations or after exposure to cold. This is accom- plished through the peripheral vaso- dilation which it produces. It must not be forgotten, in this connection, that peripheral vasodilation results in in- creased heat loss; if, during exposure to cold, peripheral vasodilation be pro- duced and maintained for some time, as by repeated ingestion of alcohol, the result cannot but be an excessive loss of body heat, with merely temporary re- lief, and ultimate lessening of the resist- ing powers. Hence alcohol to warm the body surface should only be given after exposure or just before the period of exposure is to terminate. In the initial stage of colds and of acute catarrhal inflammations of the respiratory passages in general, alco- holic preparations have been much used with the idea that by sharply activating the circulation of blood at the periphery local congestions will be relieved and the cold thus aborted. The patient takes a good-sized dose of whisky, followed by smaller doses every three or four hours, and stays in bed for a day, to facilitate the re-establishment of the circulatory equilibrium. While there is no doubt that alcohol, in combination with external warmth, will often bring about the desired result, the same ef- fect can be procured by means of a hot bath, a coal-tar drug, and a saline pur- gative, without resorting to the use of alcohol. In arteriosclerosis alcohol will act as a vasodilator and doubtless frequently performs this office in elderly individuals 1-S4 530 ALCOHOL (SAJOUS). accustomed to its use, but it should never be prescribed as such by the physician. Where the eruption is delayed in the acute exanthematous diseases, a dose of whisky, taken hot, may bring- about its early appearance. As a Narcotic and Hypnotic, — The slightly depressing action of moderate doses of alcohol on the cerebral func- tions is a contributing factor in its use- fulness in febrile conditions. Mild de- lirium will be relieved by it, or if no delirium be present the oncoming of sleep will be favored. The narcotic action of alcohol, however, is only of secondary importance, and should not be utilized unless there are other indica- tions for the use of the drug. In febrile states a part of the quieting effect on the brain is due to a lowering of the tension in the cerebral circulation through the general vasodilation which the drug produces. In mild degrees of insomnia in the aged, a little alcohol taken before retir- ing will promote sleep. But it is pref- erable to use other remedies; thus where the insomnia, as is often the case, is due to high blood-pressure, nitroglyc- erin should be substituted for alcohol, as a vasodilator. A mixture of equal parts of hot milk and of good ale or beer has been recommended as a promoter of sleep. Although alcohol in proper dose and in the proper form has an hypnotic effect not only by dilating the peripheral vessels and relieving the tension of the cerebral circulation, but also by its quieting effect o the nervous system, it should not -frequently be considered or used as a hypnotic. Still, instances occur both in acute illness and in de- bilitated patients vvrhere it seems to be the safest and the most satisfactory of hypnotics. Of course, v^^hen alcohol is used thus as a drug it should be stopped by the physician as soon as he considers that the patient can tolerate another hypnotic, or that the positive indication has ceased to exist. In very old people who cannot sleep, alcohol as a "night- cap" has been frequently advised. Sleeplessness in senility is frequently due to high-tension circulation, and one can often cause these patients to sleep as vi^ell virith small doses of nitro- glycerin, administered at bedtime, as by alcohol so administered. (Jour. Amer. Med. Assoc, Nov. 6, 1909.) Similarly, in insomnia in greatly weakened individuals, where alcohol may seem, for a time, the best hypnotic to use, other drugs should be substi- tuted for it as soon as the patient's general condition permits. Beer or well-diluted spirits are most effective where the hypnotic action of alcohol is desired. In neuralgia as well as melancholia and other forms of mental distress alco- hol has given relief through its nar- cotic effect, but the danger of inducing chronic alcoholism in these cases is such that it is questionable whether it should ever be employed. As a Stomachic, Antemetic, etc. — Ingested before or during meals, alco- holic preparations will frequently exert a pronounced beneficial effect in cases of atonic dyspepsia or in anorexia or poor digestion due to physical or mental fatigue, acute illness, etc. A small amount of wine or beer, or a little brandy diluted with water, by exerting a mild stimulating eft'ect locally im- proves the gastric circulation and there- by promotes the secretory activity where this is deficient. The psychic effect of the odor and taste of wine, when agree- able to the patient, probably also plays a not inconsiderable part in improving the appetite. Dry wines should be given the preference in these cases, the sugar of sweet wines being detrimental, ALCOHOL (SAJOUS). 531 VVliere anorexia is very marked, bitter tonics, such as caltimba or quassia, in the form of tinctures or gentian or cin- chona, in the compound mixtures, may be given in addition. In certain forms of indigestion, alco- hol does more harm than good, e.g., where there is hyperacidity, or where the gastric mucosa is acutely inflamed. In all cases, moreover, where the neces- ■ sity for gastric stimulation is likely to persist, e.g., in the chronically debili- tated and in the neurotic, the use of alcohol as a stomachic and stimulant to digestion is to be entered upon only with extreme caution, lest chronic alco- holism be the final result. This danger is less to be feared in the aged than it is in the young or middle-aged. In vomiting, e.g., in seasickness and in the vomiting of pregnancy, alcohol, especially in the form of champagne, sometimes proves helpful. A little brandy may be given on cracked ice in these disturbances, but champagne is decidedly the most effective preparation, combining the local anesthetic property of alcohol with the sedative action of carbon dioxide gas. In a somewhat similar manner, the pain resulting from flatulence, as well as gastralgia, may be relieved by the use of brandy (Butler). In diarrhea, brandy is generally be- lieved to exert a favorable influence, though the reason for its beneficial ef- fect is not known. Red wines, by virtue of their tannin content, also tend to counteract diarrhea, — especially Bor- deaux, dark Burgundy, and currant wine. In conditions of general debility and during convalescence from exhausting diseases, even in the absence of gastric symptoms, alcoholic preparations are frequently given as general stimulants and reconstructives. The benefit pro- duced results in part, doubtless, from activation of the digestive processes, but the food value of the preparations used, generally rich red wines, such as port and Madeira, or else beer, ale, porter, brown stout, and malt extracts, because of the additional nutritive substances they contain, must also be given due credit. To these favorable influences may be added the tendency to sleep and rest as a result of the narcotic action of alcohol, the improved distribution of blood through peripheral vasodilatation, the lessened resistance to cardiac action offered by the vessels, and the euphoria of the primary stage of alcoholic action. In severe cases of diabetes mellitus alcohol has also been used as a food. Use of alcohol as a food in cases of severe diabetes. For years its value in such cases has been known clinically. But 'until recently we did not know whether the action was pharmacological or whether it was nutritive. In 1906, Benedict and Torok, in studying the origin of acetone bodies in diabetes, substituted the fat of the dietary by alcohol and found a marked decrease in the output of acetone, sugar, and nitrogen. The sugar alone decreased 18 per cent. In severe cases with high ammonia the output was greatly de- creased. Their work added further evidence of the protein-sparing action of alcohol. Neubauer, simultaneously, found alcohol of great service in severe diabetes. He used a wine containing 10 per cent, alcohol, allowing daily 12 to 24 ounces, equivalent to 450 to 900 calories of energy. He found regularly in severe cases a marked reduction in the output of sugar, acetone, oxybutyria acid, and ammonia. The total nitrogen and the amount of urine were decreased. In light cases of this disease, alcohol was of much less importance, but in severe diabetes, where the tissues can- not utilize carbohydrates, where only a little or no fat is allowable, and where protein alone tends to aggravate the 532 ALCOHOL (SAJOUS). conditions, alcohol finds an invaluable place in the dietary. Aside from its action in diabetes and a few conditions of malnutrition, there has been no evidence produced thus far that alcohol is a better food than the sugars and starches. There is some reason to believe it somewhat inferior to them. There is abundant evidence that, on account of its habit-producing power and its baneful effects when used in excess, it should be condemned as food for healthy, normal individuals. Scar- brough (Yale Med. Jour., Feb., 1910). As a Diuretic. — Dilute gin, light acid white wines, and light beers are the most strongly diuretic preparations of alcohol. This property can, however, only be considered as a relatively unim- portant adjunct to the other actions of alcohol. In Phenol Poisoning. — The value / of alcohol in phenol poisoning has been shown to be due to the ready solubility of the phenol in it, the local action of phenol in concentrated form being thereby hindered. It is to be observed that this very dilution of the phenol is likely to hasten its absorption into the general system. Hence after giving the alcohol— preferably dilute — the physi- cian should see that the stomach is emptied as soon as practicable. External Uses. — Applied locally, alcohol has antiseptic, anesthetic, cool- ing, stimulating, solvent, astringent, dehydrating, and hemostatic proper- ties. It is, therefore, a valuable agent in the treatment of wounds, espe- cially infected wounds, in the man- agement of which whisky, undiluted or diluted in the proportion of 1 to 4 of water, miay be employed with ad- vantage. In snake-bites concentrated alcohol mixed with ammonia may be used as a lotion after the poison has been sucked out; it is similarly use- ful in insect stings. In puerperal sepsis 50 per cent, alcohol has been used as an intra-uterine douche, and in 25 to 50 per cent, strength as a packing; better agents are, however, at our dis- posal. For the treatment of sprains, in- flamed joints, contusions, strained muscles and tendons, headache, neu- ritis, abscesses, slight burns, ery- thema, and erysipelas, alcoholic evap- orating lotions are extensively used. A lotion composed of alcohol 8 parts, ammonium chloride 1 part, vinegar or dilute acetic acid 4 parts, in water 64 parts, will be found generally serviceable. Where a greater degree of absorption is desired, a gauze pad may be moistened with alcohol, applied over the involved area, and covered with rub- ber tissue. In phlegmonous inflamma- tions, Salzwedel cleanses the part with ether, applies thick layers of cotton saturated with 90 per cent, alcohol, and covers the whole with an impermeable material, perforated in such manner as to delay, but not entirely prevent, evapo- ration. By this plan, he states, fever is lowered and the suppurative process hastened. Similarly, in sycosis, furun- culosis, indolent ulcers, whitlow, etc., Heuss employs compresses consisting of 6 to 8 folds of gauze wet with 95 per cent, alcohol and covered with an imper- meable dressing. Kaiser employed alco- hol dressings in 93 cases of various inflammatory affections, and claimed very gratifying results; the distinctive feature of this method was that as a preliminary step, all fatty matter is re- moved from the involved area with benzine and alcohol (Bulkley). Permanent applications of strong al- cohol of great service in combating all inflammatory conditions in which there is a tendency toward suppura- tion. It causes a local dilatation of the blood-vessels, and thereby the ALCOHOL (SAJOUS). 533 formation of alexins and consequent greater capacity for resisting the spread of infection. Thick layers of gauze are saturated with alcohol and then covered with some impervious material. The dressing is left in place for days at a time, resaturating it with alcohol once every twelve hours. Graescr (Miinch. med. Woch., July 17, 1900). Following combination recommended as a clean and effective substitute for the ordinary lead and laudanum dress- ing: — IJ Morphince acetatis.. 0.65 Gm. (1 gr.). Liq. plumbi subace- tatis 30 c.c. (1 oz.). '■AlcohoUs ...q. s. ad 120 c.c. (4 oz.). M. Sig. : Apply on 1 layer of muslin or cotton and allow to evaporate. W. Brady (N. Y. Med. Jour., April 24, 1909). The benefit derived from the use of the tincture of arnica in sprains, and spirit of camphor in mastitis, seems to depend entirely on the cooling produced by the rapid evaporation of the alcohol contained in these preparations. The benefit derived from the popular "alco- hol rub" is entirely a matter of sugges- tion, and its supposed strengthening properties are mythical. Alcohol is not absorbed when rubbed on the skin. When used in this way in depressed conditions, it is liable to do harm, by reducing the body temperature when it should be sustained. Olive oil or cacao butter should be used instead of alcohol in massage. G. A. Graham (N. Y. Med. Jour., May 8, 1909). Alcohol recommended as a final ap- plication in all cases of wounds, dress- ing with either plain or carbolized gauze. In bruises and sprains equal parts of extract of witchhazel and al- cohol, applied as hot as can be borne, gives much better results than liniments or any of the clay and glycerin mix- tures, and is much more agreeable to the patient. In burns and scalds, with suppuration, alcohol is an ideal applica- tion, and where carbolic acid is in- dicated it can be used in any strength if followed immediately with alcohol. This also applies to suppuration in all kinds of wounds. In patients confined to bed for any length of time, the use of alcohol after bathing prevents bed- sores. Alcohol is one of the best anti- septics to clean instruments outside of an operating room. The hypodermic needle will always be ready if kept in alcohol, and there will be no need of inserting wires in it. It is best not to use a weaker solution than 60 per cent, of alcohol. Care is required, however, to get pure alcohol, as so many inferior brands are offered, which, if used, give disappointing results. S. S. Royster (Intern. Jour, of Surg., Oct., 1909). Reports concerning the therapeutic uses of alcohol in dermatology have recently been reviewed by Bulkley. In eczema Unna recommends an alcohol dressing having the following composi- tion : Sodium stearate, 6 parts ; glyc- erin, 2.5 ; alcohol, to make 100. This has the advantage of greater perma- nency of effect than the rapidly evapo- rating pure alcohol, can be employed where the application of a bandage is im- practicable, is non-irritating and strongly bactericidal. In herpes simplex as w^ell as herpes zoster, the virtues of alcohol, applied on cotton and re- newed at frequent intervals, vv^ere pointed out by Leloir and Dupas; if it be applied in the stage of erythema the eruption w^ill disappear in a few hours ; if in the vesicular stage, in the course of a few days. Leloir recommends that a small quantity of phenol be added, in order to alleviate further the burning and pain. In lupus erythematosus, striking results were obtained by Hebra, Jr., and by Kohn from the frequent application of alco'hol, — 40 to 50 times daily. Continued applications of alcohol led to cure in a case of favus reported by Cantoni. In acne rosacea, Abrahams has given subcutaneous injections of 20 to 30 drops of 95 per cent, alcohol. 534 ALCOHOL (SAJOUS). repeated at most three times a week, and found that, after a temporary local anemia, the injections produced a hyperemia lasting for some hours, by which obliteration of the dilated vessels could be secured, providing the treatment be kept up for two or three months. In frost-bite, insect-bites, and itch- ing conditions in general the local anesthetic property of alcohol comes into play. According to Lauder Brunton, the itching in pruritus ani can be checked with absolute alcohol. In sprains and contusions a rubefa- cient as well as a cooling effect is exerted. In fever the body temperature may be lowered by bathing the surface with alcohol, diluted with 2 parts of water. Applied to aphthae or sluggish ulcers of various kinds, alcohol, undi- luted, acts as a stimulant to the proc- esses of repair. Used hot in a 10 to 20 per cent, solu- tion, alcohol has long been used as a gargle in tonsillitis and pharyngitis. In the prophylaxis of bed-sores and of cracked nipples, dilute alcohol is very effective when systematically rubbed over the areas exposed, hard- ening the skin so that it is rendered more resistant to external influences, and bringing an increased amount of blood to it, thus antagonizing local necrosis. Where the nipples are already the seat of fissures or excoriations, alcohol will not only tend to relieve discomfort by obtunding the sensory nerve-endings, but will harden the surrounding healthy skin and, by coagulating the albumin in the secretions of the raw surfaces, cover these areas with a thin, protective film. The same astringent property of alcohol is of value in the treatment of hyperi- drosis (excessive, sweating) and ten- der feet. As a hemostatic, alcohol is of some value in minor hemorrhages, espe- cially where tiherq is merely an ooz- ing of blood from ruptured capillaries. As a solvent of fatty substances, and likewise as a bactericidal agent, alcohol is of value when applied to the hands and operative area previous to minor surgical procedures. The removal of fatty material from the skin surface facilitates the action of germicides, such as mercury bichloride, subsequently ap- plied. According to von Bruns, the value of alcohol in the preparation of the skin before operations is due not alone to its solvent and germicidal prop- erties, but also to the fact that it hardens the skin and thereby keeps the deeply lodged bacteria from coming to its sur- face. That this factor in the action of alcohol is not in reality of great mo- ment, however, would seem to be sug- gested by the recent experimental work of Ritchie, which tends to minimize the importance of the sweat-glands a*id hair-follicles of the normal skin as restive places for bacteria. A dilution of alcohol of 55 : 100 is toxic to staphylococci, and is but slightly inferior to 1:1000 corrosive sublimate, and equal to carbolic acid in 3 parts per 100. Alcohol to which is added an alkali for the purpose of saponifying fat greatly increases the disinfecting powers. A dilution of 80 parts in 100 is an exceedingly efficient disinfectant for the hands. G. Fisher (La presse med., July 7, 1900). Property of alcohol in the steriliza- tion of the hands. It is in abstracting air from the pores and fissures of the skin that the true value of the applica- tion lies ; a previous treatment with alcohol enables subsequent aqueous solutions to penetrate much more thor- oughly and completely into all the mac- roscopical and microscopical interstices ALCOHOL (SAJOUS). 535 of the cutaneous surface. Rraatz (Miinch. med. Woch., July 17, 1900). In the various preparations of alco- hol, those with a higher specific weight have more energetic disinfectant action. The most energetic prepara- tion is 40 per cent, alcohol, which boils at about 90° C. Frank (Miinch. med. Woch., Jan. 22, 1901). Advantages of skin disinfection with alcohol pointed out. If the skin is bathed and shaved, then rubbed for five minutes with sterile gauze saturated with absolute alcohol, its disinfection is accomplished more perfectly than by any other physical or chemical method. Dehydrated alcohol or wood alcohol may be used instead of pure grain alco- hol in order to save expense. For effectiveness it is essential that the alco- hol used be nearly or quite absolute alcohol. Meissner (Beitrage z. klin. Chir., S. 198, 1909). Experiments with von Herff's method of disinfecting the hands with acetone alcohol. It is thought that the com- bination of acetone enables the mixture to be used on all portions of the body, and attacks the fatty tissue and disin- fects it more thoroughly than alcohol alone. The use of the nailbrush may be omitted, and a longer disinfection is obtained by this method. The use of soda solution for ten minutes increases the efficiency of the method somewhat. As the method is a simple one, it is especially adapted for the use of nurses and midwives. In the clinic the alcohol employed was 95 per cent., and the pro- portion of acetone, after some experi- ment, was fixed at 10 per cent. The most efficient combination, however, seemed to be that of SO per cent, alco- hol and SO per cent, acetone. Pre- liminary cleansing with soap, water, and brush was omitted. Four minutes were occupied in disinfection. The method did not seem to irritate the skin, and one of the staff, who acquired eczema through other methods of disinfection, was much improved. Oeri (Zeit. f. Geb. u. Gyn., Bd. Ixiii, Hft. 3, 1908). Alcohol used as a disinfectant found effect for a short time only^for opera- tions not exceeding five minutes in length. Pfisterer (Zeit. f. Geb. u. Gyn., Bd. Ixiii, Hft. 3, 1908). Comparative study made of the value of alcohol and of Grossich's iodine method. The two methods appeared equally good, though the iodine method is more rapid. In the alcohol method the hands are washed with soap and water, dried with a towel, then scrubbed for five minutes by the clock, with gauze wet in 95 per cent, alcohol ; finally the hands are dried. No gloves are worn. During the operation the hands are dipped in alcohol, without trying to get rid of the blood on the hands, which are blood-stained at the end of the operation. For the field of operation the author uses alcohol or tincture of iodine on the dry skin. There is no previous preparation, with the exception of a bath the night be- fore. Grekow (Arch. f. klin. Chir., S. 1073, 1909). Two years' experience has demon- strated to the author's satisfaction the superi6rity of this simple and con- venient method over all other techniques in which soap and water are permitted. He rubs the field of operation for five minutes with the 10 per cent, alcohol acetone solution and then applies a var- nish, the formula for which is 10 parts each of benzoin and dammar resin in 100 parts ether, stained with 20 per cent, of an alcohol iodoiodide solution (7 parts iodine, 5 parts potassium iodide and 100 parts alcohol). Von Herff (Therap. der Gegenwart, Dec, 1909). Comparative tests of various methods of sterilization performed. A 5 per cent, alcohol solution of tannin sur- passes all the other techniques with the exception of tincture of iodine; it ranks with this, while it is free from its disadvantages. The tannin solution is applied to the hands for two minutes and to the field of operation for one minute ; the previous use of water does not affect it. Zabludowski (Deut. med. Woch., March 2, 1911). Finally, the value of alcohol as a pre- ventive and curative aerent in carbolic 536 ALCOHOL (SAJOUS). acid burns is well recognized. The phenol is dissolved by the alcohol. Efficiency of alcohol as an antidote to carbolic acid questioned. According to experiments high concentrations of al- cohol and low concentrations of carbolic acid seemed to increase the toxicity of the latter. A 1 : 100,000 solution of carbolic acid was more toxic in the presence of 10-per-cent. alcohol than without it. The antagonism of alcohol to carbolic acid observed in practice probably depends on a physical rather ■ than a chemical basis. Taylor (Jour. of Biol. Chem., Dec, 1908). The peculiar phenomena by reason of which alcohol has been acclaimed an antidote to phenol are the result of its solvent and repellent properties and not of any chemical antagonism. Phenol, though a powerful corrosive, limits its destructive progress by the formation of an albuminous coag- ulum. Alcohol is of great value externally when used early, but when used late the destruction of tissue is not prevented, although the appear- ance is better. On account of the repellent and solvent properties of alcohol it is dangerous to leave it in the stomach together with the phenol. The treatment advised is, first, lavage with some solution, as the magnesium- sulphate, albumin mixture, followed by lavage with a solution of alcohol as a clearing agent. Novack (Mo. Cyclo. and Med. Bull., Aug., 1909). Internally, there are but five indica- tions for alcohol that justify its use under our present knowledge: (1) As an antidote to carbolic acid — only when it can be administered shortly — within one or one and a half hours — following the poison. Life saved in two instances by this measure. Diluted alcohol (50 per cent.) is better than brandy and whisky. (2) As a fuel, in fevers, exhausted states of the body, and marasmus of infants. Here our purpose must be to give only a quantity that the patient can metabolize or oxidize and derive therefrom energy. When we can detect alcohol on the breath, the dose must be decreased. An average dose of alcohol for this purpose is 2 to 4 c.c. (4 to 8 c.c. whisky; 30 c.c. or less of wine, according to variety; 10 to 30 c.c. of any of the "medicinal" proprietary foods), given every four to six hours, with or following other food, preferably. (3) For the chill of fe- brile stages — such as pneumonia, ma- laria, septicemia — here alcohol in medicinal dose {e.g., 15 c.c. or more of whisky) opens the surface capil- laries that are contracted in chill and so gives a sense of warmth to the patient, lowers the fever, and through cerebral depression blunts the pa- tient's mental anguish. Of course, the chill of hemorrhage, shock, or other condition not accompanied with fever contraindicates alcohol. (4) To reduce fever. In some cases of typhoid, where the plunge or sponge bath fails to lower an excessive tem- perature, 30 c.c. of brandy immediately preceding the bath will insure a notable reduction, by driving the warm blood to the surface to be returned cooled to the internal organs. In the presence of a low arterial tension or a very weak heart muscle, however, this use of alco- hol would hardly be justified. (5) As a narcotic, in many persons of ad- vanced years and a few with earlier arteriosclerosis who are apt to suffer from insomnia, a "night-cap" of brandy in the form of a "sling" will act favorably and is free from the unpleasant sympjtoms that often fol- low the use of the old or new hyp- notics. Fear of habit, in this in- stance, need hardly be considered. Prescribing alcohol to enable a pa- tient to withstand the strain of having a tooth extracted, an abscess opened, or wound sutured, on the other hand, is crude therapeutics. William Brady (N. Y. Med. Jour., April 24, 1909). Alcohol Injections. — Neuralgia and Neuritis. — Injections of alcohol into or in the vicinity of nerve trunks for the purpose of relieving pain are em- ployed particularly in trifacial neural- gia (tic douloureux) and in sciatica. ALCOliUL (SAJOUS). 537 but have also been utilized in intract- able neuralgias of other nerves, in neuritis following influenza, in bleph- arospasm, and recently in laryngeal tuberculosis. The Schlosser plan of injection in tic douloureux, viz., the injection of alco- hol into the second or third divisions of the trifacial nerve at their emergence from the cranium, has been extensively tested and, owing to the prompt benefit it affords, is growing in favor, though it cannot be considered as a uniformly curative measure, a certain number of cases relapsing after a variable number of months of freedom from pain. The mode of action of the alcohol in these cases was elucidated in 1910 by Schlos- ser, who found through animal experi- mentation that alcohol of 70 to 80 per cent, concentration, when brought in re- lation with a nerve, caused degenerative processes to take place in all the ele- ments of the nerve except the neu- rilemma. Leszynsky, reporting 15 cases of tic douloureux successfully treated by a:lcohol injection, stated his belief that this method is practically equivalent to a section of the nerve, with the added advantage of absence of an operative scar. The method is not applicable, however, to neuralgia of the first division of the trifacial, a certain amount of danger having been found to attend injections of this branch. Report of 63 cases, 41 women and 22 men, in which alcohol injections were given. In 21 cases the second divisions were involved, in 31 cases the first and second divisions, and in 11 cases the second division alone. As regards re- sults, the cases were divided into two classes: (1) those previously treated surgically; (2) those not so treated. The cases of the first class were not half as much benefited by alcohol in- jection as those of the second. In 1 case, previously operated upon at three different times, no effect on the pain was produced until the branches of the trigeminal on the sound side had been injected. With the exception of 2 cases the results were uniformly good. Three of the cases had already re- mained well from eighteen months to two years. In most cases the treat- ment must be resumed at the end of six months, but recurrences are apt to be less severe each time they appear. Sicard (Presse med.. May 6, 1908). Report of 190 cases of trifacial neu- ralgia injected with alcohol since 1906. The number of injections varied from 2 to 10, the average being 3. Results : S failures and 185 cases free from pain for varying periods. Kiliani (Med. Record, June 5, 1909). Alcohol injections given in 75 cases of unmistakable tic douloureux, in- variably with relief. Thirty-six pa- tients were between 60 and 70 years of age, 13 between 70 and 80 years, and 1 over 80 years. All the patients had al- ready tr.ied other forms of treatment and a considerable number had under- gone operation. Alcohol of 85 per cent, strength was used, 4 grains of cocaine to the ounce being added. About 2 c.c. of the solution were injected each time. The injections were made with a straight needle about 10 cm. long, 1.5 mm. thick, and fitted with a stylet or obturator, the blunt end of which was flush with the needle-point. The sharp point was used to puncture the skin, after which the stylet was pushed home, making a blunt instrument for the re- mainder of the penetration. The needle is introduced at the lower border of the zygoma, the aim being to attain the inferior maxillary division of the nerve at the emergence from the foramen ovale (about 4 cm. in depth), and the superior as it leaves the foramen rotun- dum. Patrick (Jour. Amer. Med. As- soc, Dec. 11, 1909). Laryngeal Tuberculosis. — Alcohol injections into the superior laryngeal nerve for the reHef of dysphagia in tuberculosis of the larynx were intro- duced by Hoffman, of Munich. Recent 538 ALCOHOLISM (CROTHERS). experiences with this procedure have only served to confirm and establish its usefulness as a palliative measure. Alcohol injections into superior laryn- geal nerve employed in a series of cases with gratifying results. The duration of the relief experienced is the striking feature of this method of treat- ment. The solution employed consists of 2 grains of hydrochloride of beta- eucaine in an ounce of 80-per-cent. alco- hol. The patient being placed horizon- tally, the sound side of the larynx is pressed toward the middle line with the thumb of the left hand so that the affected half projects distinctly; the other fingers of the hand lie on this half. The index finger enters the space between the thyroid cartilage and the hyoid bone from without until the patient announces that a painful spot has been reached. The nail of the in- dex finger is now placed upon the skin in such a way that the point of entrance for the needle lies oposite its middle. The needle is pushed in for about 1.5 cm.; this distance is marked off on the needle perpendicularly to the surface of the body. According to the thinness of the subcutaneous layer of fat, the per- foration has to be more or less deep. The needle is then carefully moved so as to seek a spot at which the patient feels pain in the ear. The syringe, filled with the alcohol, warmed to a tempera- ture of 45° C. (113° F.), is screwed to the needle and the piston slowly pressed down. The patient now feels pain in the ear, the passing off of which he indicates by raising his hand. During the operation swallowing and speaking must be avoided. The injection is kept up until no further pain occurs in the ear. Then the needle is removed and collodion applied. The point of the needle is bevelled much more obtusely than the ordinary hypodermic needle, to avoid the danger of puncturing a A^es- sel. Dundas Grant (Lancet, June 25, 1910). Tumors. — Carcinoma of the uterus was treated with alcohol as long ago as 1878 by Hasse, who made injections into the circumference of the tumors in 3 cases with good results ; after twenty- three years the patients were alive and well. Obliteration of the Blood-vessels and shrinkage of the tumor were found to have taken place, through connective- tissue proliferation around the growth. A similar plan of treatment has also been utilized in cancer of the breast. As a palliative measure, interstitial injections of alcohol were used by Vulliet, of Geneva, in inoperable cases of uterine cancer. The benefit ob- tained was ascribed by him to the local ischemia induced. C. E. DE M. Sajous AND L. T. DE M. Sajous, Philadelphia. ALCOHOLIC NEURITIS. Neuritis. See ALCOHOLISM, OR ALCOHOL INEBRIETY. —DEFINITION.— Alcoholism is frequently defined as the result, in the organism, of excessive consumption of alcohol. The term, thus interpreted, should refer only to indi- viduals profoundly poisoned and dis- eased from this specific cause. Mod- ern research has shown, however, that there exists a large class of cases in Avliich the excessive use of alcohol is a predominant feature, but which are not accurately described by the term "alcoholism," viz., those in which the use of spirits is only symptomatic of a neurosis of different nature and causa- tion. It is probable that at least 50 per cent, of all so-called alcoholics have suffered from disease of the nervous system before acquiring the alcoholic habit. Inebriety, meaning a poisoned or stuporous state directly or indirectly the result of alcohol, is, in reality, a ALCOHOLISM (CROTllERS). 539 more general term than "alcoholism," since it refers to the condition of all those who use alcohol to excess. This term is also emj^loyed, however, to des- ignate toxic states resulting from the use of various other drugs, such as opium, cocaine, chloral, chloroform, etc. [Alcoholism received very little attention as a distinct malady until recent times. Yet, there is abundant evidence that the excessive use of wine and beer was recognized as a disease in the civilization of Egypt at least seven or eight thousand years ago. This belief existed also in early Grecian times, and some very acute reasonings as to the causes and means of prevention were brought forth, although wine was, nevertheless, de- fined as a means of inducing a supposed highly esthetic condition of the mind. In later j^ears, when alcoholism became wide- spread, and was given place among the great national vices, many physicians began to consider it as a disease and a curable one, and laws were passed based on the recog- nition of this fact. Although the physical nature of inebriety had been recognized in many directions and fragmentary statements concerning it had ap- peared in foreign literature, it was reserved for Dr. Benjamin Rush, of Philadelphia, to give it a permanent setting in a small book published in 1S09. He urged that alcoholism was a disease curable and preventable. The medical interests of the subject seem to have dated from this point. Although many foreign authors have given very minute descriptions of the pathological effects of alcohol on the body, the disease of inebriety or alcoholism has been given but little at- tention. To. American physicians, therefore, is very largely due the promotion of this idea. The creation of an institution at Bingham- ton, New York, in 1864, for the treatment of inebriety as a disease brought the subject into prominence, and gave permanence to the belief which had persisted in the midst of more or less uncertainty through all the centuries past. The organization of a society for the study of the subject, and the publica- tion of a journal as its organ, still further developed, and brought into public notice. this great question. Though sharply con- demned at first, and pronounced an extreme and untenable view, it has grown to be a settled fact, accepted in practically all cen- ters of scientific inquiry, that the inebriate and alcoholic is suffering from a distinct neurosis — a disease requiring special study and treatment. During the last half-century a consider- able literature on this subject has appeared, much of it merely formative and dogmatic, but clearing the way and establishing funda- mental principles for a more rational view and explanation of the morbid processes entailed. The amount of alcohol consumed per capita has been increasing, and it is fair to judge that this indicates an increased num- ber of persons to be suffering from the dis- ease produced by it. Researches into the etiology of various maladies show that as a source of degeneration and as a contribut- ing cause the use of alcohol is a very promi- nent factor. Whether there are more alcoholics than formerly, meaning by this persons who are notoriously "affected by the use of spirits, is an open question. Many are convinced that the number of inebriates or alcoholics is diminishing, and this would appear to be true from a mere casual observation. Fewer men are arrested for drunkenness on the streets, while the number of persons who are in the incurable stages apparent to all is diminishing. It IS, nevertheless, evident that the mor- tality among persons who drink alcohol has greatly increased, and that it is not possible in this country to drink alcohol in so-called moderation, according to the European standards. This is illustrated by the fre- quency and extreme fatality of pneumonia in alcoholics. Cerebral hemorrhage is another common sequela, and is given as the cause of death in a large proportion of cases with an alcoholic history. Nephritis and cirrhosis are other familiar causes of death in persons addicted to alcohol. The mortality in all these diseases being high, it is evident that alcohol is a dangerous beverage and drug. The high degree of mental activity and nervous strain characteristic of American civilization has much to do with intensifying the toxic action of alcohol and lowering the resisting power and vitality. The average 540 ALCOHOLISM (CROTHERS). American business man, too, is far more susceptible to the poisonous effects of alco- hol than individuals of the same class in Europe. On the whole, alcoholism in America is a far more serious and fatal disease than in any other country. The results from the i:se of spirits are more destructive, and the injury less easily repaired. Alcohol is a more grateful and fascinating narcotic in America than elsewhere, because it produces seductive effects of relief, and covers up exhaustion. The enormous sale of proprietary drugs containing alcohol is evidence of this. Even in colleges and training schools many young men are impressed with the accuracy of the old-time theory that alcohol has a stimulant and invigorating action, and use it upon the advice of their teachers or from the con- tagion of their associates. On the whole, the fact is becoming more and more prominent not that alcoholism is of greater prevalence, and the victims more numerous, but that any use of alcohol is d,angerous to both brain and muscle workers, and is obstructive to all success and prog- ress in every department of life. T. D. Ceothers.] Alcohol really plays an enormous role in bringing about degeneration of the race. This is most clearly seen in the growing inability of mothers to nurse their offspring; thus, when mother and daughter of one family were not obliged to resort to artificial feeding, the father was a drunkard in only 2.6 per cent, while,- where both were unable to nurse, a history of ex- cessive drinking was obtained in 42.2 per cent. All cases of functional de- rangement owing to imperfect condi- tion of the nipples were ruled out. The condition is hereditary, for if the mother has lost the power it will never be regained in that particular genera- tion. Other stigmata go hand in hand with deficient nursing capacity, and a pro- nounced disposition toward tubercu- losis, nervous diseases, and psychoses is very evident. The offspring of alco- holics also suffer more frequently from carious teeth. G. v. Bunge (Vir- chow's Archiv, Bd. clxxv, Nu. 2, 1904). TOXICITY OF THE ALCO- HOLS. — All alcohols are poisonous, though their toxic power varies con- siderably in accordance with the va- riety of alcohol ingested. Thus, the heavier members of the series (pro- pyl, butyl, and amyl alcohols), which have a higher boiling point than ordi- nary ethyl alcohol, are more toxic than the latter. Methyl alcohol, though the lightest of all the alco- hols, is, nevertheless, more poisonous than ethyl, forming an exception to the general rule that the toxicity of the alcohols rises with the increase in their molecular weights. The toxic action of methyl alcohol, or "wood spirits," has already been described {v. Methyl Alcohol). That of ethyl alcohol, which forms the subject of this article, is modified, to a certain extent, by the nature of the preparation con- taining it. Spirits exert a more rapid toxic effect than wines or beers, owing to the greater concentration and quan- tity of alcohol present in the former. The different kinds of spirits them- selves exhibit differences in toxicity in accordance with the material from which they are produced, the variations being due to differences in the amount of certain additional toxic compounds contained, such as aldehyde, ketones, furfurol, ethers, etc. Thus, according to Dujardin-Beaumetz and Audige, spirits made from wine (brandy) are the least toxic; next follow in or- der spirits made from perry, cider, grain, beets, and molasses; finally come spirits made from potatoes and sorghum, which are the most toxic, owing to the relatively large pro- portions of isobutylic and amylic al- cohols they contain. Spirits of in- ferior grade are especially dangerous because they are made with impure ALCOHOLISM (CROTIIERS). 541 alcohol, the disagreeal)le taste and odor of the impurities being- masked by admixture of artificial flavors and essences (Pouchet). In addition to the true spirituous liquors already referred to, there is a large group of liquors representing a solution of various aro- matic principles, either of vegetable origin or produced synthetically, in a menstruum of alcohol. Here the ef- ■fects of the aromatic principles are added to those of alcohol, and these fluids may, therefore, be divided into two groups, according as the tendency of the aromatic principle contained is to produce epileptiform convulsions (best illustrated in the case of ab- sinthe), or to bring on stupor (anise, mint, angelica, etc.). The fatal dose of alcohol varies within wide limits. The factors influ- encing it include not only the individ- ual's habits with respect to alcoholic indulgence, but in addition his state of health, the climate and tempera- ture, and the rapidity of absorption (Pouchet). The average lethal dose has been stated to be 60 to 180 Gm. (2 to 6 ounces, approximately). Less than 1 pint of whisky has sufBced to cause the death of an adult. In the lower animals, Lussana and Albertoni give 6 Gm. (V/2 drams) per kg. of body weight as the minimum lethal ■dose. VARIETIES. — There are two forms of alcoholism: (1) the acute, in which alcoholic poisoning is speedily manifested in active excitement and disturbance, or in which a sudden ex- acerbation of the disorders attending the chronic type gives rise to a corre- spondingly marked symptomatic activ- ity; (2) the chronic, in which the continued ingestion of alcoholic bever- ages in more or less considerable amounts sets up gradually progressing pathological changes in the various organs and tissues, thereby giving rise to chronic disorders of each of the parts thus affected. Under acute alcoholism are to be considered not only acute alcoholic poisoning, intoxication, or "drunken- ness," but also acute alcoholic epilepsy, acute alcoholic hysteria, acute alcoholic delirium or delirium tremens, and acute alcoholic mania or mania a potu. ACUTE ALCOHOLISM. DEFINITION. — A condition re- sulting from the ingestion, within a short period, of alcohol in sufficient quantity to produce exaggerated physiological effects or actual poison- ous effects. The amount required to intoxicate varies widely according to the natural susceptibility of the in- dividual, and to whether or not his organisni has become accustomed to the action of alcohol through re- peated use. SYMPTOMS.— Three stages are discernible in this condition : The first is that of beginning vascular relaxation and primary excitation. The intoxi- cated individual is usually lively, merry, agile, and joyous ; all excitement and energy; in the highest spirits, cheerful, hopeful, and communicative ; mercurial and confiding, often telling of his pri- vate affairs to strangers. There is a warm glow on his countenance, and he appears at his best. Gradually his spir- its rise still higher; he becomes more demonstrative in love or in argument, more emphatic in his gestures, more furious in his fun, and very much louder in his laughter as the second stage is ushered in. With this he be- comes much less reasonable and amen- able, incoherence of thought and speech gradually sets in, the imagination rev- 542 ALCOHOLISM (CROTHERS). els, exaggeration is a prominent fea- ture, and the emotions dominate the subject, intellect, reason, will, and con- science rapidly fading into the back- ground. In some cases his thoughts, speech, and actions are exaggerated. In other instances they are transformed, the habitually modest, retiring man be- coming a boaster and a braggart, the truthful a liar, the meek violent. With all this, the speech thickens, the lower and then the upper limbs cease to act in unison; the intoxicated cannot stand, but staggers with a paralytic un- steadiness, the muscles becoming flabby and feeble. The third stage, that of "dead drunkenness," reveals the sub- ject unconscious, with the pallor of ap- parent death on the face, extreme cold- ness of the skin, accompanied by total insensibihty, and an utter disregard of the "world without." Sensation, per- ception, volition, and emotion, all are absent. Through this living death there lingers in the heart the only spark of vitality that keeps the unconscious drunkard alive, till the faculties have emerged — if, indeed, they do emerge — from the depth of narcotism into which they were plunged. The first, pleasur- able stage, and the second stage, less pleasant, may vary in intensity and du- ration, but the third stage, that of insensibility, usually lasts from six to twelve hours (Xorman Kerr). In the first stage, that of exhilaration or apparent stimulation, there is an in- crease of the heart-rate, and frequently a rise in the blood-pressure. The breathing is generally hastened and be- comes deeper. The skin is reddened, and the surface temperature rises slightly, owing to the paralyzing effect of the alcohol on the superficial blood- vessels, through which an increased amount of warm blood, therefore. courses. The pupils are of normal size or slightly dilated, and the higher psy- chic processes — those involving contin- ued attention, reflection, judgment, self- control — gradually fall in abeyance. The manifestations of the second stage are similar to those of the first, but more pronounced and wath the added presence of motor inco-ordina- tion, due to the effects of the drug on the cerebellar and spinal centers. A subjective feeling of intense peripheral warmth is experienced, the pulse is full and bounding, and the respiration hur- ried and frequently irregular. Inco- herence of speech and staggering gait are the most prominent symptoms of this stage, though the relative time re- quired for the appearance of each va- ries notably in diflrerent individuals, some getting drunk first "in the legs," others "in the tongue." Xausea and vomiting may also appear, and toward the close of the period facial pallor and a tendency to syncope may be present. In some instances the first and sec- ond stages, instead of showing the individual in a condition of general excitement, are characterized by de- pression of spirits, merging more or less insensibly into the ultimate stage of total cerebral inaction. In another group of cases, on the other hand, the. initial excitement is unusually pro- nounced, the subject crying out loudly, experiencing illusions, and even com- mitting acts of violence. The third stage of alcoholic intoxi- cation, that of unconsciousness and deepening coma, is characterized by successive abolition of the functions of various portions of the central nervous system. The spinal cord and cranial nerve-centers becoming depressed, mo- tion and sensation are progressively lost. The subiect cannot be awakened ALCOHOLISM (CROTHERS). 543 by shouting- in the ear ; his nnisculature, inckuHng- the sphincters, is completely relaxed, and general sensibility is abol- ished. The pulse may be full and ap- proximately normal in rate, or may be feeble and slow. The breathing is slow, labored, and sometimes irregular — an indication of beginning paralysis of the medullary centers. It is also stertorous, owing to relaxation of the muscles of the soft palate. The skin is now pale and covered with cold sweat, though the face is bloated, the lips purplish and swollen, and the con- junctivae markedly congested. The tem- perature of the body is lowered, the rectal reading being invariably reduced by 1, 2, or even 4° F. (Butler). The pupils may be dilated, especially in cases of severe intoxication, and the light-reflex abolished. The knee-jerks and other reflexes are likewise lost. In cases terminating fatally, death takes place from respiratory arrest after a period ranging from one-half hour to fifteen or twenty hours (Pou- chet). When an unusually large amount of alcohol has been taken — true cases of acute alcohol poisoning, as distin- guished from those of ordinary "intox- ication" — the stages of excitement are apt to be of very brief duration (es- pecially if the alcohol has been taken on an empty stomach), the subject sink- ing promptly into coma. Vomiting, swallowing movements, piercing cries, and muscular contractures betoken a brief primary excitation of the nerve- centers, after which depression quickly appears, indicated by respiratory and circulatory disturbances and general anesthesia. Convulsions and death from respiratory paralysis or edema of the lungs may finally result. Acute alcoholic intoxication in some instances brings forth phenomena for- eign to the conventional manifestations already described. Thus, in some cases, an epileptic attack is the most prom- inent result. It may occur either in an individual already subject to epilepsy, in which event the alcohol acts indi- rectly, being merely an exciting cause of the paroxysm ; or, it may take place as a direct result of the efl^ects of al- cohol, in persons previously not subject to epileptic seizures, under which circumstances the condition may be termed a true acute alcoholic epilepsy. Again, an outburst of acute mania may be the result of alcoholic intoxication. Such a result is seen most frequently in cases of incipient or fully developed general paralysis. Similarly imbeciles and epileptics are particularly likely to experience hallucinations under the in- fluence of alcohol, and to commit acts of violence " upon the impulse of the moment (Pouchet). Finally, hysterical paroxysms may also result from the consumption of alcohol, even in rela- tively small amounts, and in individ- uals otherwise never hysterical (Kerr). DIFFERENTIAL DIAGNOSIS. — In the first two stages of acute alcoholic intoxication, those of excita- tion and of motor inco-ordination, the symptoms present are sometimes dis- tinguishable with difficulty from those produced by the ingestion of other drug excitants, such as opium, or from those of apoplexy, unless, as is fre- quently the case, a clue to the cause of the disturbance is furnished by the find- ing of alcohol on the premises, or a history of alcoholic indulgence can be obtained. In the case of apoplexy, however, the uncertainty is not likely to be of long duration, the symptoms of excitation soon passing ofif entirely, or being promptly replaced by coma. 544 ALCOHOLISM (CROTHERS). A more important and difficult dis- tinction is that to be made between the third stage of intoxication by alcohol, that of sleep and insensibility, and comatose conditions, such as uremia, apoplexy, concussion of the brain (in cases of fractured skull), acute opium or chloral poisoning, and diabetic coma. In police stations so-called "drunks" are often not such, and a fatal result may thus be practically insured. An alcoholic odor of the breath is, of course, characteristic of alcoholic intoxication, but it is not path- ognomonic ; an individual uncon- scious from another cause may, per- haps, have taken or been given alcohol in quantity insufficient to in- toxicate. Though, according to quite a number of observers, pressure on the supra- orbital nerves in their respective notches will elicit signs of life in the alcoholic when it would not in other states of unconsciousness, the fact remains that mistakes have been, and are still, frequently made in the dif- ferential diagnosis between ordinary cases of "drunkenness" and cases of fractured skull. It mav, indeed, in some instances! be practically impos- sible, even for the medical expert, to form a correct opinion as to the caus- ative agent until time has been given for the disappearance of the alcoholic symptoms. To facilitate the recognition of the morbid condition that may be present, the following chart is presented . PATHOLOGY.— The most prom- inent of the post-mortem appearances in fatal cases of acute alcoholic poison- ing is cerebral congestion. While no noteworthy destructive lesions of the cerebral substance proper may be found, hemorrhagic extravasations may quite frequently be discovered in the meninges at the base of the cerebellum, in the subarachnoid space, or even in the lateral ventricles (Pouchet). Marked congestion of the lungs and respiratory passages is also coinmonly a feature. The right heart cavities may be found distended with semifluid blood. Tardieu in one case discovered apoplectic extravasations of blood in the lungs. The gastrointestinal mucous membranes may also be markedly con- gested, though such a condition is, of course, in no sense peculiar to alcohol poisoning. In the case cited by Kerr, of a man found dead after a drinking bout, "the mucous membrane of the stomach was so inflamed and angry, with patches of a deeper hue extending over the pyloric surface to the duode- num, and a grumous, slightly muco- purulent exudation from bleeding points, that arsenical poisoning was sus- pected." Hepatic congestion we would naturally expect to, and frequently do, find as a post-mortem evidence of acute alcohol poisoning. Dana studied the brain-cells in 10 cases of acute alcoholism by the Nissl method of staining with methyl violet: (a) patients who died of alcoholism with all the symptoms of meningitis showed congestion of the membranes (pia, arachnoid), with some edema in their texture; (b) microscopic exam- ination rarely showed any migration of leucocytes or anything approaching en- cephalitis; (c) the larger (pyramidal and giant) nerve-cells showed pigmen- tation to an intense degree, the pigment being diffused through the cell-body; (d) the cytoplasm showed various de- grees of degeneration (fatty and gran- ular) ; (e) the cell-body generally was shrunken, and the nucleus partially so; (/) pericellular nuclei had proHf- ALCOHOLISM (CROTHERS). Differential Diagnosis of Acute Alcoholism. 545 Consciousness. Temperature. Pulse. Respiration, Pupils. Skin. Reflexes. Convulsions. Paralyses. Odor. Urine. Emunctories. Special signs. Acute Alcoholism. Uremic Coma. Not absolutely Completely lost; can usu- lost. ally be aroused by shouting or shaking. Often sub- normal. Prequen t; later weak. Stertorous. Usually di- lated; equal, and react to light. Face flushed. Sluggish or abohshed. Uncommon, except in dan- gerous cases. None. Alcoholic odor of breath. Contains al- cohol; other- wise not char- acteristic. Frequently incontinence of urine and feces. Variable; not uncommonly subnormal. Often Cheyne- Stokes. Normal dilated. Waxy pallor. Common. Rare. Urinous odor sometimes. Contains al- bumin, casts, and decreased urea. Anuria com- mon. Edema of face and feet; albuminuric retinitis. Apoplexy. CONCUS.SION OF THE Brain. Partially or entirely lost. Usually rises above normal. Slow, tense. full. Slow, sterto- rous, and puff- ing. Dilated or CO nt ract ed ; sometimes un- equal. Face flushed or cyanotic ; sometimes pale. Lost on para- lyzed side and often on sound side. Usually only at time of stroke. Hemiplegia. None. Not charac- teristic. Deviation of head and eyes to side oppo- site that of paralysis. Rarely com- pletely lost. Subnormal. Frequent and weak. Slow and shal- low. Usually di- lated ; equal, and react to light. Cold and pale. Sluggish lost. Late, if any. Transient, if any. , None. Not charac- teristic. Retention of urine; incon- tinence of fe- ces. Probably ev- idence of trau- ma to head. Opium Poisoning. Profound stu- Often sub- normal. Slow, full. Very slow. Contracted. Face flushed, sometimes cy- anosed. Uncommon. None, Laudanum odor on breath sometimes no- ticeable. Not charac- teristic. No involun- tary evacua- tions. Diabetic Coma. Completely lost. Subnormal. Frequent. Long-drawn inspiration , sighing expi- ration. Dilated. Sometimes cyanosis. Lost, Rare. None. Sweet odor of breath. ' Glycosuria, acetonuria, di- aceturia. erated, and were freely present in the pericellular sacs. In cases where death was due to exhaustion the shrinkage of cells was marked. TREATMENT. — In common drunkenness, where the pallor and depression are not too marked, and where the respiration is active and the pulse is good, the patient may be allowed to sleep. The elimination of the poison occurring rapidly, he awakes after several hours with more or less headache, depression, irrita- bility of the stomach, and tremor as results of the intoxication. Light and easily digested food, Vichy and milk as beverages, and a light aperient, if required, will soon be followed by recovery. Ammonium carbonate, 1 dram (4 Gm.) in a glassful of water, will' counteract depression. Alcohol for the latter purpose should never be given. In severe cases in which there is -35 546 ALCOHOLISM (CROTHERS). a- tendency to coma, with shallow breathing and feeble pulse, the prob- ability that a quantity of alcohol is still present in the stomach should be borne in mind. The stomach should be emptied by means of the stomach tube and washed out with warm water. External heat should be ap- plied, especially to the abdomen and feet, and the patient placed in a warm room. Depressing emetics are con- traindicated, since the depression is already excessive and the dangerous feature. No alcohol should be admin- istered as a stimulant. Hypodermic injections of strychnine, atropine, or digitalis are of great value to restore the equilibrium of the circulation. In acute alcoholism attended by excitement and perhaps convulsions, especially in robust patients, free emesis should be procured promptly by giving %o grain (0.006 Gm.) of apomorphine hydrochloride. This usually causes vomiting in four or five minutes, and is then followed by relaxation and sleep. Digitalis or digitalin has also been recommended in this class of cases to counteract the morbid effects of the poison on the heart and circulation, and thus restore the patient to his normal con- dition much sooner. Hot (105° F.) rectal enemata of saline solution are also valuable in these 'Cases during the acute attack to reduce the tox- icity of the blood, if the enema is retained long enough to insure ab- sorption. Hypodermoclysis should be resorted to if the rectal injections do- not prove satisfactory. To obtain the hypnotic action of apomorphine hydrochloride it should be given hypodermically. The dose cannot be fixed. It is well to begin with %o grain, or less, and to repeat this or give a slightly larger dose within a short time. Should vomit- ing occur, the drug should be discon- tinued for several hours. Doses re- peated in two or three hours have but little beneficial effect. The ad- ministration of apomorphine should not be repeated in patients who are weak. The hypnotic action of the drug lasts only a few hours, and when the patient awakes the condition is practically unchanged. The best re- sults are obtain from the drug when it is followed in two or three hours by some recognized hypnotic. Apomor- phine should always be given in fresh solution. W. Coleman and J. M. Polk (Amer. Med., March 8, 1902). In the acute stage of alcoholism, a very useful drug for hypodermic in- jection is apomorphine. In the excite- ment of delirium tremens a small in- jection of this drug will at once produce a calm, the patient will yawn, and is fast asleep almost before he can be got to bed. This sleep is sometimes pre- ceded by vomiting. As the patient is liable to faint if sitting up, the injection should be given when he is in a recum- bent position. Usually about four hours' sleep is thus obtained. But apomorphine is no remedy for alcoholic craving; while a good way of com- mencing treatment, it is only temporary. The drugs to be relied on to do away with the craving for alcohol are strychnine and atropine; they should be kept in solution and the injections given into the biceps muscle twice or three times a day. Bolton (Brit. Med. Jour., Oct. 12, 1907). The value of apomorphine hydro- chloride in acute alcoholism was pointed out by C. J. Douglas, of Bos- ton, in 1899, but remains almost un- known. The drug acts promptly when administered as an emetic in doses of %o or % grain, and it acts with almost equal promptness when administered as an hypnotic. The alcoholic, however wild or noisy, will, as a rule, be peacefully sleeping in ten or twelve minutes after %o to %o grain is administered subcutaneously. This sleep may last several hours, when the patient awakens refreshed ALCOHOLISM (CROTHERS). 547 and sober. Douglas employed the remedy, with these doses, in over 200 cases, mostly alcoholics, including cases of delirium tremens, and with gratifying results. Drs. Coleman and Polk, of Bellcvue Hospital, New York, used it in over 300 cases of alcoholism ; also with gratifying results. Dr. Rosen- wasser, inebriatist to Newark Dispen- sary, Newark, N. J., has also used apomorphine in the same manner, and for the same purpose, and with equally satisfactory results. The dose admin- istered was from 1-30 to ^^0 grain. With these doses, the hypnotic effect is se- cured in 67 per cent, of the cases. Even ^0 grain, in the author's experience, is effective with some patients. A. M. Rosebrugh (Can. Jour. Med. and Surg.. Oct., 1908). Apomorphine is of great value in acute alcoholism. The desire for liquor in these cases becomes imperatively dominant. Apomorphine enforces sleep, and when the patient awakens his chain of thought has been broken and the attack is over in many cases. In all such cases the action of an emetic is of some value in sobering the patient and diminishing or abolishing the desire for more drink, and, therefore, the dose usually given is %o grain by hypodermic injection, adding %o grain strychnine if the heart is acting poorly. When- ever possible when given the injec- tion the patient should be hnng in bed, and basins should be in readi- ness, as the action of the drug is rapid. The author has always been able to secure the hypnotic effect. In many cases %o grain given hypo- dermically will be found sufficient to induce sleep. If the general condition of the patient is fair the dose may safely be repeated in about three hours, if necessary, as the drug is not cumulative in its action. C. A. Rosen- wasser (Med. Times, Dec, 1910). CHRONIC ALCOHOLISM. DEFINITION.— A condition re- sulting from the long-continued use of alcohol in excessive amounts. As was stated to be the case with acute alcoholism, the quantity of alcohol necessary to cause harmful results varies considerably in different per- sons. The manifestations of chronic alcoholism are varied. Many symp- toms due to toxemia and functional derangements closely simulating or- ganic changes are observed in the beginning. Later evidences appear of true organic disease, affecting one or more organs or systems of organs in individual cases. Thus the stom- ach, the nervous system, the circula- tory organs, the kidneys, the liver, are all common seats of special inva- sion. In many cases the S3^mptoms are very complex, and are not such as lead to the discovery of any par- ticular organic lesion. As already stated, the alcoholism is itself some- times secondan,' to a neurosis of other nature, in which event complex- ity of symptoms is to be expected. Dipsomania signifies a condition, he- reditary in origin, in which uncon- trollable desire for alcohol is present at intervals only, the patient being free of alcoholic tendencies in the intervening periods. Delirium tremens is another special manifestation arising from the pro- longed eft'ects of alcohol on the brain. It will be discussed later in a separate section of this article. SYMPTOMS— Most cases will ex- hibit in the beginning deranged diges- tion, fermentation in the stomach and bowels, constipation or diarrhea, muf- fled heart-sounds, irregular action with high-tension pulse, and increased dull- ness over the liver, perhaps with tenderness in spots. There is very commonly trembling, the hands are un- steady in their movements, the reflexes are diminished or absent, and there are areas of extreme tenderness over the 548 ALCOHOLISM (CROTHERS). body, while numbness of the Hnibs, rheumatic pains in both the lower and upper extremities, congested conjunc- tivje and retinae, and defects of both sight and hearing are often present. The patient may complain of anorexia, insomnia, chills, and frequently talks about malaria as the cause of his symp- toms. The urine is likely to be of high specific gravity, and to show albumin and an excess of phosphates. Chronic catarrhal conditions of the pharynx and larynx, dilatation of the skin ves- sels, sometimes pustular eruptions, are other early symptoms often seen. At a later period the symptoms are more likely to point to certain struc- tures of the body upon which the alco- hol has exerted its chief effect. They may be grouped as follows : — ( 1 ) Digestive System. — Chronic gas- tritis is a very frequent result of alcoholism. The patient complains of anorexia, nausea and vomiting, acute pain over the stomach, and constipa- tion. The breath is foul and the tongue coated. These symptoms, usually most marked in the morning, the subject finds to be best relieved by further use of alcohol. The relief is but temporary, however, and when it ends the diffi- culty is increased. Long-continued alcoholic intoxica- tion produces in some cases pronounced structural changes in the liver, most frequently cirrhosis, with contraction of the organ, or fatty infiltration, with increased size. The symptoms of the former are those of chronic catarrh of the stomach and intestines (anorexia, nausea, flatulence, constipation, some- times light-colored stools), — which is favored by the congestion caused in these organs through compression of the portal vessels,^ — together with others directly due to the same con- dition, such as hemorrhages from the lower esophagus, nose, pharynx, or even the stomach or intestines; hemorrhoids; distention of the veins of the face, especially the nose, or of other portions of the body, usually combined with flushing due to over- filled capillaries; occasionally jaun- dice. Later there may appear ascites, edema of the right pleura or of the lower extremities. Enlargement of the spleen is common late in the disease. Fatty infiltration of the liver produces no such distinctive symptoms, since there is no portal obstruction. The organ shows a moderate increase in size, but its functions are not mark- edly altered. Fahr reports a series of 309 autopsies performed at the Hafenkrankenhaus (harbor hospital) of Hamburg on vic- tims of chronic alcoholism dying from either alcoholism alone or from other causes, no less than 98 being suicides. In nearly all the cases the alcohol had been taken in the formi of spirits, not as beer or wine. The results of these autopsies are distinctly not in harmony with the conception that alcohol is a poison which produces widespread and gross anatomic changes throughout the body, or that it is a common cause of either arteriosclerosis or nephritis. Even cirrhosis of the liver is far less common in alcoholics tha- it is usually supposed to be, for, of the 309 cases, in but 11 was cirrhosis the cause of death ; in 2 other bodies there was an advanced cirrhosis, but death was due to some other cause. Of 100 cases of cirrhosis in which autopsies were per- formed by Simmonds in Hamburg, alcoholism could be excluded in 14; in 60 it was evident, and in 26 there was no reliable information as to alcohol ; therefore, it must be concluded that, while only a very small proportion of drunkards suffer from cirrhosis (about 4 per cent.), there are not a few cases of advanced cirrhosis which are not due to alcoholism, although alcohol is ALCOHOLISM (C ROT HERS). 549 responsible for far more than a major- ity of all cases of cirrhosis. On the other hand, in nearly every case of habitual drunkenness the liver shows fatty changes, usually severe, but not ordinarily associated with connective- tissue increase, and this is by far the most frequent change in alcoholism. Editorial (Jour. Amcr. Med. Assoc, Nov. 27, 1909). (2) A^crvous System. — In many- cases alcohol acts most prominently as a motor paralyzer, the control over the muscles being- greatly impaired. The hands are unsteady in their movements, and protrusion of the tongue is im- perfect. Ultimately paralysis is a pos- sibility. Of 500 alcoholic cases examined, a considerable number showed no tremor. A moderate trembling of the hands does not necessarily point to an abuse of alcohol. In about one- half of the writer's cases, a tremor was noted which had no relation to the use of alcohol. A slight tremor is more often seen in total abstainers and moderate drinkers than in ex- cessive drinkers. Women show a greater tendency to tremor than men. Fiirbringer (Berl. klin. Woch., May 22, 1905). In other cases cerebral symptoms are especially marked, the prolonged action of the narcotic having caused a gradual loss of mental power. Normal cerebral activities are replaced now^ by exhilara- tion, again by depression. The subject becomes sluggish mentally, weak mor- ally, and loses in memory and will power. He may also show great irrita- bility, or be in a continuous state of ex- citement. His ideals are changed, and egotistic tendencies appear. Later, evi- dences of abnormal cerebration may oc- cur in the form of varying delusions and delirium. Permanent dementia is the terminal stage in this morbid chain of events, the patient becoming in his de- lusions timorous, suspicious, and some- times grandiose. The symptoms of simple or multiple neuritis are also very frequently seen in cases of alco- holism, occasionally to the extent of permanent local paralysis (see Alco- holic Neuritis under Neuritis). If carefully sought for, various forms of insanity following the use of alco- hol can easily be distinguished from the ordinary intoxications. In favor of insanity are: A neurotic family taint; slight changes in character and dis- position, especially moral and ethical changes; periodicity of the drink habit, weakening of the memory and of the will, a tendency to excessive anger, and periods of depression. A point of great significance, the writer believes, is the fact that occasionally, after the with- drawal .of the whisky, there will a;)- pear periodically a condition closely resembling that of intoxication. This he regards as a sure sign of mental change, which should be treated by re- straint o"f the patient for a long period. The author makes a strong plea for State provision for the cure of dip- somania. Dunning (St. Paul Med. Jour., Sept., 1903). Alcoholic insanity presents special characteristic features which it is not difficult, in the majority of cases, to distinguish from other analogous con- ditions. Acute cerebral alcoholism pre- sents 3 states : delirious, confusional, and stuporous. The intensity of these states varies according to whether we deal with a subacute form or with delirium tremens. The chronic form leads inevitably to dementia. In the course of develop- ment of the latter, delusions with hallucinations and illusions may and may not manifest themselves. In the latter symptoms it may some- times present a picture of any other psychosis ; this resemblance is only ap- parent, as in the majority of cases close observation will enable us to find the proper interpretations. If the symptoms characteristic of cerebral alcoholism sometimes de- 550 ALCOHOLISM (CROTHERS). velop in individuals affected with other psychoses who happen to com- mit excesses, or do so because of the perverted mode of thinking- or feeling caused by the psychoses, it does not follow that alcohol is capable of producing these psychoses. The con- ception of alcoholic melancholia, mania, paranoia, or paresis is un- scientific. Alfred Gordon (Jour, of Inebriety, AA'inter, 1908-9). (3) Circulatory System. — Alcohol causes irritation of the intima of the vessels and gradual degeneration of the vascular walls. The symptoms pro- duced are those usual in widespread arteriosclerosis: vertigo, hemorrhage or throm.bosis of the cerebral vessels, etc. The heart and kidneys are very likely to be involved as a result of the same changes and undergo correspond- ing alterations in function. In some instances the heart seems seriously affected. The patient com- plains of distress and pain over the precordial region, with alternate feel- ings of exhaustion and exhilaration. The pulse is frequent, and surface con- gestion is very intense. The heart may become dilated. (4) Kidneys. — Chronic parenchyma- tous nephritis is not uncommonly caused by prolonged alcoholic excesses. Its manifestations include disorders of digestion, increased vascular tension, anemia with characteristic translucent pallor, tendency to swollen face and extremities, together with more or less distinctive changes in the urine. The latter consist of abnormalities in quan- tity (at first diminished, later in- creased), lower specific gravity, albu- minuria; granular casts, sometimes fatty; epithelial and waxy casts, and decreased proportion of urea. The late symptoms include marked weakness, general anasarca, dyspnea on exertion, and uremia, From a clinical study of 460 cases of chronic alcoholism the writer concludes that alcohol when taken daily, as it is by chronic inebriates, dipsomaniacs, or drinkers, is not an irritant to the kid- neys. \A'hen nephritis occurs in a chronic alcoholic, it is probably due to some other concomitant toxic agent, and not to alcohol. Overeating, acute intoxicants, exposure to colds, auto- intoxications, infections either mani- fest or latent, and some metabolic dis- orders as jet unknown are the real causative factors of nephritis. Alcohol when taken by drinkers as food or. stimulant, such as seen in chronic alcoholism, is a diuretic. Those tissues which eliminate alcohol are least affected by it. This applies to the lungs and especially to the kidneys. While an intoxicant, alcohol is also a de- toxicant, ridding the body of various deleterious catabolic products. The comparative integrity of the kid- neys in alcoholics may be due to the fact that the renal cells contain very few lipoids and lecithins, and that, therefore, they are not at all acted on by the narcotic molecule. J. F. Hult- gen (Jour. Amer. Med. Assoc, July 23, 1910). DIAGNOSIS. — This is facilitated if a history of excessive use of alcohol — at times in the form of proprietary remedies — be obtainable. If not, alco- holism is suggested by the presence of symptoms such as those given in the beginning of the section on symptoms, these representing mainly functional derangements and toxic effects, but few of them being the results of organic alterations. Active treatment is then begun. Under rest, restricted diet, and hydrotherapeutic measures many of these symptoms disappear, leaving only those expressive of permanent lesions. Quinquaud's sign consists in a series of quick tappings or the sensation of slight shocks made by the phalanges when the patient's fingers are spread apart and extended and pressed perpen- ALCOHOLISM (CROTIIERS). 551 dicularly against the palm of the ex- perimenter. It is only after a few seconds that the phalangeal shock is felt, and then only in case the subject is an alcoholic. Maridort (La med. moderne, July 18, 1900). The writer has investigated Quin- quaud's symptom in a large number of cases and concludes that the crepita- tion does not come from the joints, but results from slight lateral motions of the tendons in their sheaths, set up by the involuntary muscular contractions so common in alcoholics. The symptom is present to a slight extent also in nor- mal individuals. M. Herz (Miinch. med. Woch., May 30, 1905). Of 14 total abstainers, ranging in age from 22 to 35, 10, or 71.3 per cent., showed Quinquaud's phenom- enon, which was well marked in 50 per cent. In a group of 25 moderate drinkers the phenomenon was present in 14, or 56 per cent.; very marked in 28 per cent. Minor (Berl. klin. Woch., May 6, 1907). A careful re-examination at the end of two or more weeks will now indicate how many of the symptoms were func- tional, and which of them seemingly Avere organic departures from health. The special effects of the alcohol on particular organs or systems of the body are ascertained by noting the presence of symptoms referable to them, such as have already been men- tioned under that heading. It must be admitted, however, that in many cases the symptoms will appear very com- plex and refer to no particular seat of organic disease. At this second examination the diag- nosis of the patient's psychic state can also be made with some accuracy. This should comprise a study of the pa- tient's powers of reasoning, of his ideals, of his ethical conceptions of life, of the end and object in living, of his purposes and ambitions, of the ef- fects of losses and mental strains on his character, of the dominance of cer- tain passions and unrestrained emo- tional activities, and of the presence of morbid impulses and egotism. The inquiry should extend to the every- day habits of the patient. Not infre- quently periods of unexplained absence from home and business, and of unex- pected and obscure conduct, will be revealed. Such occurrences justify the inference of the paroxysmal use of al- cohol. Often the pronounced convic- tions of the patient as to the cause of his condition are significant of the use of spirits, which he denies. The diag- nosis can then be made with great clearness not from what he says, but from the fact* he conceals or appears to be trying to cover up. Material assistance will sometimes be derived from a study of the family history and past medical history. He- reditary tendencies, the diseases of childhood, profoundly exhausting fe- vers, and injuries to the body may all be of importance in reaching a decision. The heredity element in inebriety is considerable and is undoubtedly a powerful predisposing cause in in- ebriety. A history of decided intem- perance in the parents existed in over 40 per cent, of the writer's 700 cases, while 15 per cent, gave a history of defective ancestry, insanity, neuropathy, drug addiction or tuberculosis being present on the maternal or paternal side. Approximately 5 per cent, of the patients showed pre-existent mental symptoms which could be differentiated. Some of these were distinct cases of psychasthenia , others were of the milder forms of mani'c-depressive in- sanity. Neff (Boston Med. and Surg. Jour., June 16, 1910). The influences and conditions sur- rounding the subject at the period of puberty, the effects on him of losses and failures early in life should likewise be ascertained, since they may have a 552 ALCOHOLISM (CROTHERS). marked bearing on the establishment of vicious habits. If alcohol has been taken, no matter how moderately at first or at what long intervals, its in- fluence upon subsequent morbid devel- opments should be given due consider- ation. Where the symptoms are complex and the diagnosis obscure, it is usually safe to give prominence to alcohol as a causative factor. In many such cases alcohol is used to conceal the taking of other drugs. The diagnosis can then only be a tentative one, the strong probability of an alcoholic neurosis be- ing, however, kept in mind. It may have to be altered at any time upon the discovery of new facts in the patient's history or in his present condition. PATHOLOGY. — In this are in- cluded changes in a large number of organs and tissues. It has been shown, indeed, that alcohol has de- structive effects on protoplasm in general. Hence, cellular elements of all kinds are open to its action, though it has been recognized that it is the most highly differentiated cells, such as those of the nervous sys- tem, which are the most easily affected. Its influence on the cells is exerted by reduced oxidation and altered metabo- lism. Destroyed cells, in virtue of a low-grade inflammatory process it produces, are replaced by connective tissue. The- effect of alcohol in dimin- ishing oxidation is most prominently expressed in the failure to oxidize fats normally, with consequent accumula- tion, as in the liver and subcutaneous tissues. Distinction made between the diffuse, irregular spinal cord changes brought about by alcohol and the more system- atized processes. The diffuse changes consist in a thickening of the vessel walls and increase in the connective tissue of the pia and of the cellular tissue surrounding the cord, hyaline degeneration of the small vessels, and a diffuse gliosis, which destroys the nerve-fibers. The changes are not different from those found in arterial sclerosis and marasmus. Commonly the changes are most marked in the posterior portions of the cord. The more symmetrical changes are found in the posterior column, with projections into the posterior roots, especially marked in the lumbar enlargement. This was frequently associated with changes in the peripheral nerves. The changes could not be distinguished from those of beginning tabes. E. A. Homen (Zeit. f. klin. Med., Bd. xlix, H. 1-4, 1903). PROGNOSIS. — This is generally very favorable. Statistical studies in well-conducted institutions show that at least one-third of all the cases are permanently restored. The state- ments that 90 per cent, are cured have reference to present conditions, and are probably true for a limited time. On the turn of the drink cycle relapse occurs, and later recovery. Statistics of cure are unreliable. In the treatment by gold chloride 95 per cent, were claimed to be cured. At the end of one year after treatment 55 per cent, had relapsed. At the end of the second year another 20 per cent, began to drink again. In the third only 10 per cent, continued temperate and free from spirits. On the other hand, at Binghamton, N. Y., where the first exhaustive study was made of the sub- sequent history of 1100 patients, ten years after they had been treated, the results showed 61 per cent, still temper- ate and well. These and other statistics, while open to error, clearly suggest that at least SSy^ per cent, may be rea- sonably considered permanently re- stored. The future of the inebriate depends ALCOHOLISM (CROTHERS). 553 largely on the removal of the exciting causes, whatever they may he, and their avoidance in the future. In a certain numher of cases there is a complete cessation and physiological change in the organism in which the impulse to use spirits passes away forever. This is now' well known. It cannot be pre- dicted, but it occurs so often that we cannot but credit the results to greater knowdedge, and to the use of more ex- act means in the treatment. It may be stated that the prognosis is always good, even in cases that have apparently reached the terminal stage. This prediction refers specifically to the craze for alcohol. This dies out, is overcome by drugs and rational treat- ment, while other conditions of degen- eration may remain. The alcoholic or inebriate is a com- pound of a great variety of causes, the removal of which brings about cure. Sometimes those causes are very insig- nificant, sufficiently so, in fact, to be readily overlooked. TREATMENT. — This resembles the prognosis in uncertainty and wdde variations, indicating beyond ques- tion that the subject has been scarcely touched. Both hospital and home treatment, and even moral measures, show examples of permanent restora- tion. The field is very wide and largely unknowm. Home Treatment, — First, there is the home treatment, i.e., care given to the patient in his own home by the family physician. It is evidently pos- sible to restore many persons, partic- ularly if they give their full assent and co-operation and carry out the meas- ures laid down for them. Home treatment requires implicit confidence in the medical adviser, and should consist of the absolute with- drawal of spirits and the use of means and measures to restore and relieve the conditions of starvation and poisoning present. While the causes difi:'er in each case, their removal and the after-treatment are substantially the same. Thus, one whose living, both in regard to nutri- tion and rest, is bad nequires a change. Nerve rest and regular diet must be a part of the treatment. In one who has become poisoned by spirits and highly stimulating foods, the withdrawal of these agents and rest are essential. Probably hy- dropathic measures to insure elimina- tion by means of the skin represent the most efifective method of treat- ment. Many of these patients are sufifering from delusional egotism and inability to recognize their condition (con- stantly overrating their strength), and are unwilling to use the means so evident to others. The family physician should be dogmatic and ex- act the use of means and measures that will break up the impulse to use spirits. He should treat the pa- tient mentally as well as physically, and the danger of the situation should never be minimized; he should not permit the patient to think that he can depend on his own will to over- come his diseased impulses. In many instances the patient is impressed with the gravity of his disorder. He must be urged to make radical changes in his living and conduct. If his work is indoors, a change to out-of-door life is requisite. If he has neglected proper exercise, this should be ar- ranged for in some satisfactory way. Everything that will change the pres- ent current of thought wath mental and physical activity belongs to rational 554 ALCOHOLISM (CROTHERS). treatment. Of course, with this, ap- propriate remedies and measures to neutraHze and diminish exciting causes Avill suggest themselves to the physi- cian. He should recognize that these are often border-line cases in which both reason and will are clouded and the patients are irresponsible. They need suggestion, forcible and em- phatic; physical treatment, and per- sistent use of all therapeutic means. The family physician can do a great deal in this field if he will prepare himself for it and study the peculiar- ities of the patient. Office Treatment. — This is equally promising in results where the patient is recognized by the physician and his condition understood. Drug treatment forms a very important part of the means to bring relief. Probably the most practical drugs are combinations of strychnine and atropine, given at short intervals for a few weeks, then replaced by some other agent. Strychnine is the physiological an- tagonist of alcohol, and when properly administered it will remove the appe- tite for alcohol. It will do this without detriment to the system in any respect, and usually with the greatest benefit. Other remedies may with advantage be combined or alternated with strychnine, especially atropine or hyo scy amine ; but it is strychnine which does the lion's share of the work, and it can usually be done with strychnine alone. J. M. French (Merck's Archives, April, 1907). Favorable report of treatment, essen- tially that first proposed by McBride, which consists in the hypodermic in- jection of atropine and strychnine twice or thrice daily for a month or six weeks, with attention to general hygienic condition, and tonics by the mouth. At the commencement of the treatment patients were told that its success depended on their regular at- tendance for injections. The writer reports 7 cases, all of them presenting marked degrees of alcoholism, which had been treated in this way. In 5, treatment was commenced in Septem- ber, 1905; July, 1907; March, 1908 (2 cases), and July, 1909, respectively. These cases had remained cured up to date. In the 2 other cases relapses had occurred after two months and four years respectively. W. Asten (Lancet, Nov. 6, 1909). The impulse to drink may be effect- ually controlled by small doses of apomorphine given hypodermically or by the mouth. Concentrated aqueous infusion of quassia given every hour very quickly breaks up the drink im- pulse, and frequently destroys the taste for tobacco, which is often a very important factor in the use of spirits. In the office treatment care should be exercised not to substitute for spirits narcotic drugs that are likely to produce poisonous effects if taken without caution. Chloral hydrate is one of these drugs, commonly admin- istered, but it is unsafe and dangerous ; also many forms of opium and its de- rivatives. Humulus is a narcotic of great power at times, and is often an excel- lent substitute for spirits. It is not wise to give tinctures to patients who come to the office for treatment. Give infusions always. Salines are very practical measures and can be given freely without risk. Office patients of this class want remedies that will impress them at once ; hence, the physician must study the drugs whose effects are more or less certain. Sodium bromide is a favorite drug, and can be used with safety; only, the physician must realize that it is cumulative in its ac- tion, and that baths, cathartics, and ALCOHOLISM (CROTHERS). SS5 diuretics are to be associated with its use constantly. Office patients should be urged to take daily baths and exercise in the open air, but should be impressed psychically with the need of avoiding causes which lead or predispose to exhaustion. It is impossible to spec- ify particular drugs and a plan of treatment applicable to every case. The conditions vary so widely and the active and exciting causes de- pend on so many circumstances — sur- roundings, occupation, success or failure in life, diet and social influ- ences, rest, etc. — that each case be- comes a law unto itself, and requires a very close study of the conditions present. Hospital Treatment. — This is far more successful, particularly in per- sons who have reached the later stages of degeneration. It is a common ex- perience to have persons go to a hos- pital or sanatorium and recover from the immediate effects of spirits, and have a period of rest, change, and thor- ough elimination of the active exciting causes. They can then return to the family physician and remain under his care for an indefinite period. It often happens that hospital treatment and re- straint is the only measure that has any promise of permanency. Such hospital treatment is effectual by combining hydrotherapeutics and sanitary appliances with hygienic measures specifically adapted to meet the wants of every person. Drugs are very essential adjuncts and aid materially in restoring the vigor and metabolism of the body. Diet and exercise are also very im- portant remedies. These, with nerve rest, change of thought and surround- ings, are followed by restoration, and where these measures are con- tinued over a certain length of time the cure is permanent. The actively working inebriates and alcoholics who are carrying loads of responsibility need hospital-homes in the country or by the seashore where absolute rest and quietness can displace their usual unhygienic ac- tivities. The diet, exercise, baths, electricity, tonic drugs, new duties, and new conceptions of their actual conditions must be forced upon them and become a part of their everyday life. Here psychic therapeutics comes in as a very important means of treat- ment; and as a supplement to other and physical remedies. A sanatorium hospital will supply these needs, af- ford a clear knowledge of the pa- tient's condition, and train him in the conduct he should observe in the future. The writer divides inebriates into 2 classes, those whose will power is not destroyed, but only latent as it were, and capable of being revived, and those in whom it is hopelessly impaired. It is the first of these classes that fur- nishes the converts in the temperance revivals and the so-called successes of the various specifics or "cures" for al- coholism, and the good result here is not due to the medication, which acts indirectly perhaps as an aid to mental suggestion, but to the psychic stimulus and the environment. The conductors of the so-called "cures" are illogical in their use of remedies and, therefore, untrue in their assertion Their prac- tice is irrational and unethical, and they are in no sense humanitarian. They should not have the protection afforded regular medicine, but should be brought under the laws regulating "patent" or proprietary medicines. There is no specific in the treatment of alcoholism or inebriety in the proper sense of the word. In a certain class of selected S56 ALCOHOLISM (CROTHERS). cases it is proper to use psychic treat- ment, especially before complications develop and while the patient is still responsive. If the case is complicated with organic disease appropriate medi- cal treatment should precede or accom- pany psychotherapeutic measures if the latter are deemed advisable. L. D. Mason (Jour. Amer. Med. Assoc, Feb. 23, 1907). There are many hospitals and sana- toria with varied meastires of treat- ment, but in none of those worthy of confidence are there any specifics en- veloped with mystery. The treatment has passed beyond the empiric stage, and is now as thoroughly fixed with its positive results as that of any other disease, and there are no specifics or combinations of drugs that can efl^ectually check the drink impulse unless at the peril of its breaking out again with greater force. [A second class of hospitals should be organized on the workhouse plan, providing all the means and measures found best in the sanatorium with the addition of making labor a part of treatment. These would re- ceive the indigent and the terminal cases, which would be sent there by process of law, and which would become more or less per- manent residents. T. D. Crothers.] GENERAL TREATMENT.— Ev- ery inebriate is toxemic^ and every attack of drunkenness is a period of exacerbation of this toxemia. The first measure is to withdraw the spir- its and remove the poison by stim- ulating the bowels and the skin to insure its elimination. Calomel, either in a large dose of 10 grains or a small dose of 1 grain every two hours, until 6 or 8 grains are taken, together with salines, are the most efi^ective cathartics, and should always be used at the beginning. If the patient objects to the sudden removal of alcohol, and his condition; borders on delirium, %o of a grain of apomorphine hypodermically should be given as a relaxant. This will be followed by vomiting, free perspira- tion, and sleep. On awakening a hot bath of the temperature of 105° or 110° should be given. If the patient will consent to lie in the bathtub for an hour or two at a time, then be rubbed 'down and recline in a cool room, ex- cellent effects will be obtained. If he will not, an ordinary hot bath should be followed by a vigorous hand rubbing and reclining in bed. If the desire for spirits continues and the depression is not marked, %o grain of strychnine with %oo o^ atro- pine should be given every two hours. To get a man on his feet with a clear brain, and with the craving for nar- cotics removed, a mixture of drugs given to the writer by Mr. Charles B. Towns has proven of value. It con- sists of a mixture of 15 per cent, tinc- ture of belladonna, 2 parts, and 1 part each of fluidextract of xanthoxylum and fluidextract of hyoscyamus. From 6 to 8 drops of this are given every hour, day and night, until either the patient shows symptoms of bella- donna excess or, with the cathartics about to be described, the patient has a certain characteristic stool. This dose of the mixture is increased by 2 drops every six hours, until 14 to 16 drops are being taken ; it is not increased above 16 drops. Usually an alcoholic can be given 4 compound cathartic pills (U. S. P.) at the same time that the specific is begun. After the mixture has been given for fourteen hours, a further dose of C. C. pills is given, either 2 or 4, depending upon the amount of action obtained through the use of the previous dose. If these have acted very abundantly, only 2 are now necessary. At the twentieth hour of the mixture 2 to 4 more C. C. pills are given, and after these have acted, should the patient begin to show abun- dant green movements, an ounce of ALCOHOLISM (CROTIIERS). 557 castor oil should be given, and a few hours later the characteristic thick, green, mucous, putty-like stool will ap- pear. Usually the mixture has to be continued, and at the thirty-second hour 2 to 4 C. C. pills are again given, and a few hours later the castor oil. The mixture can then be discontinued. Of course, in treating alcoholics, one finds in the majority of cases the neces- sity to stimulate them and to give them some hypnotic, but this can be done without interfering with the hourly ad- ministration of the above. Alexander Lambert (N. Y. State Jour, of Med., Jan., 1910). The belladonna treatment properly given will totally eradicate the physio- logical craving for narcotic drugs, in- cluding alcohol. To secure permanent results it is necessary to pay as much attention to the after-care in both alco- holic and drug cases as is given to the derivative treatment. This after-care consists in regular supervision over several months and a thorough under- standing of the needs of the patient by both himself and his friends. The treatment consists in the hourly ad- ministration of a mixture of bella- donna, hyoscyamus, and xanthoxy- lum, in connection with increasing vigorous catharsis at stated intervals. At the end of this course a so-called ''typical stool" is obtained, and the patient emerges into a very unusually comfortable condition with little or no craving remaining. There are several points to be noted about this vigorous derivative treatment. The belladonna mixture must be pushed to the physiological limit and not beyond. Atropine poisoning must be sighted, but not reached. To fall short of this point spells failure to actuall}' obliterate the craving; to overstep it intimidates the patient. Ross Moore (So. Calif. Pract., July, 19in. If the restlessness and excitement continue, repeat the apomorphine in /'20-g'i'ain doses every two hours. Should the stomach be irritable, use hot and cold fomentations over it, and give carljonated waters, usually Vichy. The patient should not take any food, for, as a rule, digestion is impaired to the extent that food can- not be assimilated. If the patient is restless and insists on moving about, have an attendant go with him and walk him until he shows fatigue, then bring him back and give a hot tub bath or shower with apomorphine and strychnine. Never give chloral or morphine. The latter may be used under special circumstances, but the former is con- traindicated. For the insomnia lupu- lin, valerian, cannabis indica, and other vegetable narcotics may be given, but never in the form of tinc- tures. Often some of these drugs produce sleep at once. Others have little or no effect and should not be given. The size of the dose will depend upon the apparent sensitiveness of the patient to the effects. Occasionally, where there is a tend- ency to delirium, bromide of sodium in from SO- to 100- grain doses may be used. Not more than 3 or 4 doses at intervals of three hours should be given. After g-iving this drug the patient should take a hot bath, which has the effect of producing more rapid absorption of the salt. Some- times a salt bath is preferable to plain water, if there is much de- pression. Cinchona bark in infusion has a very good effect, and infusion of quassia chips is another remedy of great value, but for the acute stages hot water, hot baths are most prac- tical. In the course of a day or so a disgust for spirits begins. In the mean time salines should be given and the bowels kept loose. 558 ALCOHOLISM (CROTHERS). The strychnine combination should be kept up, and should the atropine symptoms appear the size of the dose diminished. Food should be taken very sparingly for the first two days. After that a diet rich in cereals and malted milk may be given. As a rule, milk is not a good diet for these cases. Coffee and tea may be used according to the taste of the patient. Exercise in the open air and reclining in a cool room, with nerve rest, are very essential. The disposition of the patient tO' eat inordinately should be suppressed. If there is a tendency to constipation, mineral waters that are laxative on an empty stomach should be given. Caffeine is almost a specific in alco- , holic toxemia. This drug in doses of 1 to 2 grains every one, two, or three hours will usually, in from twenty-four to forty-eight hours, quench the thirst or craving frr alcohol to such an ex- tent that the most confirmed habitues will voluntarily abandon its use. Four cases are reported which seem to uphold the author's contention. Hall (Med. News, Oct. 31, 1903). Elimination through the skin, bow- els, and kidneys should be the main purpose of the treatment, all with proper nutrition and rest. Where there is a history of specific disease, mercury or arsenic in small doses is required. When the paroxysm sub- sides and the patient is restored, the great question becomes to determine the exciting causes which produce the return of the drink craze, and as- certain their periodicity. In most cases it is wise to discon- tinue the strychnine compound and continue the free use of baths, care- fully regulated diet, with salines, for some time, until evidence of the re- turn of the drink craze appears. If the patient keeps in close touch with the family physician his diges- tion, nervous symptoms, and habits of living can be studied and properly treated. Where possible, Turkish baths, with prolonged rest afterward, should be given at least once or twice a week. If the physician can secure the full confidence of the friends as well as the patient, and impress upon him the necessity of extraordinary care and the methodical use of hydro- pathic measures, a great deal can be accomplished. In the country, baths may be im- provised in a tub, and water falling on the patient in a narrow stream has an excellent sedative efifect. Hot packs or sheets wrung out in hot or cold water covering the body, over which are spread dry blankets, pro- ducing intense or rapid perspiration, are often most valuable. The physician should always study the digestion of the patient and de- termine the states of acidity or alka- linity of the stomach and correct them as required. Exhaustion and depression fre- quently precede a drink impulse. Small doses of ipecac, ^ of a grain given at intervals of two hours, pro- duce a pronounced relaxing efifect, and where the patient has high-ten- sioned arteries and excitable pulse this is an excellent remedy. Quassia chips in a concentrated so- lution are almost a specific for the drink craze, but they must be given in large doses at intervals of an hour or so, and followed by free use of ca- thartics and baths. Quinine has some value, particularly where there is a history of malaria, but it should not be used more than two or three weeks. ALCOHOLISM (CROTHERS). 559 All such cases are self-limited and will recover with the use of h3^gienic measures. The great value of the physician is to determine and remove the causes and, where there is a peri- odicity in the return of the paroxysm, to have the patient under treatment and anticipate this condition. The nervous disturbance of drug habitues depending upon the disturbance of the vascular system, the indication is to bring about promptly an equilibrium of the circulation, and for doing this the hypodermic injection of ergot is the most certain method. Ergot con- tracts the muscular coats of the blood-vessels, but its most pro- nounced action is upon areas of such tissue as is weak and relaxed, and, hence, its action on dilated blood- vessels is peculiarly satisfactory. The first step in the treatment of these drug habits is to discontinue the use of the narcotic, or of any substitute there- for. The use of ergot is begun at once, giving a purgative at the same time, and the bowels are kept open. In general, 2 or 3 doses of ergot of Yz dram each of a solution consisting of 1 dram of the extract dissolved in an ounce of water are given daily, but in extreme cases it may be necessary to employ the drug at intervals of two hours. The ergot method acts ad- mirably in the morphine habit, the most difficult of all to cure. A. T. Living- ston (Merck's Archives, Nov., 1903). The writer carries out the "gold cure" for alcoholism in the following man- ner : The patient is put tmder the pleasantest surroundings, no restraint whatever is used, and he is allowed all the alcohol he wishes. Atropine (or daturine) and strychnine are given hypodermically, and a mixture of chloride of gold and sodium, ammo- nium chloride, aloin, viburnum, and cinchona is given every two hours during the day. By the fifth day the patient voluntarily abstains from al- cohol, and at the end of four weeks the drink-sodden victim of intem- perance is transformed into a healthy and sober man. The treatment is necessarily institutional from its very nature. Of the author's patients he estimates that 60 per cent, remain total abstainers. Fenn (Brit. Med. Jour., April 30, 1904). The treatment of drug and alcohol habitues with hyoscine will remove the desire for these drugs, thus eliminating the element which pre- vents the patients from abstaining by force of will power. Having lost the desire, they do very well without intoxicants or the drugs, as shown by the increase in appetite, gain in flesh, and their general improvement. The question of relapse lies entirely in the sincerity and environment of the patient. The favorable alcoholic addicts are those who earnestly desire to discontinue the use of intoxicants and are willing to change their mode of living and environment, but who can- not until relieved of the craving for liquor. Relapse in both drug and liquor cases is not due to a desire nor suffering after the treatment, but to their curi- osity to test the necessity of total ab- stinence, or to the temptations of social life. A single dose of the drug or drink of liquor, even after one year of total abstinence, is very apt to start the craving, resulting in a condition which is no better than before treatment. This method may prove a valuable treatment in apparently hopeless cases of opium poisoning. Interesting experi- ments along this line might be carried out. The one contraindication for this, treatment is the presence of Bright's disease. No patient should be treated unless put to bed and watched by com- petent nurses day and night during the first week. Riewel (Monthly Cyclo. and Med. Bull., Oct., 1909). In delirium opium and its deriva- tives and many of the other drugs that are powerful narcotics should be avoided. All proprietary drugs are dangerous, and should be condemned no matter what the experience may be. Every physician is capable of do- ing far more for the relief of this con- 560 ALCOHOLISM (CROTHERS). dition by adapting the remedies to the particular case than by any widely exploited compound. [Workhouse hospitals for inebriates are just being recognized and will take the place of the present ruinous jail and fines sys- tem of the courts. Nothing is more unscientific than treating the inebriate as a moral delinquent and punishing him as though sound and capable of doing other- wise. All physicians should protest vigorously against this relic of barbarism, and insist that the alcoholic be cared for in hospitals, the same as any other sick person. Every- where a new field of practice is evident, and the possible restoration of a large number of the drink and drug ukers is absolutely certain from a larger knowledge and more exact study of their conditions. The important fact should be recog- nized that at least 70 per cent, of all inebriates and alcoholics are of the de- fective, degenerate classes whose condi- tions are the result of causes pronouncedly physical and preventable with more exact study and knowledge. The remaining 30 per cent, are the victims of circumstances, surroundings, and conditions which are equally preventable. In this field there are possibilities of successful treatment and prevention that will exceed all ex- pectations. T. D. Crothers.] ACUTE ALCOHOLIC DELIR- IUM, OR DELIRIUM TREMENS. This is a condition of acute alcoholic poisoning, associated with exhaustion and cell starvation. It occurs chiefly in habitual drinkers, but it is also ob- served in ordinary temperate per- sons after a prolonged drinking spell. Though mostly met with in spirit drinkers, it is occasionally seen in beer, wine, and cider drinkers. SYMPTOMS.— Two forms are dis- tinguished : the traumatic and the idio- pathic. They differ little except in the prodromata. In the traumatic form, after an accident (sometimes only slight trauma) the characteristic tre- mors, etc., appear, frequently without ^varning. In the idiopathic form, the patient who is about to have an attack is restless, uneasy, irritable ; he sleeps badly, if at all, suffers from digestive troubles, and has little desire for food. Delirium then appears. The patient cannot rest, but must be in constant motion. He is shaking all over ("the shakes"), is consumed with terrors, continually in deadly fright of things which he mentally sees, or of persons whom he thinks are after him for the commission of some crime. At other times his dread is of something terrible, though he cannot tell what it is. He is all the while trying to escape from these well-defined or undefined horrors, and, in the attempt to escape, fatal- ities sometimes occur. Hallucinations of sight are most common : snakes, rats, mice, loathsome things, flames, and, in a case of the writer's, roaring lions bounding down the chimney, be- low the chairs, and rushing in at the windows. According to Liepmann, visions of animals are present in 40 per cent, of cases at most. The delirium is best described as one of busy w^akefulness and suspicion. There is a third non-febrile, innocent form, in which the temperature does not rise above 100° F. Hallucinations of hearing are not so common, but exist in probably 10 to 20 per cent, of cases. Delusions (false perceptions concerning self) are found in from 5 to 9 per cent., — mostly delu- sions of persecution. Sometimes there is one hallucination, illusion, or delu- sion throughout; sometimes thene is a succession. . The tongue is white and furred. Tremor of this organ, and especially of other muscles, is a more or less marked and generally present symp- tom. ALCOHOLISM (CROTHERS). 561 The fever is not very high, being- about 100° to 103° F. If higher, it is an unfavorable omen. The pulse is soft, rapid, and readily compressed. The skin is clammy. Insomnia is con- stantly present, but usually sleep and improvement occur on the third or fourth day. In unfavorable cases the patient grows gradually worse and dies of heart-failure (Norman Kerr). Anabasis of the material of the Mos- cow Clinic as regards the statistics of alcoholic delirium. Only cases of chronic alcoholic delirium in which the presence of insanity of any other type could be excluded were utilized. Out of 4813 insane registered in the clinic since its opening, it was found that there had been 33 cases of chronic alcoholic delirium. Of these, 30 were in men and 3 in women. Of 29 cases in which the heredity was noted 20 showed alcoholism in the parents, principally in the father; 3 patients showed nervous or mental diseases in the immediate family. Heredity was, therefore, present in 96.55 per cent., and these figures, according to the authors, showed conclusively enough the hereditary nature of chronic alcoholism. So far as the small number of cases observed war- rants a conclusion, chronic alcoholic delirium develops much later in life in women than in men, and this is be- cause the women begin to abuse liquor much later than men. Soukhanoff and Vvedenski (Roussky Vratch, July 12, 1903). Case of death from delirium tre- mens after a slight fall whicli without this complication would have been comparatively harmless. The spon- taneous pain of the contusion sub- sided under repose by the second day, but then delirium tremens de- veloped, fatal on the sixth day. The writer has witnessed a number of cases of this kind and discusses the question from the standpoint of acci- dent insurance. There can be no question as to the connection be- tween the accident and the develop- ment of the fatal complication. Forgue (Presse med., July 24, 1909). Delirium tremens, other conditions being equal, attacks males and fe- males alike. The greatest number of cases was found at an age between 31 and 45 years. A congenital psycho- pathic diathesis is not uncommon in patients having delirium tremens. Epilepsy is extremely frequent as a sequela of alcoholism, and was re- peatedly noted in these cases. There are numerous epileptics from abuse of alcohol, however, who never de- velop delirium tremens; and on the other hand, many individuals suffer- ing from delirium tremens have never had an epileptic seizure. Epilepsy was noted in 43.66 per cent, of the delirium tremens cases. Among 284 cases observed by the writer, there were 27 deaths, 9.5 per cent. The principal danger is of heart-failure, and in these cases there is no objec- tion to the medicinal use of alcohol. Wassermeyer (Archiv f. Psychiatric, Bd. xliv, 1909). DIAGNOSIS.— Alcoholic delirium may be mistaken for the delirium of meningitis, of typhus and typhoid fevers, and of chronic alcoholism. The history and progress of the case determine the first two, and the ab- sence or significance of thirst, tongue trembling, and tremors the third. Pulmonary disorders ; congestion, es- pecially when of traumatic origin, and pneumonia may also give rise to delir- ium simulating that of delirium tre- mens. Fractured ribs may thus become the primary factor of violent accesses. The same may be said of erysipelas. PATHOLOGY.— Acute alcoholism is due to gradually produced changes in the nerve-tissues, and especially to retained products of metabolism. The cerebral lesions in alcoholic delirium are of 'two varieties. The first is observed in all alcoholics, and is due to the alcohol itself: atheromatous de- 1—36 562 ALCOHOLISM (CROTHERS). generation of the vessels, the degree of disorder increasing as the cahber of the vessel is reduced. The nerve-cells also show granular pigmentation and fatty degeneration. The second variety is derived spe- cially from the character of the delir- ium, and not from the alcohol itself. It consists in congestion, hematic pigmen- tation in the capillaries and nerve-ele- ments, and degeneration of the nerves and fibers of the corttex, the precursors of general paralysis (Norman Kerr). According to Jacobson, delirium tremens occurs when a brain, deterio- rated by chronic alcoholism, is influenced by a toxic agent, either due to the action of bacteria or to autointoxication from diseases of the digestive tract, the kid- neys, or the liver. The changes in the central nervous system and spinal ganglia are quite uniform; they consist essentially, first, in thickening of the walls of the arteries, proliferation of the connective tissue in the media, and dilatation and infiltration of the lymph-spaces. These changes are more pronounced in the cortex, and frequently lead to minute hemorrhages, as many as 200 of these having been counted in a square centi- meter of the cortex. The capillaries appeared to be proliferated, particu- larly in 1 case, but they and the veins showed no pronounced anatomical al- teration. The neuroglia fibers of the cortex showed, according to Weigert's new method, considerable proliferation. The Weigert cells were more numerous than normal. The free nuclei, both the small and large varieties, were in- creased in number in the second and sixth layer of the cortex, and appeared to be accumulated around the degener- ating cells. The spinal cord was ap- parently liormal (Tromner). Of 247 recovered personal cases of delirium tremens studied by Jacobson, 202 were uncomplicated and 45 compli- cated by other diseases. Although the delirium tremens cannot be regarded as caused by the action of the pneumo- coccus, it resembles, in all its features, an infectious disease : it has a stage of incubation — a duration of about four days ; it ends with a critical sleep ; is accomlpanied by rise of temperature, and almost in all cases by albuminuria, and when autopsy is made the spleen is generally found to be the seat of parenchymatous degeneration, as well as the heart, the kidneys, and the liver. PROGNOSIS.— In private practice the prognosis is favorable in ordinary cases; in hospital practice it is much less so. Of 1241 cases admitted to the Philadelphia Hospital during a fixed period, 121 died. Recurrence occurs if drinking is continued. Norman Kerr noted recurrence from one to five times in 104 out of 442 cases treated in a spe- cial institution. TREATMENT.— The first indica- tion is to remove the causative tox- emia; this can be done by persistent and active hydropathic measures. Hypnotics are not always necessary, and may be dangerous. They should be avoided if possible. The best treat- ment is continuous baths, showers, sa- lines, restraint, exercise, massage, good air, and little or no food until the de- lirium subsides. The following repre- sents, however, the measures generally recommended in such cases : — The patient must be kept in bed and carefully watched. Strapping in bed should not be practised, as the restraint causes muscular movements and delirium. A sheet tied across the bed is preferable, as this allows more freedom of motion. Attendants or a ALCOHOLISM (CROTHERS). 563 padded room is best of all. No alco- hol should be given, the strength be- ing sustained by foods, milk, soups, etc. The immediate suppression of alco- hol in delirium tremens and the em- ployment of hydrotherapeutic meas- ures advised rather than of hyp- notics; the former serve to increase and to maintain the activity of the heart, although one would expect an opposite effect. In instances of car- diac weakness stimulants, strophan- thus, digitalis, camphor, caffeine, are employed, and in about three days, when the delirium begins to lessen, 30 to 60 grains of chloralformamide are given; this quickly induces sleep. Thirst is controlled by bitter infu- sions. If pneumonia appears as a complication, digitalis and alcohol are administered. In these patients the prognosis is distinctly bad. Eichelberg (Miinch. med. Woch., Bd. xx, S. 978, 1907). Potassium bromide, ^/o dram, v^^ith tincture of capsicum given every three hours, is recommended for mild cases by Osier. Sleep is, however, deemed neces- sary by some authorities. According to Lancereaux, for example, the real chance of recovery in alcoholic de- lirium lies in sleep. The patient is, therefore, isolated in a quiet, dark, and, if necessary, padded room, no physical restraint being employed. To procure sleep the patient is given 1 to 1^4 drams of chloral hydrate, with ^ grain of hydrochlorate of morphine, in an infusion of limes. If sleep does not come on in about ten minutes, from Yq to % grain of morphine is injected hypodermically. After the alcoholic disturbance has subsided strychnine or nux vomica is given, followed by hydrotherapeutic measures. If there should be gastric complication, an antacid, such as sodium bicarbonate, is administered. The author describes the treatment- that he uses in cases of delirium tre- mens. The patient is stripped naked and lies on a blanket over a waterproof sheet. A copious supply of ice-cold water is provided, and a large bath sponge dripping with the iced water is dashed violently on the face, neck, chest, and body as rapidly as possible. He is then rubbed dry with a rough towel, and the process is repeated a second and a third time. The patient is now turned over, and the wet sponge is dashed on the back of the head and down the whole length of the spine two or three times, vigorous friction with a bath towel being employed between the cold-water applications. By the time the patient is dried and made comfortable, he will be fast asleep. William Broadbent (Brit. Med. Jour., July 1, 1905). The writer reports the result of five years' use of veronal in delirium tremens. His method of administra- tion is as follows: An initial dose of 1 Gm. -is given in all incipient cases. If sleep does not follow within three hours, another gram is given. Sleep then follows and lasts six to eight hours, or even twelve. On waking the patient is clear, quiet, and feels well. If there is yet some tremor, 0.5 Gm. of veronal is given, and by evening all tremor has, as a rule, dis- appeared. If the patient remains in the hospital some time longer for other reasons, 0.5 Gm. is given every evening to insure against sleepless- ness. If the delirium is not con- trolled from the 2 Gm. as given above, another gram may be given five to six hours after the second dose. Only 3 patients have failed to re- spond to this treatment out of a total of 100. There were 2 deaths from double pneumonia. In all the author's experience he has only seen 1 case of veronal rash, and absolutely no other symptoms of veronal poison- ing. V. F. Moller (Berl. klin. Woch., Dec. 27, 1909). Delirium tremens, on alcoholic basis, even in strong men of middle age, is a serious illness, with a mor- 564 ALCOHOLISM (CROTHERS). tality variously stated as 3 to 19 per cent. The writer treated 396 cases from 1901 to 1906 with chloral hydrate (1 to 3 grains) and with bromides. Digitalis was given only when neces- sary, and alcohol was withheld. The mortality was 9 per cent. Of the cases, 17.4 per cent, belonged to the type of delirium imminens. Between 1907 and 1909, 264 cases were treated almost exclusively with veronal. The drug was dissolved in warm tea. Soon after admission the patient re- ceived 1 Gm. (15 grains), and one to two hours later a second gram. If necessary, a third gram is adminis- tered within five hours and a fourth gram within twelve hours. There never was the slightest untoward effect on pulse or respiration. The mortality sank to 3.4 per cent.; the percentage of cases where the de- lirium could be prevented rose to 28. The majority of fatal cases already suffered from pneumonia. This ob- servation proves that veronal is far superior to chloral and bromides to check the attack in its incipiency, and also to prevent a fatal issue. Ernst V. d. Porten (Therap. d. Gegenwart, June, 1910; Merck's Archives, Nov., 1910). Incipient cases, with insomnia, rest- lessness, tremor, occasionally hal- lucinations, should receive large doses of hypnotics, preferably veronal; whisky should be given regularly, and ergot at frequent intervals, either by intramuscular injection or by mouth. Discontinue medication gradually, and only after all restlessness and tremor has disappeared. More advanced cases, with marked delirium, inco- ordination, usually fever, slight leuco- cytosis, and profuse perspiration, should receive veronal in moderate doses; also ergot. Ranson and Scott (Amer. Jour. Med. Sci., May, 1911). It must not be forgotten, however, that large doses of narcotics, with the cardiac depression apt to follow their exhibition, are dangerous, especially in the aged and infirm inebriates. Kerr preferred repeated doses of liquor ammoniae acetatis (B. P.), Sleep, thus quietly and safely in- duced, has proved much more cura- tive than narcotics in his practice. Trional and opium, if given, should be administered cautiously. If fever is present, the cold douche, bath, or preferably the wet pack may be tried. If the pulse becomes too rapid and weak, very small doses of digitalis in aromatic spirit of ammo- nia should be given. Digitalis in large doses is dangerous (Osier, Delpeuch, Kerr). The author witnessed the collapse and death of a robust man in delirium tremens while being given a prolonged warm bath. One of his patients suc- cumbed in collapse during a wet pack, and he has consequently abandoned these measures. In treatment of 1051 cases of delirium tremens in the last sixteen years, he has made it a rule to allow no alcohol. In the first series of 486 cases the mortality was 6.37 per cent., while in the last 565 cases it has been only 0.88 per cent. He ascribes this improvement in the results to his observation of the fact that the cause of death in delirium tremens is gen- erally paralysis of the heart, and he now addresses treatment to the heart regardless of whether cardiac symp- toms are apparent or not. The agita- tion and motor excitement react on the heart, and signs of heart weakness soon become manifest. He makes it a rule to give digitalis from the very first, giving 1.5 Gm. in an infusion in the course of the da^^ and repeating this dose two or three times. If it can- not be given by the mouth, he gives it in a rectal injection. At the first signs of heart weakness other heart tonics are used; 1 Gm. of camphorated oil is injected subcutaneously every hour or so until the critical symptoms subside. A tablespoonful of ice-cold cham- pagne every half-hour was also found useful — the only way in which he allows alcohol. To promote the washing out of the toxins causing ALCOHOLISM (CROTHERS). 565 the attack, he has the patients drink copiously, and supplies them for the purpose with a drink which has the color of beer and tastes refreshing, and is taken eagerly by the delirious patient. It is merely a 1 per cent, solution of sodium acetate in water to which a little common syrup has been added. S. Ganser (Miinch. med. Woch., Bd. liv, Nu. 3, 1907). The writer ascribes the symptoms of this condition to the accumulation of toxic products, autogenous as well as alcoholic, in the blood. Accord- ingly, he aims at the removal of these deleterious substances. He gives nor- mal salt solution in large quantities by the rectum, hypodermically, or, if necessary, intravenously. Thus the entire circulatory system is flushed with fluid to its utmost capacity, and this is then relieved by free purgation with large and repeated doses of Epsom salt. Calomel in full doses is also given. Sparteine is administered in 2-grain doses for the purpose of supporting the heart and promoting diuresis. For the delirium itself gel- semine is given every hour, or every two hours, until its physiological effect is produced; the dose advised is %5 grain. Alcohol is reduced to moderate limits, but is not entirely withdrawn: opium and other nar- cotics are condemned as not merely dangerous, but useless. Physical re- straint is also held to be not permis- sible. In 450 consecutive cases the results of this line of treatment are described as excellent, and no death from delirium tremens occurred in the whole series. G. E. Pettey (The Hospital, Jan. 15, 1910). The patient should be carefully fed, milk and concentrated broths being especially useful. If necessary, nutri- ent enemata are to be administered. Excellent is hypodermoclysis or the intravenous infusion of saline solution in dehrium tremens, which increase the amount of the circulating; medium in which the toxic materials are dis- solved, thereby diluting the poison and bathing the nerve-centers with a more attenuated solution of the same. The amount of circulating fluid is increased above the normal, so that the excretion of fluids through all the eliminatory channels is augmented, thereby carrying off in solution much ' of the contained toxins. The action of the heart is improved by the filling of the relaxed vessels. These suffice to restore the physiological equilibrium and turn the balance in favor of recov- ery (Warbasse, Ouenu). [Delirium without hallucinations, and hal- lucinations alone without any particular de- lirium are conditions that require special study and care. The physician should not permit such cases to go about without special attendants and watchful care. Under all circumstances they need the closest watching and are really dangerous, unless guarded, not only to themselves, but others. A delusional alcoholic should be guarded all the time, for the reason that dangerous 'obsessions may appear any mo- ment. T. D. Crothees.] ACUTE ALCOHOLIC MANIA (MANIA A POTU). SYMPTOMS. — The patient, in a wild, ungovernable fury, shouts, stamps, strikes, or kicks, and is, for the moment, uncontrollable. The eyes roll, the face is flushed, and the veins dis- tended and engorged; the muscles are at their highest point of tension, and are in continuous, violent action. The pulse is strong, bounding, and tumultu- ous. Though mechanically conscious, the subject is filled with "blind fury." He is carried away in a tempest of nerv- ous excitation and passion. The par- oxysms of violence sometimes last only a few minutes, at other times for from an hour to several days, with quiet intermissions. Rarely are there delu- sions, though the infuriated subject may vent his violence on the first ani- mate or inanimate object in his way. 566 ALOES (SAJOUS). In a few cases the fury is directed against a certain person or tiling. Vio- lence is succeeded by calm ; a few min- utes after a storm the temperature is normal, and during the paroxysm rarely raised. In some constitutions a paroxysm may be provoked by a small quantity of alcohol (Kerr). DIFFERENTIAL DIAGNOSIS. — It may be differentiated from delir- ium tremens by the absence of tremors, terror, hallucinations, delusions, the white tongue, nausea, and the delirium of the latter. Further, mania a potu may arise from a small quantity of an intoxicant taken in a short time, while delirium tremens is due to large quan- tities taken in rapid succession, or from smaller quantities long continued (Kerr). ETIOLOGY AND PATHOL- OGY. — Mania a potu is occasionally seen in chronic inebriates, and most frequently in periodic tipplers. In the latter it often occurs when, after an interval of abstinence, an intoxicant is freely partaken of. Some chronic inebriates invariably suffer acute mania if they drink a single glass of spirits, wine, or beer beyond their usual allow- ance. The paroxysms of acute mania resemble those of epilepsy, and a large proportion of police-court drunken of- fenders are patients of this class. The symptoms are evoked by the patho- logical action of acute alcoholic in- toxication on nervous systems liable to such excitation, either oongenitally or from the effects of intemperance, traumatism, or brain-tire. According to Jones, the forms of insanity met with which result from alcoholism are: 1, amnesic; 2, delusional and, 3, chronic varieties which end in de- mentia. PROGNOSIS. — The prognosis is much more favorable than in ordinary acute mania, the paroxysm usually rapidly passing away, leaving the pa- tient exhausted and peaceful. Unless alcohol be taken again relapse is rare. TREATMENT.— But little treat- ment is generally needed in this con- dition. Non-alcoholic liquids, such as milk, iced milk, milk and soda, or saline draughts with ipecacuanha and bromides are sufficient to bring about recovery. Sometimes cold affusions and, in prolonged paroxysms, wet packs prove valuable adjuncts. When violent mania is present, apo- morphine, % to % grain, hypodermic- ally, causes nausea and vomiting and rapid removal of the violent symp- toms. If it persists, potassium bromide, in 30-grain doses every two hours, or morphine, % grain at long intervals, must be resorted to. T. D. Crothers, Hartford. ALEPPO BOIL. Sore. See Oriental ALOES (Aloe).— The inspissated juice of the leaves of Aloe vera or A. chinensis (Curagao or Barbadoes aloes) or of other species, such as Aloe Perryi (socotrine aloes, East Africa) and Aloe spicata or A. ferox (Cape aloes). The plants are indigenous in Africa and India, and are naturalized in the West Indies and along the Med- iterranean shores. PROPERTIES AND CONSTIT- UENTS. — Curaqao aloes occurs in orange-brown, opaque, and resin-hke masses which give off an odor of saf- fron and have a very bitter and some- what nauseous taste. Socotrine aloes varies in color from yellowish brown ALOES (SAJOUS). 56; to dark brown ; its odor and taste are similar to those of Barbadoes aloes. Cape aloes is reddish brown or olive- black. According to A. R. L. Dohme, Curagao aloes is as efficient as socotrine aloes and less expensive ; the greater portion of the latter now sold is made up of the former. Purified aloes (aloe pnrificata), the form generally employed in medicine, is aloes which has been softened by heating and the addition of alcohol, strained, and dried. It occurs in com- merce in pieces or in powder form. Aloes contains: 1. Aloin, a bitter, crystalline principle present in amounts ranging from 4 to 30 per cent., and composed in socotrine aloes exclusively of barbaloin, to which, in Curagao aloes, is added the isomeric body iso- barbaloin. 2. Emodin (Kraemer), an acftively cathartic principle. 3. A yel- lowish, odoriferous volatile oil. 4. A resinous material, varying according to the species of aloes. 5. Albuminous bodies. 6. Fatty substances. 7. A small amount of gallic acid. Aloin, official as Aloinum, occurs as minute orange-colored crystals or as a microcrystalline powder varying in color from lemon-yellow to yellowish brown. It has little or no odor, is bitter to the taste, and remains unchanged in the air. It is soluble in 65 parts of water and in 10.75 parts of alcohol. Its solutions turn brown on continued ex- posure, and when alkalies are added present a dark-red color with greenish fluorescence. DOSE AND PREPARATIONS. ■ — the dose of purified aloes in adults is % to 10 grains (0.03 to 0.6 Gm.), the average dose being officially given as 4 grains (0.25 Gm.). The dose of aloin is % to 2 grains (0.03 to 0.12 Gm.). Average dose: 1 grain (0.065 Gm.). The other official preparations of aloes are : — Tinctura Aloes (10 per cent.), con- taining also 20 per cent, of licorice. Dose: ^/4 to 1 fluidram (1 to 4 c.c). Average dose: 30 minims (2 c.c). Tinctura Aloes et Myrrhcc, contain- ing aloes, myrrh, and licorice, of each, 10 per cent. Average dose : 30 minims (2 c.c). Extractiim Aloes. — A watery extract, dried and powdered. Dose : % to 6 grains (0.03 to 0.4 Gm.). Average dose: 2 grains (0.125 Gm.). Piliila Aloes, containing aloes and soap, of each, 2 grains (0.13 Gm.). Dose : 1 to 4 pills. Piliila Aloes et Ferri, containing purified aloes, dried ferrous sulphate, confection of rose, and aromatic pow- der, of each, 1 grain (0.07 Gm.). Dose: 1 to 4 pills. Pilula Aloes et Mastiches (Lady Webster's Dinner Pill), containing purified aloes, 2 grains (0.13 Gm.) ; mastic, % grain (0.04 Gm.), and pow- dered red rose, % grain (0.03 Gm.). Dose : 1 to 4 pills. Pilula Aloes et Myrrhce, containing purified aloes, 2 grains (0.13 Gm.) ; myrrh, 1 grain (0.07 Gm.), and aro- matic powder, f^ grain (0.04 Gm.). Dose : 1 to 4 pills. Aloes is also a constituent of the following : — Tinctura Benzoini Composita, con- taining benzoin, 10 parts; aloes, 2; storax, 8 ; tolu, 4. Dose : 30 minims (2 c.c). Extractum Colocynthidis Composi- tnm, containing extract of colocynth, 16 parts; purified aloes, 50; resin of scammony and powdered soap, of each, 14 ; cardamom, 6. Dose : 7 ]/> grains (0.5 Gm.). 568 ALOES (SAJOUS). Pilula cathartica composita. often considered preferable because of B Ext. colocynthidis the smaller dose required and less lia- comp gr. 1% (0.08 Gm.). . u ■ ■ „ j. ■ r Hydrarg. chloridi _ bility to cause griping. It is fre- m-itis gr. j (0.06 Gm.). quently employed in the aloin, bella- ResincB jalaps .. gr. % (0.02 Gm.). . j ^ u • -n r u- u CambogL pul- 'donna, and strychnine pills, of which veris gr. M (0.015 Gm.). the official form {Pilula Laxativa Dose: 2 pills. Comp.) has already been referred to. Pilula cathartica vegetahilis. INCOMPATIBLES. — Aloes is in- IJ Ext. colocynthidis compatible with mineral acids, iodine, comp gr. j (0.06 Gm.). .. •- , . • -j i i Ext. hyoscyami . gr. ss (0.03 Gm.). silver nitrate, tannic acid, phenol, men- Resince jalapce .. gr. % (0.02 Gm.). thol, thymol, and salicylic acid. RfsiJ^^fodo-''' CONTRAINDICATIONS. — It is phylli aa gr. ^ (O.OIS Gm.). generally inadvisable to prescribe aloes Olei menthcB • r i i • i • .■. v piperitce gr. ^ (0.008 Gm.). ^ cases of hemorrhoids, owing to its Dose : 2 pills. effect of causing congestion of the pel- Pilula rhei composita. ^i^ organs; in cases accompanied by B Rhei puheris ... gr. ij (0.13 Gm.). free secretion of mucus m the bowel. Aloes gr. iss (0.10 Gm.). however, it may, on the contrary, prove OlIilZnthcE'pip'. In i/J%-005"Gm.). beneficial. Aloes is likewise contrain- Dose : 2 pills. dicated in pregnancy and in menorrha- Pilula laxativa composita. gia occurring in plethoric women. In IJ Aloini gr. % (0.013 Gm.). view of its elimination, in part, through Strychnines gr. 1/128 (0.0005 Gm.). the milk, it is not available for use as Ext h^llddoiii'icE fol gr. ^ (0.008 Gm.). a purgative in nursing women. Ipecacuanhce pulv. gr. He (0.004 Gm.). PHYSIOLOGICAL ACTION.— Glycyrrhisce pulv. gr. ^/i (0.046 Gm.). _ „ . , 1 1 • In small doses aloes and alom exert a MODES OF ADMINISTRA- stomachic Qflect. The secretions of the TION.— Aloes is entirely soluble in alimentary tract are augmented. With 5 parts of alcohol, but only partly sol- larger doses (2 to 4 grains) its well- uble in water. It is generally admin- known laxative effect is obtained, ten istered in pill form on account of its to fifteen hours usually elapsing from strongly bitter taste. It acts slowly, the moment of extubation until the first and can, therefore, be administered at evacuation results. The effect is due bedtime with the expectation that its to stimulation of the muscular coat as effects will be exerted the next morn- well as the glands of the large intestine, ing. Aloes may be used alone, but is and is generally attended with a cer- oftener given in conjunction with other tain amount of griping pain. Through cathartic remedies and correctives, as its property of inducing hyperemia in in several of the preparations above the ovaries and uterus, aloes also has mentioned. Certain agents have been distinct value as an cmmcnagogue. found to increase its effects, including Though easily absorbed through bile, iron, and the alkahes. Equal parts abrasions and ulcerated areas (exercis- of purified aloes and dried oxgall may ing thereafter its characteristic laxative be administered in a salol-coated pill and other effects), aloes exerts no local with advantage. Aloin, while somewhat therapeutic action. It is eliminated with less certain in its action than aloes, is the feces, slightly with the urine, and. ALOES (SAJUUS). 569 in nursing women, with the. mammary secretion. Aloin, the so-called active principle of aloes, is believed not to exert its ef- fect in the bowel until it has undergone certain changes in composition. The resulting active compound, which can be made from the pure, crystalline aloin by boiling a solution of the latter (Cushny), is probably contained in the crude drug after the crystalline aloin has been extracted. Hence, the fact that in practice crude aloes is found to act with greater certainty and speed than the principle aloin. It has been found that in human beings placed upon an exclusive meat diet aloin acts much more strongly than in persons subsisting on a mixed diet. The aloin is believed to be altered through proc- esses of hydrolysis and oxidation into emodin (oxymethylanthraquinone), an active constituent of many other drugs of this class, such as senna, cascara sagrada, and rhubarb, which induces the purgative effect. Injected under the skin or into a vein, aloin for the most part passes into the bowel, there exerting an irritant effect and inducing purgation. In the rabbit, however, in which aloin is excreted to a large ex- tent through the kidneys, pronounced irritation of these organs is produced, ■catharsis being, on the other hand, an infrequent result. A nephritis is gen- erally induced, in which the epithelium of the tubules is particularly involved, the glomeruli being largely spared. The urine contains casts, blood, proteids, and leucocytes; it may be either aug- mented or decreased in quantity (Miir- set). UNTOWARD EFFECTS.— The use of aloes over long periods is said to favor the production of hemor- rhoids. Large doses of aloes induce burning at the anus ; sometimes blood- stained stools, painful micturition, and uterine discomfort. Dosage ex- ceeding 0.20 Gm. (3 grains) per diem, when persisted in for any length of time, leads inevitably to intestinal irritation and congestion. According to Pouchet, massive sing-le doses of aloes may induce gen- eral prostration with slowing of the pulse and a fall in the temperature. THERAPEUTIC USES. — As a Laxative.— Aloes is most frequently used in the treatment of constipation due to intestinal atony. In moderate doses it stimulates the intestinal mu- cosa to increased secretory activity, thereby facilitating the discharge of the bowel contents. Its continued use is, however, to be avoided, since on pro- longed administration a tendency to aggravation of the disorder present is likely to appear. A characteristic feature of the ac- tion of aloes is the congestion it tends tO' produce in the intestinal tract (es- pecially the rectum) and pelvic organs. This property has led tO' its occasional use as a derivative in conditions asso- ciated with cerebral or pulmonary con- gestion, blood being thereby removed from the engorged area. Experimental work has shown that aloes, in common with other purgatives of the anthracene series, does not act as a true chola- gogue, i.e., does not increase the ambunt and concentration of the biliary secre- tion. It does, however, by accelerating peristalsis, promote the removal of bile from the intestinal tract, and prevent Its reabsorption from the duodenum into the liver. For the relief of hepatic congestion, Rendu has recommended the use of aloes in combination with calomel and gamboge. The cathartic effect of aloes has been found to be 570 ALOPECIA (SCHAMBERG). greatly favored by the presence of bile, which is believed to assist by exerting a solvent action on the drug, thereby hastening its effect. In view of this observation, too, it is thought that in cases of obstructive jaundice the action of aloes is interfered with owing to the deficiency of bile. Alkalies and iron assist the purgative action of aloes. The former facilitate the decomposition of aloin, whereby a more strongly irritant and cathartic substance is formed. Iron similarly favors the oxidation of aloin. In chlo- rosis the aloes and iron combination is often employed, as in the official pill of aloes and iron. It is best, however, not to use this pill, owing to the par- ticularly marked constipating effect of the preparation of iron it contains. The pyrophosphate of iron or dialyzed iron is to be preferred. Nux vomica and belladonna, or their active alkaloids, are also frequently combined with aloes, the former to improve the tone of the intestinal muscles, and the latter to prevent "griping." The last-named effect can also be minimized by giving the drug after meals. Robin recommends the following pill as a mild, but efficient laxative : — H Aloes, Ext. of liquorice ..aa 1 gr. (0.06 Gm.). Gamboge ^ gr. (0.03 Gm.) . Ext. of belladonna, Ext.ofhyoscyamus,3ia 1 gr. (0.06 Gm.). Enough for 1 pill. Take one or two on retiring. Aloin possesses over crude aloes the advantages of smaller bulk and less tendency to cause intestinal irritation, but these are partly offset by the dimin- ished certainty and celerity of its action. In large doses aloes acts as a drastic, inducing first eructations and a feeling of weight in the stomach, then copious stools with colicky pains. Its use as such, however, is to be avoided, because of the marked intestinal irritation and congestion it causes. As a Stomachic. — In doses not ex- ceeding 1 to 1% grains (0.06 to 0.10 Gm.) daily, aloes improves the appe- tite and stimulates the gastric func- tions. As an Emmenagogue. — In anemic women with amenorrhea aloes is sometimes given to favor the men- strual flow. It is best given four days before the expected period, and its action is greatly enhanced by combi- nation with iron. In amenorrhea due to other causes the official pill of aloes and myrrh may be tried, the congestive influence of the active drug tending to facilitate menstruation; good results, however, are to be ex- pected less frequently than in the anemic cases. In Hemorrhoids. — Though the use of aloes as a laxative is contraindicated in the presence of hemorrhoids, this drug, given in small doses, has been claimed by some to be beneficial in cases where the circulation in the in- ferior hemorrhoidal veins is particu- larly sluggish and the pile masses protrude, inducing tenesmus. The use of aloes in very small doses when hem- orrhoids are associated with irritation and frequent small, thin evacuations has been advocated by Fordyce Barker. C. E. DE M. Sajous AND L. T. DE M. Sajous, Philadelphia. ALOPECIA.— Baldness; calvities. DEFINITION. — Alopecia is a physiological or pathological deficiency or loss of hair, either partial or com- plete. The forms of alopecia may be classified as follows : — ALOPECIA (SCHAMBERG). 571 I. Congenital alopecia. II. Senile alopecia. (a) Idiopathic. III. Premature alopecia. Hereditary predis- position. (1) Local diseases. (&) Symptomatic. ^ (2) General eases. Congenital Alopecia. — This com- monly manifests itself either as a scanty growth, a development only in certain localities, or as a retarded, appearance of the hair. In rare cases there may be complete absence of the hair due to arrested development of the follicles. In such cases hereditary predisposition is usually present, and there are apt to be, in addition, delayed or defective dentition, and at times developmental defects of the nails. [J. H. Hill (Brit. Med. Jour., vol. i, 1881, page 177) has described a race of hairless Australian aborigines. Jay F. Schamberg.] "Alopecia congenita familiaris," a congenital absence of hair occurring in several members of a family, observed in a brother and sister, aged respectively V/z and 3H years. They were both born with hair on the scalp, but this began to fall out in a few weeks, till the scalps became perfectly bald. When dis- Acute Seborrhea. Eczema seborrhoicum. Psoriasis. Erysipelas. Lupus erythematosus. Syphilodermata. Folliculitis. Tinea tonsurans. Tinea favosa, etc. Typhoid fever. Variola. Scarlatina. Pregnancy. Syphilis. Leprosy. Myxedema. Neurasthenia. Chronic intoxications Anemia. Diabetes. Cancer. Uric acid diathesis. Phthisis, etc. Chronic ^ examined the scalps were smooth, atrophic, and gloss^^ Inflammatory changes were absent. In both the lanugo hair was absent in the breast and extremities, and the ej'elashes were deficient.' The nails were not affected in either case. The mother gave a his- tory of another boy in the family whose hair had come out at four weeks, and a fourth case was also mentioned. Histological examination of the first 2 cases showed the remains of the original lanugo hairs in the forms of shrunken hair follicles, in which the papillse were absent and the inner root- sheaths, as well as the hairs, had dis- appeared. In some cases the follicles had become transformed into cysts con- nected with the sebaceous glands. The parents were healthy and had normal hair. Personal conclusion that the condition .is the result of an inter- ference with the normal hair change which should begin in utero. The lanugo follicles had undergone regress- ive changes, and no permanent hairs 572 ALOPECIA (SCHAMBERG). had developed. Kraus (Archiv f. Derm. u. Syph., Aug., 1903). Congenital alopecia may be divided into three classes : 1. Complete and universal absence of hair at birth, not succeeded later in life by a piliary growth. This is believed to hz an intra- . uterine atrichia due to a failure of de- velopment of the hair-pouches. 2. Uni- versal congenital hypotrichiasis, in which at birth hairs exist in all regions of the body, but later fail to be suc- ceeded by filaments normal in length, vigor, color, and texture. Two sub- varieties of this condition have been recognized: (a) the infant at birth is provided with the relatively long hair of most normal infants; this in due time fails and is replaced by a scanty down, which later in life fails to insure a normal hirsuteness of the scalp; (fc) after birth the infant fails to lose the temporary hair of the scalp, which per- sists, but later develops merely a scanty or ill-developed piliary growth. 3. Complete or partial absence of hair at birth in definitely circumscribed regions, such as the scalp, the brows, the pubes, or the axillae. The anomaly is rare, and persistence through life still rarer. Many published observations are lack- ing in detail of special importance. Nevins Hyde (Jour, of Cutan. Dis., Jan., 1909). Senile Alopecia. — As the name indi- cates, this form of baldness is observed in the aged. With the atrophic skin changes that accompany senility there takes place a gradual thinning of the hair, beginning upon the vertex of the scalp, the frontal and the temporal regions, and slowly leading to a more or less complete baldness of the cal- varium. Under the microscope the cutis' proper and the hypoderm exhibit thinning and atrophy. Case of periodical shedding of the hair in a woman aged 21 years. Her hair was shed every winter and grew in again in the summer. Last winter she became entirely bald, and this sum- mer her hair did not grow in again, Absence of hair existed on the general surface, which began in circular patches when she was 12 years old. H. Leder- mann (Jour, of Cut. Dis., Jan., 1904). Premature Alopecia. — This form of alopecia is encountered chiefly in in- dividuals between the ages of 20 and 35. G. T. Elhott found that among 344 private cases of premature alopecia, 64 per cent, occurred under the age of 30. Premature alopecia may be either idio- pathic or symptomatic. In the idiopathic variety the scalp presents no abnormal condition. At first only a few hairs fall out from time to time, being replaced by a shorter or finer growth. Later these fall and are followed by still finer hairs. In this manner the greater part of the hair of the scalp may be gradually lost. The afirection occurs in both sexes, although much less frequently and less com- pletely in women than in men. Heredity appears to be a strong predisposing factor. There is a growing opinion that the so-called idiopathic baldness is excep- tional, and that most cases of premature alopecia are associated with seborrhea in some form. Of 344 private cases of premature alopecia studied by Elliott, 316 had seborrhea. Jackson found 75 per cent, of 300 cases due to seborrhea. The symptomatic form results from various local and general diseases. Rapid falling of the hair (defluvium capillorum) commonly follows acute diseases, such as typhoid fever, small- pox, etc. Full regeneration of the hair follows the restoration to health. Rapid and extensive loss of hair occurs with frequency in the early stages of syphilis. The hair is also thinned or lost in such cachectic condi- tions as phthisis, myxedema, di-abetes mellitus, leprosy, etc. ALOPECIA (SCHAMBERG). 573 Areas of absolute alopecia which oc- cur iu the scalp or beard in sj-philis may be small and few, well circum- scribed, lasting a short time, but recur- ring often. This is very different from the general thinning of the hair seen early in the disease, which never re- turns. A. Fournicr (Jour, des Prati- ciens, Jan. 19, 1901). Alopecia is not a common or regular symptom of the early stages of syphilis. The slight loss of hair which is con- stantly taking place in healthy individ- uals as the result of the physiological change in the hair continues its exist- ence through and beyond the course of S3'philis, and must be taken into con- sideration before attributing to syphilis a loss of hair so slight as to pass un- noted or scarcely attract the patient's attention. Klotz (Jour, of Cut. Dis., Mar., 1907). Alopecia Seborrhceica. — Consider- able difterence of opinion exists as to what constitutes the seborrheic proc- ess ; the comprehension of the relation of seborrhea to baldness is thereby embarrassed. Nearly all writers are agreed that dandruff has not the same sig^nificance for all observers. Sabour- aud holds that dry pityriasis of the scalp is not a depilating affection itself, but that it is frequently asso- ciated with the true seborrhea. Many clinicians speak of an alopecia pityrodes in which there is either a seborrhea with fatty crusts or a pityriasis with abundant scaling. Crocker does not restrict alopecia seborrhceica to the oily form : according to his experience there is either "an excessive greasi- ness of the surface from oily sebor- rhea, or fine, glistening, powdery scales, or greas}- scales lying closely on the scalp and requiring to be scraped ofif, or yellowish, fatty matter looking like pale-yellow wax." New clinical form of atrophic alo- pecia, for which the term "pseudo- pelade" is adopted. It is a process of atrophy and sclerosis affecting the hair- covered regions of the body, especially the scalp, terminating in patches of baldness, smooth, of pseudocicatricial aspect. It seems to be closely allied to erythematous lupus and keratosis pilaris. Brocq, Lenglet, and Ayrignac (Annales de dermat., vol. i, No. 3, 1905). Analysis of 679 cases of loss of hair, chiefly alopecia simplex and alopecia furfuracea. There were, however, 86 cases of alopecia and lesser numbers due to ringworm and syphilis, and 2 cases from X-rays. Women seemed to be more affected by loss of hair, in the relative proportion of 54 to 46, but possibly they consult physicians more freely on this account than do men. The author finds that heredity, dan- druff, systemic depression, fever, opera- tions and maltreatment of the scalp have been connected in the patients' minds with the fall of hair and, accord- ing to his figures, hereditary taint ex- ists in 30 per cent, while dandruff was present in 443 patients, a percentage of more than 79. Systemic depression was recorded in 120 cases, fever in 63, and maltreatment was evident in 277 cases, or nearly half of the whole num- ber. Most patients were unable to re- member the date of beginning alopecia, but it seems, with all the accurate data that could be obtained, that in the clinically imcomplicated loss of hair, it began before 30 in 84 per cent, of the males. In females it appeared at this early age in a much less percentage and seemed to be of later development. Dandruff appeared also earlier in men than in women, being about twice as frequent between the ages of 16 and 25. C. J. White (Jour. Amer. Med. Assoc, Sept. 24, 1910). ETIOLOGY AND PATHOLOGY. — Dandruff is generally regarded as the most potent cause of baldness. It is a plausible and attractive theory to attribute the process to microbic invasion. Sabouraud has brought forth strong evidence to show that his microbacillus is intimately asso- ciated with, if not the cause of, oily 574 ALOPECIA (SCHAMBERG). seborrhea. He likewise regards this org-anism as the cause of baldness. The microbacillus, according to him, enters the mouth of the hair follicle, multiplies, and forms a thin microbic lamina, which separates the hair shaft from the follicular wall. Epithelial irritation causes the encysting" of the bacilli in a plug or cocoon. Then Alopecia from a cured tinea favosa. (Schamberg. ) follows increased sebaceous flow, hypertrophy of the sebaceous gland, and progressive atrophy ol the hair papillae. Sabouraud recognizes other causes which render the soil favor- able, such as city life, insufficient exercise, excessive meat diet, gout, heredity, etc. If baldness has a mi- crobic origin, Sabouraud is certainly correct in regarding the above causes — causes which are operative in the busy life of great cities — as of vast impor- tance. Premature baldness is rare or absent among savages and is less com- mon in country than in city districts. Many other factors have been in- voked . as causes of baldness, such as the too frequent wetting of the hair, the wearing of stiff hats which con- strict the temporal arteries, etc. It is also stated that brain workers are particularly subject to premature alo- pecia ; this is probably more the result of sedentary life than of intellectual activity. The skin of the scalp overlying the epicranial aponeurosis has no under- lying muscles to exercise it, and has onl}'- the action of the occipitofrontalis to depend on, and moves only when that muscle is put into action. That is not often. The scalp is very vascular ; there is nothing to interfere with or retard the arterial supply, but there is also nothing to accelerate the return flow — no active muscular exercise in the part whatever to hurry along the waste products and the deoxygenized blood in the vessels. These structures being su- perficial and easily compressible, their compression by the rim of the hat will further retard the flow. In women the scalp is well exercised by the combing, plaiting, and throwing from side to side of the hair — men scarcely give more than a moment to the brushing and combing of their hair. Massage is the treatment to be applied, especially as a preventive. George Elliott (Dominion Med. Monthly, Mar., 1902). Alopecia areata is often caused by traumatisms of the head. The exist- ence of anatomical and functional lesions of the central nervous system must be admitted, the state of central irritation giving rise to peripheral trophic disturbances, which manifest themselves by the appearance of hy- peralgesic zones. Possibly, vascular lesions analogous with arteriosclerosis are the cause of the falling out of the hair. At any rate, the nervous lesion is the predominant etiological factor. Psychic traumatism, especially fright, has an identical effect. Weichselmann (Deut. med. Woch., Nov. 12, 1908). Alopecia of dental origin often fol- lows a painful attack of trigeminal ALOPECIA (SCHAMBERG). 575 neuralgia caused by the teeth (18 out the scalp to s.unlight, the restricted of 25 cases). This attack may pre- ^gg ^f j^g^^s (Sabouraud says bald- cede the depilation by two or three . , . " . . ,, , ^ , V ness IS less common m ves"etanans), months, but more commonly it occurs == ^ ' in the preceding month. It occurs on the avoidance of excesses of all kinds, the same side as the trigeminal attack, are to be recommended, more frequently on the left side be- Such tonics as iron, Strychnine, cause dental lesions are more common phosphorus, arsenic, and codliver oil on the left side. It appears bv pref- . ,, , ., , . , J. , ' may occasionally be prescribed with erence m certam predisposed zones, as -' - ^ if there was a relation between the advantage. seat of the dental irritation and the Local treatment is of great impor- seat of the initial area of alopecia, tance, particularly when dandruff is ■ Thus, in 16 cases of trouble with the present. It consists of the proper lower wisdom tooth the author found , . - , , , , . , , • 1 T 1 „ 4.U o o c.;^^ r.( cleansing of the scalp and the stimula- alopccia localized on the same side oi _ ° >- the nucha in 14. It follows alveolar tion of the sebaceous glands to healthy and gingival irritation rather than den- action. tal irritation proper. Thus, in 25 cases The tincture of green soap makes an of dental alopecia the author traced admirable shampoo for the removal of the cause m 3 cases to inflammation of . , ,. , , . rr. . the dental pulp, in the remaining 22 to epithehal and sebaceous debris. This troubles outside the teeth. These irri- may be advantageously followed by tations seem to act differently upon the such a hair- wash as : — trigeminus. It is accompanied by cer- ^ Resorcinolis 3ij (8 Gm.). tain phenomena, such as hyperesthesia, Acidi acetici ... f3j-f3ij (4-8 c.c). erythrosis, hyperthermia, adenopathy, Ql. ricini' fSss-fSj (2-4 c.c). lymphangeitis, and edema, grouped by Alcoholis, q. s. ad fHvj (180 c.c). Jacquet under the name of the dental Ql. bergamott... n^xl (2.4 c.c). syndrome. The areas are generally T^n ^ j- i .• ■■,•■, 1, . . 1 r • 1, rru When greater stimulation is desired, small m size and few in number, ihe ° ' prognosis is good. The cure is rapid ^he following lotion may be used :— and often immediate after dental in- ^ Hydrarg. chlor. tervention alone. Rousseau-Decelle corros gr. viij (0.5 Gm.). (Presse med., Feb. 6, 1909). BetanaphthoUs . gr. xxv (1.6 Gm.). PROGNOSIS. — Alopecia sebor- GJycerini fSj (4 c.c). , . , „ ^ , Alcohohs fgiv (120 c.c). rhoeica gradually progresses, unless ^^^ ^^;^^^^.. checked by treatment, to a denudation gnsis fHss (15 c.c). of the vertex leaving a fringe of hair Aqucs fSiiss (75 c.c). in the temporal and occipital regions. Sig. : Hair-wash ; part the hair and apply Appropriate treatment, particularly if ^^*^ ^ '"^^^^ ^P°"S^- instituted early, will sometimes check Another lotion frequently prescribed the hair loss and lead perhaps to some ^^^^^re stimulation is desired is as regrowth. If systemic conditions are lollows : present which render the scalp a favor- ^ Tmct. canthar- able nidus, the outlook is more un- rJ- ^^, "•'.■'■ ^^ ^ 1 met. capsici, favorable. Olei rkini ....aa ni.xxx-f3j (2-4 cc). TREATMENT. — The treatment Spts. myrcice (bay must be directed toward the existing rum), q. s. ad f5vj (180 c.c). seborrheic process. The measures em- It is a good plan in many cases to use ployed relate both to general and local an ointment in conjunction with hair treatment. Outdoor life, exposure of lotions. The lotion may be used each 576 ALOPECIA (SCHAMBERG). day, and the pomade applied once or nally, an ointment is applied contain- twice a week. The latter should be "^^ ^ P^^t of salicylic acid, 2 of tinc- , , , . . 11 ■■ ture of benzoin, and 50 of vaselin. In rubbed m m very small quantities, so as u .■ . \.t. ^ . . ■ -u ■' ^ ' obstinate cases the treatment is be- to avoid disagreeable greasing of the gun by the application of tar liniment, hair. When ointments are used con- which is removed ten minutes later jointly with washes, the glycerin or with the soap. Lassar CDeut. med. oil in the lotion may sometimes be ad- Woch., July 5, 1906). vantageously omitted. Sulphur is the The most satisfactory lubricant is ,1 , , 1 1 cocoanut oil. It keeps the hair soft most useful agent for scalp pomades , ... , , ^^ . .i. i • ° ^ ^ ana silky and does not mat the hair when any seborrhea is present. ^ The ^^ pj^g^^^ j^ ^^^^^_ ^ ^^^^ shampoo following ointment gives most satisfac- about once a month suffices. The torv results :- — wire brush keeps the scalp pretty i Sulph. prcEcip 3j (4Gm.). ^^^^ ^^°"^ ^^^t ^"^ dandruff. By its Adipis Bj (31 Cm.-) . ^^"tle a-nd not disagreeable friction 01. bergamott ^xl (2.4 c.c). °^ ^he scalp, it promotes the circula- tion and thus brings nourishment to Daily digital massage of the scalp the hair-bulbs, and gives vigor to the is distinctly useful, as is also the vig- growing hair. S. Hendrickson (Jour. orous use of the hairbrush to produce ^^"^e''- ^^^- ^^s°^-' Sept. 2, 1911). hyperemia of the scalp. The frequency with which the scalp Successful treatment depends upon should be washed depends entirely upon the promptness with which one first the degree of oiliness of the SCalp and notices that the hair is beginning to j^^ir. A greasy scalp requires more fre- fall. Healthy hairs do not come out, ^1-^1 1 t , ., , . , , , .„ quent cleansing than a dry one. In a and if hairs are found on the pillow, . -^ . on the clothing, or in the hairbrush, the general way it may be said that the indication is given for beginning the scalp should be washed about once in treatment. One of the most important, two or three weeks. If the skin is very yet very generally neglected, prophylac- ^j-y afterward, a pomade should be tic measures consists in frequent ablu- 110 . • • 11 J. , , J 1 . emploved. Soaps containing sulphur tion of the head, a measure that is ^ - ^ » r still considered injurious by many ^^^ tar are useful. Some of the Ger- people. On the contrary, frequent man superfatted soaps, especially one shampooing and rubbing of the head containing sulphur, salicylic acid, and is the best preventive of baldness, resorcin, are particularly eligible for Another feature on which the author ., 1 u . • ..1, -^ r the purpose. lays much stress is the necessity for cleanliness in all utensils used in the Several cases of very severe alopecia barber shop or in private. i" which the employment of static Actual baldness cannot be cured, but electricity had given the best results. a great deal can be done to prevent its I" 4 cases this mode of treatment was onset by properly treating the tendency successful; in 1 unsuccessful. The to falling of the hair. A course of successful cases were all cured, and this treatment is outlined, of which the fol- after about twenty or thirty sittings, lowing are the most important features : The patients were submitted to the elec- Daily shampooing with soap and hot trie bath, and sparks were discharged water, followed by drying and the ap- on the smooth, hairless patches. R. plication of a 1 : 1000 solution of bi- Pivani and J. Blasi (Annali di Elet. chloride of mercury. This is allowed Medica e Terapia, Apr., 1902). to evaporate, and the scalp is then The high-frequency spark employed rubbed with a 1 : 400 solution of in a lady, aged 30 years, who had some thymol or naphthol in alcohol. Fi- early osteoarthritic changes in the small ALOPECIA AREATA (SCHAMBERG). 577 joints of the hand and came to the writer complaining of slight schorrheic rash on the face and considerable thin- ning and falling of hair. The results were brilliant. A thick growth of hair of good quality ensued, but the same application failed afterward in appar- ently similar conditions. David Walsh (Lancet, June 15, 1907). The drugs most successful in treating loss of hair are euresol, bichloride of mercury, captol and chloral hydrate. The final results of treatment are al- most disheartening, but from a tem- porary point of view we may expect good or very good response in 48 per cent, of men and in 56 per cent, of women. C. J. White (Jour. Amer. Med. Assoc, Sept. 24, 1910). Jay F. Schamberg, Philadelphia. ALOPECIA AREATA.- Alope cia circumscripta; area celsi. DEFINITION.— Alopecia areata is a disease of the hairy system char- acterized by the more or les's sudden occurrence of round or oval circum- scribed bald patches, in rare cases coalescing and producing total bald- ness. SYMPTOMS. — The disease is usually limited to the scalp. The patches are circumscribed and round, and vary in size from a coin to the palm of the hand. The skin is smooth, soft, of a dead-white color, and totally devoid of hair. Occasion- ally the patches are pinkish as a result of slight hyperemia. The fol- licular openings are contracted and less prominent than in the healthy scalp. To the feel the skin is thin, soft, and pliable. In the beginning, the patches are level or slightly ele- vated, while later they are sometimes slightly depressed. The course of the disease is ex- tremely variable. In some cases the bald patches develop suddenly in the course of a few hours. ' In other cases, the hair loss is gradual, extend- ing over a period of a few days or weeks. The areas then spread by peripheral extension until they reach a certain size, when they remain sta- tionary. Alopecia totalis following an ordinary alopecia areata. (.Schamberg.) In some cases the entire scalp becomes denuded of hair, giving to the patient a most grotesque appear- ance. In extensive cases it is by no means rare for the eyebrows and eye- lashes to be lost. In men the bearded region of the face may be involved, either alone or in conjunction with the scalp. The duration of the disease varies greatly. Recovery seldom occurs in less than a few months, while many cases last several years. The disease 1—37 578 A.LOPECIA AREATA (SCHAMBERG). may occur at any period of life. In young- individuals the hair usually returns sooner or later. In adults, the baldness may persist and prove refractory to all treatment. When regrowth occurs, the patch is first covered by fine, downy, whitish hairs which are either shed or later converted into coarse and pigmented Alopecia areata. (Schatnherg, ) hairs. Not infrequently the hair grows in and the patient thinks he is on the road to recovery, only to have his hopes shattered by the hair falling out again. As a rule, there are no sub- jective symptoms. Alopecia areata occurs with similar frequency in the two sexes. It is more common in youth and early adult life than in other age periods. Crocker states that, of 506 hospital cases, 214 were under 15 years of age, and 214 occurred in persons between the age of 15 and 35. Case in a well-developed girl, 4 years of age, whose general health had al- ways been good. She is said to have had fairly thick blond hair until two years ago, when small bald patches be- gan to appear. These rapidly increased in size, and soon the case became one of the so-called malignant type. At present practically all of the scalp hair has been lost, as well as the eye- brows and lashes. Kingsbury (Jour, of Cutan. Dis., July, 1909). ETIOLOGY.— They are two dis- tinct theories of the causation of alopecia areata. One school insists that the disease is parasitic, and cites occurrences of epidemics in institu- tions as proof of this view. Epi- demics have been observed chiefly in France and Germany : Bowen and Putnam describe an outbreak in an institution in this country. The bacteriological theory of alopecia areata still requires confirmation, none of the organisms at present found hav- ing justified a claim to be regarded as the specific cause. On the other hand there is evidence of contagiosity and infectiousness. As regards the fre- quency of the affection, it would appear that this is on the increase. Caution must, however, be used in assuming this increase to be actual. The greater frequency with which people now con- sult specialists, and the consequently greater accuracy of diagnosis, may give rise to fallacies in this direction. It represents 1.4 per cent, of all -cases treated by the writer. The chief age incidence lies between 20 and 30, and the sexes are affected in the proportion of about 7 males to 3 females. O. Lassar (Dermat. Zeit., Sept., 1900). • Among 30 cases observed within a brief period by the writer, there were no instances in which contagion could be traced. He does not think that the existence of this disease in epidemic form has been proved, notwithstanding that instances in which it occurs in barracks are well known. This fact may be explained in other ways. M. Cruyl (La Clinique, Apr. 27, 190]). Alopecia areata (schamberg). 579 The cause of alopecia areata is not an infection, but some neurotrophic in- fluenie. Division of the second cra- nial nerve experimentally causes it; besides, thallium acetate applications cause neurotrophic affections of the entire body. And with atrophy of the fibers of the sympathetic nerves in cer- tain regions alopecia results, especially when the trigeminus is afifected. From his observations the writer believes alo- pecia areata always to be neurotrophic in character. E. Richter (Berl. klin. Woch., Dec. 29, 1902). Giovanni observed that patients to whom he was administering acetate of thallium became affected with alopecia. The writer studied the effect of small doses of this drug on mice, given in food. The result of its administration was that the hair came out on different parts of the body. This effect was not due to any appreciable local action of the drug on the skin, but in the writer's opinion to certain disturbances affect- ing the peripheral nervous system of a trophic nature. Buschke (Berl. klin. Woch., Nu. 53, 1900). Alopecia areata is trophoneurotic in origin, as first urged by Jacquet, who noted some close relation between alo- pecia and dental neuralgia. His investi- gations show that neuralgia occurs be- fore, with, or after the alopecia, in al- most all cases. This dental theory of the origin of alopecia is confirmed by a case-history which the writer quotes, a child in whom the condition disap- peared after the affected gum had been cauterized. F. Tremolieres (Presse med., June 14, 1902). Case of alopecia areata affecting man and wife. In the man alopecia, vitiligo, and blanching of the hair and beard occurred almost at the same time after emotional trouble in a patient of a neuroarthritic diathesis. The wife, also a neuroarthritic subject, suffered from the same emotional cause, and had loss of hair and eyebrows. In these cases the cause appears to be trophoneurotic. In the male the patches were typical of alopecia areata ; in the female, irreg- ular and disseminated. Levy (Jour, des tnal. cut. et syph., May, 1902). Recalling Jacquet's theory that bald- ness is of nervous origin, and is con- nected with skin diseases, dental trou- bles, and crises of gastrointestinal and other origin, the writer refers to a case in which the cure of a fistula in ano, complicated with entire loss of hair, was succeeded by complete res- toration of eyelids, eyebrows, and hair of the scalp. Eyraud (Presse med., Mar. 30, 1904). On the other hand, there is irrefu- table clinical evidence of the neuro- pathic origin of cases of alopecia areata. Nervous shock, such as fright, prolonged anxiety, etc., and traumatism to the scalp have been directly followed by areate loss of hair. [I recently saw a boy admitted to the Polyclinic Hospital for the fracture of the skull who developed alopecia areata before leaving the institution. Max Joseph has produced the disease in cats by excision of the second cervical ganglion. J. F. S.] It v^ould, therefore, appear that there are two varieties of alopecia areata, the one parasitic and the other trophoneurotic. In the epidemic observed by Bowen and Putnam, the patches were not identical with those commonly observed, but were smaller and more irregular in shape. Some of the English dermatologists are of the opinion that alopecia areata is prone to occur in those who have at some previous period suffered from ringworm of the scalp. Sabouraud regards his microbacillus as the prob- able cause of alopecia areata, though the influence of syphilis is not over- looked by him. Extensive alopecia due to syphilis, either acquired or hereditary, oftener than to any other single cause, as suggested by the success obtained with antisyphilitic remedies. Sabour- aud (Ann. de derm, et de syph., p. 545, 1910). Alopecia areata (schamberg). Study of 14 typical cases of alopecia areata. In 11 of these the writer ob- tained a positive Wassermann re- action, when there were no symptoms of syphilis, either hereditary or ac- quired. The 3 negative cases were the subjects of single alopecic patches which were speedily cured by local stimulation. Du Bois (Ann. de derm, et de syph., Nov., 1910). PATHOLOGY. — Both Giovanni and Robinson found evidences of in- flammatory disturbances, chiefly in subpapillary layer. Perivascular cell infiltration was observed in both ■early and late lesions. Subsequently atrophic changes take place with destruction of the hair papillse. The characteristic hair of alopecia areata has the shape of an exclamation point. The upper part is pigmented and normal, while the lower portion is atrophied and without pigment. Sabouraud describes an ampullar swell- ing (the peladic utricle) filled with the microbacillus in the upper third of the hair follicle. . Alopecia Areata. 1. Rapid onset. 2. Patches are : — (o) Totally devoid of hair. (&) Pale or whitish in color, (c) Smooth or soft, (c?) Follicles contracted. 3. Absence of fungus. 4. Common in adolescence and adult life. The baldness of early syphilis may bear some resemblance to alopecia areata. Apart from the presence of other evidences of the disease, the patches are moth-eaten in appearance and not sharply circumscribed. The surrounding hair and scalp are luster- less and dirty, whereas in alopecia are- ata they are perfectly normal. PROGNOSIS.— In children recov- ery usually takes place. In young adults the prognosis is usually favor- able, while in advanced adults it is un- favorable. The longer the disease has persisted, the more unfavorable is the prognosis. The duration of the disease is uncertain and relapses are not un- common. TREATMENT.— The internal treat- ment consists of the use of such tonics as iron, strychnine, quinine, codliver oil, phosphorus, and arsenic. Duhring considers arsenic to be "especially ser- viceable." The local treatment has for its pur- pose the stimulation and rubefaction of the scalp with the object of increasing the blood-supply to the follicles. Many cases terminate in spontaneous recov- ery^ and conservative judgment is de- sirable in interpreting the value of remedies employed. Among the many medicaments which have been advised are alcohol, cantharides, capsicum, the essential oils, turpentine, carbolic acid, trikresol, ammonia, sulphur, Ringworm. 1. Slow, insidious onset. 2. Patches are : — (a) Covered with broken-off stumps, (fo) More or less reddened, (c) Rough and scaly. {d) Follicles prominent; "goose-flesh" appearance. 3. Trichophyton fungus present. 4. Occurs almost exclusively in childhood. iodine, mercury, chrysarobin, beta- naphthol, etc. The following lotion will be found of value : — R Tinct. cantharides^ Tinct. capsici, of each fHiss (6.00 c.c). 01 ricini fSij (8.00 c.c.) . Aquce cologniensis . f§j (30.00 c.c). Sig. : Brush in vigorously each day. Instead of lotions, ointments such as the following may be employed: — ALOPECIA AREATA (SCHAMBERG). 58i B Bctanaphthol 3j (4.00 Gni.). J-aselini 5j (31.00 Cm.). 01. bcrgamott ni.xl (2.46 c.c). Sig. : Rub in twice a day. An efficient treatment consists in the swabbing of the bald areas once or twice a week with B Acidi carbolici, Spts. villi rcct., of each f5ss (15.00 c.c). Or, 50 per cent, trikresol may be employed. Within recent years I have em- ployed a chrysarobin ointment which has given me more uniformly good results than any other topical appli- cation : — IJ Chrysaro- biiii gr. x-xxv (0.65-1.62 Gm.). Lanolini ... 3j (4.00 Gm.). Adeps beii- zoat 3vij (27.21 Gm.). M. Rub in in small quantity. Protect the eyes from contact with ointment. The routine treatment adopted by the writer is of an antiseptic nature. The head is washed daily for several min- utes with a strong tar soap, which is then sluiced off and the head dried. Then the scalp is treated successively with 2 per cent, sublimate solution, absolute alcohol, with the addition of J/2 to 1 per cent, naphthol, and finally with 2 per cent, salicylic acid in oil. In all moderately fresh cases the dis- ease is brought to a standstill at once. O. Lassar (Dermat. Zeit., Sept., 1900). Cases under the author's observation that were benefited or cured by appli- cations of chrysarobin ointment, 10 to 15 per cent, strength, used daily for a week or ten days, followed by pure carbolic acid applied lightly with a swab. The ointment referred to sets up considerable inflammation, and must be used cautiousl3^ When this inflam- mation has subsided, areas here and there the size of a silver dollar are touched from time to time with the acid. The results in the cases given were highly satisfactory. E. J. Emerick (Columbus Med. Jour., Feb., 1901). A preparation of 30 per cent, of chrysarobin applied for two to eight weeks in alopecia areata causes vascular dilatation, thickening of the vascular walls, proliferation of the pSrithelial cells, infiltration of the connective tis- sue round the vessels, and hypertrophy of the connective-tissue cells. Numer- ous mast cells were seen round the ves- sels. In some places there were poly- nuclear leucocytes, but no agglomeration of lymphocytes. In the upper layers of the epidermis there was edema, with the formation of parakeratotic des- quamative lamella, and in the deeper layers there was proliferation of the prickle cells round the follicular ori- fices, which gives rise to the formation of the cellular sheaths, in the center of which new hairs form. By repetition of the chrysarobin irritation this cellu- lar proliferation is repeated till new follicular sheaths are produced. New sebaceous glands are also forxned later- ally. Finally, new arrector muscles form and new papillae, in which develop new hairs. Hodara (Jour, des mal. cut. et syph., Sept., 1903). The following treatment has given the most satisfactory results : Every night for one week the aflfected spots should have w^ell rubbed into them an ointment of chrysarobin, of a strength of from 20 grains to 2 drams of the drug to 1 ounce of petrolatum. If the disease is not checked this treatment should be repeated. After the disease has stopped spreading, precipitated sul- phur ointment (1 to 2 drams to the ounce) should be used. Severe or chronic cases may call for other meas- ures. Dillingham (Amer. Med., Mar. 12, 1904). Case of a young girl in which there was a circular patch three inches in diameter on the scalp at the side of the occiput, hairless, smooth, and shining. The treatment consisted in painting it with a 30 per cent, solution of formal- dehyde. This was done every day for the first week or two, until signs of inflammatory reaction appeared. The treatment was then suspended, and a sedative ointment applied. When the inflammation subsided the formalde- 582 ALUM (SAJOUS). hyde was again continued, stopping the application as soon as inflammatory- trouble appeared. This routine of treatment was persevered in for about six or nine months. About this time a growth of hair made its appearance, continued to grow, and in every way corresponded with the surrounding hair. One year after cessation of treatment the growth of hair was continuing in a perfectly normal way. J. J. Mc- Inerny (Brit. Med. Jour., Jan. 25, 1908). The faradic current applied with a wire brush electrode is often useful, as is likewise the use of high-frequency currents. In obstinate cases blister- ing of the affected areas may be re- sorted to. PHOTOTHERAPY.— Many writ- ers, including Finsen, Hyde, Mont- gomery, Kromayer, and others, have testified to the value of actinic light rays in this disease. It is admitted that many cases in which light is used might have recovered spontaneously. Kro- mayer's results, however, in cases of extensive and even total alopecia of years' standing indicate that light therapy is one of the most useful measures in the treatment of this dis- ease. The iron arc or carbon arc may be employed. The ordinary London Hospital type of lamp suffices for this purpose and permits of the exposure of an area the size of a silver dollar. Reaction varying in degree from an erythema to the formation of a blister results at the end of some hours. The same area can be again treated after a lapse of two or three weeks. Cases illustrating the rapid improve- ment under phototherapy with the ultraviolet rays. Success was ob- tained in many cases in which pre- vious measures applied for months had failed to benefit. Joachim (Deut. med. Woch., May 13, 1909). Piffard's iron spark-gap lamp — a small lamp made of rubber with a handle «» to hold it^recommended. For use it is attached to a coil. The quartz lens is removed in treatment, as it allows only ultraviolet rays to pass through. The lamp is held just far enough away from the scalp to prevent sparking, and continued for five to ten minutes, and the applica- tion is repeated in two to four days. Heat is thrown out by the lamp and the skin gets reddened. G. T. Jack- son (Jour, of Cutan. Dis., Jan., 1910). Jay F. Schamberg, Philadelphia. ALSOL. See Aluminum: Alu- minum ACETOTARTRATE. ALUM (Ahimen). — The alum used in medicine is, chemically, the double sulphate of aluminum and potas- sium [A1K(S04)2+12H20]. It oc- curs in large, octahedral, translucent crystals, or as a colorless powder, odor- less, but with a sweetish, strongly as- tringent taste. When left in an open bottle, the salt becomes whitish on the surface, owing to the absorption of ammonia from the air. Dried, "burnt," or exsiccated alum (Ahimen Exsicca- tiim), i.e., alum from which the water of crystallization has been driven out by heating, occurs as a white, granular, strongly hygroscopic powder. DOSE. — The dose of alum for in- ternal use (rarely employed) is 5 to 30 grains (0.03 to 2.0 Gm.) ; the average dose is 7^ grains (0.5 Gm.). To se- cure an emetic effect, 1 to 2 drams (4 to 8 Gm.) must be given. MODES OF ADMINISTRA- TION. — Alum is soluble in 9 parts of cold water (the saturated solution thus containing, roughly, 10 per cent.), and in 0.3 parts of boiling water. It is completely insoluble in alcohol, but dis- solves readily in warm glycerin. Dried ALUM (SAJOUS). 583 alum, possessing greater concentration than the crystalHne form, requires more water for dissolution — 17 parts of cold and 1.4 parts of boiling water. When exhibited for other purposes than as an emetic, alum is best given in a fla- vored syrup, e.g., syrup of orange peel. When it is used to secure emesis, a small amount of simple syrup may be employed as vehicle. The subsequent ingestion of warm water augments its emetic effect. For astringent gargles, sprays, anhydrotic lotions, and rectal or vaginal injections, solutions contain- ing 21/4 to 20 grains (0.15 to 1.2 Gm.) of alum to the ounce (30 c.c.) of water should be prescribed. When an astrin- gent eye-wash is desired, 2 or 3 grains (0.12 to 0.20 Gm.) of alum to the ounce of water may be used. The "alum curd," made by adding to a pint (473 c.c.) of milk 2 drams (8 Gm„) of alum, boiling the mixture, and straining off the curd, is also a useful preparation for this purpose. Dried alum, being anhydrous, is especially adapted for use as a dusting powder, for insuffla- tion, and in ointments. It is applied to superficial growths as an escharotic. A glycerite of alum is official in the Brit- ish Pharmacopoeia. INCOMPATIBLES.— The salts of aluminum, including alum, are incom- patible with the alkalies and carbonates of the alkali metals; with the tartrates; with tannic acid, and with salts of iron, mercury, and lead. CONTRAINDICATIONS.— In individuals subject to bronchial irrita- tion, the long-continued use of alum is inadvisable, in view of the exciting ef- fect it exerts on these structures. PHYSIOLOGICAL ACTION.— When applied externally alum causes hardening of the skin, or, if used in concentrated solution, exerts a slight caustic effect. Whenever it is brought in contact with albumin, as occurs when it is applied to a denuded area, the al- bumin is coagulated. The precipitate is soluble, however, if an excess of albu- min be present. The astringent and antiseptic effects of alum and other aluminum salts depend upon this coag- ulating property. Their power of pen- etrating into tissue-cells is, however, very limited (Siem). Small doses of alum taken orally at first stimulate the flow of saliva, then reduce it through their astringent ef- fect. The buccal mucosa becomes whitish and shriveled, owing to coagu- lation of the albuminous constituents, and the enamel of the teeth is likely to crack in places. On reaching the stom- ach, the drug causes a decrease in the amount of gastric juice secreted, and coagulates, the pepsin. A similar effect beiijg exerted in the intestinal canal, constipation results. In larger doses, the emetic effect of alum becomes man- ifest, and a purgative effect may also he noted. UNTOWARD EFFECTS AND POISONING.— The injurious effect of alum on the teeth may be avoided (1) if care be taken to cleanse them well at once after employing an alum gargle or mouth-wash; (2) by limiting the use of alum to applications of a strong solution or of the solid salt in all cases in which local astringent ef- fects will suffice. The unfavorable ac- tion of alum when long employed by persons subject to bronchial irritation has already been referred to. Large amounts of alum taken inter- nally cause nausea, vomiting, pain in the abdomen, and diarrhea, owing to the inflammation of the gastrointestinal ' mucosae produced through the cellular albumins. 584 ALUM (SAJOUS). Case in which, through gargling with a concentrated alum solution, a portion of the fluid was accidentally swallowed. This was followed by severe abdominal pains, vomiting of mucus and blood (39 times), and voiding of blood- stained urine. Recovery only after the lapse of thirteen days. Kramolin (Therap. Monatsh., 325, 1902). Alum baking powders and pastry to which alum has been added in order to whiten the product are possible sources of gastrointestinal irritation, though the amount of aluminum liberated, at least in the case of bread baked with alum powders, is often so slight as to be of doubtful irruportance. THERAPEUTIC USES. — As an Astringent. — This is the chief use of alum. Combined with it is an antisep- tic effect, which is also of value. In all catarrhal and relaxed states of the mucous membranes, as well as in certain skin affections, alum is bene- ficial when locally applied. Aqueous solutions of from 5 to 20 grains to the ounce (1 to 4 per cent.) strength are chiefly employed; stronger solutions in- duce undesirable secondary irritation. In catarrhal throat afTections fluid preparations containing alum (1 to 5 per cent.) form a useful gargle or spray. Since alum is injurious to the teeth, the mouth should be washed out, preferably with some alkaline so- lution, after using this drug. A glycerite of alum (10 to 20 per cent, solution of alum in glycerin, the prep- aration of which is greatly facilitated by heating) is very efficacious when applied locally in subacute pharyn- gitis and laryngitis, especially where a tendency to edema of the tissues in- volved is. present. For the relief of hoarseness or of tickling sensations in the throat, a mixture of equal parts of powdered alum and sugar, placed on the tongue and allowed slowly to dissolve, is productive of benefit (Bunnell). In acute coryza alum has been incorporated in snuff, to which it imparts astringency. The following preparation is suitable for use in the early stages of coryza: — IJ Alum 3 grs. (0.2 Gm.) . Morphine sulphate . 2 grs. (0.13 Gm.). Cocaine hydrochlo- ride Igr. (0.065 Gm.). Camphor, Bismuth of each 2 drs. (7.77 Gm.). M. bene. Sig. : To be used as snuff every two hours ; a small quantity in each nostril. In follicular tonsillitis and diph- theria alum in pencil form may be applied to the involved surfaces with benefit. In conjunctivitis alum may also be used. A 0.5 per cent, solution may be used as a lotion, or the alum curd, made by the addition of powdered alum to milk or white of egg until a curdy mass is formed, may be ap- plied to the eye every two hours. Similar applications prove effective in ecchymosis of the eyelid (black eye). In gonorrheal ophthalmia alum has also been used in a solution con- taining 6 grains of the salt in 1 ounce of water, applied four times daily. In granular conjunctivitis a crystal of alum may be drawn over the involved mucous surface after turning the lid (Bunnell). In salivation or ptyalism of mer- curial origin a 4 per cent, solution of alum may be employed for its astrin- gent action. In the treatment of night-sweats, or in sweating of the hands and feet (hyperidrosis) , washing the skin sur- faces with a 0.5 per cent, solution of alum will markedly improve the con- dition. ALUM (SAJOUS). 585 In chilblains a 4 per cent, solution of alum has been applied with benefit. In gonorrhea and leucorrhea alum has been used as an astringent injec- tion or douche in I2 to 2 per cent, strength. In pruritus vulvas a 4 per cent, so- lution of the salt will not infrequently relieve the itching. In ingrowing toenail with granula- tions absorbent cotton soaked in a 6 per cent, solution of alum may be in- troduced under the edge of the nail. In chronic dysentery a 1 per cent, solution of alum is sometimes em- ployed as a rectal injection. As a styptic alum is likewise an effective agent. In epistaxis it will often act promptly. Pledgets of cotton should be dipped in a saturated solution of alum and packed in the bleeding cav- ity; they may be left in until all danger of recurrence has passed — generally about twelve hours. In minor degrees of hemorrhage the alum solution may be sprayed in, or powdered alum may be used as snuff or introduced by means of an insuf- flator. Similarly, in hemorrhage succeed- ing upon the extraction of teeth, the placing in the cavity of cotton dipped in a saturated solution, or the intro- duction of powdered alum, will often be effective in arresting the bleeding. In hemoptysis a fine spray of 5 per cent, alum solution is claimed to have been productive of benefit. In the intestinal hemorrhage of ty- phoid fever alum has been recom- mended by many clinicians, Whitla in particular. It is believed to do good in this condition through its antiseptic properties, as well as through its astringency. In uterine hemorrhage of all kinds alum is a useful styptic. It may be employed as an injection in the strength of 1 dram to the pint, or, as R. Beverly Cole recommended, an egg-shaped piece of alum may be inserted into the uterine cavity. Not only is the styptic effect produced, but the tissues of the uterus are stim- ulated and the organ is caused firmly to contract. As a Caustic. — Dried ("burnt") alum, which exerts an escharotic ef- fect, owing to the fact that in addi- tion to the inherent properties of alum it withdraws water from the tissues, may be applied to exuberant granulations, condylomata, chronic conjunctival inflammations, etc. Burnt alum may also be used as a dressing for sluggish ulcerations and as an application to swollen gums and in ulcerative stomatitis (Bun- nell). As an Emetic. — In doses of 1 or 2 drams alum has been used as an emetic, especially in the treatment of croup in children. A teaspoonful of the salt may be dissolved in 6 table- spoonfuls of a mixture of syrup and water, equal parts, and administered every fifteen minutes. This sometimes serves quickly to ar- rest an impending attack of croup, the astringent effect of the salt upon the mucosa of the throat contributing in the benefit by counteracting the local hyper- emia. As a Stimulant to Peristalsis. — In doses of % dram every four hours alum has been found to induce purga- tion. The large amount of watery fluid thrown out from the mucosae in the presence of alum apparently obviates its irritating influence on these mem- branes. In tympanites due to peri- 586 ALUMINUM (SAjOUS). toneal inflammation succeeding upon abdominal operations in cases suffer- ing from infective states of the ab- dominal viscera, the high rectal in- jection of an ounce of alum in a quart of water has been found effectively to excite contractions of the paretic gut. Case in which Epsom salt, calomel, soap and water, castor oil, glycerin, turpentine, and oxgall were success- ively used without avail. A solution of an ounce of powdered alum in a quart of warm water was injected into the rectum, and in ter minutes flatus escaped from the rectum. In an hour the enema was repeated successfully. The patient was practically convales- cent on the following day. Since this case, the author has used the alum enema in hundreds of cases, and always with good results. Sometimes it is necessary to repeat the injection be- fore it will act, and this can be done with safety an indefinite number of times. There is sometimes some pain, not severe, attending its use. Injected like any other enema, probably in no instance does it go above the sigmoid flexure. The throwing off by the bowel of a tubular cast is of no importance, as it is composed simply of mucus whose albuminous elements have been coagulated by the alum. The alum seems to have as specific an action in inducing intestinal peri- stalsis as has castor oil when taken into the stomach. It does not produce a serous exudation from the intestinal walls, and for that reason the author prefers it to Epsom salt when the stomach will retain it. During nine years in which alum enema was used, percentage of mortdity in abdominal work has been a little less than one- half of what it was during the pre- ceding seven years. Hardon (Amer. Jour, of Obstet., June, 1901). C. E. DE M. Sajous AND L. T. DE M. Sajous, Philadelphia. ALUMINUM (Aluminium). — A bluish-white, silvery metal, noted for its low specific gravity (2.7) and its unalterability on exposure to the air. The most important of the com- pounds of the metal aluminum em- ployed in medicine, viz., the double sulphate of aluminum and potassium, has already received separate consid- eration (v. Alum). Numerous other salts have been used, chiefly exter- nally, as astringents and antiseptics. Taken internally, the salts of. alumi- num are, according to some observers, not all absorbed from the gastrointesti- nal tract, this accounting for the fact that no functional disturbances in the organism at large occur as a result of their ingestion. According to others, however, alum (and probably other salts) is absorbed, in extremely small amount, in the alimentary canal, and is eliminated with the bile and urine. When administered experimentally to animals by subcutaneous injection, soluble salts of aluminum cause no symptoms at all until several days or even weeks later (Siem), when the metal is no longer present in the cir- culation. In mammals the symptoms appear in from three to five days, and are in many ways similar to those of subacute arsenic poisoning. The ani- mal shows loss of appetite, obstinate constipation, emaciation, and languor. Next there appears vomiting. Vol- untary movements, executed only upon coercion, are attended with trembling and twitching. Sometimes there is general tremor or convulsive twitching, and sometimes extreme weakness or partial paralysis of the posterior limbs. There is complete loss of sensibility to pain, though iconsciousness is retained. Finally, control of the tongue and the power Aluminum (sajous). 587 tyf swallowing are completely lost, sa- liva dribbling' from the mouth. The symptoms correspond precisely to .those of human acute bull^ar paraly- sis. Such phenomena never result from the oral use of aluminum salts, even where long- continued (Soll- mann). Diarrhea and albuminuria appear before death. On post-mortem examination the gastrointestinal mu- cosae are found hyperemic and swol- len, and the kidneys and liver fre- quently show fatt}^ degeneration, the former presenting, in addition, corti- cal hemorrhages. Following are some of the more important salts of aluminum em- ployed in medicine : — Aluminum Hydroxide {Alumini Hydroxidum), Al(OH)3, made by precipitating a soluble salt of alumi- num with an alkali or alkaline car- bonate. It occurs as a light, amor- phous, colorless, tasteless powder, soluble in acids and alkalies. It is used as an astringent in inflamma- tory skin affections. Aluminum Sulphate {Alumini Sul- phas), Al2(S04)3 4-18H20, prepared from the hydroxide by dissolving it in dilute sulphuric acid. It occurs as a white, crystalline powder or in larger crytals or pencils, and, like alum, has a sweetish and astringent taste. It is freely soluble in water, and has been used for much the same pur- • poses as alum itself, viz., as an astrin- gent, antiseptic, and caustic in the treatment of affections of the nose and throat, including enlarged tonsils and nasal polypi ; of the uterus, includ- ing endometritis ; as a lotion for foul ulcers, and in vaginal conditions as- sociated with offensive discharges. The strength of the solutions used is the same as with alum. The following aluminum compounds are non-official : — Aluminum Acetate (basic), AloO,- 4C2H;{02 + 4Ii20. Obtained in solid form from its solutions by rapid dry- ing on glass at a low temperature, this salt occurs as a colorless, crystal- line or amorphous powder which is insoluble in water. It is antiseptic and astringent, and has been used in- ternally in dysentery in doses of 5 to 10 grains (0.3 to 0.6 Gm.). An 8 per cent, solution of aluminum acetate is known as "liquor Burowii," which has been extensively used as an appli- cation in skin affections, and in sup- purating wounds. One to 3 per cent, solutions are useful as a mouth-wash, and are particularly effective in over- coming fetid breath. In a solution of 1 to 150 strength, this salt of aluminum may be used as an astringent enema in affections calling for such a measure. Antiseptic properties of moist appli- cations of a solution of aluminum acetate used quite generally by the author after operations where there is the slightest danger of infection. The solution is also invaluable in the mouth, particularly for necrosis and suppura- tion, where it does more good than mouth-washes. An excellent method of treating tears of the perineum, after confinement, is to apply gauze saturated with the solution, and to have the pa- tient lie on the abdomen for a few days. F. Weitlaner (Klin, therap. Woch., Nu. 6, 1908). Usefulness of aluminum acetate solu- tion emphasized. For certain surgical purposes this is one of the best anti- septic solutions, though it is unknown to most surgeons and practitioners. Burns may be treated with dressings wetted with a 1 per cent, solution of aluminum acetate. This solution, while . antiseptic, is also non-toxic, non-irri- tant, and yet markedly astringent. It is not to be employed in surgical opera- tions, as it spoils steel instruments ; but 588 ALUMINUM (SAJOUS). as an antiseptic for moist fomentation of wounds that are infected or prob- ably unclean, or as a medicament for a bath in which to place an infected . hand or foot for continuous irrigation, . it is to be strongly recommended. The common strength is that of 1 dram of the liquor aluminii acetatis of the Ger- man Pharmacopoeia (a 7^ per cent, solution) to 1 fluidounce of water. There is no danger of poisoning from it. By the employment of continuous irrigation by means of a bath of the 1 per cent, solution, pyogenically in- fected hands and feet, which but for the action of the solution would have called for amputation, have been saved. For dermatitis, whatever its cause; for suppurating open wounds, and for cu- taneous erysipelas, much is to be said for the favorable results obtained. One objection that should be mentioned is that after three weeks of continuous irrigation of a member such as the hand the surface tissues may assume a ligneous hardness. M. F. Waterhouse (Hospital, Aug. 27, 1910). Aluminum Acetotartrate (Alsol), prepared by mixing a 5 per cent, solu- tion of basic aluminum acetate with a 2 per cent, solution of tartaric acid and evaporating" to drjmess. It occurs in colorless crystals, or in whitish amorphous masses having a slightly acid, astringent taste. It dissolves slowly, but completely, in water, but is insoluble in alcohol and ether. This substance has an action sim- ilar to that of aluminum acetate, and is one of the best of the aluminum salts used in medicine. It has been employed largely, though not exclu- sively, in diseases of the respiratory passages. Thus in G.05 to 2 per cent, solutions it has been used as a nasal douche. Mixed with 2 parts of pow- dered boric acid it may be used as a snufif. In tonsillitis a 1 per cent, so- lution of it makes a suitable gargle. Strong solutions {e.g., 50 per cent.) have been employed with advantage in the treatment of chilblains and skin diseases of various kinds — also in wounds as disinfectants. Eye af- fections, such as ophthalmia neona- torum, chronic types of conjunctivi- tis, etc., have also been treated with this salt. In a 5 per cent, solution, alsol inhibits the growth of gonococci, streptococci, and anthrax bacilli. In the treatment of wounds, it is astringent, disinfect- ant, and antiseptic and does not irri- tate the tissues. In a 1 per cent, solu- tion, it is useful as a gargle in ton- sillitis, J. W. Frieser (Wiener klin. Rundschau, Aug. 12, 1900). Alsol in a 5 per cent, solution de- stroyed the spores of anthrax in ten hours, acetate of aluminum in an 8 per cent, solution in two hours, while carbolic acid in a 5 per cent, solu- tion had no effect whatever on their development. In the case of Strepto- coccus pyogenes, Staphylococcus pyog- enes aureus, the gonococcus, and the tubercle bacillus, however, carbolic acid has a greater bactericidal power than acetate of aluminum. The combina- tion of the acetate with the tartrate greatly raises the bactericidal power, so that alsol is considerably more potent than carbolic acid. Aufrecht (Deut. aertzl. Zeitung, Feb., 1900). Alsol exerts an action similar to the acetate of aluminum. It is said to possess a somewhat stronger disinfect- ant action than the same strength solu- tion of carbolic acid, and is mildly astringent at the same time. The author employed it in a concentration of from %. to y2 per cent. Finding that warm and cold compresses are of value in the treatment of certain eye affec- tions, he attempted to extend their use by employing alsol. In blennorrhoea neonatorum he washed the eyes out every half an hour, both during the day and night, and obtained excellent results. The direct forms of treat- ment, e.g., painting with silver nitrate, etc., must be carried out as well, the alsol solution only acting as a disin- ALUMINUM (SAJOUS). 589 fectant and mild astringent. In acute conjunctivitis and acute granuloma cold compresses applied for ten to twenty minutes three or four times a day found of value. The same re- sults were obtained in chronic con- junctivitis and chronic trachoma. In scrofulous ophthalmia warm com- presses were applied three times a day for about half an hour. In hor- deola and in ulcers of the cornea, iritis, etc., satisfactory results were obtained with alsol. L. Pick (Therap. Monats., July, 1903). Aluminum Boroformate, prepared by saturating with freshly precipi- tated and well- washed aluminum a solution of 2 parts of formic acid and 1 part of boric acid in 6 or 7 parts of water. It occurs in pearly scales, which are hygroscopic and dissolve completely, though slowly, in water. Its. solution has a sweet, faintly astringent taste, and does not co- agulate solutions of albumin. Mar- tenson in 1894 recommended this salt strongly for use as a gargle in the throat affections in children, prefer- ring it to all other preparations of aluminum. Aluminum Borotannate (Cutal), a product of the reaction of tannic acid with borax and aluminum sulphate. It is a brownish insoluble powder, which combines with tartaric acid to form Aluminum Borotannotartrate (soluble Cutal). This salt, in common with the other aluminum compounds, is anti- septic and astringent. It has been used chiefly in skin affections and is recommended particularl}^ in weep- ing eczema and pruriginous affec- tions. The following formula may be employed : — IJ Aluminum boro- tannate 1 dr. (4 Gm.) . Olive oil 2^ drs. (10 Gm.). Lanolin., to make 10 drs. (40 Gm.). When the flow of secretions has been arrested, the drug may be used with advantage as a dusting powder in the following mixture : — I^ Aluminum boro- tannate. Zinc oxide, Powdered talc, of each 2^ drs. (10 Gm.). In hemorrhoids Koppel has recom- mended the use of an ointment con- taining 10 per cent, of cutal, and in fissures of the hands of one formu- lated thus : — IJ Cutal ^ dr. (3 Gm.) . Oil of sweet alm- onds. Lanolin ..of each 3^ drs. (15 Gm.). Orange-flower water 2>^ fl. drs. (10 Gm.). Aluminum borotannotartrate, or soluble cutal, has been used in the treatment of second-degree burns, as a 10 per cent, solution in glycerin in follicular throat affections, in catar- rhal metritis, in hemorrhoids, and in gonorrhea. Aluminum Borotartrate (Boral), a combination of aluminum, boric acid, and tartaric acid. It occurs as white crystals having a sweetish, astringent taste, and is freely soluble in water. It is useful in inflammatory diseases of the nose and nasopharynx, in ery- sipelas, and, in solution with tartaric acid, has given good results in gonor- rhea. It may be employed either alone in watery solution or in glycer- inated mixtures. Aluminum Carbonate, AI2 (003)2, occurring in chalky-white, easily pow- dered, tasteless masses. According to Gawalewski, it constitutes an ex- tremely mild styptic and astringent, and is hence better adapted than are burnt alum and other aluminum prep- arations in the treatment of ocular 590 ALUMNOL. affections, croup, diarrhea, hemopty- sis, skin eruptions, and hyperidrosis. Aluminum Chloride, AI2CI6 -|- 12- H2O, a yellowish granular, crystal- line, hygroscopic powder, soluble in water, alcohol, and ether. It has been used internally in tabes in doses of 11/4 to 4 grains (0.1 to 0.25 Gm.), and externally as a disinfectant. Aluminum Phenolsulphonate (Sul- phocarbolate), Al2(C6H4HS04)6, a reddish powder with weak phenol4ike odor and a strongly astringent taste, soluble in water, alcohol, and glycerin. It has been recommended as a sub- stitute for iodoform in the treatment of superficial, circumscribed, suppu- rating lesions, and of cystitis. Aluminum Salicylate, A1(C6H4- OHCOO)3, a reddish powder, insol- uble in water and alcohol, soluble in alkalies. Used as an antiseptic pow- der for insufflation in catarrhal states of the nasal and pharyngeal mucous membranes, and in ozena. Aluminum. Silicate, Al2Si309, a white substance, insoluble in water and acids. It has been recently rec- ommended in the treatment of gastric hyperacidity and hyperesthesia. Investigations of the action of silicate of aluminum upon the gastric secre- tions and upon disease symptoms re- sulting from abnormalities of secretion. Under the name 'neutralon, this sub- stance occurs as a fine, tasteless, odor- less, and insoluble powder. Taken into the stomach it reacts with the excess of hydrochloric acid to form silicic acid and aluminum chloride. The latter acts as a protective and astringent to the gastric mucosa in a manner similar to silver nitrate and bismuth, and has no toxic effect. In all cases of hyper- acidity or hypersecretion, whether of neurotic origin or due to organic disease or injury, the remedy was found to be very effective in reducing the acidity, relieving pain, and aiding digestion. Results especially good in persistent cases of hypersecretion with motor in- sufficiency. Gastric hyperesthesia as- sociated with anemia and chlorosis favorably influenced in several in- stances. Excessive acidity in cases of gastric ulcer was also reduced. The drug was given in doses of ^ to 1 teaspoonful in 3 ounces of water, one- half to one hour before meals. No untoward symptoms. Rosenheim and Ehrmann (Deut. med. Woch., Jan. 20, 1910). C. E. DE M. Sajous AND L. T. DE M. Sajous, Philadelphia. ALUMNOL the aluminum salt of betanaphthol-disulphonic acid [Al2(Cio- 115011(503)2)3], is made by adding a solu- tion of barium naphthol-disulphonate to one of aluminum sulphate, filtering off the precipitate of barium sulphate, and evap- orating to dryness. It contains about 5 per cent, of aluminum, and occurs as a fine white or slightly reddish, non-hygro- scopic powder with a sweetish, astringent taste. It is readily soluble in cold water and in glycerin, slightly so in alcohol, and is insoluble in ether. On exposure to the air it becomes darker in color, by virtue of its reducing properties. MODE OF EMPLOYMENT.— Alum- nol is employed chiefly in solution, though also frequently as a dusting powder. As a mild astringent and antiseptic it is used in solutions of 0.5 to 5 per cent, strength. For caustic effects, a 10 or 20 per cent, solution may be employed. Where the action of several antiseptics at once is desired, alumnol may be used in com- bination with agents such as corrosive sub- limate, resorcin, etc.; it is incompatible, however, with silver nitrate or other re- ducible salts, as well as with alkalies. THERAPEUTIC USES.— The almost unirritating and non-toxic qualities of alumnol in weak solutions render it avail- able as an astringent and antiseptic for the treatment of chronic catarrhal proc- esses, and also in sluggish ulcerations. In acute cases, however, it generally proves too irritating to be of value. It has been employed mainly in gynecology and gen- ALUMNOL. 591 itourinary surgery, and, to a less extent, in general surgery, laryngology, and derma- tology. In y2 to 1 per cent, solution alumnol was found useful by Hcinze and Liebreich in gonorrheal endometritis and in colpitis not of gonorrheal origin. Kontz, employ- ing alumnol in a series of 16 gynecological cases, found that cervical catarrh and simple perimetritis yielded to its repeated use, and that gonorrheal vaginitis was readily cured by it. In endometritis ac- companied by adnexal lesions, however, pain was augmented, owing to the irrita- tion. This author employed a 3 per cent, solu- tion for lavage, a 10 per cent, solution in the treatment of endometritis and ero- sions, and powders and bougies of 20 per cent, strength. Marfan used 3 per cent, bougies of alumnol in vulvovaginitis. Intra-uterine injections of the iodide of alumnol have been recommended by Gram- matikati as a substitute for curettement of this organ. Though alumnol has been claimed to exert a peculiarly destructive action on gonococci, its use as an injection in gonorrhea in the male has not led to re- sults commensurate with early expecta- tions. Casper employed it in 12 cases of acute gonorrhea, 20 chronic cases, 4 cases of gonorrheal epididymitis, 2 of post- gonorrheal adenitis, and 2 of soft chancre, administering intraurethral injections of 0.25 to 2.0 per cent, solutions; he did not find it superior to other drugs in general use. Samter confirmed these findings, though Chotzen claimed to have obtained good results. In the cases of soft chancre in Casper's series healing was promoted by the application of alumnol. Asch used a 10 to 20 per cent, solution for cauteriz- ing the lacunse and crypts at the urethral orifice. As a surgical antiseptic, alumnol is used in O.S to 3 per cent, solutions. In the dressing of wounds and in ulcerations, specific or non-specific, Eraud found it to produce no irritation or pain. As a desic- cant powder for wounds this author con- siders it efficacious. In nose and throat practice, alumnol has been found valuable in simple chronic and hypertrophic rhinitis, in ozena, in catarrhal and follicular tonsillitis, and in acute and chronic pharyngitis. It is used cither in a 1 per cent, solution as a douche, in a watery glycerin solution (1:5), to be ap- plied to the affected parts, or as a powder, mixed with starch (10 to 20 per cent.), for insufflation. Stepanicz found that in acute laryngeal affections the roughne-^s of voice generally disappeared after a single in- halation of a 1 per cent, solution. In chronic cases, insufflations of alumnol and starch (2 to 10 per cent.) also gave good results. Metzerott used alumnol with satisfaction not only in laryngitis, pharyn- gitis, tonsillitis, and peritonsillitis, but also in edema, syphilis, and tuberculosis of the larynx. In a case of symptomatic laryn- geal edema, probably of syphilitic causa- tion, with a severe grade of stenosis, the administration of alumnol solutions in the form of injections and the steam spray made it possible to defer tracheotomy for six months. In the case of a singer troubled with subglottic laryngitis, with wave-like fluttering of the vocal cords, an alumnol spray gave early relief; also in one of chorditis nodosa (singer's nodules), strong solutions of the remedy proved beneficial. In otology alumnol has also been em- ployed. In suppurative otitis media Heath noticed, however, that it sometimes caused persistent burning sensations, and that it tended to unite with pus in the exter- nal meatus to form stone-like pellets, — a peculiarity condemning its use in this disorder. In dermatology alumnol has been found serviceable in powder form (12 to 25 per cent.), collodion (5 to 10 per cent.), and ointment (1, 5, and 12^ per cent.). It has proven effective in dermatitis, acute eczema of all sorts, and chronic eczema, but in syphilis and the parasitic skin affections did not yield much benefit. In acne and acne rosacea as good results have been obtained with it as by most other methods of treatment. Chotzen found alumnol effi- cacious in acute and chronic inflammations of the skin and mucous membranes, in- cluding erysipelas, favus, lupus, soft chan- cre, and erosions. Eraud made the state- ment that alumnol appeared to be useful in certain varieties of pruritus, especially of the anus and scrotum. S. 592 AMAUROSIS (HANSELL). AMAUROSIS. -DEFINITION. — Amaurosis, formerly used to desig'- nate partial or complete blindness, has become, since the common em- ployment of the ophthalmoscope, much more limited in its meaning and application. At present, imper- fect vision not due to errors of refraction or visible pathological changes may be classified under '■'amblyopia" ; complete blindness of one or both eyes and usually that form of blindness caused by disease of the nervous apparatus of sight, the retina, optic nerve, and cerebral centers under amaurosis. [Both words should be so used that they refer only to certain kinds of blindness which are to be described by a preceding adjective, and unless thus defined their meaning is vague and uncertain, carrying no suggestion of etiology or pathology. When the media of the eye are transparent, normal or abnor- mal conditions of the fundus are as easily diagnosed by the expert ophthalmologist as are diseases of the skin by the dermatologist ; therefore, except as a convenience or as a substitute for the word blindness, amaurosis might well be omitted from ocular vocabu- lary. Eyes blinded by disease of or trau- matism to the middle or anterior third are seldom described as amaurotic eyes. H. F. Hansell.] Amaurosis in Brain Disease. — Tumors or other organic changes in the brain by which the optic tract is directly compressed or the ventricular fluid is forced into the optic nerve sheaths will produce blindness. The process is a mechanical one. In the former the optic nerve fibers in the tracts are directly compressed and deprived of their function; in the latter, the optic nerve is surrounded by fluid contained within a sac of only moderate distensibilit}^ The gradually induced compression of the nerve induces arterial anemia and venous congestion of the nerve-head and retina, which is soon followed by serous and solid exudation into the distal extremity of the nerve. Finally the optic nerve fibers become atro- phied from stoppage of circulation and pressure of exudation. The loss of vision may commence in the pe- riphery of the field and advance by slow stages toward the center until finally the entire field is wiped out ; or, as may be the case in apoplexy, a section of the field, one-half, one- quarter, or less, or the region about the fixation point and including it, is suddenly lost. Continuation or ex- tension of the brain lesion will be fol- lowed by loss of the entire visual field. Amaurosis in Nephritis.— Disturb- ance of vision may be caused by hemorrhage or edema into the cere- bral centers, by pressure upon the chiasm or tracts, or by the action of the poison of uremia, by which the brain functions are held in abeyance. In the first and second it may affect one or both eyes and be partial or complete. In the third it comes on rapidly, involves both eyes, and dis- appears in a few hours or in a day or two. There are no ophthalmoscopic changes visible in the retinal circula- tion or structural alterations in the nerve or retina. The blindness is strictly cerebral. In the early stages of hemorrhage or edema the eye- g'rounds are normal; later they show the signs of intracranial pressure. In a man who died twelve hours after cerebral hemorrhage and who was unconscious from the time of the at- tack until his death, the ophthalmo- scope showed only moderate dilatation and tortuosity of the veins. These forms of amaurosis are not to be AMAUROSIS (HANSELL). 593 confounded with the amblyopia of albuminuric retinitis, in which the vision is aiTected in several ways; by edema of the nerve-head, edema of the retina, hemorrhage in the foveal region, and patches of degeneration of that area. The diagnosis may be at once established by the Ophthalmo- scope. Amaurosis in Hysteria. — Neuroses, the result of an unknown derange- ment of the nervous system originat- ing within the body or of traumatism, may reduce or altogether destroy temporarily the visual power in one or both eyes, rarely the latter. The traumatism may be ocular or involve any other part of the body. In order to induce blindness or even amblyopia the causative disease or injury must affect an individual of peculiar or sus- ceptible organization and makes manifest a tendency toward magnifi- cation of trifles for the sake of bring- ing into prominence the ego or for the sake of imposition. In traumatic cases the diagnosis between hysteri- cal amaurosis and malingering is not always easy. Both offer no evidence externally or internally in the eye of any mark of injury or disease suffi- cient to account for the symptoms. In hysteria the well-known stigmata may be found — tubular field, transient and recurring ocular parah^ses, re- versal of the color field, well-defined patches of localized anesthesia of the skin, inexplicable and transient pains distributed anywhere and everywhere in the body and created by cleverly directed interrogation. The majority of the subjects are women who are more or less mentally unbalanced by disease of the sexual organs or by physical or mental idleness. The ma- lingerer is usually a man who resorts to the excuse of blindness in order to avoid unpleasant or dangerous duty or -to collect damages from a rich cor- poration. The symptoms of hysterical amaurosis are altogether subjective and of cerebral origin. The eyes cannot be held responsible. Commonly, in the recorded cases, there have been other manifestations of hysteria, but amaurosis may be the sole expression of this disorder. Unilateral hysterical amaurosis occurs rather more rarely than the bilateral form, according to Kron, and offers distinctive different diagnostic problems. But bilateral hysterical amaurosis is almost as rare an affection. The writer describes such a case which presents several interesting features : The sud- den blindness, and later sudden meno- plegia with loss of pain sense, the loss of stereognosis sense in the affected member due apparently to loss of mus- cular and articular sensation, and con- tracted visual fields of the tubular variety. The author reports 2 other cases. Diller (Jour. Amer. Med. Assoc, Apr. 24, 1909). Amaurosis in Spinal Disease. — Primary atrophy of the optic nerves preceding or accompanying disease of the spinal cord and spinal nerves is a common affection. It is "pri- mary" because it is initiated and carried to its finish without inflam- mation of the optic nerve visible to the ophthalmoscope. There is no edema or exudation. The disk mar- gins remain clear cut and well de- lined. The first noticeable change is a loss of the normal pink color on the temporal half of the papilla and a diminution of the size of both the arteries and veins of the retina. Gradually the vascularity becomes less, the nerve becomes paler and finally white, all the fine vessels having become absorbed from the surface. Contemporaneously with the 1-^ 594 AMAUROSIS (HANSELL). atrophic process the vision declines until complete amaurosis results. Early in the disease the field for colors is concentrically contracted or the perception of green is lost, and the retina becomes less sensitive to light or the optic nerve less capable of transmitting feeble stimulation. The affection is binocular, although one eye is usually more affected. Secondary atrophy, that following inflammation of the intraocular end of the optic nerve, presents entirely different ophthalmoscopic appear- ances, and no confusion need arise in the diagnosis between the two affec- tions. The diseases of which primary optic nerve atrophy is a prominent symptom are tabes, disseminated and lateral sclerosis, dementia paralytica, and paralysis agitans. The pupillary and visual disturbances may precede by many years the development of spinal affections, particularly posterior sclerosis, and many of the so-called idiopathic cases really belong to this class. The writer believes this is true also of paralysis agitans. He has at present a patient who seven years ago had incipient atrophy of the optic nerves with shallow excavation and for the past two years has slowly advancing paralysis agitans. Amaurosis following Hemorrhage. — After extensive loss of blood from any cause, but especially from disease of the stomach, intestines, or uterus, blindness affecting both eyes, com- .mencing two or three days after the hemorrhage and advancing rap- idly, may ensue. The ophthalmoscope shows marked ischemia of the retina with low-grade edema of the nerve- head. The blindness may be complete and permanent, terminating in optic nerve atrophy; or, in an individual with good recuperative power or when the loss of blood has been moderate, restoration of sight may be complete. Amaurosis in Pregnancy. — Toward the completion of the term of preg- nancy or during confinement, vision may be entirely suspended in both eyes for some hours or days. The amaurosis is usually associated with convulsions or other signs of puer- pural septicemia. It should be re- garded as a strong indication of intense and general poisoning. The fundus either shows no deviation from the normal or the retinal veins are distended and dark in color, the nerve-head is slightly edematous, and an occasional hemorrhage is found in the retina. After safe delivery, vision rapidly returns and the eyes are restored to their previous condition. Atrophy of the nerve and permanent amaurosis as a result of pregnancy alone have not, as far as the writer knows, been described, yet he has seen cases in which no other cause for the blindness could be assigned. Case of amaurosis gradually develop- ing in the course of pregnancy. The first signs of optic neuritis were noted about the fourth month; both eyes were affected and external causes could be excluded. The optic nerve was atro- phied when the patient was first seen and the indications for interruption of the pregnancy were beyond question. Sight began to improve at once, and within two weeks vision was restored in the right eye. The other eye was first involved, and the nerve was atrophic beyond relief. The woman was a multipara of Zl , with 8 children, and the author deem^ed it necessary to insure future sterility by an operation on the tubes. The case confirms anew the importance of immediate interrup- tion of the pregnancy in case of optic neuritis from this cause. Holzbach (Zentralbl. f. Gynak., May 23, 1908). AMAUROSIS (HANSELL). 595 Case of a woman of 34, with chronic nephritis, who in the fifth month of her seventh pregnancy developed amaurosis with headache and detachment of the retina on both sides. Abortion was in- duced and was followed by retrogres- sion of the detachment of the retina, but the atrophy of the optic nerve proved irreparable. The trephining to relieve the pressure on the brain evi- dently came too late ; the pupil reaction was abolished by the second day after the woman had entered the hospital. The case teaches the importance of emptying the uterus and of prompt measures to reduce the intracranial pressure if vision is not promptly re- stored. Himmelheber (Miinch. med. Woch., Oct. 19, 1909). A form of amaurosis or amblyopia, not accompanied by ophthalmoscopic signs, or, at least, by none adequate to account for the condition, may super- vene during pregnancy, parturition, or the puerperium. Rarely it may assume the form of a hemianopic defect or of a central scotoma in the fields of vision, and still more rarely of hemeralopia (night blindness). It is often associated with such signs and symptoms of toxemia as headache, edema, eclampsia, and scanty urine containing albumin, casts, and blood. It appears to form one of the rarer manifestations of toxemic poisoning. It is not proved to be dependent upon uremia, although it has usually been confused with so-called "uremic amaurosis." Recovery occurs, as a rule, completely within a few hours or days. Sydney Stephenson (Ophthal- moscope, March, 1910). Amaurosis from Fracture of the Skull. — Numerous cases have been recorded of complete blindness of both eyes some months after a trau- matism of the skull. The common lesion is fracture at the apices of the orbits with or without involvement of other bones at the base. Hemorrhage from rupture of a large blood-vessel either anteriorly at the base or in- volving the basal or cortical centers of vision, a frequent complication of fracture of the skull, will destroy vision. In the latter lesion the amauro- sis is more rapid in its onset and temporary. Absorption of the blood is followed by gradual return of vision unless the nerve structures have been destroyed by the insult or by press- ure. Transient blindness from contusion of the skull in a boy o!" 12 who had been run over by an automobile, brain substance protruding from a gash in skull. The boy was unconscious at first and was blind when he roused, the amaurosis being complete with no per- ception of light. Vision then grad- ually returned and by the third day was normal and it has persisted so to date, the other injuries soon healing. C. Hirsch (Deut. med. Woch., August 4, 1910). Congenital and Hereditary Amau- rosis. — Infants born with ocular or cerebral defects, such as buphthalmus, microphthalmus, or other deformities, or "amaurotic family idiocy," by which the essential parts of the eye or brain are wanting or so disturbed that function is absent, are hope- lessly blind. Hereditary optic nerve atrophy, transmitted usually to males through the female line, appears sud- denly between the twentieth and thirty-fifth year as a loss of central vision. The scotoma increases and the periphery of the field becomes contracted until the patient is per- manently and totally amaurotic. Having found in the family history of an inmate of the Missouri School for the Blind the presence of cataract in all the members of the family for at least five generations, the writer after receiv- ing the opinions of 152 oculists con- cludes as follows : 1. All whose life work brings them into relationship with the blind should be aware of the dan- 596 AMBLYOPIA (HANSELL). gers connected with the marriage of a blind person. 2. The blind themselves should be warned of the danger to their children in case of marriage. 3. A distinction must be made between hereditary and non-hereditary forms of blindness. 4. Legal assistance should be invoked to prevent blind people from marrying. 5. This law should apply only to those cases of blindness in which heredity has been proved. With the exception of glaucoma and cataract, these diseases usually mani- fest themselves at or before the marry- ing age. 6. A law compelling every person to have an oculist's certificate before marriage, though idealistic, would be impracticable. 7. The general public should be educated in the dan- gers arising from hereditary blindness. C. Loeb (Annals of Ophthal., Jan., 1909). Howard F. Hansell, Philadelphia. AMBLYOPIA. — DEFINITION. — The word "amblyopia" signifies, without specializing the cause, that the acuity of vision is below the nor- mal. The degree of the loss of vision is not suggested by the word itself, nor has there been any attempt, as far as I am aware, to define its lim- itations. It has been inherited from the preophthalmoscopic times, when the two words amblyopia and amaurosis were commonly used, the former to mean dull vision and the latter, blind- ness. [Today we seldom hear of amaurosis, but we have tenaciously held to amblyopia. Its use is convenient, but unless preceded by a descriptive adjective, such as toxic, hysterical, its meaning is indefinite and vague. The sense in which the word is properly used is to express partial loss of vision due neither to dioptric abnormalities nor to visible or- ganic lesions, or, as expressed by the older writers, "amblyopia without ophthalmoscopic appearances." It is, therefore, not a disease, but a symptom, and is due to many causes. H. F. Hansell.] The varieties of amblyopia are usually classified into organic from toxic and intracranial causes, functional, exanopsia (disuse, non-use, argam- blyopia) ; hysterical, simulated, and from exhaustion. Toxic Amblyopia. — The ingestion of or absorption into the system through the lungs, intestinal tract, or skin, of large quantities of certain substances without adequate elimination, or of small quantities in the case of some susceptible organisms, will produce a loss of vision varying in degree from slight up to total blindness. The com- monest agents are alcohol and tobacco in combination, lead, quinine, methyl alcohol, Jamaica ginger, coffee, mer- cury, phosphorus, chloral, opium, ergot, the salicylates, ptomaines. The sight is affected by these substances in several ways — by altering the constituency of the blood and lessening its nutritive value to the ocular structures ; by excit- ing disease of the retinal nerve-cells leading to degeneration of the cells and of the optic-nerve fibers connecting them with the brain-centers and induc- ing structural changes in the centers for vision. The amblyopia may be acute, as in quinine and methyl alcohol, or chronic, as in tobacco and alcohol poisoning. The symptoms common to the chronic form are : — Loss of T^ision. — The deterioration is gradual and is usually neglected by the patient until the ability to read is diminished or abolished. Examina- tion shows that vision has fallen to one-half or more for distance and near and is not to be improved by glasses. The patient complains of a bluish-gray smoke or mist constantly before the eyes, and of partial night-blindness. He has no pain and rarely phosphenes or AMBLYOPIA (HANSELL). 597 other signs of irritation of the retina or nerve. Central scofofiia, either relative (col- ors only) or absolute. Early in the affection, probably contemporaneous with the beginning of the deterioration of vision, the perception for green in the small region of the field controlled by the fovea centralis is lost. Then follows the perception for red and possibly blue. The scotoma may be confined to these colors. Should the disease advance, the scotoma becomes absolute, the perception of all objects being lost in an area of about 10° from the fixation point. The periph- ery of the field retains its normal dimensions until the onset of optic nerve atrophy, when it undergoes a concentric narrowing. Papilla Changes. — The ophthalmo- scope shows in nearly all instances a whitening of the temporal half of the papilla, with retention of the normal coloring and vascularity of the nasal half. The retina and choroid are un- changed. Even the macula, the point of the fundus which is symptomatically most involved, appears healthy. In about one-third of the cases the optic disk is slightly hyperemic early in the disease and the vessels on the disk are veiled, reflecting the earliest signs of optic neuritis. Acute poisoning from absorption of methyl alcohol, quinine, pure spirits, etc., causes sudden and complete blind- ness, even to the loss of perception of light. The action of the poison may be sudden or cumulative. A man of 35 was exposed by the nature of his occu- pation to the fumes of varnish. Ele absorbed them through the lungs and the skin of the hands and arms. Feel- ing in his usual good health when he went to bed, he was awakened several hours later by some cause unconnected with his eyes and discovered he was totally blind. Examination of his eyes the following day disclosed excessive anemia of the disks. The arteries and veins of the retina were invisible a short distance from the nerve-head. A boy of 19 drank an unknown quantity of "white whisky" (95 per cent, alco- hol). He was blind the next morning and, except for the temporary return of perception of light lasting a few days, remained blind. The ophthalmo- scopic appearances were similar to those in the former case. The promi- nent symptoms of acute toxic amblyopia are illustrated by both cases : Sudden and complete blindness, partial tempo- rary recovery, ischemia followed by atrophy of the optic nerves and retinas, and permanent blindness. Amblyopia from Intracranial Causes. — •.In the preceding paragraph the morbid processes are presumed to be limited to the nervous mechanism of the eye, lying anterior to the chiasm or, if they invade the cerebral tissues, the involvement is secondary and may be considered as a complication. In the intracranial amblyopias the original le- sion is cerebral, the secondary in the optic nerves and retina. Uremia of Bright's disease, of pregnancy, and of scarlet fever is a common cause. The amblyopia is usually binocular, rapid in its course, and leads often to coimplete, but temporary blindness. The prognosis is good. No changes in the eye-grounds commensurate with the degree of loss of vision are to be seen. The retinal veins are dis- tended, dark, and tortuous, and the edges of the disk veiled by edema of the nerve and adjacent retina. The cerebral vessels present a similar condition, namely, reduced supply of 598 Amblyopia (hansell). arterial blood, venous stagnation, and diffused serous exudation into the brain substance. The foreign elements con- tained in the blood doubtless are a con- tributing cause to the disturbed brain functions. With the establishment of free secretion of urine or artificially induced active diaphoresis the poison is eliminated from the blood, the serum absorbed, and the vision and cerebration restored; or, the kidneys refuse to act, the skin cannot be stimulated, and death ensues. Rarer forms of amblyopia due to obscure intracranial lesions are the "crossed" and the "hemianopsias." Mills says (Posey and Spiller) : "As the fibers of the macular bundles are undoubtedly distributed to the pre- geniculatum, complete destruction of this body, or of a special portion of it, would cause -central amblyopia of the crossed variety." In the hemian- opic variety one-half of the macular field is lost and the other half pre- served. Thus one-half of a word or other small object cloise to the eyes is obscured and can be seen only by movement of the ball. In explana- tion Mills further says : "A strictly limited lesion of the calcarine cortex on the one hand and of the angular region on the other may cause blindness in half of the macular field of the cor- responding sides." Hysterical Amblyopia. — The fea- tures characteristic of this affection are partial or complete blindness, monocu- lar or binocular, without discoverable changes in the ocular structures or signs in the eye or elsewhere in the body of organic disease of the brain or nervous system. The loss of vision may arise spontaneously, or appear at the termination of an attack of general hysteria, or be due to a slight trauma- tism to the eye or head. The trau- matism is, as a rule, slight and out of all proportion to the seriousness of the subsequent complaints. Amblyopia may be the only ocular symptom or it may be complicated by ptosis, recession of the near-point, pupillary inequalities, or disturbances in the field of vision. The alteration in the size and form of the field presents three possible fea- tures : concentric contraction, which is not in the least characteristic of hys- teria ; reversal of the normal limits of the color fields, and the tubular field. Traumatic cases recover promptly and wholly after the cause, for instance a suit for damages, is removed. Cases of spontaneous origin and those dependent upon functional derangements of the nervous system are more persistent, often recur, continue weeks and months, and recover only upon the restoration to health of the inclividual. It must not be forgotten that blindness without ophthalmoscopic findings or evidence of disease of the cerebrospinal system may not always be diagnosed as hys- terical, and that it may have an organic cause to become manifest in time. To make the diagnosis positive it should be associated with at least some of the well-known stigmata of hysteria. Simulated Amblyopia. — The differ- ential diagnosis between simulated and hysterical amblyopia is rendered diffi- cult by the similarity of the two affec- tions and because both occur in the same class of patients, the neurotic and those of hypersensitive organizations. Pretended, feigned, or simulated blind- ness is found among recruits for the army and navy services, those who wish to escape positions in which danger or punishment may be incurred, and those who wish to create false impressions and exaggerated estimates of their Amblyopia (hanselL). 599 physical disabilities, especially in law- suits for damages. Simulated am- blyopia of both eyes is rare and detec- tion difficult. Reliance must l)c placed on the action of the pupils and the want of relation between tiie apparently nor- mal eyes antl the symptoms. The mo- nocular form, however, may be, as a rule, easily detected. The ophthalmo- scope shows clear media and healthy eye-grounds ; a strong spherical lens placed before the sound eye will prevent accurate vision in that eye beyond the focal distance of the glass ; a prism of 5°, base down or up, will give vertical diplopia; a prism of 10°, base out, will cause a manifest rotation of the eye inward, unconsciously made to fuse the horizontally induced double images ; a lead pencil placed before the sound eye will not interrupt reading; the pupils respond to light and convergence almost uniformly. The tests will more suc- cessfully deceive the patient into admit- ting visual power in the assumed blind eye if his attention is directed by them to the sound eye. Radiography is also valuable in the diagnosis. An individ- ual may claim that the blind eye con- tains a fragment of glass or other foreign material impervious to the rays. In such cases a shadow is cast on the plate when the claim is true. In trolley accidents it frequently happens that the glass of the doors or windows is shattered and the hysterical or fraud- ulently inclined passenger asserts that he was blinded by the entry and reten- tion in his eye of glass. Examination with the ophthalmoscope cannot inva- riably exclude the presence of the foreign body, particularly when it has lodged in the ciliary region or when the media are clouded. Amblyopia Exanopsia. — From con- genital defects in the ocular structures, such as cataract, polar and lamellar; coloboma of the lens or uveal tract; persistent pupillary membrane; albi- nism. Rays of light are obstructed in their passage through the eye by the opaque media, they are not clearly focused on the retina by reason of irregular refraction, or they fall upon insensitive retinas or those unsupported by choroidal pigment. In these cases it is probable that early in life the retinal centers in the brain are active and do not, either by disease or congenital anomaly, contribute to the blindness. The cataracts may be removed and vision restored when the operations are performed at an early age. Later, when the brain-centers have been trained and the habits of special sense perception have been formed, operations, although surgically successful, do not materi- ally improve vision. From Defects of Refraction. — In grades of hyperopia from 2 D. to 5 D. in childhood, binocular vision may early become unattainable. The child uncon- sciously, in order to obtain good vision, makes extraordinary claims on the ac- commodation. But the ciliary muscle (accommodation) is supplied by nerve power by the third or motor oculi nerve, which also supplies the muscles of convergence. Therefore, excessive stimulation of accommodation or that surpassing the normal relation between accommodation and convergence com- pels a proportionately equal degree of convergence. Since both eyes can- not converge simultaneously in dis- tant vision, one eye assumes the abnormal convergence and the other eye is used for fixatiion. Both eyes retain their normal power of rotation, but each becomes in a sense inde- pendent of the other : the one is used for seeing; the other squints. The 600 AMENORRHEA (MONTGOMERY). former has been the better eye from the beginning, either by reason of less error of refraction or more per- ceptive retina. The latter gradually becomes amblyopic from disuse. The retina loses its sensibility, the optic nerve its conductility, and the cerebral centers their function. In some chil- dren no reason can be assigned for preference of one eye. The error of refraction may be no greater and the rotatory power no less in the squinting than in the fixing eye. Here we must assume that the fault lies in the retina, nerve, or brain. Improvement of vision may be obtained by the forced use of the eye and the compulsory activity of the cerebral center, but vision equal to that of the non-squinting eye is seldom or never acquired unless the usefulness of that eye is destroyed by accident or disease. Habit and the cultivation of the visual apparatus that accrues from habit can not be ignored. Should, however, the treatment for defective vision be instituted very early, before anesthesia of the nervous apparatus of the squinting eye has developed, an appreciable benefit may be gained by the use of the amblyoscope, closure of the fixing eye by bandage, or atro- pinization of that eye. Amblyopia from Exhaustion.. — Am- blyopia in consequence of excessive indulgence in coitus or masturbation has been recorded. It is a purely nervous affection. Upon removal of the cause and the administration of strychnine the cure is generally rapid and complete. Sudden loss of blood in large quantities, occurring sometimes in intestinal ulceration, after delivery of the child in confinement, rupture of blood-vessels by ulceration or accident, may be followed in a few hours by temporary loss of vision. The ambly- opia becomes permanent only in cases of degeneration of the ganglion cells of the retina or of the fibers of the optic nerve. Howard F. Hansell, Philadelphia. AMENORRHEA. — D E F I N I - TION. — Absence of the menstrual flow in women of a suitable age who are not pregnant. Suppression of menses, the menstruation having ceased through some local or remote disorder, is also termed amenorrhea. VARIETIES. — Amenorrhea may be complete, when the menstruations will have completely ceased; comparative, when it appears occasionally; primary, when the menstruation has not pre- sented itself at the age of puberty nor subsequently; secondary, when transi- tory or accidental, or, having already appeared, the menstruation ceases. SYMPTOMS.— No other symptom than absence of the menstruation may be present, or the monthly flow may be absent and the general attendant phenomena usually preceding men- struation occur. Frequently the pa- tient complains of headache, heat- flashes, fever, nausea and vomiting, and heaviness in the abdomen. Con- comitant nervous disorders may form the basis of acute manifestations, hysterical especially. When the amenorrhea is due to obstruction, v/hether congenital or acquired, the patient does not experience severe pain, but rather a continuous dull aching in the pelvis and over the sacrum, aggravated at the periods when the menstruation should occur by .the symptoms above mentioned, known as menstrual molimina. Pure suppression of the menstrua- tion rarely causes symptoms, espe- AMENORRHEA (MONTGOMERY). 601 cially when the impcndinsa: general disorder is I'he cause of the amenor- rhea. Case of complete amenorrhea in a Greek woman of abot 40 years with no evidence of defects of any kind, and with good average intelligence, who complained of minor nervous troubles which accompany menopause. The woman never had menstruated ; she had given birth to 11 children, 5 of whom were living at time of examination ; the grandmother of the patient had never menstruated; "the mother of the patient had menstruated only once in every 6ne or two j-ears. Of the patient's children, 1, a girl of 14 years, had not yet menstruated. The patient herself was married at the age of 15 and gave birth to her last child four years ago. Patient further said she had never had symptoms of a menstrual molimen of any sort whatever, no knowledge of when her menstrual time might be due, no malaise, no pain, nothing, in fact, saying that she simply lived like a man and didn't know what it was to be sick. A. R. Hoover and J. K. Marden (Surg., Gynec. and Obstet, March, 1911). The menstrual flow may be sub- stituted by a profuse leucorrhea which is thick, viscid, and of a yellow or greenish-yellow color. Remote symp- toms may present themselves, doubtless of reflex origin. ETIOLOGY.— The discussion of the causes of amenorrhea is rendered difficult by our want of knowledge of the forces which produce the periodi- cal recurrence of menstruation. Pri- mary amenorrhea is generally due to imperfect or insufficient develop- ment. In cold countries the individ- ual matures more gradually and the menstrual flow appears later than in warm countries, where development is rapid, but where, also, w^omen enter stages of decrepitude at an earlier date. Anatomical imperfections and anomalies, the absence of any of the genital organs, or a rudimentary or infantile uterus may thus account for the total absence of menstruation. Imperforate hymen is a frequent, though easily recognized, cause. Whether we ascribe the periodi- cal occurrence of menstruation to nervous irritation, to the influence on the mucous membrane of the uterus of a superabundance of lime salts in the blood or to the chemical influence through the blood of a secretion of the corpus luteum, the causes of amenorrhea can be divided into four classes : — Nervous Disorders. — Grief, anxiety, fright, and anger are as many possible primary causes, especially if the patients are poorly fed. According to Bloom, probably not less than 33 per cent, of women emigrants under 30 years of age suft'er from suppressed menstruation after a sea-voyage. Many have abdominal distention, and not in- frequently girls have been innocently charged with being pregnant. Obsti- nate constipation is a common symptom. The true etiology is largely psychical and neurotic. Series of cases which present certain well-defined clinical features. These prominent characteristics are: (1) di- minished or arrested menstruation; (2) local symmetrical imperfect oxygena- tion of the blood of the extremities, especially the arms and hands — a con- dition known as "Raynaud's phenom- ena," and (3) pulmonary tuberculosis. The presence of any single one of these symptoms in patients is observed every day, but attention has not hitherto been called to the remarkable association of all of these clinical features in the same individual. This trilogy of symptoms did not always appear contemporane- . ously in any of the patients who were affected. In all of them, when first seen, the local asphyxia and the irregularity of menstruation were marked; in two 602 AMENORRHEA (MONTGOMERY). of the patients pulmonary tuberculosis was also coexistent with the other clin- ical features mentioned, while in two other patients it developed at a subse- quent period. J. W. Byers (Lancet, Aug. 26, 1899). Case of a young married woman who found that, as soon as she left London and went to the country, her menstrua- tion would return at the regular times, but would not if she remained in town. By leaving town for two days each month it was possible for her to regu- late the monthly function. W. J. H. Hepworth (Lancet, Nov. 10, 1900). The causes of primary amenorrhea at puberty not due to congenital atresia may be distinguished into three varie- ties, viz. : 1. Cases without discover- able cause, in which the genital organs are apparently perfectly normal. 2. Those due to some congenital defect. 3. Amenorrhea accompanying some gen- eral disease, as diabetes or tuberculosis. In the first, local or general treatment may cause appearance of the menses, the prognosis in the other two varieties being unfavorable. The writer cites a case in which menstruation occurred after grafting of a healthy ovary from another subject in the uterine wall. V. le Larier (Paris Thesis; Zentralbl. f. Gynak., Nu. 35, 1905). Women who either greatly fear or greatly desire to become pregnant, newly married women, and women who are confined in prisons or insane- asylums furnish a large proportion of the cases. Removal from country to city or vice versa, especially when coupled with nostalgia, is a prolific cause. On general principles, change in the mode of living or of climate, especially with an intervening sea- voyage, appears to frequently act as the etiological factor. Amenorrhea may be an early symp- tom of brain tumor and in acromegaly may precede -- every other symptom by several months and be followed by optic atrophy. General Affections. — Amenorrhea frequently occurs after d, serious ill- ness, such as typhoid fever, eruptive fevers, mumps, pneumonia, or during the course of any chronic disease, diabetes, cancer, malaria, at the onset of severe syphilis. Intoxication of the system, as in morphinism, alco- holism, and hydrargyrism, is also a recognized cause. Syphilis is also thought capable of causing amenor- rhea. Eighteen cases in which the morphine habit caused amenorrhea. It is usually complete and accompanied by loss of sexual desire, but the functions are re-established if the habit be broken. Lutaud (Revue gen. de clin. et de then, May 2, 1889). Three cases, aged from 28 to 42, in which amenorrhea persisting from six to eight years was probably due to syphilis. They all exhibited character- istic symptoms of tertiary syphilis, and were subjected to a rigid mercury and iodide treatment which resulted in the return of the menstrual flow. Meirow- sky and Frankenstein (Deut. med. Woch., Aug. 4, 1910). It may be consequent upon an acute or chronic surgical affection, a blow, or injury. Luxurious living and want of exercise, obesity, and excessive in- tellectual labor at the period of puberty, when not counterbalanced by fresh air and active exercise, may retard the development of the genera- tive organs and thus induce the disorder. Blood Disorders and Wasting Dis- eases. — Anemia and idiopathic chlo- rosis, pernicious anemia, leukemia, and Hodgkin's disease are the most prominent factors. The following causes of waste— and directly, there- fore, of amenorrhea — are also to be remembered : Hemorrhage, albumi- nous discharges ; hemorrhage from AMENORRHEA (MONTGOMERY). 603 piles, scurvy, purpura, and injury, as in hemophilia ; hemorrhage from the stomach, as in gastric ulcer; from the lungs, or from the nose, and from a rare disease produced by a parasite in the duodenum: the Aiikylostoma ditodotalc. Long-continued suppura- tion, albuminuria, chronic diarrhea, malignant ulcers, tubercular disease, all impoverish the blood, and so may cause anemia. All diseases that cause wasting of the body finally cause the menstruation to cease. Chief among these are phthisis, dia- betes, caries of bone, protracted or febrile illness ; anorexia nervosa, the patient wasting because she will not eat; and gastric ulcer. The occurrence of menstruation is associated with increased vascular ten- sion ; hence, any condition which de- creases tension will favor amenorrhea. Lesion of Genitourinary Organs. — Amenorrhea may be associated with any lesion of the genital tract, though less likely to occur in inflammatory conditions. Adhesions from pelvic peritonitis are an occasional cause of hyperinvolutions of the uterus and amenorrhea as a symptom. In those cases where the follicular stroma of the ovary has been the seat of an inflammatory process during the infectious fevers, the patient may have an amenorrhea which may remain and become permanent. Alexander Simp- son (Practitioner, Aug., 1898). Atrophy of the ovaries, senile atro- phy following pregnancy, and cystic ovarian degeneration are among the less common etiological factors. A most complete examination of the pelvic organs, under ether, if necessary, should be made in such cases. If menstruation does not appear at the age of puberty, a careful scrutiny on the part of the physician is obliga- tory and imperative. Case of a young woman, 24 years of age, in whom the amenorrhea was of organic origin. A dermoid and a suppurating multilocular cyst were found and removed. Report of the pathologist harmonizes with the theory of the case, both from physio- logical and pathological standpoints : 1. That the dermoid had usurped the place and destroyed the function of the right ovary. 2. In one of the cyst-walls of the multilocular ovarian cyst was found a shrunken ovary the size of a large lima bean, and within this ovarian stroma was found a corpus luteum spurium. To the presence of this ovarian stroma was due the womanly development, with ovulation and the futile effort of menstruation and its consequent suffering. 3. The case dem- onstrates the possibility of ovulation without menstruation. 4. It leaves doubt whether the absence of the ovi- ducts was primary or secondary to the grave disease of the ovaries, with the possibility that they were congenitally absent. ■ S. It presents the rare and ex- ceptional condition of a perfectly de- veloped woman who had an ovary and a uterus, who ovulated, was sterile, and never menstruated, and yet was ruined in health by nature's effort to establish an impossible normal function. W. B. Chase (Amer. Jour, of Obstet. and Dis. Women and Children, Oct., 1898). Exposure to cold during menstrua- tion, by inducing congestion of the pelvic organs, is one of the most active exciting causes, especially when supplemented by a local chronic disorder. The most important condi- tion with which this disorder might be confounded is pregnancy. Case of a healthy girl, aged IS, who had been subject for a year to gradual swelling of the abdomen. The period had ceased for two months only. The breasts became hard and tense. The hymen was intact. Peritonitis of tuber- . culous origin suspected. On opening the abdomen an enormous cyst, which contained twenty pints of fluid, discov- ered. Its pedicle was twisted and had 604 AMENORRHEA (MONTGOMERY). risen in the parovarium. On the day after the operation the catamenia re- appeared and the abdomen soon re- sumed its normal form. Cortiquera (Anales de Obst., Gine., y Fed., Jan., 1896). Case of a young woman who pre- sented many of the usual signs of pregnancy, including cessation of the • menses, prominence of the abdomen, etc. On examination deposits of adi- pose tissue were found in the abdominal walls, while the uterus was small — smaller, indeed, than usual. Subsequent events proved it to be a case in which obesity had led to disturbance, if not, indeed, early appearance, of the men- strual function. Robert A. Reid (Mass. Med. Jour., Aug., 1898). Case of two girls, 19 and 21 years old, in whom a dense circular band high up in the uterine cavity seemed to obstruct completely the escape of the menstrual fluid. No definite diag- nostic features suggested the presence of this unusual condition. In both cases it was accidentally discovered when through a vaginal incision the anterior uterine wall was split longi- tudinally and the uterine cavity laid . open. In hoth cases the operation was followed by menstrual discharge. Rieck (Miinch. med. Woch., March 16, 1909). PATHOLOGY. — A pathological identity can hardly be attributed to amenorrhea, owing to its complex causes, the diverse physiological con- ditions peculiar to the cases, and the diathetic conditions that may be present. The fact that the true nature of menstruation itself is un- known adds another objection, and it may safely be said that the pa- thology of amenorrhea is that of the diseases causing it, until the local disorders brought about by each will have been determined. DIAGNOSIS. — Primary amenor- rhea — that is, total absence of men- struation — is usually due, as already stated, to the absence of one or more of the organs of generation. It must be distinguished from retention of the menses due to atresia of the cervical canal, of the vagina, or of the vulva. In the latter case no menstruation has existed, but the general premonitory symptoms of menstruation have oc- curred, though followed by no men- strual flow. Cases in which one or more of the organs are absent are not very infrequent, while cases of im- perforate hymen are comparatively common. PROGNOSIS.— Amenorrhea due to absence of any of the organs is, of course, incurable. The same may be said where the approach of the meno- pause or other conditions point to pre- mature senility of the uterus, which involves the inhibition of the menstrual period. Although amenorrhea, when due to a serious chronic disease, is usually cured with difficulty, hope may always be entertained when the causa- tive disorder is not in itself a fatal one. Return of the menstruation in any chronic disorder, when the blood presents its normal appearance, is an encouraging sign. TREATMEN T.— No woman should be treated for amenorrhea until the possibility of its being caused by pregnancy has been elimi- nated, if necessary by a careful physical examination. Not infrequently will pregnant women desirous of escaping the responsibilities of maternity seek a consultation with the hope that some drug shall be administered or instru- ment inserted which will terminate the condition. Amenorrhea should always arouse concern ; it may be the first symptom of acromegaly, to which it stands in about the same relation as ordinary goiter does to exophthalmic goiter, the hypophysis cerebri being so often in- AMENORRHEA (MONTGOMERY). 605 Volvctl. Tlie amcnorrhcic should take special pains to avoid chilling, espe- cially of the feet, and every catarrhal affection should be treated with great care. Three such patients in the \vritcr's practice had previous sinusitis, commencing in 1 case at the time the menses became irregular. Special care should also be paid to treatment of syphilis in this connection ; it may be injuring the hypophysis even when there are no apparent manifestations elsewhere. His experience further in- dicat-es that a pregnancy is liable to aggravate disease of the pituitary body. He discusses the points in which mor- bid amenorrhea resembles and differs from natural amenorrhea in pregnancy and after the menopause. Acromegaly is the form of amenorrhea in which there is sugar in the blood in almost half of the cases, and there is hyper- trophy of the bones of the face. Rosen- berger (Zentralbl. f. innere Med., Feb. 25, 1911). It should be kept in mind that amenorrhea is a symptom, and its cause be diHgently sought as a preHmi- nary measure to treatment. Drugs which are considered to exert an in- fluence in promoting the menstrual flow are known as emmenagogues, and are divided into two classes, medicinal and physiological. Severe physical shock or fright sometimes causes the menstruation to return suddenly. When the arrest of menstruation is due to exposure to cold, warm baths and vaginal injections, sinapisms to the thighs and calves of the legs, saline laxative and manganese-bin- oxide pills (2 grains each), 1 or 2 after each meal, are frequently suc- cessful. This drug acts by increasing the vascularity of the pelvic organs. The permanganate of potassium, or the lactate, in 1 -grain doses three or four times daily, after meals, act in the same manner. Potassium permanganate may be given daily until the catamenia appear and . complete their course, when the salt should be discontinued ; it should be recommended four days before the access of the next period, and continued until the flow ceases. It is useful in girls who, on leaving the country and coming to town, suffer from arrested menstruation ; also in the amenorrhea induced by seasickness and in the case of women, between 30 and 40, generally married, who while rapidly increasing in weight suffer from a diminished menstruation. Potassium permanganate is given up to 1, 2, or more grains in pill form thrice daily, after meals. The pills should be made after the following formula : Potassium permanganate, gr. j ; kaolin and petroleum cerate, in equal parts, q. s. Certain observers deny that the permanganate produces abortion, but some cases of abortion ap- parently due to the drug have been observed. (Practitioner, Feb., 1911). In the amenorrhea following sea- voyages the preparations of manganese and oxalic acid hold the first place. When the manganese preparations fail, santonin, 10-grain doses at bed- time, is especially valuable in chlo- rotic subjects. The general system should be in- vigorated by attention to diet, sleep, and clothing. Out-of-door life, light exercise, and sunlight are most im- portant. This is especially the case when there is rapidly increasing obesity. In the latter case the diet should be regulated, saline laxatives adminis- tered, or a cure at Marienbad recom- mended. The administration of thyroid extract is especially effective in pre- mature menopause from obesity, and should be associated with active exer- cise. Stimulation of the ovaries and uterus by the faradic current is espe- cially efficient in such cases. Cupping or scarifying the cervix is sometimes successful. These means 606 AMMONIA (SAJOUS). increase the pelvic congestion and tend to counteract uterine or ovarian torpidity. Rudimentary organs or atrophy of the uterus, if not too great, should be treated by dilatation of the uterus with tents and stimulated by the faradic current. The introduction of a stem pessary which is to be worn for a number of months not infre- quently increases the growth of a rudimentary organ and establishes the function of menstruation. Exer- cise and nourishing food should also be given. Sea-bathing is of assistance in such cases. The stem pessary yielded excellent results in the writer's hands in the treatment of the following special types of primary and secondary amenor- rhea : 1. In the small, narrow infan- tile uterus in otherwise well-developed girls. 2. In a class of cases in which menstruation has been regular and nor- mal for years, but at the age of 30 or 35 becomes scanty and skips, and is painful in unmarried women who take little exercise, but work hard mentally. The uterus undergoes premature at- rophy and is found small. 3. In women who live high, have good digestion, and become fleshy, the menstruation becomes scant and sometimes disap- pears entirely. J. H. Carstens (Jour. Amer. Med. Assoc, Nov. 20, 1909). The rheumatic diathesis occasion- ally plays a part as an etiological factor. In such cases the ammoniated tincture of guaiac, 1 dram in milk three times a day, or the tincture of colchicum root, 10 drops every three hours until the bowels become free, will sometimes restore arrested men- struation. The salicylate of sodium is also valuable in this connection. Apiol, 4 grains daily in 1-grain pills, for fifteen days, has given good results. Fuchsin has been highly rec- ommended as an effective drug in re- establishing the menstrual flow. Two cases in which amenorrhea was due to pressure upon the uterus, in 1 case by a cyst, in the other by a hema- tosalpinx. Removal of these obstruc- tions was followed by regular men- struation. Rieck (Miinch. med. Woch., March 16, 1909). Electricity is of great value, fara- dism, static electricity, galvanism, and galvanic intra-uterine pessaries being applicable according to the nature of the case. Extract of cows' ovaries has been used with success, but further trials with this agent are required to estab- lish its actual value (see Animal Ex- tracts: Ovarian Organotherapy). E. E. Montgomery, Philadelphia. AMIDOAGETPHENETIDIN HYDROCHLORIDE. See Pheno- coLL Hydrochloride. AMINOFORM. See Hexame- thylenamine. AMMONIA. —Ammonia, chemi- cally NH3, is made in large quantities from coal gas by heating the ammo- niacal liquor with calcium hydroxide, thus conducting the gas formed through tubes containing charcoal. It may be conveniently obtained in smaller amount by heating an ammonium salt, such as ammonium chloride, with dry caustic soda (sodium hydroxide) or slaked lime (calcium hydroxide). It can be formed by the direct union of nitrogen and hy- drogen under the electric sparky and is widely produced in nature through the putrefaction of albuminous substances. PROPERTIES.— Ammonia is a transparent, colorless gas, having an ex- tremely pungent odor and acrid taste. It is strongly, alkaline in reaction, and AMMONIA (SAJOUS). 607 dissolves very readily (to the extent of 700 volumes) in water, forming a strong solution designated as ammonium hy- droxide (sp. gr., 0.807 at 25° C, U. S. P.). PREPARATIONS AND DOSE.— The preparations of ammonia included in the U. S. Pharmacopoeia are as fol- lows : — Aqua ammonicc (ammonia water, hartshorn), containing 10 per cent, by weight of ammonia gas; dose, 10 to 30 minims (0.6 to 2.0 c.c). Aqua ammonia: fortior (stronger am- monia water), containing 28 per cent, by weight of ammonia gas ; used chiefly externally as a vesicant. Spiritus ammonicc (spirit of ammo- nia), an alcoholic solution, containing 10 per cent, of ammonia ; dose, 10 to 30 minims (0.6 to 2.0 c.c). Spiritus ammoiiirc aromaticus (aro- matic spirit of ammonia), composed of ammonium carbonate, 34 parts by v/eight; ammonia water, 90 parts by volume; oil of lemon, 10 parts; oils of lavender flowers and of nutmeg, of each, 1 part ; alcohol, 700 parts ; water, enough to make 1000 parts. A nearly colorless liquid when fresh, but gradually becom- ing darker; dose, 30 to 60 minims (2.0 to 4.0 c.c). Linimciiturn ammonice (ammonia lini- ment), composed of ammonia water, 350 parts by volume ; alcohol, 50 parts ; cottonseed oil, 570 parts ; oleic acid, 30 parts. Should be freshly prepared when wanted. The following non-official prepara- tions have also occasionally been used : — Fetid spirit of ammonia, composed of asafetida, 1 part; spirit of ammonia, 21 parts; dose, 30 minims (2.0 c.c). Camphorated ammonia liniment, com- posed of ammonia water, 30 parts ; cam- phor liniment, 70 parts. Ointment of ammonia, composed of ammonia water, 17 parts; lard, 32 parts; oil of sweet almonds, 2 parts. MODES OF ADMINISTRA- TION.— Ammonia is' miscible in all proportions with water and alcohol. The most agreeable preparation for in- ternal use is the aromatic spirit, which should always be given well diluted with water. As a stimulating inhalation, the gas arising from ammonium carbonate (the ordinary "smelling salts") is fre- quently employed; but this may readily be replaced by the simple ammonia wa- ter, or, if additional care is used, by the stronger ammonia water. The spirit and the water of ammonia have also been administered hypodermically, or even intravenously, as stimulants, though their action is but fleeting, and consid- erable local irritation may arise. In pneumonia and other dyspneic states a little ammonia water dropped into boil- ing water" at frequent intervals will "soften" the atmosphere and greatly facilitate breathing. Externally, the stronger ammonia water may be applied in full strength as a vesicant, and the area under treatment should be covered with a watch-glass to prevent evaporation. For counterirritant efTfects,a 10 percent, aqueous preparation, such as the weaker ammonia water, or a stronger oily prep- aration, such as the official ammonia liniment, is suitable. In children with delicate skins these preparations should be further diluted. In spasmodic croup a little ammonia added to water and ap- plied to the child's neck and chest by means of a cloth will often bring con- siderable relief, though much care is re- quired to have the fluid sufficiently di- lute and not to leave it on too long. The evanescence of the effects of ammonia resulting from its volatility requires 608 AMMONIA (SAJOUS). that its administration be frequently re- peated. INCOMPATIBLES.— Mineral or vegetable acids and acid salts, which ammonia neutralizes with the formation of neutral salts; salts of the alkaloids, which ammonia may cause to be precip- itated by combining with the acid radi- cal (thereby setting free the more or less insoluble pure alkaloid) ; chlorine, bromine, and iodine, with which ammo- nia combines to form corresponding salts ; mercurial and most other metallic salts, with which ammonia forms in- soluble mixed salts or hydroxides. CONTRAINDICATIONS.— In acute inflammations of the stomach and in cases where the urine is abnormally acid the internal use of ammonia is to be avoided. In small children and in persons with a sensitive respiratory tract, the inhalation of ammonia fumes is likewise apt to be prejudicial, large amounts giving rise to a bronchitis. PHYSIOLOGICAL ACTION.— Local Effects. — Solutions of ammonia strongly irritate any tissues with which they may be brought in contact. Ap- plied to the skin, they act as rubefa- cients or vesicants, according to the con- centration of the preparation used and the length of time it is left on the tis- sues. On the mucous membranes, es- pecially the conjunctivae, the buccal and the respiratory mucosae, ammonia vapor acts primarily as a stimulant, exciting the local nerve-terminals, causing in- creased flow of glandular secretions, and, when concentrated, spasm of the glottis; when kept in contact for a longer time, ammonia preparations cause inflammatory changes which may result in local death of the tissues, fol- lowed by sloughing. The caustic action of ammonia is due, as is the case with oth/^r alkali^ .a c/^^kinati&a w'^h the tissue albumins, resulting in the forma- tion of alkali albuminates, and with the fats to form soaps. The great penetrat- ing power of ammonia, due to its vola- tility, renders it, when concentrated, one of the most deeply acting of corros- ives. Effects on Internal Use. — Nervous System. — After being absorbed into the circulation, ammonia stimulates, for a short period, the medulla oblongata and the motor side of the spinal cord. The higher brain-centers are, if anything, shghtly depressed. The spinal stimula- tion results in an exaggeration of re- flex activity and, with excessive doses, in convulsions. Succeeding the stage of stimulation, a secondary stage of de- pression of the medullary centers and spinal cord may occur with large doses. Circulation. — Ammonia stimulates the heart muscle, the vasomotor center in the medulla, and, to a less extent, the inhibitory (vagus) center, likewise in the medulla. These effects result mainly in a pronounced rise of the general blood-pressure. The heart beats more strongly, but its rate is frequently slowed. Excessive doses may lead to a secondary depression of both the heart and vasomotor mechanism. Respiration. — The respiratory centers in the medulla are strongly stimulated by ammonia. Both rate and depth of breathing are increased through its ac- tion. Secretions. — ^Ammonia and the am- monium compounds stimulate the flow of body secretions, especially the sweat, saliva, and mucous secretions. The dia- phoretic effect is believed to be wholly central, i.e., due exclusively to excita- tion of the sweat-center in the medulla. The other secretory effects are ascribed both to a central action and to a local ^£ect on the gland-cells. AMMONIA (SAJOUS). 609 Digestive Tract. — Moderate doses of ammonia stimulate, like other alkalies, the gastric glands if taken before meals. After meals they neutralize the acids of the gastric juice. Large amounts of ammonia exert a corrosive action on the mucosae (r. Ammonia Poisoning). Absorption and Elimination. — Con- cerning the manner in which ammonia exerts its stimulating effect, there are still differences of opinion. Some claim that, after being rapidly absorbed, am- monia, circulating with the blood, stim- ulates the vital centers directly; others believe that the centers are stimulated mainly reflexly, as a result of the local irritation produced in the stomach. The researches of Magnus showed ammonia to be neither absorbed nor ex- creted by the lungs. Hence, in so far as its administration by inhalation is con- cerned, the stimulating effects of am- monia would appear to be due largely to peripheral sensory stimulation. When taken internally^ on the other hand, ammonia is readily absorbed; but on reaching the blood-stream it rapidly undergoes a chemical change whereby it is converted into the relatively inert substance urea. Whatever direct stim- ulating action it may exert on the nerve- centers and heart is, therefore, quickly brought to an end. By the conversion into urea, the am- monium in ammonium hydroxide loses the characteristics of an alkali metal. For this reason ammonia does not in- crease the alkalinity of the body fluids, differing thus from the hydroxides of sodium and potassium, which cannot undergo the change referred to. The urea produced from the ammo- nia is naturally eliminated largely with the urine, which may be somewhat in- creased in amount owing to stimulation of the renal cells by the excess of urea. TOXICOLOGY.— The ingestion of strong solutions of ammonia results in corrosion or violent inflammation of the mucous membranes of the mouth, esophagus, and stomach, and in marked irritation of the larynx and trachea, owing to the penetration of ammonia vapor into the respiratory passages. The symptoms consist of violent pain in the mouth, throat, and abdomen ; sali- vation ; vomiting, sometimes bloody, and, occasionally, purging. The intense irritation of the respiratory mucous membranes may cause, at first, a mo- mentary arrest of breathing and de- pressed heart action, as well as spas- modic contraction of the laryngeal and bronchial muscles. Later, the persist- ing laryngeal irritation causes intense local burning and a characteristic diffi- culty of respiration, due to actual edem- atous swelling of the glottis. Sudden death by asphyxia may result, though more frequently it is due to shock aris- ing from the pronounced local destruct- ive effects of the alkali, or to collapse, possibly owing to a secondary depress- ive effect of the drug on the heart and medullary centers. Convulsions, how- ever, are comparatively infrequent in ammonia poisoning, and this fact would tend to indicate that in the majority of cases the amount of ammonia absorbed is insufficient to cause violent direct ef- fects on the nerve-centers. The ultimate results in cases of am- monia poisoning can seldom be pre- dicted with certainty. Not only may laryngeal or bronchial inflammation fol- low, but the gastric mucosa may be so greatly injured as permanently to im- pair the functions of the stomach, and even cause death from inanition. More- over, in cases that recover from the acute effects, stricture of the esophagus is a frequent sequela. As with other 1—39 610 AMMONIA (SAJOUS). caustics, the upper and lower extremi- ties of the gullet and the point at which it crosses the left bronchus are the fa- vorite seats of corrosion. Large doses of ammonia (providing a sufficient amount is absorbed) are said to diminish the oxygen-absorbing power of the red blood-corpuscles and to inter- fere with coagulation. Treatment of Ammonia Poisoning. — The chief ends to be sought in the treatment of the first stage of the poison- ing are neutralization, dilution, and re- moval of the obnoxious agent. Vine- gar, lemon juice, or any other avail- able acid (preferably a vegetable acid), well diluted, should be given, together with a large amount of water. Where no acid is at hand, an oil, such as olive oil or linseed oil, forms the best substitute. The stom- ach-pump may then be cautiously used, though, if sufficient time for marked corrosion of the tissues has al- ready elapsed, its passage is attended with some danger, owing to the liability of the weakened tissues to perforation. Morphine should be given if the pain is severe, and tracheotomy may be required if asphyxia threatens. If symptoms of shock or secondary collapse appear, the usual measures for combating these states — hypodermic injections of ether, digitalis, atropine, strychnine; hot, strong coffee by the rectum ; external heat, artificial respi- ration, etc. — should be availed of. Demulcents, such as olive oil, starch paste, tragacanth mucilage, milk, white of egg, or an infusion of elm bark, should be freely administered to soothe the inflamed mucous mem- branes. No food is to be given by the mouth for twoi days after the accident. Strictures of the esophagus should be treated by dilatation with bougies {v. Esophagus, Stricture of). APPLIED THERAPEUTICS OF AMMONIA.— As a Stimulant.— Am- monia is of great value as a rapidly acting "diffusible" stimulant, exerting a marked beneficial effect in all forms of acute circulatory, respiratory, and nervous depression. It may be admin- istered either by the mouth, by inhala- tion, or by hypodermic or intravenous injection. For internal use, the aro- matic spirit of ammonia, always well diluted, in doses of 15 minims to 1 dram (1 to 4 c.c), is the best prep- aration. For inhalation, ordinary am- monia water, or "smelling salts," may be used. The effect of ammonia, when it is taken internally, is believed by some to be chiefly reflex, varying in intensity with the degree of local irrita- tion produced. A similar mode of ac- tion is known to obtain when ammonia is inhaled; none of it is absorbed through the lungs, and the effect is cor- respondingly fugacious. The true stim- ulating effect of ammonia is best ob- tained by intravenous injection, though the hypodermic method is oftener em- ployed. In asphyxia, whatever be its origin, ammonia is a valuable agent. It may, wath advantage, be given at once inter- nally and by inhalation. During the latter procedure care should be taken not to spill any of the strong liquid into the patient's mouth or nose, — an acci- dent which is likely to occur when the patient is recumbent, and which is apt to yield a more pronounced effect, how- ever, than its ingestion. In cases of sudden heart-failure or collapse, as may result from the pres- ence of bacterial toxins or poisoning by depressant drugs, such as hydro- cyanic acid, chloroformj chloral hy- AMMONIA (SAJOUS). 611 drate, aconite, etc., repeated ingestion of 15 minims to 1 dram of the aro- matic spirit of ammonia, diluted with half a tumblerful of water, or the in- travenous injection of like amounts of ammonia water, diluted with 6 drams of sterile water, will usually exert a powerful stimulating action. Ammo- nia may likewise be used internally to combat the effects of bites of poison- ous animals. In ordinary "fainting" and the lighter forms of shock, the inhalation of ammonia from its solution or from smelling salts may suffice to bring about the desired result. In infants, collapse occurring in summer diarrhea may be combated with occasional doses of a few drops of am- monia, well diluted. For the algid stage of cholera, am- monia internally and ether hypoder- mically, with simultaneous free admin- istration of alcohol, have been highly recommended by Giacich. Marked im- provement in the general condition was noted within two hours after the insti- tution of this mode of treatment, and over 50 per cent, of cases already in the algid stage are said to have recov- ered. In acute alcoholic intoxication, the ammonia preparations are consider- ably used. Lavage of the stomach, followed b}^ the administration of 10 drops of ammonia water in a half-tum- blerful of water, will often counteract promptly the effects of the alcohol. Ammonia has also been used with benefit in the treatment of delirium tremens (Butler). As an Antacid. — Internally, am- monia may be used to counteract gastric hyperacidity, indicated by such symptoms as acid eructations ("heartburn") and flatulence. Par- ticularly where there are pronounced abnormal fermentative processes, re- sulting in the formation of vegetable acids, does ammonia appear to be effi- cient. A few drops (3 to 5) of the water of ammonia, or 10 drops of the aromatic spirit, well diluted, will often give relief under these circumstances. It should be remembered that, al- though the ammonia introduced will tend to neutralize any acids present, the local irritation produced by it will, in addition, tend to stimulate the gas- tric glands and musculature. Hence the special degree of benefit obtained where there is flatulence and in cases where the gastric functions are weak- ened by general debility or excessive alcoholic indulgence. In poisoning by mineral acids, such as hydrochloric or sulphuric acids, well- diluted ammonia may be given as an antidote (though a less-irritating alkali, when at hand, is much preferable). Externally, in painful insect bites, ammonia may be used to neutralize the acid (frequently formic acid) intro- duced at the moment of stinging. Its; antiseptic action is also helpful. As a Counterirritant, Rubefacient, or Cauterant. — Ammonia water ap- plied to the skin acts powerfully in re- lieving subjacent pain, though the su- perficial pain attending its use is not infrequently more severe than is the case with other counterirritants. In patients with kidney affections, in particular, it has been used as a vesi- cant in place of cantharides, which causes harmful renal irritation in these cases. It has the property of passing through the horny layer of the epider- mis without destroying it (as would other strong alkalies), and of inducing blister formation through irritation ol the dermis. 612 AMMONIUM (SAJOUS). In bruises, chilblains, and other su- perficial lesions, ammonia liniment may be employed as a rubefacient. It sometimes relieves the milder forms of chronic rheumatism, including the joint manifestations and lumbago. The corrosive and antiseptic prop- erties of ammonia may be utilized Avith great advantage and convenience in treating the bites of carnivorous animals, venomous reptiles and in- sects. In snake-bites, for example, strong ammonia w^ater may be applied directly to the wound, the general stim- ulating effect of ammonia being also availed of by giving an intravenous in- jection of 30 to 60 minims of the weaker solution in 6 drams of sterile water. In insect stings, the local appli- cation of ammonia water will often greatly reduce the pain or itching; es- pecially where a tendency to local in- fection exists, the antiseptic property of the remedy may be utilized with great benefit. The patient should al- ways be cautioned, however, to remove the ammonia when marked redness of the skin appears ; otherwise, consider- able local injury is likely to result. In a case witnessed by the writers, the pa- tient had used it in the form of a com- press to treat a horse-fly bite. The large area thus "treated" resembled a burn of the second degree. Most people handle ammonia carelessly. In the "hair tonics" recommended in premature alopecia, ammonia wa- ter is considered a valuable ingre- dient. The aromatic spirit of am- monia is also used in various other affections of the scalp, including pityriasis, etc. C. E. DE M. Sajous AND L. T. DE M. Sajous, Philadelphia. AMMONIUM.— A metal-like body, never yet isolated in pure form, but known, from the manner in which its compounds can be formed by the in- teraction of ammonia gas and acids, to have the chemical composition NH4. The compounds of ammonium greatly resemble those of potassium; hence the inclusion of ammonium in the group of alkali metals. The official salts of am- monium are the following: — Ammo'iiii hensoas (ammonium ben- zoate) ; dose, 5 to 30 grains (0.3 to 2.0 grams). Ammonii hromiduni (ammonium bro- mide) ; dose, 5 to 30 grains (0.3 to 2.0 grams). Ammonii carbonas (ammonium car- bonate) ; dose, 2 to 15 grains (0.12 to 1.0 gram). Ammonii chloridum (ammonium chloride) ; dose, 2 to 30 grains (0.12 to 2.0 grams). Ammonii iodidum (ammonium io- dide) ; dose, 3 to 15 grains (0.2 to 1.0 gram). Ammonii salicylas (ammonium sali- cylate) ; dose, 3 to 15 grains (0.2 to 1.0 gram). Ammonii valeras (ammonium vale- rianate or valerate) ; dose, 2 tO' 10 grains (0.12 to 0.6 gram). Ammonium acetate is ofificial in liquor ammonii acetatis (spirit of Min- , dererus), a solution of diluted acetic acid nearly saturated with ammo- nium carbonate; dose, 4 fluidrams (16 c.c, containing about 15 grains or 1 gram of ammonium acetate), and in liquor ferri et ammonii acetatis (Basham's mixture), which is made up of tincture of ferric chloride, 1 fluidram (4 c.c.) ; diluted acetic acid, 1% fluidrams (6 c.c.) ; solution of ammonium acetate, 12^^ fluidrams (50 c.c.) ; aromatic elixir, 3 fluidrams AMMONIUM (SAJOUS). 613 (12 c.c.) ; glycerin, 3 fluidrams (12 c.c), and water, enough to make 25 fluidrams (100 c.c.) ; dose, 4 fluidrams (16 c.c). PHYSIOLOGICAL ACTION.— The efl:"ects of the compounds of am- monium are a composite of those of the ammonium group or ion itself, and of the acid group in union with it. The latter may not only modify that of the ammonium, as in ammonium bro- mide, but may completely overshadow it, as in ammonium arsenate. The effects of the ammonium ion, when it enters the circulation, are, in general, those of a promptly acting, but fleeting stimulant. If the amount in- troduced be excessive, depression may follow the primary stimulation. In the nervous system the stimulat- ing effects of ammonium bear chiefly upon the spinal cord and medulla. The motor spinal centers are excited to in- creased activity, exaggerated reflex ac- tion, and even convulsions, being among the most evident results. The cere- brum, however, is, if anything, de- pressed rather than stimulated. The circulation is influenced in various ways : 1. Stimulation of the vaso- motor center in the medulla causes a rise of blood-pressure through constriction of the peripheral blood- vessels. 2. The heart muscle is directly stimulated, the result being a strengthening of its beats and further rise in the blood-pressure. 3. Excitation of the vagus (inhibitory) center in the medulla may cause some slowing in the heart rate. Respiration is accelerated and deepened through stimulation of the medullary centers presiding over this function. The body secretions, especially the sweat, saliva, and mucous secretions of the alimen- tary and respiratory tracts, are in- creased by ammonium, partly through stimulation of the nervous centers gov- erning secretory processes (exclusively so in case of the sweat secretion), and partly owing to local effects on the se- creting cells. Though most of the ammonium com- pounds are readily and promptly ab- sorbed from the stomach and intestines, their excretion through the urine and other secreted fluids is so rapid as to greatly limit the power and duration of their effects when taken by the mouth. Further, certain of the salts of ammo- nium, i.e., the acetate and citrate, when absorbed, are oxidized to ammonium carbonate in the system, and this, in turn, undergoes a rapid decomposition, probably mainly in the liver, whereby it is converted into urea. The ammo- nium group is thus destroyed, and its specific effects promptly disappear. Only by intravenous injection of rather considerable amounts Of ammonium salts are the effects of the NH4 group obtained with any degree of intensity. The decomposition of the NH4 group into urea involves loss of the alkaline properties of its compounds. For this reason the alkalinity of the blood is not increased and the acidity of the urine not diminished by the administration of alkaline salts of ammonium, as they would be by giving alkaline salts of so- dium and potassium. Ammonium salts which are not changed to the carbonate and elimi- nated as urea — e.g., ammonium chlo- ride — are excreted as neutral salts, and, therefore, also fail to influence the re- action of the urine. The contrast between the stimulating action of ammonium hydroxide (am- monia) or ammonium carbonate and the almost complete absence of it in the case of amrnonium chloride is now b^- 614 AMMONIUM (SAJOUS). lieved to be due not to any greater ra- pidity of absorption or more prolonged persistence of ammonium in the blood (the reverse being, in reality, the case), but to the reflex stimulation caused by the caustic alkaline action of the first- mentioned two compounds on the gas- tric mucosa (or wherever else brought into relation with the organism), as compared to the low degree of local ir- ritation caused by the practically neu- tral chloride of ammonium. As already mentioned, some of the ammonium compounds owe their therapeutic value chiefly to the acid group — benzoate, bromide, salicylate, etc. — with which the ammonium is in combination. For information con- cerning these the reader is referred to the headings under which the respect- ive acids are considered : Benzoic acid, bromides, salicylic acid, etc. The more important of the compounds in the physiological action of which the ammonium group plays the leading part will be treated of in the following sections. AMMONIUM ACETATE.— Am- monium acetate (CH3. COONH4) oc- curs as a white crystalline solid, freely soluble in water. It is seldom used in its natural state, but enters into the composition of the official liquor am- monii acetatis (spirit of mindererus), which is extensively employed. This fluid is prepared by neutralizing dilute acetic acid with ammonium carbonate (5 grams of the former in 100 c.c. of the latter, according to pharmacopeia! directions), the result being a colorless Hquid, which may give off a faint odor of acetic acid, and has a mildly saline, acidulous taste and an acid reaction. The preparation is required to contain not less than 7 per cent, of ammonium acetate, and should be freshly prepared when wanted. The dose of spirit of mindererus is 2 fluidrams to 1 ounce (8.0 to 30.0 c.c), repeated every two or three hours. Liquor fcrri et ammonii acetatis (Basham's mixture) will be considered among the preparations of iron. MODE OF ADMINISTRATION. — Liquor ammonii acetatis is best ad- ministered well diluted in sweetened water. Sparkling water (charged with carbon dioxide) is also advantageous as a diluent. INCO MP ATIBLES. — Strong acids, which enter in combination with the ammonium, replacing the weaker acetate radical; compounds of bases stronger than ammonium (sodium, po- tassium), with acids weaker than acetic acid, e.g., the carbonates of sodium and potassium; lime water (calcium hy- droxide) ; metallic salts, such as those of silver and lead. PHYSIOLOGICAL ACTION.— Ammonium acetate, especially when given in the official solution, is the most strongly diaphoretic of the salts of am- monium. Its action is believed to take place largely, if not solely, through stimulation of the sweat-center. The diaphoresis occurring under its influ- ence is greatly assisted if the cutaneous vessels are already in a state of dilata- tion or are caused to dilate by the ap- plication of warmth — blankets — to the patient's skin, or by combination with sweet spirit of niter or aconite. A second useful property of this salt is its action as a diuretic. This ac- tion is exerted most strongly when diaphoresis is held in abeyance, i.e., when the skin vessels are not dilated. The diuretic effect of ammonium ace- tate is not produced through irritation of the kidney-cells. This is one of the ammonium salts which are rapidly con- AMMONIUM (SAJOUS). 615 verted in the system, first into ammo- nium carbonate, then into urea; hence the diuretic effect is probably chiefly that of urea, — a normal stimulant to the renal function. Ammonium acetate is believed to be one of the most rapidly absorbed of the ammonium salts ; we should, therefore, expect that some of the stimulating ac- tion of ammonium on the medullary nerve-centers and circulation would be exerted on ingestion of this salt. Such stimulation does not, however, with the exception of the sweat-center, appear to occur to any marked extent. The reason for the special preponderance of diaphoresis in the action of this salt of ammonium is not definitely known. THERAPEUTICS.— As a Diapho- retic and Diuretic. — The solution of ammonium acetate is useful as a mild sweat-producer and diuretic in febrile diseases, including acute coryza, in- fluenza, mumps, the eruptive diseases of childhood, etc. The elimination of toxic products, in which the skin, as well as the kidneys, plays so important a part in these affections, is hastened by it. It also tends to reduce excess- ive temperatures by increasing the amount of fluid evaporated from the skin. In the diseases of childhood, when the eruption is delayed, am- monium acetate will favor its ap- pearance. It has also been found serviceable in muscular rheumatism (Butler). In acute alcoholic intoxication am- monium acetate has been found to re- move promptly the symptoms. In migraine, too, through some obscure mode of action, and in amenorrhea, the remedy has sometimes proved beneficial (Butler). Externally, solutions of ammonium acetate have been applied as a lotion over contusions, beginning abscesses and glandular enlargements, and cer- tain skin diseases, e.g., prurigo. In chronic ophthalmic inflammations, also, it has been used as an eye-wash, a little laudanum being added to the acetate solution in order to relieve local discomfort. AMMONIUM CARBONATE.— The substance used under this name is not the pure carbonate of ammonium, (NH4)2C03, but is a mixture in va- riable ratio of acid ammonium bicar- bonate, (NH4)HC03 or CO(OH)- ONH4, and ammonium carbamate, CO- (NH2)ONH4. This mixture is also known as ammonium sesquicarbonate, hartshorn, sal volatile, Preston salts, or bakers' ammonia. It is made by heat- ing an ammonium salt, such as the chlo- ride, with chalk (calcium carbonate), and occurs in white, hard, translucent masses having a sharp, saline taste, a strong odor of ammonia, and a strongly alkaline reaction to litmus. It loses both ammonia gas and carbon dioxide when exposed to the air, and effloresces, becoming opaque and friable. When heated it volatilizes completely. When dissolved in hot water it is decomposed, ammonia and carbon dioxide being driven off; upon further boiling it dis- appears from the solution by volatiliza- tion. It is soluble in 5 parts of water at a temperature of 15° C. (59° F.), and in 4 parts at 25° C. {77° F.). Al- cohol dissolves only its carbamate con- stituent, the acid carbonate remaining. In glycerin it is soluble to the extent of 1 in 5 parts. The purity standard set for ammonium carbonate by the United States Pharmacopoeia is that it should contain 97 per cent, of the constituents above mentioned, and should yield not less than 31.58 per cent, of ammonia gas. 616 AMMONIUM (SAJOUS). The dose of ammonil carbonas is 2 to 15 grains (0.12 to 1.0 gram), the average being 5 grains (0.3 gram). The aromatic spirit of ammonia (spiritus ammonicB aromaticus) , already- considered under ammonia (q.v.), con- tains about 4 per cent, of ammonium carbonate. MODE OF ADMINISTRATION. — Ammonium carbonate should not be given in any form other than a well- diluted solution, thus avoiding excessive gastric irritation and facilitating absorp- tion. The evanescence of the effects of this salt, in common with other ammo- nium salts, requires that it be frequently repeated, e.g., every two hours. Its un- pleasant taste may be covered by lico- rice. INCOMPATIBLE3.— Ammonium carbonate is incompatible with acids, with acid salts, and with lime water. PHYSIOLOGICAL ACTION.— Ammonium carbonate possesses, to a certain extent, the stimulating proper- ties of ammonia. As has already been stated, the general stimulant effect of the latter, taken internally, is now be- lieved due not so much to a direct ac- tion of the ammonium group on the nerve-centers and circulation after ab- sorption as to the irritation of the gas- tric mucous membrane due to the strong alkalinity of ammonia. The same view is held with regard to am- monium carbonate, the lesser extent of its stimulating effect corresponding with its lower degree of alkalinity as com- pared to ammonia. Taken in consider- able amounts, the salt causes vomiting. If ammonium carbonate is injected subcutaneously or intravenously, direct stimulation of the respiratory and vaso- motor centers, spinal cord, and heart by the ammonium circulating in the blood (in addition to the reflex stimu- lation from local irritation, when in- jected subcutaneously) is produced. Like the acetate of ammonium, the carbonate acts as a mild diaphoretic and diuretic. It possesses also, to a considerable degree, the property of increasing the bronchial secretions and mucus in general. After absorp- tion it is partly oxidized to urea; but some of it is excreted unchanged by the bronchial and other glands, which are stimulated by it. According to Sollmann, ammonium salts in increas- ing secretions of the respiratory tract and the saliva act in no less than four ways: 1. By reflex stimulation from the mucous membranes with w^hich the salt is brought in contact. 2. By direct stimulation of the secretory nerve-centers, which the drug reaches through the circulation. 3. By a local stimulating action on the gland-cells themselves, with the secretions of which the salt is excreted. 4. Through liquefaction of the mucous secreted, owing to the alkalinity of the am- monium carbonate eliminated with it. (Several ammonium, salts, besides the carbonate itself — the acetate, citrate, etc. — are converted in the system into, and partly eliminated as, the carbonate.) Ammonium carbonate, like ammonia, is, to a certain extent, antiseptic, owing to its alkalinity. Applied to the skin, it acts as a rubefacient. The pure neutral carbonate of am- monium — (NH4)2C03 — is of physio- logical importance. The nitrogenous waste product of the activity of mus- cles is ammonium lactate. This, ac- cording to the belief of some, is con- verted in the tissues into ammonium carbonate, which, in turn, is dehydrated in the liver to ammonium carbonate, and, finally, to urea. Where the hepatic functions are deficient, ammonium car- AMMONIUM (SAJOUS). 617 bonate or carbamate may persist, and cause symptoms of ammonium poison- ing, somewhat resembling those of uremia. TOXICOLOGY.— Ammonium car- bonate, ingested in large amount, brings about nausea and vomiting througb local irritation. If brought in contact with the mucous membranes in concen- trated form, destructive lesions, some- what similar to those produced by am- monia, may result. For symptoms and treatment the reader is referred to the section on the toxicology of ammonia. THERAPEUTICS.— As an expec- torant, ammonium carbonate is of considerable value. The secretions are both increased and rendered more fluid, being, therefore, removed with greater facility. In bronchitis, pneu- monia, asthma, and pulmonary tuber- culosis, the combination of the ex- pectorant effect with the stimulating action on the respiratory centers is very advantageous, more especially in cases where dyspnea is marked. In these af- fections it should be given in doses of 5 or 10 grains (0.3 to 0.6 gram), re- peated every two hours. In acute coryza it may also be em- ployed with satisfactory results. As a Stimulant. — The stimulating effect of this remedy on the medullary centers and heart is of great value in all conditions of general adynamia, w^ith or without involvement of the respiratory tract. In the acute exan- themata of children, and continued fevers of various kinds, it may be used with great advantage to sustain cir- culatory and respiratory activity. In bronchopneumonia, chronic bron- chitis Avith marked general weakness, it is a favorite remedy. In chronic heart disease with failure of compen- sation it is also frequently used. The effect is, of course, of brief duration, and frequent administration being re- quired to keep up the action. In "faint- ing" (syncope) and shock the inhala- tion of "smelling salts" (ammonium carbonate reinforced with ammonia water) is a time-honored and effective procedure. As a Gastric Stimulant or Emetic. — In indigestion due to general weak- ness, and in cases where flatulence is a prominent symptom, ammonium carbonate may be used to tone up the gastric functions. Its effects are, however, evanescent. In the indi- gestion of alcoholics it has also proven very useful. Emesis may be obtained by the ad- ministration of large doses, e.g., 30 grains (2 grams), of ammonium car- bonate. The absence of concomitant depressing effects distinguishes this form of emesis from that caused by de- pressing drugs, such as tartar emetic. As a Rubefacient and Discutient. — Ammonium carbonate may be em- ployed as a rubefacient in a manner similar to ammonia {q.v.). In psori- asis, baths containing ammonium car- bonate are given for the purpose of dis- solving off the scaly coverings of the lesions, in order that the local remedies subsequently applied may act directly on the skin. AMMONIUM CHLORIDE, also known as "sal ammoniac" or muriate of ammonia, has the chemical formula NH4CI. It may readily be produced by the interaction of ammonia and hydrochloric acid, but is more usually produced by neutrahzing ammonia with sulphuric acid, separating by crystalli- zation the ammonium sulphate thus formed, and subliming it with sodium chloride. It occurs as a white, crystal- line powder, odorless, but having a cool- 618 AMMONIUM (SAJOUS). ing, saline taste. In contrast with am- monium carbonate, ammonium chloride is permanent in the air. When strongly heated it is completely volatilized, with- out decomposition. Ammonium chloride is soluble in 2 parts of water, in 50 parts of alcohol, and in 5 parts of glycerin at 25° C. {77° F.), and in 1 part of boihng water. Though ammonium chloride is a neu- tral salt, its solution in water has a slightly acid reaction. This is due to the fact that small amounts of NH4OH and of HCl are formed in the solution by reaction of NH4CI with H2O, and that the HCl is dissociated into its ions to a greater degree than the NH4OH, therefore being chemically more active and producing the acid reaction. The dose of ammonii chloridum is 2 to 30 grains (0.12 to 2.0 grams), the average being 7)4 grains (0.5 gram). The trochisci ammonii chloridi (tro- ches or lozenges), also official, each consist of ammonium chloride, 0.1 gram {iy2 grains); extract of glycyrrhiza, 0.2 gram (3 grains) ; tragacanth, 0.02 gram (^ grain) ; sugar, 0.4 gram (6 grains), with syrup of Tolu, q. s. MODES OF ADMINISTRA- TION. — Ammonium chloride is best given in solution or in the form of loz- enges. Licorice is decidedly the most advantageous agent for disguising its unpleasant salty taste. The mistura ammonii chloridi of the National For- mulary, e.g., contains 2j4 parts each of the salt and of pure extract of licorice in 100 parts of water. Similarly, the mistura glycyrrhijsce composita (brown mixture) of the U. S. P. is often used as a vehicle for ammonium chloride. In affections of the lower respiratory passages inhalations of freshly formed ammonium chloride vapors are also fre- quently utilized. INCOMPATIBLES.— Ammonium chloride is incompatible with alkaline compounds or carbonates of the stronger alkali metals, — sodium and potassium, — or of the metals of the al- kaline earths, — calcium, strontium, ba- rium ; the more strongly basic metals in these compounds tend to displace the ammonium from its chloride. If an ammonium chloride solution to which sodium or potassium hydroxide has been added is heated, gaseous ammo- nia is evolved. Salts of silver, mercury, or lead, in solution, are precipitated as insoluble chlorides if combined with the chloride of ammonium. PHYSIOLOGICAL ACTION.— Taken internally, ammonium chloride, being less irritating than ammonia or ammonium carbonate, causes but little reflex irritation of the central nervous system through irritation of the gastric mucosa. In view of the fact, however, that it is destroyed in the blood to a much less extent than ammonium car- bonate and ammonium acetate (which, as has already been stated, are largely converted to the relatively inert sub- stance, urea), we would expect ammo- nium chloride to exhibit the direct stim- ulating effect of ammonium on the nerve-centers more clearly than the compounds just mentioned. That this is not the case, ammonium chloride be- ing but slightly a general stimulant, tends to support the view, now held by many, that the stimulating effects of ammonium compounds taken internally are exerted through a reflex, rather than a direct, action on the centers. Nevertheless, if the salt be given intra- venously, the direct stimulating action of ammonium on the spinal cord, the respiratory, vasomotor, and other cen- ters, as well as the heart muscle, be- comes clearly manifest. It may be pre- AMMONIUM (SAJOUS). 619 Ceded by a period of central nervous depression, as was well illustrated in the results obtained by Gourinsky in experiments on frogs and pigeons. His findings were these : In frogs whose spinal cord has been divided below the medulla oblongata ammonium chloride produces, from the first, a marked aug- mentation of reflex action. In normal frogs and pigeons, on the other hand, ammonium chloride produces, at first, depression of the central nervous sys- tem, then convulsions ; the higher cen- ters at first exercise an inhibitory influ- ence on the spinal reflexes. When the salt is introduced rapidly, the first stage (that of depression) is but slightly marked, and soon gives place to the sec- ond stage (that of irritation, ushered in by convulsions). When it is intro- duced slowly the depression is well marked and lasts a long time. In frogs and pigeons deprived of the cerebral hemispheres only, whatever be the method of introducing the salt, convul- sions are not preceded by depression, but the latter is sometimes replaced by irritability. All the facts, according to Gourinsky, can be explained only by the reciprocal action of the nervous centers on each other, modified by the ammonium chloride. It should be men- tioned, in this connection, that, in the frog, ammonium chloride has a ten- dency to paralyze the motor nerve-ter- minals in the muscles ; in mammals, however, this effect is hardly noticeable, even with large doses. The most important action of ammo- nium chloride is that on the secretions of the respiratory passages, stomach, and mucous membranes in general, which are increased and rendered more fluid by it. The several ways in which this effect may be produced have been set forth under ammonium carbonate (q.2'.). The fact that some of the salt is eliminated by the mucous membranes suggests that the direct action of the drug on the gland-cells must play an important role in the effect produced. Its elimination with the sweat and urine also causes it to be mildly diaphoretic and diuretic, as well as expectorant. Ammonium chloride has been found to produce an increase in all the solids of the urine, except in uric acid. When given continuously for some time, it is believed to cause pathological alterations in the blood, which may eventuate in general prostration, to- gether with hemorrhage under the skin, from the mucous membranes, and hem- aturia. Externally, ammonium chloride, in strong solutions, acts as an irritant. THERAPEUTICS.— As a Stimu- lant to Mucous Membranes. — In Dis- orders of the Respiratory Tract. — Am- monium chloride has long been consid- ered an effective remedy in almost every disorder of the respiratory tract. More recently the carbonate has re- placed it in the treatment of pulmonary disorders, but the chloride is still widely used in chronic bronchitis and acute bronchitis after the initial stage of the bronchial inflammation has passed that of marked congestion and dryness. In whooping-cough, also, ammonium chlo- ride has given fairly good results. The drug acts, at least in part, directly on the gland-cells of the mucous mem- branes, with the secretions of which it is eliminated into the bronchi. The cells are stimulated by virtue of its "salt action," the result being a less tenacious and more watery secretion of mucus, which is more readily evacuated. Fre- quently the drug is given in combina- tion with other stimulating expectorant remedies. In the terminal stage of 620 AMMONIUM (SAJOUS). acute coryzaand in subacute or chronic forms of pharyngitis and laryngitis, the beneficial efifects of ammonium chloride on the mucous membranes are also util- ized with advantage. In pneumonia, ammonium chloride has been given in 10-grain (0.6 gram) doses every two hours, in the hope of in some way favorably modifying the inflammatory process in the lung, but the results obtained have not been strik- ing (Brunton). Fumes of nascent ammonium chlo- ride, generated by the action of hydro- chloric acid on ammonia, are frequently administered by inhalation in respira- tory disorders, and have proven quite effective in mild chronic affections of the mucous membranes, including bron- chitis, pharyngitis, laryngitis, etc. It is a constituent of the official mis- tura glycyrrhizcs composita (U. S. P.), of mistura ammonii chloridi (N. F.). The value of ammonium chloride troches, or lozenges, for local stimula- tion in pharyngeal disorders is well known. They serve the double pur- pose of increasing local lubrication by exciting the glandular acini and of gently stimulating the hepatic functions after the salt has been absorbed. The official ammonium chloride lozenge has already been referred to; 1 to 6 or more of these lozenges may be taken daily. Ammonium chloride solution has also been used in throat affections in the form of a spray. In Aural Disorders. — The use of chloride of ammonium vapor in affec- tions of the middle ear has been prompted by its effectiveness in catar- rhal affections of the nasal mucous membrane. In Gastric Catarrh. — That ammo- nium chloride is of value in catarrhal disorders of the stomach, especially in children, is indicated by the frequency with which it is still resorted to. Pre- sumably, its chief action is to loosen the mucous secretions. It may be given in solution or in pills ; if in the latter form a half-tumblerful of pure water should be taken simultaneously to prevent un- due irritation of the gastric mucosa by the salt. Instead of water, milk may be used. In Cystitis. — In catarrhal cystitis ammonium chloride sometimes proves very effective. Ten grains (0.6 gram) every four hours on the first day, in a tumblerful of water, and 5 grains (0.3 gram) on the second day and there- after soon cause the local distress greatly to diminish. As a Stimulant to the Liver. — In all conditions associated with torpidity of the liver, whether this be due to a subacute hepatitis or to general as- thenia, ammonia chloride, in doses of 20 grains (1.3 grams) three times a day, has been found of great value. In Alcoholism. — In alcoholic intox- ication ammonium chloride has been said to act as effectively as ammonia. Thirty grains (2.0 grams), repeated in half an hour, were found to bring the sufferer to his normal condition, in so far as the mental aberration was con- cerned. If emesis or lavage had been resorted to before the administration of the salt, the action of the latter was greatly prolonged. In Neuralgia and Migraine. — Am- monium has been found frequently to afford considerable relief in these dis- orders, especially if given with tincture of aconite. Twenty grains (1.3 grams) of the ammonium salt with 2 minims (0.12 c.c.) of the tincture, repeated twice after the first dose, at intervals of half an hour, usually procured marked dimi- nution of the suffering. AMYLENE HYDRATE. 621 External Uses. — In superficial in- flammatory swellings, caj., buboes, mammary abscesses, testicular inflam- mations, etc., ammonium chloride solu- tions have been applied locally with benefit. In vaginitis a solution of 3 drams (12.0 grams) of ammonium chloride in 1 pint (475 c.c.) of water can be used as an injection or applied on a tampon with benefit (Butler). ■ A saturated solution of the salt may be used with advantage in bruises, to re- duce swelling and diminish discolora- tion. The antiseptic qualities of am- monium chloride in the treatment of wounds have been emphasized by H. C. Wyman, who obtained good results, es- pecially in contused wounds, from the use of gauze steeped in a solution of 1 ounce of the salt in half a pint of water. The circulation of blood in the injured parts also appeared to be improved by it. In senile gangrene a good therapeu- tic measure is to place the foot in a solu- tion of 8 ounces (250 grams) of ammo- nium chloride to 1 gallon (3800 c.c.) of water (Butler). It increases the alka- linity of the blood and thereby its os- motic properties, and facilitates its cir- culation. C. E. DE M. Sajous AND L. T. DE M. Sajous, Philadelphia. AMMONIUM ICHTHYOL GROUP. See Ichthyol. AMPUTATIONS and RESEC- TIONS. See Resections, Amputa- tions, ETC. AMYL NITRITE. See Nitrites. AMYLENE CHLORAL. See DORMIOL. AMYLENE HYDRATE. - This siilistancc is chemically tertiary amyl alcohol or dimethylethylcarbinol [(CH3)2- C(C2H.r,)OH]. It occurs as a colorless, volatile, oily liquid, having an unpleasant ethereal odor and a burning, camphor-like taste. It is produced by the interaction of amylene, water, and sulphuric acid. Its specific gravity at ordinary temperatures is 0.820, and its boiling point is 99°-103° C It is soluble in 8 parts of water and mixes freely with alcohol, ether, chloroform, and glycerin. It should be kept in well- stoppered bottles. DOSE AND MODES OF ADMINIS- TRATION. — The dose of amylene hydrate taken by the mouth, for adults, is 30 to 90 minims (2 to 6 c.c). If it is to be admin- istered by the rectum, slightly larger amounts are required. The disagreeable taste of amylene hy- drate may be avoided by enclosing it in capsules (15 minims in each; 3 capsules at a dose) or by administering it in fla- vored solutions such as the following: — IJ Amylene hydrate. 1 dr. (4 Gm.). Water 2 oz. (60 c.c). Orange-flower water 2 oz. (60 c.c). Syrup of bitter orange 1 oz. (30 c.c). M. Of this one-half may be taken at night. Where an analgesic effect is required in addition to the hypnotic influence, mor- phine may be combined with amylene hy- drate, as in the following formula, recom- mended by Fisher: — IJ Amylene hydrate. 1^ drs. (6 Gm.). Morphine hydro- chloride ^ gr. (0.015 Gm.). Distilled water .. 3 oz. (90 c.c). Extract of lic- orice 2j^ drs. (10 Gm.) . M. Sig. : To be taken in two doses two hours apart. Amylene hydrate may also be given in wine, beer, or brandy. A mixture of wine and syrup of licorice forms an especially good vehicle. It cannot be employed subcutaneously, owing to the severe irritation and pain produced. PHYSIOLOGICAL ACTION.— Amy- lene hydrate, like alcohol, causes a primary apparent excitement followed by depres- 622 AMYLENE HYDRATE. sion and ultimate paralysis of the nerve- centers. The brain, cord, and medulla are stimulated and depressed in succession, the secondary results being sleep, aboli- tion of reflex activity, and respiratory arrest. In the lower animals large doses have been found to induce cardiac depres- sion and a pronounced fall in the body temperature. The latter effect has been credited to a direct action of the thermic centers. In man, however, amylene hy- drate in moderate doses does not influence the temperature to any degree, even in fever. Neither does it depress to any marked extent, except in grossly excessive doses, the cardiovascular functions and respiration, — a feature in which it is supe- rior to chloral hydrate. Amylene hydrate has but little influence on general metab- olism. The elimination of urea is said to be more or less diminished after its in- ternal use. Locall}^ it is somewhat of an irritant. Upon subcutaneous injection tissue necro- sis and abscess formation may result. UNTOWARD EFFECTS; POISON- ING. — According to Scharschmidt, some patients perspire freely at the beginning of the effects of amylene hydrate. Occa- sionally excitement similar to that pro- duced by alcohol or slight degree of stupor are produced by it. Headache and dizzi- ness in a few instances follow its use. Four cases of poisoning from overdoses were witnessed by Dietz. The symptoms consisted of deep sleep, from which the patients could not be aroused, complete motor paralysis, and loss of sensibility, including both touch and pain. The pupils were dilated, and reacted but slowly to light; the corneal reflex was abolished. Respiration was slow, superficial, and irregular; the pulse small, soft, and in- frequent, and the temperature, in two in- stances, lowered to 95° F. Artificial res- piration was required in one case. During recovery mental confusion and motor in- co-ordination were conspicuous. In each case the overdose had been taken through neglect to shake the bottle in which the drug was mixed with syrup. Dietz advises that to avoid such accidents the drug be administered in capsules. No instances of amylene-hydrate habit or cachexia have been observed (Flint). THERAPEUTIC USES.— Amylene hy- drate was introdviced in medicine as a hypnotic by von Mehring, and has since held a favorable position as such, though, as Cushny states, it "has not received so wide a trial as it would seem to merit." Its effects rather closely resemble those of paraldehyde, but it leaves no bad taste in the mouth or disagreeable odor on the breath, such as are noticed with paralde- hyde after the patient has awakened. In hypnotic power it is stronger than paralde- hyde, but weaker than chloral hydrate. Likewise it is believed to exert a greater depressing influence on the heart than paraldehyde, — though less than chloral hydrate. Kirby and Griffith recommended that this drug be always used in heart disease in place of chloral. They also stated that in their experience amj'lene hydrate did not lose its efficiency upon continued use, — though given during three months in some cases, — and that the deep and refreshing sleep produced by the drug was praised by patients oftener than in the case of any other hypnotic. Amylene hydrate differs in its action from chloral in that it does not increase nitrogenous wastes. According to Peiser the quantity of nitrogen eliminated by the urine after amylene hydrate is, in fact, lessened. This author therefore prefers the drug to chloral whenever the hypnotic effects are to be continued for a long time and in all affections associated with an exaggerated decomposition of albumins, — ■ in fever, in anemia, pulmonary tuber- culosis, and diabetes. Sleep follows the ingestion of amylene hydrate much more promptly than after sulphonal, and it does not tend, as does the latter, to produce drowsiness and giddiness on the following day. On the whole, amylene hydrate is, ac- cording to Kirby and Griffith, a reliable hypnotic if given in sufficient dose, though it is somewhat less certain in effect than chloral or morphine. When given by the rectum (in an enema with gum arabic and water), amylene hydrate brings on sleep in fifteen to forty-five ininutes, or even sooner, though occasionally it fails entirely to do so. Amylene hydrate acts satisfactorily in insomnia associated with nervousness, ex- AMYLOFORM. 623 cessive mental strain, fevers, and anemia. Its usefulness in cardiac states has already been referred to. In gastric disorders its oral use is apt to result in local irritation and nausea; in such cases it should be administered by the rectum. It is less irritating to the rectal mucous membrane than chloral hydrate. In the insomnia of mental diseases, amy- lene hydrate has seen extensive service. In a series of 149 cases Lehmann obtained good results with it. In mania large doses were required. Cases of paralysis of the insane were benefited, but in the insomnia of melancholia it was less effective. It proved to be more efficacious and less un- pleasant than paraldehj^de. Avellis found amjdene hydrate generally effective in alcoholic delirium. In a case of opium addiction in which chloral, bromides, paraldehyde and hyos- cine, singly or variously combined, had given indifferent results, amylene hydrate produced sleep lasting through the night with but little or no intermission (Kirby and Griffith). Like results have been noted by other observers. In pulmonary disorders, G. Mayer found amylene hydrate not only to produce sleep, but apparently to exert a decided sedative influence on the cough. In tuber- culosis it sometimes proved useful in this respect after morphia had had but little effect. When there was pain or very troublesome cough, however, it was not uniformly successful. S. AMYLOFORM.— Amyloform is a condensation product of formaldehyde and starch, first prepared by Classen, of Aachen, in 1896. It occurs in the form of very fine, white, odorless, and tasteless powder, which is insoluble in ordinary solvents. It remains undecomposed at a temperature of 180° C. PHYSIOLOGICAL ACTION.— Amylo- form is but slightly irritating. It is strongly antiseptic, disinfectant, deodor- ant, and absorbent, and is said to have all the advantages of iodoform without pos- sessing its disagreeable odor. When ap- plied to living tissue it is broken up into its two components, — formaldehyde and starch, — as shown by the fact that formal- dehyde can be detected in the purulent discharge from suppurating wounds to which it has been applied (Classen). No symptoms of general intoxication are pro- duced by the application of amyloform, though temporary smarting sensation locally is sometimes complained of. The secretions from open surfaces are rapidly checked by it. THERAPEUTIC USES.— The drug is employed either as a dusting powder or in an ointment. Its uses are much the same as those of iodoform. Bongartz employed it with success in cases of deep wounds with bone suppuration and in varicose ulcers of the leg. Heddaeus laid stress on its rapid disinfecting action on tuberculous lesions. Its most important use, accord- ing to this author, is in the treatment of superficial suppurative affections. Lou- gard and Beauchamp used the drug in numerous cases of phlegmon, abscess, fu- runcle, etc., including gynecologic affec- tions. Krabbel, who tested it both bac- teriologically and clinically, came to the conclusion that amyloform was in no way inferior to iodoform as an antiseptic. C. L. Schleich, however, contends that it holds fre.e starch, which smears up the wound and greatly hinders favorable action of the formaldehyde it contains. Contrary to iodoform, amyloform can be sterilized in dry or moist heat without being decomposed. Because of this property, amyloform gauze affords some assurances of asepsis which are not found in the other antiseptic gauzes. An emulsion for preparing amyloform gauze is: — B Amyloform.. 7S grs. to 2^ drs. (5-10 Gm.). Glycerin ...2^ drs. (10 Gm.). Alcohol ....12^ drs. (50 Gm.). Ether 10 drs. (40 Gm.). 01. ricini .. 7^^ mins. (0.5 Gm.). The indications for amyloform are the same as for iodoform. (Presse med., Sept. 15, 1900.) Good results obtained with amylo- form. The writers prefer it to the latter drugs in incised abscesses, ulcers, wounds, burns, and purulent otorrhea. Besides being harmless and free from any compromising odor, it remarkably hastens cicatriza- tion. Cipriani (Monats. f. prakt. Der- mat., Oct. 15, 1900). 624 AMYL VALERATE. ANALGEN. Amyloform used in fresh and neg- lected wounds, ulcers of the leg, excoriations, intertrigo, felons, car- buncles, osteomyelitis, tuberculous ulcerations, etc. The pure powder usually employed. This occasions slight burning in sensitive patients, which, however, disappears soon. The chief features of its action are that it hastens granulation, diminishes secretion, and is, as a rule, non-irri- tating. Its freedom from odor and toxic effect is also noteworthy. A. Gerlach (Therap. Monats., Bd. xvi, Nu. 10, 1902). S. AMYL VALERATE (Amyl Vale- rianate). — This is the isoamyl ester of iso- valeric acid, and is a reaction product of amyl alcohol with sulphur and valeric acids. It represents the odoriferous prin- ciple of the apple, and occurs as a color- less liquid of specific gravity 0.858 and boiling point 190° C. (374° F.). It is in- soluble in water, but dissolves in alcohol, ether, and chloroform. When in dilute solution, its ethereal apple-like odor is plainly evident. PHYSIOLOGICAL ACTION.— Cider has long been believed by the laity to exert some favorable effect on calculous formations, and this seems to be borne out by the fact that amyl valerate actually does possess a certain solvent power with reference to cholesterin. Fifteen grains of cholesterin are dissoVed by 70 grains of amyl valerate at 99° F., and by 46 grains at 104° F. Where the amount of choles- terin present exceeds the dissolving power of the valerate, it is, nevertheless, greatly softened, — to the consistency of gelatin. The ingestion of amyl valerate induces primary general excitation and accelera- tion of the pulse, followed by somnolence (Pouchet). In addition to modifying or dissolving cholesterin, it tends to relax the bile-duct when in spasm. THERAPEUTIC USES.— Amyl vale- rate was introduced by Blanc as an anti- spasmodic for use in hepatic and renal colic, and as a solvent for cholesterin cal- culi. It is said in hepatic colic not only to overcome the acute attack, but to prevent recurrences. No solvent effect on renal calculi is, however, claimed for it. The drug is administered in capsules; a cap- sule containing 2 to 6 minims (0.12 to 0.4 c.c.) may be given every half-hour, or one containing a somewhat larger amount, three times daily. The use of amyl vale- rate should be continued for some days after the acute disturbance has subsided. Amyl valerate has also been employed in muscular rheumatism, in dysmenorrhea, and as a sedative in hysteria. S. ANALGEN (quinalgen; labordin) is, chemically, the benzoylamido derivative of orthoethoxyquinoline [C9H5.(OC2H5)- N.H.(C0.CcH.5)N]. It bears the same relation to quinoline as acetphenetidin does to benzene, with the exception that in analgen the benzoyl group takes the place of the acetyl in acetphenetidin. With the exception of thallin and ther- mifugin, it is the only member of the quinoline group of coal-tar analgesics or antipyretics which is still occasionally pre- scribed. It occurs in the form of color- less, tasteless crystals, soluble in hot alco- hol and in acidulated water, slightly so in cold alcohol, and insoluble in pure water. PHYSIOLOGICAL ACTION.— Anal- gen possesses the same antipyretic and analgesic properties as acetphenetidin, and its mode of action is .closely similar (v. Acetphenetidin). With large doses, the same circulatory depressant tendency is present as with other coal-tar drugs. Analgen is more toxic than acetphenet- idin, though less so than acetanilide. It is the least dangerous of the quinoline derivatives. Analgen given experimentally to mam- mals induces motor depression and dimin- ished reflex response, followed, with toxic doses, by cyanosis and convulsive move- ments. The effects of analgen, when it is in- gested, begin only after the benzoyl group in it has been set free by the gastric juice. Its action is, therefore, somewhat slower in appearing than is the case with ace- tanilide and antipyrin, and is to a certain extent inconstant. A special feature of the action of anal- gen is that in large doses or upon con- tinued use it produces a reddish discolora- tion of the urine. This coloration, when slight, is rendered more marked by the ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 625 addition of acetic acid (1 to 10). Accord- ing to some, the coloration is due merely to the presence of decomposition products of analgen in the urine; according to Moncorvo, on the other hand, it is due to blood-coloring matter. THERAPEUTIC USES.— The average dose of analgen for adults is lYi grains (0.5 Gm.). According to Goliner, the maximum single dose is 15^4 grains (1.0 Gm.) and the maximum daily amount 45 grains (3 Gm.). The drug has been used chiefly as an antineuralgic and antipyretic. Of late its use has, however, greatly diminished, the official drugs acetanilide, antipyrin, and acetphenetidin meeting with greater favor. Besides, the use of any anti- pyretic has justly lost favor. Scholkow, Foy, Spiegelberg, and Maas found analgen effective in a large number of cases of neuralgia. According to Foy, who used it. in 200 patients, the full dose of 15 grains (1.0 Gm.) was necessary to produce relief. In the pains of tabes, zona, and hysteria, the results were less brilliant, but in acute articular rheumatism and mus- cular rheumatism distinct benefit was noted in many instances. According to Maas, patients suffering from pulmonary tuberculosis experience "a peculiar feel- ing of well-being" from its use. Moncorvo used analgen in 59 children, 33 of them presenting various malarial manifestations, with satisfactory results. It was readily taken, because tasteless, and in no instance exerted any unfavorable action of the cir- culation or respiration. The urine became colored a deep yellow or red, but albumin and sugar were never detected. It acted satisfactorily as a sedative in chorea, hysteria, and partial epilepsy and was found useful to relieve pain of various kinds, including that of Pott's disease and hip-joint tuberculosis. Occasional instances of untoward sec- ondary effects are recorded by Scholkow and Spiegelberg, including headache, tin- nitus, nausea, diarrhea, and tremor. Pa- tients taking analgen should be informed of the red discoloration likely to appear in the urine, lest they be unduly frightened thereby. S. ANEMIA. See Anemia, Sec- ondary. ANEMIA, PERNICIOUS PRO- GRESSIVE. — DEFINITION. — A form of secondary anemia character- ized by a progressive destruction of the red corpuscles which tends toward a fatal issue. SYMPTOMATOLOGY.— Per- nicious anemia develops insidiously, though an abrupt onset occasionally oc- curs, especially in pregnant or puerperal women. The most evident symptom is pallor of the face and body, which gradually becomes extreme and as- sumes a lemon-yellow tint. This yel- lowish color deepens as the case pro- gresses ; it may appear suddenly, but in the majority of cases it develops grad- ually, following the insidious course of the disease. The mucous membranes are similarly affected. There is great weakness with all its attending symptoms : inordinate palpi- tations and dyspnea on exertion, sigh- ing, and slow delivery in speaking. The pulse, which may be strong at first, is regular, but rapid, soft, and compress- ible, in the majority of cases, more or less fever being usually present. The temperature is extremely irregular. Slight evening pyrexia is seldom absent in advanced cases. Cardiac murmurs, especially of the hemic type, are usually to be heard, es- pecially at the base, and signs of fatty degeneration may be detected by aus- cultation, although there is usually no arterial degeneration or valvular dis- ease. A loud venous hum can some- times be detected in the vessels of the neck, the so-called hridt de diable with exaggerated cardiac impulse. Edema of the ankles, face, and lungs and drop- sical effusions may appear at any stage. Retinal hemorrhage is a symptom of great value. The ophthalmoscope may thus reveal the cause of the so-called 1—40 626 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). "anemic amaurosis" observed in these cases, though the whites of the eyes are pearly and the conjunctivae pale. There may also be hemorrhages into the mucous membranes, epistaxis, menor- rhagia, and purpuric eruptions in ad- vanced cases. Ecchymoses in the skin and mucous membranes are sometimes noticeable in advanced cases. Retinal hemorrhages are also wit- nessed. In the diagnosis of pernicious anemia examination of the retina is of great Fundus oculi in a case of pernicious anemia, showing retinal hemorrhages. {Bramwell. ) value, especially in those cases in which the blood-picture is indefinite. In about 47 out of SO cases of pernicious anemia, retinal hemorrhages were found to be present; while in 51 cases of severe secondary anemia, in which the hemo- globin was below 50 per cent, and in 121 cases with a hemoglobin of 50 per cent, to 70 per cent., retinal hemor- rhages were never found. In 72 in- stances of malignant tumor (43 of car- cinoma and 29 of gastric carcinoma) in which there is especially liable to be confusion with pernicious anemia, the writer never saw retinal hemorrhages. Not only does the presence of hemor- rhages favor the pernicious type of anemia, and their continued absence a secondary anemia, but they are of prognostic importance as well. The retinal hemorrhages are larger and more numerous in the severe cases; and clearing up of the hemorrhages is one of the earliest indications of be- ginning improvement. Hesse (Deut. med. Woch., Aug. 12, 1909). Gastric and intestinal disorders are the rule, although the general nutrition is apparently preserved, the appetite being sometimes voracious, and the pa- tient becoming obese. Nausea is fre- quently an early symptom. Dyspepsia, vomiting, and diarrhea usually prevail, though some cases suffer from consti- pation. The gastric region is tender to pressure, and the tongue is pale and smooth. Eructations and anorexia are common. Involvement of the osseous system is occasionally indicated by sen- sitiveness of the bones, especially those of the sternum. The respiration is usually acceler- ated, and dyspnea, air-hunger, and op- pression in the chest are frequent symptoms. Pericardial and pleural ef- fusions are sometimes observed. Drowsiness is present in the major- ity of cases, but insomnia is occasion- ally noted. The patient is readily fatigued and even exhausted on the least exertion. The weakness increases until attacks of faintness supervene. The patient ultimately becomes bed- ridden. Headache, vertigo, tinnitus, apo- plectiform attacks, delirium, and other disorders of the nervous system, such as paresthesia, neuralgia, and extensive paralyses, have been noted. Mental torpor, somnolence, peevishness, con- fusion, delirium, and various psychic phenomena may also occur. Case in which there were not only symptoms of spinal cord disease, but a peculiar psj'chosis existing as well in connection with the pernicious anemia, ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 627 Changes in the psychic function have seldom been mentioned in relation with pernicious anemia. Disturbances as a result of a mere anemia, such as lowered mental capacity, occur, according to Strumpcll. Consciousness is retained, but the mental processes are dull and apathetic. In most textbooks of psy- chiatry anemia is given as an important cause of various psychoses, especially of mental confusion and delirium. Mental disturbances, other than indo- lence, apathy, and somnolence, except delirium just before death, have not been mentioned. Henry Marcus (Neu- rol. Centralbl., May 16, 1903). A number of patients have been observed whose chief symptoms were of a distinctly mental and nervous character, but who in the course of time were found to present the char- acteristic blood conditions and bodily signs of pernicious anemia. In some, the nervous and mental symptoms ap- peared to be secondary to, in others to precede the development of, the anemia. Clinically, these cases collectively have seemed to present a rather characteris- tic syndrome, the principal features of which are as follows : 1. General ill health. 2. Mental symptoms, viz., in- termittent attacks of loss of inhibition, peevishness, and gradual mental de- terioration. 3. Sensory disturbances: (o) Subjective, consisting of intramus- cular and articular dull aches and pains, seldom accompanied by effusion and never by true inflammatory action. With these, and perhaps rather more frequent, are sensations of numbness, tingling, and weight in the extremities, especially the legs, (b) Objective sen- sory disturbances: These are common and consist in patchy losses of pain and tactile sensibility about the feet and ankles. Sometimes there may be only retardation of sensation at first. Tabes is excluded by the other positive and negative symptoms. 4. Plus knee jerks, ankle clonus, and the Babinski sign are sometimes present. 5. Ataxia of gait and station is often present. 6. Diarrhea of the mucous types is apt to occur sooner or later. 7. The peculiar lemon-yellow tint of pernicious anemia occurs in the later stages. A combina- tion of all these signs or a majority of them should suggest the possibility of a pernicious or prepernicious anemia, and a careful blood examination may then confirm the diagnosis. Eight cases more or less typical of the condition are reported. F. W. Langdon (Jour. Amer. Med. Assoc, Nov. 25, 1905). Absence of the knee-jerk is frequent, and is indicative of degeneration of the posterior columns of the cord. Jaundice is occasionally met with. The urine is dark and highly colored; it is of low specific gravity, and shows an increase of urea and uric acid and pathological urobilin. Indican may also be detected. When the end is approaching, the temperature, which in the course of the disease is apt to rise toward evening, sometimes reaching as high as 102° F. (38.8° C), recedes markedly, and the patient enters, into a torpid condition ending in coma. BLOOD EXAMINATION. — Be- fore describing all the characteristics of the blood, a summary of its morbid changes may prove useful. Though sometimes dark and watery, the blood is, as a rule, pale. The red corpuscles are greatly reduced, sometimes as low as 143,000, though, as a rule, they do not go below 500,000. The percentage of hemoglobin is also greatly reduced, but not in proportion with that of the red corpuscles. The latter also show considerable alteration in size and shape. Some are large and ovoid (megalofytes) ; others are small, round, and dark red (microcytes), while oth- ers again are very irregular in shape (poikilocytes). Nucleated red cells, both normoblasts (normal in size) and megaloblasts (when very large), are a marked characteristic of the disease, while blood-plaques are either absent 628 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). or present in very small number. The leucocytes, though relatively increased in respect to the red corpuscles, are usually normal in number, with the smaller mononuclear forms predom- inating. To understand these blood changes, however, they must be analyzed from the standpoint of their cause. The two prevailing theories as to the pathogen- esis of pernicious anemia are: 1. That the disease is due to breaking up of the blood-corpuscles (hemolysis). 2. That, owing to some defect in the blood-making (hemogenesis), the blood becomes vulnerable to the destructive influence of micro-organisms. At the present time the former view strongly prevails, the hemolysis, as urged by Grawitz, Hunter, Stengel, and others, being ascribed in great part to poisons absorbed from the alimentary canal, the disease being thus an autointoxica- tion. The toxics, according to Sajous, promote and sustain hemolysis by caus- ing an overproduction of antibodies, which not only destroy the pathogenic poisons, but also the red corpuscles. By the subcutaneous injection of the muriate of phenjdhydrazin into animals a condition of the blood similar to that in pernicious anemia is obtained. S. Kaminer and R. Rohnstein (Berl. khn. Woch., July 30, 1900). Pernicious anemia is probably due to an intoxication, possibly from the stomach, and the cases referred to are probably to be placed in the same category. It is easily understood that with an absence of free hydrochloric acid enormous bacterial growth can take place in the intestines, and that changes in the digestion of the proteids will follow. The treatment of the con- dition is self-explanatory. Grawitz (Berl. klin. Woch., June 29, 1903). Pernicious anemia is a definite hemo- lytic disease \^'ith disturbances of the alimentary canal and fever. The course of the disease is marked not only by slight variations from time to time, but usually by one or more periods of dis- tinct improvement, lasting sometimes many months, in some cases even a year or two — sometimes occurring in- dependently of treatment, but without doubt greatly due to the beneficial effect of arsenic. The tendency to relapse is in reality due to the remarkable per- sistence of the specific hemolytic infec- tion underlying the disease, since it is always accompanied by a recrudescence of the lesions in the tongue, stomach,, or intestine, and by the glossitic, gas- tric, or intestinal symptoms connected therewith. Hunter (Brit. Med. Jour., Nov. 9, 1907). In an attempt to isolate a hemolj'tic substance from the stools of patients suffering from pernicious anemia with ulceration of the intestines, the authors studied the stools from 106 cases, all but 11 of which showed some gastro- intestinal lesion. A hemolytic substance was constanth^ found in the stools of patients suffering with tuberculous en- teritis (10 ovit of 11 cases), while nor- mal cases gave practically negative re- sults. The hemol3i;ic substance appears in the stools whenever there is a dis- turbance of fat absorption. Grafe and Rohmer (Deut. Archiv f. klin. Med., Bd. xcvi, S. 397, 1909). Deficiency of red corpuscles (oligo- cythemia) is always very great; the blood is, therefore, pale and thin, re- sembling sherry wine. The oligocy- themia is sometimes so marked that the normal proportion of 5,000,000 red corpuscles to the cubic centimeter is reduced to one-twenty-fifth of that number. Quincke reported a case in which, as previously stated, there were only 143,000 to the cubic centimeter immediately before death. This is an important diagnostic feature. There is no disease, except pernicious anemia, in which the number of red corpuscles is at any time reduced below 20 per cent. This affords a distinction between ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 629 pernicious anemia and latent gastric cancer, a disease with which the former is most hkely to be confounded. The hemoglobin is also greatly re- duced (oligochromemia), but not in proportion with the cell reduction. The hemoglobin percentage was greater by 10 per cent, in a case seen by Osier. The relatively high percentage of hem- oglobin depends upon increased aver- age size of the corpuscles and in some cases on the presence of an unusual number of highly colored and minute microcytes. It also depends, in a meas- ure, upon the time at which the ex- amination is made. The icteric color of the skin and the dark urine are caused by dissolution of the red blood- corpuscles, and the hemoglobin esti- mated at one of these periods will thus be higher, owing to the more highly colored plasma. The red blood-cor- puscles show marked signs of reversion tq the type of blood which is normal in the cold-blooded animals. There is also a species of degenera- tion closely resembling coagulation ne- crosis, and an alteration of the cor- puscles, characterized by the appearance in their interior of certain corpuscles composed of modified hemoglobin — degeneration hemoglobinemique. The process of regeneration is man- ifested by the presence of nucleated red corpuscles, which are divided by Ehrlich into two varieties : the normo- blasts and the megaloblasts, the former corresponding to the hematinic evolu- tion of adults, the latter to that of the embryo. The nucleus of the normo- blast is extruded to form a new red corpuscle, while the nucleus of the meg- aloblast is absorbed. Fresh blood shows nucleated red corpuscles of large size, the megalocytes and gigantocytes previously mentioned. Fiirbringer has shown that a case is to be considered as one of true per- nicious anemia only when one-fourth of the red corpuscles are macrocytes. The presence of megaloblasts is a sign that certain pathological changes are taking place in the red marrow rather than a distinctive feature of pernicious anemia. The macrocytes are more characterisic of pernicious anemia, be- cause they are the direct precursors of the large red-marrow cells. Misshapen corpuscles (poikilocytes) are very frequently observed, oftener, indeed, than in any other affection. Many small, imperfectly developed corpuscles (microcytes) are generally found. In marked cases corpuscles endowed with motion are occasionally observed. According to Hayem, the red blood- corpuscles of normal blood are motion- less. Conversely, the elements observed in cases of high degree of anemia are endowed with four kinds of motion : 1. A movement of the entire mass of the corpuscle. 2. The projection of mo- bile prolongations. 3. A movement of oscillation, manifested slowly by minute corpuscles. 4. A movement which re- sults in changing the position of the corpuscles. These movable corpuscles are bodies arrested in their evolution and still retaining the contractile prop- erties of the hematoblasts from which " the red corpuscles originate. On super- ficial examination they might readily be mistaken for parasites. Many years ago I observed distinct movements in the red corpuscles in a case of pernicious anemia, but made no public mention of the interesting fact. Senator has also called attention to the presence of small, mobile bodies observed staining the same as red cor- puscles and resembling fragments of 630 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). hematin, thought to possess pathogno- monic value. Pernicious anemia is essentially a hemolytic disease, the hemolysis being due to some as yet unknown poison comparable in its effect on the blood and blood-organs to the action of toluylenediamine — whether autointoxi- cation or infection remains yet to be determined. The poison of pernicious anemia stimulates the phagocytes of the spleen, lymph- and hemolymph- glands, and bone-marrow to increased hemolysis (cellular hemolysis). Either the phagocytes are directly stimulated to increased destruction of red cells or the latter are so changed by the poison that they themselves stimulate the phagocytes. The hemolysis of perni- cious anemia differs only in degree, not in kind, from normal hemolysis or the pathological increase occurring in sep- sis, typhoid, etc. It is not improbable that from the destruction of hemoglo- bin poisonous products (histon?) may be formed which have also a hemolytic action ; a vicious circle of hemolysis may thus be produced. No proof of this exists at present. The hemolysis of pernicious anemia is not confined to the portal area, as according to Hunter, but, in some cases at least, takes place also to a large extent in the prever- tebral lymph- and hemolymph- nodes and bone-marrow. In the majority of cases the spleen is the chief seat of the blood destruction. No evidences of hemolysis in the liver, stomach, and intestinal capillaries were found in the 8 cases. The hemosiderin of the liver and kidneys is carried to these organs as some soluble derivative of hemo- globin, is removed from the circulation as hemosiderin by the endothelium, and then transferred to the liver- or kidney- cells. The deposit of iron in these organs is of the nature of an excretion. In the majority of cases only slight reaction for iron is found at the sites of actual hemolysis (spleen, lymph- and hemolymph- glands, and bone-marrow). The greater part of the pigment in the phagocytes of the spleen, lymph- and hemolymph- glands does not give an iron reaction while in a diffuse form. When changed to a granular pigment the iron reaction may usually be obtained. The change to hemosiderin is for the greater part ac- complished by the endothelium of the liver and kidneys. The varying path- ological conditions found in these dif- ferent cases of pernicious anemia can be explained only by a theory of cyclical or intermittent process of hemolysis. This theory is also borne out by the exacerbations so frequently seen clin- ically. The autopsy findings, in so far as evidences of hemolysis are concerned, will depend on the relation between the time of death and the stage of the hemolysis. The changes in the hemo- lymph-glands found constantly in these 8 cases were : dilatation of the blood- sinuses and evidences of increased he- molysis, as shown by the increased number of phagocytes containing dis- integrating red cells and blood-pigment. In some of the cases these changes were accompanied by great increase in size and apparent increase in the number of hemolymph-glands ; in other cases there was no hyperplasia, the only evidence of the changes present being that ob- tained by the microscopic examination. The changes found cannot be regarded as a specific of pernicious anemia, since it is probable that they may be produced by other infections or toxic processes characterized by great hemol- ysis. The lymphoid and megaloblastic changes in the bone-marrow do not form an essential part of the pathology of pernicious anemia, and are to be regarded as of a compensatory nature : an increased activity of red-cell forma- tion to supply the deficiency caused by the excessive hemolysis. A. S. War- thin (Amer. Jour. Med. Sciences, Oct., 1902). PATHOLOGY.— In cases in which the urine is dark the latter is found to contain pathological urobilin: a sub- stance known to be derived from, the disintegration of hemoglobin, and which, according to Hunter, is of high diagnostic significance. A peculiarity ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 631 of this highly colored urine is that it presents a low specific gravity, averag- ing 1.014. Occasionally, however, the urtne is habitually pale. The kidneys are often the seat of fatty infiltration, accompanied sometimes by thickening of the interstitial tissue. Case in which hemolysis in pernicious anemia was augmented by urinary re- tention. The urinary retention was secondary to relapses of the anemia which caused weakness of the bladder musculature. Cunningham (Annals of Surg., Feb., 1907). Case similar to Cunningham's, but in which an enlarged prostate, which was present in both cases, was primarily responsible for the urinary retention. Following this there was a retention and absorption of the hemolysins which failed to be excreted, with consequent changes in the course of the disease. When the poison that is normally being excreted from the kidneys is added to that in the general circulation, increased hemolysis is to be expected. H. A. Freund (Jour. Amer. Med. Assoc, May 4, 1907). Examination of the kidneys in 12 cases of pernicious anemia of unknown etiology showed that in every instance fat was present in the kidneys, but in slight amount and in special arrange- ment in the cells, being rather of the nature of a fatty infiltration than a ' degeneration of the renal epithelia. In long-continued or very rapidly progress- ing cases focal deposits of furruginous pigment were present, but only in the cortical substance in the epithelia of the convoluted tubules. In all cases there was a marked increase and thicken- ing of the interstitial tissue resem- bling sclerosis, most pronounced in the medullary substance. L. Paszkiewicz (Virchow's Archiv f. Path. Anat., Bd. cxcii, S. 324, 1908). Case illustrates the relations between periiicious anemia and renal lesions. A man aged 52 years came under treatment for a grave anemia, weak- ness, and generalized edema. The pa- tient grew steadily worse, and died m apparently uremic coma. The examina- tion of the blood showed an intense plastic anemia with myeloid reaction and hyperleucocytosis ; some nucleated reds were present, and the corpuscular resistance was normal. At autopsy the main lesion present was nephritis with a kidney of the large white type. The factors of dilution of the blood, toxic hemolysis, or a defect in the corpus- cular resistance the authors do not think can enter into this case. It is possible, however, that both the renal and blood lesions are the result of some infection or intoxication. At any rate,- this association of the two lesions is frequent and should be noted in a con- dition the cause of which is so often unknown. Labbe and Joltrain (Arch, des mal. du cceur, des vaisseaux, et du sang, vol. i, p. 366, 1908). The gastric and intestinal disorders are probably due to the formation of poisons, which, we have seen, act, in turn, as the etiological factors of the general disease. The gastric and in- testinal walls are often found to be the seat of fatty change, and atrophied. Carious teeth have been regarded as potent factors in the etiology of per- nicious anemia by Hunter, but this view has not been sustained. Intestinal en- tozoa, hoAvever, undoubtedly underlie many cases. The writer considers that the causa- tive process of infection is double: (1) a specific infection of which the chief evidence is a glossitis, and (2) a septic infection of the mouth, stomach, and intestine of which the chief evidences during life are varying degrees of "oral sepsis" and "septic gastritis," the latter recognizable during life by the vomit and various symptoms of oral, gastric, and intestinal disturbance, and after death by the conditions of gas- tritis, gastric and intest'nal atrophy, and now and again erosions and ulcers. Sepsis alone is incapable of giving rise to true pernicious anemia, for in septic anemia there is no evidence in the liver of hemolysis. A peculiar form of 632 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). glossitis had been found in every one of the 25 cases included in the present paper. There was great thinning of the mucosa, which in places was entirely lost, so that the lymphatics of the tongue were left in direct continuity with the buccal cavity. This thinning of the mucosa produces the peculiar glossy surface of the tongue characteristic of the disease. Hunter (Practitioner, July, 1902). Repeated intravenous injections of living cultures of the colon bacillus into rabbits found to cause the de- velopment of a state of advanced anemia not quite comparable with any of the classical forms seen in man. In some respects it resembles pernicious anemia, namely:' in the very great diminution of erythrocytes, the marked poikilocytosis, and the appearance of nucleated red corpuscles. On the other hand, it differs from pernicious anemia in the fall of the amount of hemoglobin being parallel with the decrease of the red corpuscles, in the absence of a dis^ tinct and extensive Inincke's siderosis, in the absence of any clear evidence of inflammatory or other disturbances of the digestive tract, and of well-marked changes in the bone-marrow. In the advanced stage of this anemia a diffuse degeneration of the spinal cord was set up, affecting the posterior and lateral columns of the cord, in the lumbar and dorsal regions. This degeneration con- sisted in a fatty degeneration of the myelin sheaths of the fibers and certain pigmentary changes in the nerve-cell bodies of the gray matter. The ventral columns of the cord and the gray matter were not affected. Similar con- ditions of anemia and spinal-cord degen- eration could not be produced by inject- ing killed cultures of the colon bacillus, nor by filtered cultures. When the living cultures were acted upon by pep- sin, and injected intravenously, they did not differ materially in their action from the original living cultures. G. A. Charlton (Jour, of Med. Research, May, 1904). Pernicious anemia may be due to an infection of the intestinal tract with the Bacillus aerogenes capsulatus. The writer finds this organism regularly and in large numbers in the fecal matter of patients with pernicious anemia, whereas in ideal conditions of human digestion the organism is present only in small numbers. Reductions in the number of capsulati, in these patients, are followed by an improvement of symptoms. Neutral filtrates from cul- tures of this bacillus in blood bouillon were found to have a marked hemo- lytic power. Seventeen cases of anemia were studied, 9 imdoubtedly pernicious, 4 probably pernicious, and 4 possibly belonging to the same class. Herter (Jour, of Biol. Chemistry, Aug., 1906). The writer has found no oral sepsis in any of his cases, and does not be- lieve this has the influence in the pro- duction of the disease which some authorities have suggested. The glos- sitis from which many patients who are affected with pernicious anemia suffer is a consequence rather than a cause, due, presumably, to the same toxin, whatever it may be, which is the cause of the anemia. Byrom Bramwell (Brit. Med. Jour., Jan. 22, 1909). Tallquist has shown that Dibothrio- cephalus latus, which may cause an anemia similar to pernicious anemia, contains a powerfully hemolytic lipoid which can be extracted from the body of the worm, and has been able to demonstrate quite similar substances in the mucosa of the human digestive tract. The writers have pursued in- vestigations of like nature, the results of which follow : 1. In pernicious anemia there is present in the gastric and intestinal mucosas a lipoid substance soluble in ether, which is about ten times as powerful a hemolysin as the lipoid obtained from the normal mucosa 2. Tested experimentally on animals, this lipoid shows weak, but definite hemolytic properties when administered either subcutaneously or by the stom- ach. That obtained from the normal mucosa exerts much less action or none at all. 3. The resulting anemia has the characteristics of pernicious anemia. 4. In dogs it is possible, to obtain a lipoid similar in action to that in per- nicious anemia, after first producing ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 633 a gastrointestinal catarrh. 5. The con- clusion seems justified that the origin of the so-called cryptogenic form of pernicious anemia is to be found in the hemolytic action of this lipoid ma- terial, with secondary insufficiency of the bone-marrow. 6. The place of origin of this powerfully hemolytic lipoid is in all probability the gastro- intestinal mucosa ; the cause of its pro- duction seems to be a chronic inflam- mation of the mucosa. Berger and Tsuchiga (Deut. Archiv f. klin. Med., . xcvi, S. 252, 1909; Amer. Jour. Med. Sci., Sept., 1909). Experimental research with the ex- tract of the gastrointestinal mucosa after death from pernicious anemia and with the mucosa from dogs with gas- trointestinal affections. The extract of the mucosa under certain conditions had a pronounced hemolytic action. It seems probable that an inflammatory infiltration in the gastrointestinal mu- cosa plays an- important part in the development of pernicious anemia. The inflammatory catarrhal process leads to the production of an intensely hemo- lytic lipoid substance. That every catarrhal affection is not accompanied by anemia is dvte to the compensating action of the bone-marrow which re- places the destroyed blood-corpuscles as fast as they are destroyed. The proc- ess has to be very severe or very long continued to result in a pernicious anemia. Schmidt (Deut. Archiv f. klin. Med., Bd. xcvi, Nu. 3-4, 1909). The spleen is generally thought to present no characteristic lesion, al- though the amount of iron in it is usu- ally increased. It may, however, be slightly enlarged, and be the seat, as observed by Stanley, of sclerotic changes, along with similar changes in the pancreas and adrenals. In every spleen finely granular cells, as myelocytes, found. Eosinophilic my- elocytes and normoblasts are only seen in spleens which have suffered altera- tion through congestion, infectious processes, and severe anemias. Under certain conditions the spleen may undergo myeloid transformation, partly through the proliferation of the pre- existing myelocytes and partly through emigration to other cells, to which class belong the eosinophiles and normo- blasts. Kurpjuwcit (Deutsch. Archiv f. khn. Med., Bd. Ixxx, p. 168, 1904). Changes in the spleen and liver similar to those described by Meyer and Bleinecke in man in pernicious anemia and in other severe anemias may be produced in animals by the administration of hemolytic substances ; the writer's results confirm those ob- tained by Morris. In some instances, especially in chronic anemias with re- generation, the liver and spleen both resembled the organs of the embryo at the stage when these organs are en- gaged in hematopoiesis. Domarns (Archiv f. exper. Path. u. Pharm., Bd. Iviii, S. 319, 1908). Jaundice is probably due to accumu- lation of iron in the hepatic system. In a case studied by Ruttan and Adami, the total quantity of iron found in the liver was '0.2433 per cent, by weight calculated to the fresh undried tissue. This is equivalent to about 0.72 per cent, to the dried tissue. The estima- tion accords fully with the observations of previous observers, as showing the very great increase in the iron con- tained in the liver in this disease. Kely- nack and Coutts found it to be five times greater than normal. The iron is mainly deposited about the periphery and middle zone of the lobules, and is derived from the vast number of de- stroyed red corpuscles. The kidneys, spleen, pancreas, hemolymph-glands are also laden with iron-pigment derived from these cells. Inquiry into the after-history of 22 cases. The disease believed to be due to an increase in the destructive action of the liver upon the red blood-corpus- cles. While the 22 cases were thought to be "cured" by various means, 10 died of the disease, and only 2 were known 634 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). to be living at the time of the investiga- tion. H. C. Colman (Edinburgh Med. Jour., March and April, 1901). Case of jaundice associated with weakness in which there were no ab- dominal symptoms or evidence of obstructive lesion of the bile-ducts. The blood-picture was typical of Addison's anemia. There was marked improvement of health and disap- pearance of jaundice under arsenic and appropriate hygienic measures. Vanderhoof (Old Dominion Jour, of Med. and Surg.,. April, 1911). The posterior and lateral spinal tracts present changes resembling those observed in tabes, but most marked in the posterior lateral columns, as observed by Nonne, and to a less degree in the lateral columns. All these changes are not typical of pernicious anemia, however, and may be met with in other diseases in which cachexia and marasmus predominate, such as Addi- son's disease and diabetes. Hemor- rhagic areas in the cord and brain due to hyaline degeneration of the blood- vessels are also met with. We have seen that retinal hemorrhages consti- tute a diagnostic feature of the disease. Study of pathological lesions found in the spinal cord in cases of pernicious anemia showed that there was usually a degeneration affecting the posterior columns, sometimes the posterior and lateral together, but never the lateral alone. This degeneration was chiefly in the nerve-fibers, and was unaccom- panied by shrinking of the cord, such as was seen in locomotor ataxia. Seventeen cases analyzed in which in- itial nervous symptom was always a persistent paresthesia, usually of the foot, associated with some weakness. This was generally followed quickly by ataxia and loss of motor power, and severe pains in the back and limbs were not uncommon. The disease progressed rather rapidly, so that often within one or two months the symptoms were well developed. In from six months to a year the progress commonly reached its acme, and during this time the anemia became marked. After a time the con- trol of the bladder and the rectum was lost, and in fatal cases death occurred in from six months to two years. The essential nature of the process was a primary nerve degeneration affecting the neuraxons first, particularly in the columns of Goll and the crossed py- ramidal tract. The same poison which caused pernicious anemia was respon- sible for this disease. It usually de- veloped between the ages of 50 and 60 years, and followed the acute infec- tions, prolonged diarrheal or dysenteric attacks, lead poisoning, malarial infec- tion, etc. In 10 per cent, or more of the cases pernicious anemia undoubtedly coexisted. Charles L. Dana (N. Y. Med. Jour., Nov. 19, 1898). Examination of the spinal cord in cases of pernicious anemia by the Marchi method. Results summarized as follows: (1) the changes in the spinal cord in fatal cases of anemia are not systematic, but should be regarded as acute disseminated myelitis; (2) the foci exhibit a local association with the blood-vessels; (3) it is probable that a noxious material is carried to the cord by the blood-vessels, and this acts upon the nervous tissue ; similar changes are found in old age ; (4) even in advanced cases the gray matter may escape in- volvement; (5) if diseased, it is not pri- marily affected, — that is to say, it and the white matter are involved as the re- sult of a single cause ; (6) the diffuse character of the degeneration in these conditions justifies the conclusion that there is a trophic alteration, and not a functional injury of the nervous ele- ment; (7) the greater part of degen- erated fibers are found in the posterior roots and the anterior commissure. Nonne (Deut. Zeit. f. Nervenheilk., March 9, 1899). There is a well-established relation of diffuse cord degeneration with per- nicious anemia. It seems highly prob- able that the hemolysis and the cord changes are due to the same toxin. While the source of the toxin is un- known, the fact that gastrointestinal ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 635 disturbance is so common in the disease would lead one to suppose that it is of intestinal origin. The diffuse de- generations of the spinal cord which occur in conditions without pernicious anemia do not appear to differ essen- tially from those of pernicious anemia. It is possible that a common blood- circulating poison exists, which may expend its force upon the blood in one individual, upon the nervous apparatus in another, and coincidently upon the blood and spinal cord in others. Frank Billings (Boston Med. and Surg. Jour., Aug. 28 and Sept. 4, 1902). Case which shows the alterations in the sympathetic nervous system in per- nicious anemia. The celiac and superior cervical sympathetic ganglia were ex- amined microscopically after having been stained by Nissl's method. The nerve-cells were found profoundly al- tered; in fact, in most of them the nucleus was either no longer visible or cloudy, deformed, and displaced toward the periphery of the cell. In many cells there was a granular pig- ment scattered through the protoplasm in the form of yellowish-brown refrac- tile granules. In other places the protoplasm was found in a condition of fatty degeneration. In places the cell body was but very faintly visible, and the nerve-processes indistinct, at- rophied, and in some cases fatty. G. Vincenzo (Gaz. degli osped. e delle clin., Sept. 23, 1900). Out of 50 cases of pernicious anemia, about 20 showed nervous manifestations of one kind or another. The writer analyzed the cases with the view of classifying the nervous symptoms, but without determining any definite groups. At one end of the series are merely sensory disturbances, and at the other complete paraplegia with loss of control of bladder and rectum. Report of 3 cases as examples of different types. McCrae (Bull. Johns Hopkins Hosp., Feb.-March, 1902). Two cases illustrating 2 of the types of nervous-system involvement. In the first case, which had the longest and more pronounced history of anemia, the nervous symptoms were at a mini- mum and the posterior columns of the cord, particularly in the cervical region, alone showed degeneration, characteris- tically patchy in distribution. In the second case, the nervous involvement, particularly in the later stages, over- shadowed the anemia. Here the spinal cord presented very extensive, yet in- complete degeneration with slight re- placement gliosis in the posterior col- umns, and also a similarly irregular, but more diffuse degeneration in the lateral tracts, which, however, was a rather less complete and apparently somewhat more recent process. Camac Milne (Amer. Jour. Med. Sci., Oct., 1910). The bone-marrow usually presents changes which indicate abnormal activ- ity, being composed mainly, when the case is not too far advanced, of hemat- oblasts, as emphasized by Rindfleisch. It resembles in this state, as noted by H. C. Wood, Pineau, and others, the hemoblastiQ marrow of childhood. Other changes frequently found, ac- cording to Muir, are (a) increased number of nucleated red corpuscles in the marrow; (b) transformation of the fatty marrow in the shafts of the long bones into red marrow; (c) absorption of the bone trabeculse between the red marrow. Later, it presents all the signs of excessive compensative func- tion, being actually hypertrophied in some instances. When this stage is reached the bone-marrow may lose its power to create red corpuscles. The proteids of the plasma may be altered in their respective proportions, and considerably reduced — 40 per cent, below the average normal quantity, ac- cording to Ruttan and Adami — the globulins being especially reduced. As ill understood as the etiology of the disease is the actual condition of the blood. The microscopic appearances are well known, but the true chemical 636 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). changes have ahuost entirely been neg- lected. The blood in pernicious anemia contains a larger quantity of water than normal blood, a smaller quantity of solids, a higher proportion of chlorine, and a lower proportion of potassium, iron, and fat. There is not sufficient so- dium to hold the chlorine fixed, and the potassium is also deficient. In various tissues the proportion of water was higher than normal in the heart, and lower in the liver, spleen, and brain. Treatment of pernicious anemia with potassium carbonate, tartrate, and cit- rate in 4 cases, 3 of which were dying, resulted in recovery. Th. Rumpf (Berl, klin. Woch., May 6, 1901). Although fatty degeneration is pres- ent in practically all organs, emaciation is exceptional, though the adipose tis- sue is pale and yellowish, contrasting with the usually red muscular tissue. The heart, however, is enlarged and flabby, and its muscular elements are pale, friable, and fatty, its cavities containing light-colored blood. The general fatty degeneration affecting markedly the vessel walls, these are extremely friable; hence, the hemor- rhages, retinal, cutaneous, etc., and the ecchymoses so frequently witnessed. DIAGNOSIS.— While pernicious anemia possesses characteristics that readily distinguish it from other blood affections, — the color of the skin, the retinal hemorrhages, etc., — the early stages are generally such as to suggest diseases that do not present the same degree of danger. Benign Anemia. — Intractability of the disease, after the removal of sup- posed causes and the faithful use of appropriate measures of treatment, strongly suggests the presence of per- nicious anemia. Chlorosis. — From this affection per- nicious anemia may readily be dif- ferentiated by the blood examination. Instead of relative increase of hemo- globin, the presence of gigantoblasts, marked oligocythemia, and macrocytes differentiate. The red corpuscles, in chlorosis, may be normal in number and size, the only change being a deficiency of hemoglobin. Again, the corpuscles may be normal in number, but dimin- ished in size, while the percentage of hemoglobin is normal ; finally, the cor- puscles may be diminished in number with either a diminished, normal, or perhaps an increased percentage of hemoglobin. The important diagnostic points ob- served in 20 cases were: (1) the high color index; (2) the severe degree of poikilocytosis ; (3) the constant pres- ence of polychromatophilia ; (4) the number of megaloblasts, usually pre- dominating over the normoblasts. The writer considers these points to be pathognomonic of the disease. Billings (Amer. Jour. Med. Sci., Nov., 1900). Of all the morbid changes which oc- cur in the blood, the most important is the presence of megaloblasts. In 29 cases of the malady observed by the author, only in 1 could these large corpuscles not be found on repeated examination ; in the remaining 28 they were present, and in the majority of instances could be detected on the first examination. Naegeli (Wiener med. Woch., Aug. 22, 1903). Leucocythemia. — This disease may be excluded by the absence of the characteristic blood-change: excess of white corpuscles. Pseudoleucocythemia is excluded by the absence of the affection of the lymphatic glands which characterizes this disease, more commonly known as Hodgkin's disease. Leukemia. — In leukemia the patient often does not show enough pallor to make the physician suspect the disease. The lips have a dirty-red color rather than a peculiar pallor. The number of white corpuscles would cause pallor in ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 637 a patient with simple anemia, but in this disease the opacity of the l)loo(l is great and the pallor fails to show (Jane way). Gastric Cancer. — This condition al- most always shows itself after the age of 40 years, whereas pernicious anemia is generally observed early in life. In cancer the skin is pale; in pernicious anemia the peculiar lemon color is striking in the majority of cases. While gastric symptoms and absence of hy- drochloric acid are prominent features of cancer, the digestive disorder is slighdy marked in anemia and exam- ination of the gastric contents is nega- tive. The reduction of red cells is greater in pernicious anemia than in cancer. The reduction of hemoglobin relative to corpuscles is not so great in per- nicious anemia as in cancer. The aver- age size of red cells is greater and polychromatophilia is marked in per- nicious anemia. In cancer the cells are small and may show fissures, but not so marked polychromatophilia. Megalo- blas!s are present generally in greater numbers than normoblasts in pernicious anemia; their mere presence is of great importance, as, although normoblasts are common, megaloblasts occur with very great rarity in cancer. In the absence of complication there is fio leucocytosis, and in the absence of fever there is lymphocytosis in perni- cious anemia. In cancer leucocytosis is the rule; lymphocytosis does not occur. The author refers to four groups of cases, and in each group the blood characteristics have something in com- mon : acute favorable cases ; chronic cases; subacute cases; acute unfavorable cases. Alexander Goodall (Scottish Med. and Surg. Jour., April, 1902). The value of laboratory methods in the dififerential diagnosis of pernicious anemia and cancer of the stomach is illustrated by the case of a man 50 years of age who had been regarded as a case of gastric cancer by other physi- cians until his blood had been carefully examined. In such cases when megalo- blasts are found in the blood we have a positive diagnosis of pernicious anemia, while if there is cancer of the stomach the principal feature of the blood is a marked leucocytosis. Cer- coni (Riforma medica, July 6, 1907). Finally, increasing emaciation at- tends a cancerous disorder, whereas in cases of pernicious anemia the patient not only retains his adipose tissues, but sometimes becomes corpulent. In rare cases, however, there has been extreme emaciation. Is it possible to diagnose pernicious anemia by the early symptoms before the appearance of the characteristic blood-picture of the disease? While the literature shows that there is no regularity in the order of their appear- ance, there are facts enough to indicate their importance. In the writer's 20 cases, achylia gastrica, with its asso- ciated diarrhea, was present in 14, and in 9 it was a very early symptom. In one case it seemed to have been present thirty-five years before the blood con- dition was recognized, and in another it was present eight years before the blood-picture developed ; i i still another case reported it was present six years before. The nervous phenomena may occur early or late, and in only 1 of his 6 cases with early nervous symptoms did they appear before the signs in the blood were found. The cardiovascu- lar are the least characteristic early symptoms; in only 1 of his 5 cases presenting them as such did he prop- erly interpret them before finding the pathognomonic blood signs." The au- thor, therefore, is unable at present to describe a symptom-complex indicating pernicious anemia before the occur- rence, or discovery, of the blood changes, but he believes, nevertheless, that a more careful study of patients in the early stages of the disease will give considerable evidence that such a symptom-complex exists. J. A. Lichty (Jour. Amer. Med. Assoc, June 29, 1907). 638 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). The pernicious anemia of infants — a rare condition — is recognized, ac- cording to Rotch and Ladd, through the following diagnostic points: The insidious onset with moderate and par- oxysmal attacks of indigestion, the extreme pallor, great loss of strength, slightly elevated temperature for months, and absence of glandular or splenic enlargement or of any demon- strable cause for a secondary anemia. The signs which are almost pathogno- monic in adults lose significance, on account of the greater instability of the infant's blood-making function. Mega- loblasts, normoblasts, macrocytes, and poikilocytes may occur in grave anemia as other than "pernicious"; still, these elements are needed for diagnosis. ETIOLOGY. — The main patho- genic factor, hemolysis, has been re- viewed under a preceding heading; we still have to consider, however, the con- ditions which either predispose to the disease or are capable of causing it. As to predisposing agencies, although the disease occasionally occurs in chil- dren, it is most common in adults be- tween the ages of 20 and 40 years. Males are attacked more frequently than females, with a slight difference in favor of the former. The disease is more prevalent among the better than in the lower classes, and is miost com- mon in Europe, especially in Switzer- land, e.g., in regions in which the peo- ple are badly fed and hve in poorly ventilated and badly lighted houses. F>ight and grief are prominent etiolog- ical factors. Syphilis, sarcoma, and other disorders capable of impairing hematopoietic functions of the bones are also capable of bringing on the disease. According to Grawitz, the following group of etiological factors has been established : 1. Gastrointestinal disease of long standing, poor food, impaired digestion; chronic constipation, espe- cially in women frequently pregnant; irregular defecation in women and girls, especially those of hysterical temperament. In such cases it is due to intoxication from the gastrointes- tinal tract. 2. Pregnancy. Here, too, probably, there is an autointoxication from the intestinal tract, on account of pressure exerted by the gravid uterus on the bowel. 3. Chronic hemorrhages, especially of small size. 4. Constitu- tional syphilis, particularly when asso- ciated with sclerosis of the marrow of the long bones. 5. Bad hygienic con- ditions of various kinds, especially in the female sex ; hard work, with insuf- ficient food, bad air, and emotional excitement. In higher social strata the disease may be found in women who are subjected to intense mental strain as the result of a desire to equal men in physical efforts. Frequent preg- nancy and prolonged lactation are also factors. 6. Chronic poisoning, as, e.g., by carbon monoxide. 7. Bothriocephalus and ankylostomum — those cases belong here that are not cured after the expul- sion of the worms. Variations in nitrogenous metabolism of 21 cases of bothriocephalus anemia studied at the Helsingfors medical clinic. In all cases there was a distinct nitrogen loss up to 8.8 grams per day before the worm was expelled. After- ward the nitrogenous balance was at once or by degrees entirely regained. In some cases there was retention of nitrogen. The writer ascribes the in- creased nitrogen output to the action of a toxin produced by the worm upon albuminous matter. No parallel was found between the blood conditions and the nitrogenous excretion. With a purin-free diet the urinary purin excre- tion showed marked variations. Dur- ing the toxic period — that is to say, ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 639 while the worm was present in the in- testines — the endogenous purin excre- tion was very large. When the worm has been removed, the quantity of purin excreted sank rapidly to the normal. In some cases, however, it continued high for some days after the expulsion of the worm. The toxins secreted by the worm evidently incite leucocytosis to a high degree, and also extensive destruction of nuclear matter. E. Rosengrist (Zeit. f. klin. Med., Bd. xlix, 1903). Pernicious anemia is not a specific entity, but a clinical syndrome of var}'- ing etiology. Etiologically, the disease can be considered as cryptogenetic, or of concealed origin. Under the former the writers group : (1) repeated hemor- rhage (gastric, uterine, nasal, and ves- ical) ; (2) intestinal parasites (bothrio- cephalus and ankylostoma) ; (3) ma- laria; (4) bacterial infections; (5) tuberculosis; (6) syphilis; (7) cancer, especially gastric ; (8) gastrointestinal disorders and autointoxications, which are said to be the cause of the so-called idiopathic cases; (9) nephritis; (10) pregnancy; (11) lead; (12) carbon monoxide, arsenic, and opium. The factors necessary for any of the above conditions to result in this syndrome are (a) an excessive intensity of the morbid cause; (b) the localization of the infection ; (c) the duration or rep.etition of the cause; (d) an accumu- lation of the morbid condition ; (e) predisposition. On the whole, pro- gressive pernicious anemia can be the final stage of secondary anemias. Ladd and Salomon (Revue de med., April and May, 1908). Three cases of severe anemia wit- nessed due to repeated small bleed- ings and occasionally larger ones from varicosities situated 10 to 15 cm. above the anus which could easily be seen with the proctoscope. Destruc- tion of these varicosities by the Paquelin cautery rapidly cured the anemia. C. A. Ewald (Berl. klin. Woch., Jan. 9, 1911). Pregnant women represent the larg- est proportion of cases. Repeated par- turition is probably the most prolific cause of the disease, for it is seldom met with in primiparre. Excessive and prolonged lactation and puerperal hem- orrhages and other exhausting- condi- tions frequently appear as the primary element in the causation of the disease. Certain atrophic conditions .of the, gastric mucous membrane, ulcers of the stomach, malaria, syphilis, cancer, • and alcoholism have also been consid- ered as etiological factors. PROGNOSIS.— Although the dis- ease terminates fatally when left to itself, the mortality from very nearly 100 per cent, has been reduced since the introduction of arsenic. A guarded prognosis should always be given, how- ever, relapses being exceedingly com- mon. About one-half of the fatal cases last from one to six months ; the re- maining seldom reach beyond the sec- ond year. Periods of transitory im- provement of varying duration are often a part of the natural course of the disease; so that too much impor- tance must not be attached to the favor- able results that may follow the special line of medication employed. Even if such improvement continues for a long time, the conclusion must not be too hastily reached that the disease is cured. According to Goodall, the prog- nosis may to a certain extent be based upon certain characteristics of the course of the blood-picture : — 1. Acute Favorable Cases. — In these the symptoms are marked; the red cells are much diminished, but show a tend- ency to rise ; the megaloblasts are atyp- ical and not numerous ; the normoblasts are numerous ; the color index is high, but tends to fall ; the polychromato- philia is not marked; the percentage of polymorphonuclear cells is high ; the myelocytes are absent or scanty. 640 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). Course. — A remission to a fairly normal condition may occur, which may be maintained for years. 2. Chronic Cases. — In these the symptoms are not well marked ; the red cells tend to remain about one or two million; the megaloblasts are absent or scanty; the normoblasts are absent or scanty ; the color index is generally low; the polychromatophilia is slight; the percentage of lymphocytes is high; the myelocytes are scanty. Course. — The cases are apt to be chronic. The patients can work, though they feel weak, and, though febrile attacks, etc., may occur, they have little bad effect. The improve- ment seldom occurs, but the duration may be for several years. 3. Subacute Cases. — In these the symptoms are fairly well marked ; the red cells about one million, showing slow and irregular tendency to rise ; the megaloblasts are numerous ; the normo- blasts are less numerous than megalo- blasts; the color index is high; the polychromatophilia is distinct; the per- centage of lymphocytes is high in the absence of fever; the myelocytes are fairly numerous. Course. — Symptoms improve; blood improves to a certain extent. The duration is about two years, unless com- plications reduce this period. 4. Acute Unfavorable Cases. — In this type the symptoms are marked, and there may be hemorrhages ; the red cells are about one million, and tend to remain or go lower; the megaloblasts are typical and numerous ; the normo- blasts are less numerous than megalo- blasts ; the color index is high ; the polychromatophilia is marked ; the per- centage of lymphocytes is high in the absence of fever; the myelocytes may be numerous. Course. — A fatal termination is to be expected in a few months. With improvement of blood condi- tions improvement of the general health by no means always follows. Patients with pernicious anemia do not always die of the anemia itself, for many cases with abnormally low hemoglobin and blood-count improve. They die more frequently of the secondary organic changes caused by the anemia, chief among which are fatty degeneration of the heart muscle and functional dis- orders of the nervous system. The prognosis is, therefore, not alone de- pendent upon the blood conditions, but also upon that of the other organs. Conclusions from the blood alone can lead to great error in the prognosis. Hirschfeld (Therapie der Gegenwart, Nu. 8, 1907). The tendency to relapse is in reality due to the remarkable persistence of the specific hemolytic infection under- lying the disease, since it is always ac- companied by a recrudescence of the lesions in the tongue, stomach, or in- testine, and by the glossitic, gastric, or intestinal symptoms connected there- with. Hunter (Brit. Med. Jour., Nov. 9, 1907). The immediate prognosis in certain cases of pernicious anemia with blood depletion below 400,000, although seri- ous, is not hopeless. The prognosis de- pends on the degree of red-cell regen- eration in the bone-marrow, the age of the individual and the potency of the hemolytic poison being important fac- tors. Stone (Jour. Amer. Med. Assoc, April 18, 1908). Report of 3 cases of pernicious anemia .with remissions, with tabulated blood-counts. In one case the improve- ment followed the removal of the pa- tient from the. county farm to the hos- pital, where the better hygienic and dietary conditions were undoubtedly a strong factor. In several cases ob- served, out of a total of 25 in the last two and a half years, in which fermen- tative changes in the intestines were a prominent symptom, high colonic irri- gations with physiological salt solution ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 6+1 seemed to be connected with remissions of improvement. Though the blood- count shows a marked improvement in the remissions, there are still abnormal features indicating that a disturbance in hematogenic function still exists. At best a remission is but a partial cure, and reserve in prognosis and caution in interpreting apparent therapeutic results are alwaj'S advisable. W. L. Bierring (Jour. Amer. Med. Assoc, Aug. 1, 1908). Case of pernicious anemia in which there was a period of complete remis- sion of symptoms, amounting to a cure for some sixteen years, with final re- lapse showing all the characteristic symptoms and pursuing a truly pro- gressive course to a fatal ending. A. McPhedran (Amer. Jour. Med. Sci., Aug., 1910). TREATMENT.— Arsenic cures the curable cases and benefits the others. Iron is worse than useless, having shown itself injurious in several cases reported — doubtless because the liver is already overladen with iron. Fowl- er's solution may be given in 3-minim doses three times a day, increased by 1 minim daily until 30 minims are taken after each meal, provided the stomach does not rebel, which is seldom the case. The patient should be watched and the drug reduced or discontinued temporarily on the appearance of any of the physiological effects of arsenic: edema of the lids, etc. In some in- stances the doses have been increased with marked benefit until as much as 20 drops were taken at a dose. According to Grawitz, rest in bed is one of the first requisites ; the assimi- lation of food must be stimulated. The patient should be placed on a milk and vegetable diet. Lavage of the stom- ach, intestinal irrigation, and saline laxatives are useful. If the urine con- tains much indican intestinal antisep- tics are indicated. He also regards arsenic as the best remedy ; it can be given with quiiine. Inhalations of oxygen have been employed with ad- vantage. Massage and gymnastic ex- ercises are often of service. After apparent recovery the patient must be carefully observed, as relapses are likely to occur, particularly if the hy- gienic and dietetic conditions are un- favorable. Case of pernicious anemia treated by Grawitz's method. The patient was a man 33 years old who was admitted to the hospital after suffering for five weeks from anemia and weakness. All the symptoms manifested by the patient were that of a typical case of pernicious anemia. Treatment consisted of a strict diet of milk and vegetables, daily ene- mata, with arsenic and hydrochloric acid given by the mouth. Lavage of the stomach was not performed, owing to the strenuous objections on the part of the patient. After eight weeks in the hospital and a month's holiday in the mountains his general condition was excellent, and there has been no relapse. The adventitious sounds which had been heard over the heart and cervical veins had disappeared. He no longer felt dyspnea on slight exertion, the temperature became normal, and the pulse was 68-80. The blood-count showed 4,235,000 red cells and no ab- normal cells, as compared with 1,300,000 red cells and numerous microcytes and megalocytes and a marked poikilocyto- sis' and polychromatophilia on admis- sion to the hospital. The success ob- tained in this and similar cases tends to confirm the view that the disease is toxemia, caused by a deficiency of hy- drochloric acid in the gastric juice and a possibly subsequent splitting up of albuminous molecules into toxic bodies rather than to a primary disease of the blood or blood-forming organs. L. Nicolayson (Lancet, Nov. 7, 1908). Experiments based on the hemolytic action of distilled water show that arsenious acid forms a fixed combina- tion with red blood-cells and acts as a protective agent against hemolytic agen- 1—41 642 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). cies. The protective action of arsenic was perceptible when the experimental solution was as weak as 1 : 400,0(30. The ordinary maximum dose of arsenic is 0.005 gram, and if this was all ab- sorbed the amount of arsenic in the blood would be 1 : 1,000,000. How- ever, arsenic is frequently given in larger doses in the organic combina- tions, and it is very slowly eliminated. Furthermore, arsenic seems to attach itself so rapidly and so firmly to the red blood-cells that it is probable that the drug is largely taken up by them. Therefore, the writer believes that arsenic is of benefit in pernicious anemia because it prevents the destruc- tion of the red blood-cells, and that arsenic protects the red blood-cells from invasion by the malarial parasite, but that it does not destroy the parasite. Gunn (Brit. Med. Jour., No. 2481, p. 145, 1908). When the gastric disorder, which is a usual symptom, prevents the admin- istration of arsenic, the latter may be given subcutaneously, while the stom- ach is treated directly by lavage. 'An excess of hydrochloric acid is not uncommonly found in the gastric se- cretions. In such cases See recom- mends an almost exclusive diet of meat and other albuminous foods : raw meat to the extent of 10 to 12 ounces daily. As a rule, however, there is deficiency of hydrochloric acid and pepsin, especially in advanced cases. Good effects have been obtained from large doses of hydrochloric acid and pepsin under these conditions. The great majority of cases of per- nicious anemia suffer from an absence of hydrochloric acid and pepsin in the gastric secretion, and this condition is further harmful in that the essential element for pancreatic secretion is pro- duced only under the stimulus of the acid chyme passing over the duodenal mucosa. To cause an artificial diges- tion, pancreatic as well as gastric, hy- drochloric acid and pepsin in much larger doses than are usually considered permissible prove effective. In a per- sonal case, the patient received 30 grains of pepsin and 105 minims of dilute hy- drochloric acid three times a day, the latter being given in IS-minim doses every ten minutes in albumin water to disguise the taste. The fact that the acid was given combined instead of free did not affect its action. The fur- ther treatment consisted in daily irri- gations of the colon and a liberal mixed diet. It was shown from the blood examination that the treatment had been followed by most satis- factory results. Julius Rudisch (Med. Rec, March 5, 1910). The use of bone-marrow, intro- duced by Fraser, has given good re- sults in some cases and no results whatever in others. Freshly prepared each day with an equal quantity of glycerin, red marrow, 1 or 2 ounces daily, has seemed to give the best re- sults. It should be tried only where arsenic has failed. Transfusion of blood should never be omitted when improvement does not follow the administration of arsenic. The best method is that employed by Brakenridge, of Edinburgh. The blood is kept fluid by admixture with one- third part of its bulk of a 1:20 (5 per cent.) solution of phosphate of soda in distilled water kept at blood heat. John Duncan, who performed the transfusions in Brakenridge's cases, insists upon the necessity of slowness in operating. He regards thirty minutes as the minimum time that should be occupied in injecting 8 ounces of the fluid. Case in which such a rapid trans- formation in the general condition and in the blood-picture followed the transfusion of blood that it is impos- sible to ascribe the phenomena ob- served to a mere coincidence. The technique was as follows: Injection of about 325 Gm. of defibrinated blood ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 643 into the median vein of the patient, about 250 c.c. actually entering the vein. There was no disturbance at the time, but a chill occurred in thirty minutes with transient rise in tem- perature. The improvement com- menced the next day and the curves appended showed the transformation, the hemoglobin running up to 75 per cent, and the reds from 985,000 to 3,720,000 in one month. The prin- cipal danger from therapeutic trans- fusion of blood lies in the loss of vitality of the red corpuscles. They die if they are heated too much; con- sequently the blood to be injected must never be warmed over 45° C. They also die if they remain too long outside the body, although they may be kept on ice up to seventy-two hours. If blood is used from persons requiring therapeutic venesection on account of eclampsia, uremia, or edema of the lungs, there is a pos- sibility that such blood may prove injurious, and there is also a pos- sibility of transmission of consti- tutional disease. As the fibrin-fer- ment is released by the destruction of white corpuscles, blood unusually rich in leucocytes should never be used for transfusion. Sachs (Zeit. f. Geburts. u. Gynak., Bd. Ixiv, Nu. 2, 1909). Seven cases in which threatening anemia was benefited to a remarkable extent by transfusion of only 5 c.c. of human blood. The transfusion of this small amount is simple and generally harmless, but in a few cases there were signs of mild disturbances after the transfusion. It seems as if the blood from certain persons displays more toxicity than from others, 3 patients injected with a certain blood all pre- senting the same transient disturbances. It was never noticed that when two or more patients received blood from the same source the one presented dis- turbance and the other did not. A. Weber (Deut. Archiv f. klin. Med., Sept. 4, 1909). No actual progress has been realized of late in treatment of pernicious anemia. The trouble is seldom recog- nized early enough for eflfectual treat- ment, but the writer's experience with 4 cases seems to confirm the possible benefit from transfusion of small amounts of dclibrinated blood injected into the gluteal muscles. The writer obtained very favorable results from such injections. The first patient was a woman teacher with symptoms of severe pernicious anemia for three years. After 14 injections of 10 or 20 and up to 50 c.c. of blo«.d in the course of eleven weeks, the reds increased from 1,200,000 to 4,500,000 and the hemoglobin from 18 to 92 per cent. The benefit was equally striking in the case of a man of 41, given 9 injections in less than three months, the reds increas- ing to 5,200,000. In a young girl with ordinary anemia and chlorosis the hemoglobin increased from 40 to 75 per cent, and the reds from 3,200,000 to 4,800,000. The blood injected subcuta- neously does not pass directly into the circulation and is still evident four or five days later at the point, the reds still retaining largely their normal shape and staining properties, but the hemo- globin probably lakes out into the cir- culation and thus aids in restoring nor- mal conditions in the general blood- supply, or the injected blood may pro- vide certain other substances lacking in pernicious anemia. The injections do not act on the cause of the anemia, and arsenic is needed for this. By-effects were rare and slight, merely occasional painfulness at the point of injection. Huber (Deut. med. Woch., June 9, 1910). Three cases in which transfusion of blood was resorted to. The trans- fusion proper occupied an hour or more, as a rule. During that time the appearance of death-like pallor which these patients presented changed to that of comparative health. The color first reappeared in the cheeks and tongue and then mounted into the lips, the conjunctivae, and the skin generally. The hemoglobin can easily be followed, and in Dare's or Fleischl's instru- ment showed a steadily increasing per- centage. In the 2 favorable cases this amounted to an increase of three or four times the original percentage. 644 ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). There was a corresponding change in the patient's mental condition and vitality, which seems, in patients so near to death, almost miraculous. This was strikingly true in the first case. In both favorable cases the transfusion introduced a period of improvement which in the first case has now lasted nine months; in the third, two. The hemoglobin and the number of red cells have increased steadily until 80 per cent, and more has been attained. Bovaird (Med. Record, Feb. 11, 1911). Defibrinated blood has been used subcutaneously by Westphalen with success. Subcutaneous injections of normal saline solution every alternate day, and on the intervening saline ene- mata, with arsenic internally, have been recommended by McPhedran. Intestinal antiseptics have been rec- ommended. Hunter holds that the best intestinal antiseptic is betanaphthol and salol, along with arsenic when that can be borne. I consider thymol entitled to the first position, a fact which seems to be more fully appre- ciated in Italy than elsewhere. In accordance with the view that perni- cious anemia is due to the absorption from the intestine of substances for- eign to the healthy body, and de- structive to the red corpuscles, its treatment by intestinal antiseptics is certainly most rational. When the disease is due to the Anky- lostoma duodenale, thymol, 2 to 3 drams daily, is a very effective vermi- cide, according to Bozzolo. Two cases due to Bothriocephalus latus, the infection being accompanied by the severest kind of anemia. In one patient the red corpuscles fell to 780,- 000 and the hemoglobin to 15 per cent. The second case was even more severe, the red corpuscles falling to 660,000 and the hemoglobin to 10 per cent. Hemor- rhages were noted along the veins of the retina. The improvement in both cases after thymol treatment was marvelous, and in the second patient in thirteen days the number of red corpuscles trebled. A. Meyer (Med. News, April 8, 1905). . Serum therapy seems to merit fur- ther trial, though not much more than temporary benefit can be expected from its use. Antistreptococcic serum used with gratifying resvtlts in 2 cases of anemia: one pernicious, the other simple. In the former, examination of the blood showed 4000 white and less than 1,000,- 000 red corpuscles to the cubic centi- meter, and 30 per cent, of hemoglobin. Eight injections of 8 c.c. each were given at intervals of two or three days. After the third, improvement began and progressed steadily. Three days after the last injection the blood con- tained 5000 white and 4,960,000 red cor- puscles, and 90 per cent, of hemoglobin. W. H. deWitt (Cin. Lancet-Clinic, Ixxxiv, p. 61, 1900). Typical case in a man 37 years of age. The treatment consisted of oral and gastric antisepsis. During July three injections of antistreptococcic serum were given. After the first the red cor- puscles rose to 36 per cent. ; after the second to 52 per cent., and in three weeks the red corpuscles rose to 65 per cent, and the hemoglobin to 72 per cent. In September arsenic was added to the other treatment, and by December the red corpuscles had risen to 94 per cent, and the hemoglobin to 100 per cent. William Hunter (Lancet, March 30, 1901). Herter recommends frequent and thorough irrigation of the colon, since it is the chief thriving place of the anaerobic bacteria which cause the spe- cific putrefaction. Following this sug- gestion, Dittmar and Hollis were able to report a few months ago recovery in 2 cases of pernicious anemia by irriga- tion of the colon which had resisted all other methods of treatment. ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 645 In all cases of pernicious anemia, the stools should be examined to determine the presence of a Bacillus capsiilatus acrogciics infection. If these bacteria are present in great quantities, then high irrigation, combined with arsenic internally, should be used; and if the patient fails to improve, then the appen- dix offers the best route for thorough irrigation. Lucius E. Burch (Jour. Amer. Med. Assoc, March 13, 1909). When the Bacillus capsulatus aerog- eiies or the percentage of anaerobic bacteria found in evacuations from bowels is large, then, after thorough trial at colonic irrigation and failure to improve the symptoms or to lessen the percentage of bacteria, the opera- tion of appendicostomy is warranted. J. A. Witherspoon (Southern Med. Jour., July, 1909). Cholesterin has been introduced into the therapy of pernicious anemia because of Ransom's finding that it prevented the hemolytic efTects of some substances, such as saponin and cobra poison. A 3 per cent, solution of cholesterin in oil is given in 100- Gm. (3% ounces) doses daily. It is apt, however, to disagree with the patient. The objections to the use of choles- terin consist mainly in the fact that this substance is not at all decreased in the blood of the patients, but is often increased above the normal figures. Cholesterin in 3 per cent, solution in oil was given by the writer, but this disagreed with most patients. The feeding of milk, cream, and butter, however, accomplishes the same results by increasing the fat and the choles- terin contents in the blood. Large amounts of these substances were used in the diet, and the results were very favorable, though it is impossible to. say whether the cholesterin had anything to do with it. Arsenical preparations were also given. Klemperer (Berl. klin. Woch., Nu. 52, 1908). Cholesterin tried in 6 typical cases of cryptogenetic pernicious anemia, one of them being of the so-called aplastic type. Three patients were in an ad- vanced state of the disease when com- ing under observation and only lived for a few weeks ; in these no effect whatever was observed from the use of the cholesterin. A fourth patient was discharged unimproved after a three weeks' course of the treatment and died a few days later. In the fifth only 24 Gm. had been administered when the treatment was suspended, and death occurred shortly thereafter. An apparently beneficial effect was obtained in the remaining case, but, as the patient at the time when the choles- terin treatment was begun was virtually in her first attack, one naturally hesi- tates to ascribe the noted improvement to any one therapeutic factor. It is noteworthy, however, that the resump- tion of the cholesterin some months later, when a relapse had occurred, was again followed by marked improvement. This patient is still living and in good condition. When first seen the red cells numbered 1,744,000, while the hemoglobin was 46 per cent. ; there was then marked anisocytosis with a dis- tinct tendency to macrocytosis ; there were poikilocytosis and extensive granu- lar degeneration (so-called). C. E. Simon (Jour. Amer. Med. Assoc, Dec. 19, 1908). Three cases of pernicious anemia and 1 of secondary anemia referable to nephritis in which cholesterin was used for therapeutic purposes, the aim being to counteract any hemoly- sins that might be active in a manner analogous to the action of cholesterin on cobra lecithide. Of the 3 cases, one patient remained unimproved, while in the other two cholesterin was de- cidedly beneficial. The latter case was in a wretched condition, with intense dyspnea, ascites, pleural effusion, edema, and a red count of 750,000 with 18 per cent, of hemoglobin. After a week the count had risen to 1,750,000 and the hemoglobin to 30 per cent., while the threatening symp- toms had all disappeared. The im- provement was thus quite remark- able, but after a few weeks no further 646 ANEMIA, SECONDARY (DA COSTA). gain was obtained and still later a re- lapse occurred which ended fatally. Reicher (Berl. klin. Woch., Nu. 41-42, 1908). Glycerin has also been tried in para- sitic pernicious anemia, as a result of Tallquist and Faust's . suggestion that glycerin might combine with the lipoid substance assumed to be responsible for the disintegration of the red cor- puscles and thus combine to form a harmless product. The special lipoid substance found in the anemia from in- testinal parasites proved to be oleic acid, and this combines with glycerin to form triolein. In the first of 2 cases in which glyc- erin was tried, the result was very- encouraging, and in the second admin- istration of 3 tablespoonfuls of glyc- erin a day, with lemon juice, was fol- lowed in the course of two and a half months by an increase in the red cor- puscles from 990,000 to 4,760,000, and of hemoglobin from 20 to 90 per cent. No other drugs were given, except a little antipyrin and cafifeine, for a day or so to combat a neuralgic headache. Vetlesen (Norsk Mag. f. Laeger, Oct., 1909). Case in which there were only 970,- 000 red and 4000 whites, with 20 per cent, hemoglobin. Death seemed im- minent when a tablespoonful of glyc- erin was given three times a day at first, and later up to 70 Gm. The man, a syphilitic in whom the iodides and mercury had been tried, began to improve at once and by the end of a month the reds numbered 4,200,000, the whites 5300, with 100 per cent, hemoglobin. This confirms Tall- quist's experience in a similar case. Both patients seem to be permanently cured: The writer's patient is still taking glycerin, but is strong and well. Muktedir (Deut. med. Woch., May 18, 1911). Frederick P. Henry, Philadelphia. ANEMIA, SECONDARY, OR SYMPTOMATIC. — D E F I N I - TION, — A deficiency either in the quantity or the quality of the blood, affecting the blood mass or the cellular and albuminous constituents. Genuine secondary anemia is essentially a symp- tomatic disorder, referable to obvious pathological conditions, which deplete the blood volume, diminish the number of erythrocytes, and reduce the amount of hemoglobin and albumin. ["Anemia," "Primary" or "Idiopathic Anemia" are now obsolete as designations, all anemias being, in the light of modern research, due to some underlying cause — ■ though many of these are still undetermined ■ — and therefore "secondary" or "symptom- atic." Hence the above heading and defini- tion. The Editors.] TYPES OF SECONDARY A N E M I A. — It is convenient to classify the simple secondary anemias into several clinical groups which relate directly to the predominant factor active in the individual case. While a classification of this sort must needs be imperfect, for fre- quently several factors are concerned in a single instance, it will serve to designate the important underlying condition of which the blood im- poverishment is symptomatic. The following groups are sufficient for the inclusion of all anemias of secondary origin: I, posthemorrhagic; II, infec- tious and toxic, and. III, trophic. I. Posthemorrhagic anemias com- prise that varied class of cases directly traceable to bleeding, irrespective of its extent, duration, and character. In this group, therefore, are included the acute anemias due to loss of blood by trauma, operation, abortion, par- turition, epistaxis, hemoptysis, gastric and intestinal ulcer and neoplasm, ANEMIA, SECONDARY (DA COSTA). 647 hemorrhagic pancreatitis, and under the same heading are the grave ane- mias consecutive to the rupture of an aneurism, of a Fallopian tube, and of a large mass of varicose veins. The hemorrhagic diseases (purpura, hemophilia, scurvy), hemorrhoids, and uterine fibroids, all of which are capable of causing persistent, though perhaps moderate, loss of blood, may also excite a secondary anemia, per- haps of pronounced severity. II. Infectious and toxic anemias develop chiefly as the result of hemo- lytic agencies, and are encountered in the specific infections, malignant dis- ease, intestinal helminthiasis; in poi- soning by certain so-called blood poisons — nitrobenzol, potassium chlo- rate, lead, mercury, arsenic, antimony; and in states of autointoxication — uremia, cholemia, pregnancy. Of the acute febrile infections that account for anemia of moderate intensity, enteric fever, sepsis, variola, erysipe- las, rheumatic fever, and scarlatina may be named as typical examples. The anemia excited by malignant neoplasms is attributable partly to the action of circulating tumor-toxins and partly to concomitant factors, such as hemorrhage, ulceration, and interference with nutrition, as in esophageal and gastric growths. The anemia of helminthiasis is due prin- cipally to the hemolytic action of poisonous substances elaborated by the worm, notably in the case of uncinariasis and bothriocephaius dis- ease, and to a less extent in persons harboring oxyurides, ascarides, .and filariae. Helminthiasis anemia is also favored by the associated gastroin- testinal disorders, and, in uncinari- asis, the parasites suck blood from the intestinal vessels of the host and pour out an absorbable anticoagulant material which may act deleteriously upon the circulating blood-cells. The luetic virus materially damages the hemoglobin and erythrocytes, and syphilitics as a class are subject to a form of toxic anemia which as a rule attains its greatest development dur- ing the tertiary stage of the infection. In malarial fever it is probable that the presence of a circulating specific malarial toxin, produced by myriads of parasites, has much to do with provoking the attendant anemia, and it is certain that in this infection the blood must sufifer from the whole- sale destruction of parasitiferous eryth- rocytes. There is a type of apparent anemia which is often mistaken for real chlorosis, until an examination of the blood shows that the number of red corpuscles and the percentage of hemo- globin are normal. In such cases the writer thinks a history of past or pres- ent tuberculous disease can always be found. This condition was recognized by Trousseau, and was called by him "false chlorosis" or "tuberculous ane- mia." Several cases of this condition are cited in detail. In treatment, iron is to be avoided, and open air and hygiene are important. A. James (Brit. Med. Jour., Dec. 28, 1907). Insufficiency of the blood-forming function is not, primarily at least, at fault in the production of the secondary anemias following chronic gastrointes- tinal disease. The writer considers the anemia more probably due to the ex- istence in the blood-serum of hemolytic substances, perhaps produced by chem- ical changes connected with functional disturbances in the digestive organs. Besides the indirect pathological evi- dence of the existence of such hemo- lytic action, the writer has been able to demonstrate it directly by the action of the serum of anemic rabbits on the blood of normal ones. With its globu- licidal power it has a certain stimulant 648 ANEMIA, SECONDARY (DA COSTA). action on the blood-forming apparatus in the bane-marrow, which, however, seems to be more quickly exhausted than is its destructive action. The author considers that his study empha- sizes the importance of functional over anatomical gastric lesions in the produc- tion of anemia. Tixier (Semaine med., June 19, 1907). Cultures of dysentery, colon, and typhoid bacilli grown upon agar sus- pended in salt solution and then ex- tracted with alcohol at 37° C. ; these ex- tracts were found to have a slight hemolytic power for dogs' blood in vitro. When injected into rabbits these extracts produced a distinct, but mod- erate anemia. An attempt was then made to increase the hemolytic activity of these organisms by enhancing their virulence. For this purpose irritation of the gastrointestinal tract was brought about in dogs and rabbits by means of chemicals, and later large quantities of cultures of the organisms were introduced into the stomach. Twenty-four to forty-eight hours after the intestinal infection had been set up the animals were killed and the organ- isms recovered again from the intes- tinal tract. Extracts of the organisms which had caused these intestinal in- fections were found to have increased considerably in hemolytic activity in vitro. When the extracts were inocu- lated into dogs and rabbits a marked and rapid anemia developed, with re- duction in both hemoglobin and red corpuscles. Fejes (Deut. Arch. f. klin. Med., Bd. cii, S. 129, 1911). III. Trophic anemias, or those of nutritional origin, are met with com- monly in subjects that suffer from chronic malnutrition due to faults in the quantity and quality of their food, to defective absorption and assimilation, or to a combination of these two causes, and in many such instances deficient air and sunshine, lack of exercise, confining occupation, and unsanitary surroundings must likewise be reckoned with as contrib- uting elements. Drains upon the albumins of the system, as in habit- ual nephritis, persistent suppuration, prolonged lactation, and chronic dys- entery, ultimately provoke well-de- fined, stubborn anemia of the trophic type. Congenital anemia is sometimes due to heredity. Habitual anemia of the parents, cachexia as a result of tuber- culosis, malignant neoplasms, diseases during pregnancy, poor nutrition and lack of hygiene, may all, according to the author, give rise to anemia in the child. The anemia is transmitted by means of the placental circulation and continues to develop in the fetus in utero. The alimentary form when present in the non-anemic newborn is due to an exclusive milk-diet which in itself is deficient in iron. L. Fiirst (Therap. Monats., Nu. 9, 1900). An anemia is often observed in young children that is due to improper feed- ing. This may consist of carelessly prepared artificial food, bad quality of milk, irregularity of feedings, the use of too large quantities of food, the use of solid food before the age of 9 months, stimulating drinks, insufficient nursing, brutal weaning, and the abuse of milk after weaning. The writer believes that this form of anemia is more frequent in young children than the anemia of tuberculosis, of syphilis, of malaria, or of lymphadenia. Rougier (Paris Thesis, No. 13, 1901-1902; Gaz. heb. de med. et de chir., Feb. 9, 1902). In patients with insufficient or absent secretion of gastric juice there is al- ways evidence of anemia. In hyper- acidity the hemoglobin was found above normal, and in nervous dyspepsia it was practically normal. Only in the cases ranging from subacid gastritis to gas- tric achylia was anemia the constant finding. The writer's experience fur- ther demonstrated that administration of natural gastric juice from the dog, supplying the missing element for gas- tric digestion, was followed by the subsidence of the anemia. The sup- plementary gastric juice insured proper ANEMIA, SECONDARY (DA COSTA). 649 nourishment for the ckincnls of the blood. F. RoHin (I'.erl. klin. Woch., Bd. xliii, Nu. 5. 1904). In the majority of cases of serious anemia anhematopoiesis is not ana- tomically demonstrable, and there is usually, if not always, the destruction of the blood which is related to de- globulization. That is to say, in most cases of anemia the study of the an- hematopoiesis should not lead one to forget the investigation of the causes of the anemia, the mechanism of the destruction of the blood-globules, which is of great importance from both the pathogenic and therapeutic points of view. C. Aubertin (La semaine med., July IS, 1908). In severe anemias experimentally produced the oxidations in the tissues are not carried out completely to the final products of metabolism, but are brought to an end partly in the blood or in other organs. The true cause may therefore be lack of oxygen. Morawitz and Pratt (Miinch. med. Woch., Sept. 1, 1908). The writer refers to the anemia with- out appreciable cause, and experience has convinced him that these anemic infants are suffering from lack of iron. This form of anemia is more common in families in which the infants are allowed nothing but milk, while it is rare when the children early eat at the family table. He does not give iron directly, but during or after the third month allows, once a day a little meat broth with one-half and later the whole yolk of an egg. During the fourth and fifth months gruel is given once or twice a day, made of zwieback with butter, milk, salt, and sugar, to which the egg-yolk is added. By the sixth or ninth month he gives spinach; by the tenth and eleventh months a small amount of meat. When the child is a year old he reduces the milk to a pint or a pint and one-half a day and accustoms the child to a mixed diet. By this means, the anemia is prevented and always cured when developed. Infants seem to feel the need of iron mostly in the fourth month, and by giving them in this way a little food that contains iron it is possible to keep the hemoglobin at 100 per cent. The children take this diet without disturbance. Yolk of egg and spinach contain 22 and 35 mg. iron in 100 Cm. of dry substance, while cows' milk contains only 2.3 mg. The writer thinks it is not a mere coincidence that none of the children given iron in this way has ever developed rachitis. Milk does not contain enough iron for the proper development of the infant, and sooner or later the child will suffer, especially about the fourth or sixth month, at which time a little mixed food containing iron is given whether the child is getting breast milk or is bottle-fed. J. Katzenstein (Miinch. med. Woch., Aug. 10, 1909 ; Jour Amer. Med. Assoc, Sept. 18, 1909). PATHOLOGY.— The principal pathologic alterations incident to ane- mias of the secondary type relate to the composition of the circulating blood and to the histology of the bone-mar- row, of which the former changes are the more important, and, obviously, more readily available to the clinician. The blood changes vary within wide limits, depending upon the grade and the chronicity of the individual case; but in general it may be stated that they are of very moderate intensity in the average example of general symp- tomatic anemia. There is a more or less decided diminution in the number of erythrocytes (oligocythemia), with a tolerably proportionate reduction in the percentage of hemoglobin (oligochro- memia), and, in severe cases, one ob- serves structural changes implicating the erythrocytes' stroma and eventually leading to the production of corpuscular deformities of shape (poikilocytosis) , and of size (megalocytosis; micro- cytosis). Not always, however, is the hemoglobin-erythrocyte reduction pro- portionate, for in some forms of sec- ondary anemia the hemoglobin loss is 650 ANEMIA, SECONDARY (DA COSTA). greatly disproportionate to that of the cells, as, for example, in so-called "syphilitic chlorosis," which, hemat- ologically, counterfeits maiden's chlo- rosis; on the contrary, in other types the erythrocytes suffer chiefly, as in that variety of parasitic anemia pro- voked by the Bothriocephalus latus, which apes true pernicious anemia in every detail of the blood-picture. These facts call for great caution in attempting to diagnose a secondary anemia by the blood changes alone, without due regard for the discovery of some adequate causal factor to be correlated therewith. In active, severe cases of anemia young, nu- cleated erythrocytes (normoblasts) es- cape prematurely from the bone- marrow and appear in the circulating blood in limited numbers, and in the event of intense retrograde marrow changes an occasional nucleated cor- puscle of fetal type (megaloblast) also may be observed. With such evidences of high-grade blood deterioration one also meets with cells disfigured by atypical staining proclivities (polychro- matophilia), and with cells whose proto- plasm is stippled with fine and coarse basic granules {granular basophilia), both of which abnormal findings point to a considerable degree of stroma degeneration, whereby the affected cells no longer react toward acid aniline dyes, as they do normally, but show a selective affinity for basic colors, by which the stroma of the healthy red corpuscle is never stained, when exposed to a mixture contain- ing both acid and basic dyes. The behavior of the leucocytes in second- ary anemias is most inconstant. In chronic cases, especially those due to trophic defects, and in certain of the slowly progressive toxic anemias the leucocyte count does not deviate from normal, or, if it shows any ap- preciable change, becomes subnormal {leucopenia). In these leucopenic ane- mias it is also the rule to find a dis- proportionately high percentage of lymphocytes {relative lymphocytosis), these cells increasing in number chiefly at the expense of the poly- nuclear forms. The writer using Wright's modifica- tion of Leishmann's stain, in studying the blood from cases of anemia, ob- served peculiar stained ring formations within certain of the red blood-cor- puscles. These figures were seen in 3 cases of pernicious anemia, 4 of lead poisoning, and 1 of lymphatic leukemia. Unlike the ordinary basophilic granula- tions found so often in the red blood- cells from cases of lead poisoning and pernicious anemia, these figures stained not blue, but bright red. The rings were quite perfect. They varied in size : in some instances being very small, in others encircling the extreme periphery of the corpuscle. Rarely they were twisted or had a figure-of- eight form. Occasionally basophilic granulations were noted in the same corpuscle which contained a ring body. Such figures did not appear in blood specimens stained with hematoxylin. The author believes that they may be connected in some manner with cell regeneration, and suggests that they ' may represent nuclear remains, or, per- haps, portions of the nucleus which have resisted those forces destructive to it, and ultimately to the cell itself. Cabot (Jour, of Med. Research, vol. ix, p. 15, 1903). Effort to reproduce in the lower animals by repeated bleedings his- tological changes analogous to those occurring in the aplastic anemia of man. The experiments were carried out upon dogs and rabbits. The dogs were bled daily from a vein, over a considerable period of time ; with the rabbits leeches were used to remove the blood. Young animals were found to be suitable for the work because of the rapidity with ANEMIA, SECONDARY (DA COSTA). 651 which their blood is regenerated after hemorrhage. In older animals, in which the hematopoiesis is less active the bone-marrow showed only slight hyperplasia; this was of the myelo- blastic type — the predominating cell being mononuclear and non-granular, nucleated red blood-cells ; granulocytes were very few in number. In the spleen megalokaryocytes were found, but no evidences of blood formation were observed here. In one instance the spleen contained numerous phago- cytes filled with red cells. No signs of blood formation were observed in the liver. The peripheral blood, which was frequently examined, resembled that seen in aplastic anemia in man in the absence of poikilocytosis and the small number of nucleated red blood-cells, and differed from it in the presence of basophilic granules and polychroma- tophilia in the red cells, and in the absence of leucopenia and lympho- cytosis. The basophilic granules of the erythrocytes the writers look upon as nuclear in origin ; the granules were found in the blood of those animals in which regeneration was most active; they were not found in association with aplastic bone-marrow, evidence of their nuclear source. Blumenthal and Mora- witz (Deut. Archiv f. klin. Med., Bd. xcii, S. 25, 1907). Case in which the presence of peculiar red corpuscles was evidently chronic as revealed by the history of the past three years, with yaws and suppurating otitis as predecessors, yet with acute exacerbations. The condition was not clearly explained on the basis of an organic lesion in any one organ. There was cardiac enlargement, albuminuria, and cylindruria, general adenopathy, icterus, with a secondary anemia not remarkable for the great reduction in red corpuscles or hemoglobin, but strikingly atypical in the large number of nucleated red corpuscles of the nor- moblastic type and in the tendency of the erythrocytes to assume a slender sickle-like shape. The leucocytosis with a rather high eosinophile count was also noted. Syphilis was suggested by many of the facts, such as adenopathy and the conditions of the heart and kid- neys ; it might explain the anemia, the arthritis and perhaps also the tempera- ture, cough, and attacks of pain re- sembling hepatic or gall-bladder dis- ease; for, as is well known, visceral syphilis may furnish a most bizarre group of symptoms. The Wassermann test was not in use at this time. The. scars said to have been due to yaws were like those left by syphilis. The patient coming from the tropics, one thought of intestinal parasites such as uncinaria as a possible explanation of the anemia and the eosinophilia. What were thought to be eggs were found on one occasion only, and after thymol there was temporary improvement. The odd blood-picture made one examine for possible toxic effects of the coal- tar preparations, but neither from the history nor from the examination of the urine was there any evidence that such drugs were habitually taken. The question of diagnosis, therefore, re- mains an open one unless reports of other similar cases with the same peculiar blood-picture shall clear up this feature. Herrick (Archives of Intern. Med., Nov., 1910). Other anemic blood changes, of very minor importance, comprise in- creased rapidity of clotting and sub- normal specific gravity values. Anemia appearing in the face of active hemorrhage, of acute infectious processes, and of malignant disease is ordinarily attended by a leucocyte increase affecting mainly the poly- nuclear cells ipolynuclear neutrophile leucocytosis), and in helminthetic dis- eases of recent origin there is a very constant increase in the percentage of eosinophile cells (polyniiclear eosino- phile leucocytosis). The presence of small numbers of immature polynuclear neutrophile cells (myelocytes) in the blood is frequently noted in many of the severer anemias of symptomatic character, irrespective of the presence or absence of a leucocytosis. 652 ANEMIA, SECONDARY (DA COSTA). The bone-marrow in a severe case of anemia undergoes a moderate de- gree of softening and acquires a some- what reddish hue, the attendant his- tological changes of this transforma- tion consisting of a hyperplasia of the lymphoid elements and a diminution in the number of fat-cells, which are replaced by marrow-cells or myelo- cytes charged with neutrophilic and eosinophilic granulations. Nucleated erythrocytes or erythroblasts, chiefly of the normoblastic type, are numer- ous when active powers of hemo- genesis persist. H. C. Bunting's studies of the blood and bone-marrow in rabbits rendered anemic by the injection of hemolytic poisons has thrown a clear light upon the dif- ference between the marrow changes incident to anemias of different grades of development. This investi- gator showed that hemolytic anemia excited by saponin is associated with more or less effectual depletion of the marrow-centers wherein prolifera- tion of the blood-cells takes place, and with fragmentation and other degenerative changes in the other marrow-cells, the blood-picture be- traying this grave myeloid lesion virtually corresponding to that of true pernicious anemia in man. In contrast to these findings, posthemor- rhagic anemia, despite the presence of characteristic changes in the pe- ripheral blood, does not affect the in- tegrity of erythrogenic and leucogenic centers of the marrow. Furthermore, it would appear that in some in- stances the proliferating centers of the marrow become quite replaced by scar tissue, in ' which event the hematopoietic function, now impos- sible for the crippled marrow to carry on, is undertaken by the spleen. There is a well-established relation of diffuse cord degeneration with per- nicious anemia. It seems highly prob- able that the hemolysis and the cord changes are due to the same lesion. While the source of the latter is un- known, the fact that gastrointestinal disturbance is so common in the disease would lead one to suppose that it is of intestinal origin. The diffuse degener- ations of the spinal cord which occur in conditions without pernicious anemia do not appear to differ essentially from those of pernicious anemia. It is pos- sible that a common blood-circulating poison exists which may expend its force upon the blood in one individual, upon the nervous apparatus in another, and coincidently upon the blood and spinal cord in others. F. Billings (Boston Med. and Surg. Jour., Sept. 4, 1902). Examination of a large number of cases proves that the changes in the cord are in a sense mechanically located, that is, those portions of the cord less well supplied with blood are the first to suffer. The posterior half containing the sensory and motor con- duction paths is, therefore, more fre- quently involved, but the gray matter, or even the anterior horns, may be affected. The symptoms are variable and obscure, and may be overlooked ; but in some cases they are prominent enough to lead to the diagnosis of tabes, spastic paraplegia, or a neuritis. Symptoms of any of these conditions may be present, depending upon the portion of the cord involved, x^lmost invariably these patients complain prin- cipally of disturbances of sensation. They describe numbness, tingling, and formication, usually in the lower ex- tremities, sometimes in all four. The sensation may be that of pressure from within or without; some feel as if tight bandages were drawn around their limbs. With these sensations there may be a reduction in the reflexes, causing a suspicion of neuritis. There is usu- ally very little atrophy, and the elec- trical reactions are normal ; but some- times the gray matter of the cord is involved, and both atrophy and elec- ANEMIA, SECONDARY (DA COSTA). 653 trical changes may be present in the terniinal stages. Paralyses,, loss of sphinctcric action, and marked mental disturbances have been observed, and severe cases usually perish miserably. A. Church (N. Y. Med. Jour., July 26, 1902) . The visceral chanp^es to be noted in cases of chronic secondary anemia in- clude granular degeneration of the liver, kidneys, and heart, and, in some instances, fatty changes in these organs. These lesions depend more upon concomitant disturbances, such as toxemia and nutritional faults, than upon the efifect of the anemia per sc, and it seems within the bounds of reason to assume that they arise in part from an undue visceral activ- ity excited b}- the organism's attempt to maintain a normal process of oxidation. Two cases of primary chronic anemia in men of 62 and 68. In this type the anemia is moderate in degree, and is accompanied by enlargement of the spleen, slight poikilocytosis of the red corpuscles, and excessive leucopenia, as low as 660, without essential marrow elements. The affection progresses to a fatal termination in about six months, with variable moderate or high fever of a continuous or intermittent type. The signs of a hemorrhagic diathesis do not appear until late, and are not severe. The bone-marrow becomes completely atrophied or shows signs of acute degeneration. The blood find- ings are not those of pernicious anemia, especially the leucopenia. The symp- toms resembled those of what has been called "aplastic anemia," but the writer thinks that the findings in the bone-marrow were of a different nature. O. Kurpjuwelt (Deut. Archiv f. klin. Med., Bd. Ixxxii, Nu. 5-6, 1905). The liver, the spleen, and frequently the lymph-nodes assume a fetal type in grave or pernicious anemias as far as their cellular character is concerned. Erythroblastic cells and newly formed leucocytes appear in them, while the blood-making organ of the adult, the bone-marrow, shows likewise a picture of greatly increased activity. The writer, together with Heinecke, has in- terpreted these phenomena as repara- tive in nature in opposition to another conception of the findings which seeks to interpret them as the primary result of some unknown harmful agent. Von Domarus has greatly strengthened the standpoint maintained by the writer by producing experimental anemias in animals and showing that the changes in the blood-making organs of intra- uterine as well as of extrauterine life were similar in these animals to those observed in patients with pernicious anemia. Meyer (Miinch. med. Woch., June 2, 1908). SYMPTOMATOLOGY. — Pallor, the suggestive hallmark of all ane- mias, is usually well marked in the secondary type of this affection, and the subject's skin, mucosa, and nails may become so blanched as to ap- pear almost colorless. In other in- stances, the loss of color is much more moderate, and in still others the actual pallor is more or less ob- scured by a yellowish or muddy or icteroid staining of the integument. In passing, it may be remarked that pallor of itself does not justify a diagnosis of anemia, for many persons with unnaturally pale faces have a perfectly normal blood-picture, in view of which the blood examination must invariably be the court of final appeal. Pallor is often confounded with anemia. The blood should be examined in all cases of pallor, since many con- ditions may give rise to ochriasis, viz. : The emotion experienced by some pa- tients when undergoing examination at the hands of the physician, their tem- porary pallor subsiding as they become more reassured ; insufficient outdoor air and exercise, giving rise to insuffi- 654 ANEMIA, SECONDARY (DA COSTA). cient peripheral circulation though the quantity and quality of the blood may be normal; ill-defined myxedema, in which the blood-vessels are narrowed by pressure upon them from the gela- tiniform edema and sclerosis of the subcutaneous tissues. The resulting pallor may give rise to a faulty diag- nosis of anemia. Though pallor may be due to the mechanical influences mentioned, thyroid insufficiency may, in itself, produce anemia; hence, the im- portance of blood examination ; the scrofulous or lymphatic diathesis, with the thickening of the integument upon face and extremities, may produce pal- lor for the same mechanical reasons obtaining in myxedema, though exam- ination may show the blood to be nor- mal; aortic insufficiency with periph- eral vasoconstriction gives rise to a pallor which at first sight suggests anemia; peripheral vasoconstriction is, in the majority of cases, responsible for the pallor seen in Bright's disease, though anemia secondary to the ne- phritis may occur. Finally, in a certain proportion of cases, a condition of oligohemia may be responsible for pal- lor, the quality of the blood being nor- mal, though the quantity is insufficient to thoroughly irrigate the skin. M. Labbe (Gaz. med. Nantes, April 11, 1903). Aside from pallor, the most con- spicuous symptom groups in anemia are attributable to disturbances of the cardiovascular, the gastrointesti- nal, and the nervous systems. Of the circulatory symptoms, dyspnea, car- diac palpitation, and dropsical swell- ing of the ankles and legs are likely to prove sources of great distress to the patient, while the discovery of hemic murmurs at the base of the heart and of a venous hum at the root of the neck affords findings of the utmost pertinence. These anemic murmurs, generally situated at or near the pulmonic orifice, are almost invariably systolic in time and re- stricted to the precordial area or to its immediate vicinity. They are sometimes associated with a percepti- ble increase in the size of the cardiac outline, indicative of dilatation of the heart from defective myocardial nu- trition, overstrain, and, exceptionally, fatty degeneration. Alterations in the size of the heart in anemic subjects. Dilatation is com- monly met with, and sometimes, es- pecially in chlorosis, elevation of the diaphragm displaces the heart upward and an apparent dilatation is found. Anemic dilatation is to be considered true idiopathic dilatation resulting from overstrain. None of the usual symp- toms are present; gastralgia alone is complained of. Wybauw (Jour. med. de Brux., Mar. 15, 1900). There is nothing pathognomonic about the anemic murmurs which dis- tinguishes them from the organic heart bruits. The most trustworthy charac- teristics of these murmurs are their slight tendency to transmission, their appearance during the systole, as a rule, over the area of the pulmonary artery, their variability and their increase in intensity in the standing posture and decrease in the recumbent position. As a rule, the general examination of the patient determines whether we have to deal with an anemic or an organic mur- mur. Orlofsky (Roussky Vratch, June 7, 1903). The distinct positive venous pulse ob- served in endocarditis is not an uncom- mon symptom of anemia and is due to a relative muscular insufficiency of the tricuspid orifice. The cause is the same as that of the mitral insufficiency so common in chlorosis. In order to make sure of the functional character of the condition, it is important to bear in mind that a relative tricuspid insuffi- ciency in anemia develops at the same time as the mitral insufficiency, while in endocarditis the tricuspid lesion usu- ally develops long after the mitral. Besides, disturbances of compensation are usually absent. Von Leube (Zeit. f. klin. Med., Bd. Ivii, Nu. 3-4, 1905). ANEMIA, SECONDARY (DA COSTA). 655 The foregoing symptoms, which are prominent only in severe anemias, promptly vanish as the normal compo- sition of the blood is regained, and fre- quently in such cases the pulse is in- ordinately rapid, of low tension, and subject to arhythmic disturbances, while occasionally the abrupt, jerky beat of the Corrigan pulse is superficially imitated. Of the symptoms referable to the ■ gastrointestinal tract, anorexia, pyrosis, abdominal distention, sensitiveness, and unrest, nausea, and constipation may attract attention. In the average case of secondary anemia the motor powers of the stomach are unaltered, and the secretion of hydrochloric acid remains normal or is even increased. On the other hand, there is a decided tendency toward weakening the intestinal motor function, although the juices of the gut flow naturally (Boas, v. Noorden). Ulcers in the throat may be due to anemia or lowered vitality. The writer has seen 3 cases; all in young women. The ulcer is round, small, with scanty secretion. There was no history of either tuberculosis or syphilis and no swelling of the glands. Pohly (N. Y. Med. Jour., x\ug. 27, 1910). Of the various nervous disturbances, headache, vertigo, syncope, insomnia, phosphenes, muscse volitantes, and tin- nitus aurium are familiar examples. Moderate, irregular fever is occasion- ally observed as a consequence of nerv- ous factors and as a sign of septic processes. Most anemics, particularly those of chronic character, complain of unnatural fatigue, both mental and muscular, and in severe cases the pa- tient may be incapable of sustained in- tellectual effort, exhibits curious mental caprices and irritability, and develops a myasthenia amounting almost to com- plete debility. Menorrhagia as a symptom of ane~ mia must be regarded as a result of muscular inadequacy, the cause of so many varieties of uterine hemorrhage. The uterine muscle, by compressing the uterine blood-vessels, controls the blood- supply of the organ and the escape of blood from its lining membrane. Any defect in uterine wall muscularity, as compared with vascularity, permits of pathological uterine hemorrhage. For months before puberty the uterine mus- cle grows in bulk and the uterine vessels increase in size and number. When the first menstruation occurs, if the uterine muscle be well developed, as is usually the case, no undue hemorrhage appears, but if muscle growth lags behind vessel development muscular inadequacy per- mits prolonged and profuse bleeding. Puberty menorrhagia usually disappears in a few months, since muscle growth increases and gains control over the blood-vessels. W. E. Fothergill (Med. Chronicle, July, 1905). Six cases of anemia of the central nervous system, resulting in sclerosis of the cord. The onset of the disease is gradual. The symptoms are very variable, as are the changes in the spinal cord. Sometimes the pos'.erior columns are involved; sometimes the lateral tracts are added; again, there is a dif- fuse sclerosis of the entire cord. Pares- thesia and ataxia may persist for years with few changes in the cord, or the intensity of the alterations may be much greater than the clinical symptoms. The mental state may be dull and inattentive, and there may be various muscular pal- sies of eye m.uscles or face. Leopold (Med. Rec, Mar. 5, 1910). The blood-picture of secondary anemia is in no wnse distinctive, as already pointed out in the remarks on the pathology of this aftection. Usually there is a moderate and roughly parallel loss of hemoglobin and erythroc3-tes, the former being diminished approximately 45 per cent, and the latter 30 per cent, below the normal standard, in the case of 656 ANEMIA, SECONDARY (DA COSTA). average severity. The stained film generally shows nothing more than simple pallor of the erythrocytes with, perhaps, a few misshapen cells and some tendency toward irregu- larity in their diameter measure- ments. Normoblasts and erythrocytes with stroma degeneration are met with only in anemias of great inten- sity, characterized by excessive de- struction of the cells, and under such conditions an occasional megaloblast, indicating a fetal reversion of the marrow, may enter the blood-stream. Leucocytosis, developing under the circumstances referred to in a pre- ceding paragraph, means stimulation of the marrow's functional activity, the exhibition of which is regulated largely by the nature of the excit- ing cause and by the individual pe- culiarities dominant in the case under consideration. The coagulation-time (hcmatopexis) of the blood is shortened in close relation with the degree of existing anemia. Case of ankylostomiasis in which there were hemorrhages into the retina. The patients did not complain of their eyes, and yet hemorrhages were found in the retina. They probably constitute a con- stant symptom in severe forms of ane- mia due to ankylostoma. These hemor- rhages appear in the form of round spots, bands, and semilunar marks (pre- retinal hemorrhages), and are chiefly found in the neighborhood of the pos- terior pole of the ej^e. Their presence has an unquestionable influence on the prognosis. They take place by diapede- sis, are absorbent without leaving any traces, and do not give rise to any in- flammatory symptoms. They occur chiefly in the layer of nerve-fibers, but may penetrate to the outer layers of the retina, even to the external limiting membrane. Changes in the smaller ret- inal vessels consist in swelling of the nuclei of the endothelial cells. Tchemo- lossoff (Roussky Vratch, Nov. 29, 1903). It was at first believed that in severe anemia the relative and absolute con- sumption of O2 and production of CO2 diminished. Later it was shown (Kraus) that the gaseous metabolism tended, on the whole, to be increased above the normal rather than diminished in severe anemia, and was capable of still further increase on exertion. Patients with only 10 per cent, of the normal amount of hemoglobin are not rarely met with, and Xageli has described one with only 7 per cent. ; the authors set out to investi- gate how this drop in hemoglobin is compensated. In the first place, they remark that no other substance in the blood, besides the hemoglobin, can act as an oxygen carrier; further, in all anemias, except, perhaps, chlorosis, the total volume of the blood is lessened. Hiifner has always argued that the 02-capacity of hemoglobin is constant, 1 gram of Hb taking up 1.34 c.c. O2," but Bohr and many other writers bring forward good reasons for supposing that its specific 02-capacity is variable — at any rate to the extent of 20 per cent. — and that hemoglobin is not a single or uniform chemical compound. Thus Kraus found that 1 gram Hb could take up from 0.9 to 1.97 c.c. Oo. Mohr found the specific 02-capacity to rise from 1.26 to 2.0 c.c. O2 per gram of Hb, in the course of six days and after two bleedings, and so was led to regard the variability of the 02-capacity of the hemoglobin as a compensatory protect- ive mechanism for use in anemia. Sev- eral observers have found the Oo-capaci- ties (0.8 to 1.0 c.c O2 per gram of Hb) in patients with polycythemia ru- bra, and these observations have been used to explain the polycythemia noted in that condition. The authors believe that the 02-capacity of blood varies with its coloration (=Hb-content) exactly, as Haldane stated, and they find this to be the case in polycythemia and in anemia. They were unable to find any increase in the Oo-capacity of the Hb in anemic patients; but in a number of these the percentage of oxygen used up in the capillaries was above the normal — ven- ous blood is normally saturated with 02 to the extent of about 60 to 75 per ANEMIA, SECONDARY (DA COSTA). 657 cent., but in severe anemia perhaps only to the extent of 15 to 50 per cent. They agree with Mohr that this increase in the percentage of oxygen consumed in the tissues is an important compensatory mechanism in anemia. But it is not the only, nor indeed even the most impor- tant, compensatory mechanism ; they be- lieve that increased speed in the flow of blood through the vessels must be the most important of these. In two pa- tients with polycythemia rubra they found no diminution in the maximum Oo-capacity of the hemoglobin, nor did the patients exhibit any increase in their tissue respiration such as Senator be- lieved to obtain in this condition. Mora- witz and Rohmer (Deut. Arch. f. klin. Med., Bd. xciv, S. 529, 1908; Med. Chronicle, Nov., 1909). DIAGNOSIS.— The diagnosis of secondary anemia invariably must be based upon a suggestive blood picture plus the discovery of some factor responsible therefor. Given a blood poor in hemoglobin and erythrocytes in an individual suffering, for instance, with sepsis or gastric cancer or rheu- matic fever, the diagnosis Can tax no one's intelligence. But given an ob- scure etiological factor in an anemic person, one must carefully interrogate through a long list of potential causes of blood impoverishment in order to detect a satisfactory cause. The dif- ferential diagnosis of secondary ane- mia includes the consideration of pseudoanemia, chlorosis, pernicious anemia, splenic anemia, leukemia, chloroma, and Hodgkin's disease. We must not judge entirely of the presence or absence of anemia by the volume and condition of the blood alone, but also by the function of the tissues which are dependent on the blood for their well-being. Thus 85 per cent, of hemoglobin, with 4,000,000 red cor- puscles, may be normal for one indi- vidual in apparently perfect health, and yet another person of the same body- weight with this condition may sufifer to a considerable degree from anemia. Brooks (Med. News, Oct. 21, 1905). Pseudoanemia versus true anemia is a differentiation constantly to be borne in mind in examining a patient for the first time. Spurious anemia, which, of course, shows a normal blood report, is characterized by un- natural pallor of the skin and mucous surfaces, probably of hereditary origin and explainable on the grounds of a deficiency of skin pigment and abnor- mal constriction of the superficial capillary network. Apart from pallor, the aff'ection is quite symptomless. In this connection may be mentioned an angiospastic type of pseudoanemia, recognized by the abrupt appearance of attacks of transient grayish pallor induced by emotion, fatigue, exposure to cold, and similar vasomotor stimuli. Chlorosis^ though its blood picture may be precisely counterfeited by certain forms of secondary, anemia (such as Chlorosis, q.v.), is readily dis- tinguished from the latter by its oc- currence exclusively in girls and in young women who exhibit, with pass- able fidelity, a varied train of un- mistakable chlorotic stigmata — green- ish pallor, menstrual disturbances, perverted appetite, indigestion, con- stipation, slight enlargement of the thyroid gland, and many symptoms referable to functional neuroses. Pernicious anemia in its typical form gives rise to three most pertinent blood changes : extreme oligocythe- mia combined with a disproportion- ately slighter oligochromemia ; the presence of numerous erythroblasts, of which cells those of a megaloblastic tj^pe predominate ; and many de- formed and otherwise degenerate erythrocytes, notably megalocytes and basophilic corpuscles. The first 1—42 658 ANEMIA, SECONDARY (DA COSTA). detail of this blood-picture means that the hemoglobin content of the erythrocytes {color index) is unnat- urally high ; the second indicates active compensatory hemogenesis and fetal reversion of the bone-marrow, and the last points to the manufac- ture by the marrow of numerous faultily formed, functionless erythro- cytes, of little or no use as oxygen carriers. Leucopenia, relative lym- phocytosis, and a moderate degree of myelocytosis are among the other hematological features of this disease. In addition to these findings, it must be recalled that true pernicious ane- mia arises insidiously, is entirely un- connected vi^ith any tangible causal factor, and invariably progresses steadily, perhaps with temporary periods of remission, to a fatal ter- mination. An aplastic type of per- nicious anemia has been described, in which, owing to extraordinary atro- phy of the bone-marrow, there arises an intense oligocythemia and oligo- chromemia with but trifling evidence of structural degeneration and nuclea- tion of the red corpuscles. In at- tempting the antemortem differentia- tion of aplastic anemia and anemia of the symptomatic variety (which at- tempt must needs frequently be con- jectural), attention should be paid especially to these hematological pe- culiarities of the first-named disease: relatively low color index; absence of erythroblasts of both types — normoblasts and megaloblasts ; scar- city of cells showing stroma defects and -anomalies of shape and size, and extreme lymphocytic leucopenia. It is also helpful to remember that aplastic anemia is prone to affect young women, is commonly asso- ciated with severe hemorrhagic phe- nomena, and, arising from no apparent cause, pursues a fatal course of short duration, unbroken by periods of remission. Splenic anemia, a rare and somewhat questionable clinical entity, causes a blood deterioration in no wise different from that accompanying an ordinary symptomatic anemia with leucopenia. But in splenic anemia there is an idio- pathic splenomegaly without enlarge- ment of the lymphatic glands, and, in the later stages of the disease, biliary hepatic cirrhosis, jaundice, and ascites supervene, to complete the symptom group sometimes spoken of as Banti's disease. Disturbances due to severe anemia and to the pressure of an enor- mous spleen are generally conspicuous, and the disease is likely to develop insidiously, drags along for several years from bad to worse, and eventually kills. Leukemia is easily distinguished from secondary anemia by means of its dis- tinctive blood picture, as well as by certain objective symptoms. In the myelogenous form the combination of a high leucocyte count and excessive numbers of myelocytes (myelemia) is conclusive, and in such cases the spleen is generally enormous ; in the lymphatic variety the detection of a high absolute and relative lymphocytosis (lymphemia) is equally convincing, and here it is the rule to find great hyperplasia of the lymphatic glands. Chloroma may account for an anemia identical with that of the secondary type, and it may also produce a blood picture closely comparable to that of lymphatic leukemia. In the former instance the low hemoglobin and eryth- rocyte values are accompanied by a relative increase in the number of lymphocytes, though the total leucocyte ANEMIA, SECONDARY (DA COSTA). 659 count does not exceed normal, while in the latter the blood shows great anemia with decided lymphemia. This being tlie case, one must recognize chloroma not by any distinctive blood formula, but by the chloromatous symptom-complex, made up of exoph- thalmos, deafness, severe orbital pain, elastic swellings in the orbital and tem- poral regions, and the formation of metastatic "green tumors" in the peri- osteal structures. In Hodgkin's disease, which in time gives rise to high-grade secondary anemia, the existence of a progressive glandular hyperplasia in the neck, axilla, and groin is conclusive evidence, apart from the presence of pressure symptoms, irregular fever, cutaneous bronzing, asthenia, and extraordinary emaciation, which together spell this malignant affection. PROGNOSIS.— It is scarcely nec- essary to state that the prognosis in a given case of secondary anemia must depend upon the circumstances prevail- ing in the instance in question, the character, duration, and curability of the primary lesion being the decisive determining points of the forecast. The outlook in gastric cancer, for ex- ample, is very dift'erent from that in simple inanition or in one of the milder infectious diseases. On the whole, secondary anemia is a symptom that is promptly amenable to intelligent treat- ment, in strong contrast to which fact •is the utter hopelessness of accomplish- ing a permanent cure in those deadly primary diseases of the blood, perni- cious anemia and the leukemias. TREATMENT.— Iron and arsenic, nutritious food, and correct hygiene will cure secondary anemia — provided that the essential cause of this symptom be removed. It is just as important to attend to a mass of bleeding piles or to treat an albuminuria in an anemic per- son as it is to prescribe hematinics, and, by the same token, it is equally impor- tant to outline a regimen in which an out-of-door life, ample sleep, and ra- tional personal hygiene are items of strict observance. The percentage of hemoglobin in in- fancy is below 55 at birth and not rising above 70 during the period properly- so-called of infancy. The number of red corpuscles varies between 5,500,000 and 6,000,000. This low hemoglobin per- centage is presumably due to an insuffi- cient supply of iron in its food and the lack of sufficient reserve of iron in the liver at birth. It is probable that true chlorosis never occurs in infants as a disease, but it is a fact that the chlorotic type of blood is very common at this age. Iron is, therefore, specially indi- cated, but it is difficult to get infants to take iron by the mouth, and it is very liable, moreover, to disturb the diges- tion. It is desirable, therefore, to give it some other way, and infants take it subcutaneously without injury. A very serviceable form for subcutaneous use is the aqueous solution of the citrate. This can be put up in pearls, each one containing a single dose, in which form it remains sterile indefinitely. It is ab- solutely non-irritating, and never causes abscess or induration if properly given, though it is somewhat painful. A glass syringe with an asbestos packing, which can be sterilized, and platinum needle that will not corrode with the iron. The average dose during infancy is three- quarters of a grain every other day. He has used this treatment in a number of cases in different types of anemia and with pretty satisfactory results, even in the severe cases. In the mild cases the improvement was very rapid, and the writer's experience leads him to recom- mend the use of iron in this way. The results are more marked and more quickly obtained than by oral adminis- tration, and it is much less liable to dis- turb digestion. It is especially indicated in severe cases of secondary anemia 660 ANEMIA, SECONDARY (DA COSTA). with digestive disorder and in those of a sclerotic type. J. L. Morse (Jour. Amer. Med. Assoc, July, 1910). The form of iron to be administered, it is almost needless to state, should be readily absorbable, and unlikely either to upset digestion or to constipate. The carbonate of iron, in the pill suggested by Blaud, meets these requirements as well as any other preparation, and has the prestige of a long and dependable clinical usage. Excessive dosage is to be avoided, since the use of 6 or 8 grains a day will accomplish just as satisfactory results as a much larger amount, and will not tend to disturb the stomach or to constipate. Ferratin is a meritorious chalybeate, and is, if any- thing, even less astringent than Blaud's pill. Of the other iron preparations sometimes chosen for the same reason, the phosphate, lactate, and citrate all enjoy considerable vogue. The most satisfactory result is ob- tained with the peptomanganate of iron; it is easily absorbed by the entire intestinal tract and evokes no concomi- tant effects. In 12 out of 23 cases the hemoglobin was normal after fourteen days; in 5 after three weeks, and in 5 after a month. In acute anemia very good results were also obtained by this mode of treatment. H. Metall (Med. chir. Centralbl., June, 1902). Inorganic preparations of iron are well utilized by the organism and give better and more rapid results than or- ganic preparations, the most rapid and marked increase in hemoglobin being seen after endovenous injection of in- organic preparations of iron. Experi- mentally there was but slight difference seen in the effects of inorganic and or- ganic preparations administered through the digestive tract, the results obtained depending, in both classes, upon the amount of iron contained in them. F. Aporti and S. Aporti (II Policlinico, Sept-Oct, 1902). Subcutaneous injections of the arsen- ate of iron valuable in anemia. In a previous article the author has shown that injection of iron salts, if continued for a sufficient length of time, produce very constant and trustworthy results in anemia. The arsenate of iron used because the addition of arsenic improves the action of iron. This method of . treatment used in a large number of cases and considered the best mode for administering iron. The author em- ployed the solutions prepared by Zam- beletti, in which the arsenate was per- fectly dissolved. The injections were made preferably into the nates, with the usual aseptic precautions, by means of a syringe with a rather long needle. The doses were gradually increased until about 60 or 80 injections had been given, when the doses were gradually diminished again. Toward the end of the treatment the injections were alter- nated with the administration of iron, arsenic, and phosphorus, as well as nux vomica or strychnine by mouth, the latter being continued for some time after the injections were abandoned. The results obtained with this method of treatment were uniformly satisfac- tory in a large number of cases. Nicola Fedele (Gaz. degli osped. e delle clin., Feb. 1, 1903). The headache of anemia is due chiefly to the deficiency of hemoglobin, and consequent tendency to edema, with the simultaneous starving of the meninges. It is usually frontal, but may be vertical. In certain individuals of lymphatic type, subject to anemia, chilblains, and cold extremities, there may be a deficiency of calcium salts in the blood, and the administration of the calcium salts may be of great service in relieving the head- aches of such patients. The lactate should be given in doses of 15 to 20 grains, three times a day. The head- aches of the morning after copious liba- tions have been ascribed to a lack of calcium salts in the blood, these having been precipitated by the organic acids contained in the wine. This headache may be very quickly removed by a dose of 20 to 30 grains of calcium lactate shaken up with a ANEMIA, SECONDARY (DA COSTA). 661 little water. Wilfrid Harris (Prac- titioner, July. 1906). There has been distinct progress in the treatment of anemia. The first of these is the method of direct trans- fusion introduced bj' Crile, whose ex- periments and results the author con- siders a brilliant illustration of the value of vivisection to humanity. The second is the use of colonic irrigations in pernicious anemia, as recommended by Herter, and successfully employed by Ditmar and Hollis. Herter's discovery that special putrefactive processes in the intestines are due to the prevalence of anaerobic bacteria, particularly the Bacillus capsiflafus aerogenes, and the parallelism of their presence with the symptoms of the disease suggested this treatment by injections, which the writer considers a valuable therapeutic advance. The third point touched on in his paper is the establishment of the clinical value of inorganic iron in the treatment of anemia. Ingested iron, like the carbohydrates, is converted into intermediate organic compounds and enters into the reser^'e iron stored up in the body, which is normally in excess of the needs of the system. S. J. Melt- zer (Jour. Amer. Med. Assoc, Aug. 24, 1907). Employing the hemoglobin contents as an index of the degree of secondary anemia, as well as an actual erythroc}-te count, the writers found that the hypo- dermic use of the citrate of iron in the secondar}' anemia of tuberculosis per- mitted them to control the anemia with almost mathematical precision, and that it actually in no single instance failed to improve the quality of the blood to at least some degree in the 256 cases in which they had employed it. Over 70 per cent, of these cas;s were in the advanced and far advanced classes, in which the anemia is a commonly mani- fested phenomenon. The measure was uniformly successful in raising the hemoglobin standard to normal in all cases in which the patient might be considered to be doing well, or in which the status quo was seemingly maintained. It is not necessary to use a larger dose of citrate of iron than 0.05 Gm. Others who have used larger doses have observed sudden vomiting to fol- low its administration. The technique of the method is to employ the ordinary hypodermic syringe and needle, select- ing the buttock as the least incon- venient site of injection, and giving an injection daily until the result is ob- tained. E. S. Bullock and L. S. Peters (Jour. Amer. Med. Assoc, Oct. 28, 1911). • Arsenic is of indispensable value as an adjunct to iron in dealing with anemia, particularly those forms dis- tinguished by relatively excessive oligo- cythemia, as in those severe instances consequent to infectious and malignant processes. The time-honored Fowler's solution answers well in themajorit}-of cases, but where an idiosyncrasy exists toward this preparation, as it frequently does, or where it is imperative to stimulate hemogenesis xevy rapidly, atoxyl 'sodium anilarsenate) will prove the better form of arsenic. It should always be given hypodermically, in doses of from ^ grain to 2 grains, on alternate days, until the patient has received about 20 grains, after which the drug is discontinued for a week, and then readministered according to the plan originally followed. Given in this manner, one need not fear that lamentable complication, optic neuritis, which has been produced by the ill- advised use of atoxyl. Or arsacetin (sodium acetyl arsanilate) may be used, in the same dose and by the same method advised for atoxjd, if it is thought best to employ an even less toxic preparation of arsenic. While useful, manganese, phosphorus, red bone-marrow, hemoglobin, oxygen, and the cacodylates are in no sense adequate substitutes for iron and arsenic in the treatment of anemic conditions. 662 ANEMIA, SECONDARY (DA COSTA). Hypodermic medication with iron and arsenic, together with strychnine and the hypophosphites, offers a prompt and powerful reconstructive adjunct to the pure air, good food, and sensible hy- giene that are essentials in pretubercu- lous conditions. The green ammo- niated iron citrate can be introduced into the system, without danger, in doses of from }i to 1^ grains, while sodium arsenate is given in doses of from %o to Yso grain. The injections of solu- tions of these drugs are given deeply into the muscles of the buttocks or back. Only slight pain attends the procedure, and a general feeling of well-being follows the treatment. A full dose of the iron within five minutes causes a feeling of tension in the head, tingling sensations, and a flushing of the face. Doses larger than 1^^ grains may cause nausea or vomiting. B. R. Shurly (Jour. Amer. Med. Assoc, June 16, 1907). The anemic subject should eat plentifully of nutritious, and, it must be insisted, palatable, food — red meats, strong broths, eggs, butter, cream, fruits, and ferruginous vegetables like spinach, asparagus, lentils, and cauli- flower. If the appetite flags it may be advisable to whip it up with a glass of stout or of mild claret at mealtime, or by the use of the bitter tonics, the amount of food at the same time being intelligently re- stricted. Indigestion, if not fore- stalled by a rational dietary, must be combated by such useful remedies as pepsin and hydrochloric acid, pan- creatin and diastase, pawpaw, char- coal, and bismuth. It is most neces- sary for the patient to have a free bowel movement each day, to insure which, if other measures fail, i't is good practice to resort to cascara sagrada, phenolphthalein, singly or combined with aloin, strychnine, and belladonna, and supplemented by a dram or two of Carlsbad salts dissolved in a tumblerful of hot water, to be slowly sipped each morning directly on arising. Intestinal fermentation, the bane of so many anemics, is best treated dietetically (eggs are noto- rious offenders ), by intestinal irriga- tion, by the administration of cultures of the lactic acid bacillus, and by the use of B-naphthol, salol, bismuth salicylate, phenol, and similar anti- fermentative drugs. In patients with troublesome nervous symptoms stron- tium bromide and the valerianates of iron, quinine, and zinc are helpful ad- juncts to the therapeusis suggested above. Alimentary fermentation being in great measure responsible for the blood deterioration of anemic states, lysol is a good intestinal antiseptic to correct this condition. Under its influence the movements from the bowels become fewer, formed, less foul, and free from mucus; the appetite becomes increased, and the patients rapidly gain strength. The drug is given in capsules containing each lyi minims; one capsule every two hours. F. Burges (Miinch. med. Woch., Nu. 9, S. 416, 1905). Case of probable hemophilia in a child of 2 years. The anemia from the re- peated losses of blood was combated by injection of from 10 to 18 c.c. of de- fibrinated blood from healthy adults. The improvement under these injections was pronounced and striking, and the restoration of normal conditions in the blood was accompanied by improvement in the general health. Five of these injections were made in the course of six weeks. It is useless to attempt this transfusion of blood, according to the writer, when the blood-producing ap- paratus is irreparably injured. It should not be done as a last resort, but should be tried as early as possible when ane- mia in children is assuming a grave form. The injections were made under the skin of the thigh. Some substance in the serum evidently acts as a stim- ulus for the blood-producing organs. ANEMIA, SECONDARY (DA COSTA). 663 Schelblo (Jahrh. f. Kindorhoilk., Oct., 1908). Ill aiKMiiiri duo to autointo.xication from the gastrointestinal tract, as often occurs in chlorosis : 1. I'avor gastric functions by proper diet. 2. Secure reg- ular bowel movements by laxatives. 3. Begin the use of iron, giving following pill: Subcarbonate of iron, 0.10 gram (V/2 grains) ; powdered aloes, 0.02 gram iVi grain) ; extract of rhubarb, 0.05 gram (^ grain) ; two pills before meals. Huchard and Fiessinger (Revue • de therap., March IS, 1910). The gastric and hyper- esthesia in anemia and chlorosis were favorably inHuenced in several instances by alu- minum silicate, given in the form of neutralon, in doses of ^ to 1 dram in 3 ounces of water, one-half to one hour before meals. Rosenheim and Ehrmann (Deut. med. Woch., Jan. 20, 1910). In the management of acute ane- mias of grave character {i.e., post- hemorrhagic variety) the direct trans- fusion of an homologous blood, by Crile's or by Carrel's method, may prove to be a life-saving expedient. The technique and other details of this operation are discussed elsewhere in this work. (See Transfusion.) Seven cases of severe anemia greatly benefited by transfusion of only S c.c. (75 minims) of human blood. No benefit was observed in cases of leu- kemia. Transfusion of this amount is generally harmless, though the blood from certain persons showed some toxicity. Weber (Deut. Archiv f. klin. Med., Sept. 4, 1909). Four cases of severe anemia greatly benefited by intramuscular injections of defibrinated blood. The writer drew off venous blood from a healthy subject into a small flask, stirred for ten or fifteen minutes, filtered through wool, and incubated for one-half to one hour. He then injected 10 to 30 c.c. in the gluteal muscles ; the procedure is almost painless. Arsenic in increasing doses should be given at the same time. liuber (Deut. med. Woch., June 9, 1910). Observations on twenty dogs killed by chloroform and resuscitated after periods varying from three to fourteen minutes, with a view to determining the limits of recovery after a total anemia of the nervous system. In human resus- citation the technique i" as follows : The patient, in the prone posture, is sub- jected at once to rapid rhythmic press- ure on the chest, with one hand on each side of the sternum. This pressure produces artificial respiration and a moderate artificial circulation. A can- nula is inserted, toward the heart, into an artery. Normal saline, Ringer's, or Locke's solution, or, in their absence, sterile water, or, in extremity, even tap water is infused by means of a funnel and rubber tubing. But as soon as the flow has begun, the rubber tubing near the cannula is pierced with the needle of a hypodermic syringe loaded with 1 : 1000 adrenalin chloride, and from 15 to 30 minims is at once injected. The injection is repeated in a minute if needed. • Synchronously with the injec- tion of the adrenalin the rhythmic press- ure on the thorax is brought to a maximum. The resulting artificial cir- culation distributes the adrenalin, that spreads its stimulating contact with the arteries, bringing a wave of powerful contractions and producing a rising arterial, hence coronary, pressure. When the coronary pressure rises to, say, 40 mm. or more, the heart is likely to spring into action. Just as soon as the heart-beat is established the cannula should be withdrawn. Bandaging the extremities and abdomen tightly over the masses of cotton is very useful. From a personal experience in attempts at resuscitation of the human being it became apparent that the human heart seems to respond even more readily than the heart of a dog. Crile (Amer. Jour. Med. Sci., Apr., 1909 ; Jour. Amer. Med. Assoc, May 1, 1909). Hydrotherapy and general mas- sage must be regarded as most useful aids to the drug treatment of anemia, and such measures, when sanely car- 664 ANESTHESIN. ried out, will do much to promote adequate excretion and secretion, to maintain a healthy balance of the blood and lymph streams, and to stimulate oxygen and carbon dioxide interchange. A regime^ of fresh air, sunshine, and gentle exercise is of great value, added to the fore- going hygienic measures, and in this connection it is interesting to recall Gardinhhi's statement, recently voiced by Pope (N. Y. Med. Jour., No- vember 2, 1907), that the presence of sunlight promotes the absorption of iron from the liver, where this metal, after ingestion, is presumably stored in no inconsiderable quantity. J. C. Da Costa, Jr., Philadelphia. ANEMIA, SPLENIC. See Spleen, Diseases of, ANESIN. See Chloretone. ANESTHESIA. See Various Anesthetics: . Ether, Chloroform, ETC. ANESTHESIN. — Anesthesin is, chemically, ethyl para-aminobenzoate [Cq- H4.NH2.COOC2H5]. It occurs as a white, odorless, and tasteless powder, almost in- soluble in cold water, with difficulty solu- ble in hot"*water, sparingly soluble in fatty oils (2 to 3 per cent.) and in dilute glyc- erin, easily soluble in alcohol, ether, chlo- roform, benzene, and acetone. It melts at 90° to 91° C. Though decomposed by prolonged boiling, it can be rendered sterile without deterioration when dis- solved in oils. Alkalies and alkaline car- bonates are incompatible with it, removing the ethyl group to form alcohol and set- ting free para-aminobenzoic acid. PHYSIOLOGICAL ACTION. — The most conspicuous feature of anesthesin is its local anesthetic property. The drug differs radically from cocaine in that it is but very feebly toxic and is insoluble in water. The low toxic power was shown in the experiments of Binz, who adminis- tered 0.6 Gm. (10 grains) of the drug in 20 c.c. of oil by stomach tube; on the next day the animal was in good health, with urine normal. The dose required to kill was found to be 1.15 Gm. (18 grains) pei kilo of animal, the symptoms produced being paralysis, gradual loss of sensibility in the hind limbs, and dyspnea terminat- ing in asphyxia. The drug was also ad- ministered intravenously in dogs and in- traperitoneally in guinea-pigs, with simi- lar results indicative of a low degree of toxicity. The intoxication produced by anesthesin is in some ways comparable to that of acet- phenetidin ; massive doses lead to the forma- tion of methenioglobin, with consequent methemoglobinuria. Anesthesin placed upon the tongue pro- duces a feeling of numbness in two to three minutes. By virtue of the insolu- bility of this substance, its anesthetic action is more strictly localized than that of cocaine. It is also feebler, but is more enduring. It is said to exert no action on the vessels at the site of application, caus- ing neither vasoconstriction nor vasodila- tion. Over orthoform it has the advan- tages of being more stable and practically non-irritating. THERAPEUTIC USES. — Internally, anesthesin, as first demonstrated by von Noorden, is useful in conditions of gastric hyperesthesia, including nervous dyspepsia and gastric ulcer. The dose is 0.2 to 0.5 Gm. (3 to 7y2 grains) ten to fifteen minutes after the ingestion of food. In laryngeal tuberculosis an insufflation of anesthesin has been found by Courtade to arrest the severe pain and, therefore, the dysphagia for nearly forty-eight hours. Earp found it very useful in very painful bleeding ex- ternal hemorrhoids. The bowels were moved freely by enemas, hot applications were used freely, and the following oint- ment was applied twice daily: — B Anesthesin 15 grs. (1 Gm.). Ergotin 1 dr. (4 Gm.). Ichthyol 30 mins. (2 Gm.) . Lanolin 3 drs. (12 Gin.). Petroleum ..to make 1 oz. (31 Gm.). Earp also found anesthesin useful in perineal eczema which had not yielded to other measures. S. ANEURISM (BABCOCK). 665 ANEURISM. —DEFINITION.— An abnormal circumscribed blood- tumor containing' a cavity communi- cating with an artery. An aneurism consists of a sac, neck, and contents. The contents include liquid blood, co- agula, and laminated fibrin. Aneu- risms vary in size from that of a millet seed to that of a child's head. In order of frequency aneurisms involve the thoracic aorta, popliteal artery, fem- oral artery, abdominal aorta, subclavian artery, innominate artery, axillary artery, iliac artery, and the cerebral and pulmonary arteries. VARIETIES.— Congenital. — Con- genital aneurisms are extremely rare, but they have been reported involving the abdominal aorta and ductus Botalli. A rare congenital deficiency of the elastic elements of the walls of the arteries may be the cause of multiple aneurisms, especially involving the smaller arteries of the body. Idiopathic. — Idiopathic aneurisms are those arising without obvious traumatic injury to the vessel -vvall. They are usually dependent upon dis- ease of the arter}^, and constitute most of the aneurisms involving the great vessels of the trunk, and the smaller aneurisms of the brain and other viscera. Traumatic. — Traumatic aneurisms are those resulting from mechanical in- juries sustained by the arterial wall, either in the form of a contusion, in- cision, or laceration. Hernial. — Hernial aneurisms are usually small traumatic aneurisms pro- duced by the bulging of the inner tunic through the divided outer layers of the arterial wall. True. — True aneurisms are those having walls formed by the normal coats of an artery. It is rare, however. to find an aneurismal sac in which in- tima, media, and adventitia can all be demonstrated. False. — False aneurisms are those in which the sac is formed b}^ tissues other than those derived from the wall of the artery. They follow arte- rial incisions or ruptures, but even W'ith these false sacs the endothelium proliferates from the intima of the artery into the sac and finally tends to line it. Diffuse. — Diffuse aneurisms are false aneurisms resulting from an ex- tensive extravasation of blood from an open artery. As a rule, they are due to traumatism, but the}" also re- sult from the spontaneous rupture of a diseased artery. Dissecting. — Dissecting aneurisms are those in which the aneurismal sac lies betw-'een the coats of the artery. As a rule, they have two mouths, the blood entering through one opening, separating the layers of the arterial walls, and then, at some distance, re- communicating by a second opening with the arterial stream. These oc- cur most frequently in the abdominal aorta and may produce a very exten- sive separation of the arterial coats. Embolic. — Embolic aneurisms are those resulting from the lodgment of emboli. By some they are attributed to the laceration of the walls of the small vessels by calcareous embolic particles. It is evident that they may also result from degenerative or inflammlatory changes of the arterial wall, secondary to the lodgment of the embolus. Embolomycotic aneurisms develop during the course of endocarditis and occasionalljr during some of the acute infectious diseases, which form a dis- tinct group by themselves, differing in pathogenesis, clinical course, and prog- nosis from those developing secondary 666 ANEURISM (BABCOCK). to chronic arterial changes. Thej^ have been recognized since 1851. They may develop in one of three ways. Most commonly they follow an endarteritis associated with lodgment of infected emboli at the bifurcation of arteries. A few cases have been reported which developed during the course of infec- tious diseases unaccompanied by endo- cardial changes. The possibility of traumatic origin is also supported by the observation of Ponfick and Thoma of calcified emboli in the arterial wall and projecting into the aneurism. Clinically, embolomycotic aneurisms dif- fer from those following chronic arte- rial changes: (1) in developing at an earlier age ; (2) in frequently being multiple, acute and chronic forms often occurring in the same individual ; (3) in the frequent involvement of visceral arteries, and (4) in the tendency to remain small. A number of cases have been reported in which no satisfactory explanation is given of the cause. About one-fourth of the cases observed developed during the third decade of life, and about one-fourth during the second. They are much more frequent in males, although the authors have been unable to demonstrate the reasons for this satisfactorily. They have collected, including their own cases, 96 aneurisms of this class occurring in 65 patients, they frequently being multiple, and re- port 3 cases observed by themselves. The largest proportion of these aneu- risms occurred in the superior mesen- teric and cerebral arteries, and in the aorta, which is in marked contrast to the distribution of the ordinary type of chronic aneurisms, which rarely occur in the superior mesenteric or cerebral arteries. There is nothing characteristic in the symptoms, and they are not often suspected until fatal ab- dominal or cerebral hemorrhage occurs. Bacteria have been found within the wall of the aneurism, showing the bacteriological relationship between the vegetations on the heart valves and the clot in the aneurism. The forms are usually the streptococcus and staphy- lococcus, though other species have been reported. In 2 of the author's cases, examinations revealed the pneumococ- cus. This infection of the aneurisms complicates any operation, the patients being usually in a critical condition and not enduring surgery well. Dean Lewis and V. L. Schrager (Jour. Amer. Med. Assoc, Nov. 27, 1909). Miliary. — Miliary aneurisms are very minute aneurisms most fre- quently observed in the brain or lungs. They involve small- or me- dium- sized arteries and often occur in great numbers. Fusiform or Ectatic. — In these forms the weakened arterial walls yield in every direction, forming a fusiform, or, rarely, a somewhat cylin- drical, enlargement. The three coats of the artery may be demonstrated in the sac ; usually there is little clot present, and there may be few symp- toms, unless through weakness of a part of the wall a sacculated aneurism follows. The walls of the fusiform aneurism may be thicker than that of the adjacent artery. Sacculated. — Sacculated aneurisms are due to the bulging of one side of an artery. The elastic and muscular layers of the artery are not found in the walls of the sac, ETIOLOGY. — Aneurisms result from conditions weakening the ar- terial wall and increasing the blood- pressure. Race. — The Anglo-Saxon race is most frequently affected; the English more than the American, a condition attributed to the greater consumption of alcohol in England. Aneurism is rare in the Asiatic races and in Italy. It is three times as prevalent in the American negro as in the white race. Age. — Aneurism is most frequent be- tween the ages of 30 and 50, a period when degenerative changes in the ar- ANEURISM (BABCOCK). 667 teries are especially found in those engaged in laborious physical work-. Sex. — Men are affected ten times as frequently as women, excepting the carotid and dissecting forms of aneu- rism, w^hich occur more frequently in women. The more laborious occupa- tions of men and their greater tendency to dissipation and excess explain the in- fluence of sex. Soldiers, sailors, athletes, cab driv- ers, furnace men, and others engaged in violent, but intermittent exercise are especially predisposed to aneurism. It is eleven times more frequent in the English army than in the civilian, and is much more frequent in soldiers than in sailors, a condition attributed to the pressure and strain from poorly fitting clothing and heavy accoutrements. Cab drivers, apparently from the pull upon the arms, are especially susceptible to thoracic aneurism. Vessels at the point of flexion and extension, such as the popliteal and iliacs, or under greater strain, such as those of the right arm rather than the left, are more frequently involved. Oc- casionally symmetrical aneurisms, as double popliteal aneurisms, occur. Those conditions that produce a weakening of the arterial wall, espe- cially all the causes of arteriosclerosis and atheroma, are important predis- posing causes to aneurism. These in- clude syphilis, alcoholism, rheumatism, gout, and the action of mineral poisons like lead. Arterial disease appears to be rare, almost unknown, in animals. Syphilis, being probably peculiar to man, is by this observation placed more firmly in the list of etiological factors. Arterial disease in children under 6 years, even in those who are victims of congenital syphilis, is practically unknown. In those from 6 to 15 years it is rare. It is found in the initial stage most com- monly between the ages of 30 and 40 years. The teratological factor, though an undeterminable one, is of great im- portance. Arterial disease seems to be attributable to syphilis in about 32 per cent. , to tuberculosis in about 16 per cent. The facts presented go to show that the colored race is affected about four times more frequently than the white. General arteriosclerosis seems to be not commonly found with aneurism, and its presence may be considered as evi- dence against the probable development of aneurism. Staining with selective stains and treating with a chemical which digests tissue show the elastic tissue to be free of histological alterations, sug- gesting that this tissue undergoes physi- cal or molecular rather than hi'^tological change. C. N. B. Camac (Amer. Jour. Med. Sci., May, 1905). The influence of rheumatism is one of great importance, especially in young patients. The writer, working with Renon, has recently published some im- portant ' observations relative to this subject. According to the cases col- lected by this author, the average age is from 10 to 16 when the patients have usually had several attacks of ' acute rheumatism. Repetition of the disease is regarded as an essential factor. The appearance of aneurism is preceded for some time by the signs of aortic in- competence and hypertrophy of the heart. After a period of considerable latency, the symptoms and signs of aneurism appear rapidly. They are dyspnea, especially marked after effort, , and characterized by forced inspiration without actual oppression. After a short time this dyspnea becomes per- manent, though occasionally varied by pseudoasthmatic crises, sometimes at- tacks of pain resembling angina pec- toris. The attacks usually appear dur- ing the first sleep. The patient retires to rest in his ordinary condition, but suddenly awakes in great agony, com- plaining of a feeling of constriction in front of the chest, air hunger, desire to cry out, and violent inspiratory efforts are made. The crisis may last 668 ANEURISM (BABCOCK). from a quarter to one hour, and then gradually disappear. Occasionally the crises are entirely painful without res- piratory trouble. They may, therefore, be pseudoasthmatic or pseudoanginal. Considerable intervals may elapse be- tween them, for in one case quoted by the author they numbered 2 or 3 dur- ing the year ; in others they are more frequent,_ occurring once a month, or even daily. The diagnosis is confirmed by the rapid appearance of physical signs. These aneurisms, as a rule, affect the upper right costal area, and do not differ from those usually ob- served in other cases. Aortic aneurism in young rheumatic subjects may de- velop fully in the course of a few weeks, sometimes in succeeding stages corresponding to the rheumatic crisis. After each crisis there may be tem- porary improvement, due to retrocession of the tumor. This improvement is re- versed by a fresh crisis of articular inflammation. The condition is, there- fore, progressive, and there is little hope of obliteration taking place in the sac. Prognosis is usually fatal, death often occurring suddenly either from hemor- rhage or as the result of an anginal seizure. ■ Treatment can only be directed toward symptoms, nitrites being given for dyspnea and pain, and salicylates should not be omitted in view of the rheumatic nature of the disease. Fey- taud (These de Paris, 1906; Brit. Med. Jour., Jan. 12, 1907). Generalized arteriosclerosis or endar- teritis is seldom followed by aneurism of any of the large blood-vessels, the pathogenic conditions of which are forms of progressive periarteritis, finally causing perforation of the elas- tic membrane of the affected vessel. Aneurisms of this kind — those due to traumatism being excluded — have an infective origin, and are the result of tuberculosis, syphilis, or malaria. Lan- cereaux (Rev. de chir., No. 8, 1906). Aneurism of the thoracic aorta is undoubtedly a syphilitic disease, though aortic strain from hard work where the tissues are already degenerated by alcoholic excesses must certainly pre- dispose. A strong alcoholic history was obtained in more than 40 per cent, of the writer's cases. Of 225 cases of aneurism, 179 were sacculated, 39 fusi- form, and 7 dissecting. In much the larger proportion of cases the aneurism occurs in the transverse portion of the arch of the aorta. Drummond (Brit. Med. Jour., June 13, 1908). Cardiac hypertrophy, plethora, and renal disease are also factors. Experi- mentally, aneurism may be produced by the repeated introduction of adren- alin into the circulating stream. PATHOLOGY.— Idiopathic aneu- risms develop in an area of atheroma, in the situation of an old scar, the point of lodgment of an embolus, or other weak area in the arterial wall. All forms of aneurism are lined by endo- thelium, excepting the fusiform aneu- risms ; the media of the artery does not constitute a layer of the abnormal sac. This is important, and it means not only that the normal muscular and elastic coats are absent, but that the vasa va- sorum upon which the arterial wall depends for its nourishment is lacking. The sacs of all saccular aneurisms tend, therefore, to be weak and from the blood-pressure to become progressively distended. In the fusiform aneurism all the layers of the arterial walls may remain and the wall of the sac may be thicker than that of the normal artery, the in- tima being thickened by atheroma, the adventitia by the deposit of fibrous tis- sue, while the middle coat is thinned. As the inner coats of an artery consti- tute' not less than three-fourths of the thickness of its wall, containing the elastic and muscular layers, and also the vasorum supplying the walls with nourishment, the thinning, absence, or damage to these structures means a weak and poorly resilient wall for the aneurismal sac. ANEURISM (BABCOCK). 669 In sacculated aneurisms there is usually a progressive deposit of layers of fibrin against the wall of the sac, tending to strengthen the walls and to lessen the fluid contents. The lessen- ing of the fluid contents is important, as the pressure on the sac wall varies as the square of the diameter of the cavity which contains the fluid. At times the blood-clot is deposited in progressive layers until the entire sac is filled, resulting in a spontaneous cure. The blood-clot at the periphery is white, laminated, and fibrous, al- though rarely organized into the true fibrous tissue, the lack of vasorum pre- venting vascularization. The aneurism, therefore, may consist of a sac or body, which in the sacculated form may com- municate by neck and opening with the artery. The sac is strengthened on the outer side by the deposit of fibrous tis- sue, an evidence of the reaction and irritation of the tissues against which the aneurism presses. The sac may contain peripherally white, laminated clot; then a layer of softer, red blood-clot, and finally fluid blood communicating with the blood- stream. In the cylindrical and fusi- form aneurisms little or no lining clot may be present. The size and shape of the sac are modified by adjacent pressure. Rota- tion of the sac may occur so that in a fusiform aneurismal sac the orifices of the efirerent and afferent trunks may lie at the sides or at the equator of the sac, rather than at the poles. Matas classifies aneurisms by the number of orifices which connect them with the parent artery. These orifices may only be accurately determined af- ter the opening of the sac. Fusiform aneurisms have two distinct orifices ; saccular or sacciform aneurisms are those which are connected with the lumen of the parent vessel by a single circular, ovoid, or elongated opening through which the blood flows in and out the sac. The sac of the aneurism may have many collateral branches corresponding somewhat with the branches normally given ofi: by the segment of the arterial wall forming the aneurism. These collat- erals may be functional or impervious and containing thrombi. The perianeu- rismal circulation may be very impor- tant in maintaining the collateral circu- lation after operation .upon the sac. An aneurism influences the blood-stream, absorbing the cardiac wave, so that the pulse distal to the sac is delayed and weakened. To compensate for this the heart may hypertrophy and anastomotic channels form. The aneurism may so press upon the main vessels as to completely inter- rupt the circulation beyond the sac. The adjacent tissues are variously afifected. Bone is eroded and pro- gressively destroyed by the continuous pressure, cartilage being much more resistant than bone. Nerves are stretched, compressed, and flattened, at times destroyed, giving rise to paresthesia and more rarely paralysis. Adjacent veins may be com- pressed with the production of cyano- sis and edema, and rarely erosion and perforation in the venous channel occur. Mucous canals are compressed and displaced, while .fibrous tissue, ten- dons, and fascia are flattened, stretched, and often incorporated into the sac. Thrombi may form. in tributary ves- sels, and emboli may result from the dislodgment of clot or fibrin. Cerebral complications, such as hemiplegia, in- farcts in the internal organs, and gan- grene of the extremities, also occur. 670 ANEURISM (BABCOCK). SYMPTOMS.— Aneurismal dilata- tion may occur suddenly from trauma- tism or a great increase of intravascu- lar pressure and may be characterized by sharp pain and rapid enlargement along the course of an artery. The sac, however, usually forms slowly and at first without pain or any other symptom. Case of a woman aged 42 years, attended by remarkable features. The aneurism was eroded and perforated the sternum in two places without ever causing pain or any other pressure symptoms; it presented externally as a tumor, and then disappeared under treatment by iodide of potassium, the skin rupturing without letting out any blyod. This series of events was re- peated several times in the course of seven years. Death occurred from the sudden bursting of the aneurism as the patient lifted a pitcher of water. R. C. Cabot (Amer. Jour. Med. Sci., April, 1900). The diagnosis of aortic aneurism still remains in obscure cases a difficult one, and even the X-ray examination maybe misleading. Attention called to the frequency with which, in aneurism of the arch, the left supraclavicular groove is obliterated or even bulges, and the left external jugular is obviously fuller than the right. The anatomical reason lies simply in the compression of the left innominate vein as a result of the dilated arch. A mediastinal tumor may have the same effect, but dilatation in cases of aortic insufficiency is apparently seldom sufficient to effect compression. Dorendorff (Deut. med. Woch., Nov. 31, 1902). Pain is one of the earliest and most constant symptoms of aortic aneurism. It was the first and most severe symp- toms in about half of the author's cases. It is possible that it should be absent, though there may be dyspnea, cough, and cyanosis, and though the sac may perforate the chest wall or erode the spine. The most common situation for the pain is in the region of the heart itself, radiating to the neck, the shoulder, and back, and down the left arm or both arms. In some cases the abdominal pain is severe. Several distinct varieties of pain may be recognized in this disease : 1. At- tacks of true angina, having paroxysms of pain of maximum intensity, with radiation to the arm. 2. Sharp neu- ralgic pain due to pressure on the nerves, perhaps extending along the course of the nerves, and associated with herpes when the descending tho- racic aorta is implicated. It is similar in character to that which is caused by the pressure of pelvic tumors, and by disease of the vertebrse, and it may be paroxysmal in character. 3. Pain of a dull, boring character which is present when the chest wall or the spine is eroded by the aneurismal sac. This is the form of aneurismal pain which is most enduring and most severe. It is due to tension and stretching of fibrous and bony structures rather than to pressure upon nerve cords. 4. Pain re- ferred to the nerves of the arms or the skin in the precordial region or to the pectoral or sternomastoid muscles. One object of the writer's paper was to narrate types of cases in which at- tacks of angina pectoris customarily precede the appearance of the aneurism for months or years. The paroxysms may not be in the least suggestive of aneurism, but they are associated with early structural changes in the wall of the aorta. In sclerosis of the aorta pain is not necessarily a symptom, the author having observed this fact in syphilitic patients. With lesions of arteries the pain may be the most in- tense, this being frequently observed in embolism, thrombosis, and the ligation of vessels. W. Osier (Med. Chronicle, May, 1906). With the exception of the rare cases in which there is trouble with swallow- ing, the early symptoms of aneurism, manifested by pressure, are usually either pain or disturbance with the re- spiratory apparatus. The latter may come either from pressure on the air passages or from pressure on the re- current laryngeal nerve. The symp- toms frequently simulate those of heart ANEURISM (BABCOCK). 671 disease, and their true meaning is learned partly by not finding a cardiac condition that will explain the symp- toms, and partly by looking for and finding evidence of an aneurism. The picture of aortic aneurism in its earlier stages is not uniform, but varies widely with the position and size of the aneurism. There are no pathognomonic signs. The most characteristic feature of one case may be entirely lacking in the next one. And yet a careful physi- cal examination and a careful consider- . ation of the physical signs and symp- toms should enable the detection of the existence of an aneurism of the ascend- ing or transverse arch at a very early stage. The X-ray examination is of use in the case of aneurisms in these two parts of the aorta as confirmatory evi- dence, as giving more definite informa- tion in some respects, and sometimes (when pulsation is seen) in deciding between an aneurism and a solid tumor. The X-rays may detect aneurisms of the descending arch and the descending thoracic aorta which cannot be detected by the ordinary methods of physical examination. On the other hand, a negative report of an X-ray examina- tion is not absolutely conclusive proof against the existence of an aneurism. The detection of an aneurism of the arch of the aorta requires no greater skill than does the recognition of in- cipient tuberculosis. It is, therefore, within reach of the general practitioner, if he will give this disease equal con- sideration with tuberculosis. When discovered early, the treatment is not the same as in the advanced stages. Moderate limitation of exertion and mental quietude are essential, but abso- lute rest in bed is not necessary. While the disease cannot usually be cured, life can be prolonged in comfort. The vasodilators are the most useful drugs so far as medication is demanded. H. D. Arnold (Amer. Jour. Med. Sci., April, 1908). An early postive diagnosis of aortic aneurism is obtainable only by the X-ray. Expansile pulsation is not con- stant. Abnormal dullness is a valuable sign when present. The most constant sign is systolic bruit, which was present in 11 of 19 cases. Tracheal tugging occurred in but 2 cases. The earliest and most constant symptoms were dyspnea and cough. Interference with passage of bismuth capsule the size of a quarter through esophagus was found present in every case tested (by X-rays). This is especially valu- able in small aneurisms growing back from the transverse part of the arch, as it shews the esophageal obstruction before dysphagia appears. Lange (Lan- cet-Clinic, Feb. 19, 1910). The aneurism forms a smooth round or oval enlargement in the course of an artery. It is not sensitive, unless in- flamed, is not adherent to the overlying skin, but may be associated with edema and venous congestion of the parts dis- tal to the tumor. The sw^elling has an expansive pulsation up to the time that a sufficiently thick layer of clot forms within the sac to abolish this sign, so that the symptoms are at times divided into those of the expansile and those of the non-expansile stage. The artery distal to the aneurism gives a retarded and feeble pulse. The expansile pul- sation may be less marked and the tumor softer when the parts are ele- vated. The pulsation is diminished by pressure upon the main artery prox- imal to the aneurism, and in some cases the sac may then become softer and collapse. On auscultation a systolic or sometimes a double rough murmur or bruit is heard, loudest at the proximal pole. A shadow, emphasized if cal- careous deposits are present, may be shown by the fluoroscope or skiagraph. Subjective symptoms include pain from the stretching and compression of nerves and the arrest of the venous or lymphatic circulation. The pressure and erosion of bone, especially noticed in aneurisms of the aorta, cause the characteristic boring, so-called osteo- 672 ANEURISM (BABCOCK). pathic pains which are usually more severe at night. In the skull the rushing sound and bruit, headache, and the evidences of cerebral pressure or irritation, such as choked disk, vomiting, dilated pupil, motor and sensory disturbances, and localizing nerve palsies, may be present. When an aneurism causes paralysis of the third nerve alone, it is uniformly seated upon the trunk of the internal carotid, between the origins of the anterior and posterior communicating arteries. When the aneurism involves the origin of the posterior cerebral artery, the paralysis of the third nerve is accompanied by paralysis of the corresponding facial. The only sub- jective symptoms (besides the diplopia) are pains in the head and constant noises upon the same side as the aneu- rism. These cases always end fatally. Pascheff (Archiv d'ophtal., Oct., 1910). In the neck the situation of the tumor, expansile pulsation, and the ef- fect upon the distal vessels are charac- teristic symptoms. In the chest the recurrent laryngeal nerve frequently is involved with the production of rasping voice, spasm or paralysis of the vocal cord, and brassy cough. Pressure upon the sympathetic may produce unilateral sweating and unilateral contraction or dilatation of the pupil as well as tachycardia. Pe- ripheral neuralgia may result from compression of the intercostals. Com- pression of the phrenic may cause dyspnea and hiccough, w^hile pressure upon the esophagus may result in dysphagia. Although there is no one pathog- nomonic sign of thoracic aneurism, there are certain symptoms and signs taken together which make its existence practically certain. The pain, often slight and not complained of except after particular inquiry, is continuous, is situated near and to the left of the vertebral column, and tends to radiate to the shoulder, the left arm, and the neck. Examination of the chest shows no loss of resonance on the left side, but the resonance is not increased as in pneumothorax. At the same time the breath sounds are dimini-hed over the left lung — this being due to partial compression of the left bronchus. The inspiratory sound is shorter over the left side, the first period of inspiration being inaudible and the air then enter- ing with a rush, as though a valve had been opened. On inspection, there is relative immobility of the left side of the chest, or in some cases there may even be definite retraction. If the above signs be present, together with dyspnea on effort, in a patient whose general health is fairly good and who has no sign of malignant disease, the presumption of the existence of aneu- rism is strong. Inequality of the pupils is often an early symptom. Clement (Lyon med., March 31, 1907). Tracheal tugging is often found in aneurism of the arch of the aorta, and is due to the transmission of the aneu- rismal pulsations to the left bronchus, and is detected by inclining the head and lifting the larynx and trachea by the finger and thumb caught under the hyoid bone. Six cases illustrating the way in which an aneurism of the aorta is liable to push the trache : backward, down- ward, and toward the left, and thus pull the larynx out of place. This dragging down of the larynx and its deviation to the left and back may, the writer asserts, be regarded as a reliable sign of aneurism of the aorta. Boinet (Bull, de I'Acad. de Med., Dec. 21, 1909). Inanition may follow in the rare in- stances in which the thoracic duct is compressed. In thoracic aneurism the distal vessels show a retarded and re- duced pulsation, so that the pulse may be weak or even absent from the one wrist. ANEURISM (BABCOCK). 673 Case of aneurism of the aortic arch in which the pulse of the carotids and right radial arteries had the reversed character of the pulsus paradoxus. There was a A'ery marked diminution in the volume of the pulse during expiration, and with the respiratory variations there was a definite ana- crotic wave. Post-mortem examination showed an aneurism involving chiefly the posterior portion of the aorta in the region of tliB transverse arch. The left carotid and innominate arteries sprang from the anterior surface of the arch instead of from the convexity, on ac- count of the distention of the aorta. With each expiratory excursion these blood-vessels were compressed against the bony thoracic walls. J. Hay (Lancet, April 27, 1901). In the course of their studies upon lesions of the aorta the writers have been impressed with the frequency with which some of the lesser signs of aortic aneurism were present. Inequality of the pulse was present in 10 out of 18 cases. In 9 of the 10 cases pulsation was more vigorous on the right than on the left side. Inequality of the pupils was present in 3 cases, but in 1 it might have been due to nervous com- plications. Suprasternal pulsation was present in 12 cases and absent in 6. Tracheal tugging of distinct downward character was present in 11 and absent in 7 cases. A systolic thrill was felt in the vessels of the neck either with or without slight pressure in 9 cases, and it could not be elicited in 9 cases. A systolic murmur usually transmitted into the vessels of the neck was pres- ent in 11 cases, but was not heard in 7. Twelve of the cases had dyspnea; in 1 of these there were physical signs of emphysema and chronic bronchitis ; in the others it was probably due to the cardiac condition. J. Sailer and G. E. Pfahler (Amer. Jour. Med. Sci., Oct., 1903). The arterial blood-pressure in most cases of aneurism of the thoracic aorta or innominate is either normal or slightly above normal. It is, as a rule, however, much higher in cases of mere dilatation of the aorta, and this fact 1—43 is of some value in the differential diagnosis of these two conditions. Williamson (Lancet, Nov. 30, 1907). In examining for aneurism of the aorta, one should carefully percuss the area of dullness of the great vessels, note the conduction of the heart sounds in this area, examine both radial pulses simultaneously, examine for the tra- cheal tug, note all evidences obtained by inspection or palpation, note care- fully all the anatomical relations of the aorta, and ever keep in mind the pos- sibility of aneurism. The early symp- toms are usually pain or disturbance with the respiratory apparatus, the latter from pressure on air passages or the recurrent laryngeal nerve. The symptoms often simulate those of heart disease. There are no pathognomonic signs; the features may be entirely different in successive cases. Arnold (Amer. Jour. Med. Sci., Apr., 1908). Case which confirms the possibility of a disconnected respiration of a stac- cato type from the hammering of the trachea by an aneurism resting against it. Ortner (Med. Klinik, April 25, 1909). In cases of thoracic aneurism, delay or increased retardation of one of the radial pulses does occur. The same delay may or may not be present in the case of the corresponding carotid pulse. If the idea, based on experimental physics, be correct, that delay of the pulse-wave is only produced as the re- sult of the wave passing through the aneurism, then the phenomenon of de- lay should be of most important diag- nostic aid in the localization of the aneurism. Digital examination is not a reliable test of the presence or absence of delay. The finger may miss the delay when present, and may diagnose it when absent. A more delicate in- strument, such as the clinical polygraph, is necessary. Leonard Findlay (Prac- titioner, Dec, 1909). Rupture is signalized by pain of sud- den onset with shock. The hemorrhage . may escape externally through the skin, into the trachea, or into the alimentary 674 ANEURISM (BABCOCK). canal; if into the pericardium there are evidences of acute heart compression; if into the cavity of the thorax, of hematothorax ; if into the muscular substance, the formation of a progress- ively enlarging tumor. The rupture may be immediately fatal, or the pa- tient may live for hours or for days, and repeated or continuous leakage may occur. Rarely does recovery follow- after an aneurism of one of the great vessels of the trunk has ruptured, al- though the patient may survive for days or weeks. Case of abdominal aortic aneurism in a man aged 41 years in whom the writer observed several hyperesthetic cutaneous zones, as described by Head. Such zones are segmental regions of the body corresponding to the various viscera, exactly at the sensory inner- vation of the skin, as described by Sherrington, Starr, Kocher, and Thor- burn. Trophic disturbances occur in the skin in disease of the arteries, as, for example, in zoster. The points noted in the study of the present case in- cluded the belt-like distribution of the radiations of pain due to the abdominal aneurism, these pains dating many years before the development of the symp- toms. E. Cedrangolo (Riforma medica, Mar. 23, 1907). COURSE. — Aneurisms tend to pro- gressively dilate and finally to rup- ture. In rare instances an aneurismal sac may remain stationary for many years, finally to again progressively dilate. In a third class spontaneous cure occurs by the coagulation of blood within the sac, which may completely consolidate it, with or without oblitera- tion of the arterial lumen. Any con- dition w^hich interrupts or retards the circulation through the sac may favor this spontaneous cure. This termina- tion at times is followed by a fatal gangrene from obstruction of the col- lateral circulation. Plastic arteritis with thrombosis and obliteration of the artery may also lead to a cure. More frequently the aneu- rism progresses to rupture. The rup- ture may occur through the skin, mu- cous membrane, into a serous or syno- vial cavity or into the subcutaneous tissues, muscles, or fascial planes. There may be repeated moderate hemorrhages, one or several large hem- orrhages, or a rapid hemorrhage suffi- cient to cause almost instant death or a progressively increasing hemor- rhagic edema from a leaking aneurism. This may lead to gangrene. Suppuration of an aneurism occurs most frequently in the axillary region and usually results from the formation of an abscess adjacent to the sac. The sloughing of the sac wall may be fol- lowed by great hemorrhage as the ab- scess opens. Rarely does a plastic arteritis produce clotting and sponta- neous cure. DIFFERENTIAL DIAGNOSIS. — The expansile pulsation, bruit, and retardation of the distal pulse are fairly characteristic symptoms of aneurism. In a consolidated aneu- rism, or one in which the sac has been filled by clot, these signs may disap- pear. The history and presence of a firm mass in the wall of the blood-vessel are suggestive. Tumors and abscesses ly- ing upon large arteries may pulsate, but the expansile type of pulsation is absent. When the skin over an aneurism has become inflamed the condition may closely simulate an abscess, so that only by a careful study of the patient is a correct diagnosis finally to be made. Before the consolidation, compression of the main artery proximal to the aneurism may produce a characteristic ANEURISM (BABCOCK). 675 collapse of the sac, a cessation of pul- sation, and bruit, changes which cannot be produced in vascular sarcomas and other tumors which may simulate aneu- risms. In aneurisms of the thorax X-ray examinations are often diagnostic. In suspected aneurisms of the ab- dominal aorta loss or retardation of the femoral pulse should be especially looked for. The marked pulsation of the undilated aorta in thin persons should not be mistaken for aneurism. In determining the compressibility of the aneurismal sac the greatest gen- tleness must be employed. We have observed hemiplegia to promptly follow the examination and the palpation of a carotid aneurism for the dislodgment of particles of contained clot. TREATMENT. — Dietetic, hygi- enic, and medicinal measures have been used since antiquity with the ob- ject of slowing the circulation- and so simulating coagulation that a clot would fill the sac. The ancient method of Valsalva included absolute physical and mental rest, a very limited diet, with the deprivation of fluid, and re- peated venesections continued until the patient was too weak to lift a hand. The more recent method of Tuff- nell's was less severe, although rigor- ous; it consisted of a reduction in the diet and absolute rest in a horizontal position; 2 ounces of bread and butter are given for breakfast with 2 ounces of milk; 3 ounces of bread and butter with 4 ounces of water or claret for dinner; 2 ounces of bread and butter with 2 ounces of tea for supper. A fat diet has been advised by Powell, and the use of meats has been condemned. Cure by what was practically the Tufnell treatment. It consisted of as nearly absolute rest as possible, re- stricted diet for a week and later an ordinary fish diet, no stimulation, and potassium iodide, 10 grains three times a day. The dose was quickly and steadily increased so that by the end of the third week 60 grains were being taken three times a day, with no ill effects at any time. As a local application to the swelling, collodion was painted all over the surface every night and morning. Instead of con- tinuing his previous downward prog- ress, he commenced to improve from almost the commencement of the treat- ment, and was discharged apparently cured in six weeks. Young (Lancet, Sept. 22, 1906). Drugs are employed to reduce the cardiac frequency, to diminish arte- rial tension, and increase the coagula- bility of the blood. Potassium iodide has been considered to be the most valuable drug. Ten grains three times a day may be increased until 40, 60, or 200 grains three times daily are administered, according to the degree of tolerance. It is especially valuable in syphilitic patients. The writer reports the marked suc- cess attending the treatment of an in- teresting and apparently hopeless case of thoracic aneurism which had threat- ened to rupture externally. The skin covering the tumor, which was located in the median line of the neck, reaching from the level of the lower Iborder of the third rib to just above the level of the lower border of the thyroid car- tilage, was extremely thin, tense, and shiny, looking like an abscess on the point of bursting. The patient was put to bed and kept absolutely quiet. The diet was restricted as far as pos- sible, and all stimulants were withheld. Iodide of potassium was administered internally, in doses of 10 grains three times a day, the dose being increased so that by the end of the third week 60 grains Mrere being taken three times a day. Collodion was painted all over the surface of the tumor every night and morning. The patient began to improve from the commencement of the 676 ANEURISM (BABCOCK). treatment, until in the ninth week he was well enough to assist in the work of the hospital ward. The tumor was very much smaller, there was scarcely any visible expansile pulsation, and the overlying skin was normal. The pa- tient returned to his work. E. E. Young (Lancet, Sept. 22, 1906). Three cases of thoracic aneurism treated by large doses of potassium iodide with excellent results. In 2 cases there was apparent recovery with disappearance of the pulsating tumor and the bruit. The third case was so far advanced that external hemorrhage had taken place from the anterior wall of the aneurism; yet on 80 grains of potassium iodide three times a day marked improvement took place, the patient being enabled to return to busi- ness and to lead a quiet life. Failure in the treatment of aneurism with potassium iodide often results from the fact that the dose is too small. Sixty- grain doses ard* necessary in bad cases. Kingdon (Lancet, Aug. 22, 1903). To increase the coagulability of the blood in the treatment of saccular aneurisms the subcutaneous injec- tions of gelatin were first recom- mended by Lancereaux and Paulesco. One or 2 Gm. of purest gelatin are dissolved in 100 c.c. of decinormal salt solution, and sterilized by heating to the boiling point for one-half hour on five successive days. Before use the gelatin is warmed to the temperature of the body and 100 c.c. injected under the abdominal skin every two, three, or four days. The injections are often followed by fever and pain. The possibility of ex- tensive coagulation and of embolism has not been demonstrated. The injec- tions may cause increase of vascular pressure and involve rupture of a large- sized aneurism whose walls are thin. The clinical observations so far made do not warrant an exact estimate of the value of the gelatin treatment. Henri Grenet and G. Piquard (Archives gen- «rales de med., June, 1901). Pica for the use of injections of gelatin in aneurism of the aorta. The danger of tetanus is removed if the gelatin is properly sterilized and no disagreeable effects are noticed by the patients. The relief of pain is always very prompt. The injections may be given as high as S per cent., although half that strength is usual. Six to 7 ounces are injected at intervals of five or six days. The usual formula is 2j4 per cent, gelatin in 7 per cent, salt solu- tion. Lancereaux (Revue de therap.. No. 13, 1906). Case of large traumatic aneurism occupying the lower half of the left popliteal space, and extending down- ward to a line about 6 inches below the knee-joint. The dilatation, it was thought, involved the trunk of the posterior tibial artery above the origin of the peroneal branch, and also the lower part of the popliteal artery above the origin of the anterior tibial. An attempt, therefore, to extirpate the sac would have completely abolished the circulation in the leg, and very prob- ably resulted in gangrene. After a prolonged and careful treatment by rest and flexion of the leg, which proved unsuccessful, the author tried repeated subcutaneous injections of sterilized gelatin serum. Seven injec- tions were made, the intervals varying from seven to twenty days. After five days after each injection the aneurismal tumor became smaller and firmer. The last injection was followed after an interval of about ten days by complete cure. Le Dentu (Bull, et mem. de la soc. de chir. de Paris, No. 10, 1905). Several cures have been reported from the use of gelatin, but in other instances undesirable thrombi have formed in the larger veins, while teta- nus has followed the use of imperfectly sterilized gelatin. Should the clot Avhich forms in the aneurismal sac soften and be absorbed, the gelatin in- jections may be repeated with a possi- bility of good eflfect. The internal administration of cal- cium chloride and the subcutaneous ANEURISM (BABCOCK). (i77 injection of horse serum have also been used to increase the coagulabiHty of tlic blood. Case of aortic aneurism in which all the symptoms, except a slight headache, had disappeared as a result of the ad- ministration of calcium chloride for about two months. The calcium chlo- ride was given three times daily. The aneurism was clearly visible undeir the X-ray. Ambrose (Jour. Amer. Med. Assoc, Oct. 31, 1908). Arterial Compression. — The object of this method is to so slow the blood- current within the sac that a coagulum may form. The pressure may be prox- imal to the aneurism and be carried out by means of a pad, tourniquet, or the pressure of the thumbs of assistants acting in relay. The pressure of the thumb is reinforced by a 6-pound weight, and before the thumb of one assistant is removed that of another is properly placed. Each assistant serves for fifteen or twenty minutes, and the treatment is continued for from, twenty- four to seventy-two hours. The method by compression is painful and when in- strumental may cause sloughing or gangrene. The digital compression re- quires many assistants and is trouble- some, but not so apt to cause sloughing. The compression occasionally cures, but often if the clot is deposited it is dissipated before organization has oc- curred. Three cases of aneurism followed, 2 for eight years and 1 for four years, in 2 of which permanent cure has re- sulted from treatment based on a reduction of vascular tension below the normal. The treatment consists in keeping the patient at rest in bed and in prescribing a diet from which soups containing an excess of fat; meats, es- pecially those cooked rare ; game, fish, cheese, salted foods, tea, coffee, spirits, heavy beers, and an excess of wine are eliminated. Tobacco is also for- bidden. Drugs, such as nitroglycerin and sodium nitrite, were adrninistered. The iodides have been overrated in this connection. In syphilitic aneu- risms mercurial injections are dan- gerous on acQOunt of their liability to affect the kidneys, and, as a conse- quence, to cause increased arterial ten- sion. The milk diet in connection with theobromine, which assists in eliminating vasoconstrictor poisons, is very helpful in reducing vascular tension. H. Huchard (Jour, des praticiens, Nu. 20, p. 307, 1906). Forced flexion of the elbow and knee, the part being held by a bandage with the pad at the flexure, has been employed for small aneurisms of the extremities. The position is uncom- fortable and the method of little ad- vantage over other methods of com- pression. The isolation of a mass of blood within the aneurismal sac by the ap- plication of an Esmarch bandage be- low and above the aneurismal sac, while efficient in causing clotting, has led to gangrene of the extremity, and the method has been abandoned. It has been advised that an Esmarch bandage be applied for one and one- half hours and then removed, with con- tinuous light compression of the artery above the aneurism for several days. Apart from the danger of compression, another danger of these methods is in the completeness of the coagulation, which may extend into the collateral vessels and so destroy their function that gangrene follows. Arterial Ligature. — Ligature of the main artery just above the sac is espe- cially efficient in interrupting the circu- lation. This is Anel's operation, but was modified by John Hunter, who placed the ligature at a distance above the sac, where he supposed that the arterial walls were healthier. Anel's operation is now preferred to Hunter's. 678 ANEURISM (BABCOCK). The most important part of the new surgical work with blood-vessels, espe- cially with aneurism, depends upon the similarity of the serous coat of blood- vessels to the peritoneum. Like the latter, the former throw out lymph for purposes of repair. Irritated surfaces in apposition adhere, and septic proc- esses in the serous coat cause changes similar to those which occur in the peritoneum. Torsion of blood-vessels also causes quick plastic occlusion that arteries of the third class may be thus treated in place of by ligation. Aneu- rism treated by digital pressure, by the introduction of coils of wire, or by electric needles causes exudation of lymph from the serous coats, fol- lowed by adhesion of apposed sur- faces. . The new work in suturing blood-vessels depends for its safety upon the prompt plastic repair of the serous coats. Morris (Annals of Surg., July, 1908). When on account of anatomical con- ditions the Hgature cannot be placed above the sac the method of distal li- gation, such as Basedow's, in which the main vessel is ligatured, or War- drop's, in which one or more of the chief branches is secured as by ligation of the right subclavian for aneurism of the innominate artery, may be tried. Rarely are they efficient. Case in which ligation of the ab- dominal aorta was performed for dis- secting aneurism involving the wall of the aorta from the celiac axis to the mesenteric vessels. This makes the fourteenth recorded operation in which the aorta has been ligatured. So far they have all proved fatal, but this case is encouraging, as showing that there is no inherent reason why suc- cess should not yet be attained. For two days the patient did very well, but on the third day she showed signs of intense septicemia, and she died fifty- three hours after operation. On post- mortem examination, it was found that the septicemia was due to gangrene of small portions of the bowel, which had lain in contact with the forceps used to clamp the ligature. The aneurism was found to be full of blood-clot, while the aorta remained patent. An embolus was found in the left internal iliac. The case demonstrates that an aneurism of the aorta can be made to fill with clots by the application of a temporary ligature to the aorta, and that circulation in the extremities may be re-established on removal of the ligature. R. P. Morris (Annals of Surg., Feb., 1900). Ligation of abdominal aorta has been done 14 times to relieve a pe- ripheral aneurism. It makes great demands on the heart and has never been successful. Collateral circula- tion soon developed, annulling the benefits of the ligation. The great number of Q.ommunications wnth the general circulation render the estab- lishment of collateral circulation inevitable. Its development, how- ever, requires extra work on the part of the heart, thus inducing con- siderable hypertrophy. In the absence of general atheromatosis of the vessels and if the operation is technically pos- sible, extirpation of the aneurism may be successful. In 10 of the 14 cases on record death was the direct result of the operation. Katzenstein (Archiv f. klin. Chir., Bd. Ixxvi, Nu. 3, 1905). A successful case (the ninth with recovery) of ligation of the innom- inate artery. The patient was a colored man aged 27 suffering from subclavian aneurism; the innominate only was tied with a largest-sized braided silk ligature in a "granny" knot drawn just tightly enough to approximate the vessel walls, but not to crush its coats. The ligature came away fifty-one days after the opera- tion while the wound was being dressed; the recovery was good prac- tically in twenty days. W. B. Burns (Jour. Amer. Med. Assoc, Nov. 14, 1908). Dix's Operation. — The artery is ex- posed and encircled by a strand of silver wire. The ends of the wire are brought through the tissues to one side of the wound, and are twisted over a ANEURISM (BABCOCK). 679 split cork until pulsation ceases in the aneurism. Later slight pulsation re- turns to the sac, and after two or three clays the wire is tightened hy i)lacing wedges under the loop. Ahout the fifth or sixth day the wire is cut and re- moved. Excision of the Sac and Implanta- tion. — The interposition of a segment of an adjacent vein has also been tried, but the procedure has rarely been suc- cessful. Removal or Obliteration of the Sac. — The ancient method of Antyllus, in which the sac was dissected out or opened and packed, has been suc- ceeded by the modern obliterative method of Matas. In this operation the patient is anesthetized, a tourniquet applied, the sac is opened by a longi- tudinal incision, emptied, and the mouth of each vessel is exposed within the sac and sutured from the inside by separate silk or chromicized catgut sutures. The redundant w^alls of the sac are then so enfolded and sutured as to form a solid pad under the skin. The advantage of this method lies in the fact that the sac is not loosened from the adjacent tissues, and, therefore, there is little risk of injuring adjacent col- lateral nerves and veins. Matas's method combines the ad- vantages of ligation and excision, while at the same time it is easier, safer, and may be more conservative. It is suitable both in the fusiform and sacculated types of the disease. After applying a constrictor above the site of the disease, if in a limb, or temporarily ligating the proximal and distal trunks, if the carotid is the vessel at fault, the operator cuts into the sac, thoroughly removes the contained clots, rubs the serosa with gauze, and proceeds to in- sert sutures. The sutures, preferably catgut, are first applied to the openings of all vessels entering or leaving the sac; then the deeper portions of the sac are closed by two rows of contin- uous Lembert sutures. The clastic con- strictor is now removed, and if any blood escapes one or two points of suture are inserted to control this. The next step consists in folding the excess of sac wall on itself, and in so doing inverting the edges of the skin wound. The operation thus performed has been very successful, and in some cases of sacculated aneurism the circulation may be re-established through the repaired vessel. Binnie (Jour. Amer. Med. Assoc, June 25, 1904). Two cases of fusiform aneurism rupturing into the surrounding tissue and treated by the writer by Matas's method of suturing the leading open- ings within the aneurismal sac. In neither case was the sac obliterated, but drainage was employed and the re- sults were satisfactory. In one of his cases to have sufired together the walls of the cavity would have required a 14-inch incision. It is better in such cases to close the incision partly and to drain, allowing the cavity to fill up by granulation, instead of closing it by suture, as is done in the unruptured cases. J. A. Danna (Jour. Amer. Med. Assoc, Aug. 5, 1905). Matas's method approaches nearer the ideal for the cure of aneurism than any other, and is more generally appli- cable. It can be employed in every accessible variety in which the circula- tion can be temporarily controlled, and it interferes less than any other with the blood-supply beyond the aneurism. The experimental work of various sur- geons shows the possibilities of vas- cular surgery, suture, anastomosism transplantation, substitution of vein for artery, arteriotomy for embolism hav- ing all been found practicable. The operation of Matas was based upon the fact that when intima is approximated to intima union occurs, and, hence, that an aneurism could be cured by closing the mouths of the vessels entering it and obliterating the sac by approximat- ing its walls. Gibbon (Annals of Surg., Sept., 1907). Results of endoaneurismorrhaphy (the writer's method) in 85 operations 680 ANEURISM (BABCOCK). by 52 surgeons up to the present date. The legitimate mortality of the opera- tion itself was 2.3 per cent.; of second- ary hemorrhage, 2.3 per cent. ; of gangrene, 4.6 per cent. Eliminating 3 of the gangrene cases in which there was simultaneous injury and ligation of veins or secondary ligature of an artery, the percentage of this accident is 1.1 only. The total of postoperative deaths from all causes was 7 to 78 recoveries. The percentage of relapses, which occurred only in the reconstruct- ive operations (4 in 13, or 28 per cent.), was only 4.7 per cent, to the total. The author believes that the fundamental principle on which the operation is based, viz., that the endo- thelial lining of the vascular system which is continued in the aneurismal sac is analogous in its pathological be- havior to the reactions and reparative processes which occur in the endothelial surfaces of the other serosa, such as the peritoneum and the pleura, has been absolutely confirmed by the experience in these 85 cases. They have also dis- proved Scarpe's law that complete ob- literation of the vessel is a;n essential to the cure, which result is also sup- ported by the facts of the suture and repair of arteries. An important point of the technique is the prophylactic hemostasis, which must be made abso- lute, and the problem increases in com- plexity and difficulty the higher the operation, and the writer mentions the methods and appliances for this pur- pose. Experience demonstrates that in all sacciform aneurisms with a single orifice of communication the closure of this orifice by suture without interfer- ing with the lumen or the capacity of the vessel is to be looked on as obliga- tory. The indication for the recon- structive operation, however, is fusi- form aneurism with separate orifices of entrance and exit, and must still be con- sidered sub j'udice. In the vast major- ity of cases of aneurism of the ex- tremities the simple obliterative pro- cedure proved satisfactory. It gives a cure with less risk to the distal parts than either the ligature or the method of extirpation. The indications in any given case will not be entirely satisfac- tory until we have a sure clinical proof of the adequacy of the collateral cir- culation. Korotkow's method of testing the most peripheral blood-pressure may be the solution* of the problem. R. Matas (Jour. Amer. Med. Assoc, Nov. 14, 1908). The advantages of Matas's endo- aneurismorrhaphy are as follows: It is more radical in its effects than liga- ture and extirpation ; it is free from risk of injury; it is only exceptionally followed by gangrene ; it does not in- terfere with the collateral circulation ; it prevents any danger of injury of a vein, and is applicable to cases in which extirpation is no longer possible. For suture chromicized catgut or fine silk is employed. The method is chiefly indicated in cases in which provisional hemostasis can be carried out and where the aneurismal sac is accessible. Altogether 149 cases have been re- ported, in 131 of which the lower ex- tremity was affected. Among the last 64 cases there have been no deaths, no recurrences or secondary bleeding, and only one instance in which gangrene occurred as a complication. F. Gardner (Gaz. d. Hop., No. 118, 1910). A second method is Matas's con- servative endoaneurismorrhaphy, to be used for sacculated aneurisms open- ing by a narrow mouth into the main vessel. This opening is sutured from the inside of the sac and the wound reinforced, pleating and suturing the overlying sac. In reconstructive endo- aneurismorrhaphy an attempt is made to restore the normal lumen of the artery in a fusiform aneurism. A rub- ber tube may be temporarily introduced as a guide between the afferent and efferent mouth of the sac, and the walls of the sac so sutured as to restore a canal having the lumen similar to that of the adjacent artery. This line of suture is likewise to be reinforced by pleating and suturing the redundant walls of the sac. ANEURISM (BABCOCK). 681 Temporary partial obliteration of the main artery by use of metallic rings or clips; Halstead and others have devised rings or clips composed of aluminum or other metal which may be applied to an arterial trunk in such a manner that the lumen in the vessel is reduced or obliterated. By reducing the lumen the current in the artery and sac distal to the ring may be so slowed as to favor curative coagulation, and if properly applied it has been found that these rings are well tolerated by the arterial wall, and have not the same tendency to ulcerate into the lumen of the vessel as a hgature. The pain of an abdominal aneurism may be greatly lessened and its growth checked by the application of a partially occluded metallic band to the aorta, proximal to the aneurism. When the aneurism is saccular and gives origin to no important vessels a cure is pos- sible by this means. When the band produces an anemia of the kidneys, there appear for a time large numbers of waxy casts in the urine. Gatch (Annals of Surg., July, 1911). The application of a ligature is not feasible in the case of the aorta, for in every case in which a ligature has been employed the patient has died, if not from the immediate danger from the operation, then some days or weeks later from secondary hemorrhage due to the ligature cutting its way through the wall of the artery. Macewen's Acupuncture. — This method aims to scarify the lining of the sac so that the granulations form upon which the blood may coagulate. One or more long fine-silk needles are thrust into the aneurism so that their points just touch the opposite wall. The pulsatile movements of the , sac wall cause the needle-points to scratch the lining of the sac. The needles may be left in place for some hours, attempts being made to so change their position that as large an area as possible of the lining will be abraded. The method is of very limited value. Electrolysis increases the efficiency of Macewen's method. Insulated nee- dles are passed and a galvanic current from 20 to 30 milliamperes. Needles should be permitted to touch the oppo- site wall of the sac so as to produce the delicate abrasion as in acupuncture. Moore's method consists in the use of a delicate wire so tempered as to coil within the sac, where it is permitted to remain permanently. A small, hol- low needle is introduced into the sac until the blood flows and from 5 to 20 feet of wire, according to the; size of the sac, passed through the needle. The end of the wire is then pushed through the needle or cut close to the skin and made to imbed itself. The Moore-Corrady method con- sists in passing the current from 20 to 80 milliamperes through the coil of wire which has been introduced into the sac. A wire of fine drawn gold is preferred, and from 5 to 20 feet intro- duced, as in the Moore method. The current is permitted to flow about one hour, negative pole being connected with a pad upon the patient's abdomen or back. The wire is permitted to re- main permanently within the sac. Aneurism of the left subclavian artery in which 20 feet of gold wire were introduced into the sac through a hollow needle, and a galvanic current, gradually increasing from 1 to 80 milli- amperes, was employed for about one hundred and ten minutes. The pulsa- tion and size of the tumor temporarily decreased and afterward increased, and death occurred on the twentieth day after operation, due to exhaustion pro- duced by long-continued pain, and hastened by the formation of a throm- bus in the left common carotid artery, 682 ANEURISM (BABCOCK). caused by the pressure of the aneurism. The necropsy showed a cocoanut-shaped aneurism involving the entire length of the artery. Its cavity was occupied in large part by a clot in varying stages of organization, through which the wire was well distributed. This operation is worthy of trial when medical treat- ment fails. The percentage of success will be greatly increased if the opera- tion be not performed as a last resort. Daland (Penna. Med. Jour., Dec, 1903). These methods have chiefly been em- ployed for aneurisms of the thoracic aorta. Occasionally cures are reported, but failures are frequent and fatal acci- dents have occurred. It is obvious that even in so-called cures the patient's ultimate condition is not a normal one. Sterilized horsehair, silk, and catgut have also been tried, but with question- able benefit. A recent addition to the methods of treatment is that of Abrams, which, though qualified by him as palliative, seems to have produced lasting bene- ficial effects in a large number (40) of his cases. It consists of repeated con- cussions over the seventh cervical vertebra, which are thought by Abrams to cause, through the vascc motor system, contraction of the diseased vascular area. Confirmatory evidence is still too scant to warrant any opinion as to the actual value of this method. A. Abrams, of San Francisco, claims that the subsidiary center of the vaso- constrictor nerves of the aorta is located in the spinal cord in proximity to the spinous process of the seventh cervical vertebra, and that by stimulation of the center in question by concussion the normal as well as the abnormal aorta may be brought to contraction. Ample evidence. is furnished of the latter fact in his work on spondylotherapy. The method, in brief, which he suggests in the treatment of aortic aneurism con- sists in concussion of the spinous process of the seventh cervical verte- bra. He deprecates the employment of the conventional vibrating appa- ratus. The vibratory apparatus which the physician must employ is one giving the percussion stroke. All other motions, such as oscillations, shaking, and friction, interfere with results. In the absence of a suitable apparatus, a pleximeter (a strip of linoleum or thick rubber) and a hammer, to the end of which is fixed a piece of hard rubber, are employed. The pleximeter is applied to the seventh cervical spine and is struck a series of rapid and moderate blows by the hammer. The daily seances, according to results, may last from five to fifteen minutes, but during the seance the treatment must be interrupted from time to time to avoid irritations of the skin. The results of Abrams's method are usually immediate, great relief follow- ing a few seances. When the writer first encountered the monograph of the latter on the subject, he was rather skeptical, although Abrams anticipates such criticism in his book by observing that any merit attached to his method may be obscured by its simplicity. The writer presents the history of a personal case suffering from aneurism of the thoracic aorta which was treated successfully by the "concussion method" of Abrams. The aneurism had per- forated the chest wall. Within one week all the symptoms had disappeared, and fourteen months after the patient's discharge he was as well as when dis- missed. L. St. John Hely (Amer. Jour, of Physiol. Therap., July, 1910). Case of aneurism of the thoracic aorta treated by Abrams's method. After the first daily seance of concus- sion, lasting ten minutes, the systolic murmur over the aorta almost disap- peared. Three days later the aneuris- mal dullness measured transversely 2.6 cm. After two more days the aneurism measured 2 cm. and the patient's weight was 123 pounds, an increase of 5 pounds. Two days later there was absolutely no dullness over the site of ANEURISM (BABCOCK). 683 the aneurism, the pains in the chest were gone, expectoration was reduced about 50 per cent., but the cough con- tinued with less frequency and severity. After about two months the patient's weight was 135 pounds. He had abso- lutely no symptom beyond an occasional slight couiih. TurnbuU (Med. Record, Sept. 9, 1911). Report of a case of aneurism of the thoracic aorta treated successfully by Abrams's method. There was no X-ray verification of the condition in this case, but the physical signs re- specting the aneurism and the results of treatment were absolutely positive and unmistakable. L. C. Boyd (N. Y. Med. Jour., Oct. 21, 1911). ARTERIOVENOUS ANEU- RISM. — These conditions, termed by Hunter aneurism by anastomosis, are characterized by an arteriovenous fis- tula. They may be divided into two chief forms : — (a) Aneurismal varix is character- ized by the direct communication of the artery with the vein. The blood-pres- sure is much higher in the artery ; the arterial flow is forced into the vein, which becomes thickened, dilated, sac- culated, and tortuous. The condition is usually due to the incised wound in- volving the contigous walls of an artery and vein, and gunshot wounds. Occa- sionally they result from contusions without external wound, and may even develop spontaneously. In the older days the common cause was phlebot- omy. In order of frequency the bra- chial, femoral, popliteal, carotid, tem- poral, subclavian, and axillary arteries are involved. Instances are recorded in which the condition has spontane- ously occurred in connection with the abdominal and thoracic aorta, and after gunshot wounds of the head a fistula may form between the cavernous sinus and internal carotid artery. (b) Varicose Aneurism. — The vein commttnicates with the artery through the medium of an aneurismal sac. This usually develops from a traumatic aneu- rism which becomes adherent to an adjacent vein and finally opens into it. Both the artery and the vein may be injured simultaneously and an interme- diate blood-clot first form, the sac finally replacing the area occupied by the blood-clot. Such an aneurism may form at the ends of the divided vessels in an amputation stump. An arteriovenous aneurism with an arterial sac, such as that developed from the erosion of a true aneurism through the wall of an adjacent vein, is rare, and has been classified as a third variety of arteriovenous aneurism. Symptoms.— A marked pulsation which is communicated widely to the communicating veins is present and', usually associated with a loud, whistling bruit. The bruit is both systolic and diastolic. The thrill may be palpable. The interference with the normal circu- lation in the vein may produce stagna- tion, local cyanosis, pigmentation, ec- zema, elephantiasis, muscular atrophy, ulceration, rarely gangrene. The pres- sure upon the nerves may result in paresthesia or paralysis. Treatment. — The treatment of ar- teriovenous aneurism is usually op- erative, as the disease is usually per- sistent and progressive. The artery may be clamped above and below the opening and the opening in the artery and vein closed by arterial suture. Where a thoracic aneurism is present the sac may be split and the communi- cating opening sutured from within the sac, as in Matas's aneurismorrhaphy. In some cases it may be necessary to ligate the artery above and below the point of communication. As a rule, the vein should not be ligatured. 684 ANGINA PECTORIS (VICKERY). In small traumiatic aneurisms in which the distended inner coat of the vessel bulged through the external coats we have found it possible to re- duce the hernia-like protrusion and to reunite the median adventitia by fine silk sutures, which reinforce the union by suturing adjacent connective tissue to the arterial wall. The difficulties which accompany the operative treatment of arteriovenous aneurisms of the subclavian artery are very great. It is not easy to work under the subclavian in the presence of an hematoma. In 4 of the cases the clavicle was resected. The effect upon the arm of the diseased side when de- prived of the support of the clavicle and of the blood-supply from its artery and vein must be considered. Another difficulty consists in the size of the vessels and in their situation. Hemor- rhage is of grave significance, on ac- count of its profuseness, its frequency, and its depth. In 3 of the cases the sac was opened in order to attach hemostatic forceps. In this location, one should also fear the entrance of air into the veins. The radical opera- tion ought, therefore, to be rejected as an operation of choice, on account of the dangers of the operation. Even if the operation should not restilt fatally, the subsequent condition of the patient may be a distressing one, as it was in 2 of the 4 patients who recovered. Pluyette and Bruneau (Revue de chir., July, 1905). Analysis of 161 cases of arteriovenous aneurisms published since 1889. The femoral was involved in 80 and the popliteal in 35 cases. Much better re- sults are obtainable, as a rule, from operating directly on the sac than from ligatures. The main drawback to a complete cure is the frequent coexist- ence of nervous lesions complicating the aneurism, which are generally solely responsible for the postoperative dis- turbances. Only when direct action on the sac is impossible should ligatures be given the preference. Removal of the sac offers the same advantages over incision for the arteriovenous as for the arterial aneurisms. Monod and Vanverts (Revue de chir., Oct., 1910). Conditions related to aneurisms in- clude certain nevi, cavernous angi- oma, aneurism by anastomosis, and arterial angioma or cirsoid aneu- rism. These conditions suggest new growths or tumors more than aneu- risms. Some are congenital ; others are acquired, and the aneurism by anastomosis, a vascular tumor consist- ing of involved arteries, veins, and capillaries, which may reach an enor- mous size, is present. The arterial angioma or cirsoid aneurism usually occurs upon the head about the time of adolescence. It may be congen- ital or follow traumatism. The ar- teries are enormiously dilated and very tortuous; the bruit may be so loud as to interfere with the patient's sleep. These conditions are usually treated by electrolysis, ligation, or excision. W. Wayne Babcock, Philadelphia. ANGINA LUDOVICI. See Pharynx and Tonsils, Diseases of. ANGINA PECTORIS. — DEFI- NITION. — Angina pectoris (steno- cardia, breast-pang) is the name given to a group of symptoms which usually depends upon organic disease of the heart or aorta. An attack consists in the sudden onset of agoniz- ing pain in the precordial or sternal regions, accompanied by a feeling of constriction and in severe cases by a sense of impending death. The pain radiates into the back, the shoulders, and the arms, particularly the left. The patient is pale, haggard, motionless, and often bathed with cold perspiration. SYMPTOMS.— Suddenly, after ex- ertion, excitement, or a hearty meal, ANGINA PECTORIS (VICKERY). 685 the patient feels an excruciating, burning-, or tearing pain in the heart or beneath the sternum, accompanied with a sense of constriction {angcre, to throttle), as if the heart were in a vise. The pain radiates into the back, upward into the shoulders, and down the left arm, often even to the fingertips. It may be felt in both arms, in the neck and head, and even in the trunk and lower extremities. "In true angina the seat of the pain may be entirely away from the chest, and may be, as in Lord Clarendon's father, at the inner aspect of the arm, or about the wrist, or in rare instances confined tio the side of the neck, or even to one testis" (Osier). After an attack, there may be tenderness above and outside the left nipple and in the left arm. The pain is explained by James Mackenzie as a sensory reflex due to irritation of the 1st, 2d, and 3d dorsal and 8th cervical nerves, and the sense of constriction to reflex stimulation of the intercostal nerves. Paroxysms occur in which pain is slight or absent (angina sine dolor e). Early attacks are often of this sort Later on there may still be no pain, or the paroxysms may sometimes be painful and at other times not. A feeling of numbness accompanies the pain. There is a sense of impend- ing dissolution. The sufferer sits or stands immobile and hardly dares to breathe. Yet there is no real dyspnea. The face is pale or livid; the forehead wet with perspiration. The pulse may remain strong and regular. Usually it is accelerated and of in- creased tension. A pulse of. habitual high tension may be somewhat lowered during the attack (Macken- zie). The pulse may intermit or vary. Exceptionally it is slowed. The paroxysm lasts a few seconds or minutes, — sometimes half an hour or even several hours. At the end of it the patient often belches gas or vomits or has a movement of the bowels, with great relief. The in- ference that indigestion has caused the paroxysm is natural, but probably erroneous; although it is true that even slight exertion directly after a meal may precipitate an attack. Study of 21 cases. The attacks usu- ally came on after a meal. In every case exertion increased the pain, and the sense of fullness was relieved by the eructation of gas. Most of the pa- tients attributed their trouble to indi- gestion. In all there was shallow res- piration with an occasional deep inspi- ration. The heart's action was usually slow, occasionally palpitating or irregu- lar, and the pulse was generally tense and sustained. In all, arterial fibrosis could be recognized by a thickening of the palpable arteries ; cardiac disease manifested by accentuation of the sec- ond aortic tone, feebleness of the first sound, cardiac murmurs, etc., was pres- ent at some time in nearly all cases. During the attacks the second aortic sound was always much accentuated, while the first sound could be heard very indistinctly. Frank Billings (Chi- cago Medical Recorder, Feb. 1901). Case in which the symptom-complex of angina pectoris showed none of the ordinary causes, namely, syphilis, alco- holism, nicotinism, or excessive exer- tion. In addition to excessive mental toil and excitement due to the patient's occupation, and the occurrence of rheu- matism nearly half a century before, the only factor of importance was the habitual bolting of large quantities of food rich in proteids and carbohydrates, producing a marked disturbance of metabolism, as evidenced by the occur- rence of indicanuria, acetonuria, and intercurrent glycosuria in quantities as great as 8 per cent. Daland (N. Y. Med. Jour., May 20, 1909). 686 ANGINA PECTORIS (VICKERY). The attack may prove 'immediately fatal. If not, the patient is left ex- hausted, but regains his usual condi- tion in a few hours or days. The attack is almost sure to be re- peated. This may happen in an hour or not for weeks or months. The length of the interval depends greatly upon the persistence of the patient in avoiding the exciting causes. After a severe attack, rest in bed is desir- able for several days, or, if the patient is much enfeebled, for a week or two. Successive paroxysms occur with gradually increasing readiness. The body position is of diagnostic value, i.e., retroversion, with the head and trunk extended, the whole body being fixed in this attitude. Not every case assumes this position, bat it is sufficiently constant to be an aid in the differential diagnosis in the various types of spasmodic dyspnea — for example, in asthma or uremia; so that in addition to the two cardinal symptoms of pain and anguish he would add a hyperextended position of the head and trunk. This attitude was exemplified in the six personal cases. Minervini (Riforma medica, Nov. 18, 1905). The diagnosis of angina pectoris, at least in its milder form, cannot be made from the history alone. The other forms of cardiac pain, of toxic or neurotic origin, the latter especially in women, may exactly simulate a true angina pectoris. After allowing due weight to the age, sex, and detailed his- tory of the patient, it is necessary to ascertain the presence or absence of signs of organic disease at the root of the aorta. On this hangs an enormously important decision. When plain signs of general arterial or aortic disease co- exist with a history of precordial pain there need be no hesitation in making a positive diagnosis of true angina pec- toris. But it is otherwise in patients with cardiac pain in whom, as may happen, the accessible arteries are soft, and who do not present signs of gross aortic or pericardial lesions. In diagnosing between true and false, organic or functional, there is one phys- ical sign which the writer believes positive. It is so slight, and apparently so insignificant, that one almost hesi- tates to mention it. It is simply a slight clicking sound, of a harsh or rough quality, accompanying, or following at barely perceptible interval, the sound of aortic closure. It is not an accentuation of the closure sound of the valve, such as the loud, clean, "cork and bottle" aortic second sound, which is significant of high arterial tension. G. R. Butler (Archives of Diagnosis, Oct., 1909). DIAGNOSIS.— In true angina pec- toris skilled observers almost invaria- bly find evidence of organic cardiac or aortic lesion. In a supposed case these should be sought most care- full}^ Particularly to be looked for are arteriosclerosis, hypertrophy or dilatation of the left ventricle, aortic regurgitation, and feebleness of the muscular power of the heart. The great fact in this disease is the existence of pain around which the at- tendant phenomena are grouped. It usually radiates to one or both shoul- ders and arms. There are usually re- peated paroxysms induced by exertion or by digestive conditions. Other sen- sations are faintness, weakness, and breathlessness. Objectively, there are pallor or cyanosis, immobility or con- tortions, dry or moist skin. The vas- cular tension varies within wide limits, and there may be an increased flow of urine and saliva. G. A. Gibson (Prac- titioner, Sept., 1906). When angina pectoris is well charac- terized, it can be differentiated in a de- cisive way from the false variety by the angor animi and the strong sense of imminent dissolution. Many additional symptoms may be associated during the paroxysms, but are not necessarihr present, and only serve to corroborate the diagnosis of true angina. Among these are : Respiratory disturbances. ANGINA PECTORIS (VICKERY). 687 including asthma, dyspeptic symptoms; and vasomotor disturbances, such as pallor of the face (rarely lividity), sweats, and coldness of the surface. Anders (Jour. Amer. Med. Assoc, Nov. 3, 1906). Intercostal neuralgia causes pain along an intercostal nerve, not radiat- ing- as in angina pectoris. It presents points tender to pressure- near the vertebrae and sternum and in the axilla. It is not associated with dis- ordered circulation. It is more com- mon in women than in men. Gastralgia is apt to occur when the stomach is empty. The pain does not stream into the shoulder and arm. While there may be collapse and a sense of impending death, there is no evidence of heart disease. Like in- tercostal neuralgia it is likely to occur in anemic young women, rather than in middle-aged men. On the other hand, the pain of true angina pectoris may be felt lower down than the precordia. And, as already stated, the termination of an attack may be marked by the dis- charge of gas. Particularly if there is no extreme cardiac pain, this may lead the patient, and in some instances has led his physician astray. Cardiac asthma is dyspnea due to a weak heart and occurring more or less paroxysmally. Pain is not prominent. The picture is apt to in- clude pulmonary edema, enlarged liver, and dropsy, and it could hardly be mistaken for angina pectoris. Mitral disease is not apt to be asso- ciated with angina pectoris, and relief from attacks is often experienced when a mitral leak develops in an aortic case. The recognition of cardiac lesions observed after attacks of angina pec- toris is of great importance, inasmuch as it leads the physician in charge to insist on perfect rest for the patient for days or even weeks after a severe attack, and thus prevents, in some in- stances, sudden death. The cases in which the attacks are followed by the appearance of clinical signs in the heart may be divided into three classes. In the first group there is a rise of temperature and a slight en- largement of the cardiac area of dull- ness. The fever may be slight, but if other causes are excluded it is of great value in the diagnosis of myo- carditis following angina pectoris. In the second group there is, in addition to fever, a distinct dilatation of one or other of the cardiac cavities, which can readily be discerned on physical exami- nation. Finally, in the third group, there develops an acute endocarditis following an attack. In spite of the fact that clinically the occurrence of acute endocarditis after angina pectoris is not a well-recognized phenomenon as yet, it has long since been described patho- logically. Kernig (Roussky Vratch, Oct. .30, 1904). "Pseudoangin a." — Pseudoangina pectoris, or hysterical angina, occurs in females or neurasthenic men, usually under the age of 40, without evidence of organic cardiovascular changes. There are low tension, feeble second sound, and soft arteries. The attacks are spontaneous and are apt to be nocturnal and periodic (menstrual). They last an hour or two, being more prolonged than the true paroxysms. The patient is agi- tated, writhes, or walks about the room, and talks. The heart feels not constricted, but distended. The pain is not apt to be so severe as in true angina pectoris. Paresthesise and vasomotor symptoms are prominent. The patient's symptoms are some- times colored by his having consulted encyclopedias and the like (Broad- bent). Death never occurs. 688 ANGINA PECTORIS (VICKERY). Angina pectoris in its typical form is a rare disease. Pseudoangina, or car- diac asthenia, as it is frequently called, is much more common. It is erroneous to speak of angina pectoris as a neuro- sis of the heart, as in the great majority of instances there are organic changes in the coronary circulation, the cardiac muscle, or lesions of the aortic orifice. Neurotic angina is exceptional, is al- most always associated with spasm, or with a sudden increase in intracardiac pressure. Beverly Robinson (Amer. Jour. Med. Sci., Feb., 1902). Painless angina is much more com- mon than one would suppose it to be from the infrequency with which it is mentioned; but, in all probability, the disease is not always recognized, and the patient's sufferings are attributed to hys- teria or some reflex disturbance. When the symptoms are accompanied by a di-' lated right heart or distinctly athero- matous changes the diagnosis is easy, but when physical signs are absent it is difficult to arrive at an absolute opin- ion. If, when free from the paroxysms, the patient continually suffers from a feeling of weight or distress over the precordia, and has a tendency to take occasional deep inspirations, there is a strong probability that the right ven- tricle is affected, and this amounts to certainty if the symptoms are invariably produced or aggravated by exertion. This form of angina is entirely different from the painful variety, and in many instances demands a diametrically oppo- site treatment. W. W. Kerr (Jour. Amer. Med. Assoc, May 29, 1909). Hysteria. — It should, of course, be remembered that hysteria may be combined with organic disease, and that a careful physical examination should be made in any suspected case; but the discover}^ of mitral dis- ease would not be inconsistent with a diagnosis of pseudoangina. There is a nervous form of syphilitic angina which is distinct from hysterical angina pectoris. The two conditions may be distinguished as follows : In hysterical angina the attacks come on. as a rule, at night; on examination there are found hysterical areas on the skin of the chest, and the attacks begin with paresthesia of such an area, and end in tears, sobs, and other manifestations of excitement. The syphilitic attack of the nervous type is preceded by fatigue, not by ex- citement. It is very important to distingish the nervous syphilitic type from the organic syphilitic angina, which depends upon a lesion of the heart muscle itself. The chief char- acteristic of these is the presence of periodic attacks of angina with dysp- nea between the attacks. M. J. Breit- man (Vratch, Nov. 14, 1900). Hysterical angina pectoris is common, especially before the age of 40. It is most frequent in women. The crises in childhood are less severe than those of adult life. Almost anything may be the cause of the attack, even acute articular rheumatism. Frequent parox- ysms are often noted about the meno- pause. Sometimes an attack occurs by suggestion from seeing a paroxysm in another. There is precordial pain, often with a distinct aura. The parox- ysms occur at night, periodically. About the precordia is generally found an area of marked hyperesthesia. Pal- pitation, rapid pulse, and vasomotor symptoms are common. In fact the symptomatology is polymorphous. In some cases true aortitis or endocarditis may exist, yet the attacks of angina pectoris are hysterical. Mercklen (Medecine moderne, Apr. 23, 1902). Syphilis. — A history of syphilis in a man, even if under 40 years of age, renders the occurrence of true angina pectoris less improbable than it other- wise would be, for there is a possibility of syphilitic aortitis obstructing the ori- fices of the coronaries. Tobacco, Tea, etc. — Excess in to- bacco (less often alcohol, tea, and coffee) and lead poisoning may occasion spurious angina, or again they may aggravate a genuine paroxysm depend- ing on organic lesions. ANGINA PECTORIS (VICKERY). 689 While certain cases are evidently true angina and others equally obviously pseudoangina, some are extremely puz- zling. All these attacks (true and ''false") have this much in common, that for the time being the heart is unable to perform the work demanded of it; so that they differ more in etiology and prognosis than in imme- diate condition. ETIOLOGY.— ]\Iales over 40 years of age in comfortable worldly circum- stances make up the majority of suffer- ers from angina pectoris. Predisposing causes are: alcohol, syphilis (arterio- sclerosis, tabes dorsalis), rheumatism, gout, diabetes, chronic nephritis, and bacterial infection (influenza, plague, malaria). Sometimes attacks are hereditary. As exciting causes may be named: physical exertion, mental strain, pro- found emotion, and digestive disturb- ances. The attacks may come in the daytime, especially at first; but some of the worst occur at night; so that finally the patient may dread going to sleep. Angina pectoris and the menopause. Attacks of angina pectoris observed for the first time at the menopause may be dependent upon the changes oc- curring at this period, or they may acci- dentally begin at this time from other and unassociated causes. In the former case the attacks may be purely neuras- thenic or hysterical, or they may be of vasomotor origin (spasm of the coro- nary arteries), giving the picture of se- vere organic angina pectoris. These two forms may, of course, be combined. T. K. Geisler (Vratch, Feb. 12, 1900). All cases of angina pectoris are of toxic origin, and the so-called coronary angina is a toxic neuralgia or neuritis of the cardiac plexus, due to uremia, and to be forestalled by the same regimen as uremia. Gilbert and Garnier (Presse medicale, Oct. 13, 1900). The writer has notes of 268 cases in all — 231 men, Zl women. If we recog- nize a mild neurotic or pseudoneurotic and a grave organic or true form, there wore, of the former, 225, and, of the lat- ter, 43. The writer omitted \es formes jrustes unless a patient had subsequent severe attacks. Of the severer form of 225 cases, there were only 14 women. On the other hand, of the minor type, of 43 cases there were 23 women. The age incidence is late, the largest number of cases occurring in persons over 50. Of the 612 deaths in England and Wales, only 36 occurred between the ages of 35 and 45, while between 45 and 65 there were 291 deaths. In Osier's list the age was much t.ie same. There were, under 30 years of age, 9; between 30 and 40, 41; between 40 and 50, 59; between 50 and 60, 81 ; between 60 and 70, 62 ; between 70 and 80, 13, and, above 80, 3. In women the age incidence is, on the whole, a little lower than in men. A point that stands out prominently in the writer's experience is the fre- quency of angina pectoris in physicians. Thirty-three of his patients were physi- cians, a larger number than all the other professions put together. Only 7 were above 60 years of age, one a man of 80, with aortic valve disease. The only comparatively young man in the list, 35, was seen nearly twenty years ago in an attack of the greatest severity. Worry and tobacco seem to have been the cause. He has had no attack now for years. Two cases were in the fourth decade, 13 in the fifth, and 11 in the sixth. Neither alcohol nor syphilis was a factor in any case ; of the 26 patients under 60, 18 had pronounced arterio- sclerosis and 5 had valvular disease. In a group of 20 men, every one of whom Osier knew personally, the outstanding feature was the incessant trjeadmill of practice, and yet every one of these men had an added factor, worry. So far as symptoms are concerned, the writer's cases fall into three groups : 1, les formes frustes; 2, mild, and, 3, severe. 1. The mildest form, "les formes frustes" of the French, with substernal tension, uneasiness, distress, rising 1—44 690 ANGINA PECTORIS (VICKERY). gradually to positive pain, is a not in- frequent complaint, one, indeed, from which few escape, is associated with three conditions. Emotion is the most common and the least serious cause. 2. Under the mild form, angina minor, come 43 cases. Osier has grouped under these the neurotic, vasomotor, and toxic forms, the varieties which we formerly spoke of as false, or pseudo-, angina. The special features of this variety are : the greater frequency in women, the milder character of the attacks, and the hopeful outlook. 3. Severe angina, angina major, is rep- resented by 225 cases, of which 211 were in men. Two special features here are, existence in a large proportion of all cases of organic change in the arteries and liability to sudden death. Osier (Jour. Amer. Med. Assoc, from Lancet, Mar. 12, 1910). PATHOLOGY.— It is exceptional for attacks of true angina pectoris to be observed in persons presenting no evi- dence of organic circulatory lesion. The commonest underlying conditions are sclerosis of the coronary arteries, degeneration of the myocardium, car- diac hypertrophy, atheroma of the aorta, aneurism of that vessel near its origin, and aortic regurgitation. There is, however, "hardly an affection of the walls or cavities of the heart, scarcely a morbid condition of the arteries that nourish it or spring from it, with which the distressing malady has not been observed to be associated" (Da Costa). Recent writers lay stress on oblitera- tion of the lumen of the coronary arter- ies as the essential basis of true angina pectoris, which obliteration may be oc- casioned either by sclerosis of the ves- sels or by changes in the aorta at their origin. "So intimately associated is the true paroxysm with sclerotic conditions of the coronary arteries that it is ex- tremely rare apart from them" (Osier). Huchard held the same view. The fact that angina pectoris occurs in lesions of great diversity indicates that some condition common to all must be the cause of the symptoms. The fact that it appears only after the heart- muscle has been long exposed to ex- cessive strain points to the cause being situated in the muscle. All the func- tions of the muscle-fibers save that of contractility can be shown to be intact in many cases that suffer from angina pectoris. The alternating action of the heart is a demonstrable sign of ex- hausted contractility, and its presence is always associated with symptoms that are included in the symptom-complex of angina pectoris. The same exciting cause- — extra strain on the heart — may provoke both the angina pectoris and the alternating action, and both may disappear with removal of the cause. The inference to be drawn from the consideration of these facts is that the sjmiptoms that are included in the term "angina pectoris" are so closely asso- ciated with an impairment of the func- tion of contractility of the muscle-fibers of the heart that in all probability an- gina pectoris will be found to be an evi- dence of the impairment of the func- tion of contractility. James Mackenzie (Brit. Med. Jour., Oct. 7, 1905). The importance of arterial reflex having its origin in the abdomen has not been fully appreciated. While the active processes of digestion are going on, there is an influx of blood into the splanchnic area. This drainage into the abdominal vessels is balanced in the general circulation by a systemic arte- rial contraction, evidently a reflex phe- nomenon originating in the splanchnic system, passing to the vasomotor cen- ter in the medulla and then transmitted to the systemic arteries. The changes in the systemic arteries are a reduction in size and an apparent thickening of the arterial wall. The degree of these changes depends on the kind of meal which has been taken. In the big eater and the wine-drinker the arterial con- traction is associated with a rise of blood-pressure and a true increase of arterial tension. This reflex varies in delicacy in different persons. It exists ANGINA PECTORIS (ViCKERY). 691 in all. The author is convinced that there is a relation between this phe- nomenon and angina pectoris, and cites several instances in support of his con- tention. He shows that this hypersen- sitiveness of the vasomotor center, even in grave angina pectoris, can be re- duced, controlled, or even removed by dietetic measures, with the result that the anginous seizures are removed or greatly modified. In cases where the arterial spasm is associated with great anatomic change, either in the myocar- dium or in the coronary vessels, abso- lute cure can hardly be looked for, but in all cases the symptoms of angina pectoris may be much ameliorated by conducting the treatment in accordance with what they indicate. Owing to the varying degree of intensity of the symptoms, the writer suggests that in classifying the cases the simplest dis- tinction might be found in the terms angina pectoris major and angina pec- toris minor, the former being confined to those cases in which there is believed to be permanent anatomic change in the heart or its vessels. W. Russell (Brit. Med. Jour., Feb. 10, 1906). The pain of angina depends upon vascular distention in the mediastinum, which is the result of a more or less localized vasodilatation and of a more or less generalized peripheral vasocon- striction. It would seem that the an- gina is not due to the organic lesions any more than is asthma due to em- physema, or migraine to atheroma of cranial vessels. The connection be- tween the organic lesions and angina should then be ascribed to the chronic peripheral vasoconstriction, which con- stitutes the earliest stages of many forms of chronic organic disease of the heart and vessels. Preventive treatment resolves itself into the prevention of exaggerated peripheral vasoconstriction, continuous or recurrent. Purin-free diet, cutting down of the intake of carbohydrates, especially the saccharine carbohydrates, and the fats, is advocated. Francis Hare (Med. Rec;, Oct. 20, 1906). Angina results from an alteration in the working of the muscle-fibers in any part of the cardiovascular system, whereby painful afiferent stimuli are ex- cited. Cold, emotion, toxic agents in- ■ terfering with the orderly action of the peripheral mechanism, increase the ten- sion in the pump walls or in the larger central mains, causing strain, and a type of abnormal contraction enough to exr cite in the involuntary muscles painful afferent stimuli. Mackenzie suggests that there is rapid exhaustion of the function of contractibility, which is, after all, only the fatigue on which Allan Burns laid stress. In a disturb- ance of this Gaskellian function is to be sought the origin of the pain, whether in heart or arteries. In stretching, in disturbance of the wall tension at any point, and in a pain-producing resist- ance to this by the muscle elements lie the essence of the phenomena. In a man with arteriosclerosis and high pressure, and all the more likely if he has a local lesion, a syphilitic aortitis for example, disturbance, at any point, of the tension of the wall permits the stretching of its tissues. Spasm or nar- rowing of a coronary artery, or even of one branch, may so modify the action of a section of the heart that it works with disturbed tension, and there are stretching and strain sufficient to arouse painful sensations. Or the heart may be in the same state as the leg muscles of a man with intermittent claudication, working smoothly when quiet, but in- stantly an effort is made, or a wave of emotion touches the peripheral vessels, anything which heightens the pressure and disturbs the normal contraction brings on a crisis of pain. Osier (Lancet, Mar. 26, 1910). The immediate, precipitating condi- tions of a paroxysm are not known, but they are supposed to be connected with disturbances of the vagus, or, perhaps, the sympathetic nerves. Nothnagel re- ported a series of cases under the title "angina pectoris vasomotoria" which seemed to be due to a pure neurosis. They followed exposure to cold, and were ushered in by spasm of the pe- ripheral arterioles, which presumably 692 ANGINA PECTORIS (VICKERY). produced the cardiac disturbance be- cause of the increased exertion de- manded of the heart in order to propel the blood through narrowed channels. Broadbent describes angina vaso- motoria as a comparatively favorable class of cases of high arterial tension associated with general arteriosclerosis and a hypertrophied heart capable of powerful contraction. "The circulation in the coronary arteries may be suffi- cient for ordinary needs, but when the arterial tension is further raised by exertion or increase of peripheral re- sistance attacks of angina are induced." From a neuralgia or a neurosis true angina pectoris differs in being fre- quently fatal, in attacking men ten times as often as women, and in being associated with organic changes in the neighboring structures, viz. : the heart and aorta. Lesions of the cardiac plexus and the branches of the vagus have been found in repeated instances of angina pectoris, but that such lesions are invariably pres- ent and essential to the disorder has not yet been proved. "The cardiac nerves may be seriously implicated in aneur- ism, in mediastinal tumors, in adherent pericardium, and in the exudate of acute pericarditis, without causing the slightest pain" (Osier). The late Sir Benjamin W. Richard- son regarded angina pectoris as an actual disease analogous (as Trousseau held) to epilepsy, and due to a disturb- ance in the sympathetic nervous system. Angina pectoris is, in the main, an angiospastic disease, and it may easily be understood how a spasm of the ar- teries may extend through the circula- tory system. In the case reported, that of a man aged 70 years, the symptoms of angiospasm in the extremities, such as cyanosis and pain, were replaced by a true gangrene of the upper limbs. The patient had suffered from anginal attacks for two years, during which he had suffered pain and numbness in his right arm and hand. The gangrenous process appeared very rapidly and con- tinued for three months, after which it healed completely, not leaving any traces whatever. It was noted that dur- ing the days which followed an attack of angina the gangrenous areas looked worse, and the secretion had a more disagreeable odor and was more abun- dant. E. Salvini (La Riforma Medica, March 23, 1907). Debove says that in tabetic angina pectoris there is no organic lesion of the heart or large vessels, and that the at- tack must be regarded as a visceral crisis. Dana refers cardiac crises in tabes to a degenerative irritation of the vagus. It should, however, be remem- bered that aortic disease is rather fre- quent in tabetic patients. In regard to the causation of attacks of angina pectoris in the graver cases which are associated with serious struc- tural disease of the heart and vessels, J. Burney Yeo states that in by far the greater number of deaths from organic disease of the heart all the various lesions may be present which have been found in fatal cases of angina and yet no true anginal attacks have ever been complained of. In his opinion there is some additional circumstance needed to account for the angina. The most serious forms of angina seem to have a complex causation. First, there must be a neurosal element; the nerves of the cardiac plexus suffer irritation, and an intense cardiac nerve-pain is excited ; this acts as a shock to the motor nerves of the heart, and thus reacts on the heart-muscle, which, in fatal cases, is already on the verge of failure from organic causes; and, if there should be excited at the same time some reflex arterial spasm, the heart will have to ANGINA PECTORIS (VICKERY). 693 encounter an increased peripheral re- sistance as well. In such cases the rapidity of the fatal issue is no argu- ment against the neuralgic nature of the angina. In certain conditions, espe- cially in habitual high arterial tension, strain is apt to fall (when the aortic valves are competent) rather on the first part of the aorta than on the ven- tricular surface, and anginal attacks are more prone to occur in these cases, as- this part of the aorta is in such close relation with the nerves of the cardiac plexus, rather than in those cases in which the strain is felt on the interior of the cardiac cavities. The causation of the less grave and more remediable forms of angina is also, in many instances, complex. A cardiovascular system feeble and poorly nourished on account of anemia may be submitted to undue strain; or there may be some intoxication — such as that of tea, tobacco, alcohol, gout, or some intestinal toxin — irritating the cardiac and vasomotor nerves, increas- ing peripheral resistance, and so ex- citing anginal attacks, which may alto- gether pass away and be completely recovered from. Vasomotor spasm as a unique cause of attacks of angina must be set aside as inconsistent with extended clinical experience. Cases of angina pectoris, both of the milder and graver forms, occur without any evidence of vasomotor spasm or of heightened arterial tension; and the conditions of heightened arterial ten- sion, together with a feeble cardiac mus- cle, very commonly coexist, without any tendency whatever to the develop- ment of anginal attacks. The argument in favor of a vasomotor causation has been inferred from therapeutic experi- ment and the relief to the paroxysm which has attended the use of agents which cause arterial relaxation. But most, if not all, of these vasodilators are also anesthetics, and, as Balfour has pointed out, it is probably to their anodyne action on the sensory cardiac nerves that they owe their chief effi- cacy ; Grainger Stewart also has pointed • out that nitrite of amyl has a direct effect on nervous structures, and that it relieves other forms of neuralgia. Certain fallacious conceptions of angina pectoris prevail. Thus, in true cardiovascular angina pectoris, peripheral arterial sclerosis, cardiac hypertrophy, and high blood-pressure are essential. This is by no means always the fact. Arterial change may be widespread and the coronaries sclerotic without hypertrophy of the heart or rise in blood-pressure. The sclerotic or atheromatous process may be quite limited, localized to the begin- ning of the aorta, and only encroaching a little on the coronaries, while the pe- ripheral vessels may be normal. Espe- cially irr syphilitic cases are the condi- tions liable to be thus localized. In some of the most serious cases there may be no abnormal arterial pressure, indicat- ing, perhaps, a weakened cardiac muscle. The finding of aneurism or lesion of the aortic valves does not exclude angina, but is rather in its favor. The attacks are not always few in number, and fol- lowing exertion, and life is not neces- sarily cut ofif within a few months after the appearance of the disease. Patients may live a number of years with com- paratively frequent attacks. While com- paratively rare in women, the disease is by no means unknown, and serious mis- takes may be made in diagnosis, espe- cially in nervous and hysterical cases. The cardiopath is often a neuropath also. Pain is not always excessive. It may be mild or even lacking; its radia- tion is variable. Even in fatal cases there may be no constant pain. Uncon- sciousness, though unusual, is seen at times, and, while the patient usually is afraid to move, and will not lie down, there are exceptions to this rule. Eruc- tations or vomiting during an attack do 694 ANGINA PECTORIS (VICKERY). not prove it to be a false angina and not organic or cardiovascular. While the disease is very grave, there is no certainty that death is imminent. The kidneys, as well as the heart, must be investigated as regards prognosis. J. B. Herrick (Jour. Amer. Med. Assoc, Oct. 22, 1910). PROGNOSIS. — The underlying condition is apt to prove fatal event- ually, and it may end life in the first paroxysm ; but a careful regimen may prolong existence for years, and Flint, Bendel, and Labolbary have each re- ported cases of recovery. The signs of danger during any par- ticular attack are the subjective sense of impending death and the feebleness and irregularity of the pulse. The gen- eral prognosis is, of course, influenced by the stage which the organic circula- tory changes have already reached. The pseudoattacks are apt to be repeated oftener than are the genuine, but the prognosis is good, both as to life and as to the final disappearance of the trouble. In common with all other observers, the writer finds that angina pectoris is more common in the male than in the female, in the ratio of 63 to 48. The youngest patient in his series of cases was 29 years old ; the oldest, 76. The longest duration of the recurring syn- drome was seventeen years ; the shortest was found in three who died in the first attack. Consideration of the various forms of angina pectoris shows the following : In coronary sclerosis there were 56 cases in all, i.e., 29 cases without other appre- ciable changes in the heart and 27 with other changes. Evidences which Forch- heimer considers as pointing to coronary sclerosis are the existence of angina pectoris and certain changes in the aorta or the aortic valves. In the aorta we find as evidence of sclerosis some dilatation. Most fre- quently a soft aortic systolic bruit is detected, which sets in a little after sys- tole, most commonly combined with an accentuation of the second aortic sound, especially characteristic when the blood- pressure is low. Over the aortic area are found systolic bruits, differing much in character, sometimes soft, sometimes harsh, but, as a rule, unlike those of aortic sclerosis due to other causes. Moreover, the second aortic sound is accentuated, which Fofchheimer says is a fairly reliable differential sign between arteriosclerotic changes in the valve and in the ordinary form of aortic stenosis. In 1 case of syphilitic endarteritis there existed angina pectoris of a very severe type, the physical evidence of a mitral lesion and of myocardiac insuffi- ciency. In 27 cases which were devel- oped on other diseases, the before- mentioned signs were present. The coexisting diseases were chronic myo- carditis in 12, mitral lesion in 6, aortic lesions in 4, obesity of the heart in 4, alcohol, diabetes, chronic nephritis, of each, 2; syphilis and cirrhosis of the liver, 1. Nearly all of these had evi- dence of arteriosclerosis. In the cases of angina in which coro- nary sclerosis alone existed we find 3 dead in the first attack and 7 others dead. Of the latter, 2 died of diabetic complications, 1 of complicating pneu- monia in the status anginosus, death being due to acute cardiac dilatation, 1 of a cerebral and another of a gastric hemorrhage. So that, in all, in only 6 cases could death be attributed to the coronary sclerosis. The duration of the disease in these cases varied from sixteen months to seventeen years, and all were males. In the 29 cases of coronary sclerosis there is but 1 female. When the obstruction is due to throm- bosis or embolism, the attack is usually fatal, either immediately or later on, as the result of changes in the myocar- dium. The attack is always immediately - fatal when one coronary artery is closed. As a rule, death occurs in- stantaneously where the descending or circumflex branches are completely closed, but occasionally the patient sur- vives for a few days, as is shown by myocardial infarcts found post mortem. Forchheimer's experience leads him to ANGINA PECTORIS (VICKERY). 695 believe that when both cardiac asthma and angina pectoris arc present from the onset the outlook for improvement is very small. Rut he does not agree with Neubiirger, who states that in coronary sclerosis there are 3 stages of myocar- dial changes, which develop and which are always fatal. So far as the duration of the disease is concerned, aside from those who died in the first attack, in 8 the disease lasted from one to two years ; in 4 from two to four years, and in 1 for seventeen years. Of those alive, 4 have had the disease from eight to ten years, the same number from five to eight years, and iO from four to five years. F. Forchheimer (Jour. Amer. Med. Assoc, from 111. Med. Jour., May, 1910). TREATMENT.— During a parox- ysm the first remedies to employ are such as will dilate the arterioles. Ni- trite of amyl is the best because it acts with the greatest rapidity. A "pearl" of this drug may be crushed in a handkerchief or in cotton placed in the bottom of a glass tumbler, and inhaled. Nitroglycerin may be in- jected subcutaneously (M-OO to %o grain), or a tablet of this substance may be masticated, or a minim of spiritus glycerylis nitratis may be placed upon the tongue. It is readily absorbed from the mouth and acts almost as quickly as when given hypodermically. Erythrol tetranitrate has an action like nitroglycerin, but milder and decidedly more prolonged. It may be given in tablets of ^ to 2 grains. Aiigina pectoris is due exclusively to a pain in the diseased aorta, and is al- ways accompanied by a peculiar anguish. The lesions causing the pain are in the first part of the ascending aorta. The attack of pain is brought on by an emotion or an effort, and these causes are precisely those which increase the blood-pressure. The diseased aorta is not pamful under ordinary conditions, but the pain develops as the blood-pres- sure rises, and it is favorably influenced by any measure that reduces arterial tension. Josue (Arch, des Mai. du Cceur, Oct. 1, 1908). Erythrol tetranitrate has a less marked, but more lasting, effect than nitroglycerin. It is especially indicated in those patients who are awakened at night by the pains. Huchard and Fies- singer (Jour, des praticiens, Dec. 11, 1909). The treatment of an actual attack of angina pectoris demands three consider- ations: (1) Rest, to promote restora- tion of heart-power; (2) vasodilators, morphine, to relieve the pain when this is not achieved by rest and amyl nitrite or nitroglycerin. In cases of severe spasmodic pain in middle-aged people, amyl nitrite, by lowering ar- terial tension, may provide instant relief; but in those cases of advanced fibroid degeneration in old people in which severe, prolonged, frequently occurring attacks of cardiac pain ren- der life a burden, the only drug which seems to give relief is mor- phine. . F. G. Thomson (Med. Press and Circular; Jour. Amer. Med. Assoc, Aug. 27, 1910). The nitrites are sometimes marvel- ously efficacious in checking an attack, and their failure to give benefit does not exclude true angina. In some cases digitalis does more good than all the nitrites or iodides, and in this the writer's experience agrees with that of Romberg, who advised it in some cases. J. B. Herrick (Jour. Amer. Med. Assoc, Oct. 22, 1910). Relief by these means is often im- mediate; but, if not, ether should be inhaled. Chloroform is also advised by excellent authorities. Flint thinks it not without danger, if the heart is weak ; ether, on the other hand, is a stimulant. Morphine, subcutane- ously, is a valuable and sometimes an indispensable remedy. Whittaker advised that it be given with cau- tion in a condition which may any- way terminate in sudden death. The 696 ANGINA PECTORIS (VICKERY). morphine (^ grain) may be guarded by atropine {Yi^o grain), and in case of alarm also by strychnine (%o to %o grain). Electricity has also been recommended. The writer has never witnessed any fatality from morphine, but has al- ways found it efficient in relieving the pain besides combating the spasm. Nitrite of amyl not only relieves but keeps the patient tranquil when he knows that he has it always with him. Local heat is also useful during an attack, and applications of dry cups in the axilla or on the back. When there is much dyspnea inhala- tion of oxygen is extremely beneficial. Michaelis (Therap. der Gegenwart, Dec, 1909). Factors capable of bringing on the pain should be carefully avoided; every renewal of it keeps up ■ the sum of stimuli. If for this end absolute still- ness in bed be required, then bed it must be, with the corresponding re- duction of food. If at first the at- tacks are not abolished, they will be mitigated, and will gradually taper off. All measures, medicinal, dietetic, etc., known to reduce arterial pressures should be enforced. Sir Lauder Brunton's potent means, the nitrites, are indispensable. To guard against vagus inhibition, atropine must be administered regularly. In very pain- ful cases morphine may be needed also. An ice-bag applied cautiously and intermittently to the upper tho- racic spine may prove helpful. The cause then requires treatment. Of new remedies two have seemed in the author's experience to be efficacious, more especially in angina minor — namely, (a) the high-frequency cur- rent, and (&) the administration of the lactic acid bacillus by the method of Metchnikoff. Baths and massage cannot be prescribed in any urgent stage of the disease. Causes of eccen- tric irritation must be discovered and neutralized. The patient must be warned never to swallow quickly, nor to bolt large morsels. Diuretin and aspirin have their advocates. Chloro- form is very dangerous in angina. In syncopic failure of the heart artificial respiration should be tried. AUbutt (Brit. Med. Jour., Oct. 16, 1909). Hot and stimulating applications over the precordia, such as a strong mustard poultice, are appropriate, as are also heat and friction for the ex- tremities. Sometimes an ice-bag is put over the heart. By some it is preferred to heat. Alcohol and aro- matic spirit of ammonia are of bene- fit in case the cardiac action is feeble. Syncope demands such drugs as digi- talin, caffeine, strychnine, and cam- ' phor, employed hypodermioally. Angina pectoris with pseudosteno- cardia. The. angina is due to probable endoaortitis, and is relieved by an ex- clusive milk diet and theobromine for two weeks. Then, one week every month, milk diet and sodium iodide. During the balance of the month, spe- cial diet, with the theobromine con- tinued. H. Huchard (Jour, des Prati- ciens, Feb. 23, 1901). The writer has employed various forms of theobromine, particularly diuretin, in a number of cases for several years, and finds it efficient in true angina pectoris. It is well borne in doses of 3 to 3.5 Gm. per day (45 to 52 grains). Occasionally it pro- duces headache. Breuer (Miinch. med. Woch., Phila. Med. Jour., Dec. 6, 1902). Good results obtained from theo- bromine in angina pectoris. In 1 case a man of 46 had been suffering for two months from repeated attacks of angina pectoris, recurring so con- stantly that he did not dare to go to bed; the attacks only lasted a few minutes, but had already induced great debility and distress. Exam- ination revealed insufficiency of the aortic valve. He was given 0.5 Gm. (7.5 grains) of theobromine, and the dose was repeated at bedtime. There were no further attacks then or later. The treatment with theobromine must be long kept up, for months and ANGINA PECTORIS (VICKERY). 697 j^ears. It is effectual in otiier dis- turbances from arteriosclerosis as well. Two of the author's patients recently had vertigo and were afraid to venture into the street on foot, but have been free from the vertigo since they have commenced taking theo- bromine. Marchiafava (Policlinico, Feb. 28, 1909). Prolonged rest in bed advocated in true organic cases. Marked improve- ment noted in most of the 20 cases studied. The patient should remain in bed at least two weeks, prolonged to six or eight weeks in cases that cannot walk without bringing on anginal pain. Milk diet to be imppsed from the start; later farinaceous foods added. Drug medication by theobromine, nitroglycerin, and even morphine and digitalin also utilized. Greatest im- provement in old patients and those losing weight during treatment; least, in cases with associated aortic insuffi- ciency. Fiessinger (Bull, de I'Acad. de med., Nov. 29, 1910). The present writer has known oxy- gen to contribute to a favorable result in collapse due to chronic myocarditis with dilatation of the left ventricle, and it might be well for a subject of angina pectoris to keep some ready in his house. The painful attacks incident to car- diac disease, such as angina pectoris, also paroxysms of tachycardia, can be mitigated by causing the patient to belch up wind from the stomach, owing to the fact that the heart and the stom- ach are both innervated by the pneumo- gastric nerve. Eructation is produced by the following procedure : The pa- tient, seated, takes a small drink of water and holds it in his mouth. He then throws his head as far backward as possible and swallows the water. The posture is such as to stretch the esophagus and induce in the pharynx a sensation which causes eructation, pro- vided the result is not voluntarily pre- vented by the patient. It is well to. warn the person that an eructa;.ion is desired; otherwise, he may restrain it out of a sense of decency. Max Herz Semaine medicale, June 3, 1908). Dyspeptic disturbances are responsible for or at least aggravate angina pec- toris in many cases. Great benefit can be derived from magnesium oxide and peroxide to neutralize abnormal pro- duction of gases and the gastric juice, and promote bowel functioning. Regu- lation of the diet between attacks is of supreme importance. Chlapowski (Med. Klinik, June 5, 1910). Between attacks it is of vital impor- tance to avoid the predisposing and exciting causes. Rest and moderation are demanded, especially after meals. As for drugs, nitroglycerin, taken af- ter meals in doses just short of caus- ing headache, has a distinct inhibitory effect upon the paroxysms. In some instances it might be better to order it every three hours, as its influence is not long continued. Nitrite of sodium (2 to 5 grains) may replace nitroglycerin. Laxatives and eliminative treat- ment by alkalies are often of great value. The persistent use of potassic io- dide is very effective. Ten or fifteen grains may be given thrice daily before meals in half a glassful of water ; , or twenty grains three times a day io'T twenty days, followed by nitro- glycerin for ten days. The iodide is believed to dilate the arterioles and to pro-mote arterial nutrition. See supposed that also by enlarging the caliber of the coronary arteries it in- vigorated the myocardium. Arsenic and phosphorus in small doses also tend to avert the parox- ysms. In case of fatty degeneration of the heart they would be contra- indicated. Barium chloride in doses of Yio to % grain after meals is a good tonic for cardiac inefficiency, and often relieves cardiac pain. 698 ANHALONIUM LEWINII. Quinine and methylene blue have also been recommended. The treatment by saline baths and by the Schott method of exercises has a most potent effect in improving the condition of the cardiac muscle and vessels, and appears to have a direct effect in making the attacks less numerous and severe, and even in causing them to cease during a period of months oi" years. The movements must be made with es- pecial care and caution in these cases, and the resistance at the onset must be at a minimum. The artificial saline baths should contain from 1 to 3 per cent, of salt, and from ^ to 1 per cent, of chloride of calcium, and should gradually be strengthened by the addition of carbonic acid. Massage three times a week and persisted in for months may be of great benefit. In most cases it is best to prohibit alcohol. The cardiac tonics — sparteine, stro- phanthus, strychnine, valerian, and in suitable cases digitalis — are of the greatest utility. The general tendency to anemia and defective oxygenation must never be lost sight of, and general tonics, including the use of oxygen gas, will be of excellent service. Attacks of pseudoangina may be treated with asafetida, ammoniated tincture of valerian, or compound spirit of ether, and the outward em- ployment of heat, friction, and rube- facients. Sometimes recourse must be had, however reluctantly, to mor- phine. The statement in clear and decided language of a favorable prog- nosis is of great benefit. Between at- tacks the underlying condition should be carefully sought and treated. Case in which during the attacks the pulse rate rose to 120 and the pressure to 240, varying directly with the severity of the pain. Following the administration of amyl nitrite, the pressure sank to ISO, coincident with the cessation of pain, but pres- sure rose and pain returned as the efifects of the drug wore ofif. Mor- phine and chloroform produced simi- lar efifects. The nervous system be- ing evidently at fault, as shown by the erethism of the vasoconstrictor mechanism, he w^as given bromides with good effect. This case presents the typical features of arterial con- striction, more marked in cases of aortic valvular disease than in other forms of angina. In all forms of angina much more efficient results can be obtained by attention to the nervous system than by cardiac therapy, and bromides are ideal for such a purpose. MacKenzie (Heart, vol. ii, p. 265, 1911). Herman F. Vickery, Boston. ANGIOMATA. See Blood-ves- sels, TUMORS'OF. ANGIONEUROTIC EDEMA. See Ascites and Edema. ANHALONIUM LEWINII (Mescal Button). — The mescal button is obtained from a plant growing in the val- ley of the Rio Grande, in Mexico. The plant is of the family Cactacese. The tops of the plant when dried constitute the commercial Anhalonium Lewinii, first in- troduced by Lewin. The buttons or seeds are brownish in color, shaped like a top, and from 1 to V/i inches in diameter. They are hard and can be pulverized in the mortar only with difficulty. In the mouth, however, under the action of the saliva, they swell and rapidly become soft, imparting a bitter, nauseous taste and causing a marked sensation of tingling in the fauces. Four alkaloids, — mescaline, anhalonine, anhalonidine, and lophopho- rine, — closely similar in their physiological efifects, have been extracted from this species of anhalonium. From the related ANHALONIUM LEWINII. 699 plant Anhalonium Williamsi the alkaloid pellotine is derived. PREPARATIONS AND DOSE.— The following preparations may be used: Tincture (10 per cent.) ; dose, 1 to 2 drams (4.0 to 8.0 C.C.). Fluidextract (100 per cent.); dose, lYi to IS minims (0.5 to 1.0 c.c). Powder; dose, TVj to 15 grains (0.5 to 1.0 Gm.). The tincture and fluidextract should be made according to the processes prescribed in the United States Pharma- copceia for "such preparations. PHYSIOLOGICAL ACTION.— Lewin found anhalonium to be an intensely poisonous drug. A few drops of the de- coction used by him in the frog sufficed to produce almost instantly changes consist- ing chiefly in the appearance of shrinking of the body, so that the batrachian seemed to pass into a mummified condition. Simultaneously the animal raised itself upon its extremities and remained stand- ing in this position like an ordinary quad- ruped, or crawled about. After fifteen minutes this spastic condition passed off and the frog rapidly returned to the nor- mal state. When larger amounts were given death occurred in tetanic rigidity. The symptoms produced seemed closely allied to those of strychnine, Lewin noting that even after the spinal cord was severed peripheral irritation induced tetanus. In pigeons it was found that the drug pro- duced convulsive vomiting in a few mo- ments when injected hypodermically. The bird spread its wings, crouched down to the ground, and when disturbed exhibited muscular twitchings. Later the head was drawn sharply back, the mouth opened widely, and general convulsions appeared. When death occurred the heart was al- ways found in diastole. In rabbits the symptoms resembled those of strychnine poisoning. In the human subject anhalonium in large doses produces an effect in some ways closely resembling that of Indian hemp: visions ranging from flashes of color to beautiful landscapes and figures, illusions of time and space, etc. This and related plants are employed as intoxicants by certain Mexican Indians in connection with religious ceremonies. According to Prentiss and Morgan, color effects consti- tute the main feature of the drug's action on the brain. Consciousness remains un- impaired throughout its effects. Mitchell states that sometimes symptoms resem- bling the visual phenomena of ophthalmic migraine are experienced. The after- effects were also found by him to be markedly unpleasant, nausea and headache appearing which lasted for S2veral hours. Heffter in 1898 carried out investigations on himself with the object of determining which of the active ingredients of mescal . produced the visual hallucinations. An alcoholic extract of the buttons equivalent to 4^2 drams was taken, and afterward a corresponding amount of each of the alka- loids. The symptoms produced both by the alcoholic extract and by mescaline (1/^ grains) were colored visual hallu- cinations, slowing of the pulse, pupillary dilatations, loss of time relations, heavi- ness of the limbs, nausea, and headache. Anhalonine and anhalonidine in like amounts induced sleepiness without visual phenomena, while lophophorine (%o grain) caused occipital headache, facial redness and burning, and a temporary slowing of the pulse. Mescaline was thus shown to be the active-constituent of anhalonium in respect of the visual phenomena. According to Dixon, who carried out careful pharmacologic studies of anhalo- nium in frogs, cats, and rabbits and wit- nessed its effects in man, the chief effects of the drug in therapeutic doses appear to be: (1) Direct stimulation of the in- tracardiac ganglia; (2) initial slowing of the heart; (3) elevation of arterial tension; (4) direct stimulation of the brain centers and of the motor spinal centers, as shown by an increase in reflex excitability. Full doses of anhalonium induce motor weakness and inco-ordination. In still larger doses difficulty of respiration ap- pears. Lethal doses, Dixon found, produce complete paralysis, and death is caused by respiratory failure. THERAPEUTIC USES.— Prentiss and Morgan employed anhalonium in various conditions dependent upon excessive nerv- ous irritability, with considerable success. While not a hypnotic in itself, the drug in therapeutic doses (7 to 15 grains) often removed the cause of the insomnia, and thus conduced to natural sleep. It has been credited with beneficial effects, espe- 700 ANIMAL EXTRACTS (SAJOUS). cially in neuralgic headache, acute de- lirium, mania, melancholia and hypochon- driasis, hysteria, irritative cough, and colic. Anhalonium tincture in drop doses has been claimed to be useful as a sustainer of the heart action. But little knowledge of its clinical value in circulatory disorders has as yet, however, been obtained. Ac- cording to Landry, the drug is a useful adjuvant to digitalis. The taste of the liquid preparations of anhalonium is bitter and unpleasant, but can readily be disguised. Lewin recom- mended for this purpose the use of fluid- extract of licorice and elixir of yerba santa (fluidextractum eriodictyi). The powdered crug may be administered in capsules or cachets. The chief untoward action to be feared in the event of excessive dosage of this drug is respiratory depression. S. ANHIDROSIS. See Sweat Glands, Diseases of. ANIDROSIS. See Sweat Glands, Diseases of. ANIMAL EXTRACTS, OR ORGANOTHERAPY.— In a re- cently published work Parhon and Goldstein, of Bucharest, state that "the importance of the internal secre- tions in physiology and pathology can today escape no one. In respect to pathology proper, we may say that there is no branch of medicine in which the problem of the internal secre- tions can pass unnoticed." That organ- otherapy has also earned for itself an enviable position can scarcely be de- nied, but here the scientific methods which pathology normally imposes have not been utilized to the same degree, and empiricism still prevails to a very large extent. Textbooks of therapeu- tics and practice still adhere to the con- venient statements that an organic preparation "is useful," that "it is rec- ommended," or "has proven valuable" in this or that disease; that is to say, without attempting to define its mode of action. The cause of this is not difficult to find : So many assumptions as to the actual functions of the organs used therapeutically have been vouchsafed on totally inadequate experimental evi- dence that textbook authors adopt none. The writer of the present arti- cle has taken another course. Reject- ing all assumptions based on inade- quate data, he has collected all experi- mental and clinical facts available, and employed these as the stones used in the elaboration of an edifice to reach each conclusion. Time has sanctioned this course. The conclusions he pub- lished in his "Internal Secretions" in 1903, vol. i, and 1907, vol. ii, and else- where, have steadily gained adherents, supported as they have been by an in- creasing number of confirmatory facts contributed independently by experi- menters and clinicians. He feels it his duty, therefore, to adopt his own views as the foundation of the following sum- mary of organotherapy, knowing, as he does, that they will best subserve the interests of the practitioner arid of the sufferers under his care. THYROID GLAND ORGANO- THERAPY.— In the latter part of the last century, King, of London, showed experimentally that the colloid substance of the thyroid gland passed directly into the lymphatics. Schiff, of the University of Geneva, reviving views in 1859 previously held by many, found that this organ played an im- portant part in the economy, through some substance which it secreted, and that intraperitoneal transplantation of the healthy gland in a dog shortly after thyroidectomy had been performed prevented the cachexia strumipriva and violent nervous phenomena which follow this operation. Then followed. ANIMAL EXTRACTS (SAJOUS). 701 in 1882, the lal)ors of the l)n)tlicrs Re- \crclin, succeeded, in turn, one year later by those of Kocher, of Uerne, demonstrating that, in man as well as in animals, the same phenomena oc- curred under identical circumstances. The principal postoperative symp- toms noted were : marked weakness and fatigue ; a sensation of cold, pallor, hardness, and dryness; edematous swelling, thickening of the skin, and loss of hair, all with, as nervous phe- nomena : muscular stiftness and pains ; tetany, sometimes attaining the violence of true tetanus, and even clonic convul- sions. The brothers Reverdin termed this condition postoperative myxedema, while Kocher called it cachexia strumi- priva. The thyroid gland per se was subse- quently found to be responsible only for the myxedematous symptoms, how- ever. The two external parathyroids, discovered in 1880 by a Swedish physi- cian, Sandstrom, and the two internal parathyroids, discovered by a French physician, Nicolas, of Nancy, in 1893, and independently by Kohn, of Prague, in 1895, were subsequently shown through the labors of Gley, Vassale and Generali, Moussous, Jeandelize, and others to be responsible for the nervous phenomena, tetany, etc. Briefly, re- moval of the thyroid alone arrested de- velopment and caused myxedema (cre- tinism in the young), while removal of the parathyroids alone was followed by tetany and early postoperative death. The observation of Schiff, con- firmed by other investigators, that grafting prevented the morbid effects of thyroidectomy as long as the grafts lived, led Murray and Ord to try the use of thyroid extract in myxedema. Not only was it found to counteract this disease by these clinicians and many others since, but thyroid gland, which includes parathyroid ; but the latter alone, as will be shown under a special heading, also proved valuable tlierapeutically in other disorders. How are these favorable phenomena brought about ? PHYSIOLOGICAL ACTION.— In a recently published work on thera- peutics (1911), one of the contributors states that : "the manner in which the thyroid gland presides over the nutri- tion of the body is unknown. It is generally admitted that it furnishes an internal secretion, that this secretion is formed by the living cells of the vesicles, and that it is poured into the colloid material they contain. But our knowledge," remarks the author, "has not advanced much beyond this point." This naturally suggests a correspond- ing lack o.f knowledge concerning the physiological action of thyroid prepa- rations and their use as remedies. But here, as elsewhere in the realm' of science, the world has not stood still. In truth, the last three decades have brought out facts which account not only for the nutritional phenomena witnessed under the influence of thy- roid preparations, however adminis- tered, but also for autoprotective or immunizing functions of the first order. ACTION ON METABOLISM.— Some physiologists hold that the thy- roid and parathyroids, by means of an internal secretion, "exercise an im- portant control over the processes of nutrition of the body," as Howell states ; others contend that the purpose of these organs "is to neutralize or de- stroy toxic substances formed in the metabolism of the rest of the body." Others again assert that it increases metabolic activity, especially catabo- 702 ANIMAL EXTRACTS (SAJOUS). lism. The one great factor which stays all progress in this connection is the persistent identification of these func- tions as separate entities, whereas they are in reality the manifestations of a single function. That such is the case is easily demonstrable : No one can deny that ''the processes of nutrition of the body" represent a phase -(that of anabolism) of the process of metabo- lism, nor can any one deny that catab- olismi, the other phase of metabolism, serves to "neutralize or destroy toxic substances" formed in the body at large — and to break down fats, as is well known. If, therefore, the thy- roid secretion serves to activate me- tabolism, as first shown by two Italian scientists, Vassale and Generali, all the other processes mentioned are also in- fluenced by the thyroid. That such is the case has now been conclusively shown. [Chantemesse and Marie, Ballet and En- riques (cited by Popoff, Arch gen. de med., Oct., 1899), Bourneville (Arch, de neurol., Sept., 1896), and Shattuck (Boston Med. and Surg. Jour., June 30, 1904), Lorand (Lancet, Nov. 9, 1907), and many other cHnicians, in- cluding myself, have noted that thyroid prep- arations caused a rise of temperature of several degrees and that it took part in the febrile process. These observations were controlled by those of Stiive and Thiele and Nehring (Zeit. f. khn. Med., xxx, p. 41, 1896), that thyroid extract increases over 20 per cent, the oxygen intake and to nearly as great a degree the carbonic acid output. This is evidently produced by the active agent of the thyroid secretion, iodine, for this halogen itself increases oxidation as well. Thus, Rabuteau, Milanese, and Bou- chard (C.-r. de la Soc. de Biol., pp. 227, 237, 1873), Henrijean, and Corin (Arch, de phar- macodyn., ii, 1896) have all noted an increase of nitrogen excretion. Wood ("Therapeu- tics," 13th ed., p. 499, 1906) and Cushny ("Pharmacology and Therapeutics, 4th ed., p. 514, 1906) state, in fact, that iodine can produce fever. Removal of the thyroid, on the other hand, lowers oxidation. Albertoni and Tizzoni and Magnus Levy (Zeit. f. khn. Med., xxxiii, p. 269, 1897) found, for example, that this procedure decreased markedly the output of carbon dioxide, and that it caused hypo- thermia. The fall of temperature is gradual, according to Lorrain-Smith (Jour, of Physiol., xvi, p. 378, 1894), and most marked, according to Rouxeau (Arch, de physiol., xxix, p. 136, 1897), at the end of the opera- tion. The proportion of red corpuscles is reduced, according to Moussu (C. r. de la Soc. de biol., p. 772, 1903). Reverdin ob- served in man that the hemoglobin was also diminished, while Horsley noted increased sensitiveness to cold. Albertoni and Tizzoni and Masoin found that the blood contained less oxygen than normally. This applies as well to removal of the parathyroids, which was found by Jeandelize ("Insufficance thyroidienne et parathyroid- ienne," p. 45, 1903) also to lower the tem- perature. That the thyroid apparatus can itself raise the temperature, is shown by the febrile process and sense of heat with flushing observed in the sthenic stage of ex- ophthalmic goiter and when the thyroid apparatus is still overactive. When thyroid extract is given to such cases, the exchanges may be increased to a surprising degree — 77 per cent, in a case observed by Hirschlafif (Zeit. f. klin. Med., xxxvi, No. 3-4, S. 200, 1898-99). The disease may, in fact, be brought on by thyroid preparations, as noted by Notthaft (Centralbl. f. inn. Med., April 9, 1898) and other clinicians. C. E. de M. S.] The process through which general oxidation and metabolism are sustained by the thyroid was shown by myself, in 1903, to be partly due to excitation of the adrenals by the thyroid secretion contained in the blood. Starling has since (1906) termed "hormones" sub- stances which thus act as stimuli to other organs, while Kraus and Fried- enthal, Caro, Hoskins, and others have found (1908-1910) that thyroid ex- tracts excited the adrenals. This indi- rect action I also found in 1907 to be supplemented by a direct action on the phosphorus of all tissue-cells (and par- ANIMAL EXTRACTS (SAJOUS). 703 ticularly of their nuclei), the iodine found by Uaumann to be the active agent, in organic combination, of the thyroid secretion (as well as of the parathyroids, as shown by Gley), ren- dering the phosphorus more susceptible to oxidation by the hemoglobin. [Telford Smith (Lancet, Oct. 7, 1897) and other clinicians have observed that the use of thyroid preparations in young cretins was sometimes attended by softening of the bones and bending of the legs, notwithstanding marked general improvement. When it is recalled that five-sixths of the inorganic matter of bone consists of calcium phosphate, it becomes a question whether the thyroid extract does not interfere with the building up of this tissue. That such is the case is further suggested by the facts that iodine, the active constituent of the thyroid secre- tion, and its salts, as shown by Henrijean and Corin (loc. cit.), Handfield Jones (cited by Wood, loc. cit.), and others, cause excessive elimination of phosphates and phosphoric acid, and that thyroid preparations, according to Roos, Scholtz (Central, f. inn. Med., xvi, pp. 1041, 1069, 1895), Pouchet (Bull. gen. de therap., Sept. 15, 1905), and others, act in the same way. "Emphasis must be laid," writes Chittenden (Trans. Congress Amer. Phys. and Surgs., iv, p. 93, 1897), "upon the apparent connection between the thyroid gland and phosphoric acid metabolism," giving as example "the increased excretion of P2O5 after feeding thyroids to normal animals, and the great decrease in the case of animals with the thyroids removed." The untoward effects of large doses of thy- roid preparations on the nervous system, owing to its wealth in phosphorus and fats as manifested by tremor, tachycardia, optic neuritis [Coppez (Arch. d'Ophtal., Dec, 1900)], etc., also bespeaks such an action; Cyon (Arch, de physiol., x, p. 618, 1898), in fact, found that injections of iodothyrin ex- cited the depressor nerve directly to such a degree that the vascular pressure often de- clined to two-thirds of the normal. A familiar action of the thyroid prepara- tions is a rapid reduction of fat in obese sub- jects when full doses are administered. The presence in the fat-cell of a. nucleus rich in phosphorus whose purpose is promptly to promote oxidation of the fat when the organism requires additional carbohydrates explains this action. Schondorff (Arch. f. d. ges. Physiol., Ixiii, p. 423, 1896; Ixxii, p. 395, 1897), in fact, found that the reserve fats could be exhausted before the nitrog- enous tissues were affected. The mode of action of the thyroid active principle, iodine, is suggested by the presence of this halogen in all nuclei, as shown by Justus (Virchow's Archiv, clxxvi, S. 1, 1904) and others. This means that iodine is found wherever phosphorus is present, while, as shown above, it is most active where phos- phorus is known to be most plentiful. Now, chemistry furnishes a clue to the manner in which all the phenomena I have enumerated are present: "If a fragment of phosphorus lying on a plate is sprinkled with iodine," writes Wilson ("Inorganic Chemistry," p. 284, 1897), "the substances unite, and heat enough is produced to kindle the phos- phorus." Nitrogen, hydrogen, and chlo- rine are ubiquitous constituents of our tis- sues, and the vigorous explosives they form with phosphorus and the intense liberation of heat the reactions entail are familiar features of the laboratory. Roos (Miinch. med. Woch., No. 47, p. 1157, 1896) found that in a dog in nitrogenous equilibrium, iodothyrin "caused at once a marked increase in the output of sodium, sodium chloride, and phosphoric oxide" (cited by Chittenden, loc. cit., p. 89). Still, as Chittenden states (loc. cit:, p. 99), "according to Baumann, doses of 1 mg. of iodothyrin which contain only 0.1 mg. of iodine will produce a decided effect upon a goiter after three or four applications, thus clearly indicating that it is not the iodine per se that is effective, but rather the iodine compound." This will recall the ob- servations of Notkin and vVhite and Davies, that the action of the adrenal secretion re- sembles that of an organized ferment, and my own, that the adrenal principle with which the iodine is combined endows it with ■ the properties of a ferment. Hence, the term "thyroiodase" I have applied to the thyroparathyroid secretion. C. E. de M. S.] When in the. light above, we admin- ister desiccated thyroid, which com- bines the actions of the thyroid and parathyroids, corresponding effects are 704 ANIMAL EXTRACTS (SAJOUS). produced: It renders the phosphorus of all tissues, and all free substances, such as bacteria, wastes, toxins, etc., containing phosphorus, more inflam- mable or sensitive to the action of the oxygen in the blood. As this applies particularly to nerves and nerve-cen- ters (all of which are especially rich in phosphorus), the adrenal center, and, therefore, the adrenals themselves, are excited, and, the adrenal secretion be- ing the agent which takes up the oxy- gen of the air to sustain the blood-oxy- genizing power, the supply of oxygen is also increased. All the various phos- phorus-laden substances are thus not only rendered more readily oxidizable by thyroid extract, but this remedy also provides indirectly the required oxy- gen. Hence also the familiar in- fluence of thyroid preparations on Dbesity, their action being mainly ex- ercised upon the nucleus rich in phos- phorus which fat-cells contain. The wonderful effects of thyroid ex- tract in cretinism can also be readily accounted for: The rise of tempera- ture is due to the increased oxidation brought about by the thyroid and adrenal oxidizing substances acting jointly; the enhanced metabolism is a normal result of the augmentation of general oxidization, while the increased appetite is due to the resulting greater ^ demand for foodstuffs. The marked improvement in general nutrition and strength is a self-evident result of the assimilation of a greater proportion of food materials, and the rapid growth likewise. The cerebrospinal system is particularly influenced owing to its wealth in phosphorus ; hence, the devel- opment of intelligence. All organs be- ing the seat of active metabolic activity and nutrition, the intestinal, renal, car- diac, and cutaneous and hepatic func- tions are all enhanced. Even the hair grows bountifully not only in cretin- ism, but when its loss is due to general adynamia. It counteracts premature senility in all its phases by restoring to the organism the one constituent which sustains the functional efficiency of all its parts. This, it must be emphasized, is the ag- gregate of effects obtained with small doses, at most, 2 grains of the desiccated thyroid (which represents 10 grains of the gland proper), three times a day. When larger doses are given another order of phenomena is awakened : those of excessive burning up, as it were, of the tissues. The inflammability of all phosphorus-laden elements being mark- edly enhanced while the quantity of oxidizing substance is as greatly in- creased, the tissue elements are broken down more rapidly than they are built up, beginning with the fats, and the patient becomes emaciated. THE THYROPARATHYROID SECRETION AS OPSONIN.— One of the functions credited to the thyroid gland, we have seen, is "to neutralize or destroy toxic substances formed in the metabolism of the rest of the body" (Howell). This is justified by many established facts. Tetany, as shown by the brotdiers Reverdin, we have seen, follows thyroidectomy; it is now rec- ognized that this is due to a general toxemia. As these phenomena were arrested by administering thyroid ex- tract, or by grafting, as long as the physiological action of these remedial agents lasted, it became evident that the thyroid supplied the blood with some substance which in some way de- stroyed the spasmogenic poison, i.e., that the thyroid product was an anti- toxic substance. This is further sus- tained by the facts: 1, that the blood ANIMAL EXTRACTS (SAJOUS). 705 of thyroidectomized animals proved more toxic than that of normal ani- mals, and that it caused convulsions; 2, that the urine of thyroidectomized animals ^vas also more toxic than that of normal animals ; 3, that the trans- fusion of blood of the latter into thyroi- dectomized animals counteracted for a time the toxicity of both their blood and urine. These and other facts had shown that the thyroid gland — mainly owing to the parathyroid secretion it contains — is endowed with antitoxic, or, as they have been sometimes termed, "detoxicatory," functions. Yes; it is evidently not only "toxic substances formed in the metabolism of the body" that the thyroparathjToid secretion proves antitoxic. Charrin, Lindemann, and others have found, for example, that animals succumbed more readily to infections after their thyroid had been removed ; Roger and Garnier, Kashiwamura, and others found that histologically the thyroid showed evi- dences of marked activity, while Torri noted that this was accompanied by an increased production of their colloid substance. Hunt has shown that thy- roid feeding renders white mice much less susceptible to poisoning by aceto- nitrile; Vincent, Frugoni and Grixoni, Leopold-Levi and Rothschild, and oth- ers have observed that thyroid prep- arations combated effectively various infectious diseases, including erysipelas and septicemia. The thyroparathy- roid thus showed itself antagonistic to bacterial toxins and certain other poi- sons, as well as to {oxic waste products. This action is accounted for by the fact, pointed out by myself in 1903 ( "Internal Secretions," vol. i), that the thyroid secretion is one of the impor- tant agents in general immunity — none of the active factors or antibodies of which had been traced to their source. I found, however, that this action was indirect, i.e., that the thyroid secretion or extracts, while a constituent of the blood's antitoxin, or alexin, increased the immunizing power of the latter by enhancing the functional activity of the adrenals. This stimulating influence on the adrenals has since been sus- tained by the investigations of Hoskins and others experimentally, while the participation of the thyroid in the im- munizing process was, four years later, confirmed by the researches of L. Fas- sin, of the Bacteriological Institute of Liege. Experiments to ascertain the influence of the thyroid gland on immunity. The first series of experiments in a large number of animals (dogs and rabbits) showed that the subcutaneous injection of thyroid product (fluidextract of the fresh gland, the thyroidin of Bur- roughs, .Wellcome & Co.) is rapidly fol- lowed by an increase of alexin in the serum, a substance discovered by Buch- ner, generally considered as playing an important role in the defense of the body. This increase becomes evident as early as ten minutes after the injec- tion; it becomes accentuated after one hour, reaches its maximum in twenty- four hours ; then the proportion of alexin in the blood recedes more or less rapidly until the normal is reached. The effects of one injection rarely last less than twenty-four hours or more than two or three days. The writer also found that the oral administration of thyroid brought about corresponding effects. To control these results as to their direct relationship with the thyroid, the writer performed complete thyroidec- tomy in 9 animals. One alone, however, survived the operation more than fifteen days, tetany occurring in all, thus show- ing that the parathyroids had been com- pletely removed. In all the operated animals there occurred a marked dimi- nution of the hemolytic and bactericidal alexin, though it never disappeared 1—45 706 ANIMAL EXTRACTS (SAJOUS). altogether. As the diminution of alex- in might possibly have been due to traumatism, the operative procedures were repeated in fresh animals, leaving the thyroid in situ. But neither the traumatism nor even removal of the spleen caused a reduction of alexin. Louise Fassin (C.-r. de la Soc. de Biol., vol. Ixii, pp. 388, 467, 647, 1907). Further researches on the nature of the process through which the thyroid secretion enhanced the autoprotective power of the blood and of the phago- cytic activity of the migrating and sta- tionary (endothehal) cells brought me in 1907 to the conclusion that the thy- roid and parathyroid secretions, acting jointly, served to sensitize all phos- phorus-laden cells, normal and patho- logical, and that this thyroparathyroid secretion and Wright's opsonin were "one and the same substance." Among the more direct facts which sustained this opinion were that, while substances capable, as are the opsonins, of sensi- tizing or enhancing the phagocytic ac- tivity of leucocytes had been found in the blood-plasma by Denys and Leclef, Bordet, and others, and Nolf had shown that they were secreted by the red corpuscles, my own observations brought out (1) that the composition of these sensitizing substances was similar to that of the thyroparathyroid secretion, i.e., that they contained io- dine, nucleoproteid, and globulin, and (2) that opsonins, which had been as- similated to Bordet's sensitizing sub- stance by Savtchenko and others, were destroyed at the same temperature as \ the thyroparathyroid secretion, i.e., at 60° to 65° C. Briefly, besides being endowed with other attributes in com- mon, the sensitizing substances of Denys, Bordet, etc. ; Wright's opsonins, and the thyroparathyroid secretion all proved to be plasmatic products of the red corpuscles, and to show similar chemical properties. Hence my con- clusion that it was as opsonin that the thyroparathyroid secretion pro- duced its main effects, and the rec- ommendation that thyroparathyroid preparations be used in various in- fections, acute and chronic, to enhance the opsonic power of the blood. My position has been sustained by several investigators. The w^riter reported the results of experimental and clinical observations which had led him to conclude that the opsonins of the tissue juices and ex- udates were, to a considerable extent, the product of the thyroid gland while simultaneously taking part in the main- tenance of health through its influence on metabolism. He noted elevation of the opsonic index of the serum after injections of thyroid extract into rab- bits. A rabbit treated with L5 c.c. of the extract at two days' interval gave three days after the injection an opsonic index = 2, 4, for example. Another, given the preceding day 1 c.c. of the extract, gave an index of = 3.0. These results, obtained in many animals, and other experiments led the writer also to ascribe the opsonizing action of thy- roid extract to the thyroglobulin of Oswald, which is normally present in the thyroid gland. Stepanoff (C.-r. de la Soc. de Biol., vol. Ixvi, p. 296, 1909). The writer, having also advanced the opinion that the glands with internal secretion probably play an important role in the phenomena of immunity, undertook to verify this view experi- mentally, as had Stepanoff, at the Pasteur Institute. The first series of experiments aimed to ascertain the influence of hyperthyroidization on op- sonic variations in* the blood of guinea- pigs and rabbits, using mainly the bacilli of tuberculosis, diphtheria, the Bacillus coll, and the staphylococcus and streptococcus. A large dose of thyroid (1 Gm. per kilo) was given the first day, but this was reduced daily. In this series, which included 116 examina- ANIMAL EXTRACTS (SAJOUS). 707 tions, tlic writer stales tliat lie always observed that the opsonic power of the blood-scrum increased very clearly after thyroid opotherapy. It was, in fact, considerably more than doubled in all but one instance, the exception being that of an animal in which an emulsion of Bacillus coli only increased the op- sonic power one-half. Might the ingestion of any animal substance by herbivora not have given rise to the increase of opsonic activity? Tlie administration of corresponding quantities of horse flesh to control failed to modify the latter in any way. The writer found, moreover, that the leucocytes of a normal animal when treated hi vitro with the serum of an hyperthyroided animal showed a dis- tinct increase of phagocytic activity. The second series of experiments had for its purpose to ascertain the effects of removal of the thyroid on the op- sonic properties of the blood. The serum obtained from 4 dogs at the time of the characteristic accidents caused by thyroidectomy showed in every instance a most evident diminution of opsonic power. The same experiments con- ducted in the rabbit gave rise to the same results, i.e., he always found a marked decline of opsonic power in thyroidectomized animals. He noted, moreover, that, while traumatism, even a musculocutaneous wound, could cause in a certain measure a reduction of opsonic power, the latter rapidly re- turns to normal, while it maintains itself a very long time at the same level in thyroidectomized animals. S. Marbe (C.-r. de la Soc. de Biol., vol. Ixiv, p. 1058, 1908). On the whole (referring the reader for experimental details to my work on the internal secretions), the physio- logical action of thyroid preparations may be summarized as follows: — 1. They enhance oxidation by in- creasing the inflammability of. the phos- phorus, which all cells, particularly their nuclei, contain, and by enhancing the functional activity of the adrenals- 2. Their power to enhance the in- ilammability of cellular phosphorus ex- tends to pathogenic elements, bacteria, their toxins or endotoxins, toxic wastes, etc. As such they act as opso- nins, and render these pathogenic ele- ments vulnerable to the immunizinsf action of the blood and its phagocytes. THE ACTIVE PRINCIPLE OF THYROID.— The thyroid product is an "iodized globulin." As Notkin and also White and Davies hold, the action of the thyroid secretion resembles that of an organized ferment. This finds its explanation in the fact that the thyroidin, to which this applies, is mainly a ferment plus iodine. The identity of this ferment suggests itself when we consider Baumann's analyses of his thyroidin. Among other tests, for example, he found that it was prac- tically insoluble in ether and chloro- form; that it was not destroyed by digestive ferments, and that it stood a temperature of 100° G. These are the specific tests of the oxygen-laden adre- nal product, my adrenoxidase. Again, I found that this substance gave the tests of the plasmatic oxidase; Lepin- ois also found that the thyroid secre- tion contained an oxidase which gave the blue reaction with tincture of guaiac. We have seen, moreover, that adrenoxidase is a globulin : Oswald termed his product "thyroglobuHn" and described it as an "iodized glob- ulin." Several other facts could be adduced to show that this constituent of thyroidin is adrenoxidase. This means that it is merely the albuminous portion of the hemoglobin which enters the thyroid and parathyroids in large quantities with their rich blood supply. Another constituent of thyroidin may be regarded much in the same light: nucleoproteid. Sherrington, Mil- ;08 ANIMAL EXTRACTS (SAJOUS). roy and Malcolm, and others have found that the granulations of the most numerous leucocytes in the blood, the neutrophiles, are composed of nucleoproteid, while the observations of Bail, Stokes, and Wegefarth, San- gree, and others have as clearly shown that these granulations leave the pe- riphery of the cell. Here, again, we find in the secretion a supposed intrinsic ■component which, in reality, is but a commonplace constituent of the blood. This harmonizes with the familiar fact that in the absence of its iodine the thyroid product is inactive. It in- dicates, moreover, the true nature of the functions of the thyroid and para- thyroids, to collect iodine (brought to them by certain leucocytes, as I have shown elsewhere) and combine it orig- inally with the free or albuminous hemoglobin and nucleoproteid. As Os- wald holds, therefore, the thyroid prod- uct is an "iodized globulin." PREPARATIONS AND DOSE. — The implantation of a portion of the thyroid gland beneath the skin was soon superseded by the hypodermic method, but the latter presented an- other drawback, that of requiring the constant attendance of the physician. Besides this the preparations often produced suppuration. The gland it- self, therefore, administered in the form of desiccated powder in tablets or cap- sules, is preferred by the majority of practitioners. This presents also the advantage of conforming to the U. S. Pharmacopoeia {thyroideum sic cum.) The average- dose recommended in the former Pharmacopoeia, 4 grains (0.250 Gm.), which suggests from 3 to 5 grains, ivas excessive, each grain rep- resenting 5 grains of the gland proper. The present official dose is 1^ grams. For reasons submitted in the fore- going pages, small doses, from ;^ to 2 grains, given three times daily in the adult, enhance metabolism, while larger doses so stimulate catabolism that they cause undue breaking down of the fats and tissues. If kept up too long, the blood ele- ments themselves (hemolysis), and even the tissues (autolysis) proper, may be destroyed. Five- or even 4- grain doses are never indicated, even in the treatment of obesity. By loading up the circulation with toxic wastes, these excessive doses may also give rise to tetanoid movements and even to true tetany. An important feature in this connec- tion, however, is that the unstandard- ized preparations of desiccated thyroid vary in strength to a considerable de- gree, and that a small dose of a weak preparation may prove practically inert in practice. Dried thyroids are now officially required to contain from 0.17 to 0.23 per cent, of combined iodine. An imported desiccated thyroid, that of Burroughs, Wellcome and Co., is also standardized, each grain (representing about 6 grains of the fresh gland) con- taining 0.05 grain of iodine in combina- tion. This product is labelled as repre- senting a given amount of the fresh gland. It is available in small tablets of Yz, 1, \y2, 2^, and 5 grains. There is also on the market an im- ported article termed iodothyrin, a milk-sugar triturate of the thyroid active principle, 1 Gm. of which repre- sents 0.0003 Gm. of iodine. The dose for adults is given as 10 to 30 grs. (0.6 to 2 Gm.), and is available in tablet form, each containing 5 grains (0.33 Gm.) of iodothyrin. Its manufactu- rers claim that, besides possessing the advantage of definite strength, it is devoid of extraneous matter. It is not ANIMAL EXTRACTS (SAJOUS). 709 regarded as efficacious as the desic- cated gland. It is a convenient prep- aration for young- children, however, owing to the fact that it occurs as a sweet, whitish powder. AMien preparations of thyroid gland — which include parathyroid — cannot be obtained, a glycerin extract may be prepared by divesting a sheep's gland of fat, and macerating it in an equal quantity in weight of glycerin twenty- four hours. From 2 to 15 minims of the extract may be given daily accord- ing to age. The writers have studied in goats the therapeutic effect of the following sub- stances : thyroid gland ; iodothyrin ; thyroglobulin ; thyroproteid ; the prod- ucts of peptic and trj^ptic digestion of the thyroid gland, including primary and secondary albumoses and further cleavage products, obtained separately. They find that thyroid gland and thyro- globulin have a marked and rapidly beneficial action. Secondary albumoses derived from hydrolysis of the thyroid are also active, but apparently less so than the former substances. Thyro- proteid, iodothyrin, and the less complex products of digestion of the thyroid were wholly inert. Their experiments offer no ground for the supposition that iodothyrin is the active constituent of the gland, or even that it is one of the active constituents. Pick and Pineles (Zeitsch. f. exper. Path. u. Therap., Bd. vii, S. 518, 1909). UNTOWARD EFFECTS AND THEIR PREVENTION.— The dan- gers attending the use of thyroid prep- arations depend, to a degree, upon the manner in which the remedy is admin- istered. Beneficial doses, by raising the activity of all metabolic processes, prove tonic, increase the appetite, the strength, and the oxidations, as shown by a slight rise in temperature. When, however, the dose is too large, a weak, rapid pulse and shortness of breath, vomiting, cardiac oppression, a feeling of tightness around the chest, vertigo, and coma may supervene. Excessive doses have also caused anorexia, diar- rhea, malaise, lassitude, and pain in the extremities ; headache, various eruptions, urticaria, transient and pap- ular erythema and eczema, and, in some cases, nervous manifestations; neuralgia, delirium, convulsions, delir- ium of persecution, aphasia, monople- gia, etc. When dried powder or com- pressed tablets that are not fresh are used, symptoms of ptomaine poisoning may be added to those mentioned. Hence, the observations that these prep- arations are more likely to produce such effects during the warm weather. The best guide is the pulse. Any considerable quickening or palpitation should lead us to discontinue the drug until the cardiac action is again normal. There areno dangers in the use of the drug, provided we begin with small doses, from % to 1 grain, and grad- ually increase, watching the pulse. It should never be given to a patient who cannot be closely watched. In some cases, although no other un- toward symptom appears, the patient loses flesh. This is apt to occur when 2 grains of the dried gland three times daily in the adult is exceeded. Chronic poisoning, characterized by rapid pulse, emaciation, weakness of the limbs, general debility, and mydria- sis have also been observed in individ- uals who had undertaken, without med- ical advice, to treat their corpulency, and who had, therefore, subjected themselves to excessive doses. TREATMENT OF THYROID POISONING.— As a rule, cessation of the use of thyroid preparations ar- rests the untoward effects. When such is not the case, however, arsenic, as 710 ANIMAL EXTRACTS (SAJOUS). shown by Mabille, antagonizes the toxic phenomena. Fowler's solution, from 314 to 5 drops three times daily, suffices in most instances to arrest all morbid effects. Mabille's observation that arsenic obviates the unpleasant symptom ex- cited by thyroid preparations con- firmed. In S cases of idiopathic goiter, in 1 case of obesity, and 1 of infantile myxedema, iodothyrin was given in progressive doses of from 3% to 30 or 3Sy2 grains daily. At the same time arsenic was given, either in pills or as Fowler's solution, in doses increasing proportionately to the iodothyrin of %4 to Yio or even % grain daily. The observations of the writer fully confirmed Mabille's experience, for, though the 7 cases took respectively 231, 111, 86, 320, 108, 296, and 125 iodothyrin tabloids, containing nearly 4 grains each, beyond occasional in- creased frequency of the pulse no symp- toms of thyroidism appeared, so that the course could be continued unin- terruptedly. Arsenic, therefore, appears to suppress thyroidism with greater cer- tainty than atropine does iodism, and it is now possible to give iodothyrin safely in doses and for a period capable of producing definite therapeutic effects. Ewald (Die Therapie der Gegenwart, Sept., 1899). The writer has also observed that arsenic exerts a specific influence upon the activity of thyroid. Patients who took an arsenical and thyroid prepara- tion synchronously never complained of any deleterious effects, while those who were treated with thyroid alone occa- sionally exhibited untoward symptoms. So pronounced was the modifying power of arsenic that in the course of time he never prescribed thyroid prep- arations without adding arsenic in some form. Heinrich Stern (Jour. Amer. Med. Assoc, Feb. 15, 1902). The addition of a cardiac tonic, preferably adonidin, to thyroid is recommended whenever the latter prep- aration is to be used for any length of time. The following formula is em- ployed : — B Sodium cacodylate %oo gf- Adonidin %o gr- Thyroid gland (dry powder) 1 gr. For 1 compressed tablet. When fresh adonidin cannot be obtained (its price is exceedingly high), caffeine may be substituted in doses of Yq grain. Thyroid therapy will receive a new stimulus as soon as the medical profession appreciates the fact that the addition to the thyroid of proper amounts of arsenic and a cardiac remedy will render the medication more efficient and deprive it of all or nearly all its deleterious effects. Heinrich Stern (American Medicine, Jan., 1910). THERAPEUTICS.— The many disorders in which thyroid prepara- tions have been recommended ("nearly all the chronic and many of the acute troubles known to humanity," as one author remarks) have naturally in- spired considerable mistrust as to their actual therapeutic value. Gradually, as the harmfulness of large doses as- serted itself and the physiological role of the thyroparathyroid apparatus be- came unraveled, however, their indi- cations became better defined. It may now be said that in sharp contrast with the empirical methods of the past thy- roid preparations, when employed in- telligently, are of great value in many disorders, both acute and chronic. As far as the author can elicit from his own investigations in practice as to the use of the thyroid gland and its preparations, the latter has a far wider sphere and use than may be realized by the average practitioner. He has tried its use and derived a great deal more benefit than he could imagine in such conditions as myxedema, obe- sity, cretinism, exophthalmic goiter, one case of acromegaly, and various skin affections. Samuel Robbinovitz (N. Y. Med. Jour., Nov. 27, 1909), ANIMAL EXTRACTS (SAJOUS). 711 In the liglit of the functions attrih- uted to the thyroid secretion in the foregoing pages, it governs tissue me- tabohsm by rendering all phosphorus- laden cells susceptible to oxidation. When, therefore, the thyroid principle is deficient in the body, both phases of metabolism — including, of course, that of carbohydrates — the building up and the breaking down of tissues, are correspondingly inhibited. The most exaggerated expressions of this condi- tion are, as is well known, the syn- dromes known as myxedema and cre- tinism. The characteristic symptoms of these disorders exemplify clearly deficient metabolic! activity and its consequences. In myxedema we have, among other symptoms, for example, the low temperature, 95.5° F. in some instances, both in the mouth and rec- tum; great sensitiveness to cold, reduction of the urea output — some- times to 50 per cent, of the normal — cyanosis of the lips, ears, and extrem- ities on exposure to slight cold„ and many secondary results of defi- cient metabolic activity, anemia with marked pallor, general relaxation of the arteries, muscular weakness, mental torpor and vertigo, and the cu- taneous anesthesia. In the cretin, we have, besides, all the phenomena of ar- rested development, both physical and mental, as shown by the dwarfed body and the idiocy. Hypothyroidia, or Hypothyroid- ism. — This is a condition akin to the above, but much less marked, fre- quently met in practice. The thyroid apparatus supphes a part only of that required by the tissues, and the result- ing phenomena recall closely some of those observed both in myxedema and cretinism : chilliness and subnormal temperature, coldness of the extrerni- ties and sensitiveness to cold ; fatigue on slight exertion ; constipation with tendency to tenesmus ; frequent at- tacks of migraine, "sick headaches" with nausea, vomiting, etc., and other periodic manifestations of autointox- ication — due to inadequate reduction of waste products and their retention in the blood. The skin taking part in the process of elimination, urticaria and eczema are frequently observed, while transitory edemas of the brow, around the eyes, and sometimes of the face, even in the absence of albumi- nuria or casts, point to renal fatigue. Enuresis is commonly observed in children of this type and may persist to adult age. The patient is subject to frequent catarrhal disorders of the re- spiratory passages, usually ascribed to colds, but due mainly to vascular and glandular relaxation. A tendency to early alopecia, including the eyebrows (especially the outer third), is also noticeable — a sign of deficient general nutrition which coincides with a marked proclivity to early senility. In women the menstruation appears late, owing to retarded development, and there is a proclivity to metrorrha- gia due to laxity of the muscular coats of the uterine arterioles, while pelvic disorders are apt to occur owing to de- ficient support of the uterus, lack of tone in its muscular elements. Leucor- rhea is also frequent, owing to relaxa- tion of the glandular elements of the whole genital tract. Such women con- ceive readily, but abortion is very fre- quent among them ; if the fetus is carried to the normal period, they have little or no milk. Children born of such mothers make up the largest number, if not all, the cases of cretin- ism, rickets, harelip, cleft palate, and other malformations usually ascribed 712 ANIMAL EXTRACTS (SAJOUS). to hereditary influence. We are deal- ing simply with deficiency of the iodine in organic combination which the thyroparathyroid glands supply to the organism to sustain their intrinsic metabolism, i.e., their vital activity. If the mother has at her disposal suf- ficient store of thyroid secretion, the child does well; but if there is thyroid equilibrium being established ; but in girls menstruation is late in being estab- lished; uterine retroflexion is frequent; the chest is undeveloped. The author has often seen women nearing 40 years of age who are fat and whose menstrual flow is excessive take thyroid extract in order to reduce their obesity. He has often seen the menstrual flow in these women become Adipositas (8 months old). Weighs 36 pounds. {Sheffield.) insufficiency, and especially if to this fault be added tuberculosis, hereditary syphilis, alcoholism, inanition, saturn- ism, or diabetes, the child will show un- doubted signs of these taints, and will probably be a myxedematous cretin, with signs of rickets and achondro- plasia, and to this cause may be assigned such malformations as harelip, cleft palate, bony deformities, hypospadias, or undescended testicle. Should the maternal taint be but slight, the child will merely be very backward, which is a matter of small amount in boys, and if after a time righted by the thyroid modified, their stoutness decrease, and the women find themselves pregnant, when they had for a long time given up all hope of ever being so again. He has often by means of thyroid extract brought to a successful end a preg- nancy in women who have repeatedly miscarried. It is often noticed that in adults incontinence of the urine can be stopped by rest in bed. This comes about from the fact that, while resting in bed, the patient is subject- ing his tissues to large doses of thy- roid secretion. In the case of a pregnant woman the increase of ANIMAL EXTRACTS (SAJOUS). 713 thyroid secretion often becomes excess- ive during the pregnancy, and the woman suffers froui the symptoms of excessive tliyri^id si-eretidu. Hertoghe (Bull, de I'Acad. R.nalc de Med. Bcl- giquc, April 27, 1907). Thyroid insufficiency is the cause of many of the phenomena noted in young infants, such as a tendency to obesity, to transient edema, cold feet and hands, experience infants became myxedema- tous when the mothers had goiter. In other cases, the healthy infants of liealtliy parents became myxedematous when they had a wet-nurse with goiter. All these children were cured with thyroid treatment and change of nurse. Experimental research with goats has confirmed the fact of transmission of thyroid secretion by the placenta and in Adipositas. Same case, back view. (Sheffield.) scanty and brittle hair, vasomotor dis- turbances, vomiting, somnolency, and slight resistance to infections. With artificial feeding, these signs become more pronounced, with eczema, urti- caria, tardy dentition, etc. It seems evi- dent that nurslings receive in mother's milk some of the products of the mother's thyroid functioning. The physiological hypothyroidism of the new- born may assume pathological propor- tions ; any derangement in thyroid functioning on the part of the mother or wet-nurse may lead to severe symp- toms of hypothyroidism in the infant. In several instances in the writer's the milk. Concetti (Annales de med. et chir. mfantiles, Aug. 15, 1909). The rudimentary forms of myx- edema or hypothyroidism in children are particularly liable to escape recog- nition, while thyroid treatment in time is almost a certain cure. In a case of this kind a boy of 6 had not grown in the last two years, but seemed otherwise normal, although not particularly bright. Under cau- tious thyroid treatment by the end of eighteen months he had grown 11 cm., nearly 4^ inches. In 2 other cases the myxedema developed after severe measles or mumps, with acute 714 ANIMAL EXTRACTS (SAJOUS). thyroiditis in the latter case. The thyroid treatment ordered was soon abandoned by the family, and the child developed pronounced myxedema, but after two years it spontaneously sub- sided. In a fourth case the myxedema developed after a severe fall over a balustrade, the throat in front bleeding from the. injury. Thyroid treatment promptly cured the child. "Pasty" children, fat, pale, and flabby, may be suffering from hypothyroidism and re- quire thyroid treatment. Stoeltzner (Jahrbuch fiir Kinderheilkunde, Aug., 1910). Diagnosis in the early stage of the malady must be very largely a matter of exclusion and experiment. The pa- tient comes complaining of debility, lack of energy, is chilly, the skin is dry, so also the hair, ideation is slow, the tem- perature may be subnormal and asso- ciated with a slow pulse rate. His complaint is chiefly regarding his weak- ness and lack of energy. If thyroid deficiency be at the bottom of the patient's trouble the administration of thyroid tablets three times a day for a short period will produce marked and continuous improvement. W. B. Thistle (Can. Pract. and Rev., June, 1910). Hypothyroidia, in so far as nutri- tion is concerned, may be defined, therefore, as that condition of the body in which, owing to deficient production of the thyroparathyroid secretion, cel- lular metabolism is slowed sufficiently to inhibit more or less all functions. Hence, the value of thyroid prepara- tions in infantile marasmus. In infantile wasting the writer gives thyroid in a diluted milk and cream mixture with sodium citrate, 1 or 2 grains to the ounce of milk. In a day or two cream is gradually added, Yz a teaspoonful to the feeding bottle. Out of 80 cases thus treated 72 were infants under 9 months and their history was simply one of wasting. TLe other 8 had a wasting" supervening on some acute diseases ; 63 cases did well ; 5 cases presented syphilitic histories in which wasting was a marked symptom. Mer- cury was first given and later thyroid. Three immediately gained and event- ually recovered. In older children the results have also been favorable, ex- cept when tuberculosis was present. In children under 9 months, the author began with % grain of dried thyroid once daily. Larger doses often seemed to induce a diarrhea. In the giving of thyroid it is advisable to test the stools frequently to see whether they are acid or alkaline. In case acidity is found the bicarbonate of soda may be given three times daily, and when the natural alkalinity of the stools is restored the thyroid will begin to exert its beneficial results. No grave symptoms followed the thyroid therapy. In 6 cases a punctiform rash appeared, confined in 2 cases to the front of the chest. It was evanescent and disappeared without treatment in the course of twelve to twenty-fovir hours. In only 1 case was it necessary to stop the thyroid (three days) in order to cause the rash to dis- appear. J. W. Simpson (Brit. Med. Jour., April 30, 1910). The wide range of usefulness of thy- roid extract as a regulator of metabolic processes is not sufficiently recognized by the profession. The writer has seen several marasmic infants transformed into normal, healthy babies under use of thyroid, and in these cases it was necessary to use it for only a short time, the gland seeming to have been stimulated to increased functional activ- ity by the use of the extract. Its administration to mothers who have not enough milk for their babies has, in the writer's practice, with one exception, been followed by an increase in the flow, making it possible to get along without artificial feeding where such feeding had been necessary with former children and would have been necessary in these cases, as shown by decreased flow whenever the thyroid was withheld. E. W. Demaree (West- ern Med. Rev., May, 1910). In contrast with this condition, and exemplifying clearly what we are to expect from thyroid preparations, is the opposite condition, that of A^riMAL EXTRACTS (SAJOUS). m Hyperthyroidia, or Hyperthyroid- ism. — The opinion of Mobius that ex- ophthahiiic goiter or Graves's disease is due to overactivity of the thyroid has steadily gained the confidence of the profession in recent years. But this imposes the necessity of estabhsh- ing clearly the diagnosis of this dis- ease, for there are many disorders that, are due to thyroid overactivity, the so- called "larval" or "aberrant" types, the "formes frustes" of the French, or "pseudo-Graves's" disease, which should not be confounded at all with true exophthalmic goiter, since the ac- tive or erethic stage of the latter is aggravated by the use of thyroid prep- arations, while the "pseudoforms" are benefited by these agents. This does not, however, militate against the fact that exophthalmic goiter and all the above-mentioned subtypes are expres- sions of thyroid overactivity, or hyper- thyroidism. In all we meet, more or less defined — in proportion with excess of thyroid secretion produced — the same group of phenomena, all of which can readily be explained by excessive tissue metabolism and its consequences. The early diagnosis of hyperthy- roidism will be aided by discard- ing such terms as Parry's disease, Graves's disease, Basedow's disease, and exophthalmic goiter and substi- tuting in discussion and in print the more natural term, hyperthyroidism, and by remembering (1) that so- called cardinal signs are usually late signs in the development of hyper- thyroidism; (2) that in the beginning of hyperthyroidism its manifestations are apt to be monosymptomatic and during this period the symptoma- tology is characterized by inconstancy and variability; (3) that a change in the nervous and mental state is the ever-present symptom and sign of hyperthyroidism; that this is fre- quently the only complaint in the beginning, and that a more intensive study of the whole individual sup- posed to be suffering from so-called hysteria or neurasthenia will fre- quently disclose other symptoms and signs of hyperthyroidism, and (4) that the fundamental source of error in the recognition of hyperthyroidism is rather in not looking than in not knowing. W. W. Graves (Jour. Mo. State Med. Assoc, Sept., 1911). As is the case, in other words, when excessive doses of thyroid preparations are administered, there occurs : a rise of temperature, a feeling of abnormal warmth ; tachycardia due to excessive excitability of the heart muscle ; pains, trembling owing to a similar condition of all muscles ; sweating due to over- activity of the sweat glands ; vomiting and diarrhea owing to abnormal irri- tability of their gastric and intestinal neuromuscular supply. Excessive me- tabolism involving the production of a surplus of wastes, the kidneys are overburdened and overactive, and the cutaneous emunctories likewise, the lat- ter causing pruritus and a papular eruption, beginning, as a rule, over the scapulas. As in Graves's disease, hyper- thyroidism and excessive doses of thy- roid may produce apparent protrusion of the eyeballs, the palpebral muscles being retracted owing to their abnormal contractility. Case of a woman who for fifteen years had had a slight enlargement of the thyroid which never gave incon- venience. Some one advised her to take thyroid extract, and she took daily 5- grain tablets for over three months. After some weeks' medication she be- gan to notice trouble about the heart. When examined she had a pulse of 140. Notwithstanding this tachycardia, the heart sounds were perfectly normal, and there was no enlargement of the organ. She showed the characteristic fine tre- mor of Graves's disease. 71-6 Animal extracts (sAjous). The thyroid extract was at once dis- continued, and a week later the pulse had dropped from 140 to 110 and the tremor was distinctly less. Eight days later the tremor had entirely disap- peared, and the patient had no further trouble, though her pulse kept up to 100. G. J. Preston (Maryland Med. Jour., Dec. 10, 1898). Thyroidism in an infant from ad- ministration of thyroid extract to the mother, a woman aged 34 who had exophthalmic goiter. On December 24th thyroid extract (two S-grain tabloids daily) was administered to the mother. On January Ist the child had been sweating profusely for several nights It was looking ill and was sleepless. It had vomited every morning for three days. The extract was consequently stopped for five days. The child im- mediately improved, and on January 4th was quite well. On the 9th, thyroid extract was again given to the mother. The next day the child vomited, was again restless, did not look well, and sweated profusely, etc. The child was weaned and after this remained per- fectly well. B. Bramwell (Lancet, March 18, 1899). The administration of thyroid gland substance, or thyroid extract, is capable, if given in sufficient amount, of inducing a toxic state which in almost every es- sential is similar to Graves's disease. An artificial state of hyperthyroidism is thereby produced, which duplicates almost in full the morbid syndrome. Even the characteristic exophthalmic symptoms have been observed after thyroid feeding by Auld, Beclere, and others, and Edmunds was able to induce proptosis, widening of the palpebral fis- sure, and dilatation of the pupils in six monkeys by this means, even after excision of a portion of the cervical sympathetic. A. R. Elliott (Amer. Jour. Med. Sci., Sept., 1907). There seem to be two distinct types of chronic intoxication from perverted thy- roid functioning, one depending on the sympathetic system and the other on the vagus system. In exophthalmic goiter the two types may be combined ; the vagus type, predominates during the remissions and the sympathetic type pre- dominates during the exacerbations. The sympathetic hyperthyroidism is the primary, the vagus type being more of a secondary, compensating process, but it may assume the preponderance in time. The morbid functioning of the thyroid which entails this modification in the tone of these antagonistic nerve systems may be the result of infectious or bacteriotoxic influences. There may be isolated patches in the thyroid in which the secretion is perverted, while the balance may be sound ; this would explain the cases in which, after re- moval of parti of the enlarged thyroid, severe acute symptoms of hyperthy- roidisin developed. Kostlivy (Mitt. a. d. Grenz. gebietend. Med. u. Chir., Bd. xxi, Nu. 4, 1910). For several years the writer has been seeing cases of hyperemic thyroid, or thyroid hyperemia, and, upon consulting reference textbooks, found pediatric literature quite barren of comment on this affection. The condition arises at puberty, and all cases seen by the writer have been girls. The usual history is that the patient has grown rapidly, has been busy at school, has been observed to be nervous, and then the discovery is made that the collar worn is unduly tight. An examination reveals a swol- len neck, and the patient is brought to the physician. The gland is found to be symmetrically enlarged, occasionally the right lobe slightly in excess ; the gland is firm, but yielding; no bruit is felt or heard. There is usually a mod- erate simple anemia. There may or may not be a tachycardia. The pa- tient is markedly nervous ; there may be a slight tremor. In 2 cases seen there seemed to be a tendency to exophthal- mos and the entire clinical picture was that of a mild exophthalmic goiter, yet recovery was prompt, there was no re- turn of the disease, and the resemblance to Parry's disease was in the end only a simulation. This transient hyperthy- roidism, which in adults may be seen at menstruation, during pregnancy, and in sexual excitement, is in reality more or less physiological and represents the ANIMAL EXTRACTS (SAJOUS). 717 overresponse of the thyroid gland to the stimulation of altered nerve activity, and, in the cases above mentioned, to the special altered internal secretions manifest at puberty. Demme and other French internists describe this as "school goiter," and a variety occurring in warm weather and occasioned in part by the wearing of constricting collars, as "summer goiter" and "garrison goiter." The course of thyroid hyperemia is ministered as required. Small doses of arsenic exert a retarding influence on the overactive gland. F. B. Cross (Long Island Med. Jour., Apr., 1910). With the pathogenesis of these two syndromes clearly defined, the various disorders in which thyroid prepara- tions are indicated suggest themselves, viz., those in which any of the signs of hypothyroidism are more or less dis- ease of cretinism. Result of four months' treatment. Growth, 4 inches. Intellect approaching- normal. (Moore.) short. With proper treatment the con- dition should disappear in a few weeks or months, and in some cases the sub- sidence of the disease appears to be spontaneous, having no relation to the treatment pursued. The treatment is largely a matter of hygiene. A rest from school activ- ities; life in the open air, preferably in the country; good nourishing food, a change in the drinking water, and an avoidance of nervous excitement are the prominent features of the treatment. The anemia should be corrected and nerve sedatives ad- cernible. The pathogenesis of hyper- thyroidism being also apprehended, the limitations of thyroid treatment also appear: the doses utilized should be adjusted in each case to the degree of hypothyroidism that is present. Cretinism. — This condition repre- sents the extreme type of hypothyroid- ism in the young. The value of thyroid gland is such in this distressing disor- der that it may be regarded as a specific — the only agent, in fact, which influ- ences it at all. The earlier it is used, 718 ANIMAL EXTRACTS (SAJOUS). however, the better the results; hence, the importance of early signs of the dis- ease, the most prominent of which are in infants (see article on "Cretinism"), enlargement of the tongue and of the thyroid, myxedematous swelling, arrest of growth, delay in learning to speak and walk, relative deficiency of intelli- gence, dryness and scaliness of the skin, scantiness of the eyebrows and eye- lashes, pufBness of the lids, and facies of old age. The enlargement of the tongue and of the thyroid are the most positive signs of cretinism in the infant. The shape of the nose and the complexion are not characteristic at this early stage, and . the myxedematous swellings are not ob- served until after the end of the first year. Early diagnosis of acquired cretinism is still more difficult. Back- wardness in learning to walk and talk is the most reliable sign. In the en- demic regions the parents are now being educated to watch for the early signs. Von Jauregg (Wien. klin. Woch., Jan. 10, 1906). Soon, sometimes within a few days, the effects of whatever preparation is used begin to appear : the appetite in- creases, the temperature rises, and, nitrogenous foods being more perfectly assimilated, the nitrogen excretion rises — sometimes beyond that ingested. There is loss of weight owing to ab- sorption and excretion of the excess of fluids in the tissues — an effect accom- panied by marked thirst — in some cases, as observed by Marie, and in- creased activity of the kidneys. The red corpuscles and hemoglobin are simultaneously increased. The wrinkles and edema disappear; the harsh, dry skin becomes soft, smooth, and moist; the hair from coarse and thin becomes thick and fine. Growth is resumed, and proceeds with great rapidity in children, sometimes at the rate of one inch per month. They do not, as a rule, however, grow tall. The brain responds more slowly, but considerable intelligence is gained in most instances, at times even that of an average child. The later in life cretinism develops, the better are the chances of improvement in this direc- tion ; occasionally none is observed. In other particulars, all degrees of cretin- ism, especially in sporadic cases, may be said to be improved, the best results being obtained in young children. Series of nearly 100 cases in which three years and more have passed since treatment was commenced. All degrees of cretinism and all ages were unmis- takably benefited by the treatment, but the best results were obtained with the younger children. Complete cure was the rule in the milder cases, without serious impairment of the hearing, when treatment was begun in early infancy (at 6 weeks in 1 case). Von Jauregg (Wien. klin. Woch., Jan. 10, 1906). Since 1905, the Austrian government has been supplying thyroid tablets free of charge in seven endemic foci of cretinism with medical inspection twice a year. About 108,600 tablets were thus distributed in 1907, and 157,900 in 1908; the number of persons taking them was 1011, and 603 were still under the thyroid treatment at the close of 1908. The results are tabulated under various headings, special attention being paid to the increase in height as the most certain index of the benefit derived. Other findings are more liable to be in- fluenced by subjective impressions. The report states that the results have been extremely satisfactory, confirming the efificacy of thyroid treat- ment as a prophylactic measure, espe- cially in endemic foci of cretinism. In 677 cases followed to date marked improvement was obtained in 48.6 per cent, and only 8.6 per cent, showed no benefit from the course. The most striking proof of the beneficial influence of thyroid treatment on the growth iis ANIMAL EXTRACTS (SAJOUS). 719 the fact that in 2i1T , that is, 85.7 per cent, of all cases, the former dwarf cretin children grew to be taller than the normal standard for their age. As a rule, treatment was restricted to growing power of the preceding years had been held in reserve, until suddenly released by the thyroid treatment, when it made all its force felt in a relatively short period. A large number of the Thyroid extract in cretinism. Cretinic idiot, 7 years old when thyroid treatment was begun. Had ceased to develop when 3 years old. Changes after one year's treatment. Growth 6)^ inches. (J". B. McQee : Cleveland Medical Gazette, December, 1900. ) school children : the oldest cretin wa? 26 years old. Even after 20 a number of the cretins grew much taller and the other symptoms of cretinism became attenuated. This growth at this age is so surprising that it seems as if the more interesting cases are cited in de- tail. One cretin, 20 years old, grew 11 cm., but then refused to continue treat- ment, as he outgrew his clothes too fast He did not lose his milk teeth until after thyroid treatment was commenced. 720 ANIMAL EXTRACTS (SAJOUS). although those of the second dentition were in place. A. von Kutschera (Wiener klin. Woch., June 3, 1909; Jour. Amer. Med. Assoc, July 17, 1909). Case illustrating the far-reaching importance of the thyroid for the physi- cal and mental growth and development and the lack of both with lack of thy- roid functioning. The child was born with typical pure myxedema and at the age of 4 looked still like a 10 months' babe, being a pronounced idiot. No traces of the thyroid could be discovered on palpation. Thyroid treatment was then commenced, and in three months the child was trans- formed under its influence; it had grown 10 cm. in height, and has de- veloped normally since, and is now lively and healthy. C. Doderlein (Norsk Mag. f. Laegevidenskaben, July, 1910). To obtain such results, however, it is important to distinguish true cretins from idiotic dwarfs in whom thyroid is less beneficial or of no benefit what- ever. These are the mongol or kal- muck idiots and the micromelic or achondroplasic dwarfs. Mongol or kalmuck idiots resemble cretins in many particulars. The mouth is kept open by the protruding and thickened tongue ; the hair is dry, scarce, and coarse ; the palatal arches are narrow, the development of the teeth is delayed, constipation is the rule, umbilical hernia is frequent, etc. But their skin is less rough, and the general development is less retarded, though that of the brain, judging from the degree of idiocy, must differ but little from that of a cretin's. In this class of idiots the palpebral fissures are narrow and slope upward from the nose; the epicanthus projects markedly over the inner canthus, as is the case in most Chinese. Nystagmus, i.e., os- cillatory movements of the eyeballs, is also common. Thyroid treatment^ though much less beneficial than in cretins, is, nevertheless, productive of good. The mental torpor is somewhat improved, the constipation and hernia are counteracted, and all functions seem to be activated. Achondroplasic dwarfs are in reality but cases of fetal rickets, are normal as to intelligence, but their face is that of the cretin, the skin, especially about the hands, also recalling that of the lat- ter. Other physical abnormahties are abnormal shortness and deformity of the limbs, marked narrowing of the palatal arch, and delay in the closure of the fontanelles. This condition, essen- tially due to morbid development of the bones and cartilages, is in no way influenced favorably by the use of thy- roid preparations. The dose should, of course, vary with the age of the patient from % grain (0.015 Gm.) by the mouth in a 1 -year-old child to 3 grains (0.2 Gm») in the adult. As tolerance varies, especially in children, small doses should be used at the start and very gradually increased until not more than 1% grains (0.1 Gm.) of desiccated thyroid in a child and 9 grains (0.6 Gm.) in an adult are given in divided doses daily. There is no condition in which the prevailing empirical method of administering remedies should be more rigidly guarded against than in this, since excessive doses of thyroid not only inhibit its beneficial effects by exciting violent catabolism, thus break- ing down the tissues instead of build- ing them up gradually, but they may, by doing so, cause death. [What unfavorable results have been re- corded can usually be ascribed to excessive doses. A certain critical author remarks, for instance, referring to personal experience of ANIMAL EXTRACTS (SAJOUS). 721 this sort : "There was no longitudinal growth of the bones nor any poisoning to be observed, but great bodily prostration and an augmentation of mental apathy, together with emaciation dependent upon a loss of fat. From these unfavorable results of therapy it is seen that the view is untenable that athyreosis is the cause of cretinism. These observations are the reverse of the favorable ones made on the treatment of myxedema by thyroid gland, both in the young .and in adults." The great bodily prostration, emaciation, increase of apathy, etc., speak for themselves. They had been caused by the excessive doses the critic had administered. C. E. de M. S.] The doses in which thyroid extract is usually prescribed are many times too large. The ordinary dose is officially quoted as from 3 to 10 grains. There are very few people, except certain types of lunatics, who will tolerate such doses under any circumstances, and not even they are able to do so unless this dose is arrived at by a gradual increase from small beginnings. It is a clinical fact, well recognized by those who have any real experience in the use of the drug, that, the more the patient re- quires thyroid extract, the smaller should be the initial dose. Since the writer has been using it he has been driven back and back in his doses. He now seldom begins with more than %. grain three times a day. He never prescribes a larger dose than 5 grains thrice daily, and then only in pronounced myxedema after sev- eral weeks' treatment. He has had many patients who were unable to take more than %o grain once a day, but this was in each case quite suffi- cient completely to protect them from the symptoms of which they origi- nally complained. In connection with the allotrophic disease, he suggests that the prophylactic dose for an adult should not exceed %o grain three times daily, and that %. grain three times daily is quite a sufficient therapeutic dose to start with. Leon- ard Williams (Practitioner, Nov., 1911). The danger signals are those of hy- perthyroidism, previously described, the principal of which are an increase of temperature beyond normal, tachy- cardia, digestive disturbances, dyspnea, and tremor. When any of these phe- nomena appear, the dose should be reduced until the temperature becomes normal — w^hich may be one or two de- grees F. above the hypothermia usually observed in these cases. It should be remembered, however, that excessive doses may also cause hypothermia by inducing collapse. If the morbid ef- fects continue, the use of the remedy should be stopped a few days and then resumed with a sinaller dose. Should the hyperthyroidism persist notwith- standing. Fowler's solution in small doses soon arrests it. A common un- toward effect is bending of the bones of the legs, owing to softening of the bones. The, child should not be al- lowed to go about too much, or when bowing of the legs appears, it should be placed in bed, as advised by Telford Smith. [This is explained, from my viewpoint, by the action of the thyroid principle upon the phosphorus contained in the calcium phosphate, which plays so important a role in giving bone its solidity and rigidity. This suggests the use of calcium phosphate as an adjuvant to the thyroid to compensate for its loss. The influence of the thyroid secretion upon calcium metabolism has been well shown by the researches of Par- hon, Macallum, and others. C. E. de M. S.] Case of tetany following an acci- dental overdose of thyroid extract in a girl aged 3 years who presented stigmata of cretinism. She was fat and plump, with reddish, somewhat cyanotic cheeks and abundant coarse hair. The anterior fontanelle was not closed. The hands and feet were . cold and blue. The eyebrows were scanty. The abdomen was protuber- ant, but there was no umbilical 1-46 722 ANIMAL EXTRACTS (SAJOUS). hernia. There was marked lordosis, and the tibiae were curved. She was short in stature, and unable to say more than two or three words. Mentally, as well as physically, she was deficient and backward. The rectal temperature was 95°. Thyroid extract, 1 grain t. i. d., was given, and the dose was gradually increased to 2j^ grains t. i. d. All went well for a month, during which time she became more active and very mis- chievous. One morning she secured the box containing 5 tablets, each of 5 grains of the extract, and swallowed the whole. She "cried and screamed" a great deal that day. Six hours after she became "stiff and convulsed." A dose of castor oil was given, and later some bromide. There was no diarrhea. The writer saw her the next day ; she was stiff, and presented pronounced signs of tetany. The eyes and limbs "twitched" a good deal. The face was very red. The characteristic "accouch- eur hand" and arched feet were typical. The fingers and wrists were swollen, and moving the joints made the child cry. The whole of each limb and the back were stiff and painful. The deep reflexes were increased. The pulse was very quick, and the child was feverish. She was unable to stand or sit without support. The treatment was suspended for a fortnight, and the symptoms gradually disappeared. Then 34 grain of thyroid extract was given t. i. d., increased to % grain. During the week after re- suming the drug the "accoucheur hand" was again noticed. The dose was again reduced, but later increased. One month later a slight recurrence of the "accoucheur hand" compelled reduction of the dose of thyroid. Subsequently, though on continuous treatment, no re- currence of the tetany has been ob- served. G. W. R. Skene (Med. Review; Antiseptic, May, 1911). [In the above case the toxic dose of thyroid produced excessive catabolism and an accumulation of waste products in the blood. Hence, the tetany which is also produced when deficiency of thyroid also leads to accumulation of spasmogenic wastes because the latter are not submitted rapidly enough to hydrolysis, a process for which the thyroid secretion prepares the wastes by sensitizing them. C. E. DE M. S.] An important feature of the thyroid treatment of cretinism is the necessity in practically all cases of continuing it to prevent recurrence. The only per- manent benefit when thyroid is discon- tinued is the skeletal growth, though the original morbid phenomena never return with the same intensity. Several cretins occasionally occur in the same family, from the same mother, long intervals between births indicating the permanence of the patho- genic influence in the parent. Herman H. Sanderson (Jour, of the Mich. State Med. Soc, April, 1906), for example, observed 3 cases in one family, the patients being 21, 11, and 8 years of age, respectively. This points to the need of administering thyroid to the mother after the birth of a cretin, and during any subsequent pregnancy. Studies and experiments in the re- gions in which hypothyroidism and athyroidism, which are known to cause idiocy, prevail — several mountainous districts in the Alps and the Karst Mountains with clay and lime subsoil. With the writer's research as a basis for work, local physicians were in- structed to administer thyroid tablets to certain idiots and to report on the results ; 124 persons were thus placed under observation. In 80 per cent, a marked improvement was obtained in four to eleven months, under adminis- tration of quantities of 36 to 100 Gm. (1 to 3 ounces) of thyroid substance; 12 per cent, showed no improvement within one year, while 8 per cent, did not tolerate even small doses well. In nearly all cases the integument became fairly normal, the height increased a little, and the intellectual qualities im- proved. Wagner (Jour. Amer. Med. Assoc, Feb. 6, 1909). ANIMAL EXTRACTS (SAJOUS). 723 Myxedema. — Thyroid preparations are no less efficacious in this disease, which typifies hypothyroidism, in the achilt than in cretinism, of which, in fact, this disorder is the prototype in adults. Here, again, we obtain those striking changes which clearly indicate that the remedy replaces in the organ- ism a constituent necessary to the vital process itself, and the least deficiency of which impairs all functions. This is further shown by the necessity of ad- ministering it continuously, year in and year out, as in cretinism, to prevent re- currence. Under the influence of thyroid prep- arations the morbid symptoms disap- pear. The dense, swollen tissues rap- idly recede, causing loss of weight; the projecting abdomen resumes its nor- mal contour; the skin loses its rough- ness and dryness ; the hair grows more or less abundantly; the face loses its coarse and expressionless appearance, the wax-yellow color of the skin being replaced by a normal hue ; the cyanosis of the lips, ears, and nose disappears. Even the slow and monotonous speech and mental torpor are promptly done away with, and if the case happens in an adolescent stunted by the disease growth is resumed and progresses rap- idly, as in cretinism,. The physiolog- ical action is precisely that defined un- der the preceding reading, since we again meet with a rise of temperature and all the phenomena that denote in- creased metabolic activity, including a marked increase in the urea excretion. Menstruation, frequently suspended during the disease, soon returns. The appetite markedly increases, and the patient experiences a feeling of well- being. The dose generally employed in this disease is, as a rule, too large ; 1 grain (0.065 Gm.) of desiccated extract daily, gradually increased until 2 grains (0.12 Gm.) are given three times a day. Even smaller doses have brought about favorable results. Case of myxedema in a woman of 60. Entire recovery of the patient was obtained under thyroid treatment on the principle of gradually increas- ing doses, commencing with doses so small as to have actually no action or next to none. For two months the daily dose was only 0.5 eg. (54 grain), and then 1 eg. (1^ grains) was taken and continued every day. By the end of six months the patient was as well as before the onset of the myxedema, and has kept well during the year since, still continuing her daily dose of 1 eg. of the extract, representing only about one-thirtieth of a lamb's thyroid gland. Alsted (Hospitalstidende, xlvii, No. 50, 1904). Inasmuch as myxedematous patients are, as a rule, more susceptible to thy- roid preparations than normal subjects, it is always best to begin with small doses, since the degree of activity of the patient's own thyroid, though greatly reduced, is an unknown quan- tity. The presence of unexpected ac- tivity is the main underlying cause of the so-called "susceptibility" often met with, a very small dose of the desic- cated thyroid sufficing in such patients to raise the standard of thyroid activity to its normal level. Again, as I have shown elsewhere (see "Internal Secre- tions," 1st ed., p. 1139, 1907), there is a true cumulative action of the thyroid secretion (thyroiodase) when thyroid preparations are administered, and there comes a time when toxic phe- nomena appear, even under the influ- ence of very small doses. The tem- perature is the best guide. As it is be- low normal in all cases, the doses should be regulated in such a manner as to raise it to normal, reducing them 724 ANIMAL EXTRACTS (SAJOUS). as 98.6° F. (37" C.) is exceeded. The quantity required — usually somewhat larger in winter than in summer — by each patient may thus be readily de- termined while avoiding cumulative effects. In some cases it is well to ascertain whether a low blood-pressure is not perpetuating the peripheral hypother- Fig. 1.— True myxedema. (Hertoghe: Bul- letin de I'Academie Royale de Medecine de Belgique.) mia by causing the blood to recede to the deeper great trunks. This may be done by giving strychnine simulta- neously in doses of ^o grain (0.0016 Gm.) three times daily. By stimulating the vasomotor center, it causes the ves- sels to contract, and thus to project the circulating arterial blood into the pe- ripheral capillaries. Strychnine, more- over, as shown by I. N. Love, tends to prevent the untoward effects of thyroid preparations. An important feature of the thyroid treatment of myxedema is that the pa- tients should be kept in bed the first few weeks and not allowed to get up suddenly, to avoid sudden syncope — the cause of death in several cases on rec- ord. This precaution is especially nec- essary in aged and weak patients and quite as much where the improvement is rapid as in less favorable cases. As Fig. 2.— The same patient after thyroid treatment. {Ilertoglie: Bulletin de I'Acade- mie Royale de Medecine de Belgique.) emphasized by Combe, Seymour Tay- lor, and others, alcohol should not be used during the treatment. Bourneville, Lancereaux, and other clinicians have called attention to the fact that symptoms of myxedema do not appear in infants until they are weaned. This is because the mother supplies her suckling what thyroid se- cretion it needs to satisfy the needs of its cellular metabolism. Thyroid ad- ministered to a nursing mother is also transferred to the nursHng in such a ANIMAL EXTRACTS (SAJOUS). m degree, in fact, that the latter may pre- sent toxic phenomena. This suggests additional caution when the remedy is used in myxedematous women during pregnancy and lactation. Contraindications. — When any ady- namic cardiac disorder is p^resent, the initial dose should he very small and very gradually increased, giving digi- talis simultaneously if indicated by the cardiac trouble. When angina pec- toris accompanies myxedema, small doses are beneficial, especially if the patient is placed on a vegetable diet. Occasionally aged subjects fail to respond to the thyroid treatment alone, and the disease progresses until mental aberration, melancholia, or even mani- acal disorders supervene. The de- pressed forms of mental disorder are probably due to the low blood-pressure which characterizes the disease, and which the thyroid tends to increase. Strychnine counteracts this untoward action, however, while enhancing the beneficial effects of the thyroid prep- aration. Case of a man of 42 years, treated with thyroid gland. Speedy improve- ment occurred, and in a few weeks all the symptoms disappeared, the weigjit diminishing from 13 to 10 stone. For several years he has taken thyroid gland regularly, and has thereby maintained a nearly normal standard of health. Straitened circumstances then pre- vented him from buying thyroid glands. A fortnight after their deprivation sev- eral of the original symptoms returned, and in less than two weeks thereafter nearly a complete picture of myxedema was reproduced, with, however, scarcely so advanced a development of the symp- toms as in the original state. Thomas Fraser (Brit. Med. Jour., March 3, 1906). The danger signals when thyroid is used in myxedema are, as in cretin- ism : tachycardia, palpitations, prostra- tion with sweating, rapid emaciation, gastrointestinal disorders, anemia, head- ache, and in some cases excitement recalling hysteria. When the doses (even though small) are too large for the patient, urticaria may appear. This is due to cutaneous irritation caused by the more or less toxic wastes produced Fig. 3.— True myxedema; sister of patient in Figs. 1 and 2. {Hertoghe: Bulletin de I'Academie Royale de Medecine de Belgique,) in excess owing to the excessive catab- olism induced, and which the kidneys cannot eliminate with sufficient rapid- ity. Cessation of the drug for a few days usually causes all these morbid effects to disappear, after which the remedy may be resumed in very small doses. Case illustrating in turn excessive and deficient activity of the thyroid in a child of 10 years: I. Hyperthy- roidism, or exophthalmic goiter, with the classical symptoms of (a) exoph- 126 Animal extracts (SAJOuS). thalmos, (&) enlargement of the thy- roid gland, (c) hyperexcitability, (rf) a moderately rapid pulse, and (