COPYRIGHT. 1022
BY
K. A. DAVIS COMPANY
Copyrigbl, Ureal Urltaiii. All Rights Reserved
v/
PRINTED IN US. A.
PRESS OF
F. A. DAVIS COMPANY
PHILADELPHIA. PA.
CONTRIBUTORS TO VOLUME VIII.
W. WAYNE BABCOCK, A.M., M.D.,
Professor of Surgery, Temple University Medical School ; Surgeon in Chief
to the Samaritan and Garrctson Hospitals,
PurLADELPHIA, Pa.
REGINALD IT. SAYRE, M.D.,
Professor of Orthopedic Surgery, University and Eellevue Hospital Medical College,
New York City.
LEONARD FREEMAN, M.D.,
Professor of Surgery, University of Colorado School of Medicine,
Denver, Colo.
ERNEST LAPLACE, M.D., lA.A).,
Professor of Surgery, University of Pennsylvania Graduate Medical School,
Philadelphia, Pa.
HENRY T. BYFORD, M.D.,
Professor of Gynecology and Clinical Gynecology, University of
Illinois College of Medicine.
Chicago, III.
ALFRED C. WOOD, M.D.,
Assistant Professor of Surgery, University of Pennsylvania Medical School,
Philadelphia, Pa.
ANTHONY BASSLER, M.D.,
Clinical Professor of Medicine, New York Polyclinic Medical School,
Xew York City.
WM. BROADDUS PRITCHARD. M.D..
Professor of Neurology, New York Polyclinic Medical School,
New York City.
EDWARD JACKSON, M.D.,
Professor of Ophthalmology, University of Colorado School of Medicine,
Denver, Colo.
G. FRANK LYDSTON, M.D.,
Professor of Genitourinary Surgery, Illinois State University,
Chicago, III.
E. D. BONDURANT, M.D.,
Professor of Mental and Nervous Diseases, University of Alabama School of Medicine,
Mobile, Ala.
(iii)
iv COXTRIBUTORS TO VOLUME VIII.
H. BROOKER MILLS, M.D.,
Professor of Pediatrics, Temple University Medical School ; Visiting Physician
to the Philadelphia Hospital for Contagious Diseases,
Philadelphia, Pa.
MYER SOLIS-COHEN, M.D..
Visiting Physician to Home for Consumptives, Chestnut Hill, and Pediatrist
to Jewish Hospital and Eagleville Sanatorium for Consumptives,
Philadelphia, Pa.
J. MADISON TAYLOR, A.M., M.D.,
Professor of Physical Therapeutics, Temple University Medical School,
Philadelphia, Pa.
MARTIN E. REHFUSS, M.D.,
Associate in Gastrological Research, Chemical Department, and Instructor
in Medicine, Jeflferson Medical College,
Philadelphia, Pa.
A. ROBIN, M.D.,
Bacteriologist of the Wilmington City Water Department; formerly Pathologist and
Bacteriologist of the Delaware State Board of Health.
Wilmington, Del.
GUSTAVUS C. BIRD, M.D.,
Professor of Rontgenology and Radiotherapy, Temple University Medical School,
Philadelphia, Pa.
ANDREW F. CURRIER, M.D.,
Mt. Vernon, N. Y.
C. SUMNER WITHERSTINE, M.S., M.D.,
Lecturer on Pharmacology, Temple University Medical School,
Philadelphia, Pa.
F. LEVISON, M.D.,
Formerly Officer of Health,
Copenhagen, Denmark.
C. E. deM. SAJOUS, M.D., LL.D., Sc.D.,
Professor of Endocrinology in the University of Pennsylvania Graduate Medical
School and Professor of Therapeutics in Temple University Medical School,
Philadelphia, Pa.
L. T. deM. SAJOUS, B.S., M.D.,
Associate Professor of Pharmacolog>' in Temple University Medical School and Instructor
of Endocrinology in the University of Pennsylvania Graduate Medical School,
Philadelphia, Pa.
CONTENTS OF EIGHTH VOLUME.
PAGE
Rheumatism 1
Rheumatic Fever 1
Symptoms 1
Complications 3
Diagnosis 6
Secondary Infectious Arthritis .... 7
Acute Osteomyelitis 7
Gout 7
Etiology 7
Pathology 10
Prognosis 11
Treatment 12
Muscular Rheumatism 21
Symptoms 21
Etiology and Pathology 22
Treatment 2Z
Gonococcal (Gonorrheal) Rheumatism. 26
Symptoms 26
Diagnosis 27
Etiology 27
Prognosis 27
Treatment 27
Rheumatoid Arthritis. See Joints, Sur-
gical Diseases of.
Rhigolene. See Petroleum.
Rhinitis and Other Nasal Disorders. See
Index.
Rhubarb 29
Preparations and Doses 29
Poisoning by Rhubarb 30
Therapeutics 30
Rhus Poisoning. See Dermatitis Vene-
nata.
Ribs, Diseases and Injuries of. See Index.
Rickets. See Bones, Diseases of.
Riga's Disease. See Mouth, Lips, and
Jaws, Diseases of.
Riggs's Disease; Pyorrhea Alveolaris
(Spongy Gums) 30
Definition 30
Symptoms 30
Diagnosis 31
Etiology 31
Pathology 23
Treatment 33
Ringworm. See Trichophytosis.
Rochelle Salts. See Potassium and
Sodium Tartrate.
Rocky Mountain Spotted Fever (Tick
Fever) 35
Symptoms 36
Incubation 36
Fever 36
Circulation 36
Eruption Z7
Gastrointestinal Tract 27
Urinary Tract 37
PAGE
Rocky Mountain Spotted Fever (Tick
Fever), Symptoms {continued).
Respiratory Tract 27
Nervous System 27
Diagnosis 27
Etiology 38
Prognosis 38
Treatment 38
Rubella 39
Synonyms 39
Definition 39
Period of Incubation 39
Symptoms 40
Etiology 42
Complications and Sequelae 43
Prognosis 43
Treatment 43
Rubeola. See Measles.
Rue 43
Preparations and Doses 43
Physiological Action 44
Therapeutic Uses 44
Saccharin 44
Physiological Effects 44
Poisoning by Saccharin 45
Treatment of Poisoning 45
Therapeutic Uses 45
Salicylic Acid, The Salicylates, and
Salicin 45
Preparations and Dose 45
Unofficial Preparations 47
Incompatibilities 49
Modes of Administration 49
Contraindications 52
Physiological Action 52
Untoward EflFects and Poisoning 53
Treatment of Poisoning 54
Therapeutics 55
General Uses 55
Local Uses 58
Saline Infusion. See Infusions, Saline . 59
Salivary Glands, Diseases of 60
Xerostoma (Dry Mouth) 60
Symptoms 60
Etiology and Pathology 60
Treatment 60
Ptyalism '. 60
Treatment 60
Ptyalism 60
Salivary Calculus 60
Treatment 61
Tumors of the Salivarv Glands 61
Cvsts ". 61
Tumors of the Parotid 61
Tumors of the Maxillary Gland .... 61
Parotitis 62
Definitions 62
(v)
VI
CONTENTS.
PAGE
Salivary Glands, Diseases of, Parotitis
(coniiiiucd).
Traumatic Parotitis 62
Infectious Parotitis 62
1. Mumps 62
Incubation 63
Symptoms 63
Diagnosis 65
Etiology 65
Pathology 65
Complications and Sequelae . . 65
Prognosis 67
Treatment 67
2. Metastatic or Symptomatic Par-
otitis 68
Symptoms 68
Pathology 68
Prognosis 69
Treatment 69
Salol. See Salicylic Acid.
Salophen 69
Dose and Physiological Action 69
Therapeutics 69
Salpingitis. See Ovaries and Fallopian
Tubes, Diseases of.
Salt. See Sodium.
Salvarsan. See Dioxydiamidoarseno-
benzol.
Sandalwood and Oil of Sandalwood.... 70
Physiological Action and Dose 70
Therapeutics 70
Sanguinaria 70
Preparations and Doses 70
Physiological Action 71
Treatment of Poisoning 71
Therapeutic Action 71
Santonica and Santonin 71
Preparations and Doses 71
Physiological Action 71
Poisoning by Santonin 71
Therapeutic Uses 72
Sapremia. See Wounds, Septic, and
Sepsis.
Sarcoma. See Cancer.
Sarsaparilla 72
Preparations and Doses 72
Therapeutic Uses 72
Scabies 73
Definition 73
Symptoms 73
Etiology 73
Treatment 73
Scammonia 74
Preparations and Doses 74
Physiological Action 74
Therapeutic Uses 74
Scarlet Fever 75
Definition 75
Symptoms 75
Ordinary Tvpe 75
Mild Type " 77
Severe Type 78
Malignant Type 78
Surgical Scarlet Fever 79
Diagnosis and Etiology 79
Transmission 82
Period of Incubation 83
PAGE
Scarlet Fever, Diagnosis and Etiology
{roiitinued).
Period of Infection 84
Pathology 84
Complications and Sequelae 84
Angina 84
Otitis 85
Adenitis and Cellulitis 85
Joint Lesions 85
Nephritis 85
Pneumonia 86
Endocarditis and Pericarditis .... 86
Nervous Symptoms 86
Serous Membranous Involvement. 86
Superficial Gangrene 86
Prognosis 86
Prophylaxis 87
Treatment 89
Schlammfieber 94
Sciatica. See Nerves, Peripheral, Dis-
eases of.
Scleroderma 94
Definition 94
Varieties 94
Symptoms 94
Diagnosis 94
Etiology 95
Prognosis 95
Treatment 95
Sclerosis. See Index.
Scoliosis. See Spine, Diseases and In-
juries of.
Scoparius and Sparteine 95
Preparations and Doses 96
Physiological Action 96
Therapeutic Uses 97
Scopolamine (Hyoscine) and Scopola . . 98
Preparations and Dose 99
Incompatibilities 99
Modes of Administration 99
Physiological Action 99
Absorption and Elimination 100
Untoward Effects and Poisoning .... 100
Treatment of Poisoning 101
Therapeutics 102
As Sedative to the Central Nervous
System 102
As Mydriatic and Cycloplegic 103
Morphine-Scopolamine Anesthesia . . . 104
Morphine-Scopolamine Preliminary
to Inhalation Anesthesia . . 105
Morphine-Scopolamine Preliminary
to Local and Spinal Anal-
gesia 105
Morphine-Scopolamine in Obstetrics. 106
Scorbutus 108
Symptoms 108
Diagnosis 109
Etiology 109
Pathology 109
Prognosis 109
Treatment 109
Scorbutus, Infantile. See Infantile
Scorbutus.
Scrofula. See various forms of Tuber-
culosis.
CONTENTS.
Vll
PAGE
Scrofuloderma. See Tuberculosis of
the Skin.
Seasickness 1 10
Definition and Synonyms 110
Symptomatology 110
Complications and Sequelae Ill
Etiology Ill
Prognosis 113
Prophylaxis 113
Treatment 1 14
Senega 115
Preparations and Doses 115
Physiological Action 115
Therapeutic Uses 116
Sepsis, Septic Fever, Septic Infection,
Septic Poisoning, Septi-
cemia. See Wounds, Septic.
Septum, Diseases of. See Nose and
Nasopharynx, Diseases of.
Sera. See Diseases in which these are
used ; also Hematology.
Serpentaria 116
Preparations and Doses 117
Physiological Action 117
Therapeutic Uses 117
Shingles. See Herpes Zoster.
Shock 117
Definition 117
Symptoms 117
Delayed Shock 118
Shell Shock 118
Etiology and Pathology 119
Kinetic Theory 121
Prophylaxis 122
Anoci-Association 122
Treatment 124
Electrical Shock 127
Treatment 127
Silver 128
Preparations and Doses 128
Incompatibilities 130
Modes of Administration 130
Physiological Action 130
Poisoning " 132
Acute Poisoning 132
Treatment of Acute Poisoning .... 133
Chronic Poisoning 133
Treatment of Chronic Poisoning . . 134
Therapeutics 134
Gastrointestinal Disorders 134
Nervous Disorders 136
Surgical Disorders 136
Disorders of the Respiratory Tract 137
Ophthalmic Disorders 138
Cutaneous Disorders 139
Venereal Disorders 139
Removal of Silver Stains 140
'Sinuses, Nasal Accessory; Diseases of. 141
Maxillary Sinus or Antrum of High-
more 141
Inflammatory Disorders 141
Acute Inflammation 141
Chronic Infiammation or Em-
pyema 142
Treatment 143
Tumors of the Maxillary Sinus, or
Antrum 147
PAGE
Sinuses, Nasal Accessory, Diseases of.
Tumors of the Maxillary Sinus, or
Antrum (continued).
Polypi 147
Cysts 147
Osteoma 147
Malignant Tumors 148
Trea anent , 148
Frontal Sinus 148
Inflannnatory Disorders 148
Acute Inflammation 148
Chronic Inflammation 149
Treatment 149
Tumors of the Frontal Sinus 152
Mucocele 152
Cysts 153
Osteoma 153
Malignant Tumors 154
Treatment 154
Ethmoid Cells 154
Inflammatory Disorders 154
Acute Inflammation ; Acute Eth-
moiditis 154
Chronic Inflammation or Chronic
Ethmoiditis 155
Treatment 156
Tumors of the Ethmoidal Cells 158
Benign Tumors 158
Malignant Tumors 158
Treatment 158
Sphenoidal Sinus 159
Inflammatory Disorders 159
Acute Inflammation 159
Chronic Inflammation or Em-
pyema of the Sphenoidal
Sinus 159
Treatment 160
Tumors of the Sphenoidal Sinus 161
Benign Tumors 161
Malignant Tumors 161
Treatment 161
Skin-Grafting 161
Reverdin's Method 161
Thiersch's Method 162
Wolfe-Krause Method 163
Skin-periosteum Bone Grafts 163
Caterpillar Grafting 163
Tunnel Grafting 163
Subcutaneous Skin-Grafting 163
Anomalies in Grafting 163
Grafting from Dead Bodies 164
Sponge-Grafting 164
Grafting from Animals 164
Histology and Pathology 164
Comparison of Methods 164
Skin, Surgical Diseases of 165
Sebaceous Cysts, or Wens 165
Treatment 165
Furuncle 165
Diagnosis 165
Etiology 165
Treatment 165
Carbuncle 165
Doliiiition 165
Symptoms 166
Diagnosis 166
Etiology 166
Vlll
CONTENTS.
PAGE
Skin, Surgical Diseases of, Carbuncle
(continued).
Prognosis 166
Treatment 166
Keratosis Senilis 167
Prognosis 167
Treatment 167
Calvus ( Corn ) 167
Treatment 167
VerrucTe 168
treatment lf'8
Hypertrophicd Scars 168
Treatment 168
Keloid 168
Symptoms 168
Diagnosis , 169
Etiology and Pathology 169
Prognosis 169
Treatment 169
Malignant Degeneration of Scars . . 169
Burns 169
Definition 169
Varieties 169
Symptoms 170
'Local Effects 170
Electric and X-ray Burns 171
Burns of Mucous Surfaces 171
Constitutional Effects 1/1
Complications 172
Diagnosis 172
Medicolegal Aspects of Burns 172
Prognosis 173
Treatment 173
Constitutional 173
Local 174
Treatment of Electrical Burns . . . . 175
Scar Tissue Deformities 176
Sodium 176
Preparations and Doses 176
Physiological Action 180
Poisoning by Sodium and Its Salts . . 183
Sodium Hydroxide 183
Treatment of Poisoning by Sod-
ium Hydroxide 183
Sodium Bicarbonate and Carbonate . 184
Sodium Chloride 184
Sodium Nitrate 184
Sodium Sulphate 185
Sodium Sulphite and Thiosulphate . 185
Therapeutics 185
Gastrointestinal Disorders 185
Cutaneous Disorders 189
Genitourinary Disorders 190
Laryngological and Respiratory Dis-
orders 190
Gynecological and Puerperal Dis-
orders 191
Constitutional Disorders 192
Surgical Disorders 193
Chlorides in Urine 194
Saline Solution 194
Preparation 194
Physiological Action and Uses 194
Modes of Administration 195
(1 ) Saline Enteroclysis 195
(2) Saline Hypodermoclysis 197
(3) Intravenous Saline Infusion . 198
PAGE
Sodium, Saline Solution, Modes of Ad-
ministration (continued).
(4) Intraperitoneal Saline Infu-
sion 199
Contraindications 199
Other Solutions 199
Dawson's Solution 200
Locke's Solution 2(1)
Ringer-Locke Solution 200
Fleig's Solution 200
H. M. Adier's Solution 200
Fischer's Solution 200
Spigelia 200
Preparations and Doses 201
Physiological Action 20'
Poisoning by Spigelia 201
Therapeutic Uses 201
Spinal Anesthesia 201
Physiological Action 202
Technique 203
Solutions Used 203
Site of Injection 204
Syringe and Needle 205
Preliminary Narcotization 206
Associated Local Anesthesia 206
Induction and Management of Spinal
Anesthesia 206
After-treatment 208
Indications and Advantages of Spinal
Anesthesia 209
Contraindications 211
Technical Difficulties, Complications,
and Sequelae 212
Position af the Patient 212
Breaking of the Needle 212
Lack of Anesthesia 212
Dosage 212
Circulatory Depression 212
Respiratory Depression 213
Early After-effects 213
Nausea and Vomiting 213
Headache 213
Backache 213
Postoperative Pain 213
Albuminuria 214
Remote After-effects 214
Injury to Nervous Tissue 214
Neurotic Symptoms 214
Mortality . . .'. 214
Sacral Anesthesia 216
Spinal Cord, Diseases of 217
General Considerations 217
Infantile Paralysis; Polioencephalo-
myelitis 217
Synonyms 217
Definition 217
Symptoms 218
Poliomyelitic Form 220
Landry's Form 221
Bulbar Form 221
Encephalitic Form 221
Ataxic Form 221
Polyneuritic Form 221
Meningitic Form 221
Abortive Form 222
Diagnosis 222
Etiology 224
CONTENTS.
IX
PAGE
Spinal Cord, Diseases of, Infantile Pa-
ralysis, Polioencephalomyelitis (con-
tinued).
Pathology 225
Prognosis 225
Prophylaxis 226
Treatment 227
Operative Treatment 229
Tenotomy and Myotomy 230
Tendon Shortening 230
Tendon Lengthening 230
Tenodesis 230
Extra-articular Silk Ligaments . 230
Intra-articular Silk Ligaments . . 230
Arthrodesis 230
Articular Transposition 231
Astragalectomy 231
Nerve Anastomosis 231
Tendon Transplantation on Ten-
don 231
Tendon Transplantation to Peri-
osteum 231
Elongation of Short Tendons
by Means of Silk Sutures . . 231
Myelitis 231
Synonyms 231
Definition 231
Symptoms 232
Diagnosis -^^
Etiology 234
Pathology 235
Prognosis 236
Treatment 236
Amyotrophic Lateral Sclerosis 237
Definition 237
Symptoms 237
Diagnosis 238
Etiology 238
Pathology 238
Prognosis 239
Treatment 239
Primary Lateral Sclerosis 239
Synonyms 239
Definition 239
Symptoms 239
Diagnosis 240
Etiology 240
Pathology 240
Prognosis 240
Treatment 241
Landry's Paralysis 242
Synonyms 242
Definition 242
Symptoms 242
Diagnosis 243
Etiology 243
Pathology 244
Prognosis 244
Treatment ■ ■ 244
Hereditary Ataxia 245
Synonyms 245
Definition 245
Symptoms 245
Diagnosis 246
Etiology 246
Pathology 247
Prognosis 247
PAGE
Spinal Cord, Diseases of, Hereditary
Ataxia (continued).
Treatment 247
Ataxic Paraplegia 248
Synonyms 248
Definition 248
Symptoms 248
Diagnosis 248
Etiology 248
Pathology 249
Prognosis 249
Treatment 249
Syringomyelia 249
Definition 249
Symptoms 249
Diagnosis 251
Etiology 252
Pathology 252
Prognosis 253
Treatment 253
Spinal Cord and Nerves, Injuries and
Surgery of 254
Nerves, Injuries of 254
Subcutaneous Nerve Injuries 254
Concussion 254
Contusion 254
Pressure Paralysis 254
Stretching and Laceration 254
Displacement 255
Treatment 255
Open Nerve Injuries 256
Effects of Nerve Division 256
Process of Repair 256
Symptoms 257
Treatment 258
Nerve Suture or Neurorrhaphy 258
Neuroplasty 259
Nerve-grafting, Anastomosis, or
Implantation 260
Tubulization 260
Peripheral Nerve Injuries 261
Nerve Stretching or Neurectasy . . 263
Nerve Extraction or Avulsion .... 264
Neurectomy 264
Neurotomy 264
Removal of the Gasserian Gang-
lion or Its Sensory Roqt .... 265
Removal of the Cervical Sympa-
thetic 266
Spinal Meningitis. See Meningitis.
Spinal Paralvsis. Infantile. See Spinal
Cord: Infantile Paralysis
Spinal Paralysis, Spastic. See Spinal
Cord : Primary Lateral Scle-
rosis.
Spine, Diseases and Injuries of 266
Tuberculosis of the Spine (Pott's
Disease; Spondylitis) 266
Symptoms and Diagnosis 266
Etiology 269
Treatment 2()9
Plaster-of-Paris Jacket 271
Management of Abscess 273
b'orcilde i\eduction of Deformity . 274
Hibbs's Operation 274
Albee's Bone Grafts 275
X
CONTENTS.
PAGE
Spine, Diseases and Injuries of (con-
tinued).
Scoliosis, or Rotary Lateral Curva-
tures 275
Etiology 276
Diagnosis 276
Pathology 278
Treatment 279
Abbott's Method 280
Spondylitis Deformans ; Bechterew's
Disease 286
Symptoms 286
Treatment 286
Spinal Localization 286
Tumors of the Spinal Cord 287
Symptoms 287
Diagnosis 287
Treatment 287
Sacrococcygeal and Sacroanal Tumors. 287
Congenital Deformities of the Spine . . 290
Myelocele or Rachischisis 290
Spina Bifida 290
Prognosis 291
Treatment 291
Technique of Excision of the
Sac 291
Wounds and Injuries of the Spine . . 293
Gunshot and Punctured Wounds . . . 293
Meningomyelorrhaphy 294
Sprain and Dislocation 294
Symptoms 294
Dislocation of a Vertebra 295
Treatment 295
Bed-sores 295
Treatment 296
Sacroiliac Disease 296
Treatment 296
Disorders of the Coccyx 297
Coccygodynia 297
Laminectomy 297
Spine, Dislocation of. See Dislocations.
Spirillosis. See Relapsing Fever.
Spirit of Mindererus. See Ammonium.
Splanchnoptosis. See Intestines : Vis-
ceroptosis.
Spleen, Diseases of 298
Functions of the Spleen 298
Anomalies 299
Movable or Wandering Spleen 300
Symptoms 300
Diagnosis 301
Treatment 301
Acute Hyperemia or Congestive En-
larsrement of the Spleen .... 301
Symptoms 302
Treatment 302
Abscess of the Spleen or Acute Sup-
purative Splenitis 302
Symptoms 302
Treatment 303
Rupture of the Spleen 303
Symotoms 303
Treatment 304
Splenomegalv, or Chronic Enlarged
Spleen 304
Syphilitic Splenomegaly 304
Tuberculous Splenomegaly ■ 305
PAGE
Spleen, Diseases of, Splenomegaly, or
Chronic Enlarged Spleen (continued).
Malarial Splenomegaly (Ague
Cake) 305
Thrombotic Splenomegaly 305
Amyloid Spleen 306
Miscellaneous Forms of Spleno-
megaly 306
Treatment 308
Splenic Anemia 308
Symptoms 309
Diagnosis 310
Treatment 311
Gaucher's Splenomegaly 312
Symptoms 312
Treatment 313
Splenomegalic Polycythemia, or Ery-
thremia 313
Symptoms 313
Etiology and Pathology 314
Treatment 314
Perisplenitis : Capsulitis : Capsular
Splenitis 314
Symptoms 314
Treatment 315
Tumors of the Spleen 315
Symptoms 315
Treatment 316
Spleen, Injuries of. See Abdominal
Injuries .
Squill 316
Preparations and Doses 316
Phvsiological Action 317
Poisoning by Squill 317
Treatment of Poisoning 317
Therapeutic Uses 317
Squint. See Strabismus.
St. Anthony's Dance. See Chorea.
St. Anthony's Fire. See Erysipelas.
St. Vitus's Dance. See Chorea.
Staphylorrhaphy. See Surgical Ana-
plasty, or Plastic Surgery :
Cleft Palate.
Status Lymphaticus. See Thymus, Lym-
phaticus, and Mediastinum.
Diseases of.
Sterilization and Disinfection 318
Thermal Sterilization 318
Mechanical Sterilization 320
Chemical Sterilization 320
Practical Uses of Chemical Disin-
fectants 320
Disinfection of Surgeon's Hands. 320
Disinfection of the Operative
Field 321
Sterilization of Surgical Para-
phernalia 321
Disinfection of Bed and Body
Clothing 321
Disinfection of Bath Water 322
Disinfection of Feces, Urine, and
Sputum 322
Disinfection of the Sickroom 322
Disinfection of Passenger Cars . . . 323
Disinfection of Books 323
Stillingia 323
Preparations and Doses . . = 323
CONTENTS.
XI
PAGE
Stillingia (continued).
Physiological Action 323
Therapeutic Uses 324
Stokes-Adams Disease. See Heart and
Pericardium : Heart-block.
Stomach Cancer of 324
Etiology 324
Symptomatology and Diagnosis 324
Laboratory Diagnosis 326
X-ray Examination 328
Treatment 329
Stomach, Diseases of 330
Gastric Neuroses 330
Synonyms 330
General Considerations 330
Neurotic Secretory Conditions 330
Hyperacidity 330
Etiology 330
Symptoms 330
Diagnosis 331
Prognosis 331
Treatment 331
Subacidity and .\nacidity 333
Etiology 333
Symptoms 333
Diagnosis 333
Prognosis 333
Treatment 333
Heterochylia 335
Treatment 335
Gastromyxorrhea 335
Etiology 335
Symptoms 335
Diagnosis 335
Treatment 335
Neurotic Sensory Disturbances 336
Hyperesthesia Gastrica 336
Etiology 336
Symptoms 336
Diagnosis 336
Treatment 336
Gastralgia Nervosa 337
Etiology 337
Symptoms 337
Diagnosis 337
Treatment 337
Neurasthenia Gastrica 338
Polysymptomatic Neurosis or Nerv-
ous Dyspepsia 338
Etiology 338
Symptoms 338
Diagnosis 339
Prognosis 339
Treatment 339
Bulimia 340
Parorexia 34;)
Polyphagia 340
Akoria 341
Gastralgokcnosis 341
Anorexia Nervosa 341
Sitophobia 341
Disturbances of Gastric Motility 341
Myasthenia Gastrica and Gastric
Atony 341
Etiology 341
Symptoms and Diagnosis 342
Prognosis 343
PAGE
Stomach, Diseases of, Disturbances of
Gastric Motility, Myasthenia Gastrica
and Gastric Atony {continued).
Treatment 343
Secondary Gastric Dilatation 344
Etiology ■ 344
Symptoms 345
Diagnosis 345
Prognosis 346
Treatment 346
Acute Postoperative Dilatation of
the Stomach and Duo-
denum 346
Etiology 346
Symptoms and Diagnosis 346
Prognosis 347
Treatment 348
Gastropolyasthenia 349
Symptoms and Etiology 349
Diagnosis 350
Prognosis 350
Treatment 350
Cardiospasm 350
Etiology 350
Symptoms 351
Diagnosis 351
Prognosis 351
Treatment 351
Gastrospasm ( Pseudo Hour-glass
Contraction) 352
Diagnosis 352
Treatment 352
Pylorospasm 352
Etiology 352
Symptoms 352
Diagnosis 352
Treatment 352
Nervous Hypermotility 353
Etiology 353
Symptoms 353
Diagnosis 353
Prognosis 353
Treatment 353
Regurgitations 354
Symptoms 354
Prognosis 354
Treatment 354
Merycism 354
Symptoms 354
Treatment 354
Eructatio Nervosa (Aerophagia) .. 355
Symptoms 355
Diagnosis 355
Treatment 355
Singultus Gastrica Nervosa (Hic-
cough ) 355
Vomitus Nervosus 355
Varieties 355
Symptoms 356
liiagnosis 356
Treatment 356
Pneumatosis 357
Symptoms and Diagnosis 357
Treatment 357
Peristaltic Unrest 357
Symptoms 357
Diagnosis 357
Xll
CONTENTS.
PAGE
Stomach, Diseases of. Disturbances of
Gastric Motility, Peristaltic Unrest
(continued).
Treatment 357
Antiperistaltic Unrest, 358
Pyloric incontinence 358
Symptoms and Diagnosis 358
Treatment 358
Duodenal Regurgitation Due to I'"atty
Foods 358
Symptoms 358
Diagnosis 3^8
Treatment 359
Acute Gastritis 359
Acute Catarrhal Gastritis (Simple
Gastritis, Acute Indiges-
tion) 359
Etiology 359
Pathology 359
Symptoms 360
Diagnosis 360
Treatment 361
Acute Suppurative Gastritis (Phleg-
monous Gastritis, Gastric
Abscess ) 362
Etiology 362
Pathology 362
Symptoms 362
Diagnosis 363
Treatment 363
Infectious Gastritis 363
Toxic Gastritis 363
Etiology 363
Pathology 363
Symptoms 363
Diagnosis 364
Treatment 364
Antidotes 364
Chronic Gastritis 364
Varieties 364
Etiology 365
Pathology 365
Symptoms 366
Complications 367
Diagnosis 367
Gastric Neuroses 367
Gastric Ulcer 368
Gastric Cancer 368
Amyloid Degeneration of the
Stomach 368
Prognosis 368
Treatment 368
Surgical 373
Gastric and Duodenal Ulcer 373
Etiology 373
Pathology 373
Symptoms 374
Special Features of Duodenal
Ulcer 3/6
Diagnosis 377
Differential Diagnosis 378
Gastralgia 378
Carcinoma 378
Hyperchlorhydria and Gastrosuc-
corrhea 37S
Hemorrhagic and Other Forms of
Gastritis 379
PAGE
Stomach, Diseases of. Gastric and Duod-
enal Ulcer, Differential Diagnosis (con-
tinued).
Pylorospasm 379
Appendicitis 379
Hyperemesis of Pregnancy 380
Uremia 380
Biliary Conditions 380
Renal' Colic 380
Arteriosclerosis 381
Spinal and Other Diseases 381
Post-ulcer Conditions 381
Prognosis 381
Prophylaxis 382
Treatment 382
Diet 382
Medicinal Treatment 385
Special Treatment of Symptoms . 387
Sippy's Treatment 388
Surgical Treatment 388
Syphilis of the Stomach 391
Pathology 391
Symptoms and Diagnosis 391
Treatment 392
Tuberculosis of the Stomach 392
Etiology 392
Pathology 392
S3-mptoms and Diagnosis 393
Treatment 393
Pseudomembranous Gastritis 394
Benign Tumors of the Stomach 394
Pathology 394
Adenomata 394
Papillomata 394
Myomata and Fibromyomata .... 394
Lipomata 394
Myxomata 394
Lymphadenomata 394
Retention Cysts 395
Gastroliths and Foreign Bodies . . 395
Hypertrophy of the Pylorus 395
Symptoms and Diagnosis 395
Treatment 396
Stomach, Injuries and Surgical Diseases
of. See Abdomen. Surgery
of, and Abdominal Injuries.
Stomatitis. See Mouth, Diseases of.
Stovaine 396
Physiological Action 397
Poisoning 397
Therapeutics 397
Strabismus 398
Definition 398
Symptoms 398
Varieties 400
Diagnosis 401
Prognosis 493
Treatment ' 403
After-treatment 406
Stramonium 406
Preparations and Doses 406
Physiological Action 407
Therapeutic Uses 407
Strontium 407
Preparations and Doses 407
Physiological Action 407
Therapeutics 408
CONTENTS.
Xlll
'page
Strontium, Therapeutics (continued).
Acute Rheumatism and Constitu-
tional Disorders 408
Nephritis 408
Cardiovascular Disorders 409
Gastrointestinal Disorders 409
Nervous Disorders 409
Cutaneous Disorders 409
Strophanthus 409
Preparations and Doses 409
Physiological Action 410
Untoward Effects and Poisoning 411
Therapeutics 411
Struma. See Goiter.
Strychnine. See Nux Vomica.
Stye. See Eyelids, Diseases of : Hor-
deolum.
Stypticin. See Cotarnine.
Styptol. See Cotarnine.
Subphrenic Abscess. See Liver, Dis-
eases of.
Suggestion-therapy ; Psychotherapy ;
Hypnotherapy (Hypnotism). 414
Psychotherapy 414
Psychotherapeutic Technique 415
Hypnotherapy ("Hypnotism") 418
Technique 419
Therapeusis 420
Sulphonal 421
Modes of Administration 421
Physiological Action 422
Contraindications 422
Untoward Effects and Poisoning .... 422
Acute Sulphonal Poisoning 423
Treatment of Acute Sulphonal Pois-
oning 423
Chronic Sulphonal Poisoning 424
Treatment of Chronic Sulphonal
Poisoning 425
Therapeutics 425
Sulphur 426
Preparations and Doses 427
Physiological Action 427
Untoward Effects and Poisoning 428
Treatment 42<S
Therapeutics 428
Gastrointestinal and Constitutional
Disorders 428
Respiratory Disorders 429
Chlorosis 430
Cutaneous Disorders 430
As Insecticide 431
Sulphuric Acid 431
Preparations and Doses 431
Physiological Action 431
Treatment of Poisoning 431
Tlierapeutic Uses 432
Sulphurous Acid 432
Action and Uses 432
Sumbul 433
Preparations and Doses 433
Physiological Action 433
Therapeutic Uses 433
Sunstroke. See Heat Exhaustion.
Suprarenal Capsules. Duscases of. See
Adrenals, Diseases of.
PAGE
Suprarenal Organotherapy. See Animal
Extracts.
Surgical Anaplasty, or Plastic Surgery.. 433
General Considerations 433
General Technique 434
Deformities of the Lips 434
Varieties 434
Median Harelip 434
Simple Unilateral Harelio 434
Unilateral Harelip with Fissure
of the Bony Parts 434
Simple Bilateral Harelip 434
Complicated Bilateral Harelip .... 434
Treatment 435
After-treatment and Complica-
tions 435
Hypertrophy of the Lips 437
Deformities Due to Injury 437
Treatment 437
Everted Lip 437
Inverted Lip 438
Excision of Labial Cancers 438
Formation of the Lower Lip after
Complete Excision 438
Restoration of the Upper Lip 439
Macrostoma (Large Mouth ) 439
Treatment 439
Microstoma (Congenital Atresia Oris). 439
Treatment 439
Cleft Palate 439
Treatment 439
Staphylorrhaphy 440
Uranoplasty 440
After-treatment 441
Rhinoplasty 442
Indian Method 442
Italian Method 442
Reduction of Hump-nose (Aquiline
Nose) 443
Stenosis of the Nose 443
Paraffin Injections (Hydrocarbon Pro-
thesis) 443
Plastic Surgery of the Ear (Oto-
plasty) 443
Outstanding Ears 443
Abnormally Enlarged Ear (Macro-
tia) 444
Repair of Clefts and Fissure of the
Lobule 444
Enlarged Lobule 444
Elongated Lobule 444
Shortened Lobule 444
Adherent and Undeveloped L(jl)u!c . 444
.Sweat-glands, Diseases of the 444
Anhidrosis 444
Treatment 444
Hyperidrosis, or Excessive Sweatin.u . 445
Treatment 445
Bromidrosis 446
Treatment 446
Chromidrosis, or Colored Sweat 447
Treatment 448
Tumors of the Sweat-glands 448
Treatment ' 448
Svcosis. See Hair, Diseases of.
Syni])le])haron. .See Eyelids.
Synovitis. Sec Joints.
XIV
CONTENTS.
PAGE
Syphilis 44H
Etiology and Symptoms 448
Incubation Period of Syphilis 449
Specific Micro-organism of Syphilis. 449
Primary Local Changes 450
The Initial Lesion, or Chancre 452
Varieties of Induration 453
Diagnosis of Chancre 454
Loss of Tissue in Chancre 454
Secretion of Chancre 455
Comparative Frequency of Chancre
and Chancroid 455
Complications of Chancre 455
Mixed Chancre 456
Phagedenic Chancre 456
Infectious Secretions in Syphilis
and Infection 456
Modes of Contagion 457
Duration of Chancre 45(S
Number of Chancres 458
General Infection, Constitutional, or
Secondary Syphilis 458
Diagnosis 458
Constitutional Syphilis 458
Wassermann Test 458
Sources of Fallacy 458
General Adenopathy 459
The Roseola 459
Syphilitic Prodromes 459
Pharyngofaucial Infiltration 460
The Papular Syphilide 460
Syphilitic Alopecia 460
Syphilis of the Nails 460
Pustules, Vesicles, and Precocious
Skin-lesions 460
Special Mucous Lesions 460
Visceral involvement 461
Early Ocular Syphilis 461
Early Osseous Symptoms 461
Earlv Nerve Involvement in Syph-
ilis 461
Late Syphilis, Sequelar or So-called
Tertiary Syphilis 462
The Tubercular Syphilide (Gummy
Infiltration) 462
The Gumma 463
Late, or Sequelar, Nerve and
Brain Syphilis 463
Syphilides 464
Prognosis 465
Curability of Syphilis 466
When May a Syphilitic Marry? 466
Congenital Syphilis 466
Acquired Syphilis in Children 466
Syphilis Hereditaria Tarda 467
Lesions of Congenital Syphilis . . . 467
Treatment 468
New Remedies 471
Salvarsan 471
Method 473
Technique 473
Local Treatment of Chancre 473
Syringomyelia. See Spinal Cord, Dis-
eases of.
Tabes Dorsal is 474
Definition 474
PAGE
Talies Dorsalis (continued).
Varieties 474
Symptoms 475
Symptomatic Analysis 477
The Reflexes 477
Pupillary Symptoms 478
Optic Atrophy 479
Ocular-muscle Palsies 479
Ataxia 479
Tabetic Crises 480
Cardiac Crises 481
Sensory Symptoms 481
Trophic Symptoms 481
Vesical, Rectal, and Sexual
Symptoms 482
Special Senses 483
Diagnosis 483
Etiology 484
Pathology 486
Complications 488
Prognosis 488
Treatment 489
Tachycardia. See Heart : Frequent
Pulse.
Talipes. See Orthopedic Surgery.
Tamarind 496
Action and Uses 496
Tannic Acid 496
Preparations and Doses 497
Physiological Action 497
Therapeutic Uses 498
Tansy 499
Preparations and Doses 499
Physiological Action 499
Poisoning by Tansy 499
Treatment of Poisoning 499
Therapeutic LTses 499
Tape-worm. See Parasites, Disease Due
to.
Tar 499
Preparations and Doses 500
Physiological Action 500
Poisoning by Tar 500
Treatment 501
Therapeutics 501
AfYcctions of Mucous Membranes. 501
External Uses 501
Lysol 502
Poisoning by Lysol 502
Therapeutics 502
Pixol 503
Taraxacum 503
Preparations and Doses 503
Physiological Action 503
Therapeutic Uses 503
Tartar Emetic. See Antimony.
Telangiectasis. See Blood-vessels, Tum-
ors of.
Tendons, Bursse, and Fasciae, Diseases
of 504
Diseases of the Tendons 504
Acute Tenosynovitis 504
Symptoms 504
Palmar Abscess 504
Felon, or Whitlow 504
Treatment 504
CONTENTS.
XV
PAGE
Tendons, Bursae, and Fasciae, Diseases of,
Diseases of the Tendons (continued).
Chronic Tenosynovitis, or Thecitis.. 50^)
Treatment 505
Injuries of tendons. Displacement or
Dislocation 506
Treatment 507
Rupture 507
Treatment 507
Wounds of Tendons 507
Treatment 508
Diseases of the Bursse 503
Acute Bursitis 508
Treatment 508
Chronic Bursitis 508
Housemaid's Knee 509
Treatment 509
Bunion 509
Treatment 509
Ganglion 510
Treatment 510
Contraction of Tendons and Fascia . . 510
Dupuytren's Contracture 510
Treatment 510
Trigger-finger 511
Treatment 511
Tendon Transplantation 511
Tetanus 512
■ Synonyms • • 512
Definition 512
Symptoms 512
Diagnosis 514
Etiology 515
Bacteriology 517
Pathology 518
Prognosis 518
Treatment 519
Prophylaxis 525
Theobromine. See Diuretin.
Theocine 527
Physiological Action 527
Therapeutic Uses 527
Thermic Fever. See Heat Exhaustion
and Thermic Fever.
Thiocol 5?7
Preparations and Doses 528
Physiological Action 528
Therapeutic Uses 528
Thiosinamine 528
Physiological Action 528
Untoward Effects and Poisoning 529
Therapeutics 529
Thomsen's Disease. See Muscles : Myo-
tonia Congenita.
Thoracentesis. See Chest, Injuries and
Surgical Disorders of.
Thoracic Duct, Injuries of. See Chest,
Injuries and Surgical Dis-
orders of.
Thoracoplasty. See Chest, Injuries and
Surgical Disorders of.
Thoractomy. See Chest, Injuries and
Surgical Disorders of.
Thorax, Wounds and Injuries of. See
Chest, Injuries and Surgical
Disorders of.
Thorium. See X-rays and Padii'.ri.
PAGE
Thread-worms. See Parasites : Oxyuris
Vermicularis.
Thrombosis. See Vascular System, Sur-
gical Diseases of.
Thrush. See Mouth, Lips, and Jaws :
Parasitic Stomatitis.
Thymol 531
Physiological Action 531
Untoward Effects and Poisoning .... 532
Treatment of Thymol Poisoning . . . 532
Therapeutics 532
Internal and Systemic Uses 532
Local Uses 533
Thymus, Lymphatics, and Mediastinum,
Diseases of 533
Functions of the Thymus 533
Functions of the Lymphatics 533
Anomalies of the Thymus and Lym-
phatics 534
Diseases of the Thymus 534
Enlargement of the Thymus and
Lymphatics 535
Status Thymicolymphaticus 535
Symptoms 535
Thymic Stridor 535
Thymic xA.sthma 535
Thymic Death 535
Thymic Symptoms 536
Lymphatic Symptoms 537
Pathogenesis 538
Treatment 538
Thymectomy Technique 539
Prevention of Paroxysms 540
Diseases of the Lymphatics 540
Lymphadenitis 540
Lymphangitis 541
Symptoms 541
Diagnosis 541
Etiology 542
Treatment 542
Lymphangiectasia ; Lymphangioma . 542
Symptoms 543
Etiology 543
Treatment 544
Tumors of the Lympliatic System . . 544
Treatment 544
Glandular Fever 545
Symptoms 545
Etiology 545
Treatment 546
Mediastinum, Diseases of the 546
Acute and Chronic Mediastinitis .... 546
Symptoms 547
Acute Mediastinitis 547
Chronic Mediastinitis 547
Abscess of the Mediastinum .... 547
Tuberculous Mediastinal Lym-
phadenitis 548
Tuberculosis of the Bronchial
Glands 548
Diagnosis 549
Treatment 550
Tumors of the Mediastinum 551
Treatment 552
Th\roi(I Gland, Diseases of 552
Functions 552
Hypothyroidia 552
XVI
CONTENTS.
PAGE
Thyroid Gland, Diseases of, Hypothy-
roidia {continued) .
Symptoms 552
Diagnosis 554
Etiology 554
Pathogenesis 555
Treatment 555
Myxedema, or Progressive Hypothy-
roidia ' 555
Definition 556
Symptoms 556
Diagnosis 558
Etiology 558
Treatment 558
Surgical Disorders of the Thyroid Ap-
paratus 559
Injuries 559
Treatment 560
Surger>' of the Thyroid 560
Indications 560
Operative Precautions 561
Operative Technique 562
Thyroid Therapy. See Animal Extracts :
Thyroid Gland.
Thyroidism. See Animal Extracts :
Thyroid Gland.
Thyroiditis. See Goiter.
Thyrotomy. See Larynx, Diseases and
Surgery of.
Tic Douloureux. See Nerves, Peripheral,
Diseases of.
Tinea. See Parasites, Diseases Due to.
Tinea Favosa, Tonsurans, Trichophy-
tina. .See Hair, Diseases of.
Tinea Nodosa. See Piedra.
Tinnitus Aurium. See Internal Ear. Dis-
orders of.
Tobacco 563
Physiological Action 563
Acute Poisoning 563
Chronic Poisoning 563
Treatment of Acute Poisonine 564
Toe, Hammer-. See Orthopedic Surgery.
Toe-nails, Ingrowine. See Nails, Dis-
eases and Injury of.
Tongue, Diseases of 564
Tongue-tie, or Ankyloglossia 564
Treatment 564
Lingual Paoillitis 564
Treatment 565
Parenchymatous Glossitis 565
Symptoms 565
Treatment 565
Chronic Glossitis 565
Svmptoms 565
Treatment 565
Leucoplakia 566
Treatment 566
Eczema of the Tongue 566
Treatment 566
Ulceration of the Tongue 566
Simple Ulcer 566
Syphilitic Ulcer 566
Tuberculous Ulcer 567
Cancerous Ulcer 567
Treatment 567
Tumors of the Tongue 567
PAGE
Tongue, Diseases of. Tumors of the
Tongue {continued) .
Treatment 567
Cancer of the Tongue 567
Symptoms 567
Etiology ■ . 568
Prognosis 568
Treatment 568
Butlin's Technique 568
Whitehead's Technique 569
Kocher's Technique 569
After-treatment 569
Injuries of the Tongue 570
Treatment 570
Tongue-tie. See Tongue, Diseases of.
Tonsils. See Pharynx and Tonsils, Dis-
eases of.
Torticollis. See Muscles, Diseases of.
Toxemia. See Wounds, Septic.
Toxic Foods, or Ptomaine Poisoning .... 570
Meat Poisoning 570
Bacillus Enteritidis 570
Bacillus Botulinus 571
Bacillus Proteus 571
Bacteria of Diseased Meat . . 571
Symptoms 571
Fish Poisoning 572
Symptoms 572
Shellfish Poisoning 572
Symptoms 573
Milk. Cream and Cheese Poisoning . 573
Symptoms 573
Mushroom Poisoning 573
Symptoms 574
Treatment of Food Poisoning 574
Grain and Vegetable Poisoning .... 575
Ergot 575
Chicken-pea 575
Sprouting Potatoes 575
Treatment 575
Pellagra, or Maidism 575
Pathology 576
Symptoms 576
Treatment 576
Trachoma. See Conjunctiva. Diseases
of.
Transfusion. See Venesection and
Transfusion.
Traumatic Neuroses. See Vascular Sys-
tem, Disorders of.
Trematodes. See Parasites, Diseases
Due to.
Tremors 577
Senile Tremor 578
Hysterical Tremor 578
Hereditary or Family Tremor 578
Toxic Tremor 578
Infantile Tremor 578
Intention or \'olitional Tremor . . 578
Etiology and Pathogenesis 579
Treatment 579
Paralysis .A.gitans (Parkinson's Dis-
ease; Shaking Palsy) 580
Symptoms 580
Diagnosis 582
Etiology, Pathogenesis, and Path-
ology 582
CONTENTS.
xvii
PAGE
Tremors, Paralysis Agitans (Parkinson's
Disease; Shaking Palsy) (continued).
Treatment 583
Multiple Sclerosis 585
Synonyms 585
Definition 585
Symptoms 585
Diagnosis 586
Etiology 586
Pathology 587
Prognosis 587
Treatment 587
Trichocephalus Dispar. See Parasites,
Diseases Due to.
Trichophytosis 588
Symptoms 588
Etiology 588
Prognosis 588
Treatment 588
Trigger Finger. See Tendons, Bursse
and Fascise, Diseases of.
Trional 589
Physiological Action 589
Poisoning by Trional 589
Treatment 589
Therapeutic Uses 590
Tropacocaine 590
Physiological Action 590
Untoward Symptoms 590
Therapeutic Uses 590
Trypanosomiasis, or Sleeping Sickness. 591
Symptoms 591
Diagnosis • • 591
Prophylaxis 591
Treatment 592
Tuberculosis, Acute 592
Acute Miliary Tuberculosis 593
Symptoms and Diagnosis 593
General or Typhoid Form 593
Pulmonary Form 594
Meningeal Form 594
Diagnosis 595
Pathology 595
Treatment 595
Acute Pneumonic Phthisis 596
Symptoms 596
Treatment 596
Tuberculosis, Chronic Pulmonary 597
Symptomatology 597
Loss of Strength 597
Indigestion 597
Anorexia 598
Anemia 598
Autonomic Disturbances 598
Lowered Blood-pressure 598
Increased Pulse Frequency 598
Fever 598
Cough 598
Expectoration 598
Hemoptysis 598
Hoarseness 599
Pain 599
Night-sweats 599
Emaciation 599
Dyspnea 599
Diarrhea 599
Neuritis 599
PAGE
Tuberculosis, Chronic Pulmonary,Symp-
tomatologv (continued).
Psychical Changes 599
Physical Examination 599
Inspection 599
Palpation 601
Percussion 601
Auscultation 603
X-ray Examination 606
The Blood 606
Sputum : Microscopic Examination
of 607
Diagnosis 608
Differential Diagnosis 609
Etiology and Pathogenesis 609
Pathology 611
Prognosis 612
Treatment 613
Fresh Air 613
Rest 614
Exercise 614
Respiratory Exercises 615
Diet 615
Clothing ■ • . 616
Bathing 616
Chest Compress 617
Tuberculins and Sera 617
Iodine 619
Creosote and its Derivatives 620
Arsenic and its Compounds 620
Calcium 620
Thyroid Gland 620
Nuclein 620
Cinnamic Acid 621
Mercury 621
Strychnine 621
Ichthyol 621
Camphor 621
Digitalis 621
Nitroglycerin 621
Quinine 621
Urea 622
Iron 622
Other Drugs 622
Surgical Treatment 622
Artificial Pneumothorax : 622
Chondrotomy 623
Extra-plcural Thoracoplasty 623
Inhalations 623
Treatment of Symptoms 623
Fever 623
Night-sweats 623
Cough 623
Hemoptysis 623
Prophylaxis 623
Tuberculosis of the Serous Membranes
and Skin 625
Mescntric Tuberculosis or Tabes
Mesenterica 625
Symptoms 625
Diagnosis 625
Prognosis 626
Treatment 626
Tuberculosis of the Myocardium 626
Treatment 626
Tul)crculosis of the Skin 626
Scrofuloderma 626
XVlll
CONTENTS.
PAGE
Tuberculosis of the Serous Membranes
and Skin, Tuberculosis of the Skin,
Scrofuloderma {c(»iliiiucd }.
Symptoms 626
Etiology and Pathogenesis 626
Treatment 627
True Tuberculosis or Tul)erculosis
Cutis 627
Treatment 627
Tuberculosis Verruca Cutis 627
Symptoms 627
Treatment 627
Lupus Vulgaris 627
Symptoms 628
Diagnosis 628
Etiology and Pathology 628
Prognosis 628
Treatment 629
Lupus Erythematosus 630
Symptoms 630
Etiology 631
Treatment 631
Turpentine (Terebene; Terpin Hy-
drate ) 632
Preparations and Doses 632
Physiological Action 633
Untoward Effects and Poisoning 633
Treatment of Poisoning 633
Therapeutics 633
Twilight Sleep. See Scopolamine.
Typhlitis. See Appendicitis.
Typhoid Fever 635
Symptoms 635
Varieties of Typhoid Fever 637
The Temperature 637
Chills 638
The Skin 638
Bed-sores 639
The Digestive System 639
The Stomach 639
The Intestines 639
Meteorism 639
Pain 639
The Rectum 640
The Abdominal Organs 640
The Gall-bladder 640
The Spleen 640
The Respiratory System 640
The Circulatory System 640
Blood-pressure 640
The Nervous System 640
The Genitourinary System 641
The Reproductive Organs 641
Complications 641
Perforation 642
Diagnosis 644
The Bordet-Gengou Reaction 645
The Ophhalmic Reaction in Ty-
phoid 646
Isolation of Typhoid Bacilli from
Body Fluids 646
Etiology 647
Pathology 649
Histology 650
The Blood in Typhoid Fever 650
Prognosis 651
Age 651
PAGE
Typhoid Fever, Prognosis (continued) .
Habits 651
Severity of Infection 651
Complications 651
Per f oration 65 1
Relapse 651
Treatment 651
1. Diet and General Management . . . 652
2. Hydrotherai)y 654
3. Medicinal Treatment 655
4. Vaccine and Serum Treatment . . 656
5. Treatment of Complications .... 656
Treatment of Convalescence 657
The Public Health Aspect of Typhoid
Fever 657
Purification of Water 658
Filtration 658
Slow Sand Filters 658
Mechanical Filters 659
Chlorine Gas 660
Flies ih Tj'phoid P'ever 660
Prophyla.xis 661
Typhoid Vaccination 663
Paratyphoid Fever 663
Symptoms 663
Complications 664
Diagnosis 664
Treatment 664
Typhoid Fever in Infancy 664
Typhoid Fever in Early Childhood . . 665
Typhoid Fever in Later Childhood . . 665
Typhus Fever 665
Definition 665
Symptoms 665
Brill's Disease 666
Diagnosis 666
Etiology and Pathologv 667
Prognosis 667
Prophylaxis 668
Treatment 668
Ulcers and Varicose Ulcers. See Vas-
cular System, Surgical Dis-
eases of.
Uremia 668
Symptoms 669
Acute Uremia 669
Chronic Uremia 669
Diagnosis 670
Etiology 671
Treatment 671
Urea, Determination of 672
Specific Gravity Method 672
Sodium Hypobromite Method 672
Davy's Method 673
Benedict's Method 673
Folin's Method 673
Marshall's Method 674
Ureters. See Kidneys and Ureters.
Diseases of.
Ureters and Bladder, Examination of.
Cystoscopy 675
Varieties of Cystoscope 675
Preparation of the Cystoscope for
Use 675
Preparation of the Patient 676
General Anesthesia 676
CONTENTS.
XIX
PAGE
Ureters and Bladder, Examination of,
Cystoscope (continued).
Technique of Cystoscopy 676
Uses of Cystoscopy 677
Ureteral Catheterizaion 678
Urinary Segregation 678
Urethane 679
Physiological Effects 679
Poisoning by Urethane 679
Treatment of Poisoning 679
Therapeutic Uses 679
Urethra. See Urinary and General Sys-
tems, Surgical Diseases of.
Urinalysis. See Index under titles of
various abnormal conditions
of Urine : Albuminuria. Lac-
tosuria, Tyrosinuria, etc.
Urinary and Genital Systems, Surgical
Diseases of 679
Diseases of the Urethra 679
Anomalies of the Urethra 679
Congenital Occlusion 679
Congenital Stricture 679
Urethral Pouches 679
Epispadias 680
Treatment 680
Hypospadias 680
Treatment 680
Injuries of the Urethra 681
Rupture of the Urethra 681
Symptoms 681
Treatment 682
Foreign Bodies and Calculi in the
Urethra 683
Symptoms 683
Diagnosis 683
Treatment 683
Gonorrhea 684
Definition 684
Symptoms 684
Acute Gonococcal Urethritis . . . 684
Chronic Gonococcal Urethritis . 685
Diagnosis 685
Complications 686
Prophylaxis 686
Abortive Treatment 687
Repressive Treatment 687
Treatment of Chronic Gonorrhea . 691
Gonorrhea in Women 692
Urethra 693
Treatment 693
Vagina and Vulva 693
Symptoms 693
Treatment 693
Periurethritis and Urethral Fistula . 694
Treatment 694
Cowpcritis 695
Treatment 695
Non-gonorrheal Urethritis 695
Symptoms 695
Diagnosis 695
Treatment 695
Stricture of the Urethra 695
Varieties 696
Symptoms 696
Diagnosis 696
Etiology_ 697
PAGE
Urinary and Genital Systems, Surgical
Diseases of, Diseases of the Urethra,
Stricture of the Urethra {continued) .
Treatment 697
Dilatation 697
Urethrotomy 698
Internal Urethrotomy 698
External Urethrotomy 699
A. With a Guide — Syme's
Operation 699
B. Without a Guide— Peri-
neal Section 699
Urethral, Urinary, or Catheter
Fever 699
Symptoms and Etiology 699
Acute Urinary Septicemia 699
Chronic Urinary Septicemia .... 700
Treatment '. 700
Chancroid 700
Definition 700
Symptoms 700
Etiology 701
Diagnosis 701
Complications 701
Treatment 702
Tumors of the Urethra 702
Treatment 703
Diseases of the Prostate 703
Anomalies 703
Injuries of the Prostate 703
Etiology 703
Treatment 703
Foreign Bodies and Calculi in the
Prostate 704
Symptoms 704
Etiology 704
Diagnosis 704
Treatment 704
Acute Prostatitis 704
Symptoms 704
Etiology 705
Treatment 705
Chronic Prostatitis 706
Symntoms 706
Diagnosis 706
Etiology 707
Treatment 707
Abscess of the Prostate 708
A Symptoms 708
Etiology 7aS
Treatment 708
Prostatorrhea 70S
Symptoms 708
Etiology 709
Treatment 709
Atrophy of the Prostate 709
Hypertrophy of the Prostate 7t)9
Symptoms 709
Diagnosis 710
Etiology and Pathology 711
Prognosis 712
Treatment 712
Operatiye Treatment 713
Vasectomy 713
Castration 714
Galvanocauterization 714
A. Bottini's Operation .... 714
XX
CONTEXTS.
PAGE
'Urinary and Genital Systems, Surgical
Diseases of, Diseases of the prostate,
Hypertrophy of the prostate, Operative
Treatment, Galvanocauterization (con-
tinued).
B. Chetwood's Operation . . 714
Cystostomy 714
Prostatectomy 715
Suprapubic Prostatectomy . . . 715
Perineal Prostatectomy . . . 715
A. Median 715
B. Extra-urethral 715
Tuberculosis of the Prostate 716
Symptoms ' 716
Diagnosis 716
Etiology 716
Treatment 716
Tumors of the Prostate 717
Cysts 717
Carcinoma 717
Symptoms 717
Diagnosis 717
Treatment 717
Sarcoma 718
Treatment 718
Diseases of the Bladder 718
Anomalies 718
Treatment 718
Exstrophy of the Bladder 718
Treatment 718
Retention of Urine 719
Definition 719
Symptoms 719
Etiology 719
Complications and Sequelae 720
Treatment 720
Rupture of the Bladder 722
Symptoms and Diagnosis 722
Treatment 723
Cystocele 723
Treatment 723
Foreign Bodies in the Bladder .... 723
Symptoms 724
Diagnosis 724
Treatment 724
Vesical Calculus 724
Symptoms 725
Diagnosis 726
Treatment 726
Lithotomy 727
Technique of Litholapaxy 727
Technique of Lithotomy 728
Perineal Lithotomy, Lateral . . 729
Median .......' 730
Suprapubic Lithotomy 730
Tuberculosis of the Bladder 731
Symptoms 731
Diagnosis 732
Treatment 732
Tumors of the Bladder 733
Varieties 733
Symptoms 733
Etiology and Pathology 733
Diagnosis 734
Prognosis 734
Treatment 734
Ulcer of the Bladder 735
PAGE
LIrinary and Genital Sysems, Surgical
Diseases of, Diseases of the I'laddcr,
Ulcer of the Blader (continued).
Diagnosis 736
Treatment 736
Varicose Veins of the Bladder 736
Treatment 736
Fistula of the Bladder 736
Treatment 736
Diseases of the Seminal Vesicles 736
Anomalies 736
Wounds 736
Concretions 737
Treatment 737
Acute Seminal Vesiculitis 737
Symptoms 737
Diagnosis 737
Treatment 737
Chronic Seminal Vesiculitis 737
Symptoms 737
Diagnosis 737
Treatment 737
Tuberculosis of the Seminal Vesicles. 738
Symptoms 738
Diagnosis 738
Treatment 738
Tumors 738
Diseases of the Spermatic Cord 738
Anomalies 738
Wounds 738
Treatment 738
Torsion 739
Inflammation 739
Treatment 739
Hydrocele of the Cord 739
Treatment 739
Solid Tumors 739
Urobilinuria 740
Urticaria 740
Definition 740
Synonyms 740
Symptoms 740
Urticaria Papulosa (Lichen Urti-
catus) 740
Urticaria Bullosa 740
Urticaria Nodosa (U. Tuberosa ) .. 740
Urticaria Hemorrhagica 740
Urticaria Intermittens 740
L^rticaria Perstans 740
Urticaria Pigmentosa 741
Diagnosis 741
Etiology 741
Pathology 741
Prognosis 741
Treatment 741
Litems, Diseases of 742
Malformations 742
Rudimentary Uterus 742
Abscess of the Uterus 742
Embryological Malformations 742
One-horned Uterus 742
Two-horned Uterus 742
Double Uterus 742
Two-chambered Uterus 742
Fetal Uterus 743
Infantile Uterus 743
Puerile Uterus 743
CONTENTS.
XXI
PAGE
Uterus, Diseases of, Embryological Mal-
formations (continued).
Puerile Cervix 743
Symptoms and Diagnosis 743
Treatment 743
Stenosis of the Cervix 744
Symptoms 744
Diagnosis 744
Prognosis 744
Treatment 744
Laceration of the Cervix 745
Symptoms and Diagnosis 745
Pathology 745
Treatment 745
Displacements of the Uterus 746
Etiology 746
Anteflexion and Anteversion 748
Symptoms 748
Diagnosis 748
Treatment 748
Retroflexion and Retroversion 749
Symptoms 749
Diagnosis 749
Treatment 749
Prolapse and Procidentia 750
Symptoms 750
Diagnosis 750
Treatment 750
Inversion of the Uterus 751
Symptoms and Diagnosis 751
Prognosis 752
Treatment 752
Tuberculosis of Uterus and Adnexa . . 753
Tuberculosis of the Body of Uterus . 753
Symptoms and Diagnosis 753
Treatment 753
Tuberculosis of the Cervix 753
Symptoms 753
Prognosis 753
Treatment 753
Tumors of the Uterus 753
Myoma of the Uterus 753
Symptoms 754
Diagnosis 754
Etiology 755
Pathology 755
Prognosis 755
Treatment 755
Carcinoma of the Uterus 757
Cervix Uteri 757
Squamous-cell Carcinoma 757
Cylindrical-cell Carcinoma ... 75S
Symptoms and Diagnosis 758
Prognosis 759
Treatment 759
Corpus Uteri 760
Symptoms 760
Diagnosis 760
Prognosis 760
Treatment 761
Dcciduoma Malignum 761
Treatment 761
Sarcoma of the Uterus 761
Sarcoma of the Cervix 761
Symptoms and Diagnosis 761
Sarcoma of the Endometrium .... 761
Interstitial Sarcoma 762
PAGE
Uterus, Diseases of. Tumors of the
Uterus, Sarcoma of the Uterus, Inter-
stitial Sarcoma {continued).
Symptoms 762
Diagnosis 762
Treatment 762
Uva Ursi 762
Preparations and Doses 762
Physiological Action 762
Therapeutic Uses 762
Uveal Disorders. See Iris, Ciliary Body
and Choroid.
Uvula. See Pharynx and Tonsils, Dis-
eases of.
Vaccination. See Varioloid and Vac-
cination.
Vagina and Vulva, Diseases of 763
Acute Vulvovaginitis 763
Symptoms 763
Etiology 763
Treatment 764
Chronic Vulvitis 764
Follicular Vulvitis 764
Glandular Vulvitis 765
Treatment 765
Gonorrheal Vulvovaginitis 765
Diagnosis 765
Etiology 766
Treatment 766
Infectious Vaginitis 766
Tuberculous Vulvovaginitis 766
Symptoms 766
Treatment 767
Diphtheritic Vulvovaginitis 767
Treatment 767
Puerperal Vulvovaginitis 768
Treatment 768
Eczematous Vulvovaginitis 768
Etiology 768
Treatment 768
Leucorrhea 769
Symptoms 769
Etiology 769
Treatment 769
Atrophy of the Vagina and Vulva . . . 770
Hypertrophy of the Vagina and Vulva 770
Treatment 770
Prolapse of the Vagina 771
Treatment 771
Vaginismus 771
Treatment 771
Vaginal Fistulae 772
Treatment 772
Mayo's Technique 772
Tumors of the Vagina and Vulva .... 773
Benign 773
Malignant 773
Hcrnije 773
Treatment 774
Cysts 774
Treatment 774
Hematomata 774
Treatment 775
Miscellaneous Growths 775
Treatment 775
Fungous Growths 775
xxn
CONTENTS.
PAGE
Vagina and Vulva, Diseases of, Tumors
of the Vagina and Vulva. Fungous
Growths (coiilinucd) .
Treatment 775
Foreign Bodies 775
Treatment 775
Malignant Growths 775
Treatment 776
Congenital Absence 776
Treatment 776
Adhesions 777
Acquired Occlusion 777
Varicocele 777
Treatment 777
Parasitic Vulvitis 777
Treatment 777
Kraurosis Vulva; 778
Treatment 778
Pruritus Vulvae 778
Treatment 778
Vaginoperineal Injuries. See Pregnancy
and Parturition, Disorders of.
Vagotonia and Sympatheticotonia 780
Symptoms 780
Pathology 780
Treatment 780
Valerian 780
Preparations and Doses 780
Physiological Action 780
Therapeutics 781
Valvular Diseases of the Heart. See
Endocardium and Heart,
Diseases of.
Varicella 781
Definition ■ • 781
Symptoms 781
Diagnosis 781
Etiology 782
Prognosis 782
Treatment 782
Varicocele. See Penis and Testicles,
Diseases and Injuries of.
Variola (Smallpo.x) 782
Definition 782
Symptoms 782
Special Forms 783
Diagnosis 783
Scarlatina 783
Measles 783
Typhoid Fever 783
Influenza 783
Meningitis 783
Cerebrospinal Meningitis 783
Etiology 783
Prophylaxis 784
Treatment 784
Varioloid and Vaccination 785
Varioloid 785
Vaccination 785
Technique 785
Prevention of Infection 786
Acupuncture Method 786
Symptoms 787
Revaccination 787
Efficacy of Vaccination 787
Vascular System, Disorders of 788
Raynaud's Disease 788
PAGE
Vascular System, Disorders of, Raynaud's
Disease (continued).
Symptoms 788
Etiology and Pathogenesis 788
Treatment 789
Erythromelalgia 790
Symptoms 790
Etiology and Pathology 790
Treatment 790
Acroparesthesia 791
Symptoms 791
Etiology and Pathology 791
Pathogenesis 791
Treatment 792
Vasomotor Ataxia 792
Symptoms 792
Diagnosis 793
Treatment 793
Traumatic Neuroses 794
Pathogenesis 794
Symptomatology 795
Vascular System, Surgical Diseases of . 797
Acute Arteritis 797
Symptoms 797
Treatment 797
Phlebitis 797
Symptoms 797
Etiology 797
Prognosis 797
Treatment 798
Venous Varix, or Varicose Veins 798
Symptoms 798
Etiology 798
Pathology 798
Treatment 798
Palliative Measures 798
Radical Treatment 798
Hemorrhage 799
Symptoms 799
Treatment 799
Injuries and Wounds of Vessels 800
A. Arteries 800
Contusion 800
Rupture 800
Punctured Wounds 800
Incised Wounds 800
B. Veins 800
Treatment 800
Secondary Hemorrhage 801
Venous Hemorrhage 801
Thrombosis 801
Varieties 801
Symptoms 801
Etiology 801
Pathology 802
Treatment 802
Phlegmasia Alba Dolens 802
Symptoms 802
Diagnosis 803
Etiology 803
Pathology 803
Complications 803
Sequelc-e 803
Prognosis 803
Treatment 803
Vasomotor Neuroses. See Vascular Sys-
tem, Disorders of.
CONTENTS.
xxni
PAGE
Veins, Disorders of. See Vascular
System.
Venesection and Blood Transfusion .... 803
Venesection 803
Technique 803
Indications 804
Blood Transfusion 804
Technique 804
Indications 805
Venomous Bites. See Index.
Veratrum 805
Preparations and Doses 805
Physiological Action 805
Untoward Effects and Poisoning 806
Treatment of Poisoning 806
Therapeutics 806
Veronal 807
Physiological Action 807
Poisoning by Veronal 807
Treatment of Poisoning by Veronal . 807
Therapeutic Uses 807
Vitamines 808
Warts. See Skin, Surgical Diseases of...
Water (Hydrotherapy) 809
Reaction . 809
Temperature of Baths 809
Hydrotherapeutic Measures 809
The Cold Pack 809
Evaporation Bath 809
The Cold Bath 810
The Half-bath of Priessnitz 810
The Spray Bath 810
The Ablution or Wet-mit Friction . 810
The Drip Sheet or Sheet Bath 810
Sponging 811
The Oil Rub 811
The Scotch Rub 811
Salt Rub or SaU Glow 811
Ice Rub or Ice Ironing 811
Alcohol Rub 811
Douches 811
Cold Applications 812
Hot Applications 812
Needle Douche or Spray ; Circular
Douche 812
Cold Douche 812
Spinal Douche 812
Alternating Hot and Cold Douches
(Scotch Douche) 812
Head Douches 812
Rain Douche 812
Fan Douche 812
Filiform Douche 812
Perineal Douche 812
Aix Douche 813
Affusions 813
Continuous Baths 813
The Warm Full Bath 813
Prolonged Warm Baths 813
Warm Baths of Short Duration .... 813
The Hot Rath 813
Special Baths 813
The Brand Bath 813
The Turkish Bath 813
The Russian Bath (Diaphoretic) ... 814
Vapor or Sweating Bath 814
PAGE
Water (Hydrotherapy), Special Baths
(cotitinucd) .
Foot-bath 814
Medicated Baths 814
Alkaline Bath 814
Pine-needle Bath 814
Sulphur Bath 814
Packs 814
Cold Wet Pack 814
Hot Wet Pack 814
Dry Hot Pack 814
Compresses 814
Cold Compress 814
Ice Compresses 815
Hot Compresses (Fomentations) ... 815
Weil's Disease. See Liver and Gall-blad-
der : Acute Infectious Jaun-
dice.
Wen. See Skin, Surgical Diseases of.
Whooping-ceugh. See Pertussis.
Wintergreen. See Gaultheria.
Witchhazel. See Hamamelis.
Worms. See Parasites, Diseases Due to.
Wounds, Septic and Sepsis 815
Prophylaxis 815
Commonly Used Antiseptics 815
Sodium Hypochlorite or Dakin-Car-
rel Solution .- . . 816
Daufresne's Technique 816
Wound Excision and Primary Suture . 819
Delayed Primary Suture 820
Secondary Suture 820
General Infections; Sepsis 822
Toxemia or Sapremia 822
Septicemia 823
Pyemia 824
Etiology and Pathology 825
Toxemia or Sapremia 825
Septicemia, Sepsis, Septic Infec-
tion 826
Pyemia 826
Prognosis 826
Treatment 827
Local Measures 827
Dichloramine-T 828
Flavine 830
Brilliant Green 830
Bismuth Iodoform Paste 831
Serums and Vaccines 833
Babcock's Method 833
General Measures 834
Puerperal Sepsis 835
Symptoms 835
Etiology 836
Diagnosis 836
Treatment , 837
Wounds, Venomous. See Wounds and
Stings.
Xanthoma 837
Etiology 837
Pathology 837
Prognosis 838
Treatment 838
Xanthoma Diabeticorum 838
Pathology 838
Prognosis 838
XXIV
CONTEXTS.
PAGE
Xanthoma Diabeticorum (continued).
Treatment 838
X-ravs and Radium 838
X-rays 838
Physiological Action 838
Untoward Effects 839
Therapeutic Dosage 839
Apparatus 839
Estimation of Dosage 840
Filters 841
Therapeutic Uses 841
Diseases which Benefit by X-ray
Stimulation 841
Diseases which Benefit by Reduc-
tion of Tissue Activity .841
Diseases which Benefit by Destruc-
tion of Cells 841
Radium 841
Physiological Action 841
Therapeutic Uses 842
Yaws 843
Synonyms 843
Symptomatologv' 843
The Primary or Prodromal Stage .. 843
The Secondary or Granulomatous
Stage 843
The Tertiary Stage 843
Infection 843
Treatment 843
Prophylaxis 843
Yellow Fever 843
Symptomatology 844
PAGE
Yellow Fever, Symptomatology (con-
tinued).
Fulminant Cases 844
Diagnosis 844
Etiology 845
Pathology and Pathogenesis 845
Prognosis 845
Prophylaxis 845
Treatment 846
Yohimbine 846
Physiological Action 846
Untoward Effects 846
Therapeutic Uses 846
Zinc 847
Preparations and Doses 847
Irritant (Soluble) 847
Mild (Insoluble) 847
Physiological Action 848
Acute Poisoning by Zinc Salts 848
Chronic Poisoning 848
Treatment of Acute Poisoning 849
Therapeutics 849
Gastrointestinal Disorders 849
Respiratory Disorders 849
Nervous Disorders 849
Cutaneous Disorders 850
Catarrhal Disorders 850
Zingiber 850
Preparations and Doses 850
Physiological Action 850
Therapeutic Uses 850
Zona. See Herpes Zoster.
/
SAJOUS'S
ANALYTIC CYCLOPEDIA
of PRACTICAL MEDICINE
R
R H E U M AT I S M. — A group of
affections, sometimes of parasitic
origin, characterized by pain and
swelling of the joints and muscles,
and which may be acute or chronic.
Under this term may be grouped
rheumatic fever, muscular rheuma-
tism, and various joint manifestations
dependent upon specific infections
such as gonorrhea, scarlatina, diph-
tlieria, etc. Of these conditions, the
first three will be considered seriatim
in this article.
Rheumatoid arthritis or, according
to the newer classification of Gold-
thwait, (1) chronic atrophic arthritis,
and (2) chronic hypertrophic ar-
thritis, have been considered in the
article on Joints, Surgical Diseases
OF, in vol. vi.
RHEUMATIC FEVER.
Rheumatic fever {acute or subacute
rheumatism; acute articular rheuma-
tism), is an acute and subacute infec-
tious, febrile disease, characterized
by migratory, multiple artl^ritis, sweat-
ing, and a tendency to complicating
inflammation of the serous membranes
and the fibrous tissues, and to re-
currence.
SYMPTOMS. — Rheumatic fever
rarely presents marked i)rodromal
symptoms, but ordinarily the patient
feels weary and ill for from one to
three days. Occasionally fugitive
pains, sore throat, or otitis media
precede the onset of the disease.
The symptoms of the acute affection
then set in suddenly with chills, which
may be repeated once or twice.
Fever appears and the temperature
rises to 39° or 40° C. (102.2° or
104° F.) ; the pulse and respiration
are accelerated, the tongue furred;
there is no appetite, but thirst is
marked. The urine is scanty, highly
acid, and loaded with urates, which
give it a dark-red color and rapidly
precipitate; the specific gravity of the
urine is high, and it is not rare to ob-
serve albuminuria on the first days of
the disease. Chemical examination
demonstrates that urea as well as
uric acid is present in excessive
quantity. Hemoglobinuria, pepto-
nuria, urobilinuria, and cystinuria
have sometimes been observed.
The skin is covered with abundant
perspiration and numerous sudamina
and miliaria often appear on it. The
sweat is acid and of a peculiar odor.
Simultaneously with the fever the
characteristic signs of rheumatic ar-
thritis appear, generally in the articu-
(1)
RHEUMATISM (LEVISON AND SAJOUS).
lations of the foot or the knee. Fre-
quently the affection begins in the
ankle-joint, and after some days the
process also invades the knee, the
shoulder, the elbow-joint, and the
wrist. Occasionally the affection
begins in the joints of the upper ex-
tremities. This, when it is the case,
ordinarily occurs in persons occupied
in hard bodily work. The larger
joints are most frequently affected,'
but sometimes the small joints of the
fingers and toes are also involved,
especially in children. A single joint
rarely continues to be the seat of
trouble for more than four or five
days ; the affection then more or less
suddenly disappears, commonly dur-
ing the night, and one or more other
joints are attacked in turn. At one
time several joints may be involved
to a varying extent. In very severe
cases almost all joints may be af-
fected simultaneously, and even the
articulations of the jaws, the spine,
and the ribs may be painful and swol-
len. Ordinarily rheumatic fever at-
tacks several articulations, but mon-
articular acute rheumatism has also
been observed.
According to statistics, the locali-
zation of the disease in the different
joints is as follows : Ankle, 27.8 per
cent. ; knee, 17.9 per cent. ; wrist, 9.6
per cent. ; shoulder, 6.2 per cent. ; hip,
4.1 per cent. ; metatarsus, Zj per
cent. ; elbow, 2.2 per cent. ; metacar-
pus, 1.2 per cent.; toes, 0.8 per cent.;
fingers, 0.8 per cent.
Analyzing 100 cases of so-called
"rheumatism," the author found that
these included 44 cases of arthritis
and 3 of muscular rheumatism to
which the term "rheumatism" might
be fairly applicable. Thirty of the
44 patients gave a history of gonor-
rhea. Among the 53 incorrectly
diagnosed cases there were 18 of
syphilis, with a positive Wassermann,
8 of neuritis, 4 of tuberculosis, 4 of
flat foot, 3 typical cases of pellagra,
2 each of neurasthenia, arterioscle-
rosis, sciatica, and tabes, and 1 each
of chronic nephritis, chronic gas-
tritis, muscular atrophy, malaria, per-
nicious anemia, and myelitis. Deade-
rick (South. Med. Jour., Dec, 1918).
The affected joints are very painful
and swollen ; the overlying skin is
red, hot, tense, and edematous, while
pressure upon it leaves an impression
which remains visible for some time.
Swelling of the joint is caused prin-
cipally by edema of the skin and
ligaments, but occasionally also by
an effusion in the articulation itself.
Upon moving the diseased articula-
tion a crackling sound is sometimes
heard ; this is commonly caused by
the inflammatory changes in the ten-
dons and their synovial membranes.
Moving and even touching the af-
fected joints is very painful to the
patient; in severe cases the pain may
be occasioned by very small commo-
tions, e.g., by walking over the floor
of the sick-room. The pain seems to
be localized in the tendons and the
muscles in the proximity of the joint.
When the patient is induced to keep
completely quiet, slight movements
of the diseased joint may be passively
executed without causing any pain,
whereas the most trifling active
movement is accompanied by ex-
cruciating pain.
The skin over the affected articu-
lation shows increased sensibility to
changes of temperature, but a dimin-
ished sensibility to faradic irritation.
Of diagnostic importance in the
cases in which they are present are
small nodules — "rheumatic nodules"
— 1 to 4 mm, in diameter, generally
RHEUMATISM (LEVISON AND SAJOUS).
not tender, appearing- in areas where
bones underlie the skin or in the
synovial sheaths of tendons. These
occur especially in children. They
may disappear rapidly or only after
some months. Fibrosis may occur in
them.
The temperature of the patient is
elevated in proportion to the number
of the affected articulations ; in un-
complicated cases it seldom rises
above 39° to 40° C. (102.2° to
104° F.), but it may also oscillate be-
tween 38° and 39° C. (100.4° and
102.2° F.). Acid sweats often take
place consentaneously with remis-
sions in the temperature.
One of the earliest and most con-
stant and obscure symptoms of rheu-
matism in children is a persistent low
fever, dropping- daily to normal, occa-
sionally below, and seldom going
above 100° F. The child usually feels
well, looks well, and the condition is
only accidentally discovered. The
first suggestion occurs after an illness
during which time there has been ele-
vation of temperature, but as the
other symptoms clear up the tempera-
ture chart reveals the persistence of
a small amount of unaccountable
fever. A complete examination may
disclose no symptoms other than
slight acceleration of the heart on
exertion. One naturally thinks of tu-
berculosis, but gets a negative von
Pirquet. Poynton considers this tem-
perature an important diagnostic
symptom of very early rheumatic in-
fection. J. A. Colliver (Arch, of
Pediat, Jan., 1914).
The pulse is soft and usually above
100 in rate. Evidences of toxemia,
such as coated tongue, constipation,
and splenic enlargement are likely to
be observed.
The duration of rheumatic fever
varies from some days to several
weeks or even months ; it is liable to
remissions and exacerbations, and,
especially when the patient leaves the
bed or the sick-room too soon, exacer-
bations are frequently observed. In
some cases, the fever having- de-
clined, one or more joints remain
swollen and painful for a long time.
A critical decline of the temperature
is rarely observed.
When the joint swellings subside
the cuticle commonly cracks and
peels off in small scales. As many
red blood-corpuscles become de-
stroyed during a severe attack of
rheumatic fever, the patients get
pale and weary. The anemia often
continues for a long- period after re-
covery from the disease itself. Leu-
cocytosis, up to a maximum of 20,000,
has been observed to develop early in
the rheumatic attack and to decline
with equal rapidity during- con-
valescence.
Some authors refer to a larval form
of rheumatic fever, characterized by
neuralgia of, e.g., the trifacial or the
sciatic nerve, accompanied by high
fever, but without involvement of the
joints, and yielding rapidly to the use
of salicylates. During an epidemic of
rheumatic fever endocarditis or peri-
carditis with high fever is sometimes
observed in patients who do not suf-
fer from any involvement of the ar-
ticulations ; such cases have been
denominated polyarthritis rhcumatica
sine arthritide.
COMPLICATIONS.— These are
very frequent and aft'ect especially
the heart and the nervous system.
Verrucose and even ulcerative endo-
carditis is observed in a large pro-
portion of cases, especially when the
fever is high and many joints are
affected. Pericarditis is not quite so
frequently observed. Endocarditis
RHEUMATISM (LEVISON AND SAJOUS).
has been estimated to occur in about
20 per cent, of all cases, and pericar-
ditis in about 14 per cent. ; but these
proportions vary, the epidemics of
rheumatic fever differing very much
in regard to severity and frequency
of complications. Bosanquet, in a
series of 450 cases, noted endocar-
ditis in 28 per cent, of the males and
33 per cent, of the females, and some
observers place the incidence of endo-
carditis at 50 to 75 per cent. The
likelihood of endocarditis is increased
by youth of the patient and where
preceding attacks have occurred.
The mitral valve is that oftenest in-
volved. Pericarditis is observed in
the majority of the cases ending
fatally, and may be fibrinous, sero-
fibrinous, or purulent.
In almost all cases some dilatation
of the right heart due to toxic myo-
carditis, is found. A murmur heard
over the heart is thus often not due
to endocarditis, but to cardiac dilata-
tion (or to anemia). In consequence
of endocarditis, the myocardium may
also be affected either by simple ex-
tension through contiguity or by em-
boli. A condition of complete car-
diac inflammation or pancarditis may
occur. Slight weakening of the myo-
cardium may be manifested by gen-
eral weakness, attacks of pain, or
tachycardia. The symptoms of endo-
carditis and pericarditis are discussed
elsewhere in this work.
D. B. Lees describes the cardiac
complications of rheumatism in child-
hood as follows : The first indication
of endocarditis is a systolic murmur
at the apex. Often the second sound
becomes doubled, after a time, the
doubling being heard only in the
apex region, different from the dupli-
cated pulmonary sound of advanced
mitral stenosis. The first element of
the second sound always remains
sharp and short as long as it is
audible at all. The second element
may be substituted by a short blow-
ing, early diastolic or middiastolic
murmur. At a later stage there may
be at the apex a presystolic murmur,
followed by a longer and louder sys-
tolic. This presystolic murmur is
blowing in character, usually short,
common in children after a rheumatic
attack, and generally accompanied
by evidences of great dilatation of the
heart. Care should be taken not to
consider a soft, double sound at the
base an evidence of commencing
aortic disease. It is often the first
indication of pericarditis.
While in adults the disease spends
itself chiefly upon the joints, in the
child it has a much greater tendency
to attack the heart; the joint involve-
ment in the latter is often so slight
as to be overlooked, yet the cardiac
• involvement may be severe. Ton-
sillitis is in the child a frequent pre-
cursor of rheumatism, while chorea
is at times a sequel. Cardiac involve-
ment might come w^ithin 24 hours of
the beginning of the rheumatic at-
tack and its discovery depends upon
a careful routine study of the heart.
The mitral lesions thus caused are
capable of complete recovery, though
the aortic lesions practically never
recover. D. Riesman (Trans. Phila.
Co. Med. Soc; Med. Rec, Apr. 16,
1921J.
Rheumatism in the child can be
discovered at the age of 5 years, pos-
sibly earlier. Earlier signs of the
disease are an incessant restlessness,
a constantly accelerated pulse rate,
often reaching 100 or over, and very
frequently a constant fever of a little
over 99° F. (37.2° C.) to a little more
than 100° F. (37.8° C). That such
a rise of temperature and of pulse
rate are not due to nervous excite-
RHEUMATISM (LEVISON AND SAJOUS).
merit is proved by their being found
for years in the same child and
always at about the same level for
any one child. This observation is
based upon over SOOO temperature
r-ecords. M. H. Williams (Lancet,
June 19, 1915).
Very dangerous and rather fre-
quent are the complications involving-
the brain. In some cases the symp-
toms are only caused by hyperpy-
rexia; when the temperature rises to
41° or 42° C. (105.8° or 107.6° F.)
or even to 43° C. (109.4° F.), when
sweating is very profuse, and signs
of endocarditis develop, there is im-
minent danger of cerebral rheuma-
tism. When symptoms of meningitis
occur, they are not necessarily due
to actual inflammation of the menin-
ges, but may be caused by hemor-
rhage, edema, or hyperemia. A
uremic condition of the blood may
also lead to cerebral symptoms.
Cerebral rheumatism may manifest
itself in different ways : —
1. When it is foudroyant the pa-
tient is suddenly seized with agita-
tion ; although previously unable to
make a movement without extreme
pain, he now leaves the bed and
walks about, speaks and cries, and
suddenly collapses and dies. The
temperature ranges from 42° to 43°
C. (107.6° to 109.4° F.) and often
even exceeds these levels after death.
2. An acute form of cerebral rheu-
matism is more often observed.
There is likewise high fever; the
delirium commences more quietly,
but after a little time the patient be-
comes agitated, and may have epi-
leptiform seizures, these symptoms
being followed by profound coma and
commonly by death. In a few in-
stances cerebral symptoms are ob-
served with a temperature, not ex-
ceeding 39° C. (102.2° F.). The
pulse rate is proportionate to the
fever and may reach 120 to 140 per
minute. The duration of this form of
cerebral rheumatism is commonly two
or three days, but may be ten to
twelve days. Recovery is rare.
3. The subacute or chronic form of
cerebral rheumatism appears in the
later stages of rheumatic fever and
is ordinarily of a melancholic and
stuporous character. The patients
refuse to speak, even to eat, and are
often harassed with hallucinations.
They may remain in this condition
for months, but the affection ordi-
narily ends in recovery.
Spinal complications have been
described, but their existence hasi not
been proved beyond doubt. The
peripheral nerves may also be affected
during rheumatic fever, but far
oftener such disturbances occur some
time later, as a sequel. Chorea, mul-
tiple neuritis, neuralgia, and sciatica
have been witnessed by trustworthy
observers. During an epidemic
Steiner saw 35 cases with disease of
the peripheral nerves — often in the
distribution of a single nerve — char-
acterized by pain and tenderness.
In 8 of these, swelling of the joints
was not important, though there was
tenderness. Steiner claims that the
nerve pains were due to a perineuritis.^
Complications involving the re-
spiratory organs are not so frequently
observed. Coryza, tracheobronchitis,
and laryngitis may be seen during
the prodromal stage. During the
acute stage the lungs may be affected
either by edema or, more rarely, by
pneumonia, particularly of the migra-
tory form. Rather frequently the
pleurae are involved. A\'hcn the peri-
cardium is affected tlic disease tends
6 RHEUMATISM (LEVISON AND SAJOUS).
to spread to the left pleura, which The affection of the joints them-
consequently is more frequently at- selves may be complicated by sup-
tacked than the right. Rheumatic purative inflammation leading- to
pleuritis is characterized by abun- opening of the articulation and to
dant fibrinous membranes, but scanty pyemia, or ending in ankylosis,
exudation of serous fluid ; it develops In occasional instances involve-
very rapidly and gives rise to the ment of the eye occurs w^ith rheu-
ordinary physical signs of pleurisy matic fever, being manifest in con-
in a very marked degree. Its dura- junctival congestion or, rarely, iritis,
tion varies from three to eight days. Some of the diseases of the eye as-
Sometimes the right pleura is ,at- cribed to the more chronic types of
tacked while left-sided pleuritis is rheumatism are: iritis and episcleritis
undergoing resolution. Peritonitis is — which are very frequent — as well
a rare complication which may be as deep scleritis, keratitis, orbital eel-
associated with serous pleuritis. lulitis, optic neuritis, choroiditis.
Tonsillitis is a frequent manifesta- ocular palsy, glaucoma, and opacity
tion of the prodromal stage, and its of the vitreous (Woodruff),
bacteria are now considered impor- Chronic nephritis and mental dis-
tant etiological factors in the develop- ease are among the possible ultimate
ment of rheumatic fever. sequela of rheumatic fever.
Albuminuria is almost constantly In children cardiac involvement is
observed; acute nephritis and hema- relatively more frequent and impor-
turia may occur. Anuria is a rare tant than in adults and generally
complication ; it may be caused either leads to a fatal termination, promptly
by acute nephritis or by emboli from or ultimately. The onset is generally
an endocarditis. abrupt, sometimes with convulsions.
Cystitis, hydrocele, and orchitis High fever sets in and anemia rapidly
have been mentioned by some as becomes pronounced. Joint involve-
occasional complications. ment is comparatively a less striking
The cutaneous complications in- feature than in adults,
elude roseola, urticaria, erythema DIAGNOSIS. — The diagnosis is
multiforme, herpes facialis, and, more usually easy, the migratory arthritis,
rarely, erysipelas, gangrene, purpura fever, acid sweats, and infrequency
with ecchymotic spots or bullse con- of involvement of joints such as the
taining a serous, bloody, or purulent sternoclavicular, temporomandibular,
fluid. Hemorrhagic complications intervertebral, and sacroiliac being
have also been observed in the form characteristic. The thyroid is often
of melena and metrorrhagia. found enlarged in children, owing ac-
The muscles in the proximity of cording to Sajous, to a defensive re-
the aff'ected joints are always painful action of this organ.
and swollen ; this may also be ob- Enlargement of the thyroid gland
served in the case of muscles more claimed to be a diagnostic sign of
distant from the diseased joints. In rheumatism in children In some
cases it preceded all other manifest
rare instances true inflammation atid
abscesses have been observed in the
muscles. the -rheumatic chain, and in others
signs of the disease; in others it ap-
abscesses have been observed in the peared as the fourth or fifth link in
RHEUMATISM (LEVISON AND SAJOUS). 7
still it was found to persist along The arthritides accompanying such
with established chronic endocarditis conditions as scarlet fever and cere-
after all other rheumatic manifesta- ^rospinal meningitis are commonly
tions had disappeared. J. R. Clemens . ' • ^ vi
(Arch, of Pediat., May, 1910). ^^ septic type, With accompanymg
In children the cardiac phenomena constitutional symptoms of sepsis.
are paramount, but compression of Acutc Osteomyelitis. — This condi-
the left lung by the pericardial exu- ^j^j^ jg characterized by grave con-
date may cause physical signs of g^itutional evidences of sepsis, and
pneumonia in this lung to occur. The . . . . r ^.^
^ , . • ,• 1 ■ 1 v.„ Jo +v,« by especial involvement of the epi-
most characteristic skin lesion is the .^ t" . , ,
so-called rheumatic nodule, which physis and shaft of one of ^ the bones
histologically resembles the mihary articulating at the afifected joint. The
nodule in the heart muscle. These upper extremity of the tibia and the
are usually few, occasionally enor- j^^^^^. ^^^ ^^ ^j^^ femur are the locali-
xnous in number and are found ^ies most frequently affected.
chiefly about the elbows, backs of the ^ , ,• , r
wrists, near the ankles, and over the Gout.—Gout may be discerned from
buttocks. D. Riesman (Trans. Phila. rheumatic fever by the fact that it is
Co. Med. Soc; Med. Rec, Apr. 16, never accompanied by fever of the
1921). same intensity as prevails in the lat-
Secondary Infectious Arthritis. — ter disease; by its predilection for the
Rheumatic fever may be confounded great toe ; by the possible presence of
with the secondary multiple inflam- uratic deposits in various parts of the
mations of joints observed in acute body, and by its special occurrence in
infectious diseases such as scarlatina, the male sex.
cerebrospinal meningitis, puerperal ETIOLOGY. — Rheumatic fever
infection, rubeola, diphtheria, etc., tends to attack especially young
and also with the pseudorheumatic adults, approximately three-fourths
affections of gonorrhea, syphilis, and of the cases occurring between the
tuberculosis. In all these affections asfes of 15 and 35. Infants are almost
the symptoms of the major disorder safe, but no age is entirely exempt,
are present and facilitate diagnosis. The disease attains its greatest fre-
In gonococcal arthritis there is a quency between the ages of 20 and
history of gonorrhea; the joint in- 25 years.
volvement is generally monarticular, Both sexes are liable to the dis-
affecting especially the knee and ease ; among adults, men are perhaps
wrist, and is extremely severe ; con- somewhat more frequently affected
stitutional symptoms are less marked, than women, Init that is probably on
and the joint lesions tend to persist account of their greater exposure to
after the febrile stage. the inclemency of the weather. Be-
In syphilitic pseudorheumatism the tween the ages of 10 and 15 the dis-
joint-symptoms are less intense than ease is somewhat more common in
in rheumatic fever; are not migra- the female than the male sex. An
tory ; show nocturnal exacerbation of hereditary predisposition seems to
pain, and yield rapidly to specific exist in some families. Cheadle,
treatment (though pain is relieved, among 32 consecutive cases, found
as it is in other forms, by the local evidence of heredity in 70 per cent.,
application of methyl salicylate). and, if chorea and erythema be re-
8
RHEUMATISM (LEVISON AND SAJOUS).
garded as forms of rheumatism, in
93 per cent.
Exposure to wet, cold, and abrupt
temperature changes predisposes to
rheumatic fever, which is therefore
commonest in coachmen, laborers,
sailors, and, among women, in washer-
women and domestics. The dis-
ease is frequent only in temperate
climates, and is not observed in
tropics or in the arctic regions.
The exciting cause of the disease is
now considered to be unquestionably
an infection. This view is supported
by the facts that it occurs epidem-
ically, as well as endemically, and
that during epidemics the cases ac-
cumulate in some houses, whereas
other houses are quite spared. Me-
teorological conditions do not appear
to be of great influence on the epi-
demics of rheumatic fever, which
have been observed as well in the
sum.mer as in winter, during dry as
well as wet seasons. The epidemics
vary greatly in intensity and dura-
tion, and occur at irregular intervals.
It is still doubtful whether rheu-
matic fever is the product of one
specific micro-organism or whether
different species act simultaneously
or independently as pathogenic fac-
tors. At all events, the clinical and
pathological features of the disease
clearly show its infectious origin.
That streptococci may produce it has
been shown by a number of ob-
servers, who have not only recovered
these organisms from the blood and
joints of patients, but, like Schloss
and Foster, reproduced lesions sug-
gestive of rheumatic fever in lower
animals. The organism considered
to be most likely the actual exciting
factor, or at least that operative in
the largest proportion of cases, is the
Diplococcus rheiintaticus isolated by
Poynton and Paine, who found it not
only in the joints and blood, but in
rheumatic nodules and the urine, and
with it produced arthritis, valvular
lesions, etc., in rabbits. This organ-
ism is distinguishable neither mor-
phologically, culturally, nor by the
opsonic and agglutinin reactions
(Tunnicliffe) from the Streptococcus
pyogenes, but only by the production of
rheumatic lesions in animals. Poyn-
ton and Paine consider their diplo-
coccus the "only bacterial cause" of
acute rheumatism. Cole believes it
imwarranted, however, to recognize
a distinct variety of streptococcus
because of its property of produc-
ing arthritis and endocarditis, as he
has provoked similar lesions in ani-
mals with streptococci from various
sources. This is in accord with the
present increasing disinclination of
bacteriologists to believe that sharp
lines separate similar organisms into
distinct varieties, and is supported by
the observations of Rosenow (1914)
that the affinity of cocci freshly
isolated from the joints in rheumatism
for the articulations, endocardium,
and often also myocardium and vol-
untarv muscles, which tends to dis-
appear on cultivation, may be re-
stored by passage through animals,
and that other strains of streptococci
under certain conditions may be
made to acquire the properties of
the strains obtained from rheumatic
cases.
Five cases have been published to
date in which the tuberculous nature
of an articular rheumatism has been
established beyond question. The
writer's patient was a girl of 19 who
had had glandular tuberculosis as a
child, and later a tuberculous process
in the lower jaw compelling total re-
RHEUMATISM (LEVISON AND SAJOUS).
section. Twelve days after the op-
eration, moderate fever developed
with multiple acute swelling of joints.
The patient died in a few months
from amyloids. Autopsy showed tub-
erculous nodules in the synovial mem-
branes. Melchior (Mitteil. a. d. Grenzg-.
d. Med. u. Chir., xxii, Nu. 3, 1911).
Cultures of exudate aspirated from
the joints in acute rheumatic arthritis
proved uniformly sterile. Non-hemo-
lytic streptococci were recovered in
blood cultures from less than 10 per
cent, of rheumatic fever patients.
Similar streptococci were recovered
from active endocardial lesions in
only half of the fatal cases. No type
of streptococcus is constantly asso-
ciated with acute rheumatic fever. If
the streptococcus actually is the etio-
logic agent, the infection occurs
through various members of the
viridans group. Swift and Kinsella
(Arch, of Int. Med., Mar., 1917).
Report of an acute case in a girl of
17, with a heart injured by a previous
attack. A general pericarditis with
copious effusion developed, and the
fluid withdrawn by paracentesis showed
numerous minute diplococci, some in
the fluid, many more in leukocytes.
This completely supports the results
of experimentation concerning the
micro-organism of rheumatic fever.
It also indicates that in human rheu-
matic pericarditis with little effusion
but with great thickening of pericar-
dial tissues, the diplococci are shut
in the necrotic areas but imperfectly
destroyed, causing the intractable re-
lapsing cases of childhood. Poynton
(Brit. Med. Jour., Mar. 29, 1919).
As for the portals of entry of rheu-
matic infection, the tonsils demon-
strajjly play an important, if not ex-
clusive, role in this direction. Not
only are the tonsils favorite abodes
of virulent streptococci, and attacks
of sore throat a frequent manifesta-
tion of rheumatism, but ori^anisms
isolated from the tonsils of rheumatic
cases have, with considerable con-
stancy, been observed to induce ar-
thritis and endocarditis when injected
into animals. Permanent cure of a
rheumatic tendency has frequently
followed removal of the tonsils. Ac-
cording to some, the gums, the nasal
mucosa, and the gastrointestinal tract
are also at times sources of infection.
The pleurisy of acute rheumatism
usually yields promptly to the sali-
cylates, but if it is left untreated,
serious lesions may be installed. The
rapid invasion of the pleura, the bi-
lateral involvement, the association
with congestion of the lungs and with
pericarditis without effusion, the com-
plete subsidence without sequels, the
fixity and long duration of the pleural
effusion, its moderate amount, and
the usually mild character of the
pains in the chest are its distinguish-
ing features. J. Mollard and M.
Favre (Lyon med., May, 1917).
Peritonitis, appendicitis, bronchitis,
and pneumonia are sometimes ascrib-
able to rheumatic infection.
Micrococcus rheumaticus takes the
path of least resistance. This may be
an unhealthy throat, absorption from
which frequently gives rise to gen-
eral rheumatic infection, including
peritonitis and appendicitis, directly
through the vascular system. Or it
may be localized in the bronchial
tubes and give rise to pneumonia,
with polyarthritis and endocarditis.
An unhealthy condition of the intes-
tinal wall may excite to activity the
rheumatic agent. Congestion of the
pharynx, palate, and fauces in a child
with a rheumatic family or previous
history, or with a rheumatic facies,
should always be looked on seriously,
and met with local applications of
salicylic acid preparations, together
with sodium bicarbonate, sodium sali-
cylate, potassium chlorate, and aperi-
ents. A 5 per cent, to 10 per cent,
solution of sodium salicylate applied
to the tonsils, palate, and pharynx
protects from further contamination;
a gargle containing 20 to 40 grains
10
RHEUMATISM (LEVISON AND SAJOUS).
(1.3 to 2.6 Gm.) to the ounce (30 c.c.)
is equally efficacious. Decayed teeth
should be filled or extracted, and
the daily use of the tooth-brush and
antiseptic powder should be insisted
on. Inhalation for half an hour, three
times a day, of 10 minims (0.6 c.c.)
of a solution of equal parts of creo-
sote and phenol is the best method
of protecting the pulmonary mucous
membrane. Sodium salicylate, com-
bined with sodium bicarbonate and
rhubarb powder, is by far the best
protective treatment in cases in which
there is any indication of excess of
mucus in the intestine. J. K. Mac-
kenzie (Brit. Med. Jour., June 1,
1912).
A woman of 28 developed subacute
articular rheumatism and endocarditis
five months after an infected abor-
tion. No benefit was procured from
a month or more of the ordinary
measures, including the salicylates,
but after straightening and curetting
the uterus the temperature dropped
to normal and rapid recovery fol-
lowed, signs of mild mitral insuffi-
ciency, however, still persisting. Ar-
ticular rheumatism of puerperal origin
generally settles down in one joint
after a time — the shoulder in the
writer's case — and stays there. Pierra
(Revue mens, de gynec, d'obstet., et
de pediat., Mar., 1914).
PATHOLOGY.— In all cases of
rheumatic fever hyperemia is present
in the joints ; but as these changes are
extremely fugacious it is ordinarily
impossible to demonstrate them at
autopsy. In more advanced cases the
synovia is augrnented and shows mi-
croscopically a great number of poly-
nuclear cells containing globules of
fat, resembling pus-cells. In some
cases the cells are not free, but are
inclosed in a network of fibrin, ap-
pearing to the naked eye as small
flakes. True pus is not found in the
joints except when other infections
have invaded the body consentane-
ously with the specific infection of
rheumatic fever. The synovial mem-
brane of the afifected joints is then
red and swollen, with its capillaries
engorged with blood; the cells of the
synovial membrane tend toward mul-
tiplication, containing 10 to 12 nuclei.
The cartilage is also involved ; its
cells multiply and form oblong cap-
sules containing many secondary
capsules. The macroscopic result of
these alterations is that the cartilage
has lost its natural polish and that
it is finely striated. These patho-
logical changes are common to all
varieties of acute arthritis and are
not characteristic of rheumatic joint
afifection. Mainly because of periar-
ticular involvement, some of the
rheumatic joints, instead of promptly
recovering from the acute process,
mav continue in a condition of sub-
acute or chronic inflammation. The
tendons and even the periosteum may
be attacked, with consequent tender
local thickenings.
The rheumatic alterations of the
endocardium, the pericardium, etc.,
revealed by autopsy present the ordi-
nary signs of an acute inflammation,
but nothing which is characteristic
of rheumatic fever proper. Acute
dilatation of the heart, according to
Lees, is much commoner, even in
slight attacks, than in diphtheria or
influenza. It is, however, far less
dangerous. Although in the rheu-
matic heart there is evidence of fatty
degeneration of the muscle fibers,
with interstitial round-cell foci, the
destruction of the muscle is much
less pronounced than in the diph-
therial heart.
Children are prone to the chronic
or subacute manifestations of rheu-
matism because the chief site of the
RHEUMATISM (LEVISON AND SAJOUS),
11
multiplication of the organism and
the manufacture of the toxins is in
focal lesions outside the blood-
stream, while in adults it is in the
blood itself. The rheumatic nodules
afiford the typical example of local
response to rheumatic infection.
They are usually associated with
grave cardiac mischief, and the more
numerous and the larger they are the
more serious the cardiac involvement.
While present, they prove the per-
sistence of the rheumatic infection.
The lesions found in the heart are
similar in stru"cture to the subcu-
taneous nodules, but their duration is
probably less prolonged. In the meso-
cardium they are found chiefly in the
walls of the left ventricle, especially
near the mitral and aortic valves. In
pericarditis the nodular lesions may
be confined to a small area or scat-
tered all over the pericardium. In
endocarditis the nodules are suben-
dothelial, and are situated mostly at
the upper part of the left ventricle,
especially in the mitral valve. Gos-
sage (Pediatrics, Apr., 1912).
Greater attention should be given
to the various types of acute aneu-
risms and their relations to acute
rheumatic fever. The almost con-
stant presence of some inflammatory
reaction in the ascending limb of the
aorta should be recognized as an as-
sociated conditi®n in this disease.
Klotz (Jour, of Pathology and Bac-
teriology, Oct., 1913).
During the course of rheumatic
fever the blood contains much more
fibrin than normal.
PROGNOSIS.— The prognosis is
rather good as regards life, as very
few cases end fatally (0.3 per cent.).
Usually the disease terminates in two
to six weeks without having caused
permanent injury to the joints in-
volved. Complications, particularly
those involving the heart, are, how-
ever, frequent and often lead to
serious consequences. In some cases
— subacute rheumatic fever — repeated
exacerbations in the joint lesions and
temperature occur before recovery
finally is complete. Hyperpyrexia
and suppurative pericarditis are com-
plications entailing immediate danger,
while endocarditis acts more slowly.
In children the remote prognosis is
always grave, death taking place in
youth or early adult life. The gravid
state also renders the condition more
serious. One attack of rheumatic
fever predisposes to others, and the
ultimate prognosis becomes more
somber in proportion with the per-
sistence of recurrence.
Twenty-three per cent, of acute
articular rlieumatism patients go
through one or more attacks without
any clinical afifection of the heart,
irrespective of the age when first at-
tacked; 22 per cent, develop signs of
carditis in the acute stage, these
signs disappearing during the con-
valescence; 18 to 20 per cent, of the
cases which develop signs of endo-
carditis, not clearing up before pa-
tient leaves the hospital, have no
permanent valvular lesion, the mur-
murs being due to myocarditis, or in-
competence from temporary hyper-
emia of the valves, associated with
dilatation. In 14.5 per cent, of cases
with acute rheumatic endocarditis of
severe type, one or more of the mur-
murs disappear, such murmurs being
due to associated dilatation. Cases
in which the heart is going to recover
completely show signs of such re-
covery within twelve months of the
acute attack, thoug'.i the process may
not be completed till some years
later. Kemp (Quarterly Jour, of
Med., Apr., 1914).
Analysis of 350 fatal cases of
rheumatism. The patients comprised
195 females, 155 males, 250 of them
under the age of 12 years. Rheuma-
tism is at its worst from the sixth to
the twelfth year, and the majority of
deaths occur before the twentieth
year. The percentage of fatal first
12
RHEUMATISM (LEVISON AND -SAJOUS).
attacks in childhood was nearly 23
per cent. In the remaining 100 cases
only 3 deaths were recorded in a
first attack. Pericarditis was found
in 215 of the 250 cases in childhood.
One may expect to detect the friction
sound in at least 80 per cent, of the
cases of recent rheumatic pericar-
ditis; it may be missed because the
pericarditis is localized posteriorly,
very limited in area, or evanescent.
In the 250 fatal cases in childhood,
the mitral valve was damaged in all
^ but 3, the aortic in 102, the tricuspid
in 78, the pulmonary in 6. Among
100 cases in children, 82 died with
evidence of acute carditis. Among
100 older cases, only 9 died of acute
carditis of the childhood type; 14 had
recent endocarditis complicating for-
mer valvular lesions; in 55 the valves
were scarred by old disease, and 22
died of malignant endocarditis. The
usual time for malignant endocarditis
is later childhood, adolescence, and
early adult life. Death from myo-
cardial failure without valvular lesion
occurred in only 3 of the 350 cases.
F. J. Poynton, C. D. S. Agassiz, and
■J. Taylor (Pract, Oct., 1914).
TREATMENT.— In the treatineiit
of rheumatic fever it is of importance
that the patient be placed in a large,
well-ventilated room. He should be
kept in bed, even where the affection
is mild. A flannel nightgown should
be worn, and the patient should sleep
between blankets. The diet should
be limited; during the febrile period
liquid food should alone be given,
with lemonade, carbonated waters,
and milk as beverages. Regularity of
the bowel movements should be
maintained.
Many authors deem it preferable
to commence the treatment by in-
stituting free purgation.
As a specific remedy against the
infection itself, salicylic acid and
combinations containing this drug
have nearly supplanted all others.
Salicylic acid may either be given
pure or in combination with the
alkalies (sodium or strontium salicy-
late). Pure salicylic acid is best tol-
erated when given in capsules each
containing 7j/2 to 15 grains (0.5 to
1 Gm.) ; this dose is to be repeated
fotir, five, or even six times per day,
until the pain is relieved and the tem-
perature falls. When symptoms of
intoxication, viz., ringing in the ears,
nausea, or occasionally, delirium ap-
pear the use of the remedy must be
discontinued for twelve to eighteen
hours, or the dose greatly reduced.
In many cases the pain is very
rapidly subdued by this treatment
and patients who, in the morning
were not able to move, are completely
relieved after a treatment of twelve
hours. In other cases the fever sub-
sides, but the pain and swelling of
one or more joints continue for some
time. Even when all symptoms have
disappeared, it is advisable to con-
tinue the use of salicylic acid for some
time, btit in lesser dose. When the
use of salicylic acid is discontinued
too soon, recurrence is probable.
Many authors prefer the use of
sodium salicylate which is sometimes
given in solution, 1 to 1^ drams (4
to 6 Gm.) or even 2 drams (8 Gm.)
being administered per diem. It has
the same effect on the disease as the
pure acid. By the third day the dose
can generally be reduced to 15 grains
(1 Gm.) every four or five hours.
Other compounds which may be
used are ammonium salicylate, salicin,
and in particular, acetylsalicylic acid
(aspirin) which, being nearly taste-
less, is easily taken with sugar and
water on a spoon or in milk, and is
non-irritating to the stomach, pass-
ing through it unaltered into the in-
RHEUMATISM (LEVISON AND SAJOUS). 13
testine where it is decomposed and passages to a healthy condition.
absorbed in the form of salicylic acid. 1^"^^*^°^ ^"^ thorough cleansing of
the nasal passages, combined with
Inflammation of the throat empha- antiseptic treatment of the nose and
sized as one of the earliest symptoms pharynx, should be a routine item of
of rheumatism and a gargle of 20 antirheumatic treatment; and the
Gni. (5 drams) of sodium salicylate operation of enucleation should be per-
in 1000 Gm. (1 quart) of distilled formed without delay upon all rheu-
water recommended. In the devel- ^^^-^^ children who exhibit chronic en-
oped disease one should endeavor to largement of the tonsils or of the
administer from 6 to 8 Gm. (VA to 2 tonsillar lymphatic glands. W. P. S.
drams) in twenty-four hours to the Branson (Brit. Med. Jour., Nov. 23,
adult; in children 1 Gm. (IS grains) 1912).
per diem if the child is 2 years of j j -i •
^ , , ^ r- /on • ^ -^ The writer recommends daily in-
age or less, and 2 Gm. (30 grains) it . i * o r- /-ic ^.^
.*= ^ -, ', , . , 1, , jections of from 1 to 2 Gm. (15 to
4 or 5. If the drug is not well borne ^ ... r i . xv,^
, , , ,1 ^1 30 grams) of sodium salicylate, ine
in such large doses, these must be ^ '. r n
, - . „ ^ /1T/ 1 1/ solution IS made as iollows: —
decreased 5, 4, or 3 Gm. (1%, 1, or %
drams) until tolerance is produced. Sodium salicylate 5.0 parts.
It should not be given if nephritis Caffeine citrate 0.25 part.
with the presence of casts in the urine Distilled ivater 25.0 parts.
exists, but if the albuminuria is slight q^ ^^-^^^ f^^^^^ 5 ^^ 10 c.c. (1^ to
and there are no casts it may be 2^/^ drams) are given daily. The
given with caution. salicylate must be chemically pure
When the myocardium shows signs ^^^ ^^^ solution kept in the dark,
of being afifected, and the pulse irreg- j^ j^ ^^ special value where medica-
ular, care must be taken not to ^.j^^^ ^^ mouth is not well borne,
depress the heart further. If the p_ y_ Cgj-jiadas (Semana Medica,
endocardium or pericardium are im- -p^^ 23^ 1915).
plicated, the salicylate may be given, t-. ' •. a ^\, a •
^ . , . , , , , The writer recommends the admin-
but It must be withdrawn where there . - v ' 1 ^^ t
. , ,. . , , . r istration of the salicylates by rectum
IS delirium and other signs of cere- . 1 u *t . t
T . or intravenously where the stomach
bral excitement. In pregnancy it • 1 n- ^u
.... is rebellious or the case requires
must be given with caution. Aspirin • 1 .• -ri • 4.
. , rr ■ 1 .1 1- r <. rapid action. The intravenous injec-
is less efficacious than the salicylates, '^ r m * on • /ha ^-^
, , , , , . . ,.-,,, tions are of 10 to 20 grains (0.6 to
and should be given in divided doses 1 o r- \ • oa <. 1 ..• a
- 5' .,- .r • X 1.3 Gm.) in 20 per cent, solution and
up to 1 to 3 Gm. (15 to 45 grains) . / Z ^- • * *
^ , ,. ., given two or three times m twenty-
focn '''rc:n°r"''^'7x/''^.''?r ^ fo"^ hours if necessary. Rectal in-
(0.50 to 1.50 Gm.-7/. to 23 grains) ^^^.^^^ ^^^ ^r.i.rr.A, and as much
also has its uses. If these remedies. or ,q \ k •
r . , J • as 2 drams (8 c.c.) may be given,
in succession do not produce im- •,, 1 c • • r^ \ : *4«^*,„...
, . J with 15 minims (1 c.c.) of tincture
provement, they can be combined . ^ a ■ ^ \ t,^„^c.
^ . . , ' o J- 1- 1 .^ of opium, repeated in twelve hours,
with advantage: Sodium sahcylate, n r \ ^ 4. 1 ^ ,„
^^^ ^ ,. ^ . . . . rtie r- The alkaline treatment may be com-
025 Gm. (4 grains); aspmn, 015 Gm. ^.^^^ ^.^^^ ^^.^^ ^^^^ ^^^.^.^ .^ ^^_ ^^
i2}i grains); pyramidon. 0.15 Gm ^O- grain (0.6 to 1.3 Gm.) doses may
(2y4 grains). In cases complicated ^^ ^.^^^^ ^^^^^ ^^^ ^^^^^ ^j^^^ p^j^^
with nephritis, cupping of the loins, .^ ^^^ .^.^^^^ j^^^ diminished. The
milk diet, and laxatives are indicated. ^^^^ combination internally is am-
Lemoine (Gaz. des pract., vol. xix, monium salicylate, 5 to 10 grains
1912). (0.3 to 0.6 Gm.), with phenacetin, 1
The commonest avenue of rheu- to 2 grains (0.06 to 0.13 Gni.), and
matic infection is the tonsil, and next caffeine citrate, 1 grain (0.06 Gm.)
to it the nose. The first essential of in capsules, every two hours. Bever-
rational treatment of rheumatic in- ley Robinson (Med. Rec, Jan. 1,
fection is restoration of the upper air 1916).
14
RHEUMATISM (LEVISON AND SAJOUS).
The first essential is the thorugh
searching out and removal of all foci
of chronic infection and the prepara-
tion of an autogenous vaccine from
organisms isolated from such foci or
from the urine if foci cannot be
definitely located. The vaccines
should be given in ascending doses,
every week or ten days, adjusting the
dose so as to secure a slight arthritic
reaction. After improvement has ad-
vanced, the intervals between doses
may be lengthened. The treatment
should be continued for a year or
more. M. J. Rowlands (Lancet, Jan.
15, 1916).
Also serviceable where the simple
salicylates are not well borne is salo-
phen, which is gradually decomposed
in the bowel into salicylic acid and
acetylparamidophenol, and may be
given in doses of 15 grains (1 Gm.)
every three hours, preferably in con-
junction with sodium bicarbonate, 10
grains (0.6 Gm.) three times a day
(W. H. Flint). This drug has also
been recommended for use late in the
course of the disease, when the acute
fever has been mastered with salicylic
acid. Oil of wintergreen may also be
substituted for the other salicylates
in doses of 20 minims (1.25 c.c), but
is not unirritating to the stomach.
Salicin. has a bitter taste, is much
less nauseous than sodium salicylate,
and can be conveniently given dis-
solved in hot water. It only yields 43
per cent, of its weight of salicylic
acid, and hence the amount required
is at least double that of sodium sali-
cylate—20 to 30 grains (1.3 to 2 Gm.)
every hour or two hours until 1 ounce
(30 Gm.) has been given, and then
smaller doses according to the cir-
cumstances. Acetylsalicylic acid is
very active and has a marked anal-
gesic effect. It cannot be prescribed
with alkalies, which decompose it,
and hence it is apt to bring on nausea
and vomiting if given continuously.
Methyl salicylate is also very apt to
irritate the gastric mucous membrane,
but in 10- to 20- minim (0.6 to 1.25
c.c.) doses up to 60 or 90 minims
(3.75 to 5.6 c.c.) per day, given in
emulsion, or on sugar, or in milk, it
acts powerfully, and externally ap-
plied it is unrivalled for its analgesic
action. Sodium benzoate has the
same specific effect as the salicylate,
but acts less powerfully. On the
other hand, it is practically non-
poisonous and has no disturbing side-
effects. It can be given in 20-grain
(1.3 Gm.) doses every two or three
hours with satisfactory results in
cases of uncomplicated rheumatic
fever, but its practical usefulness is
merely as a substitute for the more
powerful salicylate, when the latter
cannot be tolerated. Profuse per-
spirations and skin eruptions are in-
conveniences which frequently follow
salicylates. They are also often
deemed to act as heart depressants,
but this is not borne out by exact
observations. With large doses (250
to 400 grains— 17 to 27 Gm.— per
day), such as are sometimes given
with the idea of thoroughly destroy-
ing the infective germ, vomiting fre-
quently occurs, and it is possible not
only to seriously depress the nervous
system, but to bring on a dangerous
condition of acidosis. This can be
prevented, to some extent at least, by
giving about twice the amount of
sodium bicarbonate with each dose
of sodium salicylate, and taking care
at the same time to avoid constipa-
tion. But in an ordinary case of
moderate severity 15 to 20 grains (1
to 1.3 Gm.) of sodium salicylate every
three or four hours form a sufficient
dose. The joint pain and tempera-
ture begin at once to be favorably
affected, the former subsiding in from
twelve to twenty-four hours, and the
latter within forty-eight hours. The
pulse and respiration fall with the
temperature, and the joint effusion
is absorbed in two or three days.
The course of events usually resem-
bles a crisis, though sometimes a
lysis. If the temperature does not
settle satisfactorily each dose may be
RHEUMATISM (LEVISON AND SAJOUS).
15
increased, or one large additional
dose of 40 to 60 grains (2.6 to 3 Gm.)
may be given on one or on several
daj's in succession. Additional ab-
sorption of salicylic acid may be
brought about by applying a dressing
of methyl salicylate on lint to the
affected joints. Where the rheumatic
infection locates itself chiefly in the
fibrous tissues, the condition generally
in time yields to large doses of sali-
cylates, along with free local applica-
tion of methyl salicylate. When these
rheumatic indurations are quite re-
cent, potassium iodide and small blis-
ters exert a marked deobstrucnt effect.
Massage is even more effectual.
Stockman (Pract., Jan., 1912).
The writer nearly always used as-
pirin and sodium salicylate jointly,
administering as mucli as 10 or 15
grains (0.6 to 1 Gm.) of sodium sali-
cylate and 5 to 10 grains (0.3 to 0.6
Gm.) of aspirin every two hours al-
ternately. W. J. Judy (W. Va. Med.
Jour., Aug., 1912).
Sodium salicylate with sodium bi-
carbonate, 1 part of the former with
2 parts of the latter, is a most ef-
fective antirheumatic, if the dose is
gradually increased to a sufficient
extent. If, when vomiting or tinnitus
occurs, the medicine is suspended
for a few hours, the unpleasant symp-
toms will usually pass away, and the
dose can later be raised to a consid-
erably larger amount without causing
their recurrence. In a rheumatic at-
tack it is often desirable to increase
the amount of salicylate to 150 or 200
grains (10 to 13 Gm.) per day, with
double the amount of sodium bicar-
bonate, given in 10 doses. It is im-
portant to prevent constipation, to
keep the urine slightly alkaline and
to stop the drug when vomiting or
other symptoms due to salicylate
occur. Lees (Brit. Med. Jour., Oct.
12, 1912).
The nodes call for intensification of
the treatment. In 1 of 3 cases in
children of 11 and 13, salicylates in-
travenously and by the mouth were
kept up for 7 montiis with slow im-
provement and final recovery, even
the heart functioning normally and
the child increasing 22 pounds in
weight. The nodes, though extremely
numerous, persisted for 3 months. A
girl of 11 years was given orally in 4
months 130 Gm. (4% ounces) of the
salicylate besides intravenous injec-
tions up to a total of 9.5 Gm. (2%
drams). Though the treatment was
ordered discontinued, the parents
continued it for 3 months longer (32
injections by the vein) with a total of
16 Gm. (4 drams), perfect recovery
resulting. Navarro (Rev. de la Asoc.
Med. Argentina, Apr.-June, 1920).
Nothing certain is known of the
manner in which saHcylic acid and its
compounds influence the rheumatic
infection. Possibly salicylic acid has
a specific action on the micro-organ-
isms; it" is a reliable, but not an in-
fallible, remedy, relieving the joint
condition, shortening the disease,
diminishing the likelihood of relapse,
and probably protecting the heart.
Some cases are rebellious to its
action. Some patients do not toler-
ate it, vomiting being induced. It
may then be administered by inunc-
tion or enema. For inimction a 20
per cent, ointment of salicylic acid
or of methyl salicylate may be used.
For administration by enema Erlan-
ger uses the following formula: —
R Sodii salicylatis. 3iss to ij (6 to 8 Gm.).
Tincturcc opii .. Tri.lxxv (5 c.c).
Aqua f^iiiss (100 c.c). — M.
This should be injected, after pre-
liminary cleansing of the bowels, at
body temperature, and should be re-
tained as long as possible in the in-
testines.
Intrarectal administration of sodium
salicylate recommended in refractory
cases of acute and subacute rheumatism.
The salicylate enema is given immedi-
ately after a cleansing soapsuds en-
ema, and is administered with a
16
RHEUMATISM (LEVISON AND SAJOUS).
Davidson syringe and a rectal tube
inserted 6 to 8 inches. First dose
in men is usually 8 to 10 Gm. (2
to IVi drams), in women 6 Gm.
(1^2 drams), incorporated in 120 to
180 c.c. (4 to 6 ounces) of plain or
starrh water, with 1 to 1.5 <:.c. (16 to
24 minims) of opium tincture. The
dose may be repeated within 12 hours,
but usually a daily enema suffices, with
doses increasing from 30 to 50 per
cent, daily until the limit of tolerance
is reached. L. G. Heyn (Jour. Amer.
Med. Assoc, Sept. 19, 1914).
Where the effects of salicylates in
acute rheumatism are not as expected,
the so-called "alkaline treatment" may-
be instituted, or, the two forms of
treatment may be combined — a pro-
cedure especially useful in children.
This consists in the administration of
20 or 30 grains (1.25 or 2 Gm.) of
potassium bicarbonate, citrate, or
acetate, or sodium bicarbonate every
two or three hours for the first few
days, or until the urine is alkaline.
Luff advises combined salicylic and
alkaline medication in all cases of rheu-
matic fever. He gives 20 grains (1.25
Gm.) of sodium salicylate and 30
grains (2 Gm.) of potassium bicarbo-
nate every two hours until pain is re-
lieved, then every four hours till the
temperature has fallen to normal. Fif-
teen grains (1 Gm.) of the salicylate
and 20 grains (1.25 Gm.) of the bicar-
bonate are then given every four hours
until all joint symptoms have disap-
peared, and after this three or four
times a day for a fortnight longer.
Comparative statistics show that pa-
tients do not recover any more quickly
under salicylates than with the alk-
aline treatment, but with the salicylate
treatment pain is sooner relieved.
Heart complications are not any more
common when treating with the salicy-
lates. J. L. Miller (New York Med.
Jour., July 4, 1914).
Intravenous and subcutaneous injec-
tions of salicylates have been recom-
mended by several observers, both to
avoid upsetting the stomach and for
prompt, powerful effect. Behr lauds
the following combination for intra-
venous use, originated by Mendel : —
IJ Sod'n salicylatis ... 3ij (8 Gm.).
Caffeince sodiosal-
icylatis (N. F.) . . 5ss (2 Gm.).
Aqiice stcril(c, q.s. ad f5iss (50 c.c). — S.
Methyl salicylate, or artificial oil
of wintergreen, is recommended for ex-
ternal use in rheumatic fever. It is a
volatile fluid of an aromatic odor. The
affected joints are to be painted with
the drug and enveloped with some im-
pervious material. Experience has
shown that the salicylic acid contained
in methyl salicylate is absorbed through
the skin. It is also chemically demon-
strable in the urine. It removes the
pain and reduces the temperature.
In acute rheumatism and allied con-
ditions such as acute rheumatic sci-
atica, the result of thyroid treatment
may be striking. Tompkins (So. Med.
Jour., Dec, 1910).
Hypodermic injection of salicylates
advocated, for the purpose of secur-
ing prompt action and avoiding di-
gestive disturbances and toxic symp-
toms. In acute rheumatic infection
of joints, heart, pericardium, pleura,
and central nervous system (chorea),
inject 10 c.c. (2^/2 drams) of 20 per
cent, sterile solution of fresh sodium
salicylate per 100 pounds of body
weight. First disinfect a spot out-
side of the median line of the thigh
with fresh iodine tincture. Through
this inject sterile cocaine solution (^
grain — 0.008 Gm. — in 30 drops) under
the skin, and after waiting fully fif-
teen minutes inject salicylate solu-
tion under the same spot. This causes
general improvement within three
hours. Repeat the injection every
twelve hours. In severe cases, with
many seats of involvement, increase
RHEUMATISM (LEVISON AND SAJOUS).
17
the dose to 15 c.c. (^ ounce) per 100
pounds weight. In chronic cases, in-
ject every twenty-four hours 10 c.c.
(2^ drams) per 100 pounds of the
following: Salicylic acid, 10 Gm. (2^
drams); sesame oil, 80 Gm. (2%
ounces); pure alcohol, 5 Gm. (75
drams); gum camphor, 5 Gm. (75
grains). This is to be sterilized
before adding the alcohol, and after-
ward excluded from contact with
air, to avoid evaporation of alcohol.
The effect of the injection in chronic
cases is obtained more rapidly when
multiple localizations of the rheu-
matic process are present than when
one joint is affected. In the former,
pain and stiffness usually improve
after the first injection; in the latter,
after the third. The addition of
camphor (from 5 to 20 per cent.) was
found beneficial in stimulating the
heart when the pericardium or the
endocardium was involved. Seibert
(Med. Rec, Mar. 11, 1911).
Magnesium sulphate, administered
by intramuscular injection, by mouth,
and applied externally, found val-
uable in cases of acute articular
rheumatism. Intramuscular injec-
tions of 4 c.c. (1 dram) of a sterilized
25 per cent, solution of the salt, all
aseptic precautions being observed,
brought rapid relief from pain, re-
duced stiffness and swelling, and
sometimes considerably lowered tem-
perature. No pain followed the
injections. In some instances purga-
tion resulted. Injections were re-
peated on succeeding or alternate
days. A saturated solution was ap-
plied to the inflamed joints with
benefit. The intramuscular injections
are recommended for cases in which
salicylates fail to give results. A. B.
Jackson (N. Y. Med. Jour., June 24,
1911).
In many cases where the salicylates
failed in their action, or were not
well borne, coUargol in the form of
an intravenous injection, 2 c.c. (32
minims) of a 5 per cent, solution, or
an enema of 50 c.c. (1% ounces) of
a 5 per cent, solution, gave excellent
results. In giving the intravenous in-
jection the heart must be normal, as
there is a sudden rise of temperature
to 40° C. (104° F.); the injection per
rectum is not followed by this rise in
temperature, and the results are about
the same. Junghaus (Deut. med.
Woch., Nov. 1, 1912).
Case of rheumatic fever in which,
although sodium salicylate appeared
at first to be giving excellent results,
the pain, joint swelling, and fever
later returned, the heart rate in-
creased, and the first sound became
muffled. Ten days' energetic treat-
ment with the salicylate proving com-
pletely ineffectual, 8 Gm. (2 drams)
of antipyrin were administered in
two days, and the salicylate in daily
doses of 5 Gm. (75 grains) resumed
immediately after. The fever was
thus rapidly overcome and convales-
cence entered upon. The return to
a massive dose of the salicylate after
the two days' intermission seemed the
essential factor in the benefit ob-
tained. Interrupted administration of
salicylates has already been recom-
mended for obstinate cases, and anti-
pyrin seems especially suitable for
use during the intervals. Roch (Rev.
med. de la Suisse romande, Feb.,
1913).
The writer's experience with the
intravenous administration of sodium
salicylate comprises 12 cases of artic-
ular rheumatism of various degrees
of severity, in which about 130 injec-
tions were used. The two most im-
portant points to be observed in the
giving of the injections were found
to be: (1) to use only a very fine,
sharp needle, so that the trauma to
the vein wall may be as slight as pos-
sible; and (2) to have the solution
fresh and made with chemically pure,
crystalline sodium salicylate. The
stock solution was made by dissolving
10 Gm. (214 drams) of C. P. crystal-
line sodium salicylate in 50 c.c. (1%
ounces) of distilled water, freshly
sterilized by boiling. The drug was
weighed and handled as aseptically as
possible and the solution, after being
made, not subjected to further sterili-
zation. The solution should be per-
8—2
18
RHEUMATISM (LEVISON AND SAJOUS).
fectly colorless and, if protected from
the light, was found to keep for
several days. L. A. Conner (Med.
Rec, Feb. 21, 1914).
Attention to the joints in rheu-
matic fever is of great importance.
They should be placed at complete
rest by means of splints, and may
also with advantage be wrapped in
cotton or in cloths wet with a satu-
rated solution of magnesium sul-
phate or with lead water and lauda-
num. Methyl salicylate, as already
mentioned, may also be applied.
Bourget recommends the following
ointment : —
^ Acidi salicylici gr. xlv (3 Gm.).
Olei tcrebinthince ... mxlv (3 c.c).
Adipis lance hydrosi,
Adipis bcnzoinati. .3.3. 5v (20 Gm.).
Fiant unguentum.
Sig.: To be applied, and covered with
absorbent cotton and an impervious ma-
terial.
Baker finds the following collodion
useful in relieving pain : —
I^ Phenylis salicylatis 3j (4 Gm.).
Mthcris f5i (4 c.c.) .
Collodii ill (30 c.c).
M. Sig.: To be painted on the affected
joints twice daily or oftener.
Arendt praises a formula contain-
ing ichthyol : —
R Ichthyolis 3iiss (10 Gm.).
Alcoliolis dilttti fSiiss (10 c.c).
Aqu<u destillatcc f3x (40 c.c). — M.
Robinson has found the following
ointment so efficient as to permit of
dispensing with internal treatment
altogether : —
B Mentholis 3j (4 Gm.) .
Methylis salicylatis .... f3j (4 c.c).
Acidi salicylici 3ij (8 Gm.).
Alcoholis q. s. ad fjj (30 c.c).
M. Sig.: Paint jomts briskly with
camel's-hair brush, cover with absorbent
cotton and oiled silk, and bandage snugly
but not tightly.
When the epidermis begins to peel
an emollient ointment should be sub-
stituted for a day or two.
Sixteen cases of acute rheumatism
treated l)y typhoid vaccine, used only
as a standardized foreign protein.
Sixteen minims (1 c.c.) were given in-
travenously daily until a cure had
been obtained. The treatment is
justifiable where apical abscesses, in-
fected tonsils, gall-bladder, appendix,
or genitourinary tract can be demon-
strated and removed, and in those re-
fractory to other treatment. Lyter
(Jour. Amer. Med. Assoc, Jan. 5, 1918).
Excellent results from hypodermic
injections, once daily, of 150 c.c.
(5 ounces) of a solution of 7 Gm.
(108 grains) of sodium chloride and
10 Gm. (155 grains) of sodium sul-
phate in a liter (18 ounces) of water.
It is seldom necessary to give more
than 3 or 4 doses to obtain marked
improvement. S. L. Brian (La Sem-
ana Med., June 6, 1918).
Subcutaneous injection of oxygen
systematically used in thousands of
patients with rheumatism, mostly
subacute and chronic. It is a power-
ful adjuvant to other measures. The
writer usually injects 100 c.c. (3%
ounces) at the site of the pain, some-
times injecting all the larger joints at
1 sitting, using up 2, 4, or more liters.
An elderly woman with chronic nodu-
lar rheumatism for two years in hands
and knees was relieved of all pain
and inflammation by 8 injections.
The oxygen was injected into the
dorsum of the hands and massaged
into the fingers. Zabaleta (Siglo med-
ico, Aug. 10, 1918).
In subacute and chronic rheuma-
tism several writers advise the use of
a Z2) per cent, ichthyol ointment or a
20 per cent, ichthyol-glycerin solu-
tion, aided by ichthyol and iodides in-
ternally. Salicylic cataphoresis has
also 1)een used.
Report of rapid cure of acute rheu-
matism after intra-articular injections
of sodium, salicylate by the catapho-
retic method. Similar cases reported.
RHEUMATISM (LEVISON AND SAJOUS).
19
Wullyamoz (Brit. Med. Jour., Aug.
13, 1910).
Occasionally cases of rheumatism
are met with in which the pains do
not yield to sodium salicylate and yet
promptly yield to acetylsalicylic acid
(aspirin). Internal administration of
salicylates frequently fails to give re-
lief to the pain experienced about the
fibrous tissues, notably under the
heels in patients who have had a pre-
vious attack of acute articular rheu-
matism. In such cases the local use
of oil of wintergreen, 1 dram (4 Gm.)
to an once (30 Gm.) of lanolin, will
generally give relief. The same ap-
plies to the pain accompanying acute
rheumatic pleurisy or pericarditis.
For painful conditions about fibrous
structures the addition of from 3 to
5 grains (0.2 to 0.3 Gm.) of potassium
iodide to the sodium salicylate often
proves beneficial. Joint effusions of
rheumatism are responsive to salicy-
lates in proportion to the absence of
mechanical irritation by movement.
In erythema nodosum local treatment
with oil of wintergreen brings marked
relief of the pain and probably a
shortened duration of the attack. A.
F. Voelcker (Clin. Jour., Aug. 16,
1911).
The writer recommends in the
treatment of light attacks of rheuma-
tism, as well as in sciatica, gout, and
neuralgias in general, the following: —
Acidi salicylici 10 Gm. (2^ dr.).
Olei terehinthin.(c ... SO Cc. (1% oz.).
Sulphuris pnecipitati. 40 Gm. (l^/^ oz.).
M. ft. lotio.
The salicylic acid is dissolved in 10
Gm. (2^ drams) of the turpentine,
the sulphur mixed with the remainder,
and the two portions then mixed.
After the preparation has been ap-
plied to the skin, it is covered with a
layer of impermeable tissue held by
a bandage. When the dressing has
been allowed to remain for three or
four days the skin, on its removal,
will be found to have become de-
tached from the deeper layers. Un-
less the patient is sensitive, the
preparation may be applied again.
Otherwise, it is well to use a zinc
paste. Scharff (Therap. Monats.,
Feb., 1912).
Excellent results obtained by apply-
ing externally a mixture of 2 parts
of ground camphor and 1 part of
phenol, adding 5 per cent, alcohol to
the mixture. The result is an oily
fluid, sparingly soluble in water, and
free from caustic action. Only very
delicate skins feel a slight smarting.
It seems to be especially toxic to
streptococci. V. Chlumsky (Zent-
ralbl. f. inn. Med., Mar. 9, 1912).
In children the salicylates, also
hold first place. The dose must l>e
90 to 150 grains (5.8 to 9.7 Gm.) in
divided doses at short intervals dur-
ing the first 24 hours, with a nearly
equal amount of sodium bicarbonate.
Later the dose may be lessened. If
the case responds at all the fever
and pain subsides in 48 hours. In
some cases morphine must be given.
The joints may b-e wrapped in ■ cot-
ton or local applications of lead water
and laudanum, magnesium sulphate
or oil of gaultheria made. A splint
may be applied. Abundance of water,
lemonade and orangeade should be
given. The food should be in the
form of milk or milk products,
cereals and broths. Rarely, a stock
vaccine has proved beneficial. Dis-
eased tonsils should be removed.
Riesman (Trans. Phila. Co. Med. Soc;
Med. Rec, Apr. 16, 1921).
Where the joint pain remains
severe in spite of salicylates, Dover's
powder may be ^8:iven ; or, particu-
larly at nig^ht, an injection of mor-
phine may become necessary.
The complications of acute articu-
lar rheumatism should be treated ac-
cording to the nature and the indi-
cations of each. Hyperpyrexia and
cerebral rheuinatism may necessitate
the application of tepid and even
cold baths combined with large doses
of antipyretics; the cold baths or cold
pack should be begun as soon as the
20
RHEUMATISM (LEVISON AND SAJOUS).
temperature starts to rise quickly
above 105° F. (40.5° C), otherwise
considerable danger to life may be
entailed. Upon the advent of endo-
carditis the use of the ice-bag or pre-
cordial blistering should be availed
of, and digitalis may have to be em-
ployed.
A persistently high pulse rate in
acute articular rheumatism is always
to be regarded as indicative of myo-
cardial involvement, and as long as
it continues absolute rest is essential.
Rest in bed should be persisted in as
long as six months to a year if the
physical signs indicate that the heart
has not recovered completely. Dur-
ing the acute stages of the disease
the pain may make the patient very
restless. Under these circumstances
an ice-bag may be applied over the
heart, and sleep should be obtained
by the use of morphine, since the
other hypnotics do not sufficiently re-
lieve pain to permit rest. If the
patient has not much pain, but is
nevertheless restless, the bromides
are of no value. When the heart re-
mains persistently weak, and suffi-
cient time has elapsed for inflamma-
tory processes to quiet down, minute
doses of digitalis and arsenic, contin-
ued over a long period, are often of
value. Turnbull (Austral. Med. Jour.;
Therap. Gaz., Nov. 15, 1911).
When the fever declines, but one
or more articulations remain swollen
and painful, it has been recommended
to employ bandaging for some time.
Also, baths in hot water or, better,
hot-air baths, will in many cases
bring relief. Massage is likewise a
valuable measure.
Iron is usually a useful remedy
during convalescence, in view of the
rapid anemia induced by the disease.
With it may be coupled quinine and
strychnine. Arsenic may also be of
value. A generous diet should be
allowed.
In rheumatic conditions associated
with anemia and in sore throat of
rheumatic origin, following mixture
recommended: Dissolve 1 dram (4
Gm.) of sodium saUcylate in 2 ounces
(60 c.c.) of water. Add liquor ferri
perchloridi, plus an ounce of water,
giving dark-purple mixture. Then
add 1 dram of potassium bicarbonate
dissolved in 1 ounce (30 c.c.) of water,
and fill up bottle to 8 ounces with
water. Drinkwater (Liverpool Med-
ico-Chir. Jour., July, 1911).
No treatment has been found able to
prevent surely the complications or re-
currence, but most authors agree that
the use of salicylates in sufficient doses
continued for some time after the re-
turn of normal temperature gives the
best results in both respects.
Cases showing the possibility of
treatment with colloidal sulphur, of
cutting short an oncoming chronic
rheumatic state following attacks of
acute rheumatism. The patient was
completely relieved, resuming his oc-
cupation in three months, in spite of
several interruptions in the treatment.
The solution of colloidal sulphur em-
ployed contained 0.2 Gm. (3 grains)
of sulphur to every 15 c.c. (^ ounce),
and was given in doses of 1 teaspoon-
ful before breakfast and supper, grad-
ually increased to 1 tablespoonful.
The solution was rendered palatable
with sugar and an 'aromatic prepara-
tion. Sodium salicylate, having no
efifect on the pain or in preventing
recurrence of subacute attacks, may
be advantageously replaced by qui-
nine sulphate in the dose of 5 grains
(0.3 Gm.) twice a day. A. Robin and
L. C. Maillard (Bull, de I'Acad. de
Med., Nov. 25, 1913).
The writer regards all arthritic in-
flammation as microbic, and 90 per
cent, of the cases are due to strepto-
cocci. Acute inflammatory rheuma-
tism, chronic , articular rheumatism,
and arthritis deformans are but dif-
ferent manifestations of one cause,
modified by individual susceptibility,
both constitutional and local, and
RHEUMATISM (LEVISON AND SAJOUS).
21
duration of disease. He reports suc-
cessful treatment of chronic rheuma-
tism by means of autogenous vac-
cines. The preferable source for
these is the pharynx. The benefit
from vaccine ranged from total cure
in the mild cases, to disappearance
of all symptoms except transitory
slight stiffness in the most severe.
Greeley (Med. Rec, June 13, 1914).
Where a case persists over many
weeks, a focus of infection in the ton-
sils, nasal sinuses, ears, or elsewhere in
the body should be sought. Tonsillec-
tomy may be required.
The writer deprecates the general
tendency to refrain from operating on
inflamed tonsils associated with acute
joint involvement. There may be
greater danger in deferring operation
too long. If the tonsils are the source
of infection, their continued presence
increases the danger of secondary in-
volvement of the heart. Tonsillec-
tomy is indicated as soon as the acute
tonsillar inflammation sul)sides. Sali-
cylates in large doses should be used
to allay joint pains before operating.
With intensive salicylic treatment
the writer also gives sterile milk sub-
cutaneously, thus producing hyper-
emia of and exudation over the in-
volved structures. The rheumatic
process is controlled in a few days.
Of 70 cases treated, none developed
pericarditis, and but 2 a cardiac lesion.
The treatment succeeds where sali-
cylate treatment alone seems ineffec-
tive. Endocarditis is favorably influ-
enced by intramuscular injections of
10 c.c. (2;/ drams) of sterile milk.
A. Edelmann (Miinch. med. Woch.,
Dec. 18, 1917).
Nephritis plays the chief role in
causing senile rheumatism. If the
patient is robust the writer gives
Seidlitz mixture or magnesium citrate
before breakfast; if frail, a compound
cathartic pill at bedtime. Cabinet
baths once or twice a week are very
beneficial. Salicylates irritate the
kidneys. Heroine usually relieves
the pain in acute cases. Superheated
air at 130°, 180°, or 200° C. is applied
to cases with a tendency to defor-
mity. Sodium succinate, 10 grains
(0.6 Gm.) every three hours, is often
of great value. Senile rheumatism
improves on exercise. M. W. Thewlis
(Med. Rev. of Reviews, June, 1918).
MUSCULAR RHEUMATISM.
Muscular rheumatism, or myalgia, is
an affection of the muscles and the re-
lated fasciae, causing pain and stiffness,
which usually disappear after some
days. It sometimes assumes chronicity,
being then accompanied by the forma-
tion of fibrous bands and nodules in
the muscles.
SYMPTOMS.— The principal symp-
tom is pain, which may be spontaneous
or caused by movements or pressure of
the diseased parts. The pain in some
cases remains limited to the muscles
first affected, but sometimes it suddenly
disappears from these and attacks an-
other group of muscles. Slight fever
sometimes attends the affection. The
symptoms vary according to the
muscles affected. In rheumatism ot
the intercostal muscles — pleurodynia —
(sometimes with involvement of the
pectorals or the serratus magnus),
breathing is painful and the disease
may be confounded with pleurisy.
Localized tenderness may exist over
the involved muscles. When the mus-
cles of the abdominal wall are affected,
there is excessive tenderness to pressure,
and the symptoms may resemble those
of acute peritonitis ; but the absence of
fever is of great value as a diagnostic
sign. Rheumatism of the muscles of
the back occasionally gives rise to opis-
thotonos, and suspicion of spinal men-
ingitis may arise. Lumbago, or in-
volvement of the lumbar muscles, may
completely incapacitate the patient, and
may simulate disease of the sacroiliac
joint, vertebrae, etc. Rheumatism of
22
RHEUMATISM (LEVISON AND SAJOUS).
the muscles of the neck causes stiffness,
and, when the muscles of one side only
are affected, rheumatic torticollis (wry-
neck) is produced. The sternomastoid
muscle may become prominent as a
tense, tender cord, and rotates the head
toward the involved side.
Pleurodynia can be distinguished
from pleuritis by the absence of a fric-
tion rub, and from intercostal neuralgia
by the absence of the characteristic
tender or painful spots, and by the fact
that the pain does not strictly follow
the course of the intercostal nerves.
The acute form of muscular rheuma-
tism passes away in a few days. The
chronic form may continue for weeks
and months and often provokes forma-
tion of new connective tissue, with its
consequences — stiffening of the muscles
and contractures. Sometimes small
fibrous bands and nodules are formed
in the muscles and give rise to much
pain and tenderness.
Rheumatism of the muscles is in
some cases complicated Avith myositis,
which may be general or localized, —
limited, for instance, to the muscle of
the heart.
Muscular rheumatism is a danger-
ous diagnosis for a conscientious
physician to make. The correct diag-
nosis may be either aortic aneurism,
cancer of the pleura, tabes, osteomye-
litis, spondylitis deformans, bone tu-
berculosis, syphilitic periostitis, lead
poisoning, morphine habit, alcoholic
neuritis, trichinosis, gonorrheal sep-
sis, onset of an acute infection
(typhoid, influenza, variola, arterior
poliomyelitis, meningitis), intestinal
autointoxication, sacroiliac joint re-
laxation, local disease of muscle,
hematoma due to trauma, hematoma
following vascular change (as in ty-
phoid, sepsis, jaundice), muscular
cicatrices following fibrous myositis,
atheroma of arteries in muscle (as in
intermittent claudication), muscle ab-
scess, infarct, gumma, echinococcus
cyst, or new growth. The diagnosis
of muscular rheumatism must be
made by exclusion. M. A. Rabinowitz
(N. Y. Med. Jour., July 12, 1913).
ETIOLOGY AND PATHOLOGY.
— Overwork, especially when combined
with exposure to cold and dampness,
has always been considered as the com-
mon cause of rheumatism of the mus-
cles. Many persons are very sensitive
to draughts, and readily develop the
affection, especially upon sudden cool-
ing after physical motion sufficient to
cause perspiration. The disease com-
monly occurs after the thirtieth year,
but is also observed before tliat aee.
The disease is very liable to recur in
muscles which once have been affected
by it; especially in the muscles of the
neck.
In all probability the muscular form
of rheumatism, like the articular form,
is caused by micro-organisms, but their
presence in the affected muscles
has as yet not been proved by direct
observation.
The pathological condition pro-
duced is believed to be chiefiy an in-
flammation of the fibrous investment
of the muscle fibers, the attachments
of the muscles to periosteum, and the
fasciae surrounding them. Stress is laid
by some on disturbance of the sensory
nerve endings in the muscles.
J. Madison Taylor states that fibro-
myositis is often a common factor in
many states variously named where
either pain, tenderness, or lameness is
a feature. It may not be painful,
merely a latent tenderness. It is
often superadded to other causes of
disability, complicating and obscuring
them; is only to be differentiated by
expert tactile exploration ; the condition
should be remedied to permit exact
RHEUMATISM (LEVISON AND SAJOUS).
22>
diagnosis. The site can usually be
located and evaluated by alterations
in the local density, tension, mobility
or restriction of motion. Nodes are
often minute but characteristic.
Nearly always diagnostic light is
afforded by definite tenderness and
morphological alteration in paraverte-
bral structures corresponding to the
origin of the sympathetic innervation
at the site of the subsidiary centers in
the spinal cord.
TREATMENT.— For internal use
salicylic acid and its compounds are
much employed and will sometimes,
though not in all cases, bring relief.
When the salicylates fail to effect a
cure, tincture of colchicum, potas-
sium iodide, or mercury may be. tried
together with an antigout diet.
Thiosinamine at times checks prog-
ress of chronic rheumatism. Daily
dosage of 0.06 to 0.1 Gm. (1 to 1^
grains) by injection or ingestion can
be safely employed. Renon (Bull, de
I'Acad. de Med., Apr. 25, 1911).
The following treatment of muscu-
lar rheumatism recommended: (1)
rest in bed; (2) liberal diet of milk,
eggs, light meats, farinaceous articles
and cruciferous vegetables. Butter-
milk and water between meals ad lib-
itum; (3) general bath daily, with
temperature progressively increased,
followed by a blanket or alcohol
sweat; (4) massage, after pain and
tenderness under control at least
twenty-four hours; (5) in lumbago or
other localized muscular troubles
where general methods inefficient:
acupuncture or injection directly into
involved muscle of 10 c.c. (2j/2 drams)
of ice-cold normal salt solution; (6)
where severe pain: salicylates, at
first in large hourly doses, with
sodium bicarbonate. Locally, 20 per
cent salicylic acid ointment or lini-
ment of oil of gaultheria, followed by
flannel jacket or bandages, with hot-
water bottles or electric pads. Meyer
(N. Y. Med. Jour., July 5, 1913).
Externally, tincture of iodine and
all the rubefacients — ammonia, cam-
phor, turpentine, etc. — are to be tried ;
also warmth in the form of hot water,
poultices, and hot baths (Russian or
Turkish). Hot-air baths have been
much recommended. The external
use of methyl salicylate often alle-
viates the pain. Belladonna plaster,
chloroform liniment, and the galvanic
current may also be used for this pur-
pose. Massage may completely cure
a recent case. Rest of the affected
muscles should be procured by all
means possible. In pleurodynia
strapping the side with adhesive
plaster generally affords marked re-
lief. In lumbago as well as in pleu-
rodynia light application of the
Paquelin cautery is frequently of
marked value. Otto has recom-
mended a single injection of 7^ to
15 grains (0.5 to 1 Gm.) of freshly
obtained sodium iodate in 5 per cent,
solution at the site of pain. Sajous
injects normal saline solution sub-
cutaneously — 2 fluidounces (60 c.c.)
■ — daily and gives, besides sodium
salicylate and sodium carbonate (not
bicarbonate) in full doses, watching
the heart carefully.
Injection of 5 or 10 c.c. (80 to 160
minims) of salt solution into the
muscle at the most painful point will
frequently relieve the pain, though, of
course, it has no effect upon the
cause. Schmidt (Med. Klinik, vi,
131, 1910).
The chief measure, other than rest
in bed, in the treatment of muscular
rheumatism is the application of heat
in the form of fomentations, poultices,
and hot-water bags. Dry cupping
over the tender region one-half hour
twice or thrice daily is very beneficial.
One or two electric-light bulbs placed
six inches from the affected part, a
piece of asbestos, tin or woolen ma-
terial encircling, so as to concentrate
24 RHEUMATISM (LEVISON AND SAJOUS).
the heat, will produce a useful hyper- den and severe strain on tendons and
emia; the skin should be protected by ligaments; (4) absorption of irritating
anointing with petrolatum. The elec- toxins from the alimentary tract; (5)
trie-light baking apparatus is, how- tonsillitis and pharyngitis; (6) influ-
ever, more serviceable. This treat- enza; (7) febricula. The forms most
ment the author has found verj' bene- commonly seen are: (1) muscular
ficial, together with light massage, rheumatism, involving especially the
after which a woolen cloth is placed muscles of the neck, those of the
over the hypercmic area. He has also shoulder and upper arm (brachial
found serviceable light massage with fil)rositis), the intercostal muscles, or
the use of an analgesic lubricant: — the lumbar muscles (lumbago); (2)
B MenthoVis Dupuytren's contraction; (3) fibrositis
Camphom.Az ?i-ij (4 to 8 Gm.). of the plantar fascia; (4) pads upon
Chlorali hx- finger-joints, usually confined to the
drati 3ss-j (2 to 4 Gm.). dorsal aspects of the proximal inter-
Olei gaultlie- phalangeal joints, and apparently un-
■yi^cc 5ii-iv (8 to 15 Gm.). related to rheumatoid arthritis, or
Adipis lance h\<- gout. In chronic villous synovitis,
drosi ...... Bi-ij (30 to 60 Gm.). though strictly not a form of fibro-
M, r, . sitis, the correct treatment is simi-
. et ft. unguentum. , ' , ^ ,
lar to that of the other conditions
After the patient is able to be out mentioned. It is purely local, usually
of bed a suitable adhesive plaster occurs in the knee, and characterized
dressing will allow him to walk, with ^^y crepitus or creaking on movement,
slight muscular fixation. J. H. Shaw ^^^ by p^j^ ^nd tenderness on use.
(N. Y. Med. Jour., July 5, 1913). j^ j^e treatment of an acute fibro-
When the disease has passed over sitis, a saline aperient should always
to the chronic sta-e further use of be given at the onset of the attack.
, - \ . . , r • 1 snd repeated as necessary. Saucy-
massage and electricity is beneficial. j^^^^ ^^^ ^^ jj^^j^ ^^^^^^.^^^ ^,^1^^^
Iodine ointment may be used with though aspirin is of decided use for
benefit. In cases attended by indura- the relief of pain in severe cases,
tion and fibrous nodules in the mus- Potassium iodide should always, if
cles, characterized often by contin- possible, be given in full doses of 10
, . ... or 12 grams (0.6 or 0.// Gm.), com-
uous and very intense pain, excision i • ^ vu ^ • i „„^ „«r^,v,
-^ . bined with tonics such as nux vomica
of the hard nodules of fibrous tissue or the compound glycerophosphate
often gives immediate relief. syrup. If symptoms of iodism result,
Chronic fibrositis is generally la- iodipin may be tried. Fibrolysin was
belled "rheumatic," but undoubtedly employed in several cases of thicken-
not a sequel of acute rheumatism, and "^S and contraction of fibrous tissues
in no sense connected with it; the es- i" different forms of fibrositis and
sential pathological change is, in arthritis, as well as in several cases
general, an inflammatory hyperplasia o^ Dupuytren's contraction, with good
of the white fibrous tissue in various results in about two-thirds ot the
parts of the body. Such aflfections cases. It should be injected under
cause pain and stiffness, the former strict antiseptic precautions into the
aggravated by any sudden movement. ^eep subcutaneous tissues of the
Recurrence is common and if not suit- "PP^^" a™' ^ach <.rm being injected
ably treated, the thickened fibrous alternately. It is necessary to give
tissue remains as indurations in 30 to 40 injections in all, and they
various' situations. The commonest should be administered on alternate
causes of local fibrositis are: (1) cold, days. After 20 injections have been
damp, and wet; (2) extremes of heat ' given movements and massage of the
and cold; (3) local injuries, as by sud- affected fibrous tissues should be
RHEUMATISM (LEVISON AND SAJOUS).
25
commenced. In the treatment of pads
upon the finger-joints the only pro-
cedure found useful besides fibroly-
sin was the nightly inunction of a 25
per cent, iothion ointment. In the
early stages of an acute fibrositis hot
fomentations are useful. Afterward
one of the best external applications
is a mixture of equal parts of chloral
hydrate, camphor, and menthol. The
resulting liquid should be painted over
the painful area, and then gently rub-
bed in with the fingers. Another use-
ful procedure is to paint the painful
area with tincture of iodine and then
apply a hot linseed poultice or very
hot fomentation. In the latter stages
the aconite, belladonna, and chloro-
form liniment applied on lint is fre-
quently most beneficial. In a very
localized fibrositis counterirritation,
especially by the thermocautery, is
sometimes of great use. Rest of the
affected parts and diaphoresis are two
of the most important procedures in
the treatment, the latter being es-
pecially beneficial at the onset of the
attack. Heat is of great value, and
if employed early will frequently
abort an attack. If it is to be applied
to the whole body the electric-light
cabinet is most convenient and val-
uable. In lumbago and chronic vil-
lous synovitis of the knees, the most
eflfective local treatment is super-
heated air, applied for fifteen or
twenty minutes, immediately followed
by ionization (cataphoresis) for ten
to fifteen minutes. In chronic joint
cases and chronic lumbago, the author
orders for ionization a 2 per cent,
solution of lithium iodide, directing
that the negative ion (the iodine)
should be driven into the tissues. In
acute lumbago a 2 per cent, solution
of sodium salicylate should be used
at the first sitting or two in order to
relieve the pain. In the later stages
of a muscular fibrositis a rapidly in-
terrupted faradic current is beneficial,
but it should be so weak as not
to cause any muscular contraction.
Massage is very useful in the later
stages, but it should not be employed
until it causes no pain, and should be
very gentle at first. During the pain-
ful stage of muscular rheumatism rest
of the affected muscles is required,
but later on exercises of the muscles
are of great benefit. They should be
performed on rising in the morning
and followed by a cold or tepid bath
and brisk rubbing of the skin with a
rough towel. No special dieting is
required; moderation should be the
keynote. Porous linen underwear is
the most suitable for rheumatic indi-
viduals. A. P. Lufif (Lancet, Mar. 12,
1910).
The distinguishing pathological fea-
tures of fibromyositis, according to J.
Madison Taylor, are plastic adhesions
of contiguous structures exerting
compression on sensory nerve-fibers
which need to be set free mechan-
ically. While this can be achieved by
various agencies such as by counter-
irritation, blisters, electricity, etc., the
most radical, prompt, and permanent
relief is by expert manipulation, such
as deep pressures with lateral traction,
torsion, etc. ; the best is by lifting and
separating the adherent structures,
thus freeing sensory fibers from com-
pression. In some cases, fibromyo-
sitis is so persistent as to remain for
many years a source of disablement,
lameness, or deformity, resisting all
medication, yet can be removed by
manipulation in a few days. Best re-
sults from medication by sodium ben-
zoate and Martin H. Fisher's alkaline
solution by colonic irrigation.
In any of the ordinary manifesta-
tions of chronic rheumatism, as lum-
bago, sciatica, pleurodynia, or cepha-
lalgia, and with any obscure myalgic"
or neuralgic pain in any part of the
body, a careful investigation should
be made of the fibromuscular tissues
of the affected areas. In the more
recent diffuse cases there is general
tenderness of these tissues. Usually,
either with or without such general
tenderness, one will find areas which.
26
RHEUMATISM (LEVISON AND SAJOUS).
are definitely, often exquisitely, ten-
der to touch. General treatment for
a feverish attack, with the ordinary
pain-relieving drugs, generally suffices
to cure. If the pain is at all localized
a single thorough application of mas-
sage may result in cure in this early
stage. y\ny discoverable cause, such
as gastrointestinal irregularities, must
be removed. During the more acute
exacerbat'ons sodium salicylate pi"o-
duces some relief, but recurrence is
probable indefinitely. To obtain a
permanent cure it is absolutely nec-
essary to obtain locally a complete
dispersal of the indurations. Coun-
terirritation by blistering or cau-
tery produces relief, but nothing is
so efficient as the rubbing in of oil
of gaultheria.. Important also are
massage and systematic exercises.
Acupuncture is of great use in reliev-
ing pain, but does not produce com-
plete dispersal of the infiltrations. In
cases of fibrous nodules w^hich will
not yield to simpler measures, and
which by pressing on nerves cause
persistent pain, excision is not only
advisable but necessary. Telling
(Lancet, Jan. 21, 1911).
Senile rheumatism described as a
separate morbid condition. Being
one of the manifestations of aging, it
can neither be prevented nor cured.
Pain can, however, be relieved. The
pain usually disappears soon after
joint motion has ceased, but if it per-
sists, application of moist heat, fol-
lowed by an inunction of 2 per cent.
cocaine liniment or ointment, using
an animal base, will generally give
relief. Sweet butter is an excellent
base for this purpose. To prevent its
becoming rancid 2 grains (0.12 Gm.)
of sodium benzoate to the ounce (30
Gm.) should be added. The constitu-
tional measures are hygienic and
medicinal, the latter consisting of the
intermittent use of phosphorus and
the iodide of arsenic. I. L. Nascher
(Amer. Med., Dec, 1911).
The writer emphasizes the value of
local heat, especially dry, radiant
heat, combined with ionization, in
muscular rheumatism. In lumbago.
the static current may be substituted
for ionization. Massage is useful, but
it should not be applied to the af?ccted
part itself, but around it. A. P. Luft
(Med. Rec, Aug. 16, 1913).
GONOCOCCAL (GONORRHEAL)
RHEUMATISM.
Gonococcal rheumatistn, or arthritis,
is an acute inflammation of one or
more articulations occurring during the
course of gonorrhea and caused by in-
vasion of gonococci in the joints.
SYMPTOMS.— The condition ordi-
narily appears in the acute stage of
gonorrhea. In some cases the lesion of
the joints is only revealed by arthralgia :
i.e., intense pain without swelling. This
condition is particularly observed in
the small joints of the foot. The pain
is worst in the evening and is aggra-
vated by movements. The arthralgia
may also precede the evolution of
gonorrheal arthritis or continue for
some time after the disappearance of
the swelling.
In other cases the affected joint be-
comes the seat of an effusion of fluid,
giving rise to little or no pain. This,
effusion disappears very slowly, and
often leaves stiffness or fibrous adhe-
sions in the joint. This form of the
disease is most frequently observed in
the knee.
Ordinarily gonococcal rheumatism in
its mode of invasion and evolution very
much resembles the acute form of ar-
ticular rheumatism. It differs from
that disease, however, in attacking only
one or a few articulations at the same
time, and in that the affected joints
remain involved for a longer period.
Again, gonococcal arthritis does not
migrate so suddenly from one joint to
another as the acute articular affection.
No joint, however, is immune, and
even those which ordinarily escape dur-
RHEUMATISM (LEVISON AND SAJOUS). 27
ing the course of rheumatic fever, e.g., gonococcal rheumatism is a rare occur-
the articulations of the jaws and the rence. It only happens when the infec-
neck, may be attacked by the gonococ- tion with gonococci is complicated with
cal arthritis. invasion of pyogenic organisms. The
The pain is of extreme intensity. It chronic form of gonococcal rheumatism
is aggravated by movements and by often gives rise to contracture of the
pressure over the swollen articulation, joints or periostitis of the epiphyses.
Many painful points are also found. DIAGNOSIS. — The diagnosis is
Tumefaction is ordinarily very marked ; easy when the urethral discharge is still
it is caused both by effusion into the present, but difficult when it is not.
joint and by edema of the overlying The disease may be confounded with
structures. The skin over the affected acute articular rheumatism and with
joint is hot and tense. osteomyelitis. In gonococcal arthritis,
Commonly the patient tries to allevi- but few articulations are attacked at
ate the pain by keeping the affected once. The mode of development of the
joint semiflexed. If he is allowed to arthritis, the extent to which the periar-
remain in this position, contraction of ticular tissues are involved, the rela-
the extremity may result. tive absence of constitutional symp-
Gonococcal rheumatism does not toms, the inefficacy of the salicylates,
affect the articulations alone. The and, if possible, the demonstration of
serous bursse and the sheaths of the gonococci in the blood or the affected
tendons in the proximity of the diseased joint constitute the chief distinguish-
joint are always involved ; sometimes ing features.
they alone suffer, the inflammatory ETIOLOGY. — Gonorrheal rheu-
process being thus periarticular — gono- matism is caused by an infection with
coccal tenosynovitis. The muscles of gonococci, and it is only observed as
the affected extremity are always af- the consequence of a gonococcal ure-
fected and generally become atrophied, thritis. Many authors have found the
In some cases one joint only is at- gonococci in material taken from the
tacked; the pain is, then, as a rule, still affected joints or synovial sheaths, and
more excruciating and the effusion some have even observed them, in the
greater than in the polyarticular form, blood. The disease attacks both sexes
The acute stage of the disease is not equally; it may occur in children as
usually of long duration. After some well as in adults. It develops in 2 per
days or a week the pain declines and cent, of all gonorrhea cases in the male
the effusion diminishes. The disease sex.
rarely disappears completely, however; PROGNOSIS. — The prognosis as
one or more joints remain somewhat to life is good, but very often the dis-
stiff and painful several months. The ease results in stift'ness of the affected
so-called painful heel of gonorrhea is joint and weakness of the limb, due
the result of a periosteal inflammation to atrophy of its muscles.
of the OS calcis, with or without exos- TREATMENT. — Treatment by
tosis. In some instances chronic gono- means of drugs given internally is
coccal arthritis assumes the form of a not of great value; the salicylates
persistent serous effusion. have little or no influence on the
Suppuration of the joints affected by course of the affection. The same
28
RHEUMATISM (LEVISON AND SAJOUS).
appears to be true of potassium
iodide, except in the chronic cases.
Ihe use of syrup of ferrous iodide in
doses of 10 to 60 minims (0.6 to 4 c.c.)
three times a day has been recom-
mended by J. C. Wilson. Oil of gaul-
theria in doses of from 5 to 20 drops
every two hours in milk has also
been recommended, \\niere acute or
chronic gonorrhea coexists, every
means should be taken to overcome
the urethral focus of infection. In
the more chronic cases the use of
tonics such as strychnine, arsenic,
and codliver oil may prove of value.
Gonococcus vaccines have given
excellent results in a certain propor-
tion of chronic cases. Antigonococcic
serum lias also been used.
At the onset of gonorrheal rheuma-
tism, the patient should receive a
purgative of calomel to be followed
by citrate of magnesia, or salts, or a
dose of castor oil. He should be put
on a light diet with plenty of liquids,
such as soup, milk, alkaline waters,
etc., avoiding stimulating articles of
diet as tea, coffee, spices, and alcohol.
The bowels should be kept regular
and the patient drink plenty of water.
H necessary, a mild diuretic can be
given. Codeine or morphine should
be given if necessary for the pain.
Phenyl salicylate, S grains (0.3 Gm.)
and antipyrin, 3 grains (0.2 Gm.)
may be given every three or four
hours for the fever. The oil of gaul-
theria in doses of 20 drops three
times a day, or potassium iodide,
has be:n recommended. Every case
should be treated at once with anti-
gonococcic serum or gonococcic vac-
cine. The combined bacterins seem
to be more useful than the single-
strain cultures. The initial dose is be-
tween 10 and 20 million, running the
same up every second, third, or fourth
day, until about 50 million are being
given every second or third day. Im-
provement is usually noticed within a
week or ten days, but the treatment
should be continued until all the
symptoms have su])sided, which may
take from four to six weeks. Broe-
man (Med. Rev., Sept., 1913).
Local treatment is of great impor-
tance. The affected joint should be
placed on a splint in a proper position
and alxsolute rest of the extremity
enjoined. Pain may be relieved by
various anodyne measures, e.g., hot
and cold applications, tlic ice-bag,
ointments of ichthyol or belladonna,
a wet dressing- of lead-water and
laudanum, or, if necessary, a hypo-
dermic injection of morphine. Coun-
terirritation may be instituted by
means of turpentine or iodine.
Gaucher procures relief for several
hours by bathing the part for half an
hour in a mixture of equal parts of
an aqueous emulsion of black soap
and of oil of turpentine; 5 to 6
fluidrams (20 to 25 c.c.) of this mix-
ture are used with 6 gallons (25
liters) of water. The genitals should
be anointed vvith petrolatum before
the bath is administered. Balzer
uses the following ointment: —
IJ Acidi salicyiici.
Old tcrebinthin<c,
Adipis lance hydrosi.aa Siiss (5 Gm.).
Adipis benzoinati 'Siij (100 Gm.).
Fiant unguentum.
In the intervals between local pro-
cedures a bandage should be applied
as firmly as is practicable. Or, a
plaster-of-Paris dressing may be
used for complete immobilization,
applied under anesthesia if necessary.
Straightening of the limb under anes-
thesia is necessary if fixation in a
faulty position has already taken
place.
In cases in which acute pain has
subsided massage and passive move-
ments are of value to assist in res-
RHUBARB.
29
toration of joint mobility. Dry hot-
air baths, Bier's passive hyperemia,
and counterirritation with bhsters or
the thermocautery are also very
serviceable measures in the more
chronic cases. The last two pro-
cedures are especially indicated in
cases characterized by hydrarthrosis.
Compression is also of value in these
cases.
Where the above fail to bring re-
lief within a reasonable period, and
especially if the effusion becomes
purulent, arthrotomy should be per-
formed and the joint evacuated and
irrigated with an antiseptic or sterile
saline fluid, according to indications.
Aspiration followed by injection of 1
to l^A fluidrams (4 to 6 c.c.) of a
1 : 4000 solution of mercury bichloride
has been recommended by P.alzer and
others, but the more radical pro-
cedure in general meets with greater
favor. Bres, in 20 cases, after incis-
ing the joint, removed the diseased
synovial membrane and injected
dilute tincture of iodine or a weak
solution of zinc chloride. All his
cases recovered completely.
F. Levison,
Copenhagen,
AND
L. T. DE M. Sajous,
Philadelphia.
RHEUMATOID ARTHRITIS.
See Joints, Surgical Diseases of,
RHIGOLENE. See Petroleum.
RHINITIS AND OTHER NA-
SAL DISORDERS. See Index.
RHUBARB. — Rhubarb, or rheum
(U. S. p.), is the root of Rheum officinale
and of other undetermined species of
Rheum (nat. ord., Polygonacc;c) : a plant
indigenous to Asia (China, India, Tar-
tary, and Thibet), but which is cultivated
in America and elsewhere. It contains
extractive, sugar, starch, pectin, lignin,
salts, several unimportant alkaloids, a
glucoside, and acids, one of which, chry-
sophanic acid, is used in medicine. In
commerce two sorts are recognized, —
the Chinese and the European, — the for-
mer of which is considered the better.
It occurs in irregular cylindrical or
conical, flattened pieces, which are gener-
ally perforated, are covered with a light
yellowish-brown powder, and have fre-
quently a wrinkled surface. Beneath the
powder the color of the root is reddish
brown, mottled with lighter hues. The
root is dense and hard and has a bitter
and somewhat astringent taste and a
peculiar aromatic odor. When chewed,
the root is gritty (due to the presence
of crystals of calcium oxalate), and im-
parts a yellow color to the saliva.
European rhubarb is inferior to the
Chinese variety; powdered rhubarb is also
inferior, and, if not adulterated, at least
is generally made up of inferior, dam-
aged, worthless or worm-eaten material.
PREPARATIONS AND DOSES.—
Rheum, U. S. P. (the root). Dose, 5 to
30 grains (0.3 to 2 Gm.).
Extractum rhei, U. S. P, (extract of
rhubarb). Dose, 5 to 15 grains (0.3 to
1 Gm.).
rUiidextractum rhei, U. S. P. (fluid-
extract of rhubarb). Dose, K to 1
dram (1 to 4 c.c).
Mistura rhei composita, N. F. (rhubarb
and soda mixture). Fluidextract of rhu-
barb, 15; fluidextract of ipecac, 3; bicar-
bonate of soda, 35; glycerin, 350; spirit
of peppermint, 35; water, sufficient to
make 1000 parts. Dose, 1 to 4 drams (4 to
16 c.c).
Pilulcc rhei compositce, U. S. P. (com-
pound rhubarb pills, containing rhubarb,
2 grains; aloes, V/2 grains; myrrh, 1
grain). Dose, 1 to 3 pills.
Pulz'is rhei coinpositus, U. S. P. (com-
pound rhubarb powder or Gregory's pow-
der, containing rhubarb, 25; magnesia,
65; ginger, 10 parts). Dose, ^ to 1
dram (2 to 4 Gm.).
Syrupus rhei, U. S. P. (syrup of rhu-
barb, containing fluidextract of rhubarb,
10 per cent.). Dose, 2 to 6 drams
(8 to 25 c.c).
30
RIGGS'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS).
Syni/^us rhei aromaticus, U. S. P. (aro-
matic syrup of rhubarb, containinjif
aromatic tincture of rhubarb, 15 per
cent.). Dose, 2 to 6 drams (8 to 25 c.c).
Tinctura rhci, U. S. P. (tincture of rhu-
barb— rhubarb 20 per cent.). Dose, Yz to
2 drams (2 to 8 c.c).
Tinctura rhci aromatica, U. S. P. (aro-
matic tincture of rhubarb — rhubarl) 20 per
cent.). Dose, K' to 3 drams (2 to 12 c.c).
POISONING BY RHUBARB.— Rhu-
barb is not generally considered poison-
ous, but a case has been reported in
which the internal administration of
rhubarb gave rise to a hemorrhagic
eruption of macules, pustules, and blebs.
The mucous membranes were also af-
fected, and free hemorrhage from the
urethra occurred.
THERAPEUTICS.— Rhubarb is an ex-
cellent stomachic tonic in atonic dyspep-
sia associated with deficient biliary and
intestinal secretion. It is a remedy espe-
cially adapted to those of relaxed habit,
but inadmissible when an hyperemia of
the mucous membrane exists.
Rhubarb is a valuable remedy in simple
constipation, where we wish to unload
the bowels without affecting the general
system. The root is often chewed by
adults to relieve constipation. In chil-
dren the syrup is a palatable preparation
for this purpose; the pill or compound
pill may be used by adults.
Constipation and hemorrhoids depend-
ing upon pregnancy are benefited by the
administration of rhubarb.
In the summer diarrhea of children,
with green stools, the aromatic syrup of
rhubarb may be employed to empty the
bowel of its fermenting contents before
giving direct treatment. The diarrhea of
indigestion in children and adults is re-
lieved by the aromatic syrup or by the
mixture of rhubarb and soda.
In children, when constipation is re-
placed by diarrhea, if any ordinary laxa-
tive is used, rhubarb is an available rem-
edy on account of its secondary astrin-
gent action.
Functional disturbance of the liver with
deficient biliary secretion is relieved by
the administration of rhubarb, either
alone or, better, combined with blue mass.
Rhubarb is an efficient remedy in duo-
denal catarrh and in catarrh of the biliary
ducts with jaundice, especially in chil-
dren. White, pasty, or clay-colored stools
and a skin of an earthy or jaundiced hue
are indications for rhubarb.
RHUS POISONING. See Der-
matitis Venenata.
RIBS, DISEASES AND INJU-
RIES OF. See Index.
RICKETS. See Bones, Diseases
OF.
RIGA'S DISEASE. See Mouth,
Lips, and Jaws, Diseases of.
RIGGS'S DISEASE; PYOR-
RHEA ALVEOLARIS (SPONGY
GUMS).— DEFINITION.— This is a
pyogenic inflammation of the gums,
apparently starting from the gum mar-
gins, and associated with a suppuration
of the peridental membrane of the
roots of the teeth, which tends to
loosen the latter by detaching them
from the surrounding alveolar tissue.
SYMPTOMS.— The earliest symp-
toms noted, as a rule, are sensitive-
ness, redness, and perhaps swelling of
the gums, with a tendency to bleed
when touched. The development of
the disease being insidious, these
signs are in reality those of an ad-
vanced morbid process, a fact shown
in many cases by the presence of
granular pustules around and under
the edges of the gums, due to the for-
mation of deep pockets between the
latter and the teeth. An offensive
breath and a coated tongue are usual,
and periodical attacks of toothache
also, though in some cases pressure
over the gums will always elicit a dull
pain ; occasionally the latter becomes
continuous. Loosening of the teeth
in their sockets occurs quite fre-
quently. A mild stomatitis is some-
times witnessed, and persistent glos-
RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS).
31
sitis with irregular exfoliation, leaving
red patches, may also occur.
The disease is obviously a chronic
one, but it may be attended with acute
exacerbations lasting from a few days
to several weeks, during which the
gums become very tender and bleed
spontaneously. During the ulcerative
process the submaxillary or cervical
glands may enlarge and become pain-
ful, suggesting tuberculosis.
Pyorrhea alveolaris is not infre-
quently the cause of systemic dis-
turbances.
Many cases of septic fever of un-
known origin and conditions diag-
nosed as malignant endocarditis, as
well as many deaths attributed to
acute septicemia, would have been
correctly diagnosed if the oral cavity
had been examined. Many deaths
due to alveolar abscess, tooth extrac-
tion, and septic oral conditions have
been reported.
C. H. Mayo interestingly stamps
pyorrhea as the cause, not the re-
sult, of systemic disturbances. Ap-
pendicitis being caused by septic oral
conditions has been confirmed by the
bacteriological investigations of Lanz
and Tavel.
Tooth extraction has given a com-
paratively high death rate. All cases
presenting pus should be afforded
free drainage until danger from in-
fection has passed. A. W. Fossier
(N. Y. Med. Jour., Aug. 7, 1915).
Many cases of alveolar abscess are
erroneously diagnosed as pyorrhea
alveolaris. This grave error was
much more common before the ad-
vent of rontgenology. It has been
found that the toxemia resulting
from a dental granuloma is far
greater than from a pyorrheal dis-
charge. M. L. Rhein (Surg., Gynec.
and Obstet., Jan., 1916).
DIAGNOSIS.— The differential
diagnosis is sometimes difficult to
establish from alveolar disease over-
lying necrosis due to poisoning by
lead, mercury, phosphorus, or other
elements used industrially. Syphilitic
or tuberculous lesions of the gums
may also cause confusion. Scurvy,
now rarely encountered, also causes
gingival lesions resembling closely
pyorrhea. In these various conditions
the history of the case and the course
of the disease are frequently of major
assistance in the differentiation from
true pyorrhea.
Unlike dental caries which is un-
common in "native" races, pyorrhea
alveolaris is probably as common in
them as in the civilized. It is very
common in domesticated animals,
while almost unknown in wild ani-
mals. The disease has increased
enormously in civilized countries dur-
ing the last few decades. Inefficient
mastication, whether due to pre-exist-
ing disease of the teeth or to the food
being too refined and soft, is a power-
ful etiological factor. Marginal gin-
givitis having been set up, infection
with organisms rapidly follows, and a
rarefying osteitis, commencing at the
inner margin of the sockets, soon sets
in. Lime salts from the pus become
deposited on the roots of the teeth,
at first around the necks just under
the gum margin, and later on the
deeper parts. This in itself acts as
an irritant, and so a vicious circle is
set up which must be broken before a
cure can be effected — the tartar causes
ulceration, which produces more pus,
which forms more tartar. Gibbs
(Edinb. Med. Jour., Oct., 1917).
ETIOLOGY.— Pyorrhea alveolaris
was for a time thought to be due to
the Endamcba gingiz'alis (Gros, 1849),
but later work seems to have definitely
shown that this organism cannot be
considered the causative agent. As a
matter of fact, there appear to be both
predisposing causes and exciting causes
which play a role in the production of
pyorrhea. Among the former are sys-
temic diseases, localized malnutrition.
2>2
RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS).
frail bony investment of the teeth, and
trauma resulting from malocclusion
(Merritt). As for the exciting cause,
it seems probable that anything causing
prolonged irritation of the gums may
act as such. Bacteriological studies on
the disease have been based largely on
cases in a frankly purulent state; it is
considered highly probable, however,
that a non-purulent inflammatory stage
of the condition, due to trauma and
constitutional influences, may occur be-
fore micro-organismal infection takes
place.
Such constitutional affections as
gout, diabetes mellitus, and other states
indicative of deficient or imperfecl
metabolism, while incriminated as pre-
disposing causes of pyorrhea, are by
no means essential in its production.
According to Maurice Roy, unduly
early senile absorption of the bony
tooth sockets constitutes the first stage
of pyorrhea. The most plainly evident
predisposing cause is age. After the
thirtieth year its development is ob-
served with growing frequency, until
about the fiftieth year. In persons who
take good care of their teeth through
cleanliness, expert attention to avoid
cavities, badly fitting crowns or fill-
ings, etc., pyorrhea tends to remain in
abeyance. Its harmful eftects are
likely to follow opposite conditions,
particularly uncleanliness and trau-
matisms of the gums by accumula-
tion of tartar, especially when de-
bilitating diseases, such as gout,
anemia, and infectious diseases, have
weakened the bacteriolytic activity of
the buccal secretions. Autointoxica-
tion of intestinal origin is also
thought to favor the development of
the disease, possibly by overtaxing
the defensive functions of the body,
thus favoring infection from any
source. It may likewise occur in tooth-
less gums when the false teeth are
not kept scrupulously clean.
There is a frroup of cases which
the writer suspects to be caused by
the spirochete of Vincent's angina.
He has seen several cases on record
where mothers have developed this
condition, and it has been followed
by an illness in tlie child, first diag-
nosed as diphtheria and then as Vin-
cent's angina. There are also cases
caused by the Treponema pallida. W.
Sterling Hewitt (Dental Cosmos,
Oct., 1915).
The teeth, as end-organs, are the
first to exhibit a diminution in im-
munity to infection, if any form of
malnutrition exists. If, by exercise,
massage, and other hygienic meas-
ures, circulation in the ultimate capil-
laries is kept moving, the gums and
peridental tissue will frequently re-
tain their immunity, even though
malnutrition be present. Pyorrhea
alveolaris is a result of malnutrition
plus infection, and also most fre-
quently plus irritation, and it is
greatly intensified if arteriosclerosis
of the ultimate capillaries sets in.
All forms must commence with some
form of gingivitis, but the tissues
vary markedly in clinical appearance.
The writer is inclined to recognize
particular types of pyorrhea accord-
ing to the associated disease, e.g., dia-
betic pyorrhea, tuberculous pyorrhea,
etc. The symptomatology and treat-
ment difTer in each type. The prog-
nosis largely depends on the possibil-
ity of curing the malnutritional fac-
tor. Often the pyorrheal changes
will appear long before the signs of
the underlying disease are sufficiently
developed to permit a diagnosis.
There are cases, however, in which a
decrease in the functional power of
the teeth themselves is the chief
cause. This is usually due to such
conditions as loss of one or more
teeth, irritation from unpolished fill-
ings, etc. Often when the underlying-
constitutional cause is found it will
not be recognized as such, but will
RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS). 33
be regarded as secondary to the pyor- may initiate pneumonia. The chronic
rhea. M. L. Rhein (Jour. Amer. processes of the series are benefited
Med. Assoc, Feb. 10, 1917)). ^^ autogenous vaccines in most in-
Hartzell's work points strongly to ^^^^^^^^^ j^ ^^^^^^ ^^^^^ ^^ ^,^^ ^.^^^^^
the importance of the streptococcus m .
pyorrhea, indicating that approxi- there IS apparently no pus. This seem-
mately three-fourths of the bacterial ing absence may be due to shallow or
content of the pus pockets is made up wide open pockets, the pus being
of pyogenic cocci of the Streptococcus cashed away by the oral secretions as
7'fru/fl;;.y and staphylococcus types, and ... ■. ■ r j •. u j
. ., r .1 rapidly as it IS lormed. or it may be due
the remammg one-tourth ot other . . -^
organisms. Personal observations to an inactive phagocytosis, or both
relative to the occurrence of strepto- (Merritt).
cocci, staphylococci, and pneumococci TREATMENT. — One important
in pyorrhea would place streptococci feature in this connection is the pres-
in the first rank as regards frequency, r i. j. i- i i .li i j
, , , . .1-1 ence of tartar, particularly the hard
staphylococci next, while pneumo- ^ •'
cocci are observed in only a small variety derived from blood-serum and
percentage of cases. A. W. Lescohier made up of various phosphates, car-
(Jour. Amer. Med. Assoc, Feb. 10, bonates and often dark in color. This
^^^'^- is a calculus which forms along the
PATHOLOGY. — The inflamma- edges of the gums and peridental
tory process starts at the margin of membrane. The first step is to care-
the gum and soon involves the dental fully rid the teeth of any tartar that
periosteum and surrounding alveolar may be present, and the gums of
wall. The latter being a medullary decayed teeth, badly fitting crowns
space in the maxilla, a morbid process and fillings, angular projections from
similar to osteomyelitis develops, end- the latter, etc. In a word, the patient
ing in necrosis. The endameba buccalis should be placed in the hands of a
can not infrequently be detected, and all competent dentist, who should be
the more common pyogenic bacteria informed of the end in view,
may occur in the lesions. The pneu- Introduction of an accessory medi-
mococcus is also found in most cases, cinal treatment of pyorrhea followed
As shown by Rosenow and Billings, the discovery of Barrett and that an
there is a close connection between actively motile Endameba buccalis
the pneumococcus and the streptococ- occurred in pyorrhea pus pockets,
cus, some strains of the latter taken The fact that dysentery, due to an
from tonsillar crypts having been con- endameba, yielded promptly to emetine
verted under various cultural con- hydrochloride suggested its use, a
ditions into typical pneumococci. solution of J^ per cent, of this salt
The same convertibility occurs in the being injected into the pockets. In
streptococci of pyorrhea. Hence the several instances of the 13 cases
fact that, precisely -as in the case with treated the pus disa]:)peared in 24
the tonsils, streptococci in pockets of hours and the gums assumed a health-
pyorrhea alveolaris may give rise to ier appearance after the third or sec-
rheumatic joint infections, arthritis ond injection. Bass and Johns (New
deformans, endocarditis, pericarditis, Orleans Med. and Surg. Journal, vol.
exophthalmic goiter, goiter, gastric Ixvii, p. 456, 1914) then tried the
ulcer, etc., while the pneumococcus drug hypodermically, giving y^ grain
8—3
34
RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS).
(0.03 Gm.) until the amebse had dis-
appeared and keeping up the effects
by local applications of 2 or 3 minims
(0.12 to 0.18 CO.) of the fluidextract
of ipecac to the gums with the tooth-
brush after carefully cleansing the
teeth. These agents sometimes seemed
curative in mild cases, but when the
morbid process was severe the organ-
ism was observed to recur.
Of 190 cases examined 187 showed
endamebffi. Of the 187, 78 have been
treated for pyorrhea. Of the 78
treated, none lost their endamebse
permanently. The condition of the
gums and teeth was greatly improved
in 3 cases, moderately improved in 9
cases, slightly improved in 22 cases,
while 41 cases remained the same;
the results were doubtful in 2 cases
and 1 case became worse. Practically
all that were found negative for
endamebjE at the conclusion of the
injections were found positive for
endamicbae from two weeks to four
months later, in spite of using a
solution of ipecac as a mouth-wash.
Emetine is an amebicide, but alone
will not cure pyorrhea alveolaris. J.
S. Ruofif (U. S. Public Health Report,
Reprint, 320, 1916).
Suspecting that pyorrhea is due to
certain spirochetes. Kritchevsky and
Seguin have used neoarsphenamine.
Good results in 60 cases reported
from mercury succinimide injections.
In the pyorrheal secretions numbers
of large spirochetes were observed
which generally disappeared almost
completely as a result of the injec-
tions. Among 244 cases the spiro-
chetes were found in large number in
three-fourths of all instances. In
healthy mouths, they were usually
absent or few. Six to 10 injections of
0.1 to 0.6 Gm. of neoarsphenamine
among 42 patients all showing numer-
ous spirochetes caused disappearance
of the latter in 29 cases, in the ab-
sence of all local treatment. Clinical
improvement was marked. The treat-
ment recommended for pyorrhea is as
follows: Intravenous injection of 0.1
to 0.3 Gm. of neoarsphenamine. If
contraindications or special technical
difficulties exist, intramuscular injec-
tions of mercury succinimide. Where
the tooth is entirely loosened and the
alveolar process destroyed, the tooth
had best be removed. If the process
is but partly involved the roots
should be scraped and even carefully
polished. Fluorine salts assist in
breaking up the tartar. Neoarsphena-
mine should also be introduced in the
pyorrheal pockets in solution or
powder form. Recurrence is obviated
only by persistent, careful cleansing
of the teeth. B. Kritchevsky and P.
Seguin (Presse med.. May 13, 1918).
Some observers have reported good
results from the use of a stock bacterin
or autogenous vaccine.
In the cases studied by the writers,
streptococci predominated, but were
associated in some instances, either
with Staphylococcus aureus, S. albus,
or with S. citreus. In 2 cases there
. was found an association of the strep-
tococcus and of the Bacillus pHeuinojiice,
once with the Micrococcus catarrhalis,
and twice with a pneumococcus.
A sensitized vaccine against the
streptococcus, staphylococcus, pneu-
mococcus, and bacillus of Friedlander
was thereupon prepared. For M.
catarrhalis a Wright vaccine was
made. Vaccine injections were then
made. After 2 injections, when the
antibodies began to take hold, a
mechanical and dental treatment —
Younger's — was begun. After from
4 to 5 injections, it was found impos-
sible, either by microscopic examina-
tion or by cultures, to discern the
presence of the bacteria. The authors
have kept in touch with a number of
cases for six months after treatment.
These cases have shown no recur-
rence. Bertrand and Valadier (N. Y.
Med. Jour., Jan. 10, 1914).
A stock vaccine may be used, either
sensitized or unsensitized, or an
autogenous vaccine prepared from
the pus pockets may be employed.
If the autogenous is preferred, care
ROCKY MOUNTAIN SPOTTED FEVER (WITHERSTINE),
35
should be taken to select an experi-
enced bacteriologist for its prepara-
tion. If an unsensitized bacterin is
employed, the initial dose advised is
ISO million of the mixed bacteria;
250 to 750 million may be given as
the initial dose if the sensitized cul-
tures are employed. Subsequent
doses are injected at intervals of
seven to ten days, gradually increas-
ing or decreasing according to indi-
cations. If the reactions are too
severe, the doses should be reduced
or temporarily discontinued. Every
dose should be carefully gauged by
the effect obtained from the preced
ing dose. If no improvement follows
the initial dose, subsequent injections
should be increased until amounts
large enough to produce a mild clin-
ical reaction (demonstrated by symp-
toms of malaise and possibly aggra-
vation of the local symptoms) are
reached. If a marked clinical reac-
tion occurs after a dose, characterized
by rising temperature, the next dose
should be smaller. F. E. Stewart (N.
Y. Med. Jour., Aug. 7, 1915).
Injections of succinimide of mer-
cury (1 grain — 0.065 Gm.) weekly are
announced as curative by Wright and
White (U. S. Navy), from one to six
doses having been sufficient in their
cases besides the local measures.
Copeland (Dental Cosmos, Feb.,
1916) confirms these observations.
He usd a B. W. 8z Co. glass syringe
holding 40 minims (2.5 c.c.) and a
No. 26 intramuscular needle, the
solution being % grain (0.013 Gm.)
of mercuric succinimide to 4 minims
(0.25 c.c.) of hot, sterile distilled
water. The injections are made into
the buttock after sterilization of the
skin.
The writer advocates surgical meas-
ures, removing the diseased tissues
under novocaine anesthesia, then pack-
ing with iodoform gauze to promote
drainage and granulation. The pa-
tient is shown how to flush his teeth
with warm saline solution after eat-
ing for the post-operative week. This
operation does not cure pyorrhea; it
is the only method which prevents
secondary infection. Nodine (Dental
Cosmos, Ixiii, 345, 1921).
The writer resorts to gingivoec-
tomy, cutting away under local anes-
thesia all loose, infected and diseased
tissues to eradicate peridental infec-
tion. He claims to have obtained a
cure in 90 per cent, of his cases.
Ziesel (Dental Cosmos, Ixiii, 352,
1921).
Time will probably show that such
active surgical procedures are un-
necessary to cure pyorrhea.
Prophylaxis is an important fea-
ture : scrupulous cleanliness of the
mouth and regular visits to the den-
tist to check any incipient disorder of
the teeth or gums.
C. E. DE M. Sajous,
Philadelphia.
RINGWORM. See Trichophy-
tosis.
ROCHELLE SALTS. See Po-
tassium AND Sodium Tartrate.
ROCKY MOUNTAIN SPOT-
TED FEVER (TICK FEVER).-
This eruptive disease has been known
in the valley of the Bitter Root River
in Western Montana and in Idaho
since 1873, although the first specific
reference to it in literature was made
in 1896 by the Surgeon General of the
Army in his annual report. The dis-
ease has since been reported from
nearly all the States in the Rocky
Mountain group, California, Colorado,
Idaho, Montana, Nevada, Oregon,
Utah, Washington and Wyoming.
Cases have also been reported from
the District of Alaska. The disease is
especially interesting on account of
its geographical limitation, seasonal
prevalence, intimate association with
36
ROCKY MOUNTAIN SPOTTED FEVER (WITHERSTINE).
wood ticks, and variation in severity
in different localities. It is api)arently
confined to the American Continent,
being- found only between 40° and 47°
north, and at an average elevation of
between 3000 and 4000 feet above
sea level. It prevails exclusively in
the spring and early summer; in the
Bitter Root cases the earliest was
March 17 and the latest July 17.
Those whose duties take them into
the brush and expose them to the bite
of ticks are subject to the disease,
especially stockmen, sheep herders,
miners, prospectors, lumbermen and
ranchmen. The greatest morbidity is
in persons between 15 and 50 years of
age, presumably because they are
most actively engaged in outdoor
work, and, for the same reason, males
most often fall victims to this disease.
It is not contagious ; 2 cases of the
disease have never been observed in
the same family the same season.
SYMPTOMS.— Incubation.— There
is a stage of incubation lasting from
three to ten days, usually about seven.
For a few days the patient complains
of chilly sensations, malaise, and nau-
sea, then has a distinct chill and takes
to his bed. Soon there are pains in
the back and head, and a feeling of
soreness in the muscles and bones,
with a sensation as if the limbs were
in a vice. The bowels are constipated
and the tongue is covered with a
heavy white coat, but red at the tip
and edges. The conjunctivae are con-
gested, and later become yellowish in
color. The urine is usually scanty
and contains albumin and casts.
Epistaxis, at times alarming, is
always present, and slight bronchitis
appears after a few days.
Fever. — Before the distinct chill
there is a slight rise of temperature
in the afternoon, l)ut little or no fever
in the morning. After the chill there
is an abrupt rise, with a gradual
increase of the fever in the evening,
and a slight morning remission, the
maximum being usually reached be-
tween the eighth and twelfth days.
In a favorable case it then gradually
falls, reaching normal about the four-
teenth to the eighteenth day, usually
going to subnormal for a few days.
In fatal cases the fever remains higli
(104° to 106° F.— 40° to 41.1° C.;,
and the morning remissions are either
absent or very slight. Yet the tem-
perature may rise to 105° or 106" F.
(40.6° to 41.1° C.) by the seventh or
eighth day, ending in favorable cases
by lysis on tlie ninth or tenth day.
Circulation. — The pulse is acceler-
ated out of all proportion to the
temperature, a pulse of 120 being
common with a temperature of only
102° F. (38.8° C.) ; the pulse usually
varies from 110 to 140; it is weak and
thready ; a full, strong pulse is excep-
tional ; during the first week it may
be dicrotic. There is a progressive
diminution in the number of red
blood-cells, but when the temperature
reaches normal an increase begins.
The white blood-corpuscles are
increased in number varying from
8,000 to 12,000; an average differen-
tial count would give : polymorphonu-
clear leucocytes, 77 .7 per cent. ; large
mononuclears, 11.4 per cent.; small
lymphocytes, 10 per cent. ; eosino-
philes, 0.9 per cent. ; the most marked
feature being an increase in the large
mononuclears. The hemoglobin is
steadily but slowly decreased — it may
go as low as 50 per cent. The blood
will not agglutinize Bacillus typhosus;
fresh and stained blood contains three
forms of the pathogenic parasite.
ROCKY MOUNTAIN SPOTTED FEVER (WITHERSTINE).
17
A sudden rise in the leucocyte
count is an unfavorable sign.
Eruption. — On the third day the
eruption usually appears, first on
the wrists and ankles, then on the
arms, legs, forehead, back, chest, and,
last and least, on the abdomen.
Although the other portions of the
body may be closely covered by the
eruption, it is always scanty on the
abdomen.
The spots are at first bright-red,
always macular, and in size from a
pinpoint to a split pea, at first dis-
appear on pressure and return quickly ;
in severe cases they rapidly become
darker, even purplish in color. From
the sixth to the tenth days of the
disease, the spots do not disappear on
pressure and are decidedly petechial
in character. In favorable cases,
about the fourteenth day they lose
their petechial character and disap-
pear slowly on pressure. The erup-
tion may assume the appearance of a
turkey-egg, the skin being flecked
with small, brownish spots. The erup-
tion fades as the fever declines, but
an access of fever, a warm bath, or a
free perspiration will bring it out dis-
tinctly. Desquamation begins when
convalescence is well advanced and
is general. In very severe cases there
may be gangrene of the fingers, toes,
and more frequently of the skin of the
scrotum and penis. Jaundice is
always present, first in the conjunc-
tivae and later involving the entire
cutaneous surface.
The Gastrointestinal Tract. — The
tongue is covered at first with a
heavy, whitish coat, except on the
edges and tip, which are red ; later the
coating is dark brown and sordes
covers the teeth. The appetite is often
good throughout the first week.
although there may be slight nausea.
In fatal cases the nausea increases
during the second week and persists.
Constipation is always present and
continuous. Gurgling is seldom found
m the right iliac fossa and tympanites
is never excessive. Moderate increase
in the size of the liver is present, and
the spleen is enlarged early and may
extend one or two inches below the
ribs. Black vomit is common.
The Urinary Tract. — The urinary
output is one-half the normal. Albu-
min in small amount is present in all
cases, associated with granular, hya-
line, and epithelial casts. Nephritis
may appear early in the history of
the case.
The Respiratory Tract. — The res-
pirations are always accelerated, be-
ing usually from 26 to 40 per minute,
although they may reach 50 to 60;
they are regular but often shallow.
Slight bronchitis always appears in
the second week. In fatal cases lobar
pneumonia is a frequent complication.
Epistaxis is generally observed from
the beginning of the second week.
Nervous System. — Headache and
pains in the back are usually severe
during the first week. A feeling of
soreness in the muscles and bones,
often very severe, even in mild
cases, is present and persists until
recovery. The mind is usually clear,
in severe cases, until a few hours
before death.
DIAGNOSIS. — Diagnosis Is usually
easy in cases occurring in infected
localities, which present a history of
tick-bites and the typical symptoms of
this disease; a blood examination will
clear up any doubtful case. There
are, however, five diseases to which
it bears more or less close resem-
blance from which this disease must
38
ROCKY MOUNTAIN SPOTTED FEVEK (VVITHERSTINE).
be differentiated: deni^ue, cerebro-
spinal menins^itis, pcliosis rhcumatica,
typhoid and ty])hus fevers.
Dengue is a disease of tropical and
subtropical countries, while spotted
fever is found at elevations of from
3000 to 4000 feet above sea-level
The swollen joints, polymorphic erup-
tion (never petechial) over the joints,
apyretic period, and short duration of
dengue would distinguish it.
Cerebrospinal meninyitis is marked
by the characteristic stiffness of the
neck muscles, photophobia, extreme
sensitiveness to sudden noises, head-
ache, rigidity of the muscles of the
back and neck, and a rash which is
not only irregular in location, but also
in appearance.
Peliosis rhemnatica is a compara-
tively rare disease in which there is
a characteristic sore throat associated
with multiple arthritis, purpura, and
urticaria.
Typhoid fever clinically closely
resembles spotted fever except in the
rose-colored spots (papular) which
appear first on the abdomen, the diar-
rhea, the Widal reaction, the presence
of typhoid bacilli in blood-cultures,
and the absence of the parasites
formed in the red blood-cells of spot-
ted fever.
Typhus fever so closely resembles
spotted fever that cases of typhus
fever occurring in a spotted-fever dis-
trict, without a blood examination and
close clinical observation, might easily
be counfounded with it. In typhus
fever, however, we have a larger incu-
bation, absence of tick-bites, the erup-
tion which appears first on the abdo-
men and chest, and an intensely con-
tagious character. Typhus is, more-
over, especially prevalent during the
winter months, and not during the
late spring and early summer, and is
accompanied by marked nervous
sym])toms.
ETIOLOGY.— Spotted fever is
caused by a protozoan parasite which
is transmitted to man thrrjugh the
bite of the wood tick (Dermacentor
andersoni). To Wilson and Chowning
belongs the credit of discovering this
parasite, three forms of which have
been identified by John F. Anderson,
the most common is a single ovoid
body, refractile, situated within the
red blood-cell, usually near its edge,
and closely resembling the earliest
intracorpuscular parasites of estivo-
autumnal malaria. When the blood
upon the freshly prepared slide is
warmed the parasite quite rapidly
projects pseudopodia and may change
its position slightly. A second form,
somewhat rarer, is larger, and larger
at one end and showing there a dark,
granular spot; this form is also ame-
boid. The third form, arranged in
pairs, is pyriform in shape, with the
smaller end approaching, and in some
cases being united by a fine thread.
The parasite is developed in the
female tick and the young ticks, after
being hatched, transmit the infection.
The female gets her infection by bit-
ing one convalescent from spotted
fever.
Three types of the spotted fever
parasite can be recognized: (1) An
extranuclear bacilius-Hke form with-
out chromatoid granules, relatively
large and only present in ticks dur-
ing the initial multiplication of the
parasites; (2) a relatively small rod-
shaped form with chromatoid gran-
ules, probably the same form seen
within nuclei in sections of ticks, and
rarely in smooth muscle cells in the
blood-vessel of mammals; and (3) a
relatively large lanceolate paired form
present in ticks and in the blood and
RUBELLA (CRANDALL).
39
lesions in mammals. The name Der-
macentroxcmis rickcttsi is proposed.
S. B. Wolbach (Jour. Med. Re-
search, Nov., 1919).
PROGNOSIS. — The mortality
varies between 70 and 90 per cent.
Death usually occurs between the
sixth and the twelfth day. There is
no relation between abundance of the
eruption and severity of the disease.
TREATMENT. — Quinine bimuri-
ate in 15-grain (1 Gm.) doses every
six hours, preferably hypodermically,
has yielded excellent results in the
hands of Wilson and Anderson. Qui-
nine sulphate, 15 grains (1 Gm.), may
be given by mouth every four hours,
and should be begun as soon as the
■diagnosis is made, and persisted with
in decreasing doses as convalescence
begins. The heart should be sup-
ported with strychnine, whisky (egg-
nog), or other cardiac stimulants.
The severe pain in the head and
back, during the first week, may be
relieved by the use of Dover's powder
or morphine sulphate. It is well to
flush the kidneys through the use of
copious draughts of water. Warm
sponge baths or packs are useful in
controlling the fever. The room
should be darkened and free from
noise. In the way of diet milk, butter-
milk, broths, soft-boiled eggs, and
moistened toast may be given.
In the way of prophylaxis, Ander-
son advises that as soon as a person
is bitten by a tick the insect should
be removed and 95 per cent, carbolic
acid applied to the spot. If there is
difficulty in removing the tick, Ander-
son suggests the application of
ammonia, turpentine, kerosene, or car-
bolized petroleum to it.
The treatment is rather unsatisfac-
tory, being mainly supportive and
symptomatic; the only drug of much
service is sodium citrate given in-
travenously to the limit of tolerance
from the start. Sixty c.c. of a 5 per
cent, fresh sterile solution may be
given intravenously twice daily. H.
C. Michie and H. H. Parsons (Med.
Rec, Feb. 12, 1916).
C. Sumner Witherstine,
Philadelphia.
RUBELLA, Rotheln, German
measles.
DEFINITION. — Rubella is an
acute, infectious, contagious disease
of mild character, presenting some-
what variable symptoms and running
a favorable course. Its identity as a
disease, siii generis, was long doubted.
There is now no question, however,
that it is a distinct entity among dis-
eases, though it strongly resembles
in its different manifestations measles
and scarlet fever. No better state-
ment of present beliefs regarding its
true character has been made than
that of Griffith, which is as follows :
"(1) rubella is a contagious, eruptive
fever, and not a simple affection of
the skin; (2) it prevails independently
either of measles or of scarlet fever;
(3) its incubation, eruption, invasion,
and symptoms diff'er materially from
both of these diseases ; (4) it attacks
indiscriminately and with equal sever-
ity those who have had measles and
scarlet fever and those who have not,
nor does it protect in any degree
against either of them; (5) it never
produces anything but rubella in
those exposed to its contagion ; (6) it
occurs l)Ut once in the indi\'idual."
PERIOD OF INCUBATION.—
This period is, according to Holt, 8
to 16 days, the limits being 5 to 22
days ; Rotch, 21 days ; Edwards, 7 to
14 days ; Plant, 1 to 3 weeks ; Smith,
about 2 weeks. These figures clearly
40
RUBELLA (CRANDyVLL).
show that the period of incubation is
of considerable length and extremely
variable. The indefiniteness arises
not so much from lack of observation
as from variability in the disease. To
say that the period of incubation is
about two weeks is probably as cor-
rect and definite a statement as can
be made.
SYMPTOMS.— The symptoms of
rubella are extremely variable, so
much so in fact that we must agree
with Rotch that it is impossible to de-
scribe a typical case in such a way
that the disease can be certainly di-
agnosticated in a sporadic case.
Many cases, however, run a fairly
consistent and characteristic course.
The invasion is seldom severe. In
some cases there is a prodromal stage
lasting a few hours ; in others the
rash is the first svmptom to be ob-
served. The fever is rarely high and
often does not rise above 100° F.
(37.8° C), but commonly, when at its
height, on the first day of the erup-
tion, it reaches 101° or 102° F. (38.3°
or 38.9° C). It occasionally rises to
104° F. (40° C.) or more. The
drowsiness, stupor, and other evi-
dences of serious illness so frequently
seen at the height of measles are
rarely, if ever, seen in rubella. A
child with a bright and very exten-
sive eruption will frequently show no
sign of general illness.
In my own experience sore throat
has been the rule. The tonsils and
pharynx are red and swelled and there
is pain on swallowing. This is oc-
casionally so marked as to be sug-
gestive of scarlet fever; the vomiting
so common at the outset of that dis-
ease, however, is rarely present. A
secondary sore throat which comes on
as the disease is subsiding was first
noted by Eustace Smith as very char-
acteristic of rubella. It certainly oc-
curs in some cases. Koplik's spots
do not ai)pear. The symptoms of the
]M-imary angina subside on the second
or third day and rapidly disappear.
There are no catarrhal symptoms in
most cases, but occasionally slight
suffusion of the eyes and a mild ca-
tarrh will render the diagnosis from
measles more difficult. Albuminuria
is rarely if ever present, and the diazo-
reaction is extremely rare. Moderate
leucocytosis occurs during the incu-
bation period, but disappears as the
eruption fades.
Hematological diagnosis of ro-
theln. Three cases under treatment
appeared clinically as measles, but
the first soon proved itself rotheln.
Two weeks later two similar cases
were admitted. The writer then com-
pared the blood-counts of the cases
with examples of true measles. He
found that in rotheln at the high
point of the disease there was none
of the disappearance of eosinophiles
which characterizes measles; nor was
there the leucopenia regarded as
normal in the latter disease. Schwaer
(Mitnch med. Woch., May 27, 1913).
Enlargement of the postcervical
and suboccipital glands is a very con-
stant and very characteristic symp-
tom of rubella. Numerous small
glands may almost invariably be felt
behind the sternomastoid well down
toward the shoulder; they rarely be-
come very large and never suppurate.
They may be felt most distinctly
when the rash is at its height, and
disappear rapidly. While they aid
materially in diagnosis, and may per-
haps be called diagnostic, they are
certainly not pathognomonic, for they
may at times be met in measles and
in rare cases be found in scrofulous
children without febrile symptoms.
RUBELLA (CRANDALL).
41
Most salient features by which one may distinguish rubella from measles
and scarlet fever are as follows, as given by N. S. Manning: —
Rubella.
Measles.
Scarlet Fever.
Invasion
Nil.
Three to five days,
with pyrexia and
conjunctival and
bronchial catarrh.
Twelve to twenty-
four hours, pyrexia,
headache, and
vomiting.
Catarrh
Slight or absent.
Marked conjunctivitis,
coryza, cough, etc.
Absent.
Eruption
Appears on face and
chest as bright,
pink-red maculre,
first under the cuti-
cle, which become
raised, with tend-
ency to spread and
Appears on face as
darkish-red, slight-
ly raised papules ;
extends to trunk
and limbs ; papules
become confluent,
but distribution is
Appears on chest as
diffuse general red-
ness of skin.
form irregular
patches or become
diffuse.
more uniform.
Throat-lesions
Slight swelling and
injection of fauces.
Fauces injected.
All the faucial struct-
ures acutely in-
flamed, swelled and
red, or ulcerated.
Tongue
Furred.
Furred.
Thickly furred, which
begins to strip off
in twenty- four or
forty-eight hours.
Superficial lymphatic
glands
Always enlarged in
axillt-e, groins, and
behind stcrnomas-
toid muscle in neck.
May be enlarged at
angles of jaw and
behind sternomas-
toid muscle.
leaving raw sur-
face, with enlarged
papill?e.
May be enlarged at
angles of jaw and
behind sternomas-
toid muscle.
Desquamation
Absent or very slight.
Branny.
Characteristic peeling
off of large pieces
of epithelium.
Forchheimer describes an exan-
them which is seen in the mouth as
the exanthem appears on the body. It
usually lasts about twenty-four hours.
"It consists of a macular, distinctly
rose-red eruption, upon the velum of
the palate and the uvula, extending
to but not on the hard palate. The
spots are arranged irregularly, not
crescentically, of the size of large
pinheads, very little elevated above
the level of the mucous membrane,
and do not seem to produce any reac-
tion tipon it."
The eruption appears first upon tlie
face or forehead and extends rapidly
over the neck, trunk, and limbs. The
whole body is usually covered within
twenty-four hours. Occasionally the
child will wake in the morning with
a rash covering the greater portion of
the body. In many cases the rash is
limited to small areas, the greater
portion of the body escaping entirely.
It is more constant upon the face than
any other region. In some cases the
rash continues not more than twenty-
four hours, but, as a rule, it is present
from two to four days. Itching is
common at the outset.
42
RUBELLA (CRANDALL).
A slight, scaly desquamation may
follow the disappearance of the rash,
but in many cases no desquamation
can be detected. This is particularly
true when inunction of the body has
been practised.
The eruption consists of papules or
maculopapules of a red or rose-red
color. They vary greatly in size,
varying from a pin's-head point to a
large blotch. Tliis multiform charac-
ter is one of the peculiarities of the
eruption of rubella. IMost of the
spots are smaller than those of
measles and larger than those of scar-
let fever. They vary in size on differ-
ent portions of the body, and even in
the same region the rash will be
found, as a rule, to be made up of
small dots interspersed with larger
and irregular-shaped spots or blotches.
It lacks the uniformity of the rash
seen in scarlet fever or measles. The
rash more commonly resembles that
of measles and it is frequently impos-
sible to make a diagnosis from it
alone. Edwards has recently alleged
that he has not seen the rash resem-
ble that of scarlet fever. That is not
my experience. I have frequently
seen a rash consisting of small points
grouped closely upon a reddened
skin that looked extremely like scarlet
fever. Search over the body, in such
cases, however, will usually reveal
small areas of eruption composed of
maculopapules, appearing as large
spots. These are commonly found
upon the arms, wrists, or hands. I
quite agree with those who describe
a scarlatinal and rubeolar type of
eruption. I have seen these two types
well marked in two children of the
same family exposed at the same time,
and ill in the same room. The rash
of one, consisting of large maculo-
papules ver}' strongly resembled
measles; that of the other, consisting
of much finer points on a reddened
skin, as strongly resembled scarlet
fever.
A disease was described by Clem-
ent Dukes, of England, in 1900, to
which he gave the name of "Fourth
Disease." The condition which is de-
scribed is virtually that which I have
here described as the scarlatinal form
of German measles. The differential
diagnosis given by Dukes between
German measles and fourth disease
describes a condition identical except
as to the rash. He admits that in
the same patient the eruption some-
times resembles measles and may
change later to a scarlatinal type.
The subject has received extended
study since Dukes promulgated the
theory of a fourth disease. After care-
ful observation of 1335 cases seen in
the London Fever Hospital, Beards
and Goldie did not see any they felt
thev could record as fourth disease.
AVatson Williams made a very care-
ful study of 2)2 cases of rubella and
questions the existence of a fourth
disease. Pleasants, of Baltimore, also
concludes that the existence of a new
exanthematic disease has not been es-
tablished. After an extended review
of the whole subject Ker concludes
that the fourth disease is either mild
scarlet fever or atypical rubella.
From study of the literature and from
considerable experience it seems to me
that we have not sufficient evidence
to warrant us in describing a fourth
disease.
ETIOLOGY.— Analogy leads to
the belief that rubella is caused by a
specific micro-organism, but the germ
has not yet been discovered. It is
contagious, though not as strongly so
RUE.
43
as scarlet fever and measles. Its con-
tagious power at times seems to be
very slight. It is most contagious
when the eruption is at its height. It
is rarely, if ever, seen under six
months, but after that age no period
of life is exempt. It is most common
between 5 and 10 years. The recur-
rence of true rubella is rare. The
disease usually occurs in epidemics,
which are most common in the spring.
COMPLICATIONS AND SE-
QUELJE. — No other infectious dis-
ease is so free from complications.
This is, in fact, one of the most
marked peculiarities of rubella. Even
varicella sometimes shows a serious
complication : that of gangrene. No
such serious symptom is likely to arise
in rubella. The pneumonia, otitis,
erysipelas, and multiple abscesses,
which in rare instances have been re-
ported as accompanying rubella, are
perhaps not in every case a complica-
tion, but rather a coincidence.
The writer reports the following
unusual case: The patient, a male, de-
veloped, after a few days of sore
throat, stifi neck, malaise, and moder-
ate fever, a rash having the distribu-
tion and appearance of German meas-
les and accompanied by an enlarge-
ment of superficial glands, notably
those of the neck. Before the exan-
them had faded the patient began to
complain of stiffness and tenderness
in the knees and ankles, and soon
all the interphalangeal joints of the
fingers presented the spindle-like
swelling commonly seen in rheuma-
toid arthritis. There was no exacer-
bation of temperature and neither
cardiac nor other complication. A
fortnight from the appearance of the
rash all the symptoms were subsiding,
and in the six months there was only
an occasional transient stififness in
the fingers. D. A. Alexander (Lan-
cet, ii, p. 921, 1907).
In an epidemic in an institution
for children, out of 80 cases 2
children developed chickenpox before
recovering from rubella, 1 developed
rubella before recovering from chic-
kenpox, and 1 child had a severe
ulcerative stomatitis. May Michael
(Arch, of Pediat., Aug., 1908).
PROGNOSIS. — Death from ru-
bella is extremely infrequent. In rare
cases in which it occurs it is usually
the result of some pulmonary disease,
occurring either as a complication or
as a coincidence.
TREATMENT.— Rubella requires
very little, if any, treatment. Mild
treatment appropriate to any febrile
condition is permissible, but if the
patient is kept in bed while the fever
and rash continue, and is anointed
daily with oil, further treatment will
rarely be required. Symptoms must
be treated as they arise. In most
cases the disease as such is of but lit-
tle importance, its chief interest lying
in its diagnosis, owing to its resem-
blance to two more serious diseases.
Floyd M. Crandall,
New York.
RUBEOLA. See Measles.
RUE.— Rue (Ruta) is the leaves of
Riita gravcolens (fam. Rutaceas), a peren-
nial herb or undershrub of Southern Eu-
rope, but cultivated elsewhere as a domes-
tic medicinal herb. The important con-
stituent (0.06 per cent.) of rue is a volatile
oil, colorless or slightly yellow and of low
specific gravity, and extremely unpleasant
and odorous. It was official in the U. S.
r. from 1870 to 1890. Rue also contains
a glucoside (rutin-rutic or rutinic acid)
which is yellow and crystalline and ap-
parently identical with the barosmin of
buchu, considerable sugar, and possibly a
volatile alkaloid.
PREPARATIONS AND DOSES.—
Oleum mice (oil of rue). Dose, 3 to 6
minims (0.20 to 0.40 c.c), in capsule.
Ruta (rue). Dose, 15 to 30 grains (1 to
44
SACCHARIN.
2 Gm.), usually in infusion. Neither
preparation is now official.
PHYSIOLOGICAL ACTION.— Rue is
a local irritant and vesicant. Internally
it is a stimulant, carminative and em-
menagogue. In large doses it is an
irritant poison, producing severe gastro-
enteritis, vomiting, abdominal pain and
meteorism, bloody stools, suppression of
urine, or stranguary, and epileptiform con-
vulsions. Dimness of vision with con-
tracted pupils are observed. Abortion may
result from toxic doses. It has some spe-
cial action upon the genitourinary tract,
and is eliminated in the breath, the urine,
and in the perspiration. It is rarely fatal,
THERAPEUTIC USES.— In medicinal
doses it is given as a uterine stimulant in
atonic amenorrhea, menorrhagia, and me-
trorrhagia. Its employment as an aborti-
facieiit entails great danger to the mother.
Hysteria, especially when associated with
amenorrhea, is benefited by the drug. It
has also been friund xiscful in flatulence
and infantile convulsions. In defective
activity of the sexual organs, it acts as
an aphrodisiac and emmenagogue. The
bruised leaves of rue laid upon the fore-
head has been used by Phillips to check
epistaxis. Added to liniments rue has
found favor as an application to the
chest in chronic bronchitis. A decoction
of the fresh leaves may be used as
an injection against seatvirorms (oxyuris)
and has often been given internally to
expel roundworms (ascarides). W.
SACCHARIN. —Saccharin (benzo-
sulphiiiidum, U. S. P.; glusidum, Br.;
neosaccharin; gluside; benzoyl sulphonic-
imide), or the anhydride of orthosulpha-
mide- — benzoic acid (C7H5NO3S), is a coal-
tar derivative obtained commercially from
toluene discovered by C. Fahlberg in 1879.
Saccharin occurs as a white, crystalline
powder, nearly odorless, having an in-
tensely sweet taste even in dilute solu-
tions. Iti is soluble in 250 parts of water
and in 25 parts of alcohol, and but slightly
soluble in ether and chloroform. It read-
ily dissolves in 24 parts of boiling water.
Saccharin dissolves also in glycerin. Its
solubility in water is promoted by the ad-
dition of sodium bicarbonate in the pro-
portion of 2 parts to 3 of saccharin.
Saccharin forms soluble salts with the hy-
drates of the alkaline metals. It melts at
220° C. (428° F.), and when fused with
potassium or sodium hydroxide it forms
salicylic acid. It is 300 times sweeter than
cane-sugar.
Sodium saccharin, also known as soluble
saccharin, soluble gluside, and crystallose,
is prepared by neutralizing an aqueous
solution of saccharin with sodium car-
bonate or bicarbonate and slowly crys-
tallizing the solution. It occurs in color-
less crystals, very soluble in water, in-
tensely sweet to the taste, and not dis-
colored by concentrated sulphuric acid.
It is a favorite substitute for saccharin be-
cause of its greater solubility.
Saccharin when present in food products
or mixtures may be separated by extract-
ing the saccharin from an acidulated
solution of the substance with ether, sep-
arating the ether and then evaporating the
ethereal solution thus obtained. The aver-
age dose of saccharin is 3 grains (0.2 Gm.).
PHYSIOLOGICAL EFFECTS. — Sac-
charin apparently is not decomposed in
the body, as it is excreted by the kidneys
imchanged; the urine, however, does not
so readily undergo fermentation and the
chlorides are increased. Mathews and
McGuigan, in studying the effects of sac-
charin on oxidation and digestion, report
that it has a marked retarding action on
oxidation in the blood and muscles, and
also on the action of the digestive juices,
especially those of the salivary glands
and pancreas. Its prolonged use is likely
to cause digestive disorders. When in-
jected into the circulation of an animal, it
produces depression and stupor, followed
by labored respiration, similar to asphyxia.
The writers attribute these effects to its
inhibitory action on the enzymes of the
blood and tissues, which also explains the
headaches and other symptoms its use
often gives rise to. It is believed to be a
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 45
general protoplasmic poison in that it in-
hibits fiearly all the fermentative processes
of the body, and interferes with and
diminishes general bodily metabolism.
Saccharin has antiseptic properties which,
however, are impaired in the presence of
an acid medium.
POISONING BY SACCHARIN.—
Large doses of saccharin are capable of
producing marked toxic symptoms, as in
a case reported by Luth, where a woman
having swallowed about 30 grains (2 Gm.)
of saccharin was found in a state resem-
bling that of alcoholic intoxication. She
was unconscious and foamed at the mouth.
Her face was flushed and she suffered
from convulsive attacks, with choking.
The respirations were rapid and the pulse
weak, very rapid, intermittent, and irregu-
lar. Poisoning by saccharin is rather rare.
TREATMENT OF POISONING.— In
the foregoing, under artificial respiration
and massage of the heart, the pulse within
half an hour became stronger and regular,
and the respiration became normal. After
forty-five minutes the patient awoke and
felt quite well.
THERAPEUTIC USES. — Saccharin is
chiefly used as a sul)stitute for sugar in the
diet of obese and diabetic patients. Tablets
containing Yi grain (0.03 Gm.) of saccharin
combined with a small quantity of sodium
bicarbonate are conveniently carried by
these patients to be used in tea, coffee, etc.
It may also be prescribed in the form of
a syrup containing 10 parts of saccharin
and 12 parts of sodium bicarbonate in 1000
parts of distilled water, made with gentle
heat at 104° F. (40° C). Saccharin in small
doses has been used in acid dyspepsia and
in chronic cystitis with ammoniacal urine.
Two parts of saccharin in solution with
3 parts of sodium bicarbonatei forms a
good tooth-wash. Aphthae yields to sac-
charin; 15 grains (1 Gm.) of saccharin are
dissolved in IJ/2 ounces (50 c.c.) of alcohol,
of which a teaspoonful is added to a half-
cup of water, and used to wash the mouth
thoroughly four or five times a day. It
may be used to cover the taste of quinine,
1 part of saccharin to 2 of quinine be-
ing used. As saccharin retards the action
of all the digestive ferments, it is contra-
indicated in cases in which digestion is
already impaired. W.
SALICYLIC ACID, THE SAL-
ICYLATES, AND SALICIN.—
Salicylic acid, chemically ortho-oxy-
benzoic acid [C6H4(OH)COOH] is
an organic acid existing naturally in
the oils of wintergreen (GaiUthcria
procumbcns) and of sweet birch
(Bctula Icnta) in combination as
methyl salicylate. It was first arti-
ficially made in 1874 by Kolbe, who
produced it from phenol, cailstic soda,
and carbon dioxide with the aid of
moderate heat and subsequent treat-
ment with hydrochloric acid. The
solubility of salicylic acid in water,
normally relatively slight, is increased
by the addition of the phosphates,
citrates, or acetates of the alkalies,
and by borax (sodium biborate).
Pure salicylic acid should be free from
color and from the odor of phenol ;
when heated on platinum foil, it
should leave no ash.
Various salts of salicylic acid are
official. There are also in common
use a number of other substances con-
taining the salicyl radicle, including
such drugs as acetyl-salicylic acid and
salicin. The last named, a glucoside
obtained from the bark of several
species of Salix and Populiis, supplied
the original name for the entire group
of drugs, the word salicyl being
derived from Salix.
PREPARATIONS AND DOSE.
— the following salicyl preparations
are official : —
Acidum salicylicnm, U. S. P. (sali-
cylic acid), occurring in fine prismatic
needles or a bulky, white powder,
with a slight odor of wintergreen and
a taste at first sweetish, then acrid. It
is soluble in 308 parts of water at 77°
F. and in 14 jxirts of boiling water,
and in 2 parts of alcohol, in 60 parts
of glycerin, and in 2 parts of olive oil
46
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
(with the aid of heat). Dose, 5 to 20
grains (0.3 to 1.3 Gm.) ; average, 7i/2
grains (0.5 Gm.).
Ammonii salicylas, U. S. P. (ammo-
nium saHcylate) [CcH4(OH)COO-
NH4], occurring in prisms or plates
or as a white, crystalHne powder,
odorless, with a saline, bitter taste
and sweetish after-taste. It is freely
soluble in water and alcohol. Dose,
3 to 15 grains (0.2 to 1 Gm.) ; aver-
age 4 grains (0.25 Gm.).
Sodii salicylas, U. S. P. (sodium sali-
cylate) [C6H4(OH)COONa], a white
microcrystalline or amorphous pow-
der, occasionally with a faint pink
coloration, and having a sweetish,
saline taste. It is soluble in 0.8 part
of water and in 5.5 parts of alcohol,
and also dissolves in glycerin. Dose,
5 to 20 grains (0.3 to 1.3 Gm.).
Strontii salicylas, U. S. P. (stron-
tium salicylate) [(C6H4(OH)COO)o-
Sr+2H20], a white, crystalline
powder with a sweetish, saline taste,
soluble in 18 parts of water and in 66
parts of alcohol. Dose, 5 to 20 grains
(0.3 to 1.3 Gm.).
Phenylis salicylas, U. S. P. (phenyl
salicylate; salol) [C6H4(OH)COOCg-
H5], a white, crystalline powder with
a slightly aromatic odor and taste,
practically insoluble in water, but
soluble in 5 parts of alcohol and freely
soluble in ether, chloroform, and oils.
Synthetic or from Gaultheria or Be tula.
Dose, 3 to 15 grains (0.2 to 1 Gm.) ;
average, 7^^ grains (0.5 Gm.).
Methylis salicylas, U. S. P. (methyl
salicylate ; an artificial or synthetic
oil of wintergreen) [CgH4(OH)-
COOCHoJ, a colorless liqvud with a
strong wintergreen odor, a sweetish
strongly aromatic taste, and a specific
gravity of 1.18. It is sparingly soluble
in water, but dissolves readily in alco-
hol. Dose, 5 to 20 minims (0.3 to
1.3 c.c). Chiefly usecf externally.
Salicinitm, U. S. P. (salicin) [C13-
llisOx), a glucoside obtained from
several species of the willow (Salix)
and poplar (Populus), occurring in
colorless, silky, crystalline needles,
prisms, or a white, crystalline powder,
odorless, but with a strongly bitter
taste. It is soluble in 21 parts of
water and in 71 parts of alcohol, but
is insoluble in ether and chloroform.
Dose, 10 to 30 grains (0.6 to 2 Gm.).
Oleum betulcc, U. S. P., VIII (oil of
betula; oil of birch), a volatile oil
obtained by maceration and distilla-
tion from the bark of the sweet birch,
Betula lenta. Consists mainly of
methyl salicylate. Dose, 5 to 20
minims (0.3 to 1.3 c.c). Chiefly
used externally.
Oleum gaulthericc, U. S. P. VIII (oil
of gaultheria or wintergreen), a vola-
tile oil di'stilled from the leaves of
Gaultheria procumbens, consists mainly
of methyl salicylate. Dose, 5 to 20
minims (0.3 to 1.3 c.c). Chiefly used
externally.
Spiritus gaulthericc, U. S. P. VIII
(spirit of gaultheria), made by mixing
5 parts by volume of oil of gaultheria
with 95 parts of alcohol. Dose, 30
minims (2 c.c).
Bismuth subsalicylate, physostig-
mine salicylate, quinine salicylate, and
cafifeine sodiosalicylate (N. F.) are
described in the articles on Bismuth,
Physostigma, Cinchona, and Caffeine,
respectively.
Among the salicylic preparations
recognized in the National Formulary
are: —
Lithii salicylas, N. F. (lithium
salicylate) [C6H4(OH)COOLi], a
white or grayish-white powder with
a sweetish taste, deliquescent in a
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
47
moist atmosphere. It is freely soluble
in water and alcohol. Dose, 5 to 20
grains (0.3 to 1.3 Gm.).
Elixir litliii salicylatis, N. F. (elixir
of lithimii salicylate). Dose, 2 flui-
drams (8 c.c), containing 10 grains
(0.6 Gm.) of lithium salicylate.
Elixir sodii salicylatis, N. F., similar
to the preceding.
Glyccrogclatimim acidi salicylici, N.
F. (glycerogelatin of salicylic acid),
containing 10 per cent, of the acid.
Used locally, being melted by gentle
heating and applied with a camel's
hair brush.
Liquor antisepticiis, N. F. (anti-
septic solution, Lister), containing 30
per cent, of alcohol, 2.5 per cent, of
boric acid, 0.12 per cent, of methyl
salicylate and of sodium salicylate, 0.6
per cent, of sodium benzoate, 0.5 per
cent, of eucalyptol, 0.1 per cent, of
thymol, and 0.03 per cent, of oil of
thyme. Dose, 1 fluidram (4 c.c).
Chiefly used locally.
Liquor antisepticiis alkalimis, N. F.
(alkaHne antiseptic solution), contain-
ing 15 per cent, of glycerin, 3.2 per
cent, of potassium bicarbonate and of
sodium borate, 0.8 per cent, of sodi-
um benzoate, 0.04 per cent, of oil of
gaultheria, and 0.02 per cent, of thymol,
of eucalyptol, and of oil of peppermint,
colored purplish red with cudbear; 6
per cent, of alcohol. Used locally,
diluted with 2 to 5 parts of warm water.
Pasta dnci, N. F. (Lassar's zinc or
zinc-sahcyl paste), containing 2 per
cent, of salicylic acid, with zinc oxide.
Used externally.
Piilvis antisepticus, N. F. (soluble
antiseptic powder), a mixture of
powdered boric acid, 86.6 per cent.;
zinc sulphate, 12.5 per cent.; salicylic
acid, 0.5 per cent.; phenol, eucalyptol,
menthol, and thymol, of each 0.1 per
cent. Used as dusting powder or in
5 per cent, solution.
Pulvis talci composites, N. F. (sali-
cylated talcum powder), consisting of
salicylic acid, 3 parts; boric acid, 10
parts, and powdered talc, 87 parts.
Used as dusting powder.
Mulla acidi salicylici, N. F. (salicy-
lated salve mull or ointment), a 10
per cent, preparation of salicylic acid
in benzoinated lard and suet, spread
on gauze or mull, to be applied to the
skin where penetration by the sali-
cylic acid is desired.
Mulla creosoti salicylata, N. F.
(salicylated creosote salve mull), like
the preceding, with addition of 20 per
cent, of creosote.
UNOFFICIAL PREPARATIONS.
— Among the unofiicial salicylic prep-
arations used internally are : —
Acetylsalicylic acid (aspirin) \Cq-
H4.0(CH3CO).COOH], occurring in
colorless, crystalline needles with an
acidulous taste, soluble in 100 parts
of water, and freely soluble in alcohol.
Salicylic acid is liberated from it in
the intestine. It causes less sweat-
ing than the ordinary salicylates.
Dose, 5 to 30 grains (0.3 to 2 Gm.).
Diaspirin (succinic ester of salicyl-
ic acid) [CoH4(COO.C6H4COOH)2],
a white powder with slightly acid
taste, sparingly soluble in water,
easily soluble in alcohol. Dose, 5 to
30 grains (0.3 to 2 Gm.). Stronger
than novaspirin, but has marked
sudorific power (Klaveness).
Novaspirin (methylene citrylsali-
cylic acid), a white, crystalline pow-
der with a faint acidulous taste,
scarcely soluble in water, freely solu-
ble in alcohol. Contains 62 per cent,
of salicylic acid. Dose, 10 to 30
grains 0.6 to 2 Gm.). Weaker in
4S SALICYLIC ACID, THE SALICYLATES, AXl) SALICIN (SAJOUS).
action than the preceding-, though bet-
ter tolerated l)y sensitive patients.
Salicylosalicylic acid (diplosal ;
salicylic ester of salicylic acid) [Cq-
H4(COO)OH.COOH.CcH4], a color-
less, tasteless powder, almost insolu-
ble in water, readily soluble in dilute
alkalies. It yields 1.07 times as much
jf the salicyl group in the organism
as salicylic acid itself, owing to the
fact that in its molecule two mole-
cules of salicylic acid are present in
condensed form, one molecule of
water (HoO) having been eliminated.
It is unirritating to the stomach and
is absorbed from the intestine. Dose,
5 to 20 grains (0.3 to 1.3 Gm.).
Antipyrin salicylate (salipyrin)
[CiiHioNoO.CcHiOH.COOH], a
white, crystalline powder, slightly
sweetish, soluble in 200 parts of w^ater,
readily soluble in alcohol. Acids
liberate salicylic acid from it, and
alkalies, antipyrin. Dose, 5 to 15
grains (0.3 to 1 Gm.).
Ferric salicylate (iron salicylate)
[Feo(OOC(OH)C6H4)3], a reddish-
brown or violet-gray powder, spar-
ingly soluble in water, readily soluble
in a solution of potassium bicarbonate.
Dose, 3 to 10 grains (0.2 to 0.6 Gm.).
Guaiacol salicylate (guaiacyl salicy-
late; guaiacol-salol) [C6H4.OH.COO-
(C6H4.OCH3)], a white, crystalline,
tasteless powder, insoluble in water,
soluble in alcohol. Decomposed by
alkalies. Analogous to phenyl sali-
cylate (salol). Dose, 5 to 15 grains
(0.3 to 1 Gm.).
Naphthol salicylate (betol ; naph-
thalol ; betanaphthyl salicylate ; naph-
thol-salol) [C6H4-OH.COO(CioH7)],
a white, shining, tasteless, crystalline
powder insoluble in water, with diffi-
culty solube in alcohol. Decomposed
when treated with alkalies. Split up
in the intestine by the pancreatic juice
and intestinal secretions. Dose, 4 to
8 grains (0.25 to 0.5 Gm.).
Quinine salicylate (saloquinine ;
salicyl quinine), a white, crystalline
powder, tasteless, insoluble in water,
moderately soluble in alcohol, and
containing 73.1 per cent, of quinine.
Dose, 5 to 30 grains (0.3 to 2 Gm.).
Santalol salicylate (santyl ; santalyl
salicylate), a yellowish oil with faint
balsamic odor and taste, soluble in
about 10 parts of alcohol. Split up in
the intestines, yielding 60 per cent, of
santalol (santal oil). Dose, 8 minims
(0.5 c.c).
Unofficial salicylic preparations
used externally : Ethyl salicylate (sal
ethyl) [C0H4.OH.c6o.C2H5], a col-
orless, volatile fluid with a pleasant
odor and taste, insoluble in water,
soluble in alcohol. Analogous to
methyl salicylate. ]\Iay be used both
externallv and internallv.
Mesotan (methyl-oxymethyl salicy-
late; ericin) [C6H4.0H.Cob(CH2.-
O.CH3)], a yellowish, faintly aro-
matic^ oily fluid, but little soluble in
water, soluble in alcohol, miscible
with oils. To be applied, diluted
with an equal volume of olive oil, to
the skin, avoiding friction, as meso-
tan is somewhat irritating.
Salophen ' (acet3'lparamidophenol
salicylate), a white, tasteless, crystal-
line powder, almost insoluble in cold
water, freely soluble in alkaline solu-
tions, and in alcohol. It contains 51
per cent, of salicylic acid. It is broken
up in the intestine, liberating salicylic
acid, and acetylparamidophenol.
Dose, 5 to 20 grains (0.3 to 1.3 Gm.).
Used externally in a 10 per cent, oint-
ment in itching skin affections.
Spirosal (monoglycol salicylate)
[C6H4.0H.COO(CH2.CH2.0H)], an
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 49
oily, almost odorless fluid, soluble in tation, and an appropriate amount
about 110 parts of water, freely solu- ordered mixed with some sparkling
ble in alcohol. To be applied to the water at each dose. An effervescent
skin undiluted, mixed with 3 parts of preparation may be secured by pre-
alcohol or 8 parts of olive oil, or in scribed equal amounts of salicylic
a 50 per cent, petrolatum ointment, acid and sodium bicarbonate in pow-
It is absorbed through the skin with- ders, to be dissolved in water and
out irritation and sets free salicylic taken when the effervescence begins
acid in the tissues. to subside. Small doses of sodium
INCOMPATIBILITIES.— Salicy- salicylate may be given in capsules,
lates are incompatible with mineral to be taken only during or after
acids, which set free the relatively meals. Strontium salicylate is pre-
insoluble salicylic acid by combining ferred by some to the sodium salt,
with the basic element. They are Oil of gaultheria (wintergreen) or
also incompatible with sweet spirit of methyl salicylate may also be sub-
niter, with lime-water, and with qui- stituted for it, given in elastic cap-
nine salts, ferric salts, lead acetate, sules during or after meals,
and silver nitrate in solution, as well The co-operative investigation of
as with sodium phosphate in powder the eft'ects of synthetic sodium sali-
form. Mixtures of quinine and cylate and sodium salicylate prepared
acetylsalicylic acid are dangerous, de- from natural sources, reported by
veloping after a time the poisonous Hewlett, and based on about 230 sep-
substance quinotoxin, which resem- arate observations, showed that, from
bles digitoxin in its action. This toxic the clinical standpoint there is no
change develops even more readily in essential difference between the two
a mixture of cinchona and acetyl- varieties of the drug. According to
salicylic acid, and also in elixirs and Pulliam, gastric irritation by sodium
syrups containing quinine in acid salicylate may be due to deteriora-
solution. tion, moisture gradually decomposing
MODES OF ADMINISTRATION, the salt with liberation of sodium hy-
— Salicylic acid, which is irritating to droxide and salicylic acid,
mucous surfaces, should always be Where sodium salicylate given as
given in solution, preferably with above described is badly tolerated by
potassium citrate or acetate, or am- the patient, resort may be had to such
monium acetate or phosphate, all of preparations as acetylsalicylic acid,
which increase its solubility in water, salophen, diaspirin, and novaspirin,
Or, it may be given in a syrup, which liberate the salicyl group only
flavored with compound spirit of in the intestine (and therefore have
lavender, or in elixir of orange. Pref- the disadvantage of acting more
arable to the acid, however, is sodium slowly and often less powerfully),
salicylate, which, though less irritat- or to salicin, given in generous dos-
ing, should likewise be given in solu- age. Or, the cutaneous, rectal, hypo-
tion. The salt may, for example, be dermic, or intravenous routes of ad-
prcscribed in 5 parts of Aqua men- ministration may be partly or wholly
thae piperitae or Aqua gaultherise, with relied on.
a little glycerin added to reduce irri- For application to rheumatic joints
8-4
50 SALICYLIC ACID, THE SALICYLATES, AND SALICLM (SAJOUS).
methyl salicylate or oil of gaultheria after it acts by the salicylate enema,
is generally used, either undiluted, on g'^'^'" ^ith the Davidson syringe and
, ^ 1 . ^. 1 I 1 • • „„ii a rectal tube inserted 6 to 8 inches,
absorl^ent cotton or rubi)ed ni ni small .r^, , • • , ,
i no dose varies with the weight and
amounts, or diluted with an equal part ,,^ .„,^, t,,^ severity of the case. The
of olive oil or 2 or more parts of first adult dose in men is usually from
petrolatum, chloroform liniment, or 8 to 10 Gm. (2 to 2>4 drams), in women
soap liniment. To prevent evapora- 6 Gm. {\y, drams). The drug to be
.■ r ,1 -1 -1 1 -11 .„ given is incorporated in 120 to 180
tion of the oils, oiled silk or some ,, . . ^ , .
. . . c.c. (4 to 6 ounces) of plain or starch
otiier impervious covering may be ^^^^^^ ^^-^^^ the addition of 1 to L5
used. Where these oils are not at Gm. (15 to 23 ounces) of opium tine-
hand, absorption of salicylic acid it- ture. The dose may be repeated
self may be secured bv rubbing in for within twelve hours, but usually a
a few minutes a tal^lespoonful of a daily enema suffices, with doses in-
. , . , . , . _ creasing perhaps from 30 to 50 per
mixture of 1 part of the acid m b ^^^^ j^j,y ^^^jj ^^e limit of tolerance
parts of alcohol and 10 parts of cas- is reached. The largest daily dose
tor oil (Cullen), or an ointment com- given was 24 Gm. (6 drams). The
posed of salicylic acid and oil of o"ly symptoms of salicylism usually
turpentine, of each 1 part, and hy- appearing were tinnitus and exces-
, , , r o ^T-. 1 N sive perspiration. The ready absorp-
drated wool-fat, 8 parts (Bracken). ,. u u ^ t ■
^ i- \ ' tion was shown by a strong ferric
The efficiency of either of these chloride reaction in the urine within
methods is shown by the disappear- thirty minutes. It would seem that
ance of joint pain and appearance of the greatest absorption of the drug
the drug in the urine within a few ^^ ^'^^hin twelve hours. L. G. Heyn
r^^-, ,1 c ^^ (Tour. Amer. Med. Assoc, Sept. 19,
minutes. Other local uses of sail- ,g. .
cylates are described in the section on
Therapeutics '^^^ hypodermic and intravenous
For rectal administration of sodium ^^^^^^ ^^^^'^ '^^e" ^^'^'^^^ o^' ^""'^^ §^oo^
salicylate the following formula, ''^^^^t^' ^^^ ^^^^ert and by Mendel,
recommended by Crouzet, may be Rubens, and Conner, respectively,
employed : Intravenous injection of salicylates
■D c J-- T 1 J- .% /le /" \ strongly recommended. The prep-
-r> Sodii sahcylafis 5ss (15 Gm.). . , .
A •,,;„• 7- //( r- ^ aration used consists of: —
Acacia piilveris 3j (4 Gm.).
Lactis fSiv (120 Gm.). Sodium salicylate 2 dr. (8 Gm.)
Fiat mistura. Caffeine sodiosalicyl.. . Yi dr. (2 Gm.).
T-i . ^ , ' 'its ' Sterile water 1^ oz. (45 c.c).
1 he mixture contains 30 grains
(2 Gm.) of sodium salicylate to the One-half dram (2 c.c) is injected
tablespoonful, is well tolerated, and *^.^*=^ ^ f'^- /' ^^l '"'"^^' J°^"*
, . , ,-7 • 1- pains and exudates disappear even
can be given ad libitum, according to , j- r i * ^ 4. ^
o ' ^ where ordinary salicylate treatment
the requirements of the case, with a f^iis. a single dose causes marked
glass syringe or the ordinary rubber improvement. None of the unpleas-
enema bulb. ant actions of salicylates are en-
Intrarectal administration of so- countered. Cases which do not react
dium salicylate recommended in re- are not rheumatic. This is the most
fractory cases of acute and subacute certain method of diagnosing the ex-
rheumatism from experience in 125 act nature of doubtful rheumatic
cases. A cleansing soapsuds enema cases, especially in diagnosing early
is given and followed immediately tuberculous and rheumatoid arthritis
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
51
from true rheumatic cases. F. Men-
del (Miinch. med. Woch., p. 165,
1905).
The writer injects 10 c.c. (2J^
drams) of a 20 per cent, sterilized
solution of sodium salicylate per 100
pounds of body weight for acute
rheumatic infections of joints, heart,
pericardium and pleura. He first uses
a hypodermic injection of cocaine
and fifteen minutes later injects in the
same spot the sodium salicylate. The
dose is repeated every twelve hours.
In severe cases with multiple lesions
15 c.c. (4 drams) to each 100 pounds
of body weight is advised. Within
three hours after the first injection,
pain, fever, joint stiffness and pulse
rate diminish. This improvement
continues if the injections are re-
peated every twelve hours, but if
omitted the conditions grow worse.
In chronic cases, 10 c.c. (2^ drams)
per 100 pounds of body weight of the
following oily solution are injected
every twenty-four hours: Salicylic
acid, 10 Gm. (2>^ drams) ; sesame oil,
80 Gm. (2% ounces) ; pure alcohol, 5
Gm. (l]4 drams); and gum camphor,
5 Gm. (1j4 drams). This is sterilized
before the alcohol is added. It must
not be exposed to the air, as the
alcohol will evaporate and the sali-
cylic acid precipitate. The effect in
chronic cases is more rapid when
multiple localizations of the rheu-
matic process exist than when one
joint is affected. In the former, pain
and stiffness usually improve after
the first injection; in the latter, after
the third. Addition of camphor (5
to 20 per cent.) was found beneficial
in stimulating the heart when the
pericardium or endocardium was in-
volved. With this method there is
entire absence of the toxic symptoms
seen when salicylates are given by
mouth. Siebert (Med. Rec, Mar. 11,
1911).
The rapidity of absorption of
sodium salicylate when given sub-
cutaneously is about the same as by
other routes, but its concentration in
the blood does not reach one-half of
that when it is given intramuscularly.
Sodium salicylate disappears from
the blood in ten hours when given
subcutaneously; if given per os it is
present in the blood after twenty-
four hours. E. Levin (Dent. med.
Woch., Dec. 19, 1912).
Administration of sodium sali-
cylate by intravenous injections is
safe, painless, and easily performed.
The drug seems to have a much more
pronounced analgesic effect than
when givent by mouth. The solution
for injection is made by dissolving
10 Gm. (2^ drams) of chemically
pure crystalline sodiuin salicylate in
50 c.c. (1% ounces) of distilled water,
freshly sterilized by boiling. In most
cases the dose has been either 15 or
20 grains (1 or 1.3 Gm.) and the in-
jections given at twelve- or eight-
hour intervals over a period of three
to six days. Occasionally, in robust
men, as much as 30 grains (2 Gm.)
have been given at a time, and as
much as 120 grains (8 Gm.) given in
the first twenty-four hours without
any unpleasant effects. The field of
indication for the intravenous method
includes cases in which the drug is
not well borne by the stomach; those
which show little or no improvement
under the usual methods and, pos-
sibly, cases of severe rheumatic in-
flammation of the eye. Conner (Med.
Record, Ixxxv, 323, 1914).
Case of a man of 25 with extremely
severe febrile rheumatism involving
all the joints, with mj'^ocarditis and
dyspnea; the stomach being abso-
lutely intolerant for the salicylates.
The writer gave an intravenous in-
jection of 6 c.c. (1^ drams) of a
mixture of 5 Gm. (1^4 drams) sodium
salicylate and 0.25 Gm. (4 grains)
caffeine in 25 Gm. (6 drams) distilled
water. The injection was repeated
daily for six days, increasing the
amount from 1.2 to 2 Gm. (20 to 32
minims). By the fourth day the man
was able to sit up, with normal tem-
perature, pulse 84, and no further
precordial distress. Cernadas (Se-
mana Medica, Dec. 23, 1915).
52 SALICYLIC ACID, THE SALICYLATES, AND SALICIX (SAJOUS).
Phenyl salicylate (salol), in its
usual dosage of 5 or 7^ grains (0.3
or 0.5 Gm.) every three or four hours,
exerts but little of the effect of sali-
cylates and rather acts like phenol,
which it gives ofif in the intestinal
tract. Large doses of phenyl sali-
cylate are, as a rule, to be avoided,
as they may induce symptoms of
phenol poisoning, and darken the
urine. It may be given in capsules,
in taljlets, or combined, for example,
with bismuth salts, in powders. It is
almost insoluble in the gastric juice,
and does not irritate the stomach.
CONTRAINDICATIONS. — Sali-
cylates are contraindicated except
sometimes when used for local pur-
poses, in middle-ear disease, and in
conditions associated with impaired
renal functioning, as in pregnancy
and chronic nephritis. Albuminuria
is a contraindication, except in renal
disturbance of rheumatic origin,
though in infections of the urinary
tract phen)^ salicylate is used. Sali-
cylates should not be administered to
pregnant women who have a tend-
ency to abort, nor in women with
metrorrhagia or menorrhagia. Where
there is circulatory depression, some
degree of caution as to the dosage of
salicylates is required.
Prolonged administration of sali-
cylates in large dosage is unwise,
causing debility, anemia, and a ten-
dency to hemorrhage from the mu-
cous membranes.
PHYSIOLOGICAL ACTION.—
Externally, salicylic acid is an irritant,
especially to mucous membranes.
Carefully applied to the skin it is
capable of softening the epidermis or
accumulations of horny epithelium
without inducing inflammation. It
also tends to arrest local sweating
and to promote the growth of normal
skin in chronic skin affections. It is
an antiseptic, stronger than acetani-
]ide and rivalling phenol, over which
it has the advantage of not volatiliz-
ing. The salts of salicylic acid are
less irritating than the free acid, and
also much less strongly antiseptic.
The liquid salicylates, such as methyl
salicylate and the oils of wintergreen
and birch, are, however, useful as
counterirritants.
General Effects. — Nervous System.
— The chief nervous effects of sali-
cylates is manifest in relief from pain,
probably due, as in the case of
acetanilide and its congeners, either
to constriction of vessels loco doleiiti
or to direct depression of the sensory
nerve-cells in the optic thalami.
Circulation. — Small doses, if any-
thing, slightly raise the blood-pres-
sure (chiefly by central vasoconstric-
tion) and accelerate the heart.
Large doses directly depress the
heart. The skin-vessels are dilated
by all doses. According to some the
number of leucocytes in the blood
shows a marked increase, returning
to normal, however, after a single
dose, within two hours.
Alimentary Tract.— ^Idiny of the
salicylates, especially the free acid,
act as irritants in the stomach.
Acetylsalicylic acid, phenyl salicylate
(salol) and salicin, however, may not.
passing through the stomach un-
changed and only setting free the
salicyl group in the intestine. Sali-
cylic acid tends to arrest ferment
action, interfering, therefore, with the
digestive processes. It is claimed
that intestinal putrefaction can be re-
duced with it, and, according to some,
large doses of salicylates stimulate
the formation of bile.
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 53
Temperature. — Salicylates lower the
temperature where there is fever, like
antipyrin, but act less strongly. The
effect is, at least in part, due to pe-
ripheral vasodilatation and sweating,
which increase heat loss. A direct
action on the heat centers has not as
yet been proved to occur.
Metabolism. — Augmented destruc-
tion of protein is caused by the sali-
cylates, as shown by a distinct in-
crease in the output of urea, uric acid,
and sulphur-bearing compounds in
the urine.
The increased output of uric acid
following salicylate medication is
due to a lowered threshold value of
the kidney, not only for uric acid,
but in all probability for other waste
products as well. Such being the
case, it may well be that the bene-
ficial effects resulting from the use
of salicylates in acute rheumatic
fever may, in part at least, be due to
a power possessed by this class of
drugs of increasing kidney permea-
bility, thereby facilitating the rapid
and more or less complete excretion
of the toxins which produce symp-
toms of these diseases. Denis (Jour.
Pharmacol, and Exper. Therap., Oct.,
1915).
Absorption and Elimination. — Sali-
cylates are rapidly absorbed from the
stomach and duodenum, and circulate
in the blood as salicylates of the alka-
lies. Excretion is also rather rapid,
and takes place chiefly through the
kidneys, which are irritated by large
doses and sometimes react, even after
moderate doses, by a diuresis. The
chief product in salicylic elimination
has long been considered to be salicyl-
uric acid, an inert compound with gly-
cocoll yielding a violet-red color with
ferric chloride. Studies by Hanzlik
(191.S), however, cast doubt upon the
elimination of salicyluric acid in man,
products free of glycocol), and pre-
sumed to be in part an impure sali-
cylic acid, being alone found. Small
amounts of salicylates ingested are
eliminated with the bile, sweat, and
mammary secretion.
UNTOWARD EFFECTS AND
POISONING. — Overdoses of salicylic
preparations produce symptoms simu-
lating cinchonism, viz., a feeling of
fullness in the head, tinnitus aurium
and, perhaps, slight dizziness. Other
signs of overdosage are gastric irri-
tability, nausea and vomiting; head-
ache ; inental dullness and apathy, and
impairment of hearing or vision, due
either to local circulatory modifica-
tions or to degenerative changes in-
duced in the cochlear or retinal nerve-
cells or in the optic nerve. After very
large doses complete deafness or
blindness may occur. According to
Drayer, 15 grains (1 Gm.) 4 times a
day for a week will often produce
deafness lasting four months.
In some cases of salicylism, mental
excitation is a feature — the "salicylic
jag." The cerebral symptoms are
similar to those induced by atropine,
— talkativeness and great cheerfulness
passing on to delirium with halluci-
nations and motor restlessness. De-
lirium is an especially common symp-
tom among drunkards. Mental dis-
turbance may persist a week or more.
A number of patients taking sali-
cylates experienced auditory hallu-
cinations. Long- forgotten memories of
certain sounds were aroused : the roar
of a certain water-fall, the singing of
birds heard in a certain garden, etc.
The drug reaching the cells seemed to
bridge the gap between unconscious
and conscious memories. Seitz (Corre-
spondenzbl. f. schweizer Aerzte, Apr.
1, 1909).
Poisonous doses of salicylic acid
induce l)urnin-- in the throat, nausea
54 SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
and vomiting, sometimes diarrhea;
special sense disturbances, sometimes
with mydriasis, ptosis, or stralMsmus ;
thirst; precordial oppression; feeble
heart action and vasomotor weakness;
sweating; marked dyspnea; prostra-
tion ; greenish urine, and occasionally
albuminuria, hematuria, or even sup-
pression of urine ; coma. Death, when
it occurs, is due to respiratory paraly-
sis, and may be preceded by general
convulsions.
A girl, aged 10 years, had been suf-
fering from acute rheumatism for
three days. Endocarditis developed.
A purgative was given and then IS
grains (1 Gm.) of sodium salicylate
with double that amount of sodium
bicarbonate every four hours, for
four days, when the child became
delirious and vomited twice. The
salicylate was withdrawn and the de-
lirium quickly passed ofif. On the
fourth day after admission the tem-
perature, pulse, and respirations were
normal.
Later, the patient again complained
of joint pains and salicylates were re-
sumed (7 grains — 0.45 Gm. — in water
3 times a day). After two days she
again vomited. There was no deliri-
um, but the urine contained sufficient
blood to give it a deep-red color. She
also complained of severe pain along
the left iliac crest, and there was
much tenderness in the left renal re-
gion. Salicylates being discontinued,
the urine was clear in four days, con-
taining neither blood nor albumin,
and the pain had also disappeared.
The pain was probably a "referred
pain" from the kidney. J. D. Mar-
shall (Lancet, Feb. 2, 1907).
The dosage of salicylic preparations
necessary to induce circulatory de-
pression is relatively large, 20 grains
of sodium salicylate, repeated at inter-
vals of two or three hours, rarely
having an appreciable action on the
pulse and blood-pressure.
The primary effect of salicylates is
on the temperature, which drops sud-
denly owing to increased heat radia-
tion through the dilated capillaries.
The resulting depression of the nerv-
ous system determines the collapse.
These drugs should be given in small
doses, frequently repeated, to avoid
rapid temperature reduction. Bovisoff
(Roussky Vratch, Feb. 23, 1913).
Experiments showing that solu-
tions of sodium salicylate gradually
deteriorate on standing, the loss be-
ing greater in the weaker solutions.
About 20 per cent, is destroyed in the
body, and 40 per cent, when there is
fever, alcoholism, morphinism, or
exophthalmic goiter. Hanzlick and
Wetzel (Jour, of Pharm. and Ex-
perim. Therap., Sept., 1919).
Erythema with edema, intolerable
itching and tingling of the skin, and
fever, have been catised by large doses
of sodium salicylate. Other possible
effects are transitory dark-colored
spots, ecchymoses, vesicles and pus-
tules.
According to Martinet, sodium sali-
cylate sometimes induces in children
symptoms similar to those of diabetic
acidosis. Sodium bicarbonate in large
doses and catharsis are advocated in
the treatment.
A chronic form of salicylic poison-
ing has been met with in persons ex-
posed to inhalation of the acid,
marked by a subacute inflammation
of the air-passages, sometimes with a
serious degree edema. In these in-
stances potassium iodide is beneficial.
Chronic absorption from food or drink
preserved with salicylic acid may re-
sult in constipation alternating with
diarrhea, mental depression, skin
eruptions, and albuminuria.
TREATMENT OF POISONING.
— The tinnitus caused by salicylic
acid may be relieved by a 20-grain
(1.3 Gm.) dose of sodium bromide. In
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 55
the treatment of salicylism, the giving
of large doses of sodium bicarbonate
has been recommended to hasten
elimination of the drug. The treat-
ment of severe acute poisoning is
largely symptomatic, cracked ice by
the mouth and an ice-bag or mustard
plaster over the epigastrium being
used to relieve vomiting, cold com-
presses being applied for headache,
veronal or opiates given for the rest-
lessness and delirium, and appropri-
ate stimulants for circulatory depres-
sion. As in other forms of acute
poisoning the stomach should be
thoroughly evacuated with the
stomach-tube or emetics and, if it
seems advisable, a purge given to
clear the drug from the intestine. For
further suggestions as to treatment
the reader is referred to the sections
on Poisoning in the articles on Ace-
TANILIDE, ACETPHENETIDIN, and AnTI-
PYRIN.
THERAPEUTICS.— Salicylic acid
and its salts are used for both general
and local effects.
General Uses. — As remedies in
acute rheumatism, the salicylates
hold first rank by reason of the
prompt relief of pain, fever and other
symptoms of this disease they afford.
Various methods of administration
have been suggested, some of which
are referred to in the article on Rheu-
matic Fever. Plehn, among others,
lays stress on adequacy of dosage,
giving even mild cases 15 grains (1
Gm.) of salicylic acid 6 times a day
(suspending the remedy at night),
until the temperature has remained
normal for three days, after which a
few 15-grain (1 Gm.) doses are given
daily for a week, the patient then re-
maining in bed three days more, with-
out the remedy. In women the dos-
age is made smaller — often only 5 and
sometimes only 3 doses a day at the
outset. With this treatment, Plehn
observed the development of valvular
disease in only 2 out of 319 cases
treated. Plehn's dosage, however,
seems somewhat excessive from the
standpoint of special sense impair-
ment and renal irritation. Sodium
salicylate is better tolerated by the
stomach than the free acid and may
be substituted for it for this reason.
Tinnitus should be regarded as a
warning signal against large dosag-e.
Homberger advises the combination
of sodium bicarbonate (1 or 2 parts)
with sodium salicylate, given in solu-
tion in a little water, the purpose
being to prevent liberation of the
more irritating salicylic acid from the
salicylate by the hydrochloric acid of
the gastric juice, and simultaneously
to accelerate absorption of the sali-
cylate by means of the carbon-dioxide
gas evolved. He al&o advises that the
drug be given between meals, when
there is least acid in the stomach, and
not too freely diluted, as a large quan-
tity of fluid will cause it to be retained
longer in the stomach. Salicylic
treatment in those with sensitive
stomachs can likewise be carried out
with acetylsalicylic acid (aspirin),
which sets free the salicyl group only
in the intestinal alkaline medium.
Klaveness prescribes this drug in 15-
grain (1 Gm.) doses every two or
three hours, combined, in persons in
whom circulatory weakness is sus-
pected, with V/2 grains (0.1 Gm.) of
powdered ergot. In children. Osier
is credited with recommending sali-
cin in full doses; Comby praises the
action of sodium salicylate in the dos-
age of 7 grains (0.5 Gm.) a day for
each year of the child's age. The
56 SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
rectal, intravenous, intramusclar, and
percutaneous methods of administer-
ing salicylates are also available.
Renal irritation from salicylates,
manifested in slight albuminuria,
sometimes with a few casts, is gen-
erally recognized to be a temporary
condition, though it may persist for
weeks and even be serious where
some degree of nephritis already ex-
ists. .Combination with sodium bicar-
bonate was found by Glaesgen to
obviate renal irritation by the salicy-
lates. Acetylsalicylic acid is held
by some to be non-irritating to the
kidneys.
In muscular rheumatism, including
lumbago, the salicylates are of value
in relieving the pain ; likewise in the
so-called "growing pains." In gonor-
rheal rheumatism their effect is less
marked. The pains of chronic fibro-
sitis are quickly relieved by sodium
salicylate combined with antipyrin
(Stark). In sciatica and other painful
rheumatic nervous conditions the sali-
cylates are also of distinct value. In
migraine, a combination of sodium
salicylate and potassium bromide,
given at the start of the attack, often
yields a gratifying result. In rheu-
matic uveitis and scleritis marked
benefit is obtained from 15-grain (1
Gm.) doses of the salicylates, given
4 times a day.
In rheumatic conditions associated
with anemia the writer uses the fol-
lowing mixture: In an 8-ounce (240
c.c.) bottle place 1 dram (4 Gm.) of
sodium salicylate and dissolve it in
about 2 ounces (60 c.c.) of water. Add
liquor ferri perchloridi (B. P.) Y2
dram (2 c.c), plus about an ounce
(30 c.c.) of water. This produces a
dark-purple mixture with a thick,
curdy precipitate. Then add 1 dram
(4 Gm.) of potassium bicarbonate
dissolved in 1 ounce (30 c.c.) of water,
and fill up the bottle to 8 ounces (240
c.c.) with water. The precipitate dis-
solves on the addition of the potas-
sium solution, and the result is a clear
claret-colored mixture of an agree-
able taste.
The mixture was found particularly
useful in a kind of sore throat ap-
parently of rheumatic origin (primary
or secondary) with slight redness and
pain, especially on swallowing. H.
Drinkwater (Liverpool Medico-Chir.
Jour., July, 1911).
For the relief of pain in general, the
acetyl preparations of salicylic acid,
such as aspirin and diaspirin, seem
more efficient than the other prepara-
tions. In neuralgia, the pains of tabes
dorsalis, and those of peripheral neuri-
tis, these drugs often prove of value.
In mild forms of dysmenorrhea,
acetylsalicylic acid is a particularly
efficient remedy. It may also be used
in acute and subacute pelvic cellulitis,
salpingitis, ovaritis, and parametritis.
In acute tonsillitis or peritonsillitis,
frequently rheumatic in nature, sali-
cylates are considered of value, re-
lieving pain and swelling, shortening
the period of illness, and perhaps
obviating suppuration if given early.
In addition to its internal use, garg-
ling with, c. g., lyi io2 drams (6 to 8
Gm.) of sodium salicylate in 6 fluid-
ounces (180 c.c.) of peppermint-water
(Cheveller), or direct application of a
salicylate to the tonsils (Fetterolf),
has been advised.
Salicylate of iron recommended in
erysipelas and acute tonsillitis. Care
should be taken in its preparation,
that the iron is added to the sodium
salicylate, otherwise the characteris-
tic reddish-brown precipitate does not
form.
For adults, the dose generally con-
tains 7H grains (0.5 Gm.) of sodium
salicylate and potassium bicarbonate,
and 7^ minims (0.45 c.c.) of the B.
P. liquor ferri perchlor. The solution
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 57
is of a clear violet color, and is quite
palatable, though it may be sweet-
ened if necessary. It is non-depres-
sant, non-constipating, and is a well-
marked febrifuge. The feces are
colored black.
In erysipelas the mixture acts with
the greatest rapidity, cutting short
the disease, which never lasts more
than 10 days, and in most cases is
cured in 3 or 4. After the first few
doses, there is a striking alleviation
of all pain. The drug is administered
every three hours, the treatment be-
ing commenced with a purgative, such
as calomel. As a rule, within 24
hours the temperature is normal, the
disease has ceased to spread, and the
patient feels better.
The cases of acute tonsillitis in
which salicylate of iron has an ex-
cellent action are probably those of
streptococcal origin. It acts very
quickly; if, after 3 days, there is no
marked improvement, it is not worth
while continuing. In a recent out-
break of sore throats at a school, the
drug was markedly successful in
about 50 per cent, of cases.
In cases of erysipelas of great
severity, the writer often adds twice
the usual amount of iron, which pro-
duces a very dark solution but no
precipitate, and is much stronger in
its action on the disease. M. C. S.
Lawrance (Practitioner, Mar., 1913).
In influenza or grippe, Stark admin-
isters the following after a mercurial
purge :—
R Sodii salicylatis.
Potass a hicarbona-
t'ls aa gr. X (0.6 Gm.) .
Tiiictitrtc inicis vom-
ica: TTL X (0.6 c.c.) .
Aq. chlorof. ..q. s. ad fSj (30 c.c).
M. Sig. : Every two to four hours.
Good results in pneumonia of in-
fluenzal origin, in that succeeding
measles, and in pharyngitis, laryn-
gitis, and bronchitis, Ijy bical applica-
tion of a 10 per cent, solution of sal-
icylic acid and of castor oil, respec-
tively, in 90 per cent, alcohol. In the
pneumonic cases a compress moist-
ened with the solution was placed over
the entire back, covered with imper-
meable material, and held in place by
a bandage. The dressing was renewed
whenever it became dry. A prompt
and very favorable influence upon the
cough, temperature, pulse and res-
piration was noted. L. G. Boutchin-
skaia-Yourchevskaia (Semaine med.,
Sept. 11, 1912).
In acute coryza, the same author
recommends the following : —
R. Sodii salicylatis gr. x (0.6 Gm.).
Spiritus amnioiiicc aro-
matici f3ss (2 c.c).
Tincturcc belladonmr
foliorum m. v (0.3 c.c.) .
Aq. chlorof. ..q. s. ad f5j (30 c.c).
M. Sig. : Every four hours.
Stark has also found the drug use-
ful in mumps, in puerperal fever, and
in "bilious headache," in the latter
condition combined with potassium
bromide.
In gout, salicylic acid, though in-
ferior to colchictim, may be of value
for a short time. It was found by
Fine and Chace (1915), to increase
the elimination of uric acid, some-
times even more than atophan. In
phosphaturia, sodium salicylate will
clear up the urine and arrest the reflex
nerve pains.
In pleural effusion, 30 to 60 grains
(2 to 4 Gm.) of sodium salicylate are
credited with some power to promote
absorption of the effusion.
In diabetes mellitus, von Noorden
considers sodium salicylate the most
useful of the drugs, with the excep-
tion of codeine and other nerve
sedatives.
Chibret found sodium salicylate in
a daily dosage of 1 dram (4 Gm.) of
some value in l)ringing symptomatic
relief in exophthalmic goiter. Monae-
Lesser observed that the administra-
58 SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
tion of 3 or 4 15-i^rain (1 Gm.) doses
of sodium salicylate in renal and hep-
atic colic assisted the action of opiates
and, by relaxing the channels, favored
passage of the stones. The same
author advises the giving of sodium
salicylate by the mouth or rectum (15
grains every three hours) in cystitis
and acute prostatitis, and treats acute
ascending cellulitis of the extremi-
ties by administering this salt intern-
ally and applying locally an ointment
consisting of magnesium carbonate,
resorcinol, and lanum.
The value of phenyl salicylate
(salol) as an antiseptic acting in the
urinary passages is well known. A
dosage exceeding 30 grains (2 Gm.)
a day is rarely necessary, and is, in
fact, likely to produce untoward re-
sults. The drug should, therefore,
ordinarily not be employed in acute
rheumatism. It is of value, however,
in gonococcal urethritis, in pyelitis,
and in certain forms of cystitis.
For purposes of intestinal antisep-
sis, phenyl salicylate is likewise the
most useful drug of this group, hav-
ing the added advantage of not up-
setting the stomach. Diarrhea due to
an acute infection or toxic food is
frequently arrested by phenyl salicy-
late, which may be given alone in 5-
or yyz- grain (0.3 to 0.5 Gm.) doses in
capsules or tablets or with 2 or 3
parts of bismuth subnitrate in pow-
ders. Bismuth subsalicylate may be
substituted for the last-named com-
bination, but its antiseptic effect is
far inferior, ownng to the absence of
phenol.
Local Uses. — In subacute and
chronic eczema, salicylic acid often
gives excellent results, more particu-
larly in the "rubrum" and squamous
varieties, or where there is consider-
able Assuring, e.g., on the dorsa of the
liands and in the flexures of the joints.
An ointment containing 4 to 8 per
cent, of salicylic acid in either petrola-
tum, hydrated wool-fat, or zinc-oxide
ointment should be used in such cases.
In eczema of the face, in the weeping
stage, or in not too extensive ery-
thematous or pustular eczema, the fol-
lowing is of value : Salicylic acid, 5
to 10 grains (0.3 to 0.6 Gm.) ; pow-
dered starch and zinc oxide, of each 2
drams (8 Gm.) ; petrolatum, ^ ounce
(15 Gm.).
In psoriasis salicylic ointments are
of value, especially to remove the
scales. Crocker recommends salicy-
lates internally in extensive but re-
cent psoriasis guttata. In pityriasis
capitis with marked desquamation
Cantrell found useful a weak emul-
sion of salicylic acid in water with
mucilage of acacia. Pityriasis rubra
also improved under mild salicylic
ointments, and mild cases of ichthyo-
sis were likewise benefited. Lentigo
was usually cured by strong salicylic
applications. Indurated, papular acne
Avas greatl}^ improved, and seborrhea
of the scalp, chest, or nasal orifices
favorably influenced. Among the
other skin conditions in which salicy-
lic acid has proven of use are erythe-
ma multiforme, erythema nodosum,
lupus erythematosus, and miliaria.
Erythema following horseback riding,
or intertrigo, may be relieved with a
2 per cent, salicylic ointment.
The itching of urticaria may be
allayed with a dusting powder com-
posed of salicylic acid, 1 part; zinc
oxide, 3 parts, and powdered starch,
6 parts. In chronic urticaria, the in-
ternal use of 20-grain (1.3 Gm.) doses
of sodium salicylate is also recom-
mended. For pruritus of the vulva
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 59
and anus the following' may be used : any part of the growth remains, the
Salicylic acid, white wax, of each 2 treatment may be resumed and con-
drams (8 Gm.) ; cacao butter, 5 drams tinned for three days. This, however,
{20 Gm.) ; oil of nutmeg, 3^ dram is not often necessary.
(2 CO.). Soft chancres and venereal sores
In ordinary ringworm (tinea cir- may be dressed with the following
cinata) a solution of 10 grains (0.6 ointment : Salicylic acid, 20 grains
Gm.) of salicylic acid in ^^ ounce (15 (1.3 Gm.) ; alcohol, 45 minims (3 c.c.) ;
Gm.) of collodion is rapidly curative benzoinated' lard, 2 ounces (60 Gm.).
where the condition is not too long As a dusting powder, 1 part of the
standing. acid may be mixed with 8 parts of
In hyperidrosis of the feet, hands, powdered starch or chalk,
or axillae, a mixture of equal parts of A 1 : 1000 solution of salicylic acid
powdered salicylic acid and talc or has been employed as a nasal douche
starch will remove odor and tend to in chronic ozena. In chronic middle-
arrest the trouble. ear suppuration Foltz has used with
Where there is a tendency to occlu- satisfaction insufflations of 1 part of
sion of the ducts of sweat-glands or powdered salicylic acid with 6 parts
other follicles, mild salicylic oint- of boric acid.
ments are of value to prevent or over- Thiersch's solution, a non-toxic
come blockage. fluid available for general antiseptic
For corns, a saturated solution of purposes, consists of salicylic acid, 1
salicylic acid in collodion, the creosote part ; boric acid, 6 parts ; dissolved in
salicylic plaster mull of Unna (6 to water, 500 parts.
10 parts of the acid and 1 to 2 parts Application of dry powdered sali-
of creosote spread upon gutta-percha), cylic acid to suppurating and infected
or the following combination, may be wounds gives excellent results, caus-
relied on to produce the desired '"^ liquefaction and prompt disap-
pearance of the scab or slough, leav-
SO enmg. ^^^ ^ clean, bright-red, granulating
IJ Acidi salicylici gr. x (0.6 Gm.). surface which heals rapidly. Offen-
Olei terebinthincE rec- sive odors disappear within 24 hours.
tificati rn,v (0.3 c.c). It causes no pain or irritation. Doses
Acidi acetici glacialis ni.ij (0.12 c.c). of 3 to 5 gains (0.2 to 0.3 Gm.) in
Cocaina- hydrochlo- milk or bismuth suspension give fa-)
ridi gr. ij (0.12 Gm.). vorable results in typhoid fever. In
Collodii TTi^c (6 c.c). vitro, 0.2 to 0.5 per cent, of the acid
M. Sig. : Apply locally. inhibits or destroys Shiga's dysentery
T- , r • -1 bacillus, the B. typhosus, staphylo-
l^or removal of warts, smular prep- ct ,.* ^ u
' ^ ^ coccus, streptococcus pyogenes, B.
arations are advantageously used. A diphtheria, pneumococcus, and B. tet-
mixture of salicylic acid and lactic ani. A. Wilson (Brit. Med. Jour.,
acid, of each yi dram (2 Gm.) in 1 Feb. 20, 1915).
fluidounce (30 c.c.) of flexible collo- ^- E. de M. Sajous
dion may be applied to the summit ^ ^^^
of the wart with a match-stick night ^- ^- ^^ ^- Sajous,
J • r r -J * Philadelphia,
and mornmg for hve or six days.
Soaking the part in water will then SALINE INFUSION. See Infu-
cause detachment of the slough. If signs Saline.
60
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS).
SALIVARY GLANDS, DIS-
EASES OF. —X EROSTOMIA
(DRY MOUTH).— Symptoms.—
Arrest of the salivary or l^uccal secre-
tions was first studied l)y Hutchin-
son, in 1887. Since then about 40
cases have been recorded. The
tongue appears red, devoid of epi-
tlielium, cracked, and absolutely dry.
The inside of the cheek and the hard
and soft palates are also dry, and
the mucous membrane is smooth,
shining-, and pale (Seifert). Diminu-
tion in the nasal and lachrymal secre-
tions has also been noted, as well as
dryness of the skin and crumbling'
or falling out of the teeth. The
urine is normal. The general health
and the digestion are unimpaired,
but swallowing and articulation are
difficult, owing to the absence of
moisture. The disease usually reaches
its greatest intensity rapidly, and
may then remain without change for
years. It usually persists until the
patient dies.
Etiology and Pathology. — Xero-
stomia is almost always met with in
women, and about one-half of the
cases occur in subjects past 50
years of age. It sometimes follows
a shock. It is usually ascribed to
defective nerve-function, many pa-
tients showing distinct evidences of
nervous disturbance: hysteria, hypo-
chondria, anuria, etc. In some it ap-
pears to result from mere arrest of
function without impairment of the
general health. In 36 cases studied
by A. J, Hall the state of the salivary
glands and ducts was as follows: In
8 cases the parotids were enlarged,
either equally or unequally ; in 3
they were tender and painful ; in 4
they were not so, and in 1 the gland
ulcerated through into the mouth. In
5 cases enlargement varied from time
to time; in 1 of these enlargement
was most marked at the menstrual
period. With 1 exception, other
neighboring salivary glands were
not enlarged.
Treatment. — Pilocarpine has been
used with some success in these
cases, but the condition usually re-
curs. Blackman employs the drug in
/JO- to i/io-grain (0.003 to 0.006 Gm.)
doses, in a gelatin lamella, which
is placed on the tongue and moistened
with water.
PTYALISM. — Excessive secretion
of saliva occurs as a symptom of
rabies, the various forms of stomati-
tis, especially the mercurial form,
dentition, various gastric disorders,
etc. ; but as an idiopathic disorder it
is rarely met with. It is often ob-
served in neurotic subjects, especiallv
children, and usually disappears after
a few years, when the development
of the subject has become equalized.
It occasionally attends pregnancy
{q. z'.), and may occur during men-
strual periods and various febrile
disorders, particularly smallpox. The
effects of pilocarpine, mercury, iodine,
copper, and other agents in causing
ptyalism are well known.
Treatment. — The general health
r-equires attention, the idiopathic form
I'cing in realitv a manifestation of
debility. Weak astringent washes,
or a saturated solution of potassium
chlorate, may be tried. The galvanic
current, the positive pole being ap-
plied in the mouth while the latter is
full of water, the negative pole being
placed over the thyroid cartilage,
may prove of value if used daily.
SALIVARY CALCULUS.— Sali-
varv concretions of various sizes
sometimes form in the parotid gland
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS).
61
and its duct, — Stenson's, — causing in-
flammation of the organ, retention of
saliva, and enlargement of the organ.
The majority of calculi, however, are
found in Wharton's duct: the duct
of the maxillary gland. Foreign
bodies — which, as shown by Desmar-
tin, frequently enter Wharton's duct
— often act as nuclei. Klebs and
Waldeyer contend that masses of
micro-organisms are the most com-
mon causes of salivary calculi, the
phosphates and carbonates of lime,
magnesia, soda, etc., being deposited
around them. The stones may be-
come as large as eggs, and multiple,
and are occasionally facetted. In
some cases the inflammatory phe-
nomena proceed to abscess-formation,
and, spontaneous rupture taking
place, a salivary fistula is formed.
In the case of Stenson's duct the
opening is opposite the second molar
of the upper jaw. Wharton's duct
opens beneath the tongue, under the
frenum. Both openings can be pene-
trated with a probe, or a fine needle
may be inserted into the mass and
its contents thus recognized.
Treatment. — It is sometimes pos-
sible to remove a small calculus
through the canal ; but, as a rule, it is
necessary to thoroughly anesthetize
the part with cocaine and to remove
the mass by an incision through the
oral tissues.
TUMORS OF THE SALIVARY
GLANDS.— Cysts.— Cystic dilatation
of the parotid and maxillary glands
or of tlieir ducts is occasionally ob-
served, as a result of a superficial
inflammatory process or of cicatricial
stenosis of the orifices. In a case
noted by Stubenrauch the growth —
a parotid cy<,t — was found studded
with tubercular nodules. Stenson's
duct may become inflated with air
through forcible air-pressure — such
as that accompanying the playing of
wind-instruments, glass-blowing, etc.
— and simulate a cyst.
In many of these cases it is neces-
sary to remove the sac wall after
evacuating the contents by incision.
Tumors of the Parotid. — Tumors
of the parotid are often the result
of implication of the glandular tis-
sues in neoplasms of neighboring
structures. They may arise in the
gland itself, however. Almost any
variety of growth, especially ade-
noma, fibroma, chondroma, myx-
oma and the malignant varieties —
sarcoma and carcinoma — may be
encountered.
The removal of the entire gland
for large malignant growths necessi-
tates a grave operation, owing to
the proximity and frequent involve-
ment of the external carotid, the in-
ternal jugtflar vein, and other im-
portant vascular and nervous struc-
tures. For this reason, large malig-
nant neoplasms are removed with
difficulty and often imperfectly. Arr
old and good rule in such cases is to
remove movable growths: i.e., those
which are not firmly fixed to the un-
derlying tissues. Benign tumors can
usually be successfully extirpated.
After the first free incision is made
the mass should as much as possible
be removed by the fingers. The
facial nerve and the temporomaxillary
are thus less exposed to injury.
Tumors of the Maxillary Gland. —
This gland may be the seat of any
of the forms of tumor met in the
parotid, but, like it, is often involved
in growths that develop in the neigh-
boring structures, especially carci-
noma of the inferior maxillary. The
62
SALlVAkV GLANDS, DISEASES OF (CRANDALL AND MILLS).
mass usually projects beneath the
jaw. The removal is not as difficult
as is the case of tumors of the parotid,
the facial and ling-ual arteries, which
are easily tied, and the ling-ual and
hypog-lossal nerves, which can easily
l>e avoided, offering- no obstacle to a
thoroug-h operation. Here, also, how-
ever, it is always best to use the fin-
eers to decorticate, as it were, the
g-rowth after incision of the superficial
tissues.
PAROTITIS. — Inflammation of the
parotid gland.
Definition. — Parotitis is usually an
infectious disease {infectious paro-
titis), but it may result from injury
{traumatic parotitis) or from the ex-
tension of inflammatory or malig^nant
.processes in adjacent tissues {irrita-
tive parotitis).
TRAUMATIC PAROTITIS.— Inflam-
mation of the parotid gland may cer-
tainly result from injuries of suf-
ficient severity to cause an effusion
of blood into the gland or the tis-
sues surrounding it. It may also re-
sult from burns or the application
of caustics. While micro-organisms
may take part in the process, the
condition is quite different from in-
fectious or septic parotitis. Unless
infected with septic germs, suppura-
tion is not common.
INFECTIOUS PAROTITIS. — Two
forms of parotitis occur as the direct
result of germ invasion: 1. Mumps;
epidemic parotitis. 2. Metastatic, symp-
tomatic, suppurative, or septic parotitis.
The writers observed 38 cases in
which extreme swelling and pain in
one or both parotid glands had fol-
lowed typhus or relapsing fever at a
French hospital in Roumania in 1917.
The parotitis seemed to be more
common after typhus, and gangrene
from arteritis after relapsing fever.
but these complications occurred in
some of both. They recall that it is
due to secondary infection, strepto-
cocci predominating. Bonnet and de
Nabias (Lyon Chir., Mar.-Apr., 1919).
1. Mumps. — Mumps is an acute,
infectious, contagious inflammation
of one or both parotid glands, or
other salivary glands, usually occur-
ring epidemically. Although inflam-
mation of the parotid glands may be
caused by various germs, the disease
commonly known as mumps gives
every indication of being a specific
^disease. A period of incubation, the
method of invasion, and the definite
course pursued mark the disease as
a specific fever. No specific germ,
however, has as yet been discovered.
Several micro-organisms have been
isolated and held by their discover-
ers to be the causative germ of the
disease. The last of these at the
present writing was a micrococcus
described by Merelli, of Pisa, to
which he g'ave the name of Micrococ-
cus tragcnus. The correctness of this
view has not yet been confirmed by
other observers.
In 1908 Granata concluded that the
virus of mumps may be of the filter-
able type. • However, neither he nor
Nicolle and Conseil, who injected
bacteria-free fluid from the parotids
in cases of human parotitis, repro-
duced the disease satisfactorily.
The writer succeeded in reproduc-
ing the chief organic lesions of paro-
titis in animals by means of filtered ex-
tracts of saliva from human patients.
The active agent in the infectious
saliva was found to be neutralized by
the serum of an animal that had sur-
vived the injection of testicular and
parotid emulsions, while the serum
of a normal animal had no such
power. Various facts suggested the
presence of a minute filterable virus.
Martha Wollstcin (Jour. Exper. Med.,
xxxiii. 353, 1916).
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS),
63
In S cases of mumps a Gram posi-
tive diplococcus was isolated from the
spinal fluid, the blood, and a lymph
gland by the writer. The injection of
the organism into the testicle of a
rabbit produced severe orchitis in 10
days. These findings confirm the
earlier reports of similar organisms
from cases of mumps, and it appears
probable that mumps is caused by a
Gram positive diplococcus and not
by a filterable virus. R. L. Haden
(Amer. Jour. Med. Sci., November,
1919).
Incubation. — The period of incu-
bation is exceedingly variable. That
most commonly observed probably
lies between, 16 and 20 days. It has
been given by different authorities as
follows: Flint, 10 to 18 days; Holt,
17 to 20 days; Ashby and Wright,
14 to 21 days; Smith, 19 to 21 days;
Jacobi, 2 to 3 weeks; Dukes, 16
to 20 days; Dauchez, 15 days; Roth,
18 days; Henoch, 14 days.
Symptoms. — Premonitory symp-
toms are usually slight or entirely
wanting. In rare cases malaise and
headache precede the actual onset for
a week. There is frequently a period
of invasion lasting from twelve to
twenty-four hours, marked by fever-
ishness, headache, muscular pains,
anorexia, and perhaps vomiting. In
very many cases the local symptoms
are the first to appear. Pain is usu-
ally the first of these. It is stitch-
like in character and is located in
the parotid gland, but radiates into
the ear. It is increased by pressure
and by all movements of the jaw. It
increases in severity and in many
cases becomes very intense. In other
cases spontaneous pain is not felt, it
being developed only upon pressure
or movements of the jaw. Rilliet de-
scribes three painful points : one at
the level of the temporomaxillary ar-
ticulatiorv; one below the mastoid
apophysis; the third over the sub-
maxillary gland. Swelling soon en-
sues, and first appears in the depres-
sion between the mastoid process and
the ramus of the jaw, forcing the
lobe of the ear outward. At first the
parotid gland alone is involved and
the swelling assumes the character-
istic triangular shape, the upper
angle being just in front of the ear.
As the surrounding tissues become
involved, the triangular shape is
lost. The cheeks, side of the neck,
and regions behind the ear become
swelled, the swelling in some in-
stances extending almost to the
shoulder. The tumefaction in front
of the ear, however, remains as one
of the distinctive marks of parotitis.
The swelled area is often reddened,
but more commonly the skin is nor-
mal in color and appearance. Over
the gland the swelling is elastic to
the touch, but the surrounding tis-
sues are usually edematous and have
a doughy feeling and may even pit on
pressure.
The pharynx and tonsils are fre-
quently involved by the edema, caus-
ing much discomfort. When the dis-
ease is unilateral, the head is inclined
toward the affected side. When both
sides are involved, the head is held
rigidly upright, as every movement
causes pain. The appearance is char-
acteristic and striking, and in ex-
treme cases the patient becomes al-
most unrecognizable.
Both sides are usually affected be-
fore the attack runs its course. They
may be attacked simultaneously, but
more frequently the inflammation oc-
curs upon one side a day or two be-
fore it appears on the other. Of 228
cases reported by Holt, both sides
64
SALIVARY GLANDS, DISEASES OI- (CRANDALL AND MILLS).
were affected in 215. The interval is
sometimes a week or more, but more
commonly it is not more than three
days. In unilateral mumps the left
side is affected more frequently than
the right.
The swelling- commonly reaches its
height on the third day ; it remains
stationary for two or three days, and
then subsides witli greater or less
rapidity. The edema of the sur-
rounding tissues is the first to dis-
appear. After the edema has gone
the gland is sometimes slow to gain
its normal dimensions. Seven to ten
days are required for the disease to
run its course, but the duration of the
illness depends also upon the interval
between the involvement of the two
sides. A patient of my own was con-
fined to the house almost a month.
The parotid on the right side was
attacked a week after that on the left,
and this was followed by orchitis on
the eighteenth day.
The other salivary glands are not
infrequently involved, and in rare
cases the submaxillary glands alone
are affected.
The secretion of saliva is usually
diminished, but occasionally it is in-
creased. This, together with the
painful swelling of the face, edema of
the throat, and constitutional symp-
toms, renders the patient extremely
wretched. Attempts to examine the
throat are often futile, the patient
being scarcely able to open the mouth.
He will make no attempt at masti-
cation and refuse food, owing to the
pain during deglutition. These symp-
toms are especially prominent when
the tonsils are involved. Even speak-
ing is then painful. Although the
swallowing of acids commonly causes
severe pain, it does not always do so,
and the popular belief that it is an
infallible sign of mumps is erroneous.
Constitutional symptoms are usu-
ally not severe. The fever is rarely
high. The temperature ranges in
ordinary cases from 100° to 102° F.
(37.8° to 38.9° C). It frequently does
not go above 101° F. (38.3° C.) at any
time during the attack, but in severe
cases it may reach 104° F. (40° C.)
or even more. Other symptoms are
those .common to all febrile condi-
tions. When the swelling is extreme,
pressure upon the vessels of the neck
may cause headache and marked
cerebral disturbance. Delirium is
sometimes due to this cause. The
severity of the disease varies greatly
in different epidemics. In some the
children are but slightly ill ; in others
they are quite seriously so when the
disease is at its height, and are left
weak and anemic.
The blood in mumps shows defi-
nite changes in the corpuscular con-
tent consisting (a) in a slight in-
crease in the total number of leuco-
cytes, and (b) in a lymphocytosis
which is both relative and absolute.
The lymphocytosis is present on the
first day of the disease and persists
for at least fourteen days. The oc-
currence of orchitis does not invari-
ably alter the blood-picture. The
blood changes are of distinct diag-
nostic value in differentiating mumps
from other inllammatory swellings
of the parotid or submaxillary sali-
vary glands and from cases of
lymphadenitis. A lymphocytosis of
the cerebrospinal fluid occurs when
mumps is complicated by meningitis
or by lesions affecting the cranial
nerves. It has, however, also been
found in cases of mumps which have
presented no clear clinical symptoms
of any organic lesion of the nervous
system. From a consideration of the
blood and cerebrospinal fluid, one is
justified in assuming that the virus
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS).
65
of mumps excites an inflammatory
reaction, the characteristic feature of
which is a great aggregation of
lymphocytes. A. Failing '^Lancet,
July 12, 1913).
Diagnosis. — The rapid onset and
almost equally rapid subsidence of
the glandular enlargement is a most
characteristic feature of mumps.
This, together with the location of
the tumor and its peculiar shape and
large size, distinguishes it from
acute enlargement of the lymphatic
nodes, as well as chronic malignant
growths. The location of the tumor
is usually sufficient to distinguish it
from the cervical swellings of scarlet
fever and diphtheria, but examina-
tion of the throat should always be
made in cases in which there is the
slightest doubt.
Etiology. — Although mumps is
spread by contagion, susceptibility is
probably less than to any of the
other contagious diseases. Close
contact is usually necessary. The
disease is rarely carried from one
person to another by a third, but that
is known to have occurred. The dis-
ease is rare under 4 years and very
few cases in infants have ever been
reported. It is rare in adult life and
still more so in old age. It is most
common between the ages of 5
and 14.
The exact period of infection is
doubtful. Contagion is possible from
the first symptoms or even before the
swelling of the glands has appeared.
The power of infection seems to con-
tinue in some cases for several days
after the first symptoms have disap-
Epidemics of mumps occur more
commonly in the fall and spring than
at any other season. They vary
greatly in frequency of occurrence
and the extent of territory involved,
occurring in some localities almost
annually and in others only at inter-
vals of many years. The infective
power of the disease varies decidedly
in dififerent epidemics. Epidemics of
measles and mumps are frequently
associated.
Recurrence of mumps is uncom-
mon, but is not unknown, as my own
personal experience has positively
demonstrated.
Pathology. — Opportunity for post-
mortem study of parotitis is so rare
that its pathology is not yet fully un-
derstood. So far as known, patho-
logical changes are confined to the
salivary glands. Infection probably
takes place through the salivary
ducts, the gland-substance being first
involved. The periglandular tissue
is involved secondarily. In those
cases in which pathological exami-
nations have been made, the salivary
ducts have been found to be occluded
by swelling and inflammation of
their walls. The gland itself is
hyperemic and edematous. Suppu-
ration is rare and probably does not
occur in simple parotitis. Its occa-
sional occurrence is probably due to
pyogenic bacteria which have found
admission with the specific germs.
Complications and Sequels.
— Among young children complica-
tions are rare. Suppuration occurs in
about 1 per cent, of the cases, accord-
peared. Isolation, to be effective, ing to Holt, and is usually due to
must be continued for at least a week some accidental infection by pyogenic
after the swelling has entirely sub- germs. Deafness, due not to otitis
sided, or nearly three weeks from the media, but to disease of the auditory
first symptoms. nerve, has been reported in a very
8-6
(£
SATJVARV GLANDS, DISEASES OF (CRANDALL AND MILLS).
few cases. It is usually unilateral
and permanent. Facial paralysis,
multiple neuritis, and other nervous
disorders also occur in very rare in-
stances, and nephritis is not unknown
as a sequel. Meningitis and ocular
complications have also been ob-
served. Pancreatitis with epigastric
and vomiting- and glycosuria are not
uncommon complications.
The writer has seen many cases
of epigastric pain with vomiting in
the last stages of mumps. Out of 20
cases in one school, 10 followed this
course, and all showed tenderness to
pressure over the pancreas. Fox re-
ports a similar case: On the fifth day
of mumps a boy developed fever,
epigastric pain, and vomiting, and a
deep-seated swelling was felt in the
epigastric region. There was no
sugar in the urine, and the boy re-
covered. Cecil Reynolds (Brit. Med.
Jour., ii, 352, 1910).
Pancreatitis may be one or the sole
manifestation of the acute infection
called epidemic parotitis. The pain
and protrusion of the stomach region
which some writers have explained
as acute mumps pancreatitis may
have been merely an acute gastritis
as a manifestation of the infectious
process. L. Cheinisse (Semaine med.,
Feb. 21, 1912).
In the pancreatitis of mumps, pain
is the most noteworthy symptom;
tenderness in the region may persist
after other symptoms have disap-
peared. Constipation, followed by a
colliquative diarrhea, is common.
Fever, epistaxis, profuse sweating,
irregular pulse, and the facies of
grippe are also noted. Jaundice may
supervene. The diagnosis, in view
of the very obvious mumps, is there-
fore not difficult. The prognosis is
favora1)le. Raymond (Paris med.,
Aug. 3, 1912).
A most peculiar but characteristic
complication is orchitis. It is most
common in adolescents and adults
and is extremely rare ia children.
Among 230 cases of mumps Rilliet
and Barthez saw but 10 cases of
orchitis, only 1 being under 12 years.
Its frequency undoubtedly varies
in different epidemics. The disease
is a true orchitis, but epididymitis
in rare cases occurs either alone or
complicating the orchitis. The dis-
ease is, as a rule, unilateral, and oc-
curs usually between the eighth and
sixteenth day of the mumps. A chill
at the onset is not uncommon, and
more or less fever is an accompani-
ment. The acute symptoms increase
somewhat slowly during a period of
three to six davs, when thev subside
and the swelling rapidly diminishes.
So rapid, in fact, is the return to nor-
mal conditions that it is clear that
the inflammation does not go beyond
the stage of serous exudation. In bi-
lateral orchitis one side precedes the
other, as a rule, by one or two days.
In many cases, as the orchitis de-
velops the parotitis subsides, which
has given rise to the theory of me-
tastasis.
The writer has had 7 cases of par-
tial or complete (so complete that not
a vestige of prostatic tissue could be
made out) atrophy of the prostate,
in which an antecedent parotiditis
seemed to j^e the sole etiological fac-
tor; in some of these cases (5) the
atrophy was accompanied by atrophy
of the testicles; in 2 the testicles
seemed to be unaffected. W. J. Rob-
inson (Letter to the N. Y. Med. Jour.,
Mar. 6, 1915).
In a series of 115 cases, epididy-
mitis was met by the writer in 20 in-
stances, in 18 of which it was inde-
pendent of orchitis. It began about
the sixth day of the disease and lasted
fifteen to twenty days. In half the
cases it was accompanied by distinct
swelling of the organ, which in the
remaining instances was merely ten-
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS). 67
der. Inflammation of the vas defer- male patients developed orchitis and
ens was noted in 40 cases, generally 5.3 per cent, of the women had mas-
independently of epididymitis or or- titis; that is, about half of the women
chitis. It began on the second or who were nursing infants at the time.
third day of the disease, and was bi- Bertelsen (Ugeskrift for Laeger, Dec.
. lateral in 26 cases. Twenty-three 9, 1915).
cases showed prostatitis. Enlarge- ^^ ^„*._„„^ n r j-
r , , , , re ' Treatment. — Cases of ordinary
ment of the lymph-nodes of Scarpa s . ■'
triangle was met with in 10 cases, and seventy require but little medication,
of those of the iliac chain in 6 cases. A mild antiseptic mouth-wash should
Swelling of the tonsils took place in be given with a view of preventing
40 cases. Diarrhea was noted for two infection by pyogenic bacteria. The
or three days in 60 cases. In 2 cases ^.^^ ^^^^^^j^ ^^^ j. j^ ^^^^ ^^^ ^^^^^
appendicitis suddenly developed on , , , , • , , -r i • r
the tenth day; recovery in two weeks should be kept in bed if there IS fever,
took place in both instances under Warm camphorated oil is the most
rest, dieting, and local application of soothing application that can be used
ice. Ramond and Goubert (Presse locally.
med., Mar. 25, 1915). ^N\,^x^ there is considerable tension
In females inflammation of the or throbbing, the ice-bag sometimes
breast or ovaries occurs in very rare gives more relief than warm appli-
instances. The number of well- cations. In general terms, the treat-
authenticated cases of this complica- ment is the same as for other febrile
tion, it must be said, is very small, conditions.
Involvement of the thyroid gland and Buccal antisepsis, according to
of the lymphatic nodes has been Martin, diminishes the chances of
observed testicular complications in parotitis.
_,'.,, . , A 4 per cent, solution of boric acid
Prognosis.-Mumps is rarely a ^^^^^ ^^^^^ ^^^^^^^ ^^ ^^.bolic acid
serious disease. It usually runs an should be employed as a gargle, and
uneventful course, and under 12 pilocarpine subcutaneously in doses
years complications are rare. In of % grain (0.01 Gm.) once daily, to
children of the so-called scrofulous diminish the pain and lower the tem-
1 ^. . . . perature in cases of orchitis,
type resolution is sometimes slow ^ ^, . ,, .
■' ^ The following ointment is recom-
and imperfect. Among 24,635 cases mended by Tranchet:—
occurring in the army during the ^ idithyol,
Civil War there were 39 deaths: a iodide of lead, of
mortality so high as to lead to each 45 gr. (3 Gm.).
doubt regarding the accuracy of the Chloride of Ammo-
statistics. "*'«"* ^^ s^- (2 Gm.).
„ . , . . . Lard 1 oz. (31 Gm.).
tpidemic parotitis was never en-
countered in Greenland until the in- This ointment is to be applied to
fection was brought in 1913 by a ship the swelled parts three times a day.
from Denmark, and of the 2425 in- In some instances vaselin may be
dividuals in the district, about 1500 used in place of the lard, and some-
contracted the disease. In the times belladonna may be added with
writer's special district, 191 of the advantage.
285 individuals were affected, that is, Where fever and severe pain are
66 per cent, of the men and 68 per present, sodium salicylate is effective,
cent, oi the women. No infant under It should be combined with an
2 was affected; 18 per cent, of the alkali: —
68
SALIVARY GLANDS. DISEASES OF (CRANDALL AXD MILLS).
R Sadii salicylat.,
Sodii bicarb aa gr. v (0.3 Gm.).
Bcnzosnlphinid q. s.
Aqua q. s. ad fjss (15 c.c).
Sig. : Ever}' two or four hours.
Stark (Practitioner, Mar., 1911).
The application every morning of
pure tincture of iodine to the pharyn.x
and buccal mucous membrane, with
special attention to the gingival fold
and opening of Steno's duct, is recom-
mended as a prophylactic by the
writer from experience in military
barracks. A tablet of potassium
chlorate should also be kept con-
stantly in the mouth. Petrilli (Poli-
clinico, June 1, 1913).
The writer tried convalescent
serum in several cases, using 5 c.c.
for both subcutaneous and intraven-
ous injections. Very little reaction,
lessening of pain, and earlier sub-
sidence of swelling and of tempera-
ture were noted. Gradwohl (U. S.
Naval Med. Bull., Oct., 1919).
2. Metastatic or Symptomatic Par-
otitis.— This is an inflammation of the
parotid gland occurring as a result of
septic infection through the blood or
through the buccal secretions, in the
course of various affections, and often
ending in ulceration. It may be
acute or chronic. It is oftenest met
with in typhoid, typhus, and scarlet
fevers, cholera, dysentery, plague,
pyemia, pneumonia, influenza, puer-
peral fever, erysipelas, and other in-
fectious disorders. It may result,
also, from poisoning by mercury,
lead, and the iodides. Inflammation
of the testicles is another cause, espe-
cially when the process is gonorrheal.
Injuries of the alimentary canal and
of the testicle or pelvic organs may
also give rise to it. Parotitis may
follow abdominal operations, espe-
cially ovariotomy, hysterectomy, and
laparotomy for peritonitis. It has
also been observed in cases of neu-
ritis, facial paralysis, and diabetes.
Symptoms. — When acute the gland
rapidly swells. The tem])erature
rises to 103° or 104° F. (39.4° or
40° C). The whole face becomes
enlarged, when both glands are in-
volved, and the lids edematous. The
pain is sometimes very severe, owing
to the tense capsule with which the
gland is surrounded. Pus-formation
promptly follows in the majority of
cases, and the pus may burrow in
various directions, — the auditory me-
atus, the thoracic cellular tissue, the
retropharyngeal tissues, the maxillary
joints, etc., — and cause serious lesions
if not promptly evacuated by incision.
Parotitis was encountered by the
writer in 16 of the 760 cases of ty-
phoid fever in his service. Several
of the men died. The typhoid was
always unusually severe in these
parotitis cases. Cahanescu (Wiener
klin. Woch., May 27, 1915).
Case of suppurative parotiditis fol-
lowing pneumonia in a boy of 3 years.
Five days later the temperature,
which had been in the neighborhood
of 99.5° F. (37.5° C). reached 104° F.
(40° C). No signs in the chest were
demonstrable, but on the following
day a hard, tender swelling appeared
in the right parotid region. Three
days later a deep incision below the
right ear reached an abscess and a
small amount of pus was removed.
The smear showed pneumococci and
a few staphylococci. The tempera-
ture fell and the recovery was un-
eventful. J. P. Parkinson (Brit. Jour,
of Children's Dis., May, 1915).
In the chronic form — which may
result from mumps, neighboring in-
flammatory processes, syphilis, the
excessive use of mercury, etc. — the
gland is also enlarged, but less pain-
ful, and may remain so several years.
Pathology. — The process is a sup-
purative one. The pus may dis-
charge through the cheek or through
SALOPHEN.
69
the external auditory meatus, and
more rarely into the mouth, esopha-
gus, or anterior mediastinum. The
abscess may be confined to the paro-
tid g-land and its immediate surround-
ing- tissues or it may be so large as
to involve the muscles and other soft
tissues, and even the periosteum of
the bones. The middle ear is not in-
frequently involved, as well as the
central meninges. Thrombosis of
the jugular and other veins some-
times leads to septicemia. In rare
instances the process terminates in
gangrene.
Prognosis. — The result depends
largely upon the condition of the pa-
tient at the time of the onset of the
parotitis. If much reduced by the
primary disease, the complication
often precipitates a fatal result. If
it occurs during convalescence and
the patient is not already reduced, a
favorable result may be expected. In
other words, suppurative parotitis in
itself is not usually fatal. Induration
and enlargement of the glands is a
common result.
Treatment. — By introducing a probe
into Stenson's duct at the first ap-
pearance of swelling, and making
pressure from the outside, a small
quantity of pus may sometimes be
evacuated and general suppuration
.prevented. If this fails, poultices
should be applied to hasten suppu-
ration. An incision should be made,
with antiseptic precautions, as soon
as fluctuation can be detected. The
treatment throughout should be that
appropriate for any acute abscess.
Floyd M. Crandall,
New York,
AND
H. Brooker Mills,
Philadelphia.
SALOL. See Salicylic Acid.
SALOPHEN.-Salophen (acetyl-
paramido-phenol salicylate) contains 50.9
per cent, salicylic acid. It occurs in fine,
white, odorless and tasteless scales; solu-
ble in alcohol, ether, alkalies, and hot
water, and nearly insoluble in cold water.
It is not official.
Salophen was introduced as a substi-
tute for salicylic acid and salol by P.
Guttmann (Berl. klin. Woch., No. 52,
'91). It is said to be less poisonous than
salol or salicylic acid, because the phenol
of the latter remedies is replaced by an
innocuous compound of phenol.
DOSE AND PHYSIOLOGICAL AC-
TION.—Salophen, like salol, seems to
suffer no action until it reaches the in-
testines, when the pancreatic juice splits
it up into its component parts, salicylic
acid and acetyl-paramido-phenol. As the
latter appears innocuous, the further ac-
tion of salophen is that of its contained
salicylic acid. It has, however, certain
advantages over the latter in that it is
unirritating and tasteless and is not de-
pressing. It may be given for consider-
able periods of time without causing
nausea, anorexia, tinnitus, or other un-
pleasant symptoms. It possesses antisep-
tic, antipyretic, and analgesic properties,
and is given in doses of from 5 to 15
grains (0.3 to 1 Gm.). The maximum single
dose is given as 20 grains (1.3 Gm.); not
more than 90 grains (6 Gm.) should be
given during the twenty-four hours.
THERAPEUTICS. — The therapeutics
of this remedy are the same as those
of salol and salicylic acid. It is given in
the same cases, and in similar doses, and
is generally to be preferred to either of
them, for the reasons given above. It is
well suited, also, for use in diseases of
children.
Salophen has a most favorable influ-
ence upon psoriasis, used in 10 per cent,
ointment.
Salophen exerts an incontestable action
upon acute and subacute rheumatism,
but its effects are less constant than those
of salicylic acid or sodium salicylate.
In chronic and blennorrhagic rheumatism
it has not shown itself superior to other
drugs.
70
SANDALWOOD AND OIL OF SANDALWOOD.
SANGUINARIA.
In chronic articular rheumatism it is
no more useful than the above-mentioned
drugs. It is an excellent antineuralgic
and analgesic in cephalalgia, migraine,
odontalgia; facial, trifacial, and intercos-
tal neuralgia; am! in the nervous form
of influenza. It produces good results in
chorea. It acts well in various skin af-
fections which are accompanied with itch-
ing: prurigo, urticaria, pruritus of dia-
betes, eczema, and psoriasis.
SALPINGITIS. See Ovaries and
Fallopian Tubes, Diseases of.
SALT. See Sodium.
SALVARSAN See Dioxydiami-
DOARSENOBENZOL.
SANDALWOOD AND OIL
OF SANDALWOOD. -Sandalwood
(red saunders; santaluni rubrum, U. S. P.)
is the wood of Pterocarpiis santalinns (nat.
ord., Leguminosse). It occurs in the form
of raspings, chips, or splinters. It con-
tains a red coloring matter of a resinous
character, known as santalic acid, or san-
talin, which occurs in fine red, odorless,
and tasteless needles; soluble in alcohol,
ether, in concentrated sulphuric acid, and
in alkalies, but insoluble in water. It is
used in pharmacy for imparting a red
color to alcoholic solutions and tinctures.
It is the coloring principle of the com-
pound spirit for tincture) of lavender. It
has no medicinal properties.
Oil of sandalwood (oil of santal; oleum
santali, U. S. P.) is a volatile oil distilled
from the wood of Santaluni aWuin (nat.
ord., Santalaceje), indigenous to India.
East Indian sandalwood oil is a rather
viscid, yellowish, or pale-straw liquid, hav-
ing ah unpleasant, resinous, harsh taste,
and a faint but persistent aromatic odor.
The chief constituent is an alcohol known
as santalol.
PHYSIOLOGICAL ACTION AND
DOSE. — Oil of sandalwood is a stimulant
in small doses, and an irritant in large
doses, to the various mucous membranes.
It checks the secretions of the mucous
membranes and causes dryness of the
throat and thirst. S. Rosenberg has
noticed, after doses of 60 drops a day,
irritation of the alimentary canal, burning
in the urethra during micturition, and an
eruption of small red prominences upon
the entire surface of the body, involving
even the conjunctiva;. Large doses may
produce considerable lumbar pain.
Its general systemic action is unknown.
It is apparently more stimulating than oil
of eucalyptus, and rather less than tere-
l)ene. It is eliminated l)y the urinary and
respiratory mucous membranes; the odor
is sometimes perceptible in the perspira-
tion. Unlike copaiba, it causes no cuta-
neous eruptions, and is less likely to pro-
duce gastric or intestinal disturbance.
Absorption and elimination are very
rapid; it may be detected by its odor in
the urine half an hour after its ingestion.
It may be given in doses of from 5 to 30
minims (0.3 to 2 c.c), in capsules or dis-
solved in alcohol and flavored with cin-
namon, in emulsion, or on sugar.
THERAPEUTICS.— Oil of sandalwood
is an efficient remedy in asthma, chronic
bronchitis, in the later stage of acute bron-
chitis, and in the subacute or chronic stage
of gonorrhea. It is also used as an in-
gredient of perfumes. It has also been
used in cystitis, but care should be taken
to avoid large doses, and thereby the
urethral scalding pain they cause.
SANGUINARIA. -Sanguinaria, or
blood-root, is the rhizome of Sanguinaria
canadensis (fani., Papaveracese), a native of
eastern and central North America. San-
guinaria contains citric and malic acids,
red resin, and starch, but its important
constituents are its alkaloids, at least
five in number, of which sanguinarine
and chclerythrine are the most important.
PREPARATIONS AND DOSES.—
Sanguinaria, U. S. P. (sanguinaria, or
blood-root). Dose, 1 to 5 grains (0.06 to
0.30 Gm.).
Tinctiira sanguinaria, U. S. P. (tincture
of sanguinaria). Dose, 10 to 40 minims
(0.60 to 2.60 c.c).
Sanguinarine (alkaloid). Dose, Yxn to
y^ grain (0.004 to 0.008 Gm.).
Fluidextractum sanguinarise, N. F. (fluid-
extract of sanguinaria). Dose, 1 to 5
minims (0.06 to 0.30 c.c).
Syrupus sanguinaria?, N. F. (syrup of
sanguinaria). Dose, 30 minims (2 c.c),
representing 6 grains (0.4 Gm.) of san-
guinaria.
SANTONICA AND SANTONIN.
71
Syrupus pini strobi comp., N. F. (com-
pound syrup of white pine). Dose, 2
fluidrams (8 c.c), representing 5 grains
(0.3 Gm.) each of white-pine bark and
wild-cherry bark, together with small
quantities of aralia, populus, sanguinaria,
sassafras, cudbear, glycerin, alcohol, and
a little chloroform.
PHYSIOLOGICAL ACTION.— The
powder inhaled causes violent sneezing
and free secretion of mucus. It is feebly
escharotic. The taste is harsh and bitter.
In small doses sanguinaria produces a
sense of warmth in the stomach and stim-
ulates the secretions. Moderate doses
produce nausea and depression of the cir-
culation. In large doses it causes inflam-
mation of the stomach with intense burn-
ing, thirst, vomiting, dimness of vision,
dilatation of the pupils, vertigo, great pros-
tration and muscular relaxation, cold and
clammy skin, and collapse. After a pre-
liminary increase of arterial tension the
heart action becomes depressed. The
spinal reflexes are reduced and the spinal
centers paralyzed. Death is often pre-
ceded by convulsions either of spinal
origin or from carbonic acid poisoning
due to failure of respiration.
TREATMENT OF POISONING.—
The stomach and bowels should be
washed out with warm water. The dif-
fusible stimulants should be administered.
Digitalis, amyl nitrite and strychnine
hypodermically are efficient, with mor-
phine and atropine, if necessary, to relieve
pain or severe nausea. The patient should
be kept warm.
THERAPEUTIC ACTION. — Sangui-
naria is chiefly used as a stimulating
expectorant in subacute and chronic
bronchitis.
SANTONICA AND SAN-
XONIN. — Santonica (Levant or German
wormseed) is the unexpanded flower-
heads of Artemisia pauciflora (fam., Com-
positse), a native of Turkestan and the
surrounding countries. It contains about
1 per cent, of volatile oil, IK' to 3 per
cent, of santonin and a variable amount
of artemisin. Since the isolation of san-
tonin from santonica, the use of the crude
drug has been abandoned.
Santonin occurs in faintly acid, shining,
colorless, flattened, rhombic prismatic
crystals, odorless, and at first nearly
tasteless, but with a bitter after-taste. It
is permanent in the air, but turns yel-
low on exposure to light. It is soluble
in alkalies and most volatile oils, in 5300
parts of cold water, 250 parts of boiling
water, 34 parts of alcohol, 78 parts of
ether, and in 2.5 parts of chloroform, and
nearly insoluble in glycerin. Colored
santonin is an unreliable remedy.
PREPARATIONS AND DOSES.—
Santoiiinuui, U. S. P. (santonin). Dose,
1 to 4 grains (0.06 to 0.25 Gm.) for an
adult, ^ to K grain (0.015 to 0.03 Gm.)
for a child.
Santonica, U. S. P. VIII (santonica).
Dose, 10 to 40 grains (0.60 to 2.60 Gm.).
Trochisci santonini, N. F. (troches of
santonin, worm lozenges), each contain-
ing K grain (0.03 Gm.) santonin. Dose, 1
to 4 troches.
Trochisci santonini compositi, N. F., con-
taining santonin and calomel, of each, Yz
grain (0.03 Gm.).
Sodium santoninate, official in the U. S.
Pharmacopoeia of 1880, is a very soluble
salt, a fact which forbids its use and that
of other santoninates, since the object of
using this remedy is to act locally upon
the parasites. When given for other pur-
poses than as a vermifuge the dose is 5
to 10 grains (0.30 to 0.65 Gm.).
PHYSIOLOGICAL ACTION. — San-
tonin is decomposed in the blood, disturb-
ing the nutrition of the cerebral centers,
and producing xanthopsia or chromatopsia,
a condition where objects appear yellow,
red, green, or blue, either by staining the
humors of the eye or by its action upon
the retina and perceptive centers; the
urine is stained a greenish-yellow, or, if
alkaline, a reddish-purple color, due to
xanthopsin, a derivative of santonin.
Elimination is by the kidneys, is slow,
taking about two days for the removal
of an ordinary dose. There is an in-
creased flow of urine and more frequent
micturition.
POISONING BY SANTONIN.— This
often occurs l)y children eating freely of
worm lozenges, or from susceptibility to
its action. Toxic doses produce alarm-
ing symptoms — muscular tremors, vertigo,
cold sweats, mydriasis, stupor and epi-
72
SARSAPARILLA.
leptiform convulsions. Death occurs from
respiratory failure. A case of urticaria
occurred after a 3-grain dose to a child,
and a general niorbilloid eruption and in-
tense punctiform rash on the buccal and
faucial mucous membranes after a 5-grain
dose taken by an adult.
Treatment of Santonin Poisoning. — The
treatnu-nt consists of the use of diffusible
stimulants, hot baths, demulcent drinks,
belladonna and strychnine, with inhala-
tions of ether to control the convulsions.
THERAPEUTIC USES.— The most
important use of santonin is that of a
vermifuge to expel the roundworm {As-
caris lumbricoidcs or the Oxyiiris vcr~
micuJaris (thread- or seat- worm) from
the intestines. It has no efifect upon the
tapeworm. In persistent incontinence of
urine santonin has been efficient when all
other remedies have failed. It is often
useful when the optic nerve is diseased,
to restore the activity of vision, and in
some cases of color blindness.
As an anthelmintic santonin should be
administered on an empty stomach.
Whitla and Demme combine santonin with
castor oil, but in aggravated cases the lat-
ter preferred to give it in a slightly
sweetened oleaginous solution, ^ grain
(0.03 Gm.) to 1 ounce (30 c.c.) of olive
oil. A previous saline purgative (mag-
nesia or rhubarb and magnesia) removes
the mucus in which worms breed. The
dose of santonin, given at night, should be
followed by a saline purgative in the
morning, preferably before breakfast.
Santonin has been recommended by
Whitehead, of Manchester, in amenor-
rhea, especially when due to chloranemia.
He gives a 10-grain (0.6 Gm.) dose on
two successive nights. Cadogan Master-
man has found this method useful in
severe uterine colic arising from suppres-
sion of the menses.
SAPREMIA. See Wounds, Septic.
SARCOMA. See Cancer.
SARSAPARILLA.— Sarsaparilla is
the dried root of Smilax vicdica, Sinilax
ornata, Smilax papyracccc, Smilax officinalis
(fam., Liliacese), and other varieties of
smilax indigenous to central America,
Mexico, Brazil, Honduras, and other trop-
ical and subtropical American countries.
The roots are without odor and have a
mucilaginous, bitter and acrid taste. Sar-
saparilla contains about 3 per cent, of
saponin-like substance (separable into 3
glucosides), up to 15 per cent, of starch,
a little resin, volatile oil, pectin, calcium
oxalate, etc. The glucosides are the im-
portant constituents, sarsasaponin, paril-
lin, and smilasaponin, the last two being
known as smilaciii.
PREPARATIONS AND DOSES.—
Sarsaparilla, U. S. P. (sarsaparilla root).
Fluidextractum sarsaparilla, U. S. P.
(fluidextract of sarsaparilla). Dose, J/2 to
1 dram (2 to 4 c.c).
Fluidextractum sarsaparillcc compositum,
U. S. P. (compound fluidextract of sarsa-
parilla), containing sarsaparilla, 15 parts;
licorice, 12 parts; sassafras bark, 10 parts;
mezereum, 3 parts; glycerin, 10 parts;
and diluted alcohol to make 100 parts.
Dose, ^ to 1 dram (2 to 4 c.c).
Syrupus sarsaparillce compositus, U. S. P.
(compound syrup of sarsaparilla), con-
taining fluidextract of sarsaparilla (20
per cent.), fluidextracts of licorice and
senna (of each 1.5 per cent.), and oils
of anise, gaultheria, and sassafras (of each
0.02 per cent.). Dose, 1 to 4 drams
(4 to 16 c.c).
THERAPEUTIC USES.— Sarsaparilla
is probably inert, or nearly so, in the
dose usually given, though moderate doses
apparently aid digestion and improve the
appetite. Its chief value is as a pleasant
vehicle for disguising the taste of the
iodides and of the mercurial salts. While
there is no evidence of a curative action
of sarsaparilla by itself in syphilis, a tem-
porary recourse to the remedy has been
considered useful, especially in debilitated
patients in whom mercury and the
iodides have seemingly lost their bene-
ficial action or have been improperly ad-
ministered. Phillips recommends this
remedy in chronic lung affections with
much wasting; in chronic rheumatism
and cutaneous disorders with venereal
taint. Sir Astley Cooper advises its use
in the cachexia caused by chronic sup-
puration, in chronic abscesses, ulcers, and
bone disease. Zittmann's decoction (a de-
coction of sarsaparilla, calomel, cinnabar,
alum, senna, licorice, anise-seed and fen-
SCABIES.
73
nel) is much used by the German
physicians in chronic rheumatism, syphiUs,
and scrofula. In domestic medicine sar-
saparilla has been a favorite blood
purifier.
SCABIES.— DEFINITION.— An in-
flammatory contagious disease of the
skin, due to the presence of the Acarus
scabici and attended by severe pruritus.
SYMPTOMS.— The eruption produced
by the Acarus scabici consists of scattered
vesicles and papules, which are usually
located between the fingers and on the
flexor side of the wrists and elbows.
The axillae, mons veneris, abdomen and
buttocks, the penis, the mammse, and in
children the legs and feet are the points
of predilection next in order. The bur-
rows of the parasite resemble scratches,
which, upon close examination, may be
seen to be beaded. The Acarus may
readily be extracted from its burrow with
the tip of a needle for microscopic ex-
amination. The eruption is attended by
severe itching, which is especially marked
at night. The scratching to which the
patient subjects the part greatly increases
the local irritation. The eruption may
become pustular or complicated by other
dermatoses (eczema, urticaria, etc.), and
present various characteristics due to the
accumulation of epidermic detritus, dead
acari, etc., or accumulated crusts. The
hairs of the limbs afifected are often shed,
and the nails may become hypertrophied.
Schamberg and Strickler found that of
forty-seven cases of scabies, over 80 per
cent, showed 5 or more per cent, of
eosinophiles; the maximum was 19 per
cent., and the average 7 per cent, (the
normal maximum is 4 per cent.). The
incubation period extends from two days
to a week. Occasionally the itching is
absent — apruriginous scabies. During a
general illness scabies is apt to disappear
or improve; but the disease reappears as
soon as convalescence is established.
ETIOLOGY.— The Acarus scabici is about
one-quarter millimeter long, and resem-
bles an eight-footed turtle in general out-
line; the males live under the skin or epi-
dermic scales, the females under the
epidermis in the burrows, where they de-
posit their eggs. Acarus does not inhabit
the prickly layer, but the undermost part
of the middle layer of the epidermis. The
eczema of scabies is not caused by
scratching, but by irritating substances
given off by the Acarus, according to
Torok.
While the female mite is visible to the
naked eye, the male is much smaller.
Females are more numerous than males,
and when fecundated penetrate into the
epiderm, making a burrow in which they
deposit their ova, from 6 or 9 up to 30 in
number. The mite cannot retreat be-
cause of several bristling hairs project-
ing from her body; she dies in the bur-
row; the eggs mature in a few days, and
the resulting larval forms emerge upon
the surface and become sexually active,
become impregnated, burrow, deposit ova
and die, and thus the cycle continues.
The life of the individual mite is from two
to three months. The males live on the
surface near the burrows. The disease is
very contagious, through contact with af-
fected individuals and any wearing apparel
or bedclothing that they may have used.
TREATMENT.— Scabies may be rap-
idly cured by adopting Hardy's method;
scrubbing with soap and water, using a
brush twenty minutes; the same pro-
cedure thirty minutes, but with the part
immersed in the soap-water; rubbing of
the part with the Helmerich-Hardy oint-
ment: Carbonate of potash, 25 grains
(1.62 Gm.); sulphur, 50 grains (3.25 Gm.);
lard, 5 drams (20 Gm.). — M. This is
left on two hours and the parts are bathed
as before, but not brushed. Pruritus
may usually be relieved by means of a
2 per cent, menthol ointment. Petrolatum
is sometimes sufficient.
The simple sulphur ointment thor-
oughly, though gently, rubbed in at night
before retiring, followed the next morn-
ing by a warm bath, is often sufficient
to cure scabies when persisted in for two
or three weeks, but the underwear should
be very frequently changed and boiled for
half an hour or baked in an oven at
120° C. In many cases the ordinary sul-
phur ointment is too strong; it is always
best to reduce its strength by mixing
it with an equal quantity of benzoated
lard. Sulphur baths are also valuable,
but ointments can be kept in contact
74
SCAMMONY.
longer with diseased parts, and are there-
fore more destructive to the parasite.
Julien recommends painting the entire
body with balsam of Peru, 3 parts, and
glycerin, 1 part, which exercises a toxic
action on the Acarus. No soap and water
should be used before its application.
With a l)rush a thin layer of the balsam
is laid on at night, followed by gentle
rubbing. A bath is taken on the fol-
lowing morning. The remedy causes no
irritation, as a rule.
For scabies in infants and young chil-
dren, Hartzcll recommends equal parts of
styrax and olive oil, or 1 or 2 drams (4 to
8 Gm.) of balsam of Peru to 1 ounce (30
Gm.) of vaseline.
Betanaphthol (20 per cent, ointment),
styrax, creolin (10 per cent, ointment),
petroleum, and Hebra's modification of
Wilkinson's ointment (unguentum sul-
phuris comp., N. F., which contains pre-
cipitated chalk, 10; sublimed sulphur, 15;
oil of cade, 15; soft soap, 30; lard, 30
parts) have been used with success.
Scabies has been successfully treated
with nicotine soap. It is of a dark-brown
color, and may be scented with oil of
bergamot. It consists of tobacco extract,
5 per cent.; precipitated sulphur, 5 per
cent.; and ovei-fatty soap, 90 per cent.
After thorough bathing the body and
limbs may be rubbed lightly with washed!
sulphur, less than ^ teaspoonful for each
person; this to be followed by clean
underclothes and clean sheets with yi
dram (2 Gm.) of sulphur dusted between
them. If this is repeated every second or
third day the cure, in ordinary cases, is
complete in a week.
For the treatment of secondary pustular
complications Knowles, 1918, recommends
ammoniated mercury ointment, 20 to 40
grains (1.3 to 2.6 Gm.) to the ounce (30
Gm.). Incipient boils can be cured by
daily rubbing for ten minutes with 25 per
cent, ichthyol ointment. If they are re-
current, an autogenous vaccine should be
used. Septic ulceration or cellulitis may
require rest in bed, and should be treated
by the local application of ammoniated!
mercury in zinc oxide ointment.
Another plan is to change the parasiti-
cide during the treatment (Montgomery).
Use a sulphur-balsam Peru ointment for
three days, a betanaphthol ointment for
three days, and a creolin ointment for
the remaining time.
SCALP. See Head and Brain,
Diseases and Injuries of.
SCAMMONY.— Scammony is the
gum resin from Convolvulus scamnionia
(fam., Convolvulaceae), derived from the
living roots of the plant. Its chief con-
stituent (80 to 95 per cent.) is a gluco-
sidal resin called scammonium.
PREPARATIONS AND DOSES.—
Scammonke radix, U. S. P. (scammony).
Dose, 4 to 8 grains (0.25 to 0.5 Gm.).
Rcshia scammonke, U. S. P. (resin of
scammony). Dose, 3 to 5 grains (0.2
to 0.3 Gm.).
Extractum colocynthidis compositiim, U. S.
P. (compound extract of colocynth, con-
taining 14 per cent, of resin of scam-
mony). Dose, 5 to 10 grains (0.30 to
0.60 Gm.).
Pilida catharticce compositcc, U. S. P. (com-
pound cathartic pills containing 1% grains
(0.08 Gm.) of compound extract of colo-
cynth in each pill). Dose 2 pills.
Pilulce catliarticie vegetahiles, N. F. (vege-
table cathartic pills containing 1 grain —
0.06 Gm. — of compound extract of colo-
cynth in each pill). Dose 2 pills.
It is also an ingredient of pilula colo-
cynthidis comp. (pil. cocciae), N. F., of
pilul^e colocynthidis et hyoscyami, N. F.,
and of pilula colocynthidis et podophylli,
N. F.
PHYSIOLOGICAL ACTION.— Scam-
mony is a drastic hydragogue and feebly
cholagogue purgative. When given alone
it causes considerable griping. It is un-
certain in action by reason of its frequent
adulteration and its insolubility in the
gastrointestinal juices if they are acid.
Gastritis and enteritis, if present, contra-
indicate its use. Given in large doses it
may cause severe gastroenteritis and
fatal purgation. It should not be given
alone, but combined with other cathartics
and aromatics, to modify its harsh action.
Its effects are usually manifested within
four hours.
THERAPEUTIC USES.— On account
of its tastelessness it is a favorite pur-
gative in children, combined with calomel
SCARLET FEVER (CRANDALL AND MILLS).
75
and triturated with sugar of milk. It is
useful in cerebral affections and dropsies,
in the form of compound extract of
colocynth. It is useful to clear the
intestines of mucus and as an anthel-
mintic against both roundworms and
tapeworms. It is a purgative well adapted
to cases of obstinate constipation and
impaction of feces and in cases of mania
and hypochondriasis. W.
SCARLET FEVER. —Scarlatina.
DEFINITION.— Scarlet fever is
an acute, infectious, contagious, erup-
tive, disease presenting-, in typical
cases, the following features : After
a period of incubation of from two to
four days there is a sudden onset of
sore throat, vomiting, and fever;
within twenty-four hours a character-
istic eruption appears and continues
for about six days, when it terminates
in desquamation.
While the average period of incu-
bation of scarlet fever (i.e., the period
between exposure and the appearance
of symptoms) has been stated to be
from two to four days, with a maxi-
mum of seven, the latest observations
show that this period is very vari-
able. The limits of the period of
incubation are practically from four
to twenty days, with an average of
ten to fourteen days. J. W. Scheres-
chewsky (Public Health Reports,
Nov. 27, 1914).
SYMPTOMS.— From the attack so
mild that diagnosis is difficult to the
fiercely malignant form we see every
possible degree of severity. Notwith-
standing this variability of type, the
majority of cases pursue a fairly
uniform course, and may, with pro-
priety, be called ordinary cases.
Other types may be described as mild,
severe, and malignant.
Ordinary Type. — The invasion is
usually sudden, and is marked by
vomiting, fever sore throat, and rapid
pulse. Occasionally a short period of
malaise precedes the onset of definite
symptoms. In older children a chill
is sometimes the first symptom; in
younger children a convulsion. The
vomiting is usually repeated several
times, and is not accompanied by
nausea. When it occurs late in the
disease it is a far more unfavorable
symptom than at the outset. The
intensity of the period of invasion is
usually indicative of the severity of
the attack, though this is a rule sub-
ject to many exceptions.
The temperature is frequently
found to be 103° F. (39.4° C.) at the
first visit and may reach 104° or 105°
F. (40° or 40.5° C.) on the first day.
A temperature on the first day above
104>^° F. (40.2° C.) indicates a severe
attack; below 102° F. (38.9° C.) a
mild attack. The highest point is
commonly reached at the height of
the eruption. It then begins to sub-
side and becomes normal at a varying
period, ranging from the ninth to the
fifteenth day. The fever is frequently
remittent and in mild cases almost
intermittent in character. There is
no typical temperature range. The
febrile stage, even in quite severe
cases, may be limited to six or seven
days, or it may be prolonged to four-
teen or fifteen days without obvious
cause.
Any extensive rise or fall from the
level maintained during the fastigium,
or a rise interrupting the progressive
lytical resolution indicates an inter-
current or complicating condition
and not an essential part of the scar-
latina pyrexia. Lysis in scarlatina
begins on the fifth or sixth day, so
that if a febrile case shows the be-
ginning of lysis on the second day
thereafter, we know that the case was
four days old on admission. The
existence of a complication is re-
76
SCARLET FEVER (CRANDALL AND MILLS).
vealcd by a sudden rise during the
lytical stage, the character of the
complication being often shown by
the temperature curve, and the
changes in the pulse and respiration
rate. A somewhat septic curve with
increase in pulse and respiration sug-
gests bronchopneumonia; a cardiac
complication may be suspected from
a suspension of the lytical tempera-
ture curve with greatly increased
pulse rate and a moderate increase in
respiration; a meningitis or menin-
gismus attending an otitis media or
mastoiditis is frequently indicated
through an interruption of the stage
of lysis by an increase of fever of
septic character coupled with a lower
pulse rate than is usual at the height
of the fever, although it might also
indicate the presence of an acute glo-
merular nephritis. Nephritis is not
as frequent in hospital cases as in
private practice for two reasons: The
patient is kept strictly in bed until
desquamation is almost complete and
is kept on a fluid diet until he has
well passed the stage of acute symp-
toms. H. W. Berg (Med. Record,
May 11, 1912).
In a study of 17 cases of uncom-
plicated scarlet fever and of 2 cases
of scarlet fever with nephritis, the
writers found that examination of the
urine for albumin is of more value
than the functional tests for the de-
tection of the onset of kidney com-
plication. Veeder and Johnston
(Amer. Jour, of Dis. of Children,
Mar., 1920).
A pulse abnormally rapid as com-
pared with the height of the tempera-
ture is quite characteristic of scarlet
fever. It is often 150 on the first day,
and continues rapid throughout the
disease.
One of the earliest symptoms is
sore throat. The fauces, tonsils, and
pharynx are of a imiform bright-red
color, and on the hard palate numer-
ous dark-red macules may be seen.
In mild cases the throat symptoms
may be very slight; in more severe
cases the tonsils may be studded with
follicular spots, or smeared over with
a tenacious exudate closely resem-
bling a pseudomembrane. There is
frequently a discharge from the nose,
which may consist of clear, tenacious
mucus or mucopus. The glands at
the angle of the jaw frequently be-
come enlarged. Gregor of Petrograd
has recently reported observations
upon the thyroid and believes that
there is a special form of scarlatinal
thyroiditis. It is possible that these
changes may have some bearing upon
the occurrence of thyroid disease in
later life. The spleen is not usually
enlarged.
Not one of the individual symp- '
toms can be depended upon to estab-
lish the diagnosis. Next to the
throat, the condition of the tongue
is the most reliable symptom, some
enlargement of the papillae of the tip
and border being usually observable,
although this symptom is much more
frequently missing than is the angina
and may occur in other conditions.
Miller (Arch, of Pediatrics, Apr.,
1912).
As the disease progresses, the
tongue, which is at first coated, often
assumes the so-called strawberry ap-
pearance.
Considerable confusion exists as
to what the strawberry tongue really
is. It is not a white tongue with red
papilL-e ; such a tongue is seen in vari-
ous conditions. The true strawberry
tongue was originally described by
Flint as follows : "The tongue in the
first days is usually coated. In the
progress of the disease the tongue
usually exfoliates, leaving the surface
clean and reddened and the papillae
enlarged. The appearance is strik-
ingly like that of a ripe strawberry.
Differential Diagnosis of Eruptions in Children's Diseases.
1. Scarlet fever. 5. Strawberry tongue of scarlet fever.
2. Scarlet fever ; desquamation. 6. Variola.
3. Rubeola. 7. Variola ; confluence.
4. Rubella. 8. Varicella.
9. Variola-like varicella.
SCARLET FEVER (CRANDALL AND MILLS).
17
The strawberry-like tongue is a
pathognomonic symptom ; it is pecul-
iar to this disease. It is often, but
not uniformly, present." The term
should be applied to the red, clean
tongue with prominent papillae which
follows a coated tongue.
The eruption usually appears with-
in twenty-four hours after the initial
vomiting. It is not infrequently seen
after twelve hours, and is sometimes
delayed for thirty-six hours and in
rare cases to the fourth or fifth day.
There is frequently intense itching
or burning of the skin. The rash is
usually well developed during the
second day of its appearance. It
then continues from four to six days,
when it gradually subsides. It usu-
ally appears first over the front of the
neck and upper part of the chest. It
consists of minute points of bright-
scarlet color closely grouped together
on a slightly reddened skin. They
become confluent in places, forming
bright-scarlet patches, but over the
most of the surface they remain dis-
crete throughout. Being hyperemic
in nature, the rash disappears on
pressure, leaving, for a perceptible
time, a white spot. An eruption of
very fine vesicles is seen in rare in-
stances, and occasionally a blotchy
eruption appears early on the face, but
subsides as the typical rash develops.
One of the most characteristic
symptoms of scarlet fever is the des-
quamation. It rarely begins before
the sixth day, and is frequently de-
layed until the second week. It ap-
pears first on the neck and between
the fingers. It begins as fine, branny
scales, but soon changes to large
lamellar scales. Sometimes the skin
can be peeled oflf in strips. It con-
tinues from ten to thirty days, and is
most persistent where the skin is
thickest. It frequently continues
about the fingers and nails after other
portions of the body are clear, which
explains the readiness with which the
disease is conveyed by letters. When
the skin has received careful atten-
tion, the desquamation is sometimes
almost imperceptible. In rare in-
stances a second desquamation occurs.
The urine becomes scanty and
high colored during the febrile stage,
and frequently contains a slight
amount of albumin and sometimes
blood and hyaline casts. Except in
the more severe forms, suppression is
rare and dropsy still rnore so. These
symptoms usually subside as the fever
falls. The kidney symptoms at this
stage rarely prove serious. They
may, however, do so, and always de-
mand attention. The more serious
kidney symptoms occur later and will
be considered as a complication.
Mild Type. — Scarlet fever is some-
times so mild as to render diagnosis
very difficult. The symptoms may be
so slight that medical aid is not
sought. As a rule, however, there is
an onset of vomiting, fever, and sore
throat, as in the ordinary type, but
none of the symptoms are urgent.
The vomiting is not persistent, the
temperature does not rise above 102""
or 103° F. (38.9° or 39.4° C), and the
throat presents only the symptoms of
mild pharyngitis. I have seen an un-
doubted case in which the tempera-
ture never rose to 101° F. (38.4° C).
It may become normal on the fourth
or sixth day. The eruption is often
very faint, and may not appear on the
face. It may, however, be bright and
distinctive for twenty-four hours and
then fade away so rapidly as to have
disappeared by the fifth day. In rare
78
SCARLET FEVER (CRANDALL AND MILLS).
instances it is an evanescent rash
which disappears entirely within
twenty-four hours. Nephritis may be
a sequel, due in many cases to ex-
posure and lack of care : the natural
results of so mild an illness. Owing
to this lack of care and isolation, the
patient may become very dangerous
to others. It is by these mild cases
that the disease is sometimes sown
broadcast. A mild attack in one child
may produce a malignant one in an-
other.
Severe Type. — Not only are the
symptoms of this type severe, but the
various stages are prolonged. The
fever may continue for three weeks or
more, and the stage of desquamation
for even a longer time. A fatal ter-
mination is common, death occurring
usually during the second week. The
chief peculiarity which distinguishes
this from the ordinary type is the
presence of septic symptoms due to
streptococcic infection. The type
might, therefore, with propriety be
called complicated type. The throat
is usually the first to show the evi-
dence of streptococcic invasion. On
the third day, and in some cases on
the first or second day, a membranous
exudate appears on the tonsils and
soon invades the pharynx and naso-
pharynx. A purulent nasal discharge
appears, and the lymphatic glands at
the angle of the jaw begin to swell,
the cellular tissues being so involved
as to often cause immense enlarge-
ment. The Eustachian tubes are in-
volved, and purulent otitis media fol-
lows ; but the lar3aix commonly
escapes.
In 10,000 cases recorded in ten
years, 2L06 per cent, had ear disease.
There are two forms of scarlatinal
otitis. The first is a comparatively
mild ordinary inflammation, and has
no rchuion to the scarlet fever except
that it occurs at the same time. It
is most frequent in cases with little
or no throat trouble. The second
type is the so-called scarlatino-diph-
theritic or necrotic otitis, and is
brought about by the same specific
cause as the scarlet fever itself. It
differs from the first type in being
very much more severe and involv-
ing extensive necrosis of the soft
parts and bones. P. Manasse
(Monats. f. Kinderheilk., July, 1913).
The urine contains albumin and
perhaps blood-cells and hyaline and
epithelial casts. Symptoms of gen-
eral septic infection rapidly super-
vene. There is low delirium or
stupor; the child refuses nourishment
and may die from exhaustion ; but
sudden death is not uncommon.
Others, after overcoming one com-
plication after another, slowly recover
after a tedious convalescence.
Malignant Type. — Though very
rare, malignant scarlet fever does
sometimes occur. It begins with
convulsions and hyperpyrexia. The
scarlatinal poisoning may be so in-
tense as to cause death within twenty-
four hours. More commonly, death
does not occur before the third or
fourth day, the patient being coma-
tose or delirious. The nervous symp-
toms are so marked that some
waiters have given to this type the
name of cerebral scarlet fever. In a
case of my owii the initial symptoms
were convulsions, hyperpyrexia, and
hematuria.
The writer encountered 16 cases of
scarlet fever with the clinical mani-
festations of meningitis among 400
scarlet-fever patients in the course of
nine months. When the fluid escaped
under high pressure on luml)ar punc-
ture, great relief followed, but when
the pressure was not high, the lum-
bar puncture did not seem to benefit,
SCARLET FEVER (CRANDALL AND MILLS).
79
but it proved very instructive by per-
mitting the exclusion of a suppura-
tive or serous meningitis. The prog-
nosis did not seem to be affected by
the pseudomeningitis, as the severity
of the scarlet fever was what deter-
mined the outcome. Sachs (Jahrb. f.
Kinderheilk., Bd. Ixxxiii, Suppl,
1911).
Surgical Scarlet Fever. — Patients
who have undergone surgical opera-
tions are unquestionably very sus-
ceptible to scarlet fever. Such scarlet
fever, however, is not essentially dif-
ferent from the usual disease. It is
simply scarlet fever in a surgical case.
It is, no doubt, true, as Osier has
shown, that the eruption which has
frequently led to a diagnosis of scar-
let fever is nothing more than the red
rash of septicemia. It is a fact that
surgical scarlet fever is much less
common since surgical septicemia has
become less frequent.
In 12 out of 28 cases of scarlet
fever developed among hospital pa-
tients, the infection followed an ex-
tensive operation and in 1 a severe
burn. The incubation was only three
days in 10 and from five to eight days
in the others. The infection doubt-
less occurred in the operating room.
Kredel (Arch. f. klin. Chir., Bd.
Ixxxvii, nu. 4, 1908).
DIAGNOSIS AND ETIOLOGY.
— Age is first among the predisposing
causes. The disease is rare under one
year, l)ut I have seen an undoubted
attack of scarlet fever in an infant of
one week. Up to 5 years the suscep-
tibility steadily increases and reaches
its maximum; after 8 years it rapidly
decreases, and is slight during adult
life. Sex does not influence its
occurrence.
A patient of the writer developed
typical scarlet fever while nursing
her month-old babe. The disease ran
the usual course without complica-
tions and the infant continued to
nurse and thrive without contracting
the disease. Scarlet fever is rare in
infants less than a year old, and it is
possible, he thinks, that the mother's
milk confers a passive immunity on
the child. Delmas (Arch, des med.
des enfants, Feb., 1911).
Scarlet fever is rare in breast
babies, particularly during the first
six months. It is more common in
boys. The complications during the
first half-year are more frequent and
more severe, the most serious being
gangrenous sore throat, and the most
frequent lymphadenitis. L. V. Ak-
senoff (Roussky Vratch, Sept. 29,
1912).
Of 3603 cases of scarlet fever an-
alyzed by Pospischill and Weiss
there were only 28 cases during the
first year, and these had their in-
cidence during the later months of
the year. The author had the oppor-
tunity of observing 9 cases of scar-
let fever in infants less than 3
months of age and 1 case in an in-
fant 9 months old. With the excep-
tion of the last, all were the infants
of mothers suffering from scarlet
fever.
The clinical phenomena in all of
these cases were somewhat as fol-
lows: From three to seven days fol-
lowing the onset of the disease in
the mother the infant took sick with
a moderate fever lasting from two to
four days. There was the character-
istic tongue with the reddening of
the tonsils and of the soft palate. In
no instance was there any membrane
on or necrosis of the tonsils. There
was at first some difficulty in nurs-
ing and a disinclination to take the
breast. Carl Levi (Beitrage z. Klinik
d. Infektionsk. u. z. Immunit., Bd. ii,
nu. 2, 1914).
That scarlet fever is an infectious
disease does not admit of doubt, but
the specific germ has not yet been
discovered. Three theories have been
advanced as to its etiology, namely,
that it is due to (1) streptococci; (2)
80
SCARLET FEVER (GRAND ALL AND MILLS).
protozoa; (3) a filterable or ultra-
microscopic virus. That it is caused
by a protozoon is possible, but the
theory has by no means l)een con-
firmed. The filterable theory cannot
be excluded, but is largely theoretical.
The scrum of scarlet-fever patients
contains specific antibodies for an
unknown virus. This unknown virus
seems to be present especially in the
cervical lymph-nodes. K. K. Koess-
ler and J. M. Koessler (Jour, of In-
fectious Dis., Nov., 1911).
It has been fully demonstrated that
streptococci play an important role
in the causation of many of the symp-
toms. It has been urged by some that
streptococci are the cause of the dis-
ease itself, but this ground is unten-
able. They are, however, the cause
of the pseudomembranous exudations
of the throat, and undoubtedly cause
the otitis and adenitis, and probably
the nephritis, pneumonia, and joint
lesions. The streptococci thus far
found cannot be differentiated from
other streptococci. The evidence
fails to support the belief that the
streptococcus of scarlet fever dififers
from that of other infectious processes.
The writer examined the blood of
523 children suffering from scarlatina
for streptococci, and concludes that
the organism is found only in 2.1 per
cent, of all cases. V. N. Klimenko
(Arch, des Sci. Biol., St. Petersburg,
No. 3, 1912).
The cause of scarlet fever has
never been definitely determined and
the attempts to transmit it to mon-
keys have met with only very limited
success. The writer believes that it
is a streptococcic infection, though
this assumption has not been proved
or disproved with certainty. Many
clinical facts seem to prove that a
special susceptibility on the part of
the patient is an important factor in
the development of scarlet fever, and
that it may be regarded as an anaphy-
la':tic reaction to a streptococcic in-
fection. Kretschmer (Jahrb. f. Kin-
derhcilk., Sept., 1913).
Whatever the cause of the primary
disease may be proved to be, it is
certain that streptococci are the di-
rect cause of the secondary symptoms.
They are so constant in their pres-
ence, and so active in the production
of the more serious symptoms and
complications, that they must be re-
garded as important factors in the
production of the clinical picture
which we know as scarlet fever. The
disease as it commonly appears is a
mixed infection, the more malignant
and fatal symptoms being due not so
much to the primary as the secondary
infection.
Staphylococci and diphtheria bacilli
are sometimes found in conjunction
with streptococci.
The inclusion bodies studied by
Dohle, of Kiel, have been farther
studied by Nicoll and Williams, of
New York. These are small bodies
found in the protoplasm of the poly-
morphonuclear leucocytes. While
some observers regard them of im-
portance in the diagnosis of scarlet
fever, it cannot be said that their true
significance has as yet been deter-
mined. Thev are rarely found after
the sixth day of the disease.
Other diagnostic signs have in recent
years been proposed, the value of which,
as is the case with Dohle's sign described
above, has not as yet been determined.
Dohle's leucocytic inclosures are
found in many other conditions.
Their absence, however, is of diag-
nostic significance, because they are
found in the early stages of all scar-
let fevers; a negative result therefore
excludes scarlet fever, and the early
diagnosis of the disease may be made
by their presence. A. Belak (Deut.
med. Woch., Dec. 26, 1912).
SCARLET FEVER (CRANDALL AND MILLS).
81
The writer has examined a number
of scarlet-fever patients for the cell
inclusions, 14 with pneumonia and a
number of patients with other affec-
tions, including 11 with anemia and
5 with measles. The inclusions were
found constantly in every case of re-
cent febrile scarlet fever, less numer-
ous in the milder cases and declining
as the disease progressed. After the
seventh day scarcely any were to be
found. They are no aid in diagnosis,
therefore, after the first few days,
and they are not pathognomonic for
scarlet fever, as they occur with the
same constancy and as abundantly
in croupous pneumonia in children.
Schwenke (Miiiich. med. Woch., Apr.
8, 1913).
Leede's sign (Miinch, med. Woch.. Feb.
7, 1911) is obtained in the following way:
Apply a rubber band to the arm suffi-
ciently tight to render the veins very con-
spicuous and the forearms and hands
cyanotic, without obliterating pulse. After
ten or fifteen minutes remove the band.
Put the skin of tlexor surface of elbow on
stretch, to render it anemic. Hemorrhagic
extravasations on this surface, appearing
as very fine, dark points, favor a diagnosis
of scarlatina, while their absence speaks
strongly against the presence of this
affection.
The writer confirms the findings of
Rumpel and Leede in regard to
petechial hemorrhages from artificial
stasis in scarlet fever. He has no-
ticed this phenomenon frequently in
making blood examinations in scar-
let fever, and found it positive in 26
out of a series of 32 cases. In doubt-
ful cases in children, where the
throat signs were suspicious, a posi-
tive result was always confirmed by
the development of typical scarlet
fever. Bennecke (Miinch. med.
Woch., Bd. Iviii, S. 740, 1911).
Study of 100 patients with various
affections to determine the diagnostic
value of the Leede sign. It was not
positive in healthy controls, but was
found positive in heart disease, bron-
chitis, pneumonia, acute hepatitis and
nephritis, cerebral hemorrhage, ty-
phoid and puerperal fevers, and tabes.
These findings deprive the sign of
any specific diagnostic value. It
seems to be a manifestation of dimin-
ished resistance in the walls of the
smaller blood-vessels. U. Morandi
(Gazz. degli Ospedali, Apr. 2, 1912).
The tourniquet or Rumpel-Leede
sign occurs regularly in scarlet fever,
but is found also in measles, and in
some cases of diphtheria, syphilis
and tonsillitis. It permitted an early
diagnosis of scarlet fever in a num-
ber of the writer's cases, before the
eruption developed. Meyer (Deut.
med. Woch., Oct. 24, 1912).
Pastia's sign (La Tribune medicale. No.
46, p. 726, 1910) consists in a deep-rose-
colored, linear exanthem in the skin-folds
of the anterior aspect of the elbow. The
lines are usually two to four in number.
They can be caused to stand out in con-
trast by exerting gentle pressure on skin,
then quickly removing it. It was uni-
formly present in 12) cases, appearing with
the rash and usually lasting two or three
weeks longer than the rash. It occurs in
other diseases, but only in such as can
easily be differentiated from scarlatina.
The Wassermann reaction, according to
Rubens (Berl. klin. Woch., Oct. 19, 1908),
will, under certain conditions that have
remained undetermined, prove positive in
Sicarlet fever as it does in syphilis.
Case of scarlet fever in a girl, 16
years old, in which Wassermann's
test for syphilis produced a posi-
tive reaction. Four weeks after the
commencement of the illness the
test became negative, and remained
so. Holzmann (Miinch. med. Woch.,
Apr. 6, 1909).
The writer examined 55 scarlet-
fever patients and obtained a positive
Wassermann reaction in 18. This
positive reaction occurs after the
subsidence of the acute symptoms
and generally only in the severer
cases. It usually disappears by the
end of the period of desquamation
and has no effect on the diagnostic
importance of the reaction in syphilis.
Jakobovics (Jahrb. f. Kinderheilk.,
Feb., 1914).
8-6
82
SCARLET FEVER (CRANDALL AND MILLS).
The diazo-reaction seems to afford aid
in identifying scarlet fever from measles.
The diazo-reaction was found pcjsi-
tive by the writers in 17.3 per cent,
of scarlet fever, but also 12.9 per
cent, of diphtheria patients during the
first week of these infections. It is
during this week that scarlatiniform
serum rashes are so apt to develop
and make a differential diagnosis from
scarlet fever quite difficult. The per-
centage of positive reactions in
serum sickness was much lower. The
value of the diazo-reaction in dif-
ferential diagnosis is very slight. Yet
the reaction being positive in 75 per
cent, of cases of measles, a negative
reaction in a case presenting a mor-
billiform rash is of value in the dif-
ferential diagnosis from measles.
Woody and Kolmer (Arch. of
Pediat., Jan., 1912).
Copper sulphate may produce a fleet-
ing exanthem and other signs suggesting
scarlet fever.
Copper sulphate is used for spray-
ing grape-vines in France, and 2
children who had been eating grapes
thus sprayed developed symptoms
deceptively simulating scarlet fever.
The diagnosis of scarlet fever was
made without hesitation, but it had
to be revised, as the children were
quite normal again by the fifth day.
Vomiting, sore throat, headache and
a lively rash over the entire body
were the main symptoms. Lasalle
(Arch, de med. des enfants, Feb.,
1916).
Leucocytosis is found in virtually
all cases, the maximum being reached
during- the first week in uncom-
plicated cases. It then gradually
subsides.
Comparing the findings in 10 cases
of scarlet fever with those in 7 of
typhoid, pneumonia, gonorrhea or
gastroenteritis, the writer concludes
that a typical polynucleosis accom-
panies the onset of the eruption in
scarlet fever. It is pronounced and
remains high during the first two or
three days of the eruption, even in
very young children. The number of
mononuclears declines, especially the
proportion of lymphocytes. The
eosinopliiles fluctuate, but are gener-
ally increased, especially by the end
of a few days of the disease. Pater
(Arcli. de med. des enfants, Aug.
1909).
Transmission. — Grave doubts have
been expressed in recent years re-
garding the ability of the desquama-
tion scales to transmit the disease.
No positive statements can be made
until the actual cause of the disease
has been demonstrated. I can only
express the personal opinion that evi-
dence against the belief in the trans-
mission of the disease by desquama-
tion scales and clothing has not been
fully established.
Scarlet fever is not communicable
in the early stages, but is transmitted
mainly by the secretions from the
mouth, nose and ears. The exfoliated
epithelium, after the fourth or fifth
week, does not seem able to carry
contagion. Zangger (Correspondenz-
blat. f. Schweizer Aerzte, Mar. 1,
1909).
Many cases of scarlet fever are so
atypical as to go unrecognized until
a sequela makes its appearance. It
is a disease of direct infection; it is
rarely carried by a second person or
object. The most contagious period
is early in the disease during the
period of angina, rash and tempera-
ture; therefore, the danger of trans-
mitting the disease during the des-
quamation period is much exagger-
ated. Kerley (Amer. Jour, of Dis.
of Children, Jan., 1911).
So long as nasal and aural dis-
charges exist, just so long will cases
of scarlet fever be infective. Sexton
(Arch, of Diag., May, 1915).
Experiments seem to show that the
specific germ of scarlet fever exists in
the blood, for inoculation with the
cerum into susceptible animals pro-
duces a typical attack of the disease.
SCARLET FEVER (CRANDALL AND MILLS).
83
It is also found in the various secre-
tions, as shown by their power to
generate the disease.
The micro-organism, while more
tenacious of life than is that of most
other diseases, either lacks the power
of gaining a foothold, when implanted
in the system, or is less readily con-
veyed through the air. It is at least
a fact that many more children escape
scarlet fever than measles, and its
spread is more readily controlled.
The chief source of infection is the
patient himself, but the area of con-
taoion is limited to a few feet. The
desquamation scales have long been
regarded as extremely infectious.
Their retention by clothing, bedding,
and the walls of the rooms is one of
the most common causes of infection.
The purulent secretions from the
throat, nose, and ear are also very
infectious, and are probably the chief
sources of infection. .
Scarlet fever is spread by indirect
infection more frequently than any
other disease except diphtheria. Its
specific micro-organism is more tena-
cious of life than that of any other
disease, except, perhaps, smallpox.
Authentic cases have been reported in
which it maintained its vitality for a
year or more. It may be conveyed
from one child to another in the fur
of cats and dogs, and it is probable
that these animals may suffer from
the disease. The contagion clings to
rooms with great tenacity, being usu-
ally lodged in the wall-paper or in
cracks of the walls, ceilings, and
floors. The conveyance of scarlet
fever by milk and other articles of
food is undoubted.
The celebrated epidemics of Hen-
don and Wimbledon were believed by
Dr. Klein to be due to scarlet fever
in the cows, but this belief has not
been substantiated. It is probable
that the disease from which those
cows suffered was not true scarlet
fever.
An .epidemic of scarlet fever that
occurred in the city of Evanston, near
Chicago, in the winter of 1906-7
showed conclusively a connection be-
tween the extension of the disease
and the use of milk from a certain
source of supply. This source had
been under suspicion on account of
a number of cases of scarlatina oc-
curring during the previous summer
and fall, but the real epidemic began
early in January, 1907, and was at its
height between the 14th and 19th of
the month. Whole families were at-
tacked in a day, and a notable pro-
portion of the patients were adults.
H. B. Hemenway (Jour. Amer. Med.
Assoc, Apr. 4, 1908).
The disease has been conveyed
by letters written by hands in the
stage of desquamation. An attendant
upon a case of scarlet fever may carry
the infection to other children by the
clothes, hands, or beard.
The portal of entrance in most cases
is undoul)tedly the nasopharynx. It
is here that the first local symptoms
appear, and all the evidence points to
the fact that both the primary and
secondary micro-organisms commonly
enter the system at this point.
In cities scarlet fever is endemic, a
few cases appearing in the health-
reports every week, but at intervals it
becomes epidemic, usually during the
fall and winter. Epidemics of scarlet
fever usually spread very slowly as
compared with those of measles.
Period of Incubation. — The period
of incubation is shorter than that of
any other infectious disease, except,
perhaps, grippe and diphtheria. Tlie
extremes range from a few hours to
fifteen days. In 87 per cent, of cases
84
SCARl.IiT FEVER (C' RANDALL AND MILLS).
Holt found the period to be less than
six days and in 66 per cent, between
1\vo and three days.
Period of Infection. — The period of
infection is long. The disease is not
infectious during the period of incu-
bation, but it may be so from the first
appearance of changes in the throat.
The most actively contagious period
is at the height of the febrile stage:
on the third, fourth, and fifth days.
The infectious power then diminishes,
but increases again during the stage
of desquamation. The period of con-
tagion continues until the last evi-
dences of desquamation have disap-
peared. The purulent discharges
from the throat, nose, and ears are
capable of infecting others, and isola-
tion should not be relaxed until they
have disappeared. The conventional
forty days is not, in most cases, too
long. It should be as much longer as
the condition of the skin and mucous
membranes may indicate.
Report of 45 personal cases in
which children discharged from the
hospital as fully cured of scarlet
fever, the forty-second day, infected
other members in the home to which
they returned. In 6 cases the chil-
dren gave the infection in four days
to other children after their return;
in some others the interval was from
five to twenty-five days, but in the
majority it averaged seven. It is still
a question how long a child with
scarlet fever should be isolated. The
present six weeks' rule is inadequate.
The best plan would be to have spe-
cial convalescent homes for children
with scarlet fever and diphtheria.
Baginsky (Deut. med. Woch., Apr.
18. 1912).
PATHOLOGY. — In uncomplicated
scarlet fever the lesions are confined
to the skin and throat. The lesions of
the skin are those of acute dermatitis.
The papillae and the stratum beneath
become infiltrated with fluid, while
about the blood-vessels there are
aggregations of leucocytes. The pro-
duction of epithelium is greatly in-
creased during the acute stages, which
result later in profuse exfoliation of
the superficial layers. In the later
stages in addition to this, according
to Neumann, there is also a profuse
development of exudative cells, par-
ticularly among the ducts and fol-
licles. These cells easily reach the
epithelial surface : a fact which ac-
counts for the great infectiousness of
the desquamating cells.
The throat changes in uncompli-
cated scarlet fever are catarrhal in
nature, and are an essential part of
the disease. The croupous and diph-
theritic membranes must be consid-
ered as complications. The patho-
logical changes in the tongue are
similar to those in the skin.
Complications and Sequelae. — An-
gina.— Except in a very few mild
cases, the throat always shows some
pathological change. A catarrhal
condition of the throat is normal to
scarlet fever, but membranous exu-
dates and gangrene are not essential
to it.
The true nature of the membranous
inflammation seen in scarlet fever was
long a subject of discussion, which
has been settled by the bacteriologist.
With few exceptions, the angina of
the early stages is pseudodiphtheria,
that of the late stages true diphtheria.
While primary pseudodiphtheria is a
mild disease, the death rate being
rarely over 5 per cent., secondary
pseudodiphtheria is very dangerous
and fatal. The membrane may ap-
pear on the throat on the first or
second day, but it is not usually seen
before the third day. It is generally
SCARLET FEVER (CRANDALL AND MILLS).
85
confined to the tonsils, but frequently
nils the throat and nasopharynx. It
shows a tendency to invade the ears
and nose and to shun the larynx. It
reaches its height about the sixth
or seventh day. It frequently pre-
sents all the local characteristics of
diphtheria together w^ith the general
symptoms of septicemia. The excit-
ing cause of this membranous inflam-
mation is the Streptococcus pyogenes.
It is occasionally associated with the
Staphylococcus aureus or alhus, but the
streptococcus is the more commonly
observed. It occurs not only in the
pseudomembrane and the tissues
underneath it, but is found in the
blood in large numbers. Through the
agency of the toxins which it gener-
ates it is unquestionably the cause of
the complications and general sep-
ticemia. The pseudomembranes which
appear late in the disease are usually
associated with the Klebs-Loffler
bacillus. Diphtheria is, in the fullest
sense of the word, a complication, and
is not an essential symptom of scar-
let fever.
Otitis, next to angina, is the most
common complication, and in its re-
sults is one of the most serious, as it
is a common cause of deaf-mutism.
It results from extension of the in-
flammation from the throat through
the Eustachian tubes. The tendency
to ear involvement varies in different
epidemics, but it is more common in
young patients. It does not usually
occur until the second week, and, as
a rule, involves both ears. Its pres-
ence may be indicated by earache and
an increase in the fever, but fre-
quently a discharge is the first indica-
tion that the ears are involved. The
process is prone to be a destructive
one and to result in long-continued
suppuration. It sometimes leads to a
lapidly fatal meningitis.
Adenitis and cellulitis are com-
mon results of streptococcic invasion
of the throat. Not only are the
lymphatic glands themselves enlarged,
but there is more or less inflammatory
edema of the surrounding tissues.
That this is due to secondary infection
is shown by the fact that streptococci
are found in abundance in both the
nodes and edematous tissues around
them. Enlargement of the nodes may
be detected during the first week, but
serious cellulitis does not, as a rule,
occur until later in the disease. Sup-
puration, sloughing, or even gangrene
may occur.
Joint Lesions. — Although acute ar-
ticular rheumatism sometimes occurs,
the joint affection often called scar-
latinal rheumatism is, in most in-
stances, a synovitis. It is mild, and is
frequently confined to the wrist. It
appears early in the second week, con-
tinues for three or four days, and dis-
appears, suppuration being rare. It
is seldom seen under 4 years. Pyemic
arthritis occurs in extremely rare in-
stances, and affects the larger joints,
the lesions being multiple. Marsden
has recently offered the following
excellent classification of the scar-
latinal joint lesion: (a) synovitis, {b)
acute or chronic pyemia, (c) acute or
subacute rheumatism, and (d) scrof-
ulous disease of the joints.
Nephritis. — Albumin may be found
m the urine during the acute stage ;
but it is fel)rile albuminuria, due to
degenerative nephritis, which sub-
sides as the temperature falls. In the
grave type kidney lesions may occur,
to which the term septic nephritis has
been given. The urine contains albu-
min, but blood and casts are not
86
SCARLET FEVER (CRANDALL AND MILLS).
necessarily present, neither do the
rational symptoms of uremia appear.
The most characteristic and com-
mon kidney lesion is postscorlatinal
nephritis, and is a diffuse nephritis.
It develops during- the third or fourth
week, and may follow a severe or mild
attack. There may be no interval of
apyrexia between the kidney attack
and the onset of the nephritis. It
may be so mild as to almost escape
notice, or it may be so severe as to
cause speedy death. Recovery may
be complete or incomplete. The first
symptom to be noticed is usually
edema of the face, which is frequently
accompanied by feverishness and rest-
lessness. Dropsy and all the charac-
teristic symptoms of acute. nephritis
rapidly develop. The urine usually
shows a small amount of albumin for
a few days before the advent of defi-
nite symptoms. As the disease de-
velops, the urine becomes scanty and
high colored, and may be completely
suppressed. It contains a large
amount of albumin, and is loaded with
blood-cells and casts. The first evi-
dence of albumin after the second
week should be a warning of dan-
ger, and should receive immediate
attention.
Pneumonia, although commonly
found at the autopsy in patients who
have died with septic symptoms, is
frequently not recognized before
death. Endocarditis and pericarditis,
though uncommon, are sometimes en-
countered. Murmurs are occasionally
heard during th^ course of the disease,
which disappear as the active symp-
toms subside. Permanent organic
lesions sometimes develop in conjunc-
tion with the late kidney complica-
tions. Nervous symptoms are rare.
The various serous membranes are
occasionally involved. Peculiar at-
tacks of symmetrical, superficial gan-
grene have been reported. The dis-
ease may be complicated by any of
the other infectious diseases.
Second attacks of scarlet fever are
extremely rare. They sometimes oc-
cur, but in most supposed cases there
has been some error in diagnosis.
Relapses are more common than
second attacks. They result from
autoinfection, and usually occur dur-
ing the second or third weeks.
The writer has met 180 return
cases infected by 145 scarlet-fever
patients dismissed from the hospital
as completely cured and disinfected.
The period of incubation of the re-
turn cases was from three to fifteen
days in 80 per cent, and from fifteen
to twenty-five in the remainder. Of
the 4178 cases of scarlet fever de-
clared during the year in question,
2392 were treated in the hospital in
his charge. None of the adults gave
occasion for the return cases; they
occurred with children who were
much embraced and petted. Preisicn
(Berl. klin. Woch., June 21, 1909).
PROGNOSIS.— The younger the
patient, the greater the mortality.
Holt, after the study of a large num-
ber of American and European cases,
concludes that the general mortality
may be assumed to be from 12 to 14
per cent., while under 5 years it is
from 20 to 30 per cent. It is much
lower in private practice than in hos-
pitals. The majority of fatal cases
occurs in children under 7 years.
The prognosis depends upon: 1.
Amount of poison that has been ab-
sorbed. 2. Whether the child is weak
and delicate or strong and robust. 3.
The occurrence of complications,
especially cardiac, pulmonary, renal,
and otitic. Very high temperature
indicates a bad prognosis. The
younger the child the graver the prog-
SCARLET FEVER (CRANDALL AND MILLS).
87
nosis. Mortality is estimated at from
20 per cent, to 30 per cent, in children
under 5 years of age. Causes of
death: L Scarlatinal toxemia. 2.
Nephritis. 3. Brain abscess from ex-
tension. H. Brooker Mills (Therap.
Gaz., May, 1921).
Prognosis becomes unfavorable on
the appearance of the following symp-
toms, the gravity being in propor-
tion to their severity : Violent onset,
high temperatures, convulsions, ex-
tensive pseudomembranous or gan-
grenous pharyngitis, diphtheria,
croup, pneumonia, extensive cellulitis,
superficial gangrene, nephritis, and
exhaustion with general septic symp-
toms. The prognosis in uncompli-
cated cases is good.
Sudden death is not uncommon in
this disease, and is usually due to
myocardial trouble. Weill and Mouri-
quand (Presse med., Aug. 5, 1911).
Morbidity of over 7,000,000 cases
collected and studied from communi-
ties in America, Europe and else-
where. The most striking fact about
case-fatality of scarlet fever in the
past half-century has been its con-
sistent, general and marked reduc-
tion. The sexes, as a whole, show
about equal susceptibility. During
the first five years of life males are
more susceptible to the disease, while
between 5 and 15 years females are
distinctly more susceptible. Case-
fatality is higher among males at all
ages. Nearly half of the scarlet fever
cases was found to occur in the five
years between 3 and 8 years of age,
distributed nearly equally in each of
the five years, and 2 children out of
3 at this age contract the disease,
when exposed to it in their homes.
Ninety per cent, of cases occur un-
der 15 years of age. Mortality is
highest in infancy, being from 12 to
20 per cent.; lowest at about 10 years
of age, and thereafter gradually in-
creases with age. About 90 per
cent, of deaths occur under 10 years
of age. H. H. Donnally (Wash.
Med. Annals, Nov., 1915).
PROPHYLAXIS.— In view of the
gravity of the disease and the efifect-
iveness of preventive measures, pro-
phylaxis assumes unusual importance.
The most important of all prophylac-
tic measures is complete isolation of
the sick. This applies to nurse as
well as to patient. If possible, one
'person should be selected as an inter-
mediary between the nurse and the
family. The doctor should always
wear, in the sick-room, a gown of
muslin or calico fastened at the neck
and waist, and long enough to com-
pletely cover his clothes. A stetho-
scope should be used in making phys-
ical examinations of the chest.
The period of isolation should not
be less than forty days and as much
longer as the presence of desquama-
tion or purulent discharges may de-
mand.
The best prophylactic treatment is
the removal of enlarged and diseased
adenoids and tonsils.
Scarlet fever having appeared in 2
pupils in a school of over 300, the
2 patients were at once isolated and
the throats of all the contacts sprayed
with a 1 : 2000 solution of mercury
perchloride. No other cases ap-
peared, and the remaining children
appeared in perfect health, save for
the fact that in 131 cases out of the
remaining 299 an elevation of tem-
perature varying between 99° and
101° F. (37.2° and 38.3° C), and last-
ing for two or three days, was found.
There were absolutely no other
symptoms or indications of the chil-
dren being out of sorts. Thornton
(Brit. Med. Jour., Feb. 29, 1908).
In the last 28 years 4251 cases of
scarlet fever have been reported at
Brunn. Sterilization of the premises
and measures to prevent infection of
others failed in a large number of
88
SCARLET FEVER (CRANDALL AND MILLS).
cases. It is evident that the virus is
transmitted not only in the period
of incubation, but long after recov-
ery, far beyond the routine six
weeks. The aim should be to re-
move the virus from tlie mouth by
mechanical means. Kokall (Wiener
klin. Woch., Dec. 29, 1910).
Numerous observers of late, espe-
cially in England, have shown that
by the cleansing treatment of nose
and throat with a mild antiseptic
healthy children could be kept in con-
tact with children ill with scarlatina
without contracting the disease. The
writer has treated 2 families, 6 chil-
dren in each family, where one mem-
ber had contracted scarlatina, and by
the simple process of cleaning the
nose and throat three times a day for
six weeks he has prevented any fur-
ther spread of the disease. Schultze
(Med. Rec, Dec. 10, 1910).
Dischargees from the patient should
be disinfected with strong subHmate
sokitions. The bedding, carpet, and
clothinp- should be disinfected with
boiling water or steam. The mat-
tress should be destroyed. The room
itself should be thoroughly washed —
floor, ceiling, and walls — with a
1 : 2000 sublimate solution.
One room on the top floor of every
house should be arranged for a sick-
room : the moldings should be plain,
and the floor of hard wood ; the walls
and ceilings should be painted or cov-
ered with washable paper ; the bed-
stead should be of enameled iron. It
is a fallacy to suppose that dishes in
the sick-room, filled with antiseptic
fluids, can limit the spread of the dis-
ease, or that there is any efficiency, as
a prophylactic, in generating steam
impregnated with medicinal agents.
The use of such agents is liable to
generate a false sense of securitv and
lead to the neglect of more important
measures.
[The child should have its own
dishes. Everything should be disin-
fected before it leaves the room — i.e.,
sheets, pillow-cases, towels, and
everything used for the patient — in
bichloride of mercury solution 1 :500
or phenol solution 1:50; also the
urine and feces, which should be col-
lected in a bed-pan containing equal
parts chloride of lime and strong vine-
gar. So far as possible use materials
that can l)e burnt. Diapers could be
made of old sheets, and napkins could
be made of paper. Hang a sheet at
the door and keep it wet with either
of the solutions! mentioned, as this
will catch the dust from the outside
and infected material from the inside
of the room. Sprinkle one of these
solutions on the floor, or mop once or
twice a day. Have a gown and cap
handng- at the door and a pair of rub-
ber overshoes for your own use.
Take the tjown off at the door of the
sick-room, and have it disinfected be-
tween visits. When you leave the
room, go to the bath-room and wash
the hands and face in a weak bichlo-
ride solution. The mail should also
be carefully disinfected before it
leaves the house, using dry heat, and
all animals kept out of the sick-room
during the illness, as they are great
carriers of the infection. — H. Brooker
Mills.]
Streptococcic vaccines have been
tried. The most satisfactory of these
so far has been Gabritschewsky's,
reference to which has already been
made on page 342 in the second vol-
ume of the present work.
Gabritschewsky's vaccine for scarlet
fever is made from streptococci iso-
lated from the blood in the hearts of
children dead of scarlet fever. It is
a condensed bouillon culture of
SCARLET FEVER (CRANDALL AND MILLS).
89
streptococci killed by heating to 60°
C, and the addition of Yz per cent,
carbolic acid solution. Each c.c. con-
tains 0.02 to 0.03 of the bacterial
mass. The vaccine was first used in
Moscow in 1904. Usually 10 drops
were injected with an ordinary hy-
podermic syringe. The injections
were made during an epidemic of
scarlet fever, 185 persons being thus
treated, as a preventive measure. A
rise of temperature was observed in
all but one. A moderate rise in 64
persons, a faint rise in 54, a marked
rise in 66. Local tenderness was
seen in 66 patients, redness in the
injected area in 173; swelling in 103.
In many cases there was a rash re-
sembling true scarlet fever, and in 5
patients there was desquamation.
There was a general rash in 43 per-
sons, a local rash in 70; no rash in
72 of the 185 patients; only 2 devel-
oped scarlet fever; the remainder re-
mained well, save that they showed
these temporary complications after
the use of the vaccine. Schamarine
(Roussky Vratch, June 30, 1907).
The streptococcus vaccines, used as
advocated by Gabritschewsky, have
some influence in controlling epi-
demics of scarlet fever. Their use,
with proper care, is attended by no
harmful results. They should be
given a wider application in this
country to prove or disprove the con-
tentions of the Russian physicians.
Smith (Boston Aled. & Surg. Jour.,
Feb. 24, 1910).
After using the Gabritschewsky
vaccine in 700 cases the writer con-
cluded that it had a decided value
from a prophylactic standpoint. In
comparing the effects observed he
states that but one very light case of
scarlet fever has occurred among the
nurses who have received vaccine
treatment, while in a considerably
smaller group, under identical condi-
tions, 5 developed severe cases of
scarlet fever. Walters (Jour. Amer.
Med. Assoc, Iviii, 546, 1912).
During a severe epidemic of scarlet
fever in a number of villages the
writer used Gabritschewsky's bac-
terins, making about 3000 inocula-
tions. The results were very satis-
factory. It was found, however, that
a single inoculation does not confer
immunity, and that immunity does
not last over six months. Poloteb-
nova (Roussky Vratch, July 14,
1912).
[A physician should not attend an
obstetric case while in attendance
upon a patient suffering with scarlet
fever. — H. Brooker Mills.]
TREATMENT.— Many specifics
for scarlet fever have been proposed,
tried, and found wanting. Much may
be done to avert complications and to
render them less serious when they
occur, and many lives may be saved
by judicious management. Mild cases
require little or no medication ; they
usually receive too much.
The patient should be kept in bed
for at least three weeks, and should
receive a fluid diet for not less than
two weeks. Milk is the best diet for
scarlet-fever patients. It may be
given peptonized or plain. Later in
the disease broths, eggs, or meat-
jellies may be given. The stoinach
should never be overfilled.
[The diet should be liquid and
nourishing. If the child is breast-fed,
have the milk pumped from the breast
and fed to the child. If a bottle baby,
dilute one-half with water if on
straight milk, because whole milk
constipates and causes tympanites, or
give half milk and half Vichy water,
because alkalies help to neutralize the
acidity, which is one of the causes of
the nei:)hritis. Orange juice is very
beneficial. Lemonade is good, espe-
cially if one adds to every pint (500
c.c.) 1 dram (4 Gm.) of cream of tar-
tar. Cereals may be cautiously added,
and water should be given freely.
90 SCARLET FEVER (CRANDALL AND MILLS).
Avoid the use of salt and exclude The throat symptoms of the first
soups and bouillon from the diet. — few days may be mitif^^ated by giving-
H. Brooker Mills.] cool water or bits of ice. Later hot
The initial vomiting usually re- drinks may be given or irrigation of
quires no treatment, ]:)ut the bowels the back of the throat with a weak
should be acted upon mildly by small, hot saline or boric acid solution may
repeated doses of calomel. Later be employed. Chlorate of potash
they should be kept acting, if possible, should l)e avoided. Its beneficial
by means of enemata rather than by efifects are doubtful. Nasal syringing
the use of cathartic drugs. should be avoided unless clearly in-
In severe cases stimulants are re- dicated by a purulent nasal discharge
quired. In malignant cases they or obstruction of the nasopharynx,
should be pushed to the point of More harm than good may result from
tolerance. Strychnine is of great overzealous attempts at local treat-
value in septic cases with prostration ; ment of the throat and nose. The
it may often be combined to advan- most successful treatment consists in
tage with digitalis. Bathing the sur- the use, not of active and poisonous
face with warm water followed by antiseptics, but of mild and cleansing
anointing with plain or carbolic vase- washes, freely and frequently applied.
lin or a 5 per cent, ichthyol ointment [As to the toilet of the nose and
should be begun as soon as the first throat: Swab, spray, or gargle with
signs of desquamation appear, and alkaline solution, according to the age
should be continued throughout the of the child. If the patient be old
course of the disease. enough to gargle, this should be
For the itching, which is sometimes done ; if, on the other hand, it be too
intolerable, keeping the .child restless young for that, but old enough to
and irritable, the writer finds spong- opg^ J^S mouth and put out its tongue
ing the body with a warm solution i ^. u *. j ,i i i •
, ,. u . / • .- when told to do so, then swabbmg
of sodium carbonate (gram x — Gm. i i , •, .
0.6-to-5j-60 c.c), to which a little "^''^y ^'^ employed, while, if it be too
mucilage has been added, very useful young to do this, spraying with an
and soothing. Seymour Taylor (Med. atomizer would be better. Potassium
Bull., Aug., 1907). permanganate, gr. ss (0.03 Gm.),
Tepid baths (28° to 32° C.-82.4° to ^^ter f,j (30 c.c), is a good solution
89.6° F.) of 20 minutes' duration and , r .• it-,
., to use lour times a day. Do not use
given every evening, or it necessary, . , ,
morning and evening, will often in- Potassium chlorate for the sore throat,
duce sufficient sedation. The un- because of its well-known irritating
pleasant sensation of heat in the skin effect on the kidneys should any of it
is also allayed by such baths, though be swallowed or absorbed. After
still more effectually by rubbings .,^; .i ii i- i i.- • --i r
.,, r • using the alkaline solution instil a few
with the following liniment: — , . , •■, . .,
■drops m each nostril of anv oily prep-
Cold cream, _ aration, such as :-
Neutral glycerin aa 50 Gm. (12 'jr).
M. Ft. linimentum. ^ Menthol gr. x (0.65 Gm.).
The liniment should preferably be '^''^"'^^ ''^^ &''• 'J ^^-^^ Gm.).
used luke-warm. A. F. Plicque 01. eucalypt fSss (2.0 c.c).
(Med. Bull.; N. Y. Med. Jour., July Liq. albolem ....q. s. fSij (60 c.c).
27, 1912). H. Brooker Mills.]
SCARLET FEVER (CRANDALL AND MILLS).
91
Adenitis can only be controlled by
checking the septic process at its
fountain-head in the throat. The ap-
plication of hot oil or the hot-water
bag is soothing to some patients, but
the use of cold is preferable in most
cases. Poultices should not be ap-
plied continuously. Diffuse suppura-
tion requires free incision. Otitis re-
quires the treatment demanded by the
disease in other conditions. The
joint affections require but little treat-
ment other than rest and protection.
Rheumatism should receive its own
appropriate treatment. Restlessness
and nervous symptoms are sometimes
relieved by cold to the head, or by the
use of small doses of phenacetin, not
enough being given to materially
affect the temperature. Nephritis
should receive prompt and very care-
ful attention. Tts treatment is that of
nephritis due to other causes.
A study of 325 cases, with 23
deaths, in the Alexandra Hospital,
Montreal, showed that twenty-one
days' milk diet and twenty-one days'
bed should be the rule to prevent
death from nephritis J. McCrae
(Montreal Med. Jour, Sept., 1908).
The temperature may require atten-
tion from the outset, but it should
not be forgotten that a high tempera-
ture IS normal to scarlet fever. It
may be allowed to run, therefore,
without interference, to a somewhat
higher point than in most other dis-
eases. Hyperpyrexia, or a tempera-
ture continuously above 104° F.
(40° C), demands treatment. It is
best reduced by means of the cold
bath; l)Ut this, for obvious reasons, is
less practical in private than in hos-
pital practice. The cold pack or cold
sponging are more available. An
effective method of applying cold
adopted at the Willard Parker Hos-
pital IS thus described by Northrup:
"The tendency in all cooling processes
is for the feet to become cold. To
obviate this the patient is placed upon
blankets, but the legs, feet, arms, and
hands are wrapped in warm, dry
blankets, and hot bottles are inclosed
in the wrappings. An ice-bag is ap-
plied to the head. The face and
trunk are freely sponged in wann
water and alcohol, evaporation being
hastened by fanning, so long as it
cools the patient, clears the cerebrum,
gives force and improved rhythm to
the heart, and leaves the patient to a
quiet sleep."
Great caution should be exercised
in the use of antipyretic drugs. No
coal-tar antipyretics should be used.
[Treat the temperature hydrothera-
ipeutically — i.e., sponge baths, colonic
irrigations, ice-bags, etc. In cases of
very high temperature, and especially
with diminution of urine, once a day
wrap the child in a blanket and place
it in water at a temperature of 90° to
95° ; keep it there for from 10 to 12
minutes ; take out of wet blanket and
place in dry blanket, and give inunc-
tion of cacao butter. Try to have two
rooms, one for day and one for night,
preferably with a sunshine exposure.
Keep temperature of rooms at 68° to
70° F.— H. Brooker Mills.]
In all cases in which hypodermic
injections of large doses of quinine
bihydrochloride were given the infec-
tion was cut short. The fever yielded
after the second or third injection,
desquamation rapidly supervened, and
prompt recovery followed. A. Tram-
busti (Semaine med., June 18, 1913).
The writer uses quinine bihydro-
chloride, giving a 30 per cent, solu-
tion hypodermically in full doses. A
single injection is said to reduce the
temperature rapidly and to improve
92
SCARLET FEVER (CRANDALL AND MILLS).
the subsequent course. Chichkine
(Gac. Med. Catalan., Jan., 1915).
Serum treatment has been tested
very extensively, but 1 feel con-
strained to say that up to the present
time it has not proved of the value
hoped for. It is certain that the stock
antistreptococcus serums have not
shown themselves to be of striking
value. Decided results have been
claimed for Escherich and ]\Ioser's
serum, but it has not been generally
adopted. Inasmuch as the more
serious symptoms of scarlet fever are
all largely due to streptococcic infec-
tion, the theory underlying the use of
normal serum is not irrational. At
the present writing, however, no posi-
tive statements can be made regard-
ing its efificacy.
[The value of antistreptococci
serum is doubted and its use is
limited. There are several conditions
where one would not use the serum :
1. In cases with very high tempera-
ture. 2. In very young infants or pa-
tients who are greatly exhausted from
the effects of the disease. If indi-
cated, use 20 to 40 c.c. every 4 to 6
hours. The prophylactic dose to
others is 10 c.c, but a single inocula-
tion does not confer immunity, and
immunity, when present, does not last
over 6 months. — H. Brooker Mills.]
More promising results have been
obtained from serum of convalescents.
In a recent malignant epidemic of
scarlatina at Stockholm, convalescent
serum was obtained from the fourth
to the seventh week of the disease,
and 0.5 per cent, of phenol added. It
was then used exclusively in des-
perate cases, with intense intoxica-
tion, bad mental state, pulse 140 to
160, cyanosis, fever 40° to 41° C—
cases in which recovery would aver-
age much less than 50 per cent. Of
237 cases sufficiently serious to re-
ceive serum, 195 recovered, while 25
died in the first and 17 in the second
week of the disease. Of the 195
cures, 101 were very prompt. In 91
cases of the same type who received
no serum the mortality was 70 per
cent. Mild cases can supply serum
as potent as severe cases. Kling and
Widfelt (Hygiea, Jan. 16, 1918).
In treating severe scarlet fever
witli convalescent serum, the blood
was drawn from the twentieth to the
twentj--eighth day. Serums from sev-
eral patients were mixed, tested for
sterility, and stored in the refriger-
ator. The serum was injected intra-
muscularly in the thighs in doses of
25 to 90 c.c. (6% drams to 3 ounces),
60 c.c. (2 ounces) being tlie usual
dose. Commonh' a single dose was
given, occasionally 2. Xo local or
general disturbances followed. Nine-
teen cases were thus treated. Quite
constantly a fall of temperature be-
gan two to four hours after the in-
jection and continued gradually for
twelve to twent}--four hours. In
purth- toxic cases the temperature
fell to nearly normal and tended to
remain there. In cases with septic
complications it rose again after the
fall and ran a "septic" course. Weaver
(Jour, of Infect. Dis., Mar., 1918).
Report of favorable results in pro-
phylaxis of scarlet fever by the use
of a sere vaccine obtained from the
desquamated scales of scarlet fever
patients. Horses treated with it de-
veloped antibodies in their serum to
an amboceptor power of 2000. Of 40
children immunized and allowed to
live and sleep in the same bed with
scarlet fever patients, not one con-
tracted the disease. Of 25 children in
families where there was a case of
the disease, not one contracted it.
The immunized children were fol-
lowed for si.x months, and the per-
sistent presence of the amboceptors
confirmed. Di Cristina and Pastore
(Pediatria, Jan., 1919).
According to Ramond and Schultz,
sodium salicylate possesses to a cer-
tain degree specific properties.
SCARLET FEVER (CRANDALL AND MILLS).
93
Sodium salicylate is indicated in
scarlatina. It should be given from the
start, but on the fifth day discontin-
ued, and resumed from the fifteenth
to the twentieth day, when late com-
plications are due. The dose is about
6 Gm. (90 grains) per day, increased
to 8 Gm. (2 drams) or more if re-
quired. Nocturnal exacerbations be-
ing typical in scarlet fever, the drug
should be continued during the night.
At the fifteenth day the dosage need
not be as large. Under this drug the
fever subsides by the third day. The
throat lesions are rapidly reduced, but
with the recrudescence at the fifteenth
day, may reappear in an aggravated
form. They are rapidly controlled by
the salicylate. The latter may abort
late nephritis if given in time, but if
the complication has several days'
headway, should be given cautiously,
lest the kidneys be unable to excrete
it. If it can pass the kidneys the dose
may then be augmented. On all other
manifestations of the disease, the
drug acts more or less as a specific.
Ramond and Schultz (Jour, de med.
de Paris, Sept., 1916).
Salvarsan, and especially neosal-
varsan, have been much lauded, but
neither has stood the test of experience.
[But little medicine should be
given, but the free use of water is
necessary. The one and only drug"
that is usually necessary is potas-
sium citrate in 2- to 5- grain (0.13 to
2 Gm.) doses, or liquor potassii
citratis, 15 to 20 minims (0.9 to 1.25
c.c.) three times a day. Sweet spirit
of nitre should not be given freely.
The skin in scarlet fever is not active,
and therefore there is no use for a
diaphoretic ; as for diuretics, the pos-
sibility of damaged kidneys should
always be borne in mind. If renal
inflammation develops, poultices ap-
plied over the kidney region may do
good. Make flaxseed poultice with 16
parts flaxseed and 1 part mustard, or
4 parts flaxseed and 1 part digitalis
leaves. Put on every four hours dur-
ing the day, and keep on hot for half
an hour. For stimulation, when
needed, caffeine sodium-benzoate in
%-grain (0.03 Gm.) doses hypoder-
inically is among the best. Digitalis
and strophanthus, the latter especially
in very young children, may be em-
ployed by mouth. Itching is very
troublesome during desquamation in
scarlet fever; warm baths followed
by cacao-butter inunctions are very
helpful.— H. Brooker Mills.]
As emaciation and anemia are fre-
quent results of scarlet fever, active
tonic treatment should be instituted
during the convalescence, the chief re-
liance being placed upon iron. Bash-
am's mixture is especially indicated.
The patient should be particularly
protected from cold, for exposure not
infrequently seems to precipitate
nephritis long after its usual period of
occurrence.
When the depression becomes
threatening the use of adrenalin
sometimes proves very beneficial, as
shown by Hutinel. The 1 : 1(X)0 solu-
tion may be slowly injected intra-
muscularly in saline solution, the dose
varying with the age, from 5 to 10
minims, repeated every hour or two.
The blood-pressure was found in a
series of cases to be subnormal in 25
per cent. Pronounced arterial hy-
potension, especially if accompanied
by other signs of acute suprarenal
insufficiency, should be treated by
adrenalin. J. D. Rolleston (Brit.
Jour, of Children's Dis., Oct., 1912).
The writer found adrenalin very
useful in tiding the patients past the
danger point when the adrenals
seemed to be suffering acutely from
the infectious toxic process. Cam-
phorated oil, also proved surprisingly
effectual. P. H. Kramer (Neder-
94
SCHLAMMFIEBER.
SCLERODERMA.
landsch Tijdschrift v. Geneeskunde,
Sept. 6, 1913).
In the writer's service there were
34 cases of malignant scarlet fever
in a total of 550 cases of this disease;
in a previous series of 833 cases there
were 27 that terminated fatally. Re-
covery was the rule in destructive
lesions in the throat; the defects in
the tissues were filled in time and no
operation was required. Hutinel
(Arch, de med. des cnfants, Feb. 1915).
Floyd M. Cr.and.all,
New York,
AND
H. Brooker Mills,
Philadelphia.
SCHLAMMFIEBER. -This name
was applied to a form of acute infectious
jaundice which occurred among young
subjects who had worked in the districts
of Breslau that had been recently flooded.
It is not entitled to classification as a
disease, since it corresponds in every way
with acute infectious jaundice (Weil's dis-
ease), treated on page 394 of the sixth
volume of the present work.
SCLERODERMA.-DEFINITION.
— A disease characterized by induration
of the skin, and at times of the sub-
cutaneous tissues, which sometimes pro-
gresses to complete atrophy of these
tissues.
VARIETIES.— Three main varieties of
scleroderma are recognized: the diffuse,
which is generalized or limited to certain
areas; the circumscribed, or morphea,
which appears in spots; and sclerodac-
tyly, which is limited to the hands.
SYMPTOMS.— In the diffuse form,
after a series of prodromic symptoms,
sensations of chilliness or heat, pruritus,
and pain in the muscles and articulations,
the tissues becoming thickened, stifif, and
hard, and appear edematous. The skin
is cold and whitish, contracted, and some-
times painful. The face and the upper
part of the body may be the only parts
aflfected, but the entire body becomes in-
volved. The skin is, as it were, glued to
the skeleton, the fingers and toes being
thin and stifif or hooked. A variable
amount of pigmentation is usually pres-
ent in well-developed cases. Gangrene
is sometimes observed, constituting the
mutilating form.
In the circumscribed variety, the mor-
phea of Erasmus Wilson, the affected
spots are limited in area, the spots being
flat or raised, oval or rounded. Their
color varies from a light pink to a pale
or dark violet, and undergoes changes
which ultimately give the lesion a
characteristic aspect: a whitish-brown
squamous center surrounded by a bluish
or lilac pigmented border, or ring. They
are seldom painful, though pruritus is
sometimes complained of. The spots, of
which there are generally but two or
three, are usually located upon the neck,
the chest, the abdomen, the arms, or
the thighs. These spots gradually fade
away, but occasionally cicatrices are left
to mark the location of the lesions. The
prognosis in this form is favorable.
In sclcrodactyly the third phalanx be-
comes atrophied and its tissues, including
the nail, are partially destroyed by ab-
scess. The flexor tendons are contracted
and give the finger the appearance of an
angular hook by flexing the first phalanx
upon the second. Here also the skin is
hard, contracted, adherent to the bones,
and lilac in color. The prognosis is
necessarily unfavorable, owing to the
mutilations caused by the disease.
DIAGNOSIS.— The only condition with
which scleroderma can be easily con-
founded is leprosy, but the tubercles of
the latter disease, the broad dissemina-
tion of the skin lesions, the nasal dis-
order, the character of the ulcerations,
and the disturbances of sensation usually
facilitate its recognition.
Osier observes that diffuse scleroderma
must sometimes be distinguished from
brawny, solid edema, met with at times in
patients with long-standing renal or car-
diac disease, in which there is induration
following chronic dropsy. In scorbutic
sclerosis there may be parchment-like
immobility of the skin, due to extensive
subcutaneous hemorrhages, involving the
muscles.
During the stage of swelling it may
resemble myxedema. In Raynaud's dis-
ease the infiltration, pigmentation, and
extreme cyanosis are not wholly unlike
those of scleroderma. The increase of
SCOPARIUS AND SPARTEINE (WITHERSTINE).
95
pigment may suggest Addison's disease,
since the bronzing may be extreme.
ETIOLOGY AND PATHOLOGY.—
Scleroderma is an angiotrophoneurosis,
most frequently observed among neurotic
subjects and often in connection with
the rheumatic diathesis. It may appear at
any age, but chiefly in early adult life,
and is more prevalent among women than
men. The neurotic influence, however,
does not account for all cases, nerve-
changes being wanting in the majority.
Exposure to cold and wet, rheumatism,
nerve shocks, menstrual disorders, trau-
matism, etc., are named as causes.
Kaposi notes that the lesions follow,
to a degree, vascular distribution. The
morbid changes peculiar to scleroderma
include an endoperiarteritis, which may
be traced to various structures: the mus-
cles, the myocardium, the uterus, the
lungs, and the kidneys particularly. The
sclerosis would thus seem to be a result
of the vascular disturbances, through
impaired nutrition of the aflfected areas.
The chief changes in the skin, according
to Schamberg, are an increase and con-
densation of the connective tissue in the
corium and the subcutaneous tissue, an
increase in the elastic tissue, and a dimi-
nution in the caliber of the blood-vessels.
Later atrophy of the subcutaneous tissues
occurs.
Reines reported 13 cases which seemed
to confirm the connection between sclero-
derma and tuberculous infection.
Of 5 cases of diffuse scleroderma exam-
ined by Whitehouse, 3 gave a strongly
positive Wassermann reaction, 1 a faintly
positive and 1 a negative reaction.
According to Ravogli, 1917, the under-
lying factor in the disease is a disturbance
of equilibrium of the internal secretions of
the adrenals, thyroid, etc., while exposure
is often the determining factor. Criado,
1918, obtained improvement in one case by
adrenal administration, and made the sug-
gestion that adrenin be also used locally.
PROGNOSIS.— The prognosis is ex-
ceedingly unfavorable as regards cure.
The disease usually persists throughout
life. Improvement occurs in quite a third
of the cases. In adults Lewin and Heller
report 16 per cent, of cures, and 31 per
cent, in children under 15 years of age.
TREATMENT.— The treatment con-
sists in nutritious diet, good hygienic
surroundings, iron, and codliver oil in
ascending duses (the latter up to 10 table-
spoonfuls per day); sodium salicylate; ex-
ternally, steam baths, mud baths, mer-
cury (by inunction), galvanism, and mas-
sage. The most recent remedy is thyroid
gland; but, according to Osier, it is not
of much value. Brocq recommends elec-
trolysis, at first at comparatively short
intervals; then, when amelioration is
manifest, at much longer intervals. Elec-
trolysis does not act by destructive action,
but at a distance, influencing even patches
not touched. Philippsohn obtained excel-
lent results by the administration of
salol, in doses of about 7 to 15 grains
(0.45 to 1 Gm.), three or four times daily.
S. and W.
SCLEROSIS. See Index.
SCOLIOSIS. See Spine, Diseases
AND Injuries of.
SCOPARIUS AND SPARTE-
INE.— Scoparius, N. F. (spartium,
broom, broom-tops, besom), is the
dried tops of Cytisus scoparius (fam.,
Leguminos?e), a densely growing
shrub indigenous to Europe and ad-
jacent Asia, and sparingly naturalized
in sandy soil in North America. Its
long, slender, erect, and tough twigs
are arranged in large, close fascicles
which lie parallel with and close to
one another, and have a peculiar odor
wdien bruised, and a disagreeably bit-
ter taste. The quality of the drug
deteriorates with keeping, the pecu-
liar odor of the recently dried drug
being partially or completely lost.
Broom contains two active princi-
ples, sparteine and scoparin.
Sparteine (Cir,H26N2) is a trans-
parent, oily liquid, colorless when
fresh, but turning brown on exposure,
having an odor resembling that of
aniline, and a very bitter taste. Spar-
teine is heavier than water. It is but
96
SCOPARIUS AND SPARTEINE (WITHERSTINE).
slightly soluble in water, but readily
dissolves in alcohol, ether, and chloro-
form, and is insoluble in benzene and
benzin. Sparteine contains the car-
diac properties of scoparius.
The official sulphate of sparteine is
prepared by dissolving- 10 parts of re-
cently distilled sparteine in 40 parts
of diluted (10 per cent.) sulphuric
acid, and allowing the solution to
crystallize in a warm place. It should
be kept in well-stoppered, amber-col-
ored vials. Sparteine sulphate occurs
as colorless, rhomboidal crystals, or
as a crystalline powder, odorless, but
having a slightly salty and somewhat
bitter taste, soluble in 1.1 parts of
water, 2.4 parts of alcohol, but in-
soluble in ether and chloroform. It
is hygroscopic, and its aqueous solu-
tion has an acid reaction.
Scoparin (C21H22O10) is a gluco-
side, occurring in pale-yellow crystals,
without odor or taste, and soluble in
alcohol, alkalies, and in hot water. It
probably represents most of the diu-
retic properties of scoparius.
PREPARATIONS AND DOSES.
— The only official preparation is : —
Sparteincc sulphas, U. S. P. (sparte-
ine sulphate). Dose, y^ to 2 grams
0.008 to 0.13 Gm.).
Unofficial but serviceable prepara-
tions are : —
Scoparius, N. F. (broom-tops).
Dose, 15 to 60 grains ( 1 to 4 Gm.).
usually in decoction.
Decoctum scoparii (decoction of
broom, made by adding ^ ounce —
16 Gm. — to 1 pint — 500 c.c. — of water,
and boiling down to /^ pint — 250
c.c). Dose, 1 ounce (30 c.c.) to be
taken every three hours,
Fluidextractum scoparii, N. F.
(fluidextract of broom). Dose, 15 to
30 minims (1 to 2 c.c).
Infusum scoparii, Br. P. (infusion
of broom, made by adding 2 ounces —
60 Gm. — of dried and bruised l)room-
tops to 20 ounces — 600 c.c. — of boil-
ing distilled water; infusing in a
covered vessel for fifteen minutes and
straining). Dose, 1 ounce (30 c.c.)
every three hours.
Scoparin (the glucoside). Dose, 8
to 15 grains (0.5 to 1 Gm.).
PHYSIOLOGICAL ACTION. —
Internally broom, in large doses, ex-
cites vomiting and purging, and in
smaller doses increases the urinary
output. Sparteine acts upon the
heart as a stimulant or tonic like
digitalin, wiiile scoparin exerts its
action upon the kidneys. Sparteine
has a decided elTect upon the nerves
and spinal cord, lowering reflex ac-
tion, paralyzing motor nerves, reduc-
ing the electrical excitability of the
vagus and, finally, causing death by
paralysis of respiration, both as a re-
sult of its action upon the center and
upon the respiratory muscles.
In its action upon the circulation
sparteine, according to most observ-
ers, causes a transient rise in ar-
terial pressure, followed by a longer
period of diminished vascular tension.
Laborde, however, claims that spar-
teine has no influence on the blood-
pressure. Small doses slow the heart
for a short period and then accelerate
it, the volume of the pulse being sim-
ultaneously increased. Large doses
cause marked depression of the car-
diac muscle, and of the vagus. The
heart responds to its action in about
twenty to thirty minutes, and the
efifect continues for from six to eight
hours.
No cumulative action has been ob-
served. When taken regularly for
several weeks, the effects continue for
SCOPARIUS AND SPARTEINE (WITHERSTINE). 97
several days after discontinuing the solved in water with a trace of am-
remedy. monia, or in a mixture of 1 part of
In its action on the muscles, D. glycerin and 3 parts of water, given
Cerna demonstrated that sparteine hypodermically.
causes a brief period of increased Sparteine is pre-eminently a heart
muscular irritability, that it augments tonic and heart regulator, rapid in its
reflex action by a direct influence action, certain in its effects, and pro-
upon the spinal cord, this increase be- ducing a regulation of the heart's
ing followed by a subsequent depres- pulsations in more ways than one.
sion, that it gives rise to convulsions If the pulse rate is below normal, it
of a spinal origin and generally will cause acceleration, but if above
tetanic, that it causes a primary in- normal, it will bring it down,
crease in the rate and force of the Laborde calls it the "cardiac met-
heart's action by a direct influence ronome." In weak and irregular
upon the heart, the increase being heart Germain See advises doses of
soon followed by a decrease, due to from ^ to % grain (0.016 to 0.01
direct cardiac action and stimulation Gm.) every four hours. In heart-
of the cardioinhibitory centers ; it aug- failure, the result of mitral disease, it
ments the blood-pressure by an action gives the best results. In valvular
upon the heart, and also by stimulat- disease, with defective compensation,
ing the central vasomotor system ; the small doses are apparently more efifi-
arterial pressure subsequently de- cacious than large ones. Shoemaker
clines, owing to paralysis of the vaso- has found sparteine of service in
motor system and a direct depressant cases of enfeebled cardiac action from
action upon the cardiac musculature, structural lesions, and also where the
It is claimed that sparteine strongly innervation of the heart was markedly
and promptly reduces the size of the disturbed. In mitral disease it is
heart. particularly valuable, even in the ad-
THERAPEUTIC USES.— In re- vanced stage, when dilatation has be-
nal insufficiency with deficient urin- gun. In cases of dyspnea, palpitation,
ary secretion, due to lowered* arterial and cardiac debility, due to fatty de-
tension, scoparius yields good results ; position around the heart, sparteine
also in the edema, or dropsy, accom- is satisfactory. In dilatation due to
panying heart lesions. It is con- valvular disease sparteine may be
traindicated in the acute stage of given hypodermically. In functional
inflammation of the lungs, heart, or cardiac disease, the result of exces-
kidneys, but in the subacute or sive bodily or mental labor, anxiety,
chronic stage it may be used w^ith and in "tobacco heart," sparteine will
advantage. In hydrothorax and as- yield gratifying results. In chronic
cites occasional doses of compound parenchymatous nephritis sparteine
jalap powder may be combined with will aid in the elimination of urea
it to advantage. and thus prevent uremia. In valvular
Scoparin has been used as a diu- cardiac disease, due to acute articular
retic in doses of from 8 to 15 grains rheumatism, cardiac dilatation with
(0.5 to 1 Gm.) by the mouth, or ^ failing compensation, chorea asso-
to 1 grain (0.03 to 0.06 Gm.) dis- ciated with endocarditis, exophthal-
8—7
98 SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
mic goiter, etc., Cerna has obtained scopola (or scopolia) is derived from
good results from the use of si)ar- Scopoli, an Italian who was professor
teine. In morphine addictions spar- of botany in Pavia about the middle
teine is useful in supporting the heart of the eighteenth centur}^
and system during the withdrawal of Though discovered, the one in hyo-
the drug. In postoperative suppres- scyamus and the other in scopola,
sion of urine, postanesthetic nausea, hyoscine and scopolamine are identi-
and operative shock, Pettey places cal chemically. Most of the drug be-
great faith in sparteine, but insists ing obtained from scopola rather than
that the dose be at least 2 grains hyoscyamus, the term scopolamine is
(0.13 Gm.), repeated every two to six often given preference, and in many
hours, when the effect of the remedy European countries it is the only
is to be assured. Hysterical excite- appellation used.
ment is, in many cases, amenable to Officially, that is to say, from the
sparteine sulphate. standpoint of the United States
C. Sumner Witherstine, Pharmacopoeia, scopolamine and hyo-
Philadelphia. seine are identical in all respects. A
slight distinction is, however, some-
SCOPOLAMINE (HYOSCINE) times made between the two sub-
AND SCOPOLA. — Scopolamine, or stances with respect to their optical
hyoscine (C17H21NO4), is an alkaloid properties, scopolamine being taken
obtained from various plants of the to refer to a completely levorotatory
family Solanacese, including Atropa specimen of the alkaloid, i.e., one
belladonna, Datura straniomum, Hyo- which rotates the plane of polarized
scyamus nigcr, and Scopola carniolica. light as far to the left as this par-
The last-named plant is an herb ticular chemical compound is capable
growing in the eastern Alps, Car- of doing it, and is composed exclu-
pathian Alountains, and neighboring sively of levorotatory molecules,
regions, and contains about 0.6 per while hyoscine is taken to refer to
cent, of total mydriatic alkaloids, in- any specimen ranging between the
eluding 0.06 per cent, of scopolamine, completely levorotatory and the in-
Scopola japonicas is another species of active, the latter being a mixture in
the plant, growing in Japan, and con- equal parts of levorotatory and dex-
taining the same principles as the trorotatory molecules. The optically
European scopola. In these two inactive variety of hyoscine is termed
plants, scopolamine is present in atroscine. Levoscopolamine, imder
larger amount than in the other mem- the influence of light, is gradually
bers of the solanaceous group, the transformed into atroscine, thereby
next being hyoscyamus, which, in its suft'ering some reduction in its pcriph-
total alkaloidal content of 0.08 to 0.15 eral nervous effects, i.e., mydriasis,
per cent., contains 0.02 to 0.0375 per vagal paralysis, arrest of secretion,
cent, of scopolamine (Kraemer). The etc. For ordinary purposes, however,
histological structure of the scopola scopolamine and hyoscine are gener-
rhizome, which is the part of the plant ally considered equivalent. Various
used in medicine, closely resembles preparations that have, in the past,
that of belladonna root. The name been termed hyoscine have consisted
. SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 99
merely of a more or less impure ally administered hypodermically,
scopolamine. though oral use is also feasible, the
PREPARATIONS AND DOSE, alkaloids being absorbed with almost
— Scopolamincc hydrobromidnm, U. S. equal certainty, though less rapidly,
P. (scopolamine or hyoscine hydrobro- than when injected. Solutions of the
mide) [Ci7HoiN40.HBr-)-3H20], oc- alkaloids deteriorate quickly on keep-
curring in colorless rhombic crystals, ing, but Straub has found that by
sometimes of large size, with an acrid, adding to them 5 to 20 per cent, of
slightly bitter taste, and slightly efflores- mannite — a harmless substance which
cent. It is soluble in 1.5 parts of may be injected into the tissues with-
water, in 16 parts of alcohol, and in out fear of causing local irritation —
750 parts of chloroform. It should be they may be kept for an indefinite
kept in amber-colored vials. Dose, ^^o period without loss of activity,
to i/so grain (0.0002 to 0.001 Gm.). PHYSIOLOGICAL ACTION.—
The following preparations were for- Nervous System. — Scopolamine (hyo-
merl}^ official: — seine), like atropine, produces distinct
Scopola, U. S. P. VIII (scopola), effects on both central and peripheral
the dried rhizome of Scopola carnioHca, nervous structures. Its central ef-
required to yield not less than 0.5 per fects differ in quality, however, from
cent, of mydriatic alkaloids. Dose, j/i those of atropine, consisting chiefly of
grain (0.045 Gm.). a pronounced depression of the psy-
Fluidcxtractiim scopolcc, U. S. P. chic and motor centers of the brain,
VIII (fluidextract of scopola), contain- the result being a hypnotic effect,
ing 0.5 Gm. of mydriatic alkaloids in which passes, if the dose be large
each 100 c.c. Dose, 1 minim (0.06 c.c). enough, into narcosis. The electrical
Extractum scopolcc, U. S. P. VIII excitability of the brain is reduced,
(extract of scopola), made by evap- The human subject to whom scopola-
orating the fluidextract, and required mine (hyoscine) has been adminis-
to contain 2 per cent, of alkaloids, tered becomes quiet and sluggish.
Dose, % grain (0.01 Gm.). because of early depression of the
Hyoscincc hydrobromiduni, U. S. P. motor centers, and soon falls asleep.
VIII (hyoscine hydrobromide), chem- At times these effects appear, after a
ically identical with scopolamine hydro- short period of latency, with marked
bromide. Same dose. suddenness, and their intensity may
INCOMPATIBILITIES. — Hyo- prove alarming to nearby persons,
seine and scopolamine are incom- Occasionally sleep is preceded by a
patible with alkalies, tannic acid, short period of excitement, which
potassium permanganate, iodides, and may either represent an attenuated
salts of some of the heavy metals, manifestation in scopolamine of the
such as mercury bichloride, silver delirifacient action of atropine or be
nitrate, lead acetate, and ferric due to the presence of the convulsive,
chloride. highly toxic alkaloid apoatropine as
MODES OF ADMINISTRA- an impurity. (This impurity may be
TION. — Scopola, when used, is ad- detected by adding a little dilute
ministered by mouth. The alkaloids potassium permanganate solution to
scopolamine and hyoscine are gener- the solution of scopolamine, the violet
100 SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
color changing- to a yellow-brown if Respiration. — The effect on the re-
apoatropine is present.) In excessive spiratory is the same as that on the
amounts scopolamine induces either vasomotco" center. Respiration is de-
coma or — probably only if impure — a pressed by full doses,
condition of sleep and unconscious- Eye. — Scopolamine, instilled in the
ness interrupted at more or less fre- eye, acts like atropine, but more
quent intervals with a delirious rapidly and in an amount about four
outburst or low, muttering delirium, times less. A 0.2 per cent. (1 grain
Scopolamine acts upon the spinal cord to the ounce) solution will dilate the
as on the brain, a more or less com- pupil in ten to thirty minutes, and
plete depression of the spinal reflexes shortly thereafter induce paralysis of
being, therefore, characteristic, espe- accommodation. These effects are
cially after large doses. due to paralysis of the oculomotor
The peripheral nervous effects of nerve endings in the constrictor mus-
scopolamine are essentially those of cle of the iris and the ciliary muscle,
atropine, consisting of depression or respectively. The drug does not in-
paralysis of the terminals of the vago- crease intraocular tension. Its effects
sacral autonomic system and of the on the eye pass off more rapidly than
secretory nerves. The effects of atro- those of atropine, viz., in three to five
pine on the pupils, involuntary mus- days. The pupil regains its normal
cles in general, and secretions are diameter in about seventy hours, and
reproduced, though the dosage of the power of accommodation is re-
scopolamine for simple hypnotic pur- covered in four days (Oliver). A
poses being, as a rule, less than the slight stinging or feeling of astrin-
customary full dose of atropine, these gency in the conjunctiva may be ex-
effects are not as often noticed as perienced after its instillation,
w^ith atropine. Although the ability Secretions. — Scopolamine inhibits,
of scopolamine to paralyze the end- like atropine, those secretions which
ings of the vagus nerves in the heart, are under nervous control, paralyzing
and therefore to accelerate heart ac- the endings of the secretory nerves
tion is not questioned, many have distributed to them. Kamensky wit-
clinically noticed slowing of the heart nessed arrest of the salivary, gastric,
after its administration. This is pancreatic, and sweat secretions by
doubtless either an indirect eft'ect. the drug in laboratory animals; the
the result of motor inactivity, or effect on the pancreas took place
due to admixture of some cardiotoxic much later than that on the other
impurity. secretions.
Circulation.— Or d\n2ir\\y no cardiac ABSORPTION AND ELIMINA-
acceleration is induced by scopola- TION. — Scopolamine is readily ab-
mine, the dose used being too small, sorbed from mucous membranes. It
The alkaloid differs from atropine, in is more rapidly destroyed in the sys-
that it has no stimulating effect on tern or excreted than atropine, and
the vasomotor center. In large doses, its eff'ects are of correspondingly
it depresses this center from the shorter duration.
start, a corresponding reduction in UNTOWARD EFFECTS AND
the blood-pressure taking place. POISONING. — The dose of scopola-
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
101
mine borne without unpleasant re-
sulting symptoms seems to vary
considerably in different individuals.
Occasionally somnolence and dizzi-
ness appear in ophthalmic use of the
drug". In persons with an idiosyn-
crasy therapeutic doses may. in addi-
tion, produce effects similar to those
of beginning atropine intoxication,
viz., dryness of the mouth, flushing
of the skin, mydriasis, and difficulty
in swallowing. The dose ordinarily
toxic lies between ^Xoo and Yso grain
(0.0006 and 0.002 Gm.). From doses
larger than are required for thera-
peutic effects there result, in addition
to the symptoms already mentioned,
ataxia, indistinct speech, unconscious-
ness, perhaps followed by delirium
and hallucinations and an accelerated
feeble pulse.
Even therapeutic amounts at times
produce alarming effects. Thus, cases
of collapse from ^,,0 grain (0.0006
Gm.) have been reported, with pro-
nounced muscular weakness, flushing
of the face, a hard, rapid pulse, noisy,
rapid breathing, twitching of the
hands, and cool perspiration. Col-
lapse has also been recorded from
ophthalmic instillation of the drug.
M. L. Foster has reported the case of
a young man in whom four instilla-
tions of 1 drop of a 0.2 per cent, solu-
tion of scopolamine hydrobromide
had been made in each eye at ten-
minute intervals — total amount about
Yqo grain (0.001 Gm.). Fifteen min-
utes after the last instillations dizzi-
ness appeared, followed by dryness of
the throat, nausea and attempts to
vomit, flushing of the face, motor
weakness, and tachycardia (over 160
a minute), attaining their maximum in
about two hours ; the patient became
cyanotic, actively delirious, and had
what appeared to be toxic convul-
sions. Rapid recovery thereafter took
place under morphine and whisky.
S. W. Morton has recorded a case of
poisoning by Y-, grain (0.0008 Gm.)
of hyoscine hydrobromide, with in-
ability to swallow and complete pa-
ralysis of the soft palate and upper lip.
In an ataxic man Gibbs witnessed
poisoning, with delirum and convul-
sions, from y^Q grain (0.0012 Gm.).
R. A. Morton, after instillation of 2
drops of 1 per cent, hyoscine hydro-
bromide into the eyes of an adult,
observed muscular relaxation and un-
consciousness lasting four hours, fol-
lowed by delirium lasting two hours,
and then sleep lasting one and one-
half hours. F. Krauss observed excite-
ment lasting over seven hours in a
girl of 15, who had instilled 2 drops
of a 2-grain to the ounce solution in
each eye before retiring.
Fatal results from scopolamine in-
toxication have been rare. Bastedo
has met with fatal collapse from %o
grain (0.0012 Gm.) in an alcoholic
man with pneumonia. On the other
hand, he witnessed recovery from ^5
grain (0.0024 Gm.) in an alcoholic
woman verging on delirium tremens.
In each of these cases morphine had
preceded the hyoscine. Recoveries
from ^ and even 3^ grain (0.03 Gm.)
of hyoscine in cases subsequently re-
ceiving more or less therapeutic at-
tention have been reported.
Treatment of Poisoning. — If the
drug has been taken by the mouth,
the stomach should be evacuated with
emetics or the stomach-tube. Tannic
acid or Lugol's solution may precede
this, if they are immediately at hand
and the case is seen early. As
physiological antidotes, pilocarpine,
J4 grain (0.015 Gm.), and strychnine,
102
SCOPOLAMINE (HVOSCINE) AND SCOPOLA (SAJOUS).
Vso to 1/20 grain (0.002 to 0.003 Gm.),
or caffeine sodiobenzoate, 5 grains
(0.3 Gm.), or hot, strong coffee
should be given. Where delirium re-
places the unconsciousness or coma,
sedatives such as chloral hydrate, 10
grains (0.6 Gm.) ; tincture of opium,
15 minims (1 c.c), or morphine, %
grain (0.01 Gm.) hypodermically, may
be availed of. Electricity and other
excitants of the skin surface may be
used, as in opium poisoning, to com-
bat narcosis. In cases with pro-
nounced circulatory depression, digi-
talis, epinephrin, ether, ammonia
preparations, etc., should be freely
used. Artificial respiration, external
heat, skin frictions, and oxygen in-
halations are other measures that
may prove of value.
THERAPEUTICS as Sedative to
the Central Nervous System. — In in-
somnia due to mental excitement, a
persistent wandering of the mind
from one subject of thought to an-
other preventing sleep, and in the
insomnia of neurasthenia, scopola-
mine (hyoscine) in small doses, such
as %oo grain (0.0002 Gm.), is of value
where other milder hypnotics fail or
have to be discontinued because of a
tendency to habit formation. Though
less certain in its effect than chloral
hydrate, scopolamine has advantages
over the latter in being of small bulk,
non-irritating, and well suited for
hypodermic use. According to Wind-
scheid, as little as %5o grain (0.0001
Gm.) is capable of causing somno-
lence. In sleeplessness due to pain,
scopolamine is ineffectual when given
alone, but if combined with morphine
in small amounts proves useful, in-
tensifying the action of the latter.
In the insomnia due to motor ex-
citation, scopolamine is particularly
effective. This applies in delirum
tremens, in which, e.g., Lambert
recommends a combination of sco-
polamine hydrobromide, ^/|oo grain
(0.0006 Gm.), with apom^orphine hy-
drochloride, %o grain (0.003 Gm.),
and strychnine sulphate, fvQ gram
(0.002 Gm.), administered hypoderm-
ically. Liepelt found it more active
in this condition, if properly applied,
than either chloral hydrate or mor-
phine. In the delirium of infectious
diseases, including pneumonia, ty-
phoid fever, septicemir, etc., scopola-
mine is of value, especially where a
feeble, dilated heart or pronounced
circulatory impairment, e.g., in alco-
holics, contraindicate the use of
chloral hydrate. For this purpose it
should be used in moderate dosage —
yi50 to 1/100 grain (0.0004 to 0.0006
Gm.). If the first dose proves totally
ineffective, or the delirium, as oc-
casionally happens, is increased in-
stead of diminished, the drug should
not be further used. Similar consid-
erations apply in the insomnia of
infectious diseases. In pronounced
restlessness in neurasthenia, scopo-
lamine may also be used with
advantage.
In acute maniacal states the use
of scopolamine has, to a considerable
extent, replaced that of morphine.
According to H. S. Noble, in the re-
curring forms of insanity, maniacal
attacks can often be averted with it.
Such patients, at the first intimation
of approaching excitement, are given
an active cathartic, usually mercurial,
followed by 1/100 to 1/75 grain (0.0006
to 0.0008 Gm.) of scopolamine hydro-
bromide morning and evening, rarely
oftener. Little or no tolerance to the
drug is established. In agitated
melancholia Doerner found scopola-
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 103
mine often to bring about quietude scopolamine, given half an hour be-
when all other means had failed. The fore retiring, of great value in
effect comes on rapidly and lasts from controlling the spasmodic cramps
three to ten hours, according to the sometimes experienced in the lower
dose given. Insane patients are often extremities on retiring, or upon
more resistant to the effects of sco- stretching in the morning. The same
polamine than others, doses of %4 author successfully employed ^^s
grain (0.001 Gm.), or even more, be- grain (0.0008 Gm.) at night to arrest
ing sometimes necessary ; on the excessive seminal emissions. Higier
other hand, doses as small as ^-jO found the drug valuable in pruritus
grain (0.00025 Gm.) are sufficient in of all kinds, except diabetic. It has
some instances. The absence of un- also been used with benefit in
pleasant after-effects is a marked ad- hiccough.
vantage of this drug. In the tremor of paralysis agitans
Among other nervous conditions in and in senile or alcoholic tremor,
which scopolamine may be availed of scopolamine yields prompt, though
are status epilepticus, chorea, hyster- not always lasting, effects. It may
ical convulsions, and the convulsions be used in daily doses of %4o to /42o
of cerebrospinal meningitis. Higier, grain (0.00025 to 0.0005 Gm.), hypo-
in a case of obstinate chorea occur- dermically, in these conditions, and
ring in pregnancy, was able to control may be given for a long period with-
the movements by giving a %o-grain out habituation or detrimental effect.
(0.001 Gm.) dose daily for a week. It has also been recommended in
In nervous asthma, the same author multiple sclerosis.
had good results from the adminis- In the night-sweats of pulmonary
tration of %5o to %25 grain (0.00025 tuberculosis and in lead colic scopo-
to 0.0005 Gm.) subcutaneously at the lamine has also been used, with
time of the attack, together with j^artial success.
smaller doses during the intervals as For its use during withdrawal of
prophylactic. In attacks of hystero- morphine from habitues, the reader is
epilepsy Nagy usually obtained seda- referred to the article on Opium
tion in five to twenty minutes by Habit.
means of an injection of %4 grain As Mydriatic and Cycloplegic. —
(0.001 Gm.) of the drug. In tri- For refraction purposes scopolamine
geminal neuralgia with attacks of presents certain advantages over atro-
muscular contracture, Pont procured pine, and is even preferred to the
relief of pain and diminished fre- latter for routine use by some spe-
quency and duration of the attacks cialists. Two instillations of a drop
of contracture by giving daily injec- each of a 1-grain (0.06 Gm.) to the
tions, either into the cheek at the ounce (30 c.c.) solution of scopola-
painful spot or into the arm, of %-2o mine hydrobromide at an interval of
grain (0.0002 Gm.) of scopolamine half an hour are sufficient to produce
hydrobromide, four days' treatment complete mydriasis and cycloplegia
being alternated with rest periods of in less than an hour after the first in-
equal duration. Noble found ''/120 to stillation. Even a 1 in 1000 solution
Yioo grain (0.0005 to 0.0006 Gm.) of is usually sufficient, especially if the
104
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
patient is required to instill it on the
evening- before and the morning' of
the day of consultation. The myd-
riasis and likewise the paralysis of
accommodation pass off, according to
the amount of drug used, individual
sensitiveness, etc., in from two to
four days, thus markedly shortening
the period of disability experienced as
compared to atropine. Pressure over
the lower canaliculus after instillation
is recommended to minimize the pos-
sibility of constitutional effects by
preventing drainage of the drug into
the lachrymal passages and nasal
cavities, whence it is more rapidly
absorbed.
In inflammatory infections of the
eye, scopolamine is held to be equally
as valuable, or more valuable, than
atropine, and it is said not to increase
intraocular tension. In rheumatic or
syphilitic iritis, it may be combined
with or substituted for atropine in
instillations, and may also, with ad-
vantage, be given hypodermically at
night to relieve pain. In plastic iritis
scopolamine acts very energetically,
often removing synechise, which atro-
pine had failed to influence (Raehl-
mann). In uveitis (serous cyclitis),
scopolamine may be used in the ab-
sence of increased intraocular tension
(De Schweinitz). It may also be
substituted for atropine in sympa-
thetic ophthalmitis.
MORPHINE-SCOPOLAMINE
ANESTHESIA.— The first report on
anesthesia produced by a combina-
tion of morphine with scopolamine
was made in 1900 by Schneiderlin, an
alienist, who, having used the drugs
simultaneously for sedative purposes
in restless, insane patients, with sat-
isfactory results, proceeded to employ
them to induce surgical anesthesia in
demented cases. The procedure is
based chiefly on synergistic action of
the two drug's as narcotics. Although
the antagonism between them in cer-
tain of their other effects might be
thought of marked advantage, per-
mitting the use of large doses with
the exclusive view of causing narcosis
and eliminating apprehension of un-
pleasant side effects, this is true only
to a slight degree, the opposite effects
of the drugs on the pupil and heart
rate having but little value, except as
indications of the relative degree of
action of the drugs in the individual
case.
The experiences of Terrier, E. Ries,
A. C. Wood, W. Wayne Babcock,
and others, have shown that by sub-
cutaneous injection of scopolamine
and morphine alone, without any in-
halation anesthetic, a satisfactory
surgical anesthesia can, in many
instances, be obtained. This is es-
pecially the case in the aged, debili-
tated, and cachectic. The young- and
robust, on the other hand, are re-
sistant and show a tendency to
excitement and delirium under scopo-
lamine, which largely unfits them for
this form of anesthesia. Babcock,
substituting in young adults, for mor-
phine and scopolamine (or adding to
them) apomorphine, or an enema
containing Hoffman's anodyne, alco-
hol, and sometimes paraldehyde, has
found that one may produce general
anesthesia in most persons over 18
years of age without resort to in-
halation of ether or chloroform. The
procedure proved very satisfactory —
often giving results superior to any
other form of anesthesia — in opera-
tions upon the head, neck, respiratory
system, and spinal column. In ab-
dominal and rectal operations, on the
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 105
other hand, and to some extent in of the inhalation anesthetic, respira-
operations on the hands and feet, it tion is quiet and regular, and during
was found inferior owing to failure the operation there is no vomiting or
to abolish muscular rigidity and obstruction to breathing from fluid in
reflexes. the air-passages. While the pulse
Morphine-Scopolamine Preliminary may be accelerated by the scopola-
to Inhalation Anesthesia. — In spite of mine, its quality remains good. The
the numerous advantages of exclusive patient is able, where the part oper-
narcotic anesthesia, where applicable, ated upon permits, to take water or
the procedure is, in general, accorded even food shortly after awakening
only a small field of application be- without nausea or vomiting. The
cause of the special care required to procedure is especially valuable in
avoid serious respiratory depression — neurotic subjects, and in patients with
both during and for some time after organic disease of the respiratory
the operation by the narcotics given — tract. A much larger dosage is re-
especially the morphine, and the rela- quired in alcoholic, strong men than
tively high mortality which has fol- in aged persons, and in the female
lowed its application in unskilled sex.
hands. Injection of morphine and According to Biirgi, substitution of
scopolamine in smaller amounts be- pantopon (omnopon) for the mor-
fore anesthesia by ether or chloro- phine in the morphine-scopolamine
form, on the other hand, is considered combination is of advantage, in that
less dangerous and looked upon with the respiratory center is less influ-
much more favor. The dosage ranges enced and the likelihood of vomiting,
from % grain (0.01 Gm.) of morphine A %-grain (0.04 Gm.) dose of panto-
and K20 grain (0.0005 Gm.) of scopo- pon, with 1/1.50 to 34oo grain (0.0004
lamine to twice these amounts, given to 0.0006 Gm.) of scopolamine is held
either in one dose one-half to two to be without danger in strong in-
hours before the time of operation or dividuals of middle age, though in
in divided doses. In small-sized pa- delicate or old persons with respira-
tients, doses somewhat less than tory disturbances the dose of pan-
those mentioned may be given, e.g., topon should be considerably less.
% grain (0.008 Gm.) of morphine Reichel and Keim, on the other hand,
and ^.rjo grain (0.0004 Gm.) of specifically mention respiratory de-
scopolamine. pression as a possibility in the use of
The procedure is advantageous in pantopon. Reichel much prefers to
many ways, allaying the patient's ap- substitute for the latter narcophine, a
prehension, diminishing after-pain by meconic acid compound of morphine
lengthening the period of narcosis, and narcotine. Keim has found thirst
and distinctly lessening postanesthe- a troublesome symptom after panto-
tic vomiting. The inhalation an- pon-scopolamine anesthesia,
esthetic is taken quietly, rapidly, and Morphine-Scopolamine Preliminary
without struggling, little or no secre- to Local and Spinal Analgesia. —
tion in the mouth and respiratory In local and spinal types of analgesia
tract takes place, anesthesia is main- the patient remains alert and appre-
tained with a very small expenditure hensive, and at times has trouble,
106 SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
especially under local analg"esia, in any pain, or at least, if pain is ex-
keeping- himself under control. To perienced, recollection of it after the
overcome this difficulty and facilitate operation is completely or largely
the surgeon's work, as well as in local 1)lotted out.
analgesia, which is frequently incom- Morphine-Scopolamine in Obstet-
plete, to reduce the shock to the rics. — The combination of morphine
nervous system from tissue injury by and scopolamine was first employed
dulling the sensibility of the sensory in obstetrics in 1903 by Steinbuchel,
centers, morphine and scopolamine merely to reduce the pain attending
may be employed to great advantage, labor, without producing any degree
W. Wayne Babcock usually orders of narcosis. The procedure definitely
administered, one hour and a quarter intended not only to reduce suffering,
before the induction of spinal anes- but also to banish the memory of
thesia, % grain (0.01 Gm.) of mor- pain after the completion of labor
phine sulphate and Vioo grain (0.0006 was, however, elaborated by C. J.
Gm.) of scopolamine hydrobromide. Gauss, of Kronig-'s clinic in Freiburg,
Where, shortly after, the patient is who in 1907 reported 1000 cases in
not in a condition of distinct drowsi- which this method had been success-
ness (though still showing some re- fully applied. In the following year
sponse when spoken to), an additional Kronig reported a series of 15O0
dose of each remedy is given twenty cases, in which one child had died
minutes after the first. If, as is the during delivery and three others in
case in a few instances, the effect is the first three days after delivery,
still insufficient, a third dose is given. Thereafter it was not until . a more
sometimes of only one of the drugs, recent favorable report of 5000 cases
stress being laid rather on the mor- liad been made by Gauss that wide-
phine in young and on the scopola- spread interest in the method was
mine in older subjects. Before major reawakened.
operations under local anesthesia, in The price of success and relative
which a deeper soporific effect is, in safety in the use of this procedure is
general, of advantage, Babcock sup- held by many to be a rigid adherence
plements the morphine-scopolamine to the somewhat complex and pains-
administration with a narcotic enema requiring original method of Gauss,
consisting of Hoffman's anodyne who, in the process of obtaining a
(Spiritus setheris compositus, U.S. P.), simple state of amnesia with partial
^ to 1 fluidounce (15 to 30 c .c.) ; insensibility to pain, — the so-called
paraldehyde, 2 fluidrams to Yi fluid- twilight sleep (Dammerschlaf), —
ounce (8 to 15 c.c), and water, 5 carefully adjusts the dosage to the
fluidounces (150 c.c). At the con- individual case by means of a
elusion of the operation 2 quarts (lit- "memory test" carried out at inter-
ers) of normal saline solution are vals during the course of labor. In
introduced in the bowel to accelerate primiparse, the first sedative injection
elimination of the narcotics. By these is given when good uterine contrac-
means the patient operated under tions are taking place every four or
local anesthesia passes through the five minutes and persisting at least
operation without being conscious of one-half minute. This injection con-
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 107
sists of 0.01 Gm. (% grain) of mor- Gm. (Yi^o grain). This is followed
phine hydrochloride, and 0.00045 Gm. in three-quarters of an hour by 0.0003
(%40 grain) of scopolamine hydro- Gm. (^/2oo grain) of scopolamine
bromide, injected separately into the alone, and in three-quarters of an
buttock or thigh. Three-quarters of hour more by narcophine, 0.015 Gm.
an hour later, the same dose of sco- (>^ grain), and scopolamine, 0.00015
polamine is repeated alone. One-half Gm. (^/4oo grain). The sedative ac-
hour after, a memory test is used, the tion is thereafter maintained by re-
patient being asked how many injec- peating the scopolamine in 0.00015
tions she has had, and if she remem- Gm. (i/4oo grain) doses every two
bers some strange object, such as a hours. Repetition of the narcophine
drinking-cup, exhibited to her at the is seldom required, though it may be
time of the first injection. The mem- given at six-hour intervals in a pro-
ory test is repeated thereafter, using longed labor.
new objects each time, every half- Opinions as to the value of mor-
hour, and if memory is still present phine or narcophine-scopolamine ad-
one and a half hours after the second ministration in obstetrics vary from
injection a third injection of scopo- enthusiastic advocacy of the measure
lamine, 0.0003 Gm. {Y200 grain) only, as a routine procedure — barring cer-
is given. Subsequent memory tests tain definite contraindications — to
may indicate additional injections of complete condemnation. B. C. Hirst
scopolamine, but these should be summarizes the disadvantages of the
small, and given only at long inter- method as "prolongation of labor,
vals. No additional morphine is ad- tendency to atony of the uterus with
ministered after the first dose. To hemorrhage, and an increased propor-
permit the development of a proper tion of apneic babies that could not
"twilight sleep," absolute quiet and be revived." With minimum doses
plugging of the patient's ears and of the two drugs these disadvantages
covering of her eyes are of impor- disappeared, but the relief afforded
tance. The maternal pulse, pupil re- was scarcely noticeable. He found
flexes, and temperature, as well as the the method of value, however, chiefly
fetal heart rate, are to be taken every for its psychic effect, in neurotic
half-hour so quietly that the patient's primiparse in whom a long, painful
state of sopor will not be disturbed. labor is considered probable. J. C.
In order to increase the field of Applegate noted very satisfactory re-
availability of the method, Siegel has suits in a small percentage of cases,
elaborated a modified Gauss technique but accords the method only a limited
in which the attempt to individualize field in obstetrics. Polak, on the
the dosage is abandoned, a standard other hand, has reported a series of
routine dosage being prescribed, and 155 cases with but three failures, no
no memory tests used. When labor fetal mortality, and no post-partum
is definitely established, the first in- hemorrhage. He asserts that nar-
jection is given, consisting of narco- cotization of the child (beyond
phine (morphine and narcotine me- oligopnea for a few minutes), if en-
conate), 0.03 Gm. ()^ grain), and countered, is not the fault of the
scopolamine hydrobromide, 0.00045 method, but of the dosage and man-
108
SCORBUTUS.
ner of applying- it, and that the actual
fetal mortality is lessened, rather
than increased, by the procedure. In
prirnipar?e of the physically unfit type,
commonly becoming exhausted at the
end of the first stage of labor, the
method brings necessary rest be-
tween contractions, obviates ex-
haustion, and greatly reduces the
proportion of cases requiring high or
medium forceps application. In bor-
der-line disproportion cases, if opera-
tive delivery becomes necessary, this
can be done with less shock and less
general anesthesia. In cardiac and
tuberculous cases, Polak uses the
method to reduce the strain placed on
the circulation in the first stage of
labor. Contraindications to its use
are emergency conditions, such as
precipitate labor, placenta previa, ac-
cidental hemorrhage, eclampsia, pro-
lapse of the cord, primary inertia, and
a dead fetus. The procedure may be
applied, however, in the first stage
to secure dilatation in malpositions,
scopolamine, properly used, having
been shown to favor dilatation of
the cervix and reduce uterine spas-
ticity. It does not diminish mam-
mary secretion.
L. T. DE M. Sajous,
Philadelphia.
SCORBUTUS.— Scorbutus, or scur-
vy, is a constitutional disorder, dependent
upon a deficiency of vegetable food, and
characterized by a peculiar form of
anemia, great mental and bodily prostra-
tion, spongy gums, a tendency to the
occurrence of mucocutaneous and sub-
periosteal Hemorrhages, and a brawny
induration of the muscles, especially those
of the calves and the flexor muscles of
the thighs.
Scorbutus has almost totally disap-
peared owing to the wise laws enacted
by the various maritime countries, based
on the discovery that deprivation of certain
substances present in fresh fruit and vege-
tables is the tmderlying cause.
SYMPTOMS.— The early symptoms of
scorbutus are a rapidly progressive ane-
mia, the surface becoming dirty-looking,
sallow, pallid, or earthy in appearance; a
gradually increasing de))ility, emaciation,
and indisposition for bodily and mental
exertion; arthritic and muscular rheu-
matoid pains in the limbs and back; men-
tal apathy or depression; dyspnea upon
slight exertion; the tongue may continue
clean, but it becomes large, pale, flabby,
and indented by the teeth. The appetite
usually remains good. The bowels, as a
rule, are constipated.
Other manifestations now appear. Pe-
techial spots arranged about the hair-fol-
licles are observed, first on the lower
extremities, later on other parts of the
skin surface. These spots are followed
by large subcutaneous extravasations and
puffy swellings in various parts of the
body, apparently due to deep-seated co-
pious hemorrhages, as, later, the surface
over them becomes ecchymotic. These
swellings chiefly occupy the popliteal
spaces, the anterior aspects of the elbows
and of the lower part of the legs, the
space behind the angles of the jaw, and
the loose connective tissue in and about
the eyelids, giving them a puffy, bruised-
like appearance, and often accompanied by
a sanguineous accumulation in the sub-
conjunctival tissue covering the eyeball.
The gums now begin to swell, especially
at the edges, become spongy and lobu-
lated, rising sometimes above the teeth
and concealing them. They are deep-red
or livid in color, bleed easily, ulcerate or
slough, and give rise to an exceedingly
fetid odor. The teeth often become loose
and, in exceptional cases, drop out. A
tendency to ulceration or sloughing be-
comes more or less general in all parts
of the cutaneous surface, more especially
at the locations of the puffy swellings, be-
ing easily induced by a slight scratch,
pressure, or blow.
The anemia increases. The face be-
comes puffy and anasarca, more or less
marked, appears in the lower extremities;
dyspnea develops; the heart-action be-
comes feeble and irregular, and the pulse
small, soft, and, on exertion, much ac-
SCORBUTUS.
109
celerated. The slightest exertion excites
attacks of sudden syncope, which may be
fatal.
Late in the disease the appetite is apt
to fail; the bowels become loose, the
stools being usually very ofifensive, and,
not infrequently, containing blood; nerv-
ous symptoms are now manifest; visual
disorders, including hemeralopia and nyc-
talopia, tinnitus aurium, vertigo, insomnia,
and late delirium may be present; menin-
geal hemorrhage may occur. The intellect
usually remains unaffected.
During the progress of the disease
thoracic complications maj^ appear, such
as pleurisy with effusion (often bloody),
pulmonary congestion with extravasation
of blood into the lung-tissue, bronchial
congestion, cough, and blood-stained sputa,
having, not infrequently, a gangrenous
odor.
The urinary symptoms vary. Albumi-
nuria is not rare. The specific gravity of
the urine is increased, the color high, the
solids diminished, excepting the phos-
phates, which are usually larger in amount.
Nephritis may occur.
The bones in chronic cases may become
congested, or even necrotic, and the epi-
phyces separate from the shafts.
The duration of scurvy may be several
weeks or months. Death commonly re-
sults from sudden syncope or from grad-
ual asthenia, hastened, in some cases, by
the occurrence of ulceration, hemorrhage,
thoracic affections, or other complications.
DIAGNOSIS.— The diagnosis is made
from the history, the peculiar facies, the
spongy and swollen gums, the gingival
and deep-seated cutaneous hemorrhages,
the increasing loss of strength and energy,
the mental depression, and the rapid re-
sponse to correct treatment.
From purpura hemorrhagica it is dis-
tinguished by its chief causative factor —
a diet lacking in fresh vegetables and
fruits — by the spongy, swollen gums,
loosened teeth, and the brawny induration
of the limbs. In purpura hemorrhagica,
the ecchymotic spots are not arranged
around a hair-follicle, and the hemor-
rhages from the mucous membranes are
greater in amount.
ETIOLOGY. — Tn former times scorbu-
tus was prevalent among sailors on pro-
longed voyages, in armies in active service,
and among people suffering from famine.
According to Osier, the disease is not in-
frequent among the Hungarian, Italian,
■ and Bohemian miners in Pennsylvania. It
is rarely epidemic. It is, however, en-
demic, especially in parts of Russia (Hoff-
man) and elsewhere, sweeping through
prisons, barracks, almshouses, and institu-
tions of like character.
The chief predisposing cause is a long-
continued dietary, lacking in certain essential
but obscure substances found in fruits and
fresh vegetables. Unhygienic surround-
ings, excessive muscular exercise, humid-
ity, cold, and other debilitating influences
are recognized as etiological factors. Testi
and Beri have isolated a micro-organism
which the}' believe to be pathogenic.
PATHOLOGY.— The pathology of scor-
butus corresponds to the symptoms. Mi-
croscopic examination of the blood reveals
the presence of profound anemia; the
blood is of low specific gravity, thin and
dark, contains an excess of fibrin, less
hemoglobin, and fewer red blood-cells,
but there is no leucocytosis. The skin
may be the seat of ecchymoses (subcu-
taneous hemorrhages), but the most char-
acteristic hemorrhage is that under the
periosteum of the femora. Extravasations
of blood, in various stages of transforma-
tion, may also be found in the lung-sub-
stance, beneath the pleurae, in the heart-
muscle, in the subpericardial tissue, in the
intestinal parietes, and beneath the peri-
toneal membrane. Blood-stained serum
may be found in the various serous cavi-
ties. The internal organs ma}-, or may
not, be congested. The brain is usually
intact. The heart, liver, and kidneys are,
occasionally, the seat of parenchymatous
or fatty degeneration.
PROGNOSIS.— If the disease has not
progressed too far and appropriate treat-
ment is available, the prognosis is good;
otherwise, the outlook is grave. The in-
ternal symptoms, especially the pulmo-
nary, are more serious than the external
ones. Pneumonia, hemorrhagic infarct of
the lung, pleurisy with bloody effusion,
acute nephritis, or dysentery, is usually
followed by death.
TREATMENT.— Prophylaxis demands
an adequate supply of antiscorbutic food
110
SEASICKNESS (WITHERSTINE).
for long seavoyagcs, military campaign-
ers, and explorers in the frozen zones.
This is facilitated by the present-day abun-
dance of canned fruits and vegetables,
though canning may reduce their value.
In the treatment of the disease the two
indications are to provide a diet of citrus
fruits and of vegetables containing the
necessary antiscorbutic vitamincs or salts,
and to combat special symptoms and com-
plications. The use of the juice of two
or three lemons or oranges daily will be
followed by marked improvement.
If the digestion is feeble give orange- or
lemon- juice combined with meat-juice or
egg-album.in, milk and farinaceous foods.
When the condition improves, the stronger
animal foods and fresh antiscorbutic vege-
tables, such as potatoes, water-cress, raw
cabbage, onions, carrots, turnips, tomatoes
and sauer kraut should be used freely.
Orange peel has been found to be anti-
scorbutic. According to A. F. Hess, boiled
orange juice, given intravenously, acts like
a cliarm in scurvy.
Ulcerations in the mouth may be healed
by using a mouth-wash of boric acid solu-
tion. To relieve the swollen, spongy gums
a 2 per cent, solution of tannic acid, or a
mouth-wash containing boric acid, tincture
of myrrh, and compound tincture of ben-
zoin may be used.
Twelve cases of scurvy in the Idiot
Cottages at Kew, Victoria, all in crip-
ples confined to bed or chair, of both
sexes. There had been no alteration
in the dietary of the patients for
years. Other patients suffering from
the same crippled conditions and with
the same foods were unafifected. The
scurvy cleared up in t^^e majority of
cases shortly after the patients re-
ceived a special dietary of raw eggs,
lime water, lemon juice and raw milk.
Lind (Med. Jour, of Austral., Aug. 9,
1919). s. and W.
SCORBUTUS, INFANTILE.
See Infantile Scorbutus.
SCROFULA. See various forms
of Tuberculosis.
SCROFULODERMA. See Tu-
berculosis OF Skin.
SEASICKNESS.— D E F I N I -
TION, — Seasickness may be detined
as an indisposition, characterized by
giddiness, nausea, vomiting, and de-
pression, produced by the motion of
a vessel on the waves. Closely allied
and somewhat similar conditions are
elevator- and car- sickness. Regnault
recognizes two forms of seasickness,
the somatic (gastric) and the psy-
chical (nervous), or that which is the
work of the imagination or results
from seeing others affected.
SYNONYMS.— Seasickness is also
known as naupathia ; nausea marina
seu maritima; morbus maritimus
(L.) ; mal de mer, naupathie (F.).
SYMPTOMATOLOGY. — De
Vries recognizes four stages : depres-
sion, exhaustion, reaction, and con-
valescence. In mild cases the patient
is but slightly ill, sufifering from
malaise and giddiness, followed by
tinnitus, headache, yawning, and
drowsiness, with some gastric dis-
tress. In more severe cases, nausea,
vomiting, vertigo, anorexia, moderate
prostration, a greenish or grayish
pallor, and unsteadiness of gait are
present. In the very ill great pros-
tration may supervene. Constipation
or diarrhea may be present. All the
secretions are diininished (including
the menses) except the saliva, the
flow of which may be excessive.
Diplopia, pain in the eyes, scotoma,
staggering gait, muscular relaxation,
backache, neuralgic pains, alternating
warm flashes and chilliness, weak and
rapid pulse, clamni}^ skin, profuse
diaphoresis, insomnia, fear, and a
feeling of general depression are com-
monly noticed. There are more often
mental depression, nervous exhaus-
tion, unpleasant delusions of the
senses of taste and smell, and. more
SEASICKNESS (WITHERSTINE). HI
rarely, deficient intellectual control, center, which, with the nuclei of the
One of the first symptoms in certain- eighth nerve, also lies in the fourth
cases is an abnormal appetite, which ventricle. There follows obstinate
appears as soon as rough water is vomiting, often associated with great
encountered. prostration. The endolymph follows
COMPLICATIONS AND SE- the motion of the head in those
QUEL.ffi. — Cerebral hemorrhage or canals whose plane corresponds most
the rupture of a previously existing nearly to the direction of that mo-
gastric ulcer is not infrequent, tion, and when the motion is sud-
Brewer, U. S. A. Medical Corps, men- denly reversed by the oscillation of
tions a case in which the vomiting the ship, or changed in direction by
was so severe that a vessel in the a new wave striking her on another
stomach was ruptured and consider- point, the endolymph continues in its
able blood lost ; the child was ill for original direction until stopped by
several days after landing. He re- friction. This causes undue pressure
ports another case in which a phy- in one or more of the ampullae, by
sician who, in addition to the usual which wrong impressions are con-
symptoms, sufifered from a severe veyed to the sensorium, and in-
diarrhea whenever the sea was rough, co-ordination and giddiness result.
Among the most frequent sequelae Moreover, the otoliths are washed up
are vertigo, anorexia, constipation, against the nerve filaments at the
nervousness, and invalidism, these front of the semicircular canals and
symptoms persisting after the patient produce an excessive irritation, which
has left the ship. Bushby, of Liver- is expressed in vertigo and vomiting,
pool, reports two cases of severe, James L. Minor, of Memphis, calls
prolonged prostration following sea- attention to the freedom of deaf-
sickness and associated with aceto- mutes from seasickness as a proof of
nuria. Beard mentions the case of a its aural origin, adding that nausea
man, sick an entire year at sea, who and dizziness are results of irritated,
could not enter any place where the but not destroyed (as in deaf-mutes),
air was foul without feeling the semicircular contents,
symptoms of seasickness. . The theory that "anemia of the
ETIOLOGY. — The etiology of sea- brain" causes seasickness was ad-
sickness is far from being absolutely vanced by C. Binz, of Bonn. He
settled. Many theories have been claims that (1) the motion of the ship
advanced, of which the "endolymph causes constriction of the arteries of
theory" is the most generally ac- the brain and consequent anemia of
cepted one. According to William that organ ; (2) this acute, local ane-
Edgar Darnall the motion of the mia gives rise, as at other times, to
waves with the rhythmic intervals be- rapidly recurring nausea and vomit-
comes transmitted to the endolymph ing; (3) the retching and vomiting
of the semicircular canals. This con- then increases the volume of blood in
tinual flowing in a given plane over- the brain and, in that way, relieves
irritates the fine hair-like terminals of the cerebral anemia and removes the
the vestibular nerve in the labyrinth, sense of nausea ; (4) the stomach
and reflexes are sent to the vomiting plays a passive role, being influenced
112 SEASICKNESS (WITHERSTINE).
by the central nervous system to act pressed in nausea and alteration in
whether it is empty or full; (5) every- the respiratory movements,
thing that facilitates the flow of blood Dubois ascribes a causal relation to
to the brain, and increases the same, incomplete ventilation of the lungs,
acts as a prophylactic, mitigates, or with an increase in residual air,
cures the seasickness. and imperfect respiratory changes.
Germane to this is the "theory of The secondary phenomena, headache,
Pflanz," that the constant change in vomiting, and chills are referred,
blood-pressure and in the fullness of etiologically, to the spasmodic and
the blood-vessels produces an irrita- forcible contractions of the diaphragm
tion in the brain which, when it with a consequent displacement of
passes the stage at which it can the viscera.
be borne, evokes the characteristic Kenneth F. Lund, of Dublin, after
symptoms of this condition. reviewing the various theories as to
Metcalf Sharpe suggests that the the causation of seasickness concludes
condition is the result of a reflex ac- that (1) the vomiting is not due to
tion of the stomach due to a central the unusual impression of vision, for
stimulus ; the reflex action is trans- it may occur on land, when the eyes
mitted to the solar plexus by the are closed, and even to the blind ; (2)
vagi ; the stimulus probably originates it is not due to smell, as any unpleas-
in disorders of visual accommodation, ant odor may cause vomiting, and
for by paralyzing the accommoda- may occur on land, and to any, in-
tion of one eye, by means of a myd- eluding deaf-mutes, who have sensi-
riatic, he found that the symptoms tive nasal organs ; (3) it is not due to
were greatly lessened. Hewitt, of momentary displacement of viscera,
London, believes that interference for it occurs in swinging or in de-
with the visual center predisposes to scending upon an elevator. The sen-
seasickness, sation is present whether the eyes are
According to W. Janowski seasick- open or closed, but it does not occur
ness is an expression of a mild form in deaf-mutes ; (4) there is some
of oft-repeated cerebral concussion. mechanism in the auditory organ,
The surprise of the mental faculty perhaps the semicircular system,
underlying consciousness, analogous which is directly affected by the oscil-
to strong emotional disturbance, as lations of a vessel at sea, which acts
fright, joy, etc., is given by Losee as as a stimulus to the vomiting center,
the causative agent in this disorder. Finally, the nervous element and
Dastre and Pampoukis believe that power of the imagination, as causa-
there is a combination of etiological tive factors, should not be disre-
factors, of the central nervous sys- garded, especially in those of a highly
tem, the pneumogastric, the splanch- sensitive and nervous temperament,
nic, and the phrenic nerves, and that Age has some etiological impor-
the displacement of the abdominal tance. Children and the very aged
viscera and their slipping motion on rarely suffer from it, although chil-
each other probably cause stimulation dren may, purely out of sympathy,
of the Paccinian bodies of the mes- Females are more frequently affected
entery, the effect of which is ex- than males. Only from Yz to 5 per
SEASICKNESS (WITHERSTINE).
113
cent, of all persons escape. Gihon should occur, raise the head or sit up
estimates that 5 per cent, are immune, awhile. Keep always in the cool air
that 25 per cent, are but little sick, on deck with pleasant companions,
that 60 per cent, are a great deal sick, save for meals and bed, moving about
and that 10 per cent, are distressingly as little as possible, until accustomed
ill. to the ship's motion. Avoid oleagin-
PROGNOSIS. — Seasickness is sel- ous smellsi and the company of those
dom, in itself, a menace to the life of who are seasick, as suggestion is a
a patient. powerful excitant to seasickness.
PROPHYLAXIS.— Choose a fa- Avoid cold food. Vichy and Ap-
vorable season (spring or summer), pollinaris waters may be freely in-
if possible, for the voyage. Avoid
sailing on the long, narrow ocean-
greyhounds which roll with each
dulged in throughout the voyage.
Small and frequent (at least seven)
meals are best. M. Charteris. of
swell and pound the ship into con- Glasgow, insists that the diet for the
stant motion with their powerful first two days should be dry and
engines, but select, rather, one of spare, no full meals being taken, and
the broad-beamed, slow-going boats soups and pastries always avoided,
which are now so well fitted for the If there is any tendency to nausea,
comfort of the passengers, as well as exertion should be avoided, as much
carrying freight. Select stateroom as possible ; the sufiferer should be on
and deck quarters in the middle of his back, with a small pillow under
the ship, near its transverse axis, the the head, or none.
point where the rolling of the vessel As to drugs suggestions are numer-
is least felt. A thorough hepatic ous. No drug or combination of
purge should be taken the night be- drugs is infallible. A. D. Rockwell,
fore embarking, and a saline on the of New York, strongly advises bro-
following morning. Go on board the mization — 100 grains (6,6 Gm.) in
vessel rested in body and with a tran- divided doses daily for three days
quil mind, after a light meal on shore, before sailing, and for three or four
with which a little wine was taken, days after sailing. Veronal (sodium),
but scarcely any other fluids. a favorite with many, is best given
The clothing should be of light, in a suppository cont'aining 7^ grains
pure, woolen material; easy, warm, (0.5 Gm.), although 5-grain (0.3 Gm.)
comfortable, broad-soled shoes should doses may be given in tablet form, by
be worn. A good flannel roller band- mouth. Chloretone, another favorite
age, 12 feet long and 6 inches wide, remedy, may be given in 5-grain
enveloping firmly the whole abdomen (0.3 Gm.) capsules, tablets, or pow-
will frequently afford great comfort ders, every 3 hours for 3 doses, so
and prevent undue movement of the arranged that the last shall be taken
viscera. on embarking. For short voyages
A steamer-chair and rug should be this is usually effective ; for longer
provided. Recline on deck in a shel- ones the drug should be continued
tered place, amidship, on the leeward longer. Validol, higlily recommended
side, comfortably covered and with by many, is best given in liquid form
eyes closed. If cerebral congestion on a lump of sugar, the first dose be-
8—8
114
SEASICKNESS (WITIIERSTINE).
\n^ 30 drops, the second 25 drops, and
tlic third 15 drops, taken an hour
apart, the first dose two or three
lujurs before sailinj^. It may also be
lakeii in doses of 10 to 15 minims
(0.6 to 1 (ini.), repeated half-hourly,
if rc(|uircd, plain (neat), in a weak,
alrolioHc solution, or in li(|uid form.
A j)rophylactir injection of '/,„) ,i;rain
(0.0006 dm.) of atropine sulphate,
combined with Hi, ^rain (0.(X)12 Gm.)
of strychnine sulphate, as sut^^ested
by (lirard and olliers, will d(j much
to inhibit the onset. Avoid the use
of morphine, cocaine, and parej^'oric,
which at times are tlionL,ditlessly
recommended.
TREATMENT.— Whenever the
slis^lUest sensation of illness is felt He
down at once and close the eyes.
Usually one pillow suffices, and if
very ill, none should be used. Two
teaspoon fuls of peptone in sherry
wine, poured over cracked ice, may
be ,i;iven every half-hour, as su£^-
.q'ested by Sinclair Tousey. If the
patient is very ill and cannot eat or
retain food, 11. I'artsch recommends
an egg-nog, prei)ared by mixing the
yolks of two raw eggs with an equal
bulk of good brandy or sherry well-
beaten together, and given in tea-
si)oonful doses at ten-minute inter-
vals. Patients with severe retching
will be made comfortable by lying
down, without a ])illow, the eyes
closed; a pint of beer, ale, or porter
(brown stout) is then taken in six or
eight portions at fivc-minute inter-
vals. Champagne frappe or ginger
ale with 20 per cent, of brandy or
whisky is highly praised by many.
When champagne is used it is advis-
able to allow it to stand until effer-
vescence ceases, that eructations be
avoided. Beef-tea or meat broths, in
tablespoonful doses, may be retained.
Food should always be taken at
least ten minutes before arising in the
morning, and when the patient is ill
all food slunild be taken without rais-
ing the head. The best time to take
any beverage or fo(jd is just after a
l)aroxysm of retching. Should it be
taken before and vomited, then take
another dose immediately afterward,
and that will stay down (11. I'artsch).
The sicker the patient, the oftener he
must eat, and the less at a time. The
bowels should be kept open by laxa-
tives or warm-water enemas.
The drugs most in favor in this
condition aie veronal, chloretone, vali-
dol (the administrati(jn of which has
been already described under ])rophy-
laxis), atropine, atropine and strych-
nine ccjinbined, nitroglycerin (s])iritus
gly eery lis nitratisj, and amyl nitrite.
The bromides have largely fallen into
disuse, except ior rclieviiig the head-
ache, because they tend to disorder
the digestion.
Atro])ine is given, to increase the
cerebral blood-su[)ply and to relieve
atony of the vagus, hypodermically,
in doses of /■'j^o to %(» grain (0.0005
to 0.001 Gm.), to be repeated in three
or fom- hours, if necessary. Atropine
sulphate, ^^o grain (0.0005 Gm.)
may be advantageously combined
with i/;„ grain (0.001 Gm.) of
strychnine sulphate.
Nitroglycerin and amyl nitrite have
been used in full doses.
Rosenthal has shown that every
reflex action can be i)revented by
•apnea. This principle is applied for
the suppression of the vomiting
(which is due to a reflex stimulatitm
of the center in the fourth ventricle)
by directing the patient to take a
series of deep inspirations. The sue-
SENEGA.
115
cessful experiments of Rosenthal have
been repeated by R. Heinz and M.
Kaufmann.
Bier's method of hyperemia has
been successfully used by Rosen and
by Schlag"er to reheve the nausea of
seasickness. The hyperemia was in-
duced by fixing an elastic band
around the neck. This had no influ-
ence on the tendency to vomit when
the stomach was full, but when the
stomach was empty the tendency to
vomit ceased. The band was always
removed at night.
Based on his theory (see Etiology)
M. Dubois advised inhalations of
oxygen under pressure, through the
mouth. These were followed by
rapid improvement. The number of
inhalations was not very large, the
amount of gas inhaled being usually
from 30 to 40 liters. Dutremblay and
Perdriolot attest the efficiency of this
treatment.
Wolf applies hot-water compresses
to the forehead, as hot as can be
borne, and rapidly alternated. They
are at first badly tolerated, but after
a little time they produce a thorough
sense of relief. Adrenalin given in-
ternally has also been praised.
Ahhough the number of cases in
which the writer used benzyl benzoate
in seasickness is small, about 20 in
all, the results in every case were so
satisfactory that he feels justified in
recommending it. In his cases 10
drops were used. As the sea voyage
was short in all cases, he was not
able to determine how long the effect
of the drug would last. Glenn (Calif.
State Jour, of Med., Nov., 1920).
C'. Sumner Withekstine,
Philadelphia.
SENEGA. — Senega (senega, snake-
root) is the dried root of Polygala senega
(fam., Polygalacere), a perennial herb of
eastern and central North America, as far
south as North Carolina. The constitu-
ents of senega are a saponin-like mixture
made up of polygallic acid (about three-
fourths of the whole) and senegin, a
jmall amount of methyl salicylate, resin,
fat, sugar, etc. It contains neither tannin
nor starch.
PREPARATIONS AND DOSES.—
Senega, U. S. P. (the dried root). Dose,
10 to 20 grains (0.60 to 1.20 Gm.).
Fluidcxtractiiin scnegice, U. S. P. (fluid-
extract of senega). Dose, 10 to 20 min-
ims (0.60 to 1.20 c.c).
Syrupns senega;, U. S. P. (syrup of sen-
ega— 20 per cent, of the fluidextract).
Dose, 1 to 2 drams (4 to 8 c.c).
Syrupus scillce compositiis, U. S. P. (com-
pound syrup of squill, hive syrup, croup
syrup, an ofificial substitute for Coxe's
hive syrup, containing 8 per cent, fluid-
extracts senega and squill, and 0.2 per
cent, tartar emetic). Dose, 10 to 30
minims (0.60 to 2.0 Gm.).
Alistura pcctoralis, Stokes, N. F. (Stokes's
expectorant). Dose, 1 dram (4 c.c), con-
taining 2 grains (0.12 Gm.) each of sen-
ega and squill, 1 grain (0.06 Gm.) of am-
monium carbonate, and 10 minims (0.6
c.c. of paregoric in syrup of Tolu. This
is a favorite mixture, though not official.
PHYSIOLOGICAL ACTION.— Senega
is an expectorant, alterative, diaphoretic,
and diuretic The powdered root is irri-
tating to the air-passages and its inhala-
tion causes sneezing. When the root is
chewed a burning sensation follows.
When swallowed in large doses it causes
salivation and gastrointestinal and renal
irritation. It is an irritant to the skin.
Used as an expectorant, it does not
liquefy the secretions, but merely facili-
tates their expulsion; senega, therefore, is
of little use when the expectoration is
tough and scanty. It is usually combined
with other expectorants and diuretics.
Senega is excreted by the bronchial mu-
cous membrane, the skin, and the kidneys,
exerting a stimulating action upon these
organs.
THERAPEUTIC USES. — Senega is
cliicfly used in subacute and chronic
bronchitis, in the chronic bronchitis of
the aged, ijften associated with emphy-
sema, and by some in croup. In bronchial
asthma with emphysema, the drug is
116
SENNA.
SERPENTARIA.
beneficial. Whooping-cough is sometimes
relieved by senega. On account of its
diuretic action senega has given relief in
the dropsy of renal disease and in palpi-
tation unasMiciated with cardiac disease.
In amenorrhea it has given good results.
The use of senega in heart disease is not
advised on account of the depressing ac-
tion of its active principle. In doses of 2
grains (0.13 Gm.) senega has been given
to check uterine hemorrhage. Senega has
been given in chronic rheumatism for its
diaphoretic and diuretic effects.
SENNA.— Senna is the leaflets of
Cassia acutifolia (Alexandria senna) and
Cassia angustifolia (India senna), family
Leguminoseae, freed from stalks, discol-
olored leaves and other admixtures.
The principal constituents, according to
Tschirch, are one or more glucosides,
yielding emodin, an extractive substance
(cathartic acid) and a large amount of
gum resin, the non-fermentable sugar
cathartomannite, a bitter (sennapicrin),
oxalic, malic and tartaric acids combined
with calcium, and a trace of volatile oil.
Senna has a faint, disagreeable odor and a
bitter, nauseous taste.
PREPARATIONS AND DOSES.—
Senna, U. S. P. (senna leaves). Dose, 1
to 2^ drams (4 to 10 Gm.).
Fhiidextractum senivcB, U. S. P. (fluidex-
tract of senna). Dose, J^ to 1 dram (2 to
4 c.c).
Infusum sennce compositum, U. S. P.
(black draught, containing 6 per cent,
senna, 12 per cent, manna and magnesium
sulphate, and 2 per cent, bruised fennel
seeds). Dose, 2 to 4 ounces (60 to
120 c.c).
Syrupus senmu, U. S. P. (syrup of senna,
containing 25 per cent, of fluidextract).
Dose, 1 to 2 drams (4 to 8 c.c).
Piilvis glycyrrhiscE compositus, U. S. P.
(compound licorice pow^der, containing 18
per cent, senna, combined with washed
sulphur, licorice powder, fennel oil, and
sugar). Dose, ^^ to 2 drams (2 to 8 Gm.).
Efficient but unofficial preparations are:
Confectio sennse, N. F. (confection of
senna, containing the pulps of cassia
fistula, prune, tamarind, and fig, with 10
per cent, senna flavored with coriander
oil). Dose, 1 dram (4 Gm.).
Syrupus sennrc aromaticus, N. F, Dose,
2 drams (8 c.c), representing IS grains
(1 Gm.) deodorized senna, 6 grains (0.4
Gm.) jalap, and 2 grains (0.13 Gm.) rhu-
barb, with aromatics.
Syrupus sennie compositus, N. F. Dose,
2 drams (8 c.c), representing 16 grains
(1.04 Gm.) senna and 4 grains (0.26 Gm.)
each of rhubarb and frangula.
PHYSIOLOGICAL ACTION.— Senna
is an active, but not acrid, cathartic, act-
ing in about four hours and producing
copious, yellow stools, with some griping
which may be avoided by combining it
with aromatics. It is a feeble hepatic
stimulant, rendering the bile more watery.
The menstrual flow may be excited by it,
and if given to a nursing woman her milk
thereby becomes a purgative. Injected
into the veins it causes vomiting and
purging, and in overdose a drastic cathar-
tic, but it never produces poisonous ef-
fects. The urine acquires a red color
from senna medication, if it is acid, but
in an alkaline urine the normal yellow
color is more pronounced.
THERAPEUTIC USES.— This drug is
a safe, efficient, and, when combined with
other drugs, a pleasant cathartic for con-
stipation. For children and pregnant
women the confection and the compound
licorice powder are advised. It is contra-
indicated in threatened abortion, hemor-
rhoids, and where the intestines are
inflamed.
SEPSIS, SEPTIC FEVER, SEP-
TIC INFECTION, SEPTIC POI-
SONING, SEPTICEMIA. See
Wounds, Septic.
SEPTUM, DISEASES OF. See
Nose and Nasopharynx, Diseases of.
SERA. See Diseases in whicli
these are used ; also Hematology.
SERPENTARIA. - Serpentaria is
the dried rhizome and roots of Aristolochia
serpentaria, Virginia; or of Aristolochia
reticulata, Texas (fam., Aristolochiaceae).
The Virginian species may be found
throughout the eastern United States,
and is chiefly collected in the mountain-
ous districts south of Pennsylvania and
SHOCK.
117
the Ohio River. Serpentaria, an aromatic
bitter, contains a volatile oil (0.5 to 1 per
cent.), a bitter principle, tannin, starch,
sugar, gum, and resin. It has a warm,
pleasant taste.
PREPARATIONS AND DOSES.—
Serpentaria, U. S. P. (the crude drug).
Dose, 10 to 30 grains (0.60 to 2 Gm.).
Fluidextractum serpentari?e, N. F. (fluid-
extract of serpentaria). Dose, 10 to 30
minims (0.60 to 2 c.c.)-.
Tinctura serpentarire, N. F. (tincture of
serpentaria, 20 per cent.). Dose, J^ to 2
drams (2 to 8 c.c).
PHYSIOLOGICAL ACTION. — Ser-
pentaria has a stimulating effect upon
gastric secretion and is added to other
drugs to increase their absorption and ac-
tivity. It has a mild diuretic and diapho-
retic action. In larger doses it pro-
duces a sense of fullness in the head,
nausea, vomiting and intestinal griping
with frequent evacuations of semisolid
stools. Hemorrhoids are irritated and
menstruation stimulated. It is also an
expectorant.
THERAPEUTIC USES.— Serpentaria
is a good general tonic. It is seldom used
alone. In atonic dyspepsia it is useful,
combined with the compound tincture of
cinchona. In combination with the aro-
matic spirit of ammonia it is beneficial
in pneumonia of a low type, in bronchial
catarrh, and in capillary bronchitis. It is
valued as a restorative in typhus and ty-
phoid fevers. It has been used with bene-
fit in chronic rheumatism, combined with
other remedies. Serpentaria has given
good results in amenorrhea dependent
upon anemia or chlorosis.
SHINGLES. See Herpes Zoster.
SHOCK. — DEFINITION. — A gen-
eral depression of the vital functions due
to traumatism, a profound emotion, fear,
etc., characterized by chemicophysical dis-
turbances in the nervous system, in which
deficient adrenal activity and vasomotor
paresis are prominent features.
SYMPTOMS.— Shock may present it-
self in forms varying in intensity froin
slight depression to profound collapse ap-
proximating death. In severe shock the
temperature is subnormal, the surface is
pale or livid and cool or cold, the skin
being clammy and perspiring freely; the
eyes are staring or half-closed; the res-
piration is shallow and irregular, and
often gasping; the pulse weak, rapid and
compressible or imperceptible. A notable
fall of the ])lood-pressure is usual. These
symptoms in severe cases are accom-
panied by loss of consciousness; in the
less severe cases, consciousness is main-
tained as a rule, but psychic activity ap-
pears to be inhibited, the answers to
questions being monosyllabic and often
unreliable; even in mild shock mentality
may l)e temporarily dull and apathetic.
Weakness of the muscles is a striking
feature, those of the surface being flabby
and impotent; the sphincters also fail to
functionate from this cause, and involun-
tary evacuations may result. The pupils
are dilated, as a rule, and react but slowly
to light. Nausea and vomiting may oc-
cur, but this is rather a favorable sign,
since it is often the precursor of a reac-
tion. Conversely, hiccough and gastric
regurgitation are unfavorable signs. Anu-
ria is frequently noted.
In lethal cases, the mental torpor grad-
ually deepens, syncope comes on, and
death follows. This course depicts that
observed in great injury involving con-
siderable loss of blood, complicated prob-
ably with abdominal or cerebral lesions.
Neurotic individuals and drunkards are
also exposed to this rapidly fatal form.
In some cases the picture is quite dif-
ferent. Maniacal furor seems suddenly to
develop, and the patient throws himself
or his liml)s in every direction, rolls his
eyes, strikes right and left, and cries
out at the top of his voice. Usually ex-
haustion soon comes on through recur-
rence, probalily, of hemorrhage on ac-
count of the violent exertion.
In cases that proceed favorably, the
change for the better is termed the "re-
action." All the abnormal symptoms dis-
appear gradually, the return of the mus-
cular tone being manifested by turning,
shifting position, etc., while the cardiac
symptoms lessen in intensity as the facial
color returns. Some cases at this stage
go through the maniacal type of shock
through unduly rapid resumption of cere-
bral blood-pressure. In some cases it is
a sign of septic infection. The tempera-
118
SHOCK.
ture in a favorable case remains near the
normal, though it may exceed this to a
marked degree in children without indi-
cating that a complication has occurred.
This reaction fever sometimes lasts a
couple of days, then gradually disappears.
As regards the differential diagnosis of
shock, internal Jiciiiorrhage is the main
source of confusion, since a serious trau-
matism capable of causing deep shock is
capable of causing also some organic in-
jury in some part, local or remote, of the
vascular system. This question assumes
especial import after an operation owing
to the possibility of concealed hemorrhage.
In the latter case, however, restlessness,
tossing, frequently repeated yawning, in-
tense thirst, nausea, impairment of vision
due to retinal ischemia, and repeated at-
tacks of syncope are apt to occur. Re-
peated examinations of the blood will
serve to place the differential diagnosis
on a surer footing, since hemorrhage pro-
duces a gradual diminution of the hemo-
globin percentage, while uncomplicated
shock does not cause such a change. The
cell count, both as to erythrocytes and
leucocytes, may, however, indicate a
marked decrease, but this is probably due
to recession of the blood-mass into the
splanchnic area, with resulting ischemia
of the superficial vessels. It is, therefore,
an unreliable sign. An abdominal hemor-
rhage may give the physical signs of an
increasing accumulation of fluid. While
the onset of uncomplicated shock is as
a rule sudden, the exhaustion due to hem-
orrhage is gradual, and finally attended
with severe asphyxic phenomena, which
are relatively slight in shock.
Delayed shock may come on some
hours after an injury or a violent com-
motion or emotion, such as is witnessed
in street-car or railroad accidents. Anes-
thetics, especially chloroform and ether,
inay also be followed by shock, not only
in the course of buti after their use.
Shell Shock. — The European war has
shown that shells, mines, and other
agents of destruction in which high ex-
plosives are employed may, irrespective
of or without direct physical injury, give
rise to nervous and psychic phenomena
which have been variously attributed to
"shock," "physical trauma," "concussion
cerebri," etc. In the milder cases, con-
sciousness is not lost, but there may be,
for a time, severe pain in the head and
spine, incoherent speech, trembling, heavi-
ness of the extremities and temporary
anuria. When micturition is re-estab-
lished, the urine may be found to contain
albumin. Uneventful recovery is usual.
In the more severe cases, unconscious-
ness, lasting an hour or more, is fol-
lowed by a severe "bursting" headache
with some deafness, tinnitus and vertigo,
sweating, and tremor, or rhythmic spas-
modic movements. Incoherence of speech,
mutism, amnesia and various disorders
may appear. Catalepsy, followed by con-
vulsions, has also been witnessed. The
reflexes are increasingly active, and se-
vere pain with hyperalgesia in various
parts of the body, including the appen-
dical region, may be complained of. The
cases usually recover in from one to three
weeks. Epilepsy has also appeared in in-
dividuals in whom a history of this dis-
ease did not exist.
Case of a young man buried in a
trench by the explosion of a shell,
who was unconscious when rescued.
Consciousness was regained in a few
hours, but he was totally amnesic
so far as his whole life was con-
cerned prior to and including the
time of the accident. No efforts to
recall his past life were successful,
but the practice of hypnotism brought
out a startling result. While under
hypnotic influence he lost his new
personality completely and returned
to his original one with equal com-
pleteness. During this state he was
able to recognize his father, remem-
bered all of his past life to the mi-
nutest detail, and could even give an
accurate account of the accident
which caused his mental disturbance.
Upon recovery from hypnosis each
time he would relapse into his new
personality and have no memory of
his former one. During the studies
made of him in each of his two per-
sonalities, it was observed that his
voice and his handwriting were dif-
ferent in the two states. In one re-
spect his original personality was
retained to a certain extent, namely,
SHOCK.
119
his ability to play a certain musical
instrument. Anthony Feiling (Lan-
cet, July 10, 1915).
Serious disturbances are produced
by wounds of remote localities, and
are not necessarily psychogenic. The
shock of the wound may cause pro-
longed unconsciousness froin which
patient emerges speechless or voice-
less. Physical shock must be in-
voked to explain such cases. A re-
flex cause could be excluded. The
disturbances in question comprised
aphasia, phonasthenia, dysarthria in-
cluding the spastic form, and kine-
toses of all kinds, very often ac-
companied with exhaustive states.
Treatment was, for the most part,
imperfectly successful with occa-
sional good results. One soldier
upon recovering from shock after
protracted unconsciousness showed
total aphasia. As this passed off
dysarthria and dysphasia were left
and persisted for eight months. After
this bradylalia was the only symp-
tom in evidence. Thirteen months
expired before he could resume his
duties as officer. Gutzmann (Berl.
klin. Woch., Feb. 14, 1916).
This fortunate issue is not, however,
the invariable one. In some individuals,
after weeks or months, the patients,
though apparently recovered, show signs
of a changed disposition, manifested espe-
cially in abnormal irrital)ility, anxiety,
apprehensiveness, or a condition of high
emotional state. These may be attended
with hallucinations, horrifying dreams, de-
lusions, etc. They lose interest in them-
selves and in others, become unsocial and
morose. The repeated revival of memo-
ries of horrible events in the trenches, the
death of comrades, shell bursts, blowing
up of their trench, etc., serve to sustain
the psychic disturbance. The majority of
these cases recover, however, but only
under well-directed psychotherapy, in
which sympathy is freely dispensed.
Wounds tend to aggravate the trouble,
and even to produce it.
The direct effects of the contusion
from the air are of extreme variety,
as also the various conditions that
may be observed afterward. Sudden
death from the shock alone is not
rare; immediate unconsciousness is
common. It may last for hours or
weeks and be followed by total loss
of memory for the period since the
explosion. The effects of the injury
are, in reality, nothing but traumatic
hysteria. When the shell explodes
near a sleeping person, it does not
induce the nervous and mental dis-
turbances otherwise observed. This
throws light on the importance of
the fright as a factor in the shock.
The emotional-neurotic factors are
supplemented by the traits for which
physical exhaustion is responsible.
An exhausted nervous system feels
the effect of the explosion more than
when fresh or well rested. R. Gaupp
(Beitrage z. klin. Chir., Apr., 1915).
From the 156 cases studied, a large
majority of so-called shell-shock
cases admitted into the hospital with
functional neurosis in some form
occurred in individuals with a nerv-
ous temperament, or with an ac-
quired or inherited neuropathy. In
a certain numl)er of cases the cumu-
lative effect of active service had
produced a neurasthenic or hysteric
condition in a potentially sound in-
dividual. Among the large number
of officers the writer has seen sent
back on account of neurasthenia,
none have exhibited symptoms of
functional paralysis or mutism. Cases
which were supposed to have de-
veloped epilepsy as a result of shell
shock were, usually, individuals who
were either epileptics or potential
epileptics prior to the shock. F. W.
Mott (Lancet, Feb. 26, 1916).
ETIOLOGY AND PATHOLOGY.—
Although the term "shock" is applied to
a definite clinical syndrome as a rule, it
is often made to cover, pathogenetically,
very different conditions: hemorrhage,
asphyxia, reflex inhibition, etc. Each of
these, however, has its own pathology:
cerebral ischemia in hemorrhage; deficient
cellular oxidation in asphyxia; vasomotor
paresis in reflex inhibition, etc. True
shock, however, has a patliology of its
120
SHOCK.
own, changes having been shown to occur
in the nerve-cell in keeping with the older
teachings based on the histological
methods of Golgi, Marchi and Nissl in
"shocked" animals. The alterations found
by the Golgi method consist in a de-
formity of the cell-body advancing to the
grade of actual atrophy, node-like swell-
ings on the dendrites, and fragmentation
of the same. By the Marchi methods
there is noted degeneration of various
spinal tracts and columns. As observed
by the methods of Nissl, the cytological
alterations are various, but pronounced.
Chromatolysis is present in a large number
of cells. Changes in the nucleus, — disloca-
tion or vcsiculation, — are also noticeable.
As a result of the central disorder, the
vasomotor system becomes more or less
incompetent, and reduction of the blood-
pressure follows; the peripheral and cere-
bral vessels are depleted, while the larger
trunks within the abdominal cavity are
engorged. This may explain the greater
danger of a fatal issue when much blood
has been lost, the medullary and spinal
changes being thus accentuated.
That the adrenals become inadequate
from the same morbid action on their
governing center — the sympathetic center
according to Sajous — seems probable, thus
furnishing another causal factor for the
low blood-pressure noted. According to
Crile the adrenal adynamia resulting from
shock is a prominent factor of this con-
dition.
The labors of Elliott and Cannon,
Seeley and Lyon have shown that
marked epinephrin exhaustion occurs.
From the fact that the adrenal ordi-
narily contains enormous loads to
tide the individual through emergen-
cies it would seem that the storage
and discharge factors are paramount
over the secretory roles. Further
than this, the amounts of epinephrin
needed to maintain vasoconstriction
that exists in shock are evidence of
the continued output of that secre-
tion as long as an available supply
exists. The adrenal cortex in shock
seems unaffected. J. F. Corbett (St.
Paul Med. Jour., xvii, 655, 1915).
Increased quantities of epinephrin
are thrown into the blood during con-
ditions of low blood-pressure and
shock. The apparent outpouring of
epinephrin is not merely a hasty dis-
charge and depletion of the supra-
renals; since the quantity of epi-
nephric material in the blood actually
increases with the prolongation of
low blood-pressure and shock, there
must be an active secretion from the
glands. The suprarenals seem to
function as a line of secondary de-
fence against a falling blood-pres-
sure. The presence of epinephrin in
increasing amounts as shock pro-
gresses points to an attempt on the
part of the circulation to redistribute
the blood, bring about peripheral con-
striction of the arteries wherever pos-
sible, and thus maintain normal pres-
sure. Bedford and Jackson (Proc.
Soc. of Exper. Biol, and Med., 13, 85,
1916).
The writer defines shock as a grad-
ual progressive fall of blood-pressure
due to a paresis or paralysis of the
musculature of the arterioles. The
only way in which he has been able
experimentally to produce anything
like shock is removal of the adrenals.
Adrenalin produces a good effect in
shock not only because it raises the
blood-pressure, but because it sup-
plies a something which is essential
and in these cases apparently lacking.
The treatment of surgical shock con-
sists in continued administration of
adrenalin plus efforts to remove the
causative factor. J. E. Sweet (Amer.
Jour. Med. Sci., May, 1918).
Owing to these organic disturbances,
the contractile power of the vessels is lost,
the arteries and capillaries becoming de-
pleted through partial transfer of the blood
into the deeper venous trunks, thos^ of the
splanchnic area in particular. As a re-
sult, various organs, especially those far-
thest from the splanchnic area, the brain,
skin, etc., and those of the thoracic cavity
are rendered ischemic. Hence the low
blood-pressure, the feeble heart action
(due in part to deficient adrenal secretion
and the resulting deficient contractility of
its musculature), the deficient respiratory
activity and the profound adynamia ob-
served in shock.
SHOCK.
121
Henderson (1908) has attributed shock
to a loss of carbon dioxide through the
intermediary of the blood and tissues in
the course of operations or severe solu-
tions of continuity. Seelig, Tierney and
Rodenbaugh (1916) have sustained this
view by using intravenous injections of
sodium bicarbonate in shock, the benefit
obtained being attributed to the power
of this salt to break up in various tissue
fluids and thus liberate carbon dioxide.
More recently fat embolism, acidosis,
and absorption of toxic products of auto-
lysis of injured tissues have l)een empha-
sized as important or essential factors in
the production of shock.
Fat embolism emphasized as a
cause of shock. An undoubted rela-
tion exists between shock and broken
bones, particularly when large, as the
femur. In 8 experiments on cats, in-
jection of fatty substances into the
jugular vein induced a clinical pic-
ture essentially similar to traumatic
shock in human beings. Fat, ofien
in large quantities, is known to enter
the blood vessels in traumatic shock.
The injurious effects are due to fat
embolism. W. T. Porter (Boston
Med. and Surg. Jour., Sept. 6, 1917).
Where there is low blood-pressure
in shock, hemorrhage, or gas bacillus
infection, there occurs a diminution
in the available supply of alkali and
hence an acidosis. Operations in
shock and acidosis cause rapid fall of
blood-pressure and sudden decrease
in alkali reserve. Intravenous injec-
tion of sodium bicarbonate produces
quick relief of acidosis and a rise in
the blood-pressure in shocked men
after operation. Cannon (Jour. Amer.
Med. Assoc, Feb. 23, 1918).
Report of investigations showing
the extreme toxicity of crushed mus-
cle tissue, even when aseptic. Ab-
sorption of this muscle autolysate is
undoubtedly a factor in traumatic
shock. Crushed tissues in wounds
should' be cleared out as an emergency
measure at once, without waiting for
shock to subside. Dclbct (Bull, dc
I'Acad. de med.. July 2, 1918).
Kinetic Theory. — On the basis of some
1200 experiments, Crile, of Cleveland, was
led to conclude that the key to shock is not
in the vasomotor system alone, but in the
whole motor mechanism of the body.
Those parts of the body having the great-
est number of nociceptors — nerve-endings
through which defensive reactions are
provoked — and which defend the most
vitally important structures, are those
most active in producing shock on re-
ceiving trauma. Thus, the brain, pro-
tected as it is by the cranium, is not pro-
vided with such nociceptors, does not to
any marked extent awaken shock under
operation as a rule; the abdominal struc-
tures, on the other hand, which are richly
provided with nociceptors, readily pro-
duce shock when subjected to trauma.
Now, the physical basis of Crile's theory
is that when, as is the case under the
influence of certain anesthetics, ether for
example, the reflex motor activity which
normally occurs by stimulation of the
sensitive nerve-endings fails to occur, and
there is no response, the impulses which
reach the cortical centers from the periph-
eral nerve-endings excite and finally ex-
haust these centers, and produce in them
degenerative lesions similar to those that
histologists long ago identified as the char-
acteristic cellular lesions of the condition
known as shock.
Crile attributes these central morbid
changes to "work," i.e., excessive oxida-
tion or febrile process carried on by
those organs which alone are capable of
transforming latent into kinetic energy,
those constituting his "kinetic system,"
the principal organs of which are the
brain, the thyroid, the adrenals, the liver,
and the muscles. According to Crile, "the
brain is the great central battery which
drives the body; the thyroid governs the
conditions favoring tissue oxidation; the
suprarenals govern immediate oxidation
processes; the liver fabricates and stores
glycogen; and the muscles are the great
converters of latent energy into heat and
motion." Yet it is evident that, as
Sajous first pointed out in 1903 (when he
showed that the adrenal secretion circu-
lated in the brain-cells), it is to the pres-
ence in excess of the adrenal principle
that the lesions in the nerve-cells are due,
for Crile calls attention to the "striking
fact" that "adrenalin alone causes hyper-
122
SHOCK.
chromatism, followed by chromatolysis,
and in overdosage causes the destruction
of some brain-cells."
But it is not only the stress of trau-
matism or operative procedures on the
body which so morbidly affects the nerve-
cells of the cortex among others, but also
fear, anxiety, the anticipation of a surg-
ical operation, emotional excitement, etc.
All these factors added to the surgical
traumatism enhance the morbid influence
of the latter on the nerve-cell.
How prevent or, at least, reduce these
effects, which in the aggregate constitute
the condition we term "shock" and which,
moreover, reduce the chances of operative
recovery? This phase of the question is
considered below in the subsection on
Prophylaxis, under the title of "anoci-
association," a term given by Crile to the
measures through which the pathogenic
stimuli to the brain may be controlled and
at least in a great measure prevented.
PROPHYLAXIS.— The prevention of
shock during operations is receiving
greater attention as time progresses. Be-
fore resorting to any serious surgical pro-
cedure the volume of urine excreted in
the 24 hours should be ascertained, and
an examination of the urine itself made,
to ascertain that the kidneys are normal.
This is important, since diseases of
these organs predispose to shock. The
excretion of urea should be ascertained,
for if it falls below 2 per cent, metabolism
is deficient; such a condition points to
asthenia which in turn predisposes to
neurasthenic shock. Violent purging pre-
disposes to a similar condition; hence,
while freeing the intestinal contents is
advisable before operation, it should be
done only by means of aperients, or rectal
flushing with saline solution. Some sur-
geons advise the use of morphine hypo-
dermically, ^ grain (0.008 Gni.) given 20
minutes before the operation to quiet the
patient, besides the influence of whatever
anesthetic is used in that respect; yet
others are opposed to opiates in any
form. The truth lies between the two
extremes; large doses should be avoided.
The manner in which the anesthetic is
administered has much to do with the
production of shock. To clap a towel
saturated with ether on the face of the
already frightened patient and, as far as
his own experience is concerned, literally
choke him, and have a rough orderly hold
his arms and legs to prevent struggling,
besides advertising the surgeon and his
assistants as tyros, favor the production
of precisely the histological changes in
the central nervous described above under
Pathology as those peculiar to shock.
Everything should be done to divest the
patient of fear by telling him that he
will soon be asleep, perhaps feel a little
"stuffy" and the next instant (as regards
the patient's own experience is concerned)
awake in his own bed. By thus sug-
gesting that he will be subjected to no
suffering either through the anesthetic
or the operation much can be done to
pacify him and otherwise avoid shock. By
using the drop method, Allis's inhaler or
any other device which insures the pa-
tient an ample proportion of air, and
avoiding all rough handling, but little if
any struggling will occur.
Another important feature is to main-
tain the surface temperature to its nor-
mal level as nearly as possible by covering
the parts other than those exposed for
operative purposes, with warm blankets
and hot-water bottles outside of these
(and not in immediate contact with the
skin, which may thus be burnt) to sus-
tain the heat. The loss of surface heat
when the body is allowed to become cold
causes accumulation of the blood in the
splanchnic area, an important pathologi-
cal feature of shock. For the same
reason as little* blood as possible should
be lost and the operation performed as
rapidly as safety and thoroughness will
warrant.
ANOCI-ASSOCIATION.— W e have
seen under the heading Kinetic Theory un-
der Pathology, that Crile means by this
term a physical exhaustion of the cerebral
nerve-cells, brought about by abnormally
active stimuli, trauma, pain, fear, emotion,
etc. His experiments showed, moreover,
that the central lesions produced in the
course of surgical operation could be
prevented by blocking, as it were, the
connection between the traumatized part
and the brain-cells by a technique to
which he gave the name "anoci-associa-
tion." Morphine and scopolamine having
SHOCK.
123
been found to conserve the output of
energy, thus avoiding the transmission of
excessive stimuli to the brain-cells, they
form the foundation, as it were, of his
method. His technique, as exemplified by
its application in abdominal work, is as
follows: —
In patients other than infants, the aged,
and the asthenic, Crile administers, on an
average, % gr. (0.01 Gm.) morphine and
Kno gr. (0.0004 Gm.) scopolamine one hour
before operation. If local anesthesia alone
is employed, novocaine in 1:400 solution
is used by local infiltration. , If inhalation
anesthesia is employed, nitrous oxide is
administered, either alone or with ether
added as required. As soon as the pa-
tient is unconscious, first the skin and
then the subcutaneous tissues are in-
liltrated with 1:400 novocaine. The novo-
caine is spread by immediate local pres-
sure with the hand. Incision through this
anesthetized zone exposes the fascia,
which is novocainized, subjected to pres-
sure, and then divided. In succession also
the remaining muscles or posterior sheath
and the peritoneum are infiltrated with
novocaine, subjected to pressure, and di-
vided within the blocked zone. If the
blocking has been complete, then within
the opened abdomen there will be no
increased intra-abdominal pressure, no
tendency to expulsion of the intestines,
and no inuscular rigidity.
The peritoneum is next everted and in-
filtrated with a Zl-i per cent, solution of
quinine and urea hydrochloride, so that
the line of proposed suture is completely
surrounded. As before, momentary pres-
sure serves to spread the anesthetic. This
infiltration of quinine and urea hydro-
chloride serves as a block which may last
for several days. It prevents or minimizes
postoperative shock. It causes a certain
amount of edema of tissue which lasts
for some time after the wound is healed.
With this technique the relaxed abdom-
inal wall permits the easy and gentle ex-
ploration of the entire abdominal cavity.
If there is no cancer in the field of oper-
ation and if no acute infection is present,
then the following regions may be blocked
as completely and in the same manner as
the abdominal wall — namely, the meso-
appendix, the base of the gall-bladder, the
uterus, the broad and the round ligaments,
the mesentery, and any part of the pari-
etal peritoneum. Since operations on the
stomach and intestines cause no pain if
they are made without pulling on their
attachments, no novocaine block is re-
quired in such operations.
In operations carried out in this manner
the closure of the upper abdomen is as
easy as the closure of the lower; all is
done with ease in perfect relaxation. No
matter how extensive the operation, how
weak the patient, or what part is involved,
if the technique is perfectly carried out,
the pulse rate at the end of the operation
is the same as at the beginning. The
postoperative rise of temperature, the
acceleration of the pulse, the pain, the
nausea, and the distention are minimized
or wholly prevented according to Crile.
The cause of the high mortality of
operations on the gall-bladder is ex-
haustion and shock, the exhaustion
of the vital organs of the body. In
excision of the liver and adrenals
within a few hours the blood be-
comes acid. In every case of ex-
haustion the same changes were
found in the brain, liver, and the
adrenals. Postoperative pain finally
overcomes the margin of safety and
the patient dies. Neutralization of
the acids is one of the most impor-
tant functions of the liver. Every
response to stimuli produces an acid
condition. The margin of safety is
reduced in exhausted patients by
this acidosis. An increased acidity
always accompanies inhalation anes-
thesia. Ether, however, adds an-
other strain. The liver finally be-
comes no longer able to neutralize
the acidity. The only cure for the
acidosis is prevention, which may be
largely accomplished by increasing
the store of energy and preventing
the waste of it. Glucose and bicar-
bonate of soda and sleeping in the
open air will increase the store of
energy. Morphine does not increase
the aciditj^ of the blood, but if the
latter is once produced by emotion,
starvation, or whatever cause, large
doses of morphine will then rob the
body of its power to neutralize the
124
SHOCK.
acidosis. But if given before the
acidosis occurs, the morpliinc will
not have anj' effect. Psychic rest is
obtained by twilight anesthesia. If
the margin of safety is very narrow
the operation should be done in two
stages. Avoidance of injury to the
splanchnic nerves is insisted upon.
Crile (X. Y. Med. Jour., July 4, 1914).
As a preliminary narcotic a com-
bination of omnopon and scopolamine
is recommended. It is also valuable
to give a dose of veronal on the
evening preceding the operation. The
writer's method of producing local
anesthesia for abdominal operations
is essentially the anesthetization of
the several nerve-trunks laterally
upon the abdomen through 5 or 6
punctures. The solution consists of
0.4 Gm. (6^2 grains) of potassium
sulphate and 12 drops of synthetic
adrenalin to each 100 c.c. of ''/^
per cent, solution of novocaine. All
the tissues, from the skin to the
peritoneum, should be infiltrated at
the site of each puncture. In addi-
tion to this the line of incision is
infiltrated in a similar manner, and,
if necessary, additional infiltration of
the mesenteric attachments, etc., may
be made. With his technique the
writer had only 2 cases of post-
operative shock in well over 2000
cases. H. M. W. Gray (Brit. Med.
Jour., Aug. 22, 1914).
To illustrate the value of anoci-
association, the writer offers a table
of all hysterectomies operated on
since the adoption of the necessary
technique. Excluding 2 legitimate
exceptions, the average pulse rate
for 17 hysterectomies the evening be-
fore operation was 89; the average
pulse rate the evening after was 80.
Some of these patients were very
much exsanguinated by prolonged
hemorrhages and some had large
tumors. The value of the method
seems incontestable. J. M. Wain-
wright (Penn. Med. Jour., Dec, 1914).
The writer advises that glucose
solution be given as a routine after
every operation in which one has
reason to fear more than the ordi-
nary amount of postanesthetic shock;
it should be given as a routine in
every case in which postoperative
oral feeding may be difficult or in-
sufficient for a considerable period
after operation; it should be given
as an emergency measure either be-
fore or after operation for the relief
of an existing or threatened acidosis.
Burnham (Amer. Jour. Med. Sci.,
Sept., 1915).
TREATMENT.— Raising the limbs and
body in such a way as to cause the blood
to gravitate .toward the head, followed
by absolute rest and quiet in the recum-
bent position, and the external application
of heat (taking care that the skin be pro-
tected by the blanket or that the water-
bottles or bags used be wrapped in cloths
or flannel, lest they burn the patient)
around the trunk and extremities, are the
first measures to be resorted to.
Having treated 6667 wound cases,
the writer divides shock cases into 3
major groups, viz., nervous, hemor-
rhagic, and toxic. A group apart is
that by exposure or exhaustion. Of
103 cases of hemorrhagic shock oper-
ated upon at once, 96 recovered, tend-
ing to show the advisability of imme-
diate operative hemostasis in hemor-
rhage cases, whether shock is or is
not present at the same time. Under
nervous shock are placed concussion,
multiple wounds, or extensive con-
tusions. In these, the system has
reached the extreme limit of its re-
sisting powers and treatment is often
disappointing. In 4 cases of grave
nervous shock, however, expectant
treatment and postponement of oper-
ation were followed by recovery. In
toxic shock from absorption, an op-
portunity for recovery is afforded
only by prompt removal of the toxic
tissues. Of 13 cases thus treated, all
recovered. Gatellier (Presse med.,
Jan. 17, 1918).
Adrenalin has to a considerable extent
replaced all other stimulants when in-
jected in conjunction with saline solution
into the arterial sytem — for rapid action
— or into the veins. Its effect ma3^ how-
e\ er, be evanescent. Two important
measures developed and found serviceable
SHOCK.
125
during the late war v/ere, intravenous in-
jection of 6 per cent, gum acacia solution
to cause a persistent rise in the blood-
pressure, and the removal of lacerated or
crushed tissues to obviate shock from
toxic absorption.
Locke's solution plus 3 per cent, of
gum acacia used with success in the
treatment of low blood-pressure from
hemorrhage and shock. If there has
been great loss of blood, the Locke
must be preceded I:)y an infusion of
normal saline or sugar solution to
give the heart fluid to pump on, the
mucilaginous Locke solution not be-
ing given in amounts exceeding 150
c.c. (5 ounces). Delaunay (Lyon chir.,
Jan.-Feb., 1918).
In shock the catalase of the blood
and probably of the tissues is de-
creased, owing to diminished output
of it from the liver and probably to
dilution of the blood. Alcohol in
shock greatly increases the catalase
of the blood and tissues by stimu-
lating the liver to increased output.
The beneficial effect of alcohol in
shock and general depression is due
to the increase it causes in the cata-
lase of the blood and tissues, with
resulting increase in oxidation and
decrease in acidosis. Burge and Neill
(Amer. Jour, of Physiol., Feb., 1918).
Shocked patients should be placed
in the quietest available quarters,
kept darkened, with comfortable beds.
The bed may be warmed with a
cradle heated by electricity or an
alcohol lamp. The arterial pressure
should be taken every hour. Mor-
phine is given regularly as it seems
efifective in raising the blood-pressure.
Subcutaneous injections of saline
solution with adrenalin complete the
treatment, and the patient sleeps.
When the blood-pressure has im-
proved to 40 and 70 or 80 mm. Hg,
then operation is to be considered.
Necessity for local as well as gen-
eral anesthesia emphasized. Monery
and Loml^ard (Arch, de med. et de
pharni. milit.. Mar., 1918).
Primary shock tends to lessen
hemorrhage, and if the patient is
kept warm and quiet, the Idood-pres-
sure may return to normal. Partial
recovery, however, may be followed
by secondary shock. The best ex-
planation of this is an accumulation
and stasis of blood in the capillaries
— Cannon's cxoiiia. As a result the
tissues sufifer from oxygen starvation
and the vasomotor and respiratory
centers tend to fail. Acidosis is not
a serious factor in shock. It has
not yet been demonstrated that the
symptoms relieved by sodium bicar-
bonate would not be more definitely
cured by raising the blood-pressure.
The main factor in treatment is to
ensure an adequate supply of blood
to vital organs. A solution of gum
arabic (acacia) injected intraven-
ously in most cases is not inferior to
blood. A 6 per cent, solution of the
gum is best, with 0.9 per cent, of com-
mon salt. Tliis maintains the blood-
pressure indefinitely. Its value is
most strikingly demonstrated after
hemorrhage, though after grave
hemorrhage blood transfusion is the
procedure of choice. W. M. Bayliss
(Brit. Med. Jour., May 18, 1918).
Traumatic or wound shock is due
to toxic material from injured tis-
sues. If the blood-pressure falls
below 80 mm. Hg, the tissues begin
to sufifer from lack of oxygen. In the
treatment, arterial pressure should be
raised by blood transfusion if it per-
sists below this critical level. Crushed
tissue should be removed as soon as
possible. If a limb is shattered and
useless, absorption of toxic material
may be prevented by a tourniquet.
Amputation should be done proxi-
mate to the tourniquet and before re-
moving it. Loss of body heat should
be checked and normal temperature
restored by application of heat.
Since ether lowers the blood-pressure
in shock, it should be avoided. Nit-
rous oxide and oxygen should be
used in a ratio not exceeding 3 to 1,
preceded by morphine. Deep anes-
thesia and cyanosis should always be
avoided. W. B. Cannon (Proceedings
Amer. Med. Assoc, N. Y. Med. Jour.,
June 14, 1919).
Crile's technique for the resuscitation
126
SHOCK.
of a patient is as follows: The patient,
in the prone position, is subjected to
rapid rhythmic pressure upon the chest,
with one hand on each side of the ster-
num, to produce artificial respiration and
promote circulatory activity. A cannula
being then inserted into an artery, toward
the heart, normal saline solution (2 tea-
spoonfuls of sodium chloride — being care-
ful not to use the non-deliquescent table
salt now commonly employed — to the
quart of warm water) is infused through
a funnel connected with the ruliber tub-
ing connected with the cannula. As
soon as the flow has begun, 15 to 30
minims (0.9 to 1.8 c.c.) of adrenalin
chloride (1:1000) are injected at once
with a hypodermic syringe plunged into
the rubber tubing, i.e., into the saline
solution, repeating the dose in a minute
if needed. The rhythmic pressure on the
thorax being exerted with maximum ac-
tivity, plus the powerful contraction of
the arteries, including the coronaries,
caused by the infusion, promptly provokes
a powerful rise of blood-pressure. When
this attains about 40 mm. the heart re-
sumes its action, its contractions steadily
increasing in vigor. As soon as the
cardiac beats are fairly resumed, the
cannula should be withdrawn; otherwise
the marked increase of vascular tension
will drive a torrent of blood into the
tube. Pituitary extract in 1:10,000 solu-
tion seems to sustain the effect on heart
and circulation longer than adrenalin.
An important feature of arterial or
venous infusion is that it should not be
given rapidly; otherwise an excessive
amount of fluid will suddenly accumulate
in the right ventricle, and the heart, al-
ready feeble, will cease altogether to
pulsate.
In prolonged shock, high enteroclysis
or hypodermoclysis of saline solution is
indicated. Dawbarn urged that, whenever
possible, the solution should be intro-
duced into the median basilic vein, but
occasionally a vein in the operating wound
will answer the purpose, or, if necessary,
the solution may be introduced into the
common femoral artery with the aid of
an hypodermic needle attached to a foun-
tain syringe. Next in order of efficiency
to intravenous saline infusions are those
introduced into the rectum. Hypodermoc-
lysis is the slowest of all the methods.
The proper temperature for the solution
according to Dawbarn is about 150° F.,
but this seems high. At least 1 quart,
and sometimes even 2 or 3 quarts, may
be injected, providing the precaution is
taken to introduce the solution slowly.
The time occupied in introducing the fluid
should never be less than ten minutes per
quart. The employment of intravenous
injections before or at the beginning of
the operation is not good practice, since,
by increasing the blood-pressure, it en-
courages free hemorrhage.
Valuable for intravenous infusions in
shock is Ringer's solution, prepared as
follows: —
IJ Calcium chloride.. V/> gr. (0.1 Gm.).
Potassium chloride. 1 gr. (0.06 Gm.).
Sodium chloride... 90 gr. (6.0 Gm.).
Heater 1 qt. (1000 c.c).
M.
Careful asepsis of the arm, apparatus,
and solution is important; also the exclu-
sion of all air from the tube before intro-
ducing the cannula. The solution should
be free from solid particles. A probe-
pointed cannula should always be used.
The temperature of the solution should
be about 100° F.; hotter solutions are of
greater value as a stimulant; an initial
temperature of 108° to 110° F. is well
borne. The fluid is cooled from one to
two degrees by entering the cannula. The
amount of the solution to be injected at
one time varies with the rapidity of the
injection and with the quality and ten-
sion of the pulse; 1 quart, repeated when
necessary, is generally better than a large
amount given at one time. It is of great-
est value in shock accompanied by hem-
orrhage. In threatening cases of this
class direct blood-transfusion should be
resorted to.
As regards medical treatment, Senn
recommended the inhalation of nitrite of
amyl, and the administration of stimu-
lants, such as alcohol, hot coffee, and tea.
Of alcoholic stimulants, hot red wine,
rum, and brandy-punch deserve the prefer-
ence. Alcohol in small doses tends to
raise the blood-pressure by promoting
oxidation and therefore metabolism in
the muscular layer of the arteries.
SHOCK.
127
Opium is contraindicated in the treat-
ment of uncomplicated shock, but atropine
is recommended by J. C. Da Costa, par-
ticularly when the skin is very moist.
Subcutaneous injections of sterilized
camphorated oil is a valuable cardiac
stimulant, 3 or 4 hypodermic syringefuls
being administered every fifteen minutes
until reaction sets in. Digitalis may be
used, but it acts slowly in an emergency.
Strophanthin, using the 1 c.c. (16 minims)
of the 1:1000 solution in sterile ampoules
is far more effective. It should be remem-
bered that in shock the absorption of all
drugs administered by the stomach or
rectum, or even injected into the tissues,
is always slow; hence, care is necessary
to guard against cumulative action during
the recovery of the patient.
Research showing that epinephrin
has no cumulative action. Its action
occurs only on direct contact. The
continual infusion of a weak solution
of epinephrin may prove a useful
measure in therapeutics. It is thus
possible to send the solution continu-
ously into a vein and thus keep up
the blood-pressure permanently while
this is being done — the effect being
dependent on the concentration of
the solution, not on the absolute
amount of epinephrin infused. Straub
(Mimch. med. Woch., June Zl , 1911).
Adjuvant measures, such as the inhala-
tion of oxygen, mustard plasters over the
heart, the spine and shins; an enema of
turpentine, hot coffee, whisky or brandy;
Esmarch bandages around the legs and
arms or a tight abdominal binder to drive
the blood toward the vital organs and
increase the general blood-pressure, are
all helpful. Crile deems an increase of
peripheral vascular resistance advantage-
ous and places his patient in an air-tight
rubber suit which he inflates with an air
pump, thus insuring equable pressure
upon the entire cutaneous surface. Ab-
dominal massage to favor the better dis-
tribution of blood from deeper vessels,
followed by the application of the abdom-
inal binder referred to above, has been
lauded as an efficient measure. Galvanism
of the phrenic has been used to promote
contraction of the diaphragm and there-
fore excite respiratory activity.
ELECTRICAL SHOCK.— The two
main causes of death from shock due to
electrical currents, as stated by Spitzka,
Stanton and Krida and others are cardiac
fibrillation and respiratory paralysis. The
cessation of respiration is a secondary
phenomenon, however, though usually
simultaneous with cardiac arrest. Com-
mercial low-tension currents tend to kill
chiefly by producing cardiac fibrillation.
As the tension is increased the effect upon
the heart becomes less pronounced, but
at the same time the effect upon the
central nervous system becomes more and
more certain as the tension is increased;
so that with high-tension currents death
is more likely to be caused by respiratory
failure, although if the contact is pro-
longed the heart is also stopped. All
evidence points to the central nervous
system as being the chief sufferer from
the effects of currents of more than 4800
volts.
Treatment. — Even in cases of good
contact, as with a high-tension current,
according to Spitzka, there may be no
heart paralysis, but only respiratory fail-
ure, and in such cases respiration may be
re-established spontaneously or artifici-
ally. The prognosis is good only in cases
in which there is some heart action and
respiration, the former, particularly.
The stricken individual must, of course,
be taken out of the circuit, if he be not
already freed from it. Bystanders can
do this with rubber gloves, or with hands
wrapped with thick, dry, woolen material,
by pulling at the victim's clothing, by
sticks of wood, or, if in contact with a
wire, this may be cut with a nipper with
insulated handles. This must be done
with caution, as the momentary arc
formed between the separated ends may
blind the rescuers.
The patient should be laid with the
head a little higher than the body, and
artificial respiration be begun promptly by
compressing the thorax about 18 times
a minute, with the hands applied flat to
the sides and lower part of the chest.
The tongue must be drawn forward, or
the pulmotor may be used if available.
Massage over the heart, faradization, the
electrodes applied to the neck ami heart
region, or adrenalin injection by Crile's
128 SILVER (SAJOUS).
method, may be used to stimulate heart silver nitrate with 2 parts of potas-
action. The epiglottis may be tickled with gj^^^ nitrate, stirring and pouring
the forefinger. Other methods that have .^^^^ ^^^^jj^_ j^ ^^^^^^ ^^ ^ ^^.
been suggested are lumbar puncture, , . , . , ....
venesection, the application of the Leduc '^ard solid, with properties Similar to
current, and, in the last resort, a high- those of the preceding preparation,
tension shock of short duration. S. It is sohible in water, but the con-
tained 66.7 per cent, of potassium
SILVER.— Silver (argentum) in ,^5^,.^^^ jg ^j^jy sparingly soluble in
its pure metallic state has a white alcohol. Used externally,
color and a high degree of luster. It Argcnti o.vidum, U. S. P. (silver
is unafifected by oxygen or moisture, ^^-^^^^ [AgoO], occurring as a heavy,
but is readily attacked by sulphur, brownish-black powder, with a me-
and tarnishes when exposed to air ^^,jj^ ^^^^^ j^ -^ U^l^l^ ^^ reduction
containing hydrogen sulphide. The ^^^ exposure to light. It is very
metal itself is not official, but is used slightly soluble in water, to which it
at times in a colloid state in unofficial ji^^parts an alkaline reaction, and is
preparations. Of its salts, the nitrate ij^goiubig i^ alcohol. Dose, :^ to 2
is most largely used. grains (0.03 to 0.13 Gm.) ; average, 1
PREPARATIONS AND DOSE, grain (0.065 Gm.).
— Argcnti nitras, U. S. P. (silver ni- Argcnti cyanidum, U. S. P. VIII
trate) [AgNOs], occurring in color- (silver cyanide) [AgCN], occurring
less, rhombic plates, with a bitter, as a white, odorless and tasteless pow-
caustic, metallic taste. It is soluble der, gradually turning brown on expos-
in 0.54 part of water, and in 24 parts ure to light, insoluble in water and in
of alcohol. It melts at 200° C. It is alcohol. Formerly used in the prepar-
rapidly reduced by organic matter in ation of diluted hydrocyanic acid,
the presence of light, becoming gray Among the unofficial preparations
or grayish black. Dose, ^ to ^ of silver are the following: —
grain (0.007 to 0.03 Gm.). ^ Silver citrate [AggCoHgOT], oc-
Argcnti nitras ftisus, U. S. P. curring as a white, heavy powder,
(molded silver nitrate, lunar caus- soluble in 3800 parts of water, and
tic), prepared by melting silver ni- sensitive to light. It is considered
trate with ^5 its weight of official non-irritating, and has been applied
hydrochloric acid, stirring, and pour- in substance as antiseptic to wounds
ing into suitable molds. It occurs and ulcers, and injected in solutions
as a white, hard solid, usually in of 1 : 4000 to 1 : 10,000 strength into
cones or pencils, with a caustic taste, the urethra, etc.
and becomes grayish on exposure to Silver lactate [AgC3H503 + H20],
light and organic matter. It is in- occurring in crystalline needles, solu-
completely soluble in water and in ble in 15 parts of water, and turning
alcohol, the contained 5 per cent, of brown on exposure to light. Used
silver chloride remaining undissolved, externally (though irritating) for its
Used externally. powerful antiseptic effect in 1 : 100 to
Argenti nitras mitigattis, U. S. P. 1 : 2000 solutions.
VIII (mitigated silver nitrate; mitigated Albargin (gelatose silver). See
lunar caustic), prepared by melting Albargin in the second volume.
SILVER (SAJOUS).
129
Argentamin (ethylene-diamine sil-
ver nitrate), a solution of 1 part each
of silver nitrate and ethylene-diamine
[CHo(NH2)CH2(NH2)] in parts of
water, A colorless, alkaline fluid,
turning yellow on exposure to light.
Asserted to be non-irritant and more
penetrating than silver nitrate, owing
to the albumin-solvent action of the
containing ethylene-diamine. Used
in the urethra in 0.25 to 4 per cent,
solution, and in ophthalmology in 5
per cent, solution.
Argonin (silver casein), prepared
by precipitating an alkaline solution
of casein with silver nitrate and al-
cohol. A fine, nearly white powder,
containing 4.28 per cent, of silver,
easily soluble in water, forming an
opalescent solution which clears on
addition of sodium chloride. Used as
silver nitrate, generally in 0.5 per
cent, solution.
Argyrol (silver vitellin), said to be
prepared by electrolysis of serum
albumin, addition of moist silver
oxide, heating the mixture under
pressure, and drying in I'acuo. It is
probably a compound of hydrolyzed
protein and silver oxide, and contains
from 20 to 25 per cent, of silver. It
occurs in black, shining, hydroscopic
scales, freely soluble in water and
glycerin, but insoluble in alcohol and
oils. It is not affected by boiling. It
is incompatible with acids, and most
neutral or acid salts in strong solu-
tion. Used as a non-irritant anti-
septic in 5 to 25 per cent, solutions
in urethritis, cystitis, and diseases of
the mucous membranes of the eye,
ear, nose, and throat.
Hegonon (silver nitrate ammonia
albumose), obtained by treating sil-
ver ammonium nitrate with albumose.
A light-brown powder, readily solu-
ble in water, said to contain about 7
per cent, of organically combined sil-
ver. Used as substitute for silver
nitrate for irrigation purposes in
1 : 2000 to 1 : 6000 solutions.
Ichthargan (silver ichthyolate or
ichthyosulphonate), prepared by neu-
tralization of ichthyolsulphonic acid
with silver oxide, and extraction with
water. A brown, stable powder, with
a light chocolate-like odor, asserted
to contam 30 per cent, of metallic
silver and 15 per cent, of sulphur in
organic combination, freely soluble
in water, but incompatible with
soluble chlorides. It is said to com-
bine the bactericidal action of silver
with the penetrating, antiphlogistic
action of ichthyol. Used in 0.04 to
0.2 per cent, solution in gonorrhea ;
3 per cent, solution in posterior ure-
thritis, and in 0.5 to 3 per cent, solu-
tion in trachoma.
Protargol (protein silver salt), pre-
pared by treating proteins with a
silver salt, and rendered soluble by
treatment with a solution of albu-
moses. A light-brown powder, con-
taining 8.3 per cent, of silver in
organic combination, soluble in 2
parts of water. The solution is not
affected by alkalies, chlorides, bro-
mides, or iodides, nor by heat. Its
precipitation by cocaine hydrochlo-
ride is pre-vented by addition of boric
acid. It should not be exposed to
light. Used as substitute for silver
nitrate for irrigation purposes in
1 : 1000 to 1 : 2000 solutions, in 0.25
to 1 per cent, solutions in acute gon-
orrhea, and in 5 to 10 per cent, in-
stillations in chronic gonorrhea, and
in diseases of the mucous membranes
of the eye, ear, nose, and throat.
Colloid silver and its action and
therapeutic uses have been discussed
8—9
130 SILVER (SAJOUS).
under the heading Collargol, in the Where silver nitrate is to be used
third volume, to which the reader is locally at intervals in the form of a
referred. solution, addition of spirit of nitrous
INCOMPATIBILITIES. — Silver ether is considered of value in pre-
nitratc is incompatible with organic venting precipitation. The following
material, becoming transformed into formula is credited to Fox and
the black oxide of silver or black Higginbotham :—
metallic silver. With soluble chlo- ^ Argenti nitratis gr. v (0.3 Gm.).
rides or hydrochloric acid it forms Spiritus athcris nitrosi fSij (8 c.c).
the insoluble silver chloride. It is Aqncc destillatce f3vj (24 c.c).
also incompatible with bromides and
iodides, with alkalies, with acetates, Such a solution may be applied
chromates, cyanides, hypophospites, freely to the conjunctiva, without
phosphates, sulphides, sulphates, and neutralization with salt solution, in
tartrates, with copper salts and fer- all forms of conjunctivitis, from a
rous and manganous salts, with "^i'd "pink eye" to gonococcal con-
antimony salts and arsenites, with junctivitis (Valk).
morphine salts, with alcohol, with Where it is desired to use an oint-
creosote, with oils, and with tan- *"ent of silver nitrate, the following
nic acid and vegetable astringent combination may, with advantage,
preparations. be employed :—
MODES OF ADMINISTRA- ^ Argenti nitratis gr. xv (1 Gm.).
TION.-Silver nitrate, when used Acidi borici pulveris.. '^n.s {li) Gm.),
,, . , ' . . .„ Cerce flava: Sj (30 Gm.).
mternally, is generally given in pills, q^^. ^^-^^ ^^.. ^^^ ^^^
but may also be administered in a yi^
solution of 0.2 per cent, strength, c^., •, . ,, , • •
- , , , , , , Silver oxide is generally adminis-
preterably through a stomach-tube to ^ . . .,, ,
, , ■' . . . , , ., , tered in pill form,
avoid precipitation of the silver be- ^, ,< . ,, .,
, . , , . . ihe organic silver compounds,
tore It reaches the gastric cavity. , , ,
,,,, , . ." , ,, such as protargol and argyrol, are
When thus given, it should soon , . n ,, . , •
r, , , , , r-., used externally, generally in solution,
after be removed by lavage. Silver .^ i_ i i ^-i
. ^ ... , ,, , , . , (bee below, under i herapeutics.)
nitrate pills should be made with ^
kaolin or petrolatum, as glucose, PHYSIOLOGICAL ACTION. -
glycerin, extracts and other materials Locally, silver nitrate is antiseptic
commonly used as excipients render ''^"^ ^'^'y irritating. It is astringent,
the' salt inert. The following form- coagulating proteins, and also caustic,
ula for silver-nitrate pills has been ''^^d^'y destroying soft tissues with
recommended: which it is brought in immediate
■D ^ ,. ., ,. ,o/ /rM ^ A contact in concentrated form. It
tfi Argenti mtratis .... gr. 1% (0.1 Gm.).
c«^;; c.w/,/,^/;,. .^ coats moist tissues with a tough.
iioaii sulpliatis ex- ^
siccati gr. viij (0.5 Gm.). ^^ite film, and has not much
KaoUni •. gr. xv (1 Gm.). penetrating power, though Wildbolz
Aqua destiUata: gtt. x. found 1:1000 to 1:100 solutions to
Fac. in, pilulas no. xx. penetrate to the subepithelial tissue
(Each pill contains V12 grain^^.005 Gm.— in the urethra of the dog. In dilute
of the silver salt). solution it overcomes relaxation of
SILVER (SAJOUS).
131
tissues, and apparently improves
local nutrition. Its local action, if
excessive, can be quickly arrested
with a solution of sodium chloride,
which precipitates it as silver chlo-
ride. Applied to the skin, it produces
a brown and, later, a black stain, on
exposure to light.
The "organic" preparations of sil-
ver, such as argyrol and protargol,
are not precipitated by protein and
sodium chloride, and are not astrin-
gent. Protargol is but slightly irri-
tant, as compared to silver nitrate,
and argyrol hardly irritant at all.
Their efficiency as antiseptics is,
however, far less than that of silver
nitrate, for which, in spite of their
low irritant power, they are not,
therefore, adequate substitutes where
a strong antiseptic action is desired.
Post and Nicoll found the gonococcus
killed in one minute by 1 : 5000 silver
nitrate, but only partially inhibited in
the same period by 10 per cent, pro-
targol, and hardly at all influenced
by 10 per cent, argyrol. Similar re-
sults were obtained in the case of the
pyogenic streptococcus and the pneu-
mococcus, except that a 1 : 1000 silver-
nitrate solution was required to kill
these organisms in one minute. The
typhoid organism, on the other hand,
was killed in one minute only by a
1 per cent, silver-nitrate solution,
though succumbing completely in
the same period to 10 per cent,
argyrol or protargol. The antiseptic
action of silver nitrate is due, not
only to coagulation of the protein of
the bacteria, but also to a specific
action of the metal, silver proteinate
itself being antiseptic.
The bluish-white pellicle which fol-
lows the application of silver nitrate
to the conjunctiva is not coagulated
albumin, but chloride of silver de-
posited in the structure of the mem-
brane. The essential element in
determining the stain is the soluble
chlorides of the tissues. It is chlo-
ride of silver that is decomposed by
light, not albuminous material. The
brown stain is either argentous chlo-
ride or an oxychloride of silver.
Drops of silver-nitrate solution are
more potent in causing a stain than
an application of a stronger solution
by the brush.
The penetration of a 20 per cent,
solution of argyrol as compared with
weak silver nitrate is practically nil.
The amount of silver organic silver
compounds contain is no criterion of
their therapeutic utility. Argyrol may
have a mechanical effect, and its
sedative action is due to the large
amount of silver it contains, metallic
silver being sedative in its action.
Burden - Cooper (Ophthalmoscope,
Jan., 1907).
Silver acetate forms a durable solu-
tion and has the least irritating action
on the tissues of all the silver salts.
It is strongly bactericidal. It is im-
portant to follow its application by
rinsing with water or with a weak
salt solution. Schweitzer (Archiv f.
Gynak., Bd. xcvii, nu. 1, 1912).
Silver nitrate dissolved in water
killed the dysentery bacillus in five
minutes. On the other hand, in
broth, with the addition of a little
organic matter and salts, it failed in
a strength of 1 in 100. The frequent
failure of silver-nitrate injections in
dysentery is thus easily understood.
Albargin gave the best results of any
of the silver compounds in the pres-
ence of broth, as it killed the dysen-
tery bacillus within five minutes in a
dilution of 1 in 500, but it was less
efficient in a second trial. Collargol,
ichthargan, and argyrol had little or
no action in the presence of broth.
Rogers (Indian Jour, of Med. Re-
search, Oct., 1913).
General Effects. — Taken internally
in moderate dosage, silver nitrate has
132
SILVER (SAJOUS).
been held to act as a tonic to the
nervous system, exert a favorable
influence on the blood, and promote
constructive tissue metabolism, but
there exists no delinite pharmaco-
logic evidence supporting these views.
Administered subcutaneously or in-
travenously in poisonous doses in
animals, its characteristic effects ap-
pear to be primary stimulation of the
central nervous system, especially the
medullary centers, followed by de-
pression and paralysis; in slower
poisoning, a marked increase of bron-
chial secretion, ending in edema of
the lungs, has been observed. In
cold-blooded animals,' silver salts are
said to give rise to convulsions in
some ways similar to those of strych-
nine, followed by paralysis. These
effects have no evident therapeutic
bearing. Large amounts of silver
nitrate taken internally produce, by
reason of their caustic action, a vio-
lent gastroenteritis, thrombosis of the
gastric veins, and ulceration of the
gastric mucosa.
Absorption and Elimination. — It is
believed that in man the greater part
of the silver ingested passes through
the alimentary tract unabsorbed. The
remainder is apparently absorbed in
the form of a solution — none of it be-
ing found in the gastric or intestinal
epithelia — and is soon after deposited
in the tissues in minute granules., be-
lieved to consist of an organic com-
pound of silver. That it stays
imbedded thus indefinitely is sug-
gested by the fact that the resulting
pigmentation remains unaltered over
long periods.
Fraschetti and others deny that
any elimination of silver takes place
in man, either through the kidneys or
the intestines.
POISONING.— There are two
forms of poisoning by silver — that
following a large single dose (acute),
and that following the long-continued
use of small doses (chronic).
Acute Poisoning. — The symptoms
of acute poisoning by silver nitrate
are partly gastrointestinal and partly
cerebrospinal. Either series of phe-
nomena may predominate.
Almost immediately after a poison-
ous dose, a burning is felt in the
throat and stomach, and soon aftei'
violent abdominal pain, with vomit-
ing and purging, comes on. The ab-
dominal walls may become hard and
knotted, more rarely scaphoid. The
face becomes flushed or livid, and is
covered with sweat. The expression
is one of anxiety. When vomiting
occurs, the ejecta are often brown or
blackish in color, though sometimes
white and curdy, especially after
sodium chloride has been given. The
lips and mouth are covered with a
grayish-white membrane, which may
later change to brown and then black.
Occasionally, where the poison has
been ingested in solid form, this
membrane is absent.
In some cases the nervous symp-
toms are severe, consisting of inco-
ordination, paralysis, and convulsions
with coma or delirium. The convul-
sions are generally tetanic, persist,
according to Rouget, after complete
abolition of voluntary movements,
and, according to Curci, are due to
excitation of the motor cells of the
cord.
Collapse follows, because of the
gastrointestinal corrosion produced,
and death takes place from asphyxia
due to central respiratory paralysis,
accompanied by a profuse flow of
bronchial secretions.
causmg
pul-
SILVER (SAJOUS;.
133
monary edema. In a case reported
by Ueck coma returned at intervals
during several days before the patient
died.
At post mortem the stomach and
howels are found corroded, often
ecchymosed, and with patches of a
w^hite or grayish color. The lungs
are congested and the bronchial tubes
filled with fluid.
Poisoning by this drug is not com-
mon. The lethal dose is not certain ;
30 grains have killed and recovery
has followed the ingestion of an
ounce.
Treatment of Acute Poisoning. —
The chemical antidote is common
salt (sodium chloride), which should
be administered in large amounts.
Vomiting should then be induced at
once, as the silver chloride formed is
soluble in solutions of sodium chlo-
ride and in the digestive fluids. Lav-
age of the stomach with a very soft
stomach-tube may be carefully tried.
If the stomach cannot be washed out,
one may give large draughts of salt-
water and produce vomiting alter-
nately. Opium and oils may be
given to allay the irritation, and
large draughts of milk administered
to dilute the poison and protect the
mucous membranes. Mucilaginous
fluids and white of egg may also
be used as demulcents. External heat
should be applied if indicated, and in
the event of collapse, the customary
stimulant measures availed of, to-
gether with artificial respiration.
Atropine might prove of value to
counteract the excessive bronchial
secretion.
Chronic Poisoning.- — Prolonged in-
ternal use of any of the soluble salts
of silver gives rise to chronic poison-
ing, or argyria. A local argyria, or
argyrosis, may be caused by the fre-
quent topical application of a soluble
silver salt for a prolonged period.
Discoloration of the eyelids, con-
junctiva, and cornea has been ob-
served from the use of silver nitrate
in the eye, and a similar condition
noted from its local application in the
throat, or a blackening of the hands
from constant working with silver.
A few cases have even been reported
of general argyria resulting from
topical use of silver in the mouth
and throat.
General argyria was formerly more
frequent than now, arising frequently
from the administration of silver ni-
trate in epilepsy. The first sign of it
is the appearance of a slate-colored
line along the gums, associated with
some inflammatory swelling. Later
grayish spots or patches appear on
the skin and mucous membranes, and
spread over the whole body until the
skin has acquired a peculiar bluish-
slate color, which may become very
dark. In decided cases, the conjunc-
tiva and oral mucous membrane are
involved. In some cases discolora-
tion is especially marked in the face.
The silver is found in all the tissues
of the skin below the rete Malpighii,
and is deposited mainly in the con-
nective tissues, the various paren-
chymatous cells, and epithelia of the
body escaping the pigmentation. Al-
though the discoloration is long in
making its appearance, the deposi-
tion in the tissues prol^ably begins
at once, gradual accumulation there-
after taking place. Especially marked
deposition occurs in the renal glo-
meruli, the hepatic and splenic
connective tissue, the mesenteric
glands, the serous membranes, and
the choroid plexus. The connective
134
SILVER (SAJUUS).
tissues throughout the respiratory
passages and alimentary canal like-
wise show silver deposition. The
condition of argyria does not seem
to affect the general health.
Two women were workers in silver
leaf, their task being to cut the leaves
and lay them in books. One, aged
27, had wr rkcd steadily for fourteen
years. The discoloration of the skin
was first noted when she was 18, and
it increased steadily for four years,
then remained the same. It affected
chiefly the exposed parts and visible
mucosae. The other patient, 50 years
old, had begun to follow the occupa-
tion at 14, and had first noticed the
discoloration at 21. Both women
exhibited anemia and disordered di-
gestion several years before the ap-
pearance of the argyrosis. The silver
line on the gums should be watched
for as a danger signal in subjects
similarly occupied. Koelsch (Miinch.
med. Woch., Jan. 30, Feb. 6, 13, 1912).
Argyria has been induced in three
months, and after the use of j/2 to 1
ounce (15 to 30 Gm.) of silver nitrate
(Cushny).
Treatment of Chronic Poisoning. —
Prophylaxis is important. When the
salts of silver are indicated in a pro-
longed course of treatment, occa-
sional discontinuance of the remedy
is imperative. At the end of the
third week, the remedy should be
stopped for one week, and after three
months a long intermission should
follow. In the intermissions of treat-
ment, the patient should receive a
thorough course of purgatives, diu-
retics, and baths. Potassium iodide
may be given with the silver salts to
expedite its elimination.
Greater or less success has been
claimed for various treatments in
argyria, but in general they are futile.
Rogers claims that blistering will
lighten the color, but how it should
do so is not plain, since the silver
deposit lies deep down in the skin.
luchmann recommends the use of
potash baths and of soap baths, each
four times a week. The internal use
of potassium iodide may produce
some change in the color of the skin,
but perfect restoration to the normal
is generally unattainable.
Report of the case of a young
woman, supposedly suffering from
jaundice, which turned out to be
argyrism following a course of col-
largol. A dose of 10 grains (0.65
Gm.) of hexamethylenamine, given
for a coryza, caused marked improve-
ment in the patient's coloration. A.
M. Crispin (Jour. Anier. Med. Assoc,
May 2, 1914).
THERAPEUTICS. — Gastrointes-
tinal Disorders. — Silver nitrate has
been found of some value in the
treatment of gastric ulcer. It is often
given in pill form, sometimes in com-
bination with extract of hyoscyamus
or opium. As hydrochloric acid or
sodium chloride renders it inert by
precipitation of silver chloride, it may
prove useless unless its ingestion is
preceded by lavage of the stomach.
A 1 in 500 solution of it may then be
introduced through the tube to the
amount of Yi fluidounce (15 c.c), and
in a few minutes lavage with plain
water repeated. The dose of silver
nitrate in pill form in these cases is
M to y2 grain (0.015 to 0.03 Gm.).
If it is given in solution, sodium bi-
carbonate may, with advantage, be
added.
Pyrosis is frequently relieved by 1-
grain (0.065 Gm.) doses of silver
oxide, given in pill form, a half-hour
before meals.
In chronic gastritis and gastric
catarrh, when sour eructations or
vomiting occur after meals, the ni-
SILVER (SAJOUS).
135
trate in doses of % to H grain (0.01
to 0.015 Gm.), given an hour before
meals, sometimes yields good results.
Forlanini in these cases, when asso-
ciated with hyperchlorhydria, irri-
gates the stomach with a solution of
silver nitrate, 10 to 30 grains (0.6 to
2 Gm.) to the quart (liter), fol-
lowed immediately by sodium chlo-
ride solution.
Experiments and clinical experi-
ences showed that silver nitrate has
the property of increasing the acidity
of the gastric juice. It is indicated
in hypochlorhydria and in mucous
gastric catarrh. It aids in the diges-
tion of protein. The drug may be
used to advantage in abnormal fer-
mentation. It promotes the empty-
ing of the stomach. These various
effects were observed with small
doses (%2 grain — 0.002 Gm. — three
times a day), as well as with large
amounts (^ grain — 0.03 Gm. — three
times a day). Baibakofif (Archiv f.
Verdauungsk., Bd. xii, nu. 1, 1906).
Catarrhal jaundice has been re-
lieved by i/^o-gi'ain (0.005 Gm.) doses
of silver nitrate. F. Ehrlich has
recommended (1902) the introduction
of a 1 per cent, solution of the salt
into the stomach, after preliminary
lavage with warm w^ater, in angio-
cholitis, cholelithiasis, and chole-
cystitis. The solution is withdrawn
after one-half to two minutes, the
process repeated, and washing with
j)lain water then continued until a
clear fluid returns. The remedy is
asserted to act as a cholagogue and
to relieve the symptoms, sometimes
after preliminary aggravation.
Use of silver nitrate recommended
in all irritative conditions of the
gastric mucosa with increased secre-
tion, hyperacidity, nausea, vomiting,
and pain. In gastric neuroses, how-
ever, the drug exerts no influence
whatever. In the hyperchlorhydria
frequently occurring in chlorosis,
various diseases of the liver, chole-
lithiasis, cholecystitis, the early stages
of nephritis, and reflexly in constipa-
tion, especially of the spastic type,
and in mucous colitis, treatment
should be chiefly directed to the pri-
mary disease, but for the alleviation
of the symptoms silver nitrate is
valuable.
In benign pyloric stenosis with re-
tention of the gastric contents and
decomposition of the retained ingesta,
the most efifective symptomatic treat-
ment is thorough lavage followed by
silver nitrate internally. In fissure at
the pyloric orifice, lavage followed by
silver nitrate, a non-irritating diet,
and olive oil on an empty stomach,
has never failed, in the author's ex-
perience, to effect a cure. For the
pain of gastric ulcer, acute or chronic,
silver nitrate is superior to any other
drug. The heartburn, sour eructa-
tions, headache, and constipation are
also promptly relieved.
Silver nitrate is always well borne
by the stomach. In a case of severe
hemorrhage from gastric ulcer in
which the patient suffered intensely
from sour eructations and laryngeal
spasm, silver nitrate relieved both
these symptoms after the second
dose. In chronic acid gastritis silver
nitrate acts as in other forms of hy-
peracidity. In alcoholic gastritis dur-
ing the hj'peracid stage it should also
be employed. It is important in all
forms of gastritis to wash the stom-
ach thoroughly before the drug is
given.
The writer usually gives the drug
in solution in doses of J4 to ^ grain
(0.016 to 0.03 Gm.) three times a day
on an empty stomach. No food or
drink is followed for half an hour
after its administration. It is rarely
necessary to continue longer than
three weeks, though in rebellious
cases it may he given for a month
without danger of argyria. Where
the intestines react unfavorably it
should be discontinued at once. H.
Weinstein (N. Y. Med. Jour., Dec.
28, 1907).
136
SILVER (SAJOUS).
In ulceration of the cecum or rec-
tum and in acute and chronic dysen-
tery, rectal or colonic injections of
silver nitrate are of value. If the
cecum be invohcd a large bulk must
be used to reach the seat of the
trouble; if the rectum is the part
affected not more than 4 ounces (120
c.c.) should l)e used. In either case
there should be given preliminary
cleansing injections of warm w^ater.
If the condition is cecal, one may use
1 dram (4 Gm.) of silver nitrate to 3
pints (1500 c.c.) of water; if rectal,
5 grains (0.2 Gm.) to 4 ounces (120
c.c).
If the rectal disturbance is chronic
and very obstinate, the strength may
be increased to 5 grains (0.3 Gm.) of
the salt to 4 ounces of water. A
solution of common salt should be at
hand, to be injected if the action of
the silver is too severe, or to stop
the action of the remedy when the
desired effect has been produced.
The antiseptic and astringent prop-
erties of protargol proved effective in
several cases of gastrectasia with py-
loric stenosis, the fermentation, py-
rosis, and vomiting being checked.
Improvement was also noted in
chronic catarrh, gastric ulcer, and
even in carcinoma. Several cases of
dysentery and pseudodysentery were
rapidly cured by intestinal lavage
with a 2.6 per cent, solution of pro-
targol. For the enteritis of children
y2 to % pint (25U to 300 c.c.) uf a 2
per cent, solution were employed.
For gastric lavage a 2 per cent, solu-
tion is used. It is advisable to wash
out first with water, then to intro-
duce 1 quart (liter) of the protargol
solution. After eight or ten minutes,
this is again washed out with water.
For intestinal lavage, a preliminary
washing with water is not necessary.
Cantani (Gaz. degli osped.. No. 138,
1910).
Nervous Disorders. — Silver has
l)cen used in anterior and posterior
spinal sclerosis, and in epilepsy and
chorea, Ijut with little or no favorable
eft'ect, except possibly as a general
tonic.
In tabes dorsalis Curci has claimed
good results from the use of a double
salt, the thiosulphate (hyposulphite)
of sodium and silver. He gives daily
from % to 3 grains (0.048 to 0.2 Gm.)
by mouth or from % to % grain (0.01
to 0.048 Gm.) hypodermically. He
asserts that this treatment does not
cause argyria.
Surgical Disorders. — Fissures of
the lips, tongue, nipples, rectum, and
mucous patches and ulcers of the
mouth yield readily to applications
of a 60-grain (4 Gm.) to the ounce
(30 c.c.) solution of silver nitrate
applied carefully on a pledget of
cotton or by means of a camel's-
hair pencil. In some cases the solid
stick does better. It is also useful in
hemorrhage from leech-bites.
Boils and felons may be aborted
Ly early application of a strong solu-
tion of silver nitrate.
The healing of suppurating ulcers
and wounds, with large flal)by granu-
lations, is hastened by an application,
every day or two, of the solid stick
or strong solution. The surface of
indolent ulcers may be touched
lightly with the solid stick, or a line
may be traced within and parallel to
the margin of the ulcer every day or
two, the ulcer being strapped with
diachylon adhesive plaster during the
intervals and the limb dressed with
a roller bandage. Indolent sinuses
from buboes or from abscesses may
likewise be stimulated to healing
with a strong solution or the solid
stick.
SILVER (SAJOUS).
137
Powdered silver nitrate recom-
mended as a means of exciting the
proliferation of granulations and the
regeneration of epidermis over open
wounds and ulcers. As an excipient
the writer uses fullers' earth (l)olus
alba), sterilized by heating to 100°
or 150° C. The mixture should con-
sist of 1 part of silver nitrate to 99
parts of the earth. It is dusted on
the raw surface (not extending over
the parts already healed over), and
renewed every second or third or
fourth day, according to the amount
of secretion and reaction of the tis-
sues. When the wound is well on
the way to epidermization the treat-
ment should be interrupted from time
to time and simple aseptic dressing
applied. The treatment is recom-
mended especially for burns, and for
the healing of wounds following
furuncles and other infective proc-
esses of the skin. Max. Barnet
(Miinch. med. Woch., Aug. 30, 1910).
Bed-sores can sometimes be aborted
ii, as soon as the surface reddens, it
is brushed over with a 20-grain (1.3
Gm.) to the ounce (30 c.c.) solution
of silver nitrate. This treatment is,
however, frequently of no avail in
paralytics.
Lymphangitis of the forearm re-
sulting from a poisoned wound of
the finger may be cured by applying
the solid stick over the lines of
inflammation.
Rovsing prefers silver nitrate to all
other antiseptics for impregnating
gauze and drainage wicks, and in the
preparation of suture material, and
uses it extensively in his clinic for
these purposes.
Spasmodic esophageal stricture lias
been relieved by the use of a sponge
probang saturated with a very weak
solution of silver nitrate.
Gushing, Halsted, and Lexer highly
recommend the use of silver foil as
a dressing for granulating wounds,
and especially for skin-grafts and the
incisions in plastic operations on the
face. The silver leaf acts as an anti-
Leptic and minimizes scarring.
The marked tolerance of the body
tissues for metallic silver has led to
its use in bone suturing and in the
preparation of supporting filigree or
chain for use in cases of ventral
hernia or other varieties of weakened
abdominal wall.
Miller recommends, as productive
of good scar formation in burns, the
use of an ointment of protargol, 45
grains (3 Gm.), dissolved in cold dis-
tilled water, 75 minims (5 c.c), and
mixed with 3 drams (12 Gm.) of dried
wool-fat and 2^^ drams (10 Gm.) of
petrolatum.
Silver - foil platelets used over
wounds where very inconspicuous
scar is desirable. Wounds thus cov-
ered remain perfectly dry, even if
left alone for a week to ten days,
and epidermization is much acceler-
ated. In osteoplastic flaps the scars
are so faint they are scarcely visible.
Skin grafts may be left untouched for
a week to ten days, though occasion-
ally blood and serum collect beneath
some of the grafts. In granulating
wounds, healthy granulations are
rapidly covered over with epithelium
under the foil, without the formation
of much granulation tissue. They
become flatter. The silver foil ap-
parently has an inhibitory effect upon
the growth of granulation tissue.
The surface, when healed, is even
with the surrounding skin. The sil-
ver foil is also advised in skin
sutures beneath plaster-of-Paris casts.
E. Lexer (Zentralbl. f. Chir., Bd. xlii,
S. 217, 1915).
Disorders of the Respiratory Tract.
— Acute pharyngitis may be aborted
by the early application of a 60-grain
(2 Gm.) to the ounce (30 c.c.) solu-
138
SILVER (SAJOUS).
tion. In laryngitis the parts should
be cleansed with an alkaline solution,
the parts anesthetized with a solution
of cocaine, and by the aid of a brush
and mirror a 10- or 20- grain (0.65
or 1.3 Gm.) to the ounce (30 c.c.)
solution of silver nitrate applied to
the larynx.
In laryngeal tuberculosis a spray
of silver-nitrate solution in the
strength of 3^ to 2 grains (0.03 to
0.12 Gm.) to the ounce (30 c.c.) may
be of service. Crocq claims that sil-
ver nitrate is a valuable remedy in
pulmonary tuberculosis, promoting
appetite and digestion and diminish-
ing cough, expectoration, and night-
sweats. He administers from % to
Ys grain (0.008 to 0.02 Gm.) daily, in
divided doses. It may, with advan-
tage, be given in a %-grain (0.01
Gm.) dose combined with 3 grains
(0.2 Gm.) of Dover's powder.
In pertussis Ringer advised the use
of a spray of silver-nitrate solution
(>4 to 2 grains— 0.03 to 0.3 Gm.— to
1 ounce — 30 c.c.) to relieve the vio-
lence of the cough and give the pa-
tient rest at night. The spray should
be used when the stomach is empty,
as it may bring on retching. The
nozzle of the atomizer should be
placed well within the mouth to pre-
vent staining of the skin.
In atrophic rhinitis and ozena,
Gleason obtained good results by
painting a 20 per cent, solution of
argyrol over the afifected area.
Ophthalmic Disorders. — ^^Silver ni-
trate is found useful in ophthalmolog-
ical practice in all strengths from a
1-grain (0.06 Gm.) solution to the
solid stick.
In simple conjunctivitis, where the
discharge is profuse, a 2- to 5- grain
(0.13 to 0.3 Gm.) solution is of value
In purulent, including gonococcal,
ophthalmia, when the discharge is
profuse, the lids should be everted
and wiped dry, and painted with a
10- to 15- grain (0.6 to 1 Gm.) solu-
tion of silver nitrate, immediately
neutralized with a solution of com-
mon salt. This should be done once
daily.
Protargol is more satisfactory than
either argyrol or silver nitrate for the
treatment of acute mucopurulent con-
junctivitis due to the Koch-Weeks
bacillus. Argyrol is better than sil-
ver nitrate. Protargol is perfectly
safe up to 33 per cent. Its applica-
tion causes much less pain than sil-
ver nitrate, but more than argyrol.
The solution was freely used and the
excess left in the eye. It was always
applied with small pellets of absorb-
ent cotton. Drops for home use were
always given — silver nitrate in 0.2
per cent, strength, or argyrol or
protargol in 5 per cent, solution.
Butler (Ophthalmoscope, Jan., 1907).
Many more cases of conjunctival
argyria result from the use of or-
ganic silver compounds, such as pro-
targol and argyrol, than from silver
nitrate. The writer protests against
the almost universal use of such com-
pounds in acute and chronic catarrhal
conjunctivitis. For these conditions
a collyrium containing ^ grain (0.03
Gm.) zinc sulphate and 10 to 12
grains (0.65 to 0.77 Gm.) of boric
acid to the ounce (30 c.c.) is more
surely and promptly efficacious than
the silver compounds mentioned. S.
Theobald (Johns Hopkins Hosp.
Bull, Nov., 1911).
Granular lids and trachoma are
benefited by silver nitrate. If there
is slight discharge the stick should be
used; if there is copious discharge,
the use of a 10-grain (0.6 Gm.) solu-
tion, with neutralization of excess,
once daily will be followed by
improvement.
In blepharitis, Hinshelwood recom-
SILVER (SAJOUS). 139
mends the use of argyrol, a strong upon to overcome the more severe in-
solution of which is rubbed into the fective conjunctival inflammations,
lid margins after each has been Cutaneous Disorders. — It is claimed
cleaned of crusts with a camel's-hair that pitting in smallpox may be pre-
brush cut short. This procedure is vented by puncturing the vesicles, on
applied at first daily, then every the fourth or fifth day, with a needle
second or third day. dipped into a 4 per cent, solution of
In diphtheritic conjunctivitis, after silver nitrate. Others paint the skin
the absorption of the membrane and with a 1 or 2 per cent, solution, and
the re-establishment of the discharge, claim that it is equally effective. The
one may cautiously use silver-nitrate mitigated stick has also been used,
solution as in purulent ophthalmia. Silver nitrate is also used to de-
Crede initiated the use of a 1- or stroy parasitic fungi, to cause ex-
2- per cent, solution, 1 drop in each foliation of the epidermis, or for a
eye, in the eyes of all newborn in- local stimulant effect. As a caustic
fants to prevent the occcurrence of it is inferior to several other agents.
ophthalmia neonatorum. This is, by It has been found useful in some
many, made a routine procedure, forms of eczema (chronic forms and
Where all possibility of infection of circumscribed patches), and in reliev-
the birth canal can be excluded, flush- ing the itching of prurigo and lichen.
ing out with a saturated boric acid Pruritus ani and pruritus vulvae may
solution is sufiicient. be benefited by a 4- or 6- grain (0.25
Silver nitrate cannot be used safely or 0.4 Gm.) to the ounce (30 c.c.)
in the eye in a solution stronger than solution painted upon the parts two
3 per cent. A 2 per cent, solution, to four times daily,
even if neither neutralized or washed The use of silver nitrate has
out, never causes any irritation. Any also been recommended in lupus,
solution stronger than 3 per cent., psoriasis, erythema, ringworm, and
unless at once neutralized with salt erysipelas.
solution, leaves a faint film of de- Venereal Disorders. — In the treat-
stroyed epithelium, especially in ment of buboes good results have
infants (Butler). been reported from injections of a
The use of silver should be inter- 2 per cent, solution of silver nitrate
dieted where corneal ulceration ex- in the early stage,
ists, and when continued use of a In orchitis and epididymitis a
remedy is desired. The danger of strong solution of the nitrate painted
permanently staining the tissues must over the scrotum, in the early stages,
not be forgotten. will often relieve the pain and reduce
In place of silver nitrate, protargol the swelling.
(5 to 20 per cent.) and argyrol (5 to Injections of silver-nitrate solu-
50 per cent.) are often used. Their tions are most useful in the later sub-
advantages consist essentially of less acute stages of gonococcal urethritis,
irritant power and greater ease of em- in the strength of 1 part of the salt
ployment, but their antiseptic power in 500 to 3000 parts of water, bc-
is decidedly inferior. Neither (espe- ginning with the weaker solution.
cially argyrol) should be depended Strong solutions used early have
140
SILVER (SAJOUS).
been advised for the purpose of
aborting the disease ; such use is,
however, not to be commended.
Fifty-five men, suffering from gon-
orrhea, were treated with injections
of protargol, beginning with y\ io Yz
per cent., and increasmg m stiength
to 1 per cent. The patients waslicd
the urethra out with warm water be-
fore injecting the protargol. The
protargol injections were kept at first
for ten minutes, and later up to thirty
minutes. Of the 55 patients, only 2
showed signs of irritation. The aver-
age time occupied in causing the
gonococci to disappear finally from
the discharge w-as 16.3 days.
Five children with gonorrheal vul-
vovaginitis were treated with 2 per
cent, solutions for the acute stages
and 5 per cent, for the subacute
stages. The parts were cleaned and
the solution injected into the vagina
and kept there for ten minutes, the
pelvis being raised. None of the
children complained of irritation.
Sitz baths were employed as a sup-
plementary treatment. It took on an
average of three months befoie the
last cocci were removed from the
secretion of the vagina and cervix.
Protargol yielded as good or better
results in female gonorrhea than
other means. The writer employed
it in solutions of from 5 to 10 per
cent., and met with no irritating ef-
fect. Irritant effects are probably
due to worthless imitations of pro-
targol, and at times to the solutions
not being made up freshly with cold
water. C. Stern (Deut. med. VVoch.,
Feb. 7, 1907).
The drug is also^ useful in 1 : 500 to,
1 : 5000 strength in prostatitis, sem-
inal vesiculitis (after massage), and
the cystitis of enlarged prostate, or
bladder stone or tumor.
Gynecological Disorders. — In ul-
ceration of the cervix, and in those
cases of leucorrhea in which the
cervix is boggy and tender, great
benefit may follow the application of
the solid stick within the cervix.
This procedure is frequently followed
by headache about the vertex, but
this can be relieved with 10-grain
(0.6 Gm.) doses of the bromides.
Silver-nitrate solutions were used
very extensively for erosions of the
cervix, btit other remedies have sup-
planted them. Vomiting of preg-
nancy can sometimes be relieved by
brushing the cervix over with a 60-
grain (4 Gm.) solution of the nitrate.
Removal of Silver Stains. — Silver
stains on clothing may be washed off
with a solution containing 45 grains
(3 Gm.) of potassium cyanide, 5
grains (0.3 Gm.) of iodine, and 1
ounce (30 c.c.) of water. Another
method is to dissolve 15 grains (1
Gm.) of corrosive sublimate in 7
ounces (210 c.c.) of boiled water, and
add about 45 grains (3 Gm.) of so-
dium chloride just before using; the
stained material is to be placed in it
for about five minutes and then
washed two or three times. Hahn
advises the use of a solution contain-
ing 75 grains (5 Gm.) each of corro-
sive sublimate and of ammonium
chloride dissolved in 10 drams (40
c.c.) of water.
When the stains are older they
may be rubl:)ed with a mixture of
iodine and ammonia, and the part,
still wet, then washed thoroughly.
(When dry, it is highly explosive.)
Potassium cyanide in solution will
generally remove stains from the
fingers or skin. The part should be
well rinsed immediately afterward.
Or, the skin may be covered with
tincture of iodine and then washed
off with a solution of sodium thio-
sulphate (hyposulphite).
L. T. DE M. Sajoits,
Philadelphia.
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
141
SINUSES, NASAL ACCES-
SORY; DISEASES OF.— The nasal
accessory sinuses, the maxillary, or
antrum of Highmore, the frontal,
ethmoidal and sphenoidal, are com-
monly involved in various disorders :
acute and chronic rhinitis, the vari-
ous diseases of childhood, and also in
pneumonia, influenza and typhoid
fever, through extension of the infec-
tion to them. Especially is this apt
to be the case when septal deviation,
nasal polypi, turbinate hypertrophy,
or any other condition capable of in-
terfering with proper drainage of the
nasal cavities is present. These con-
ditions may also provoke chronic in-
flammation of the sinuses, due to
accumulation in them of secretions
containing pathogenic bacteria. It
may also be caused by chronic ca-
tarrhal disorders, in which intumes-
cence of the nasal mucosa is more
or less permanent, and characterized
by mucopurulent discharge. The
source of infection may be located in
the mouth. Not only may carious
teeth awaken suppuration of the an-
trum when, as in the case of certam
bicuspids and molars, this sinus is
penetrated by the roots of teeth, but
also through germs such as the end-
ameba, pneumococcus and other or-
ganisms concerned with pyorrhea
alveolaris. Tonsillar streptococci are
also thought to prove pathogenic in
some instances. Syphilis, tubercu-
losis, carcinoma, sarcoma and other
destructive processes may also extend
to, or occur in, either of the sinuses.
Their bony framework may be in-
volved in fractures, punctured wounds
and other traumatisms.
The pathological changes induced
are characteristic. Although the mu-
cosa covering the walls of the various
sinuses is hardly one twenty-fourth of
an inch thick, inflammation with the
accompanying edema may cause it to
swell to eight or nine times this
thickness, and to become polyp-like.
The cavity becomes more or less oc-
cluded as a resonance chamber, while
the pressure exerted centrifugally by
the swollen mucosa upon its walls
may cause pain, such as that pro-
duced in the frontal sinus in the
course of influenza, in the antrum
during a local inflammation, etc. The
first mucoid secretion soon becomes
replaced by mucopus, unless arrested
in the first stage, owing to invasion
by pyogenic bacteria and phagocytes.
While this may occur in any sinus,
the frontal and maxillary sinus, or
antrum of Highmore, are the seats of
predilection for a purulent process.
Important in this connection is the
formation of fistulous openings where
the orifices of a sinus are occluded
sufficiently by the swollen mucosa to
prevent the discharge of pus. These
openings, which occur through the
thinnest and weakest portion of the
walls of the sinus, may entail severe
complications, such as orbital cellu-
litis, infection of the cranial contents,
meningitis, periostitis of the osseous,
tissues adjoining the sinuses, etc.
Disorders of the nasal accessory
sinuses, therefore, may prove danger-
ous to life if neglected.
MAXILLARY SINUS OR AN-
TRUM OF HIGHMORE.
INFLAMMATORY DISOR-
DERS.— The maxillary sinus may be
seat of acute or chronic inflammation.
Acute Inflammation. — This disor-
der may occur as an extension of
an acute rhinitis or some inflamma-
tory disorder of the anterior nares.
142
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
through the antral opening below the
middle turbinate, the invasion of
pus, irritating powders or fumes, in-
sects, foreign bodies, etc., or occur as
one of the manifestations of a gen-
eral infection or toxemia.
The main symptom is a neuralgic
pain referred to the cheek of the af-
fected side. It presents as a charac-
teristic feature that of being most
severe in the region of the malar
bone. If the nasal disorder be such
as to occlude, by swelling, the ostium
maxillare, the pain may be severe and
extend to the orbital region. The pain
may also affect the upper dental arch,
even though the teeth of the corre-
sponding area be normal, owing to
the tension in the antral cavity.
All these symptoms become ag-
gravated where the antral exudate
becomes purulent. The teeth which
bury their roots in the lower portion
of the antrum, and adjoining teeth,
give rise to severe pain on being per-
cussed. While a diseased tooth —
either the second bicuspid or first
molar — in most instances is a frequent
cause of antral sinusitis and abscess,
the determination of this fact should
be left to a competent dentist. Sound
teeth have often, been removed by
incompetent or careless operators.
' The antrum, owing to its size, is
the most prolific source of discharge
of all the sinuses. At first mucoid
and gelatinous, it eventually assumes
a mucopurulent character, and is
voided through the nasal orifice if
the latter be patent and into the
nose, and drawn thence into the naso-
pharynx and expectorated or swal-
lowed, especially if the nasal passage
of the corresponding side be ob-
structed, or if the patient is in the re-
cumbent position. If the nasal cavity
is relatively ])atent, the discharge is
voided anteriorly. It is apt to have
a foul odor if the cause of the antral
purulent process be due to diseased
teeth. When the discharge is pent
up in the cavity through blocking of
the nasal orifice a fistuluus opening is
formed unless the mucopus be arti-
ficially removed or resolution occur
spontaneously. The pus may break
through the nasal wall, forming a
fluctuating tumor in the middle
meatus, i.e., Under the middle turbi-
nate, or through the lower portion of
the anterior wall of the sinus, and
escape in the sulcus between the gum
and the cheek above the first or
second molar.
Chronic Inflammation, or Empy-
ema.— This condition results from
the acute form when it fails to dis-
appear spontaneously or remain un-
treated. The membrane then be-
comes organized, thickened, irregular
and polypoid in character, polypi
sometimes projecting through the an-
tral orifice beneath the middle turbi-
nate. In most cases, however, this
orifice remains patent, and gives pas-
sage to a free discharge which is
found in this location, i.e., the middle
meatus, the elimination of which, an-
teriorly or posteriorly, is subject to
the same conditions as in acute sinu-
sitis. Exacerbations of discharge oc-
cur along with temporary catarrhal
symptoms. At times the mucopus
eliminated is very fetid and imparts
its fetor to the patient's breath. But
little, if any, pain is complained of,
and general phenomena, fever, etc.,
are seldom observed.
Although some cases may undergo
spontaneous resolution, the majority
persist sluggishly during many years,
undergoing periodical exacerbations
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
143
of activity. These may occur after
apparent cure through appropriate
measures, so that in all cases the
prognosis should be guarded.
The diagnosis of antral inflamma-
tion is not difficult when the location
of the pain, the presence of pus in the
middle meatus, and marked sensitive-
ness of the teeth immediately beneath
the antrum can be discovered. In
most cases, however, transillumina-
tion— a strong electric light being
placed in the mouth— should be used,
'showing as it does obstruction to
light on the diseased side as com-
pared with the relative free illumina-
tion on the normal side. It affords,
at least, corroborative testimony.
When both antra are diseased, an ex-
ploratory puncture of the suspected
antrum beneath the inferior turbinate,
under local anesthesia, may be re-
sorted to, but only under strict anti-
septic precautions. In marked cases
empyema may be recognized after
carefully spraying out the nose, by
causing the patient to bend his head
over to one side, when a marked ac-
cumulation of purulent exudation will
appear in the uppermost nostril. Per-
cussing the cheek and the teeth may
elicit suggestive pain.
The writer questions the efficacy
of transillumination as the deciding
factor in determining antral suppura-
tion, and places more dependence
upon the suction syringe for diag-
nostic purposes. The specially de-
vised needle is readily inserted, and
nearly a syringeful of water is quickly
injected into the cavity of the an-
trum, and at once sucked back into
the syringe, in order to obtain a
specimen of the antral contents. In
a number of cases the writer's sus-
picions of antral suppuration were
negatived by excellent transillumina-
tion, with pupil reflex, whereas, the
use of the syringe revealed the pres-
ence of thick pus in greater or less
amount, or the existence of plugs of
mucus with or without pus. Wil-
liams (Jour, of Laryn., Rhin., and
OtoL, Mar., 1912).
When from any cause, the nasal
opening of the antrum becomes oc-
cluded— through swelling of the nasal
membrane, polypi, plug of purulent
material, diphtheritic membrane, etc.
— all the symptoms, especially the
pain and swelling, become progres-
sively worse. The pain finally be-
comes intense, while the swelling in-
cludes bulging of all neighboring
parts, the cheek, palate, gums and
teeth, eyeball. Symptoms of pyemia,
chills, sweats, and high fever also ap-
pear. Thinning of the walls of the
sinus progresses, however, and finally
rupture occurs either tlyough the
palate, alveolar process, orbit or nasal
cavity. As soon as the pus is evacu-
ated in this manner all the symptoms
disappear, apart from those of the
remainine chronic inflammation de-
scribed above, and a more or less
permanent fistula.
In an examination of 100 heads in
the necropsy room, the writer found
that 37 per cent, showed some evi-
dence of pathological changes in the
maxillary antra. Of these 37 cases,
11 were examples of edema; 12 were
examples of chronic inflammation or
empyema; 1 was an example of an
alveolar or dental cyst, and 13 were
examples of retention cyst. With
one or two exceptions, all of these
cases were undiagnosed during life.
The presence of a large amount of
pus in 10 out of 12 of these cases of
empyema may have played an active
part in causing the death of the pa-
tients. J. P. Tunis (Laryngoscope,
Oct., 1910).
TREATMENT,— In all the phases
of antral inflammation careful atten-
144 SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
tion should be given to the nasal In mild or incipient cases due solely
cavity. Acute cases and exacerba- to the presence of an inflammatory
tions of activity in chronic cases may disorder in the cavities, this mild
often be checked if seen early when treatment, if persisted in, sufifices to
a nasal inflammatory disorder is the check the antral trouble. It should
cause, by thorough cleansing with be remembered that polypi, hyper-
warm saline solution, used freely with trophy of the middle and inferior tur-
a coarse atomizer, followed by the binal, a foreign body, etc., may prove
local application, with a' pledget of to be the exciting cause, and that ap-
cotton on a nasal probe, of the gly- propriate treatment of these condi-
cerite of iodotannin, which is pre- tions is necessary,
pared as follows: — The teeth, the roots of which pro-
B lodi Sss (2 Gm.). ject into the sinus from below, being
Acidi tannici ,Sss (15 Gm). occasionally the source of antral in-
^^^ Oss (250 c.c). flammation, they should be carefully
M. Filter and evaporate to Bij (62 c.c.) examined. Mere sensitiveness un-
and add i . ,
„, . cler percussion does not warrant a
Glycerini fjiv (125 c.c.) . i ■ . i . i i
J' .. ow y o c.c.;. conclusion that they are the source of
This solution is applied freely over trouble, since inflammation of nasal
the nasal mucosa, and particularly origin may also cause neuralgia in the
under the middle turbinate, the area upper dental arch. Teeth should only
forming the middle meatus into which be drawn, therefore, after an X-ray
the orifice of the antrum opens. If the bas clearly shown them to be the
tissues are sw^ollen, the application of cause of the antral disorder. Since
the above should be preceded by a the recognition of the fact that pyor-
spray of 4 per cent, solution of co- ibea alveolaris is present in most per-
caine to contract it and anesthetize it. sons after the thirtieth year, espe-
This treatment should be carried out cially in view of the resistance of the
by the physician daily. The patient Endamcba buccalis, a communication
should then be shown how to use between the mouth and the antrum
drops into the nose in such a way as should be avoided when at all pos-
to cause them to bathe the outer wall, sible. It is probable, in fact, that the
including the space under the middle persistence of empyema treated in
turbinate, i.e., by bending his head this manner and necessitating a per-
well over on side of the sinusitis. He manent tube or plug in the alveolar
should then be ordered to spray his perforation is due to constant reinfec-
nose carefully night and morning with tion by gingival organisms. When,
saline solution to cleanse it, then to therefore, the exciting cause is clearly
apply 5 or 6 drops of 1 : 5000 solution traced to a tooth and it becomes nec-
of adrenalin into the nostril of the essary to extract the latter to irrigate
afifected side, and after a few minutes the sinus, it is best to pack the open-
follow this up with a spray of the i^g with iodoform gauze, and to re-
following oily solution: — peat the irrigations a few times. If
Camphor, this does not suffice to cure the antral
Menthol aa gr. j (0.06 Gm.). disorder — which it often does in re-
Benzoinol l\] (62 c.c). cent cases — it is preferable to allow
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
145
the alveolar openingf to close and to
create an opening through the nasal
wall.
The alveolar operation should never
be done as an operation of choice,
because it establishes a communica-
tion between the mouth and a sup-
purating cavity, and requires the use
of a tube or plug, which is decidedly
disadvantageous. The open method
of doing the canine fossa operation
is likewise to be condemned on much
the same grounds. When simple
irrigation has failed or is not prac-
ticable, the next step should be a
large opening in the inferior meatus,
with removal of a portion of the
inferior turbinate. If this method is
employed, very few patients will
require radical operations. Wells
(Laryngoscope, Dec, 1906).
Having encountered a case of fatal
bleeding in entering the antrum with
a sharp trocar through the inferior
nasal meatus, as well as occasional
infections of the pterygomaxillary
fossa from excessive momentum of
the instrument and accidents from
entrance of the point of the trocar
into an orbital cell, the writer deter-
mined to discard the sharp-pointed
trocar for a smooth-tipped rasp mod-
elled after those used by Vacher and
by Watson Williams for penetrating
into the frontal sinuses. An opening
large enough to facilitate irrigation
and avoid premature closure is thus
made. Luc (Rev. de laryng., d'Otol.
et de rhinol.. May 15, 1918).
Although the ostium maxillare is
most easily reached and penetrated,
its situation, in the middle meatus,
i.e., under the middle turbinate, would
cause a trocar to enter the antrum
too high up to permit of effective
drainage through the nose. It is
preferable, therefore, to puncture the
thin wall of the antrum which faces
tlie area beneath the inferior turbi-
nate. A pledget of cotton well-moist-
ened, a 10 per cent, solution of
cocaine having been placed in this
location and left there about ten min-
utes, a Coakley or Myles trocar and
cannula, sterilized by boiling, is in-
troduced upward and outward under
the inferior turbinate until one inch
of the instrument from the lower edge
of the nostril has entered the nose.
The trocar is then pushed in through
the wall into the antrum, then with-
drawn, leaving the cannula in situ.
Through it the antrum can be
drained, then washed out by means
of syringe with saline solution, and
again drained dry — a measure which
often suffices in recent or mild acute
cases to effect a cure.
Efforts must be chiefly directed to
promoting the free and spontaneous
discharge of pus from the antrum by
way of the natural ostium, by: (a)
directing the patient to lie in bed
with the diseased antrum uppermost;
(b) the application of cocaine and
adrenalin solutions to the regions
around the middle meatus — this may
be done every four or six hours; (c)
scarification of these regions; and
(d) inhalation of mentholized steam.
If these means fail the antrum should
be punctured through its inner wall
in the inferior meatus, and irrigated.
Tilley (Brit. Med. Jour., Aug. 22,
1908).
It should be borne in mind, how-
ever, that the anatomical relations of
the frontal and ethmoidal cells with
the antrum render the latter a sort of
receptacle for discharges from the
former. When all these structures
are diseased, therefore, drainage of
the antrum in the manner described
is useful in several ways.
In those cases in which the entire
chain of cells is diseased — the an-
trum, the ethmoidal cells, the frontal
sinus, and in many cases the sphe-
noidal sinus also — Jansen has pro-
posed the extensive external opera-
8—10
146
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
tion of laying open the entire chain.
This operation is only called for and
only warranted in extreme cases in
which the cavities are the seat of
myxomatous or other growths. In
all ordinary cases of empyema of the
antrum and ethmoidal cells, asso-
ciated with nothing more than a de-
generated condition of the mucous
membrane that has resulted from a
prolonged maceration in pus, these
external operations are, in the opin-
ion of the writer, unnecessary, for
the reason that diseased conditions
of the maxillary sinuses, and also of
the ethmoidal cells, which are com-
monly associated with an empyema,
can be successfully treated by the
nasal route. J. O. Roe (Annals of
Otol., Rhin., and Laryn., June, 1909).
It is sometimes necessary, owing to
the necessity of keeping the artificial
opening patent for continued drain-
age and local treatment, to enlarge
the opening. This necessitates re-
moval of the lower anterior portion
of the inferior turbinate. Wells's op-
eration is much used for this purpose.
In this procedure the anterior half of
the inferior turbinate is first removed
under local anesthesia with a 10 per
cent, solution of cocaine and ischemia
with 1 : 5000 solution of adrenalin by
means of serrated scissors and the
snare. An opening is then made with
a trocar, as explained above, but
lower down and close to the floor of
the nose. This opening is then en-
larged by means of a rasp, used in
such a way as to extend the opening
anteriorly, following the line of the
nasal floor until the junction of the
nasoantral with the facial wall of the
antrum is reached.
Skillern's operation obviates the
necessity of resecting a portion of the
inferior turbinate. It is performed
as follows : After cleansing the nasal
cavities, anesthesia is secured by the
application f)f a 20 per cent, solution
of cocaine and l)y injections of novo-
caine and adrenalin. A s])indle-shaped
piece of mucous meml)rane is re-
moved in front of the inferior tur-
l)inate by two incisions extending
through all tlie tissues to the bone,
and the crista pyriformis is exposed.
With a chisel, forceps and an electric
trephine the antrum is then opened,
flushed out, inspected, curetted, and
packed loosely with iodoform gauze.
The gauze is removed in forty-eight
to seventy-two hours and replaced
every second day for two weeks.
This operation enables the operator
to inspect directly the sinus and to
follow dc visu local applications to
any part of the diseased area, includ-
ing some that are usually resistant
to treatment.
In acute maxillary sinusitis one
should irrigate the cavity as sug-
gested for empyema; this failing, it
may be necessary to make a wide
artificial opening in the lower part
of the nasoantral wall for ventila-
tion. In chronic maxillary sinusitis
one should make a wide artificial
opening in the nasoantral wall; this
failing, one should expose the sinus
through the facial wall, and curette
the interior. Wells (Med. Rec, Oct.
29, 1910).
We have seen that inflammation of
the mucosa of sinuses causes it to
thicken greatly and to form polypoid
projections. In the presence of pus
this thickened mucosa becomes a
soggy mass which requires the con-
servative use of the curette — not the
vigorous curetting which the late
John O. Roe has very properly con-
demned— the snare for polypoid
masses, and the application of reme-
dies to all parts of the diseased cav-
ity. This can only be done by means
of an operation which enables the
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 147
operator to reach the sinus through procedure Ly his experience in op-
the mouth and nose. Such a pro- ^''^ting by the Luc-Caldwell method,
, , .1 i-> u 11 T when he frequently found a mass of
cedure, known as the Caldwell-JLuc , . ^. • ,, n r ,u
granulation tissue in the floor of the
operation, is begun in the mouth l)y ^^trum which often led to an abscess
means of an incision in the sulcus be- about the apex of a tooth. A. R.
tween the gum and lip above the Solenberger (Colo. Med., xii, 269,
bicuspid and first molar. The perios- 1915).
teum being detached up to the infra- TUMORS OF THE MAXILLARY
orbital canal, an opening is drilled SINUS, OR ANTRUM.
into the antrum as starting for re- Polypi. — The tumors most fre-
moval, by means of rongeur forceps quently found in the antrum are
and chisel, of the greater portion of polypi, which, as stated above, often
the anterior wall of the sinus, forming occur in cases of empyema of long-
a gap through which the index finger standing. They may either develop
may easily be introduced. Through in the antrum itself or project out of
the oroantral opening thus made a the antrum into the nose and develop
disk of bone about one-half inch in under the middle turl)inate.
diameter is removed from the nasal Cysts. — These are of two kinds,
wall, including the anterior half of The one, developed from the mucosa
the inferior turbinate. of the antrum, gives rise to period-
Besides permitting any curetting or ical discharges of a. watery, odorless
snaring that may be necessary, this fluid, and, when sufficiently large, to
operation affords a free field for local deformity and' bulging of the affected
treatment. Irrigations with saline side.
solution, followed by insufflations of The second variety arises from an
iodoform over all parts of diseased alveolus, and is due to cystic degen-
surface, a-nd packing with iodoform eration of the peridental membrane.
gauze daily for ,a week or ten days, It causes erosion of the antral wall,
will usually deal effectively with a penetrates the antrum by pushing its
case of empyema. The oroantral open- mucosa before it, then grows rapidly,
ing may be closed by sutures after soon filling the cavity, and causing
free drainage and the use of the cu- deformity of the face and palate on
rette or snare, and the medical treat- the corresponding side. A character-
ment carried on through the nasal istic crackling sensation is elicited by
opening. At times stimulation of the compressing its outer wall. If it
antral membrane is necessary; this ruptures it yields a greenish, thick,
may be done by using a spray of 25 odorless fluid, containing, as a rule,
per cent, solution of argyrol. Irritant cholesterin crystals. Unlike the other
antiseptics and astringents are more variety, there is no discharge in the
harmful than beneficial in antral nasal cavity, unless it ruj^tures, when,
diseases. becoming infected, it simulates an
Removal of a tooth, unless it can empyema, giving- off a fetid discharge,
be demonstrated to be the^ offending Osteoma'!— In this form of tumor.
member, is bad practice. The author ^ i t i i
, , .... svmptoms are only awakened when
advocates an examination through a - '
sufficiently large opening in tlic an- the neoplasm has grown sufficiently
terior wall. He was led to adopt this to compress the uasal wall, and thus
148
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
gradually decrease the lumen of the
nasal passage of the correspondintj
side. No pain is experienced until a
large size is attained, and no dis-
charge of an abnormal character is
complained of. An exploratory needle
or trocar thrust into the tumor is ar-
rested as soon as the mucosa is pene-
trated, and transillumination shows
complete darkness as compared with
the other side.
Malignant Tumors. — Sarcoma and
osteosarcoma are the growths most
commonly observed in the antrum.
Cases of psamnio- sarcoma, epithelioma,
perithelioma (Sakai) and endothelioma
have been reported. These tumors,
particularly sarcoma, grow with rela-
tive rapidity and usually cause lan-
cinating pain and considerable swell-
ing. After filling the antrum, they
penetrate into the nasal or naso-
pharyngeal cavity, rapidly decreasing
their lumen and giving rise to a mu-
copurulent discharge often streaked
with blood and detritus, and giving
off a foul odor. The glands behind
the angle of the jaws are enlarged
soon after the nasal cavities are
invaded.
Unique case, as a careful search of
medical literature revealed none like
it, of a calculus made up almost
entirely of a calcium phosphate and
found in the course of an operation
for a squamous-celled epithelioma
involving the antrum of Highmore.
N. H. Carson (Interstate Med. Jour.,
Mar., 1913).
TREATMENT.— The removal of
polypi from the antrum requires, as
previously stated, sufficient room to
render the use of the curette or snare
possible. For this purpose the Cald-
well-Luc operation affords the re-
quired room. This applies also to the
removal of ordinary cysts. As regards
the cysts of dental origin an injection
of a 2 per cent, solution of phenic acid
into the cyst, through an incision
above the diseased tooth if necessary,
causes shrinking and disappearance.
If the growth cannot be reached, the
Caldwell-Luc buccal opening should
be practised, and the cyst removed,
including the offending tooth, if
necessary.
Osteomata can only be removed sat-
isfactorily by dissecting up the facial
tissues from the antral wall and by
means of chisel and gouge insure
complete excision of the growth.
This operation, which should, of
course, be done under general anes-
thesia, is but rarely followed by
recurrence. In malignant growths re-
moval of the affected superior maxilla
alone affords any hope of recovery.
FRONTAL SINUS.
INFLAMMATORY DISOR-
DERS.— The frontal sinus may be
the seat of acute and of chronic
inflammation.
Acute Inflammation. — In this con-
dition, especially when suppuration is
present, there is more or less severe
pain between and above the eyebrows,
which presents the characteristic of
being increased by leaning forward
and by coughing and of being so ag-
gravated on blowing the nose that the
patient is apt to avoid emptying the
nasal cavity properly. Percussion
over the sinus also causes pain ; this
is likewise the case when pressure is
exerted under the frontal sinus, i.e.,
on the orbital plate below the edge
of the orbit under the supraorbital
foramen. The whole superciliary re-
gion, especially over the course of the
supraorbital nerves, is hyperesthetic.
In mild cases a sensation of fullness
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
149
and weight in the frontal region is
alone experienced. The discharge, at
first serous, may become bright yellow
and purulent, and pass down into
the nasal cavity between the middle
turbinate and the outer wall of the
cavity, but if the orifice, the infun-
dibulum, be obstructed, the sinus is
distended, and a fistulous opening
may form, or the abscess may break
into and invade the neighboring an-
terior ethmoidal cells.
CHRONIC INFLAMMATION.—
Chronic inflammation of the frontal
sinus may occur as a result of acute
inflammation of the sinus, or, through
extension, a chronic ethmoiditis, in
which the anterior ethmoidal cells are
ruptured through distention and allow
their purulent contents to penetrate
into the frontal sinus. An antral em-
pyema may also act as primary cause.
The antral mucosa undergoes poly-
poid thickening, and sometimes be-
comes the source of polypi which
project into the nasal cavity and
cause considerable annoyance. In
most cases but little pain is com-
plained of, a sensation of fullness or
pressure above the brow, and some
tenderness over the latter, being usu-
ally experienced. Swelling or bulg-
ing over the frontal sinus may also
occur. There is, in most cases, con-
. siderable discharge which may be
voided anteriorly or posteriorly, the
patient complaining that he is suffer-
ing from "nasal catarrh." Periodical
discharges of mucoserous or muco-
purulent fluid may afford considerable
relief.
Pent up, the discharge may cause
rupture of the sinus and pass into the
orbit, the nasal cavity, the dura
mater, causing meningitis ; or the
lymphatics may serve as carriers of
pathogenic bacteria or purulent ma-
terials to the meninges. Edema and
redness of the upper eyelid is usually
present. Fistulous openings may also
form anteriorly, i.e., through the an-
terior wall of the sinus, opening above
the inner canthus. The pain, when the
suppuration is confined in the latter,
is severe and constant, and often as-
sumes a neuralgic or boring charac-
ter. Or, persistent headache with
insomnia may occur. The frontal re-
gion becomes markedly bulged, and
in extreme cases one or both eyeballs
may be displaced, causing diplopia.
Even amaurosis has been caused
through persistent pressure upon the
eyeball. Systemic phenomena, sug-
gesting pyemia chills, sweats, fever,
etc., are often observed in severe
cases. Persistent pressure may so
reduce the thickness of the anterior
walls as to make it possible some-
times to obtain fluctuation and crack-
ling. Unless the pent-up discharge
be removed surgically, rupture may
occur and awaken the dangerous com-
plications recited above.
The presence of a frontal abscess
is not definitely shown by trans-
illumination. An X-ray photograph
affords a clear idea of the topography
of the sinus, the diseased side appear-
ing relatively dark. If the same area
also appears dark under transillumi-
nation, the diagnosis of local disease
is correspondingly strong. This is
further strengthened if, on examining
the nasal cavity, pus or polypi are
found beneath the middle turbinate
into which the infundibulum, the
elongated outlet of the frontal sinus,
opens.
TREATMENT. — An important
feature of acute frontal sinusitis is
that it is apt to develop in conjunc-
150
SINUSES, xNASAL ACCESSORY; DISEASES OF (SAJOUS).
tion with the acute rhinitis attending
various febrile disorders. In influ-
enza, for instance, the pain aljout the
brow is due to this cause. The local
process is simply that of occlusion of
the infundibulum, through swelling
of its mucosa. The escape of the
mucus to the nasal cavity being pre-
vented, distention of the sinus and
swelling of its mucosa follow, giving
rise to the painful sensation. The
aim should be, therefore, to free the
sinus by opening it. This may be
done with a spray of warm saline
solution directed upward under the
middle turbinal. A 2 per cent, solu-
tion of cocaine, containing 2 drams (8
c.c.) of the 1 : 1000 solution of adrena-
lin to the ounce (30 c.c.) is then
sprayed in the same region, the pa-
tient leaning fonvard while using the
spray in order to cause the fluid to
flow into the infundibulum. After a
few minutes, considerable relief will
be experienced, owing to contraction
of the tissues around the infundib-
ulum, and a flow of mucus will soon
follow. Repeated every two hours,
this procedure will prevent suffering,
unless polypi or hypertrophies pre-
vent access of the remedial fluid to
the frontal passage.
In a number of acute cases marked
relief was obtained — because of the
free rhinorrhea set up — from the in-
tranasal use of the following solu-
tion: Mercuric iodide, 1 Gm. (15
grains); potassium iodide, 4 Gm. (1
dram), and water, 100 c.c. (iVs
ounces). D. Macfarlan (Jour. Amer.
Med. Assoc, Jan. 3, 1914).
The patient should be kept at rest
and placed on a light diet, avoiding
stimulants, coffee, etc.. to keep the
blood-pressure within its normal
limits. Drugs, such as opium, bella-
donna, etc., which tend to cause dry-
ness of the mucous membranes,
should be avoided. Saline purgatives
should be used if ihc bowels are not
free. The biniodide of mercury in
^20-grain (0.003 Gm.) doses three
times daily shortens the purulent
process by enhancing the antitoxic
.'uid bactericidal properties of the
blood. Hexamethylenamine, 4 grains
(0.26 Gm. ) three times daily, has
been recommended.
The same local treatment some-
times proves useful in chronic cases,
when used four times daily, the
fourth time on retiring, giving also
the biniodide of mercury. If it fails,
the frontal sinus cannula should he
introduced into the sinus, and the
frontal sinus washed out daily with
saline solution, the patient being
taught to use the cannula and to
wash out the sinus also on retiring.
In most cases the cannula is easily
introduced by passing its curved tip
upward under the anterior end of the
middle turbinate. When this does
not suffice to insure proper drainage
and restore the sinus to its normal
condition, removal of anterior portion
of the middle turbinate with cutting
forceps is indicated. This provides
free access to the sinus for local treat-
ment by injection of 20 to 30 minims
(1.25 to 1.8 c.c.) of a 10 per cent,
solution of argyrol after careful wash-
ing with the warm saline solution.
When these less radical methods
prove insufficient for proper drainage,
opening of the sinus through its an-
terior or inferior wall becomes neces-
sary. When this is done, enough of
the wall must be removed to permit
a thorough examination of the cav-
ity and enlargement of the naso-
frontal duct to an extent sufficient
for free drainage into the nose. If
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
151
operation is delayed too long, the
continued pressure may cause rup-
ture through the floor into the orbit
or through the posterior wall of the
sinus into the brain-cavity, with con-
sequent purulent meningitis or brain
abscess.
The surgical treatment of frontp-
ethmoidal sinusitis has progressed
through many ch.nges. To cure
frontal sinusitis and prevent its re-
currence it is necessary to eradicate
the cavity. The ethmoid is approached
by the endonasal route so that when
the frontal sinus is opened all that
remains to be done is to enlarge the
nasofrontal canal at the level of the
infundibular region for free drainage.
The modification of the Ogsten-Luc
operation is less mutilating and fur-
nishes excellent drainage. A rather
large bony opening is made at the
level of the frontal boss in order that
the whole frontal cavity may be in-
spected and curetted completely. E.
J. Moure (Laryng., xxxi, 479, 1921).
Such operations should be per-
formed only by a highly trained
specialist, as otherwise they are
fraught with danger.
The indications for the external
operation of the frontal sinus may
be divided into absolute and relative.
Absolute indications are: (1) Where
the disease has made such progress
as to seriously threaten some neigh-
boring organ, and even life itself is
threatened, or there are actual cere-
bral and orbital complications. (2)
When the subjective symptoms are
severe enough to interfere with the
business pursuits of the patient. (3)
When severe exacerbations occur.
(4) In abscess or fistula formation.
Relative indications are: (1) When
the headache continues with no ap-
parent change in the amount or con-
sistency of the secretion. (2) When
despite frequent irrigations the pus
continues fetid, even though dimin-
ishing slightly in amount. (3) When
the X-ray shows a large sinus with
many ramifications and the disease
does not appear to yield satisfactorily
to internal treatments.
As to the type of operation, this
is often determined by the patholog-
ical change present or the anatom-
ical configuration of the sinus. Other
things being equal, the writer per-
forms his modification of the Jansen
operation, in which he can spare the
anterior wall, but obtain the requisite
space. This is done by resecting the
superior internal portion of the mar-
gin of the orbit and the floor of the
sinus, thus exposing the entire lower
portion or funnel of the frontal sinus.
After this has been done the usual
procedures are followed, i.e., removal
of diseased mucosa, the ethmoid cells,
and, if necessary, the sphenoid is
opened. The communication with
^the nose may be enlarged to any
desired size by merely removing the
orbital plate piecemeal with the bone
forceps. The wound is closed and
dressed in the usual manner. R. H.
Skillern (Laryngoscope, xxv, 212,
1915).
The writer believes that the exter-
nal (Killian) operation on the frontal
sinus has not fulfilled the brilliant
hopes that were raised at the time
of its introduction, and that the ear-
lier successes reported have been
discounted by instances of septic
osteomyelitis, an almost universally
fatal complication, even in the hands
of skillful operators. In many cases
very grave deformity has resulted,
and, in addition, the operation often
fails to give the relief sought.
Intranasal methods for obtaining
drainage and space for lavage by the
removal of the anterior end of the
middle turbinate have long been
practised and are of value, but are
often, also, insufficient to effect a
cure. To Ingals is due the credit of
introducing the method of following
up the frontonasal duct and entering
the sinus through the normal ostium.
All subsequent intranasal methods
are developments of the Ingals op-
eration. The author believes most of
these to be dangerous, and advances
152
SINUSES, XASAL ACCESSORY; DISEASES OF (SAJOUS).
his own operation as being compara-
tively safe. He begins lielow and an-
terior to the middle turbinate and
continues upward to the frontal
sinus, "without destroying any part
of the vertical plate of the ethmoid,"
a point he thinks of much impor-
tancCj since he says it does not in-
volve fracturing through the vertical
plate in close proximity to the crib-
riform plate and laying open venules
and lymphatics in this dangerous
area to infection. The writer's op-
eration may be done with cocaine,
but he much prefers general anesthe-
sia. His technique is simply to cut
through the most anterior attach-
ment of the middle turbinate with a
conchotome and continue biting up-
ward through the anterior cells to
the crista nasalis. In the same man-
ner the cells lying behind the duct
are then removed to any necessary
extent. Sounds are passed into the
sinus and all projecting edges re-
moved. Often this will suffice, but
if enough room has not been secured
by these measures, the nasal crest
may be rasped away, but it is much
preferable to use a guarded burr for
this purpose. The advantage claimed
for the burr is that the mucous mem-
brane of the posterior wall is left
intact and the bone only laid bare
anteriorly.
He advocates the use of from 30
to 50 c.c. of polyvalent antistrepto-
coccus serum immediately before the
operation, followed by the adminis-
tration of sensitized vaccines. Sounds
should also be passed at regular in-
tervals after the operation to insure
the permanency of the opening made.
Over one hundred frontal sinuses
have been treated in this way by the
author, who claims that many have
been cured and nearly all relieved.
In a few instances he was unable to
reach the sinus pernasally. P. Wat-
son-Williams (Surg., Gynec. and Ob-
stet., from Lancet, July 15, 1915).
As stated by Shurly some years
ago, the surgery of the frontal sinus
will become more conservative as
our knowledge grows. The relief
should come, not through surgery
alone, but from prophylaxis and the
successful abortion of the common
colds. An important feature of these
cases is tlie careful treatment of
chronic rhinitis in any of its forms
(see Nose, Diseases of, in the sev-
enth volume). A change to a semi-
tropical climate, such as that of
I'lorida or Southern California, pref-
erably near the seashore, sometimes
proves curative.
TUMORS OF THE FRONTAL
SINUS.
Mucocele. — Mucoceles are but re-
tention cysts formed by closure of
the infundibulum and the accumula-
tion of the exudate within the sinus.
This gives rise to a feeling of disten-
tion and neuralgic pain in the supra-
orbital region, which is itself exceed-
ingly sensitive to palpation. In some
instances there is formed a polyp-
like tumor of the swollen mucosa
which is visible under rhinoscopic
examination if a very small mirror be
used, and sufficient often to form a
myxoma-like tumor under the middle
turbinate. In others, the pressure is
also exerted anteriorly or laterally
and by eroding the orbital wall
causes displacement of the eyeball.
Case of an unusually large muco-
cele of the frontal and ethmoidal
cells. The patient, a woman 69 years
of age, was first examined November
25, 1914, for a supposed growth of
the left orbit. There were two lumps
the size of beans just below the
brow, which coalesced and formed a
marked prominence, displacing the
eye outward and downward. There
was no pain or evidence of inflam-
mation, nor any appreciable derange-
ment of vision. She gave a history
of having had nasal catarrh several
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
153
years before, but had not been trou-
bled since. Uncorrected vision was
5/7.5 in the right, 5/9 in the left. The
fields of vision were normal. The
proptosis of the left eye was about
1.5 cm. in advance of the right.
The periocular swelling eventually
reached the size of a hen's egg and
was systic to the touch. The rhino-
logical examination showed a large
cystic mass that had apparently de-
stroyed the orbital wall of the frontal
sinus. The left nasal fossa was free,
although the lateral wall seemed
more prominent than usual in the
agger nasi region. Transillumination
of the antrum was negative. The
X-ray report was that the supra-or-
bital ridge was completely absorbed
and the sinus enlarged upward on
the frontal bone.
An external operation was per-
formed with the incision through the
brow and the sac exposed, the walls
of which were found to be composed
of thickened periosteum, which was
filled with the frontal sinus contents.
The bone of the anterior wall and
floor of the sinus had entirely eroded
away, and the ethmoid cells were
exposed on the removal of this sac.
These were partially exenterated and
drainage established into the nose.
The posterior wall was also eroded
and the meninges were separated
from the sinus only by the perios-
teum. Healing was prompt and with-
out incident. In two weeks the
wound was closed and the excursions
of the eye were normal. Uncorrected
vision was now 5/7.5 in each eye. W.
C. Posey (Ophthal. Rec, xxiv, 116,
1915).
Cysts. — Cysts similar to those ob-
served in the maxillary sinus have
occasionally been observed in the
frontal sinus. They contain a green-
ish or brownish viscid fluid, some-
times v^^ax-like, which is voided with
difficulty when they rupture. A very
gradual swelling, accompanied by lit-
tle or no pain about the brow, is
about the only symptom noted, even
though the osseous walls of the cyst
are being thinned by pressure until
palpation and slight compression im-
parts a crackling, parchment-like sen-
sation to the finger.
Case of a cyst of the frontal sinus
in a man of 56. The tumar had been
growing fifteen years, the patient
having refused operation until it
measured 38 by 35 cm. An incision
released 1800 Gm. of a reddish
brownish fluid. The brain was found
much compressed, while the bone
had been worn away. The case is
remarkable from the absence of
brain symptoms and of pain or other
sensation except the discomfort from
the large tumor, although after its
removal there was room for the fist
between the skull and the brain.
Herzenberg (Deut. med. Woch., Nov.
4, 1909).
Osteoma. — Primary osteoma of the
frontal sinus is rarely encountered.
It grows very slowly, and finally pro-
duces considerable deformity of the
face. At first the growth is insidious,
but after a time neuralgia becomes a
leading symptom, with, perhaps, un-
due sensitiveness over the growth ;
however, even under pressure, the
latter conveys to the finger a sen-
sation of flinty hardness. Trans-
illumination shows darkness on the
affected side, but the growth is sel-
dom sufficiently circumscribed to en-
dow this diagnostic resource with
much value. An X-ray plate affords
aid only within the same limitation.
Case of osteomalacia in a married
woman, aged 35, who had been op-
erated on fifteen years previously.
The main orbital projection had been
removed, with marked relief to the
orbital symptoms. The patient con-
sulted the writer because of severe
pain, obstruction of the right nos-
tril, and gradual protrusion of the
right eyeball. The radiograph gave
most valuable information as to the
154
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
position and extent of the exostosis.
A curved incision was made from the
middle of the right ej^ebrow to the
right ala nasi. The expanded and
thinned covering of bone was clipped
off, and, the pedicle of the growth
attached to the posterosuperior wall
of the frontal sinus having been di-
vided, the whole growth was re-
moved with comparative ease by-
means of a strong pair of forceps.
The growth measured 2^ inches in
length and 1J4 inches in breadth.
The wound healed by first intention.
Jones (Brit. Med. Jour., Nov. 17,
1906).
In examining the frontal sinus, an-
trum and ethmoidal cells, the writer
takes first a lateral view of the face,
and, secondly, an anteroposterior pic-
ture with the tube behind the head
and the plate in front. Anteropos-
terior pictures of the head seldom
show as well in print as in the orig-
inal print or negative, which is best
examined by transmitted light in a
negative examining box. Tousey (N.
Y. Med. Jour., Mar. 28, 1908).
Malignant Tumors. — Although all
forms of malignant growths in this
location have been recorded, epithe-
lioma and sarcoma are those most fre-
quently observed. The symptoms
being practically those of chronic
sinusitis, empyema, and mucocele, an
early diagnosis is difficult. Even the
advanced signs, such as prominence
of the eyeball with diplopia, amauro-
sis and pain, are common to other
disorders. Suggestive; however, is a
more or less foul discharge from the
nose when it is streaked with blood
and detritus, and traced with pre-
cision to the infundibulum, or, in the
case of sarcoma, recurrent hemor-
rhages, traced to the same region.
Swollen glands behind the angle of
the jaw may suggest malignancy.
TREATMENT. — Mucoceles' and
cysts can sometimes be opened in the
nasal cavity and its contents evacu-
ated. This is facilitated by causing
constriction of the surrounding tis-
sues by means of a 4 per cent, solu-
tion of cocaine, followed by spraying
with saline solution. In most cases,
however, the contents are gelatinous
and cannot be evacuated without an
incision over the projecting wall, re-
secting a sufficient portion to allow
curetting and packing with iodoform
gauze.
Osteomata require enucleation;
malignant growths likewise, if seen
in time. Unfortunately, their prog-
ress is insidious and, as a rule, they
are not recognized early enough to
permit successful operative measures.
ETHMOID CELLS.
INFLAMMATORY DISOR-
DERS.— The ethmoid cells may he
the seat of acute and of chronic
inflammation.
Acute Inflammation; Acute Eth-
moiditis. — The proximity of the an-
terior ethmoidal cells to the frontal
?nd maxillary sinus exposes them to
involvement by contamination, while
the posterior cells are exposed to it
from the sphenoidal cells. Its con-
n.ection with the nasal cavity exposes
the ethmoidal sinus to the catarrhal
■disorders and to occlusion, nasal
growths, swellings, etc. Being itself,
besides, liable to inflammatory disor-
ders, this sinus is probably more fre-
quently diseased than is generally
supposed, and the underlying seat of
many stubborn cases of chronic
rhinitis.
The symptoms of acute ethmoiditis
are not always clearly defined. The
pain is usually referred to the orow
and behind the eyes, but sometimes
only persistent headache is com-
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
155
plained of. The discharge of the an-
terior cells follows the same course
as those of the antrum and frontal
sinus, its elimination, anteriorly or
posteriorly, if the nasal cavities are
free, depending upon whether the
head is bent forward or backward.
Hence the fact that the nasopharynx
often contains accumulated discharge
in the morning after a night in the
recumbent position. The acute form,
which occurs as a complication of ar
acute rhinitis or a temporary con-
tamination from a neighboring in-
flammatory process, disappears when
the latter ceases, unless imperfect
drainage prevents it.
Chronic Inflammation or Chronic
Ethmoiditis. — In this disorder the
inflammatory process initiated by a
similar process in the neighboring
sinuses or the nose persists. In one
form, the hyperplastic, the mucosa is
swollen and gives rise to a watery
discharge which is irritating to the
nose, the aire, and upper lip. There
is severe boring pain either in the
supraorbital region, suggesting neu-
ralgia, or at the root of the nose,
radiating toward the temples. There
may be a sensation of pressure in the
eyes, muscse volitantes, and also an-
osmia. The pharynx, larynx, Eustach-
ian tubes, and middle ear may be
involved in the inflammatory process.
Asthma is sometimes witnessed in
these cases. Acute exacerbations are
common, a feature which leads to
atrophy of the muciparous glands,
atrophy, and even sclerosis. The se-
cretion may then become scanty and
form a tenacious mass which dries
and forms foul-smelling crusts.
The second form, suppurative eth-
moiditis, dififers from the former, in
that the discharge is purulent instead
of merely watery. It may be caused
by many morbid condition^ : adjoin-
ing catarrhal disorders, imperfect
drainage, syphilis, tuberculosis, ery-
sipelas, influenza, and other infec-
tions, fractures, operative trauma-
tisms, etc. In most cases met with,
however, obstruction of the outlet of
the cells beneath the middle turbinate
is a prominent cause. This may be
due to the viscidity of the discharge,
or, as is often the case, to mechanical
obstruction in the middle turbinate
or of the septum, either through
osseous malformation or hypertro-
phy of their mucosa.
An important feature of this disor-
der is that, owing to the thinness of
the partition walls, these break down
easily and necrose, giving rise to a
foul discharge. In a large proportion
of cases there is merely a copious
purulent outflow, voided through the
nose or nasopharynx, the latter of
which it reaches from the superior or
middle meatus. The pus may be
sanious, contain bits of necrosed tis-
sues and other detritus, and give off
a more or less offensive odor. Pain
is rarely observed in the chronic
form, but a sensation of marked dry-
ness may cause considerable discom-
fort.
If retention of the pus in the cells
occurs through obstruction of their
lumina, serious symptoms may be de-
veloped, such as congestion, edema,
bulging of and pressure in eyeballs,
sometimes entailing diplopia and
even blindness in neglected cases.
Systemic disturbances, suggesting py-
emia, may occur. Mental disorders
and meningitis may also supervene if
the pus invades the cranial cavity — a
not uncommon complication, which
often proves rapidly fatal. Cerebral
156
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
abscess and thrombosis of the caver-
nous sinus, from infection of the
ethmoidal veins, may also occur.
Fortunately, the most usual result is
rupture, with formation of a fistula
leading externally to and opening be-
low the brow, over the inner angle of
the eye. The pus is thus eliminated
externally.
The diagnosis of acute inflamma-
tion of the ethmoidal cells should be
based upon careful examination of the
nasal cavities. The above-described
symptoms are all observed in inflam-
mation of other disorders. Sugges-
tive in this connection, however, is
redness of the lower edge of the mid-
dle turbinate and extending beneath it.
In the chronic form, a purulent dis-
charge may be observed in this loca-
tion coursing down along the external
wall of the nose, and backward over
the inclined surface of the inferior
turbinate.
Latent sinusitis of the ethmoidal
sinus may be the underlying cause
of certain reflex neuroses. A simple
operation on the sinus in such cases
frees the patient from his "neuras-
thenia," "Meniere's disease," "hay
fever," "nervous rhinorrhca" or other
similar complaints. Menkes (Nederl.
Tijdsch. V. Geneesk., Apr. 12, 1919).
Treatment. — Acute inflammation
of the ethmoidal cells is mainly per-
petuated by obstruction of their out-
let. The treatment recommended for
acute inflammation of the frontal
sinus in this section is also indicated
here. In chronic inflammation the
causative rhinitis, septal or turbinal
malformation interfering with the
drainage of the cells must be cor-
rected. The measures indicated un-
der Chronic Rhinitis (see page 72
in the seventh volume) will prove
very efficient. Local applications of
a 20 per cent, solution of argyrol,
after cleansing the nasal cavity, in-
cluding the middle meatus, with
warm saline solution is highly bene-
ficial. This weak solution of argyrol
may also be used with an atomizer
provided with an upward tip, which
may be passed under the middle tur-
binate. If a stronger solution (50
per cent.) is used, the applicator is
preferable. Ichthiol and strong solu-
tions of silver nitrate, which some-
times are necessary, should only be
used with the applicator. The possi-
bility of involvement of the neighbor-
ing sinuses should always be borne
in mind and adequate treatment car-
ried out if needed.
The antrum often acts as a reser-
voir for the pus originating in the
ethmoidal or frontal cells, and hence
efforts to cure an antrum abscess,
without first curing the ethmoidal or
frontal sinus abscess, prove futile,
while, converse!}', the curing of the
. latter will usually result in cure of
the antrum disease without any at-
tention being directed to the antrum
itself. Todd (Jour. Minn. State Med.
Assoc, and N. W. Lancet, Oct. 1,
1911).
When medication does not suffice,
owing to obstruction ofifered by the
middle turbinate to the drainage of
the cells, the anterior portion, or in
severe cases the whole turbinate,
should be removed. By placing the
diseased cells within reach of the
remedies, and insuring efficient drain-
age and ventilation, this procedure
often suffices. When this does not
suffice, the ethmoid cells must be
opened by means of Hajek's curved
hook, and enlarged with Griinwald's
forceps. Saline solution irrigations
mav then be used to wash out the
cells, and a 10 per cent, argyrol spray
to promote resolution, which often
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
157
occurs. If it does not, and necrosed
bone be found, Bryan's ethmoid cu-
rette should be used to remove it
while continuing the irrigations.
Considerable care is necessary in this
operative procedure to keep within
the limits of the cells, as penetration
of the cribriform plate above, or of
the external cellular walls, may en-
tail serious complications, and even
death.
The writer reports 2 fatal cases of
suppurative ethmoiditis in children,
and concludes that there is an in-
creasing conviction that acute sup-
purative ethmoiditis causing orbital
and cerebral symptoms is not so
rare a condition as has been thought,
and that it is often rapidly fatal,
especially in the young. The indi-
cations for operation in acute eth-
moiditis are sudden increase in tem-
perature, delirium at night, tumor
formation in the inner wall of the
orbit, the slightest exophthalmos.
Operation should not be delayed too
long. As in appendicitis, early op-
eration is a harmless procedure, late
operation generally useless.
When there is bilateral exophthal-
mos, operation is generally useless,
as the disease has probably extended
through the cavernous and circular
sinuses, causing a general toxemia
and pyemia, or fatal brain lesion.
Krauss (N. Y. Med. Jour., Apr. 24,
1909).
If it is the wish of the operator to
clean out all the ethmoidal cells, the
posterior half of the labyrinth is en-
tered by piercing the attachment of
the middle turbinate and by curetting
still farther backward, using all the
while the outer side of the middle
turbinate as a guide. If the head of
the patient is held level, the middle
turbinate guides the curette back-
ward into the posterior ethmoidal
cell. Often the posterior half of the
labyrinth is a large cavity, made up
of only one or two cells. This por-
tion of the labyrinth has been, as it
were, exenterated by nature. When
the curette brings up against the
back wall of the labyrinth the re-
maining part of the middle turbinate
and the lower half of the superior
turbinate are removed. Then the
posterior part of the superior turbi-
nate is taken away, flush with the
front face of the sphenoidal sinus.
The operator now recognizes the
inner part of the front face of the
sphenoidal sinus, which is free in the
nasal cavity, and the outer part which
has a common wall with the pos-
terior ethmoidal cell. The posterior
outer upper angle of the posterior
ethmoidal cell is dangerous to cu-
rette or to probe. It is of the utmost
importance that the operator should
be sure of his landmarks in this lo-
cality. He orientates himself by find-
ing the upper rim of the choana and
then differentiating the free face of
the sphenoidal sinus by proceeding
upward from the rim of the choana
close to the septum. Having made
out the extent of the free face of the
sinus, the width of the common wall
between the sphenoidal sinus and the
posterior ethmoidal cell is deter-
mined. The dividing line between
the two parts of the anterior face
of the sphenoidal sinus is made by
the obliquely vertical line, which is
the attachment of the superior tur-
binate.
The usual mistake made by the
operator is to get lost in the pos-
terior ethmoidal cell — that is, he goes
too high and too far outward, and
considers the posterior wall of the
posterior ethmoidal cell as the whole
of the front face of the sphenoidal
sinus. This mistake, if persisted in,
will carry him into the brain. In-
sufficient removal of the posterior
part of the superior turbinate and
allowing the head to become tipped
upward, are the chief causes of this
confusion. After the landmarks of
the front face 'of the sphenoidal sinus
have been cleared and recognized, the
sinus is entered near the septum — if
possilile, through the ostium — and
the whole of the anterior wall re-
158
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
moved. II. P. Mosher (Laryngo-
scope, Sept., 1913).
Non-operative treatment of infected
sinuses, a suction apparatus being
substituted, advised. The author has
obtained entirely satisfactory results
and has discarded oi)erative work, ex-
cept on the antrum. Illustrative re-
ports of successfully treated cases in-
clude instances of severe acute fron-
tal sinusitis; acute suppurative of the
anterior ethmoid cells with orbital
abscess; acute suppuration of the
right frontal sinus; chronic suppura-
tion of the frontal sinus, anterior
ethmoid cells, and antrum; chronic
suppuration of the left frontal sinus,
and chronic suppuration of the pos-
terior ethmoids and sphenoids. E. B.
Gleason (Laryngoscope, 18, 1, 1918).
TUMORS OF THE ETHMOIDAL
CELLS.
Benign Tumors. — Mucocele of the
ethmoidal, irrespective of involve-
ment of the other sinuses, is occa-
sionally met with. It may occur as
a result of chronic ethmoiditis, espe-
cially when the ostium is occluded, or
of blocking of some of the glandular
acini. The tumor may fill the cell
in which it is formed, break down
the thin walls between the cells, or
project out of the ostium and appear
under the middle turbinate. Myxoma,
osteoma, fibroma, and other benign
growths may also occur in this loca-
tion. All the growths develop in-
sidiously, and cause no pain, until, in
some instances, nerves are com-
pressed, extended, or affected reflexly,
or the neoplasm encroaches seri-
ously upon neighboring structures
and deforms them. In some cases
other sinuses are penetrated by the
growth which erodes the walls,
separating them.
Case of a lady who had been an-
noyed for several months by a very
profuse serous discharge from the
right nostril when she stooped. This
discharge was found to escape from
a small opening in the top of carious
bone in tlic wall of the bulla eth-
moidalis. The dividing walls of the
ethmoid cells had all been destroyed,
making one cavity of the lateral mass
of the ethmoid bone. This cavity
was hned by a thin, white, glistening
membrane, the typical cyst lining in
appearnce. This membrane was cu-
retted lightly, the cavity was packed
for twenty-four hours to control
hemorrhage, and then removed. A
month later it was reported that the
only change was that the discharge
was now continuous, whereas for-
merly it had taken place only upon
stooping. Inspection of the nose
showed a free opening into the cyst
with fully two-thirds of the cavity
covered with normal membrane. Six
weeks later the patient reported en-
tirely well. Thompson (Laryngo-
scope, Mar., 1911).
Malignant Tumors. — Sarcoma and
epithelioma of the ethmoidal cells is
occasionally observed as a primary
process. In epithelioma the growth
may be very insidious and be discov-
ered only when stifficiently advanced
to cause nasal obstruction, when ex-
amination reveals its presence. A
fetid discharge streaked with blood
and detritus and enlargement of the
glands behind the maxillary bone are
suggestive. Sarcoma usually pro-
gresses more rapidly, and is apt to be
attended with free and, sometimes,
dangerous hemorrhages.
TREATMENT.— Surgical removal
is alone of value. Malignant growths
have often progressed sufficiently to
involve many surrounding structures
when first seen — a fact which greatly
compromises the chances of recovery.
Case in a man, aged 55 years, who
was unable to breathe through the
right nasal passage, but without any
other symptom of distress. The pas-
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
159
sage was found filled with cauliflower
excrescences which bled at the slight-
est contact with the probe. Poste-
rior rhinoscopy revealed pretty much
the same aspect, and digital explora-
tion detected a soft vegetative mass
covering the rhinopharynx, the right
choana, and reaching from the roof
to the soft palate, barely passing the
middle line, and consequently leav-
ing a free space upon the right side.
On diaphanoscopy, the frontal maxil-
lary sinuses became illuminated nor-
mally. The mass was removed by
external access with a good deal
of hemorrhage, necessitating several
tamponings. The middle and the su-
perior turbinates were destroyed, the
anterior ethmoidal cells resected to
the cribriform plate of the ethmoid,
and the septum was resected in its
posterior portion. Every suspicious
surface was thoroughly curetted, and
hemorrhage arrested by tamponing
the nasal fossse with iodoform gauze,
and the skin wound united with su-
tures. Recovery was good. Fifteen
months later the patient still breathed
freely, and his nasal fossa did not
exhibit any trace of the growth.
Audibert (Revue Hebd. de Laryn.,
d'Otol. et de Rhin., Feb. 24, 1912).
SPHENOIDAL SINUS.
INFLAMMATORY DISOR-
DERS.— The sphenoidal cells may be
the seat of acute and of chronic
inflammation.
Acute Inflammation. — Acute in-
flammation of the sphenoidal sinus
may occur as an extension of a
similar process in the neighboring
sinus, or the nasal and nasopharyn-
geal cavities. It is identified with
difficulty; the symptoms — a dull,
deep-seated headache, referred by
some patients to the occipital region,
and by others to "somewhere behind
the eyes" — constitute about all the
subjective symptoms which suggest
this disorder. Inspissated mucus, ac-
cumulated in the postnasal space, to
the exclusion of the anterior nasal
cavities, and voided, as a rule, is an-
other suggestive fact. In some cases
these symptoms persist and consti-
tute a mild "postnasal catarrh." In
others, they disappear spontaneously.
Chronic inflammation or empyema
of the sphenoidal sinus may be due to
infection by neighboring purulent
process in the other sinuses or nasal
cavities, or syphilis, tuberculosis, or
fractures of the base involving the
sphenoid. Besides the symptoms ob-
served in the acute form, neuralgia
throughout the distribution of the
fifth pair may be experienced, tinni-
tus and vertigo likewise. The dis-
charge, instead of mucoid, is now
mucopurulent and fetid, and tends to
accumulate about the posterior end
of the middle turbinate, and to pass
down into the nasopharynx. When
swallowed, especially if other sinuses
are afifected, which is often the case,
gastric disturbances and nausea may
be caused.
When obstruction of the sphenoidal
orifice occurs, the symptoms in-
crease greatly in severity, severe
pain, insomnia, a febrile reaction oc-
curring promptly. Extension of the
inflammatory process to the brain is
sometimes observed. As the disten-
tion increases, ocular phenomena ap-
pear, which may include congestion
of the conjunctiva, swelling of the
lids, and even amaurosis, owing to
compression of the optic nerve. The
swelling may block the posterior
choane and cause violent aural symp-
toms. Rupture may occur into the
ethmoidal cells, the orbit, or the
skull, and cause, in the latter case,
rapidly fatal meningitis.
The diagnosis of sphenoidal em-
160
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
pyema is based mainly upon the
simultaneous presence of a persistent
discharge into the posterior nares,
traced above the vault area, and pain
in the back of the head, after exclud-
ing tlie other sinuses.
The writer has devised an instru-
ment which can be introduced into
the pharynx by way of the mouth
and which carries a miniature plate,
so that this can be brought into con-
tact with the wall of the sphenoid.
By X-ray illumination through the
frontal region of the cranium from
above, an accurate picture can be ob-
tained of the sphenoidal sinuses. The
method is simple and yields valuable
information regarding this region
hitherto so difficult to photograph.
Bela Freystadtl (Berl. khn. Woch.,
July 13, 1914).
TREATMENT. — The treatment
of intiammatory disorders is, in the
main, similar to that of other sinuses
reviewed. After applying a 10 per
cent, solution of cocaine to the space
between the middle turbinate and the
septum, which will contract not only
the tissues of these structures, but
also those around the sphenoidal open-
ing, a sphenoidal cannula is passed
into the latter, and the cavity washed
out with saline solution. Irrigation
cannot be done sometimes without
creating an opening in the most de-
pendent portion of the sinus by
means of a gouge passed along the
surface of the middle turbinate,
p)ointing the instrument upward and
backward, under posterior rhinoscopy.
Too big an opening by allowing the
escape of a large quantity of pus to
escape may cause syncope, hence a
small opening is preferable at first.
The curette is sometimes necessary,
followed by saline solution irriga-
tions and the local application of a
10 per cent, solution of argyrol.
Although it is not necessary to
have the ostium in view in passing
a sound, to the author's mind it is
absolutely demanded when operative
measures are about to be undertaken;
the anatomic relations of the superior
wall to the optic nerve and the pitui-
tary body and the lateral walls to
the sinus cavernosus and carotid ar-
tery, to say nothing of the brain it-
self, makes this region of operating
one of extreme danger, unless the
operator has perfect vision of the
entire field. The lateral wall of the
nose, as well as the septum, is co-
cainized with a 20 per cent, solution,
the posterior half of the middle
turbinate is removed, the posterior
ethmoid cells are broken through
with Hajek's ethmoid hook, and the
debris removed with a Griinwald-
Hartmann conchotome or a similar
instrument. The evulsor is then in-
serted in the ostium and the opening
enlarged by a few well-directed pulls;
this is followed by the use of the
bent forceps of Hajek and enough
bone is removed as to insure a per-
manent opening, which should reach
as far as the floor of the nose. Com-
plete healing usually takes place in
from three to eight weeks, depend-
ing on the degree of inflammation
and the extent of the operative inter-
ference. The advantages of this op-
eration is that a full field is always
in sight; the preliminary opening of
the sphenoid from within outward
thereby incurs no danger to the
structures behind; and there is a
permanent opening which lessens the
danger of recurrence. Ross H. Skil-
lern (Jour. Amer. Med. Assoc, Dec.
19, 1908).
The writer anesthetizes the nose
with cocaine and epinephrin, and
punctures the anterior wall of the
sinus at its lower and internal por-
tion. In the absence of any obstruc-
tive deformity of the upper part of
the septum nasi this can be readily
accomplished in the vast majority of
cases, and no removal of nasal tissue
is necessary. This opening has the
SKIN-GRAFTING (FREEMAN).
161
further advantage of being in the
best position for drainage of the cav-
ity. The operation is free alike from
pain, hemorrhage, and danger. If the
cavity is normal the wound will have
closed in twenty-four hours. If the
sinus is infected the operation affords
the best possible opportunity for
making an early and accurate diag-
nosis and for the employment of
suitable measures for local treatment,
particularly lavage and drainage. C.
P. Grayson (Penna. Med. Jour., Apr.,
1913).
TUMORS OF THE SPHENOIDAL
SINUS.
Benign Tumors. — Myxomata and
osteomata, occasionally found in this
sinus, are harmful mainly because
they tend early to produce obstruc-
tion, and, therefore, bring- on em-
pyema. As the tumor grows it brings
on pressure symptoms, blindness or
optic neuritis, when the optic nerve
is compressed; exophthalmos of the
eyeball, etc.
Malignant Growths.— These pro-
duce phenomena similar to those just
described when they have progressed
sufficiently to do so. A purulent san-
guinolent discharge in the vault,
traced upward to the sphenoidal
opening, is about the only early sign
availal)le.
TREATMENT.— The location of
the sphenoid renders operative re-
moval impracticable, especially in
view of the fact that the cases are
usually far advanced when they
reach the specialist.
C. E. DE M. Sajous,
Philadelphia.
SKIN-GRAFTING. -When skin
grafts are obtained from the patient
himself, they are called autografts;
when from another person, homo-
grafts; and when from animals, coo-
gra'ffs. The best results are derived
from autografts. Homografts grow
better than zoografts, but it must not
be forgotten that they may cause dis-
ease, especially syphilis, and that they
may break down and disappear upon
slight provocation.
Reverdin's Method.— With fresh
wounds or healthy granulating sur-
faces little preparation is necessary.
Freedom from suppuration would, of
course, be desirable, but it is seldom
attainable. When the granulations
are not in good condition an effort
should be made to render them firm,
red and healthy by pressure, by re-
peated cauterization with stick nitrate
of silver, or by painting them occa-
sionally with tincture of iodine. Leg
ulcers may often be much improved
by elevation of the extremity. Cal-
lous ulcers should have radiating in-
cisions made in their borders. Foul
ulcers must receive preliminary anti-
septic treatment, and all sloughs •
should be cleared away before graft-
ing is attempted.
The grafts, which are best obtained
from the arm or thigh, should be
about the size of a grain of wheat.
They are cut by elevating a portion
of skin with mouse-toothed forceps
and dividing it with scissors curved
on the flat, removing the entire epi-
thelium and a portion of the corium
without disturln'ng the subcutaneous
fat. The bits of cuticle adhere to the
surface to be grafted, especially if
gentle i)ressure with a pledget of
gauze be employed. Nothing is
gained by scraping or m any way
wounding the granulations. The
transplantations should be close to-
gether, as the greatest size to which
a graft can grow is perhaps that of
a silver dime. Excellent grafts can
11
162
SKIN-GRAFTING (FREEMAN).
be cut with sharp-pointed scissors
from the delicate pellicle of new skin
which pushes out from the borders
of a healing ulcer (Souchon). Imme-
diately over the grafts may be placed
strips of rubber protective, or a single
layer of gauze, which may be pinned
around a limb or fastened at the
edges with collodion. Whether the
external dressing is moist or dry is
usuall}^ of little importance, but no
antiseptic stronger than boric acid
should be used. As there is gener-
ally some suppuration, it is necessary
to change the superficial portion of
the dressing every twenty-four hours
at least, leaving in place the rubber
tissue, or the undermost layer of
gauze, as the case may be. Gentle
irrigation with a solution of salt or
boric acid assists in maintaining
cleanliness. The open method of
dressing has recently come into use,
and may often be employed to ad-
vantage. In this the grafts are left
entirely uncovered, being protected
from injury by placing over them a
"cage" made of wire gauze (a kitchen
"strainer" for instance). The edges
of the gauze are bound with adhesive
plaster, a few strips of which may be
utilized to hold the cage in position.
Thiersch's Method. — There is no
process of skin-grafting so simple, so
reliable, and so generally applicable
as this. It is of great value in the
treatment of ulcers, burns, and de-
fects following operations or injuries.
The patient is anesthetized, and if
granulations are present, it is best to
scrape them away with a sharp spoon
down to the comparatively firm tissue
beneath, although this is not abso-
lutely necessary. Oozing is checked
by elevation and pressure, an Es-
march strap being unnecessary. The
grafts are cut with a razor from the
anterior surface of the thigh or upper
arm. An assistant makes the skin
tense by means of a hand on either
side of the limb, while the operator,
standing with his back toward the
patient's feet, cuts toward himself,
with his left hand stretching the tis-
sues in the direction of the knee.
With a backward and forward saw-
ing motion it is not difficult to obtain
shavings of epidermis an inch or
more wide and several inches in
length, and as thin as paper: No
objectionable scar results. The deli-
cate strips of cuticle fold up on the
blade of the razor, from which they
may be spread directly upon the sur-
face to be grafted, and so adjusted
that they overlap each other and the
edges of the skin, completely con-
cealing the raw surface. Healing
without suppuration is not uncom-
mon. Over the transplanted cuticle
are placed strips of rubber tissue, a
single layer of gauze, or simply a
wire cage as described in the Rever-
din method. Davis uses a coarse-
meshed net, such as is used for cur-
tains, for "splinting" the grafts in
position. The stiffening is washed
out and the net is soaked in gutta-
percha 30 parts, chloroform 150 parts,
and is sterilized by keeping in a
1 : 1000 solution of mercury bichloride.
If a moist dressing is employed, it
should consist of a thick pad of gauze
saturated with normal salt solution
and covered with cotton and oiled
silk. This should be renewed often
enough to keep it moist. A dry
dressing answers equally well, ap-
plied as in the treatment of ordinary
wounds. The grafts do not become
firmly fixed for nine or ten days, and
it is well not to soak off the under-
SKIN-GRAFTING (FREEMAN). 163
most layer of gauze for about two is unfavorable for their existence. In
weeks. five to seven days the granulations
The Wolfe-Krause Method, — In are cut from above and the grafts
this method grafts are employed exposed.
which fill the entire defect, and which In caterpillar grafting, which really
comprise the whole thickness of skin belongs to plastic surgery rather than
without the subcutaneous tissues, to skin-grafting, a long, narrow, full-
The fat may also be included if de- thickness flap (about 1 inch by 5
sired, although the chance of success inches) is dissected up from the ad-
is less (Hirschberg). In cutting the jacent integument with its base close
skin at least one-third must be al- to the area to be grafted. The distal
lowed for shrinkage. Sutures are extremity is then stitched close to the
usually unnecessary and artificial heat base, thus humping the flap up in its
is detrimental. center, much as a caterpillar crawls.
Wolfe's original method has been After union of the tip has taken place
modified and the technique improved in this position, the base is loosened
by Krause, who employs spindle- and the flap straightened out upon
shaped grafts, so that the wound the granulating surface. The oc-
produced by their removal may be casions are not numerous, however,
sutured immediately. The pieces of in which this "crawling" procedure
skin, cut into smaller pieces, if desir- is preferable to free grafting,
able, are accurately fitted into the Subcutaneous Skin-grafting. — Un-
defect which is to be closed. The der ordinary circumstances skin-
operation must be a "dry" one, and grafts cannot be used beneath the
the raw surfaces of the skin should surface of the body owing to the
be handled as little as possible. danger of infection. Rehn has dem-
Skin-periosteum-bone grafts are onstrated, however, that this can be
sometimes employed. They are cut done with more or less success by
out bodily, from the tibial region, for shaving off the superficial portion of
instance, without disturbing the con- the transplant, thus mechanically re-
nections of the component parts to moving the bacteria. Grafts of this
each other. character have been employed as a
Two curious methods of skin-graft- substitute for lost tendons, to close
ing introduced by MacLennan should the pylorus, etc., but it would seem
be mentioned, although they are sel- that less complicated methods are
dom employed. They are known as preferable, such as the use of fascia
"tunnel grafting" and "caterpillar lata,
grafting." Anomalies in Grafting. — Trans-
In tunnel grafting small grafts are plantation of the mucous membrane
slipped beneath the granulations into may be made. It may be shaved off
little "tunnels" made for the purpose, as in skin-grafting, — for instance,
where they are surrounded by ])l()od- from the lips, — or it may be stripped
clot and protected from external in- off in its entirety.
jury, which is supposed to facilitate More or less satisfactory results
their growth under certain conditions, can be obtained by the use of shav-
especially where the granular surface ings of callus from the palms of the
164 SKIN-GRAFTING (FREEMAN).
hands or soles of the feet, or from comes in time movable, but that pro-
sections of corns. "Epithelial rods" duced from Reverdin grafts remains
from warts have been successfully immovable, owing- to cicatricial tissue
used, as have also flakes of old, dried between the individual bits of cuticle.
epidermis from various parts of the Hairs may remain where transplanta-
body; even "epithelial dust" scraped tions of the entire thickness of the
from the surface of the skin will skin are made, but they are apt to
often grow on a granulating wound, become deformed or fall out. But
Deeper scrapings, drawing sufficient little postoperative contraction takes
blood to form a paste which may be place in the Thiersch and Wolfe-
spread upon a raw surface, are said Krause methods, but in the method
to be quite satisfactory at times of Reverdin contraction is apt to be
(Mangoldt). considerable. Exfoliation of epider-
Grafting from dead bodies or from mis may occur in any form of graft-
amputated limbs has frequently been ing, but this does not necessarily
resorted to, but the chance of success mean that the grafts are dead. A
is not great, and the danger of carry- remarkable phenomenon in connec-
ing disease cannot be disregarded. tion with Thiersch grafting is the
Sponge-grafting is now seldom em- readiness with which depressions fill
ployed. Very thin slices of sponge up to a level with the surrounding
are sterilized by boiling, and placed skin.
upon the raw surface. The material In plastic work about the face it
acts as a framework only for the should always be borne in mind that
granulations, and is soon absorbed. flaps of skin from the vicinity, for
The idea of grafting from animals instance from the neck, are preferable
is attractive, but the results are too to free grafts, especially the thinner
uncertain, and the method has largely ones, because their color and con-
fallen into disuse. Skin has been sistency will conform more nearly to
obtained from frogs (abdomen), that of their surroundings, thus ren-
chickens (beneath the wings), pigs, dering them far less conspicuous,
dogs, cats, rabbits, guinea-pigs. etc. COMPARISON OF METHODS.
Cocks' wattles, sections of the testi- — The simplest is that of Reverdin,
cles of rabbits, amniotic membrane, although the new skin is often little
and the lining membrane of eggs better than scar-tissue. It should be
have also been employed. reserved for cases where the rapid
HISTOLOGY AND PATHOL- closure of a granulating surface is
OGY. — The existence of epithelial desired without reference to anything
grafts may be said to be, for a time, else. Thiersch grafting has a wider
parasitic. In the course of about range of applicability than anv other
eighteen hours vascular connections method, and its results are uniformly
begin to form, firm adherence taking good, both functionally and cosmetic-
place by the tenth day. Successful ally ; but it must give way to the
grafts soon become pinkish in color. Wolfe-Krause process when thicker
New skin arising from large grafts, skin is desired, which more closely
which cover the entire raw surface resembles the surrounding integu-
(Thiersch and Wolfe grafts), be- ment. It may sometimes be expedi-
SKIN, SURGICAL DISEASES OF.
165
ent to graft from dead bodies or from
amputated limbs; and occasionally
use may be found for "epidermal
scrapings," or for epidermis obtained
from warts, corns, callosities, blisters,
etc., but one must not expect the
results to be brilliant.
The skin of animals does not com-
pare in vitality with that taken from
a patient's own body, or even from
some other person. It is seldom
necessary to transplant from mucous
membrane, as ordinary Thiersch
grafting answers the same purpose in
nearly all cases.
Leonard Freeman,
Denver.
SKIN, SURGICAL DISEASES
OF.— SEBACEOUS CYSTS, or WENS.
— A wen (steatoma) is a cystic tumor
varying in size from a millet-seed to an
orange, formed by the retention of secre-
tion in a sebaceous gland, and situated
in the skin or subcutaneous structures.
Wens occur most frequently on the scalp,
face, back, and scrotum, and may be
single or multiple. The contents of these
tumors are milky or cheesy in character,
but if the tumor be injured, inflammation
and ulceration may follow, or in the aged
the tumor may acquire a malignant char-
acter, degenerating into epithelioma.
Treatment. — A cure will be effected by
making an incision in the skin down to
the cyst and carefully dissecting it out.
Incision and mere evacuation of the con-
tents are always followed by a return of
the tumor.
FURUNCLE. — Furuncle (furunculus ;
boil) is a local inflammatory affection of
the skin, commonly involving a cutane-
ous gland or hair-follicle. They may oc
single or multiple, and may appear in
"crops."
The diagnosis of the affection is usu-
ally quite easy. It may sometimes be
confounded with carbuncle. General ap-
pearance, single opening, and circum-
scribed character usually distinguish the
boil.
Etiology. — Improper diet and hygiene,
nervous depression, overwork, too free
indulgence in greasy foods and gravies,
and irregular action of the bowels, local
irritation, friction, and prolonged poultic-
ing predispose to this affection. The en-
trance of pus-cocci into the skin is the
essential or exciting cause of this dis-
order. Single boils are usually the result
of local irritation; their appearance in
successive crops (furunculosis) is usually
an indication of impaired health.
Treatment. — Removal of the cause and
regulation of the diet claim first attention.
Open-air exercise and tonics are useful in
debilitated sul)jects. Strong ammonia,
caustic potash, acid mercury nitrate, and
other forms of caustic have been used to
abort in the early stage. Yeast, nuclein,
quinine, and mineral acids have been
given to prevent recurrence. Arsenic,
with or without iron, is sometimes bene-
ficial. Sodium sulphite or thiosulphate
(IS to 30 grains — 1 to 2 Gm.— every three
hours), calx sulphurata (% grain — 0.008
Gm. — every two or three hours), or sul-
phur may be given internally. A solution
of boric acid or of sublimate, a 10 per
cent, salicylic acid ointment, or a mix-
ture of equal parts of ichthyol and col-
lodion may be applied locally. White has
used full doses of mercury bichloride in-
ternallj' to prevent recurrence.
Hypodermic antiseptic injections into
the very base of a boil or carbuncle, early
in its history, are practically an unfailing
means for aborting an attack.
Heat is directly injurious to the mi-
crobes of furunculosis; active hyperemia
is induced, and the skin sterilized; the
profuse sweating induced prevents rapid
increase of temperature in the deeper
tissues. The hot air is first applied
around the circumference of the affected
part, and then to the boil itself. Two or
three applications are given on the first
day, and one daily afterward. Temper-
ature of air, 250° F. (120° C.).
CARBUNCLE.— Definition.— Carbuncle
(carbunculus; it is erroneously called
benignant anthrax, or anthrax") is a hard,
circumscribed, deep-seated, painful inflam-
mation of the subcutaneous tissue, ac-
companied by chill, fever, and constitu-
tional disturbance, and attended almost
166
SKIN, SURGICAL DISEASES OF.
always with circumscribed suppuration
and the formation of a slough.
Symptoms. — The local symptoms are
heat and aching, with throbbing and great
tenderness, which are often followed by
pain and redness along the lymphatics of
the part and pain and swelling in the
nearest lymphatic glands. There is at
first a chill, followed by a febrile move-
ment, which is generally well marked,
and often very severe. The constitu-
tional symptoms resemble those of ery-
sipelas very closelj^ and may be as se-
vere as those of the severest forms of
that disease, and the consequences may
be fully as grave and fatal.
Diagnosis, — The size of the inflamed
area, flatness- of surface, multiple open-
ings or points of suppuration and exten-
sive slough differentiate carbuncle from
furuncle. Carbuncle is single, furuncle
generally multiple.
Etiology. — A lowered vitality from any
cause predisposes to this affection. It is
especially common in diabetes. Microbic
infection is the exciting cause.
Prognosis. — Carbuncle is especially dan-
gerous when located on the scalp, abdo-
men, and upper lip; in these locations it
is apt to occur in young people, and
usually runs an acute course and, as a rule,
is fatal from pj-emia. The prognosis is
grave when extensive and attacking the
elderly, especially if complicated with
Bright's disease or diabetes. The prog-
nosis should always be guarded, even in
the most hopeful cases. Death is not in-
frequent in the old and debilitated.
Treatment. — General tonics, like quinine
and iron, with large amounts of nourish-
ing food, are indicated. Opium or other
anodynes may be required to relieve pain
and procure rest. Stimulants should be
given only when required.
Reynolds advises dilute sulphuric acid
in 20- to 30- minim (1.3 to 2 c.c.) doses in
2 ounces (60 c.c.) of water every four
hours (small doses are useless), with 5
per cent, carbolized petrolatum locally.
In the early stage 10 to 20 minims
(0.6 to 1.3 c.c.) of a 5 or 10 per cent,
solution of phenol in glycerin may be in-
jected into the central portion of the mass
with the view of aborting the mischief.
If seen later, firm compression by straps
hi adhesive plaster applied concentrically
may be made, leaving the central orifice
free for the discharge of sloughs and ap-
plying an antiseptic dressing over the
straps.
Another plan, applicable in the early
or late stage as well: Place patient un-
der an anesthetic; freeze the parts to
make them friable; make one long in-
cision or several crucial incisions through
the mass; remove all sloughs and decay-
ing tissue with a sharp curette; disinfect,
drain, and suture, as in an incised wound.
Another method of treatment is the
application of warm, moist, antiseptic
dressings, covered with thin rubber cloth
or oiled silk, removing sloughs as soon
as loosened, and using iodoform, aristol,
europhen, or similar antiseptic powder
freely. The use of poultices is harmful
and should be avoided.
The use of autogenous vaccine, once a
week in dose of 100 to 200 million dead
cocci was effectual. Bier's passive hyper-
emia by means of band around lower part
of the neck was used with success in
carbuncles of the face and high up on
neck. Mild constriction was sufficient for
twenty to twenty-two hours daily unless
edema appeared.
Ichthyol is practically a specific in the
treatment of carbuncles, applied pure, so
as to cover the entire swelling, except the
apex. The apex on which the ichthyol
is absent is covered with a piece of cloth
greased with tallow. The application is
renewed once a day. After three appli-
cations the surface should be washed
thoroughly so as to remove the varnish-
like coating which the ichthyol forms on
drj'ing, and a new application is to be
made.
Personal experience in the local treat-
ment of carbuncle with liquid air has
shown A. Campbell White that this is by
far the best form of treatment. It is less
painful to the patient than any other form
of treatment. Only one application is
necessary. In the treatment by liquid
air the spray is used, first projecting it
into the openings and using the air quite
freely; then quite thoroughly freezing the
external surface, which must be well
cleansed of discharge resulting from
sending air inside the carbuncle before
SKIN, SURGICAL DISEASES OF.
167
freezing. After freezing the carbuncle
should be dressed with a dry absorbent
dressing. The reaction from freezing
takes place in about twenty minutes, and
it is to this extreme hyperemia that the
success of liquid air in the treat-
ment of this affection is attributed
more particularly.
KERATOSIS SENILIS.— This affec-
tion is a cornification of the skin of old
people, general or partial, circumscribed
or diffuse, and often limited to the face
and the dorsal surfaces of the hands and
feet, or sometimes the forearm and chest.
The lesions consist of light- or dark-
yellow, brownish points, dry scaling and
horny, or scaling and greasy, aggregated
masses of an irregular circular or oval
outline. The surface of these masses is
insensitive, and may project about an
eighth of an inch above the surface.
These masses may be readily picked off,
leaving a small, superficial, smooth, ex-
coriated surface or one covered with
minute conical elevations (enlarged se-
baceous glands). This affection rarely
appears before the fiftieth year, and may
not claim attention until fifteen or
twenty years later.
Prognosis. — The prognosis is favorable
if the proper treatment is promptly ap-
plied. When left alone the pigmented
masses are prone to epitheliomatous de-
generation, and may become foci for
carcinoma of the face, in which case the
dry scales are displaced by a scab, the
tissues become hard, and growth is more
rapid.
Treatment. — In the early stage, in-
unctions with petrolatum or olive oil
and the subsequent use of soap and warm
water will remove the trouble. When the
masses are firmer, ointments should be
applied at night, and soft soap or sapo
viridis in the morning, removing the
soap by carefully washing with clean,
warm water; applications of diachylon
ointment will heal any excoriations that
may have been produced. When marked
projection of the mass is present, the
thorough use of the curette, or nitric
acid on a pointed stick, well worked into
the parts, will remove the affected tis-
sues. If epitheliomatous change is sus-
pected, prompt excision is indicated.
CLAVUS (CORN).— Clavus is an hy-
perplasia of the corneous or horny layer
of the epidermis, in which there is an in-
growth as well as an outgrowth of horny
substance, forming circumscribed epi-
dermal thickenings, chiefly about the toes.
Corns may be hard or soft, the latter be-
ing situated between the toes, where they
become softened by maceration. Both
forms are caused by intermittent pressure
and friction. Pressure produces pain by
driving the conical mass of hardened epi-
thelium down upon the sensitive coriuni;
constant irritation may produce inflam-
mation and suppuration.
Treatment.— The use of well-fitting,
comfortable shoes made on properly
shaped lasts is the first indication. Tem-
porary relief from hard corns may be
obtained by the use of felt rings which
are applied over the corns, allowing the
latter to project through the opening.
Prolonged soaking in a warm solution of
sodium carbonate will soften the corn,
when it may be removed by gentle scrap-
ing with a sharp knife; the tender sur-
face left may be protected by covering it
with a plaster-of salicylic acid or of sali-
cylic acid with cannabis indica. Another
method is that of hardening the surface
of the corn by applications of the tinc-
ture of iodine or silver nitrate at night,
removing the hardened tissue on the fol-
lowing morning. A third method is the
use of the salicylic-collodion mixture:
Salicylic acid, 30 grains (2 Gni.); tincture
of iodine, 10 minims (0.6 c.c); extract of
cannabis indica, 10 grains (0.6 Gm.); col-
lodion, 4 drams (15 c.c); this to be
painted on the corn night and morning
for several days and then removed with
the corn, by soaking in hot water. Soft
corns are best treated by gentle scraping
to remove the softened epithelium, the
surface being then protected by a pad of
natural wool (as it is clipped from the
sheep), or of absorbent cotton, having
previously dusted the surface with a
powder composed of equal parts of zinc
oxide and boric acid. When corns be-
come inflamed, rest and warm, moist,
antiseptic dressings meet the indications.
If pus has formed it must be afforded
an exit and the wound treated with anti-
septics, iodoform, anatol or europhen.
168
SKIN, SURGICAL DISEASES OF.
Corns should never be cut too closely, as
erysipelas and gangrene may follow, espe-
cially in the aged.
VERRUCA.— Verrucse (condylomata;
warts) are circumscribed papillary ex-
crescences on the skin, variable in color,
smooth at the summit, or studded with
moniliform elevations or with clusters
of minute, pointed, horny filaments.
They may be single or multiple, hard or
soft, rounded, flattened or acuminate.
They may rapidly attain their full size,
may last indefinitely (/'. pcrstans), or
spontaneously disappear, at any stage,
and are not contagious. If picked or
wounded, warts bleed freely, being often
very vascular. The etiology of warts is
obscure.
Treatment. — The milder applications
consist of the juice of the milk-weed (As-
clcpias coniuti sen Syriaca), the tincture
of iodine, the solution of iron perchloride,
moistened powder of ammonium chloride;
stronger applications are sublimate col-
lodion (30 grains to the fluidram), glacial
acetic acid (best of acids, as it leaves no
scar), chromic acid and fuming nitric
(nitroso-nitric) acid. Excision (warts on
the face should never be cauterized, but
excised) or curettage if the warts be
soft, is the quickest method of removal;
the hypodermic injection of cocaine will
lessen or prevent the pain, and the ap-
plication of fuming nitric acid to the
stump or base will restrain the hemor-
rhage and prevent return. A 10 per cent.
salicylic acid or resorcin ointment is slow
but effectual. Electrolysis is efficient but
painful, for large warts. Ethyl chloride
spray, liquid air, and carbon dioxide
snow are efiicient. Quicklime rubbed on
the hands and washed off in an hour is
effective when warts are numerous; this
should be done twice daily and con-
tinued for a fortnight. Intravenous in-
jections of salvarsan and neosalvarsan
have been used successfully when warts
were numerous.
The internal use of >< pint (250 c.c.) of
lime-water daily for a week (Kennard) and
1 dram (4 Gm.) doses of Epsom salt
thrice daily (Ridley) have given satisfac-
tory results.
Instead of cutting or the use of caustics,
Purdon uses an India-rubber finger-stall.
if the warts are on the fingers, or an
India-rubber bandage, if they are on the
hands. The ruljl)er exerts gentle pres-
sure, while the wart is kept moist and
macerated from retained perspiration.
Venereal warts may be washed well
with bichloride or other antiseptic solu-
tion, and then dusted with iodoform,
calomel, aristol, or europhen.
HYPERTROPHIED SCARS.— When a
wound is completely healed, a cicatrix or
scar occupies its place. Normally, two
things are observed in a scar: its contrac-
tion and the gradual perfecting of its
tissues. The principal changes by' which
the latter is accomplished are the re-
moval of all the rudimental textures; the
formatiori of elastic tissue; the improve-
ment of fibrous or fibrocellular tissue of
the new cuticle till they are almost, but
not exactly, like those of natural forma-
tion; and the gradual loosening of the
scar, so that it may move easily upon
the subjacent tissues.
Treatment. — Hypertrnphied scars may
be treated by multiple incisions and
thiosinamine. Tubb}- uses a fine and
strong-backed tenotomy knife and makes
a large number of incisions in the scar
tissue, transversely to the long axis of
the scar, not more than Yio inch apart,
and extending both into the subcutaneous
fat and for about l^ inch into the adja-
cent healthy skin. Hemorrhage is stopped
by pressure alone, and then a solution
of thiosinamine is thoroughly rubbed in.
P^'rom 15 to 20 minims (1 to 1.3 c.c.) of
the solution may be injected at one time
in an adult. After injection the part is
splinted in extreme extension.
Fibrolysin plaster applied to the scar
and left for fourteen days, gave excellent
results.
Excision of the scar and repair by
plastic operation is applicable in some
cases. See also page 176.
KELOID.— Keloid (cheloid; kelis; Ali-
bert's keloid; spurious keloid) is a new
growth of connective-tissue formation
having its seat or origin in scar tissue
and resulting in the formation of single
or multiple tumors.
Symptoms. — It first appears as a pale-
red nodule which slowly increases in size,
assuming a more or less oval form, with
SKIN, SURGICAL DISEASES OF.
169
irregular, well-defined, radiating projec-
tions. From its resemblance to a crab
it derives its name. It may more rarely
assume a linear form. The new growth
is smooth, firm, elastic, pinkish, elevated,
generally devoid of hair, usually painless,
but sometimes tender when touched or
subjected to pressure; and is occasionally
the seat of the most intolerable itching,
which no external application seems to
relieve. The favorite location of this
growth is over the sternum, but it may
be situated on the mammae, the neck,
arms, and ears. In rare instances the
growth may become inflamed and assume
for a while the appearance of malignancy,
which appearance disappears usually with
the spontaneous decline of the inflam-
matory action. The development of the
growth may be slow or rapid, until a
stationary period is reached, which varies
in duration. Spontaneous disappearance
of the growth not infrequently occurs. In
some cases the growth becomes painful,
in others a pigmentary deposit is noticed.
This condition was first described by
Alibert, and is known as spurious keloid
to distinguish it from true keloid, which
does not attack scars (Erichsen).
Diagnosis. — AUbert's keloid is dilifer-
entiated from a simple cicatrix by its
diiiference in consistence, outline, color,
and elevation, and by its increase in size.
Its points of difference from hyper-
trophicd scars have been mentioned.
Etiology and Pathology. — These new
growths have their origin at the seat of
some injury (sometimes very slight) to
the skin, as the cicatrices of burns, flog-
gings, cuts, or in the lobes of the ears
when they have been pierced for the
accommodation of earrings. They are
most frequent in middle life and in the
colored race. The growth consists of
dense fibrous tissue, which involves the
corium and extends in the direction of
the connective tissue about the blood-
vessels.
Prognosis. — The prognosis is not gen-
erally very favorable, although the growths
may sometimes disappear spontaneously.
The stationary period may extend over
years or during life. Occasionally, after
a stationary period of variable duration,
an increase in size takes place.
Treatment. — The treatment of these
new growths is not very satisfactory.
The application of anodyne liniments or
hypodermic injections of morphine will
generally relieve pain when present. The
administration of large doses of liquor
potassae will often relieve the pruritus.
Removal by knife or caustics should not
be attempted while the growth is increas-
ing. Fused caustic potash is recom-
mended as best, if any caustic is used.
Multiple electrolytic puncture and re-
peated scarification, making numerous
parallel linear cuts crossed at various
angles by other parallel linear cuts, have
been suggested with the idea of replacing
the diseased scar by a healthy one.
Sodium salicylate taken internally (20
to 30 grains— 1.3 to 2 Gm. — three or four
times daily) has a marked effect in the
resolution and absorption of keloid. In-
jections of fibrolysin (35 minims — 2.3 c.c.)
made daily or even once a week has
caused the disappearance of keloid.
Radium has proven highly effectual both
for keloids, excessive scarring, and deep
fibrous adhesions. All cases of keloid re-
ported on by F. C. Harrison (1918)
showed disappearance or marked improve-
ment under radium. Weil exposed keloid
to very hard X-rays. Lesieur reported
satisfactory results in 100 cases from in-
jections of creosote in sterile olive oil,
1:15; 2 drops to 80 minims (5 c.c.) are
injected under the keloid at each sitting.
MALIGNANT DEGENERATION OF
SCARS. — The cicatrix of a burn or other
extensive scar may undergo malignant
degeneration many years after its forma-
tion. Erichsen removed a large cancroid
growth from a cicatrix of a burn, on the
forearm of a woman, seventy years after
the receipt of the injury, which happened
in childhood.
BURNS.
DEFINITION.— A burn is a high
grade of acute inflammation, following
the direct or indirect application of dry
or moist heat to a portion of the cu-
taneous or mucous surfaces.
VARIETIES.— For ease of comprehen-
sion burns have been separated into
grades according to their severity.
A temperature, slightly increased above
the normal (as, for instance, 100° F. —
170
SKIN, SURGICAL DISEASES OF.
37.8° C), produces only a slight hyper-
emia (first degree: dermatitis ambus-
tionis erythematosa), which may dis-
appear shortly after breaking the contact,
while a rise of 150° F. (65.6° C.) will
cause some appearance of vesicles and
bull?e (second degree: dermatitis am-
bustionis vesiculosa et bullosa) and de-
struction of the epidermis, the effect of
which is not relieved for days after the
removal of the burning substance, and
yet, on the other hand, heat at the boil-
ing point of water (212° F.— 100° C.)
may cause a complete carbonization of
the part, resulting in the formation of
eschars varying in color from a yellow
up to a dark brown or black or, in other
words, the production of gangrene (third
degree: dermatitis ambustionis escharot-
ica seu gangrenosa).
SYMPTOMS.— The effects of a burn
upon the body structure are both local
and constitutional. The former often
results in great disfiguration or destruc-
tion of tissue, while the latter depresses
the vital forces or terminates in death.
Local Effects. — In burns of the first
degree the appearances produced are su-
perficial. There will be observed a dis-
tinct hyperemia with redness of varying
intensity from the slightest blush up to a
pinkish red or brownish red. This may
or may not be entirely effaced by pres-
sure. This type of burn is produced by
indirect contact with the flame of a
lighted match, proximity to a heated
metal, escaping steam, and the actinic
rays of the sun. With or without treat-
ment the effect of burning to this extent
maj' disappear shorlj' after removing the
exciting cause.
In burns of the second degree the in-
flammation, while yet superficial, may
still occupy the entire epidermis. In
some cases the upper layers alone of the
cuticle may be destroyed, while vesicles
or bullae may be observed over the af-
fected surface. In still other cases the
corium is stripped entirely of its epi-
dermal covering or particles of the mem-
brane may be rolled into whitish masses
over its exposed surface. These vesicles
or bullae may be produced directly by the
contact of the heated article or indirectly
by the consequent inflammation. They
may retain their contents or, owing to
the increased flow of serum, their walls,
becoming thin and losing their elasticity,
rupture, thus allowing the escape of a
continual discharge over the denuded sur-
face. The true skin, which is exposed
either entirely or at points, shows a
highly reddened surface, over which this
continual exudation may be observed.
In this type of condition actual contact
with the heated substance takes place
either in shorter or longer durations.
Such articles as heated iron, transient or
lengthened action of flames, aiid boiling
liquids may be the exciting agent. The
effects of this form of burn do not al-
ways show to what extent they have
progressed immediately upon the removal
of the cause, because of the systemic con-
ditions which may be induced. Pain is
always present to a minor or major
degree.
Resolution takes place through coagu-
lation of the serous discharge, which
occupies the involved area as a fibro-
albuminous covering beneath which the
new skin is allowed to form.
In the burns of the third degree the
inflammation or destruction may be su-
perficial, extending over considerable area,
or deep, affecting the subcutaneoos tis-
sues, muscles, and even bones.
Resolution takes place in the uncovered
variet}' in the same manner as described
under the foregoing degree, while in the
covered variety granulations spring up
beneath the charred remains which, after
a time, desiccate and fall off, exposing a
similar surface to that of the second
degree.
In the deeper form of burn the extent
of surface involved may be small or
large, but may dip down to varying
depths. The amount of charring will usu-
ally be very great and will lie about in
masses over the burned surface, thus
preventing a view of the destruction be-
neath. Resolution even in the milder
cases is slow, and before such happens
surgical interference may be demanded.
The cause which brings about this form
of burning is usually dry heat (flames or
contact with electric wires); it entails
much greater destruction than will moist
heat. The effect upon the system is
SKIN, SURGICAL DISEASES OF.
171
alarming, and shock may carry off the
person before relief can even be attempted.
Electric and X-ray Burns. — Burns from
electricity may be observed in all the
varieties mentioned above. They may
follow^ direct or indirect contact. Exam-
ples of direct contact are observed after
handling live (charged) wires, and may
be found to destroy all parts with which
it comes into touch, or life even may be
the forfeit. Such burns resemble moist
gangrene or severe frost-bite. The pain
is often very severe and the healing pro-
cess is much slower than in the case of
ordinary burns.
A most recent form of burning of the
skin from the indirect contact of elec-
tricity is by the X-ray apparatus. Close
proximity to the ray by either covered or
uncovered parts result either in a super-
ficial or deep inflammation of the skin. It
may be observed a few hours after ex-
posure to the rays or may be delayed for
several weeks. This form of burning at-
tacks the skin alone in some instances,
while in others the deeper structures, as
the muscles, tendons, nerves, and bones
(periostitis and ostitis resulting) are in-
volved. The effects may remain for days,
weeks, or even months after the applica-
tion. The X-ray burns are supposed by
some to be produced by the action of the
ray or by particles of aluminium or
platinum reaching and being deposited in
the tissues by others, and by others to be
the result of an interference with the
nutrition of the part by the induced
static charges.
The patient may be absolutely pro-
tected from the harmful effects of this
static charge by the interposition between
the tube and the patient of a grounded
sheet of conducting material that is
readily penetrable by the X-ray, a thin
sheet of aluminium or gold-leaf spread
upon cardboard making an effectual protec-
tive shield.
Burns of Mucous Surfaces. — The mu-
cous surfaces may be affected by the
inhalation of flames, vapors (volatile or
boiling acids), boiling liquids (water,
slacked lime), and by certain substances
acting directly, such as ammonia and
sulphuric and hydrochloric acids. The
mouth, pharynx, larynx, bronchi, and
the esophagus, as well as the stomach,
share in the attack. The eye often, from
its exposed position, is the seat of burn.
Conjunctivitis often results from irritants
coming into direct contact with the eye,
and if the exciting agent is not soon re-
moved great destruction of substance or
sight may be the result.
Constitutional Effects.— The effects of
burns of the first degree upon the system
are generally slight and are limited to
pain which disappears shortly after the
removal of the exciting agent, but often
may last for several hours.
In burns of the second degree the pain
accompanies the phenomena not alone for
hours and days, but often for weeks and
even months. The shock may be of a
transient character or of an alarming in-
tensity. It may be encountered at the
time of accident or be delayed for peri-
ods varying from hours to days there-
after. When small areas are involved,
the depression may soon be relieved, but
when one-fourth or one-third of the
body is attacked death may intervene.
Burns of the third degree may be so
severe that death intervenes before pain
has time to appear. Shock at this stage
is therefore observed early and of the
worst character. Early mortality is gen-
erally due to the shock, while late mor-
tality usually occurs during the stage of
suppuration. Vomiting is often observed
in both the second and third degrees.
Children suffer more from burns than
do adults, and women more severely than
men. The temperature is not affected by
burns of the first degree, but is a marked
symptom in those of the second and third.
At the time of the accident it may de-
cline from 1 to 3 degrees below the
normal— to 97° F. (36.1° C.) or even 95°
F. (34.9° C.) and remain at that point
until reaction begins, which is in about
thirty-six or forty-eight hours, when it
rises during the next twelve to eighteen
hours to 104° F. (40° C.) or 106° F.
(41.1° C.) or more, at which point it re-
mains for a period of eight to ten days
(possibly rising and lowering at irregular
intervals), when granulations, now in fair
formation, act as a retarding agent.
Vannini reported cases of six burns of
varying degrees of severity, in all of
172
SKIN, SURGICAL DISEASES OF.
which glycosuria was present. The gly-
cosuria was, as a rule, transitory, and
was, in all probability, toxic in its origin,
and connected with hyperglycemia. When
sugar is present after burns, the diet of
the patient should be modified.
COMPLICATIONS.— The after-effects
of burns may be concentrated upon the
viscera (neural, thoracic, and ventral cavi-
ties) or directly upon the part affected
(cicatrices, contractions, and fractures of
bone). Burns of the first degree remain
uncomplicated, while those of the second
and third present many variations. The
meninges (arachnitis following burns of
the head), as well as the brain proper,
may become congested or even highly
inflamed, the sufferer presenting all the
symptoms of restlessness and delirium
ending either in convulsions or coma.
Tetanus is an early complication ob-
served. Bronchitis and pneumonia often
result either from inhalations or indi-
rectly from surface burns. Congestion in
the kidney has been noted, with resulting
albuminuria or hemoglobinuria, while in
many cases the urine becomes exceedingly
scanty. Autopsies have shown rupture of
the diaphragm and stomach, accompanied
by contraction of the bladder. Amyloid
degeneration in the viscera has been noted
after prolonged suppuration. Inflamma-
tion of the gastrointestinal tract with
the formation of an ulcer (usually one,
but more rarely several) of the duodenum
(at its pyloric end) frequently occurs.
This ulceration may begin early (four or
five days) or it may be delayed for
weeks, although without the appearance
of rectal hemorrhage or perforation, with
consequent peritonitis, we have no means
of determining its presence. At times
this inflammation extends to the colon
and causes diarrhea. Burns affecting
either the chest or abdomen are the in-
ducing cause, although severe burns at
other points may produce them. Sep-
ticemia, pj^emia, or erysipelas (the strep-
tococci being found after death in the
blood) may be the fatal ending.
The theories of the causes of death from
burns may be divided into four classes:
(1) death from shock or extreme pain;
(2) embolism, thrombosis, and destruc-
tion of the blood-elements; (3) pyemic
infection through the burned surface;
(4) poisons formed by the action of heat
on the tissues, or autointoxication from
deficient excretion by the skin. By ex-
perimenting upon dogs and rabbits it is
personally claimed that the intoxication
theory is the correct one.
The attempt of nature to restore a cov-
ering for these denuded tissues often re-
sults unwisely. Vicious scars, adhesions
of contiguous parts (causing webbed fin-
gers, the arm being attached to the side
by granulations), and deformities may be
encountered. Calcareous degeneration or
even epithelioma may attack the scars.
Pressure upon the terminals of the nerves
may either cause neuralgia or spasm of
the glottis, which may demand surgical
interference for its removal. Finally,
keloidal tumors may be observed as a
consequence of vicious scarring. All of
the scar may not be affected with keloid,
as, for instance, one end may show the
prolongations, while the other resembles
ordinary cicatrices. The contractions of
the skin after scarring may produce great
deformit}^ and the hand may be drawn
backward upon the arm or talipes cal-
caneus may result or other disfigurations
too numerous to mention may be shown.
Exposure of joints has taken place by
ankylosis. Bones have been fractured
from loss of substance (cooking of the
muscles).
DIAGNOSIS.— Ordinarily the recog-
nition of burns is not a dithcult task, al-
though the differentiation of the varieties,
especially of the second and third degrees,
may demand careful examination. Burn-
ing flesh with destruction of its particles^,
exposure of the underlying tissues (mus-
cles, bones, etc.), will be a train of symp-
toms not to be controverted. The dif-
ference between burns and scalds often
may occasion difficulty, but the fact of
the greater and deeper destruction of the
former with the more superficial charac-
ter af the latter will generally be suf-
ficient. The loss of hair follows the for-
mer because of this deep destruction of
the hair-follicle and papilla.
MEDICOLEGAL ASPECTS OF
BURNS. — In cases where the persons
have been alive when they were exposed
to the fire, soot is found in the ramifica-
SKIN, SURGICAL DISEASES OF
173
tions of the trachea and bronchi. If the
red blood-corpuscles are found disinte-
grated and disfigured throughout, then
this is a further sign of a person having
been burnt while alive.
The presence of carbon monoxide in
the blood is an almost positive proof that
the person during life was not exposed to
the influence of fire.
PROGNOSIS.— The termination of this
class of injuries is often of serious import,
especially when medicolegal questions
arise. This should be determined by the
several factors which arise in each case.
Consideration must be given to indi-
viduality of the sufferer, both his age and
constitutional acquirements; the extent of
the burn, both as to surface and depth in-
volved; the location of the injury, and the
nature of the exciting medium. The ef-
fects upon strong, robust subjects are
not so marked as upon those of weaker
constitutions, and while the same degree
or extent of burn will soon be recovered
from by the former, the most dire results
may follow in the latter persons. Thus it
may be noticed that burns among ma-
chinists, glass-blowers, plumbers, and
foundrymen will not be so serious as
would the same degree or extent among
clerks or those engaged in gentlemanly
pursuits. Colored persons suffer less se-
verely than do the white. Females, on
account of more delicate systems, are less
able to resist shock than are the males.
Middle life is not so severely affected as
are children or aged people. Some per-
sons may be able to resist the shock only
to be carried off by the complications that
arise.
Surface involvement seems to exert a
greater depression or fatality than does
depth of tissue. A burn, even of the first
degree, which occupies an extended area
and those of the second may terminate
fatally if one-fourth or one-third of the
superficial parts are involved; a fatal is-
sue may also occur in burns occupying
one-half of the body surface. A burn of
the second degree which occupies only a
limited extent of surface, but which de-
stroys the epidermis entire, may end in
recovery, while those of the third may,
through their deep involvement, produce
complications with which we are unable
to combat. Burns occupying the abdo-
men give the highest mortality, while
those of the thorax are only second to a
slightly minor extent; but those of the
head, neck, and limbs prove fatal in
many instances. Of twenty-six cases seen
by Sajous after a boiler explosion on the
Lake of Geneva, in 1892, twenty-two died
within a few hours after the accident, al-
though, with few exceptions, the scalds,
though involving the greater part of the
body, did not reach beyond the epidermic
layer, excepting over the face and hands.
The length of time required for the
partial or complete reparation of the sur-
face may be an important question in
inedicolegal cases. This can only be gov-
erned by the type of injury, the length of
contact of the exciting agent, the nature
of the affected person, and the general
aspects of the case in question.
TREATMENT. — Constitutional. — The
constitutional treatment is to be directed
toward the relief of pain, the restoration
of the depressed vitality at the time
of accident, — i.e., sustaining the system
throughout the entire restorative process.
Pain is best relieved by opium, or its al-
kaloid, morphine (preferably by hypoder-
mic injection), because these agents have
little, if any, depressing action upon the
cardiac functions. The dose required will
be much greater than ordinarily used, be-
cause of the sudden character and great
amount of depression in these injuries.
Vitality must be restored as quickly as
possible, and the use of ammonia (prefer-
ably carbonate), strychnine, and caffeine
(because of their stimulating effect upon
the cardiac muscle) ; hot drinks, such as
milk and tea; alcohol in the form of
whisky or brandy, and the production of
local or generalized sweating. A most
desirable plan of restoring heat is by
using hot-water bottles placed at regular
points so as to diffuse its effects. Other
means, as, for instance, covering the body
with a sheet and conveying heat through
a pipe or by placing heated bricks beneath
this covering. To keep the sufferer fairly
comfortable during the local treatment
stimulation must be kept up, care being
taken not to produce overactivity and thus
allow reaction to prove as deleterious as
the effect of the burn.
174
SKIN, SURGICAL DISEASES OF.
Tlic functions of the body must be
regulated, the bowels being kept free or
confined, according to the conditions pres-
ent: the action of the kidneys should be
watched. In some cases it may be wise
to anesthetize the patient during the first
few hours immediately following the burn,
and especiall}^ during the first dressings
of aggravated cases.
Local. — The local treatment is to be
directed toward the limitation of the re-
sulting inflammation, the prevention of
septic infection, assisting the normal
elimination of the eschar, the develop-
ment of granulations, and limitation of
the deformity.
In burns of the first degree little or
no treatment may be demanded. In the
more aggravated cases of this t3'pe the
application of home measures, such as
sodium bicarbonate, the white of egg and
sweet oil (equal parts), lead-water and
laudanum, and the various hot or cold
means generally at the disposal of
housewives.
Burns of the second and third degrees
must be more strenuously treated. It is
often a difficult problem to know which
is the more soothing application to be
advised and from which we may get the
better result. In one case hot applica-
tions, in another cold; in some wet, and in
others dry measures are to be given.
The vesicles, if numerous, should be un-
touched; but if onl}'^ a few, they are best
evacuated.
Prof. S. D. Gross was wont, in many
mild and severe cases, to use ordinarj-
white-lead paint; this is a remarkably ef-
ficacious measure. Mere painting of the
burn, as if it were an article of furniture,
etc., causes immediate cessation of the pain.
The use of carbolized petrolatum (3 to
6 per cent.), watery solutions of carbolic
acid (4 per cent.), bismuth subnitrate
(Vi to 1 dram — 2 to 4 Gm. — to 1 ounce —
30 Gm. — of ointment of zinc oxide or
petrolatum), boric acid (either in watery
saturated solutions or ointments of either
zinc oxide or petrolatum in strengths
varA'ing from 6 to 25 per cent.), sodium
bicarbonate in almost full strength (in
ointment or watery solutions), and starch
in varying proportions will usually" be
found very efficacious.
Turpentine, where granulations are slug-
gish, will give excellent results used
cither in full or diluted strength, giving
care not to produce too much stimulation.
When there are large vesicles, these are
opened on the second or third day. It is
best to keep the turpentine off the healthy
skin if possible to avoid local irritation.
Surgery of this day has placed many
excellent antiseptics at our disposal, and
there is no better application than mer-
cury bichloride in the proportion of 1 to
lOUO parts of water and kept in constant
contact, the dressings being made without
removing the former cloths.
Ichthyol in watery solutions (1 to 8,
or stronger, or in glycerin, similar
strength), or even in from 12 to 36 per
cent, ointment with zinc oxide or petrola-
tum and the iodine derivatives, such as
iodol, aristol, europhen (given preferably
in ointment 3 to 6 per cent, with petrola-
tum or lard) are reliable measures.
Thiol has been found useful for all de-
grees of burn; it allaj-s pain verj- rapidly
and arrests cutaneous hyperemia, in this
manner tending to prevent ulceration and
scarring.
Aristol is another valuable agent in
burns of the second and third degrees,
and has been found strikingly effective
where other remedies have failed.
It may be used in the form of powder
or mixed with oil or petrolatum. The
application of aristol powder directly to
the wound at the beginning hinders the
dressing from soaking up the secretion;
when the latter has diminished, however,
aristol may be applied either alone or in
a 10 per cent, ointment with olive oil,
petrolatum, and lanolin.
Many authoritative surgeons have lauded
picric acid used in saturated solutions
with water (increasing the solubility by
means of the addition of 1 ounce — 30
c.c. — of alcohol, as the acid is soluble to
the extent of only 2 drams — 8 Gm. — to
the quart — liter — of water). It is par-
ticularly useful for the relief of pain
and it greatly assists the formation of
granulations. .
The combination of picric and citric
acids, which Esliach devised for the de-
tection of albumin, is more effective than
the picric acid alone, in burns of the sec-
SKIN, SURGICAL DISEASES OF. 175
ond degree. Esbach's solution consists of Granulations may often be assisted by
10 parts of picric acid, 20 of citric acid, powders of acetanilide in full strength, or
and KKX) of water. The bullae and vesi- with equal parts of boric acid, dusted over
cles should, be opened with a clean blade the area, or by means of iodol, europhen
and the fluid applied freely. Repeated ap- or aristol (3 to 12 per cent.) with powdered
plication of tincture of ferric chloride is starch or in ointment. Scarlet red in 10
another useful form of treatment. Cal- per cent, solution may also be used.
cined magnesia, in a paste made with Limitation of deformity is often a seri-
water, is serviceable in l)urns of the first ous problem though in some measure ob-
and second degrees. Iodoform, as an viated by paraffin treatment. Splints may
analgesic and antiseptic, may be left in be utilized and they should be kept applied
situ for some time. Potassium nitrate for some time after the parts have healed
solution is useful, chiefly as refrigerant. because of the inherent tendency to the
The paraffin treatment of severe burns contraction for long periods, even years,
constitutes a distinct advance over the pro- after an apparent cure. Bandages are to
cedures previously in general use. Be- be kept continuously applied to prevent
sides forming a painless dressing, which contiguous surfaces from becoming ag-
is easy of application and removal, and glutinated. Massage must be advised at
does not favor infection, it results in more the very earliest moment so as to restore
rapid healing, and leaves a smooth, soft, the pliability of the part and prevent anky-
pliable scar, with little or no tendency to losis when a joint is involved. Even with
contracture and deformity. Either am- all the measures that we can adopt the
brine or one of the numerous substitutes loss of skin-tissue may be so extensive
for it may be used. The burn is first that skin-grafting will be the only means
washed with sterile water, saline solution, with which we can hope to restore the
or boric acid solution; it may be sprayed integrity of the part. The relief of cica-
with a 3 to 5 per cent, solution of dichlo- trices or contractions, ankylosis, or pres-
ramine-T, followed, if necessary, by liquid sure upon the nerve-filaments sometimes
petrolatum to allay pain. It is then dried requires the most energetic surgical in-
with sterile gauze or an electric dryer, and terference.
the paraffin preparation applied with a TREATMENT OF ELECTRICAL
broad camel's hair brush or special sprav BURNS. — Elder advises that the part sub-
apparatus. Shere recommends the follow- jected to the burn be immersed and kept in
ing mixture: ^ warm carbolic-lotion bath, 1 per cent.,
,,„ . ,. ic ^,,„,^^ taking precautions against the possibility
White vaseline 15 ounces. , ,,"' ^ % i u
,...,,, ^ 9 ^,,„ooc of the occurrence of secondary hemor-
Liquid petrolatum Z ounces. -'
Oil of euealyptus 1 ounce. --hage. If secondary hemorrhage occur or
Paraffin (melt. pt. 42.7° C.) .. 16 ounces. ^hen a definite Ime^ of demarcation has
formed, the necrosed tissue must be re-
Iv lute uax. J T , ,. .
„. , J. , , T/ ^,,„„„ moved. In many cases amputation is
Pix burgundica, of each ^ ounce. ,.., ,-r, i,, .u
necessary, but the skin-Haps should not be
For the first few days, 1 dram each ot closed, because large masses of muscle are
thymol, iodide and menthol are added to gm-e to slough away subsequently. The
allay infection and pain; later, >2 to 1 per wound should be allowed to granulate,
cent, of scarlet red, and when epithclializa- and subsequently be skin-grafted. Imme-
tion is nearly complete, bismuth subgal- diately after the burn hypodermic injec-
late, 1 to 10. A thin layer of cotton is tions of morphine (% grain — 0.01 Gm.)
placed over the first layer of paraffin, a and strychnine (V.s(» grain — 0.002 Gm.) may
second paraffin coating applied, and the j^g given alternately. To lessen the oft'en-
dressing completed with cotton and band- give odor the 1 per cent, carbolic lotion
age. Redressing is done daily at first, niay be replaced by a bath of 1 in 10,000
later on alternate days. mercury bichloride. In addition, mor-
The lethal tendency of burns is best phine, phenacetin, caffeine, chloral hydrate,
met by removing the necrosed tissues and and potassium bromide may be adminis-
infusion of saline solution, repeated daily. tered together.
176
SODIUM (SAJOUS).
Immobilization of the part aiul protec-
tion with sterile gauze arc necessary,
and, if the hum is extensive, skin-grafting.
SCAR-TISSUE DEFORMITIES.—
Scars, even when adherent to hones, j)ain-
ful thickenings following injuries or hums,
or of the tendons, are favorably influenced
by X-rays. Grace (Am. Jour, of Pllectr.
and Radiol., Oct., 1919) uses a filter of
1 mm. of aluminium for the superficial
cases and of 2 mm. for the deeper. The
Palzsche method, a salve composed of
pepsin, hydrochloric acid, and phenic acid,
each 1 per cent., rubbed into the scar twice
daily, is also effective according to Schues-
sler (Miiench. med. Woch., Ixviii, 72, 1921).
Moist compresses are applied at night.
C, W. and S.
SODIUM* — Sodium, or natrium, is
a light, soft, ductile, malleable metal,
of silver-white luster when freshly cut,
and of dull-gray color when oxidized
by air. Like potassium, it has a strong
afifinity for oxygen, and must be kept
immersed in a liquid free from oxy-
gen, such as benzene or naphtha.
Thrown upon water, it burns with a
bright yellow flame, imiting with the
oxygen of some of the water and
forming in the remainder a solution of
sodium hydroxide. The pure metal is
not used in medicine, but yields a
larger number of official compounds
than any other element.
Upon a therapeutic basis, the fol-
lowing classification of some of the
sodium compounds may be made : —
Caustics: Soda, and soda with lime
(unofficial).
Purgatives: Sodium phosphate, sodium
sulphate, and potassium and sodium tar-
trate.
Systemic antacids: Sodium acetate, so-
dium bicarbonate, monohydrated sodium
carbonate, sodium citrate, and potassium
and sodium tartrate.
Diuretics: Sodium acetate, sodium ben-
zoate, sodium bicarbonate, monohydrated
sodium carbonate, sodium citrate, and
potassium and sodium tartrate.
Febrifuges: Sodium acetate, sodium
benzoate, sodium citrate, and sodium
salicylate.
Antiseptics: Sodium benzoate, sodium
borate, sodium chlorate, sodium hypo-
chlorite, sodium phenolsulphonate, and
sodium salicylate.
PREPARATIONS AND DOSES.
— The official preparations of sodium
are: —
Sod a hydroxidnm, U. S. P. (sodium
hydroxide or hydrate: caustic soda),
rapidly deliquescent, and acquiring a
coating of sodium carbonate; soluble
in 1 part of water and freely in alcohol.
Liquor sodii hydroxidi, U. S. P.
(solution of sodium hydroxide), of
about 5 per cent, strength. Dose, 10
to 30 minims (0.6 to 2 c.c).
Liquor soda chlorinata, U. S. P.
(solution of chlorinated soda; Labar-
raque's solution), an aqueous solution
of several chlorine compounds of so-
dium, containing at least 2.4 per cent.
by weight of available chlorine. Dose,
10 to 30 minims (0.6 to 2 c.c).
Sodii acetas, U. S. P. (sodium
acetate), soluble in 1 part of water
and in 23 parts of alcohol. Dose, 10
to 30 grains (0.6 to 2 Gm.).
Sodii arsenas, U. S. P. (sodium ar-
senate). Dose, Yxo grain (0.006 Gm.).
(See Arsenic.)
Sodii arsenas exsiccatus, U. S. P.
(dried sodium arsenate). Dose, %o
grain (0.003 Gm.). (See Arsenic.)
Liquor sodii arscnatis, U. S. P.
(solution of sodium arsenate). Dose,
3 minims (0.2 c.c). (See Arsenic.)
Sodii henzoas, U. S. P. (sodium
benzoate), soluble in 1.6 parts of
water and in 43 parts of alcohol. Dose,
10 to 20 grains (0.6 to 1.3 Gm.). (See
i^ENzoic Acid.)
Sodii bicarhonas, U. S. P. (sodium
bicarbonate, acid sodium carbonate,
baking soda), soluble in 12 parts of
SODIUM (SAJOUS).
177
water, insoluble in alcohol ; converted
into sodium carbonate on boiling its
solution. Dose, 10 to 60 grains (0.6
to 4 Gm.).
Sodium bicarbonate should only be
given in small doses (12 to IS grains
— 0.75 to 1 Gm.) several times daily.
The acidity is tlius diminished suffi-
ciently to reduce the pain, yet an
increased flow of acid is not stimu-
lated. It has been proven that 15 to
45 grains (1 to 3 Gm.) given before,
during, or after a test-meal will favor
the passage of the food from the
stomach into the intestines, while
larger doses may cause a spasm.
Even if the drug is given for a long
time in the doses mentioned, cachexia
will not set in. The fear that over-
loading of the blood with sodium
may lead to increased production of
hydrochloric acid is very remote. E.
Binet (Progres med., 3, 1911).
Trocliisci sodii bicarbonatis, U. S. P.
(troches or lozenges of sodium bicar-
bonate), each containing 3 grains (0.2
Gm.) of the bicarbonate and Vq grain
(0.01 Gm.) of nutmeg.
Mistura rhei composita, N. F. (mix-
ture of rhubarb and soda). Dose, 2
fluidrams (8 c.c). (See Rhubarb.)
Sodii bisulphis, U. S. P. VIII
(sodium bisulphite; acid sodium sul-
phite; leucogen), unpleasant in taste,
gradually oxidized to sulphate on ex-
posure to air, soluble in 3.5 parts of
water and in 70 parts of alcohol.
Dose, 7y2 grains (0.5 Gm.).
Sodii boras, U. S. P. (sodium borate;
borax), soluble in 20.4 parts of cold
water, in 0.5 part of boiling water, and
in 1 part of glycerin, with which it
reacts to form boroglyceride, with evo-
lution of gas ; insoluble in alcohol.
Dose, yj/z grains (0.5 Gm.). (See
I!oRic Acid.)
Sodii bromidum, U. vS. P. (sodium
bromide). Dose, 10 to 60 grains (0.6
to 4 Gm.). (See Bromine.)
8—12
Sodii carbonas monohydratus, U. S. P.
(monohydrated sodium carbonate),
containing only one molecule of water
of crystallization, and therefore nearly
twice as strong as the ordinary soditmi
carbonate ; soluble in 2.9 parts of water
and in 8 parts of glycerin, insoluble in
alcohol. Dose, 4 grains (0.25 Gm.).
Sodii cyanidnm, U. S. P. (sodium
cyanide), deliquescent and smelling of
hydrocyanic acid ; freely soluble.
Sodii glyccrophosplias, U. S. P.
(sodium glycerophosphate), saline in
taste ; freely soluble. Dose, 4 grains
(0.25 Gm.).
Sodii chloridum, U. S. P. (sodium
chloride; salt), at least 99 per cent,
pure, soluble in 2.8 parts of water,
almost insoluble in alcohol. Dose, as
emetic, 4 drams (16 Gm.).
Sodii citrus, U. S. P. (sodium ci-
trate), with a cooling, saline taste;
soluble in 1.1 parts of water, slightly
soluble in alcohol. Dose, 10 to 60
grains (0.6 to 4 Gm.).
Sodii hypophosphis, U. S. P. (so-
dium hypophosphite), very deliques-
cent, soluble in 1 part of water and
in 25 parts of alcohol. Dose, 5 to 30
grains (0.3 to 2 Gm.). (See Phos-
phoric Acid.)
Syrupus hypophosphitum, U. S. P.
(syrup of hypophosphites). Dose, 1
to 2 fluidrams (4 to 8 c.c). (See
Phosphoric Acid.)
Sodii indigotindisulphonas, U. S. P.
(indigo carmine), a blue powder or
purple paste ; sparingly soluble in
water, yielding a dark blue solution.
Sodii iodidum, U. S. P. (sodium
iodide). Dose, 5 to 60 (0.3 to 4 Gm.).
(See Iodine.)
Sodii nitras, U. S. P. VIII (sodium
nitrate; Ghili saltpeter; cubic niter),
with a cooling, saline, slightly bittei
taste; soluble in 1.1 parts of water and
178 SODIUM (SAJOUS).
in about 100 parts of alcohol. Dose, cent in the air; soluble in 2.8 parts
5 to 15 grains (0.3 to 1 Gm.). of water and in glycerin, insoluble in
Sod a nit r is, U. S. P. (sodium ni- alcohol. Dose, 1 to 8 drams (4 to 32
trite). Dose, 1 grain (0.06 Gm.). Gm.).
(See Nitrites.) Sodii sidpJiis exsiccatus, U. S. P.
Sodii phcnolsidphonas, U. S. P. (so- (sodium sulnhitcV with saline, sulphur-
dium phenolsulphonate or sulphocar- ous taste ; soluble in 2 parts of water,
bolate), with a cooling, saline, bitter sparingly soluble in alcohol. Dose, 15
taste; soluble in 4.8 parts of water and grains (1 Gm.).
in about 130 parts of alcohol. Dose, Sodii thiosidpJias, U. S. P. (sodium
4 grains (0.25 Gm.), thiosulphate or hyposulphite), with a
Sodii phosphas, U. S. P. (sodium cooling, afterward bitter, taste; solu-
phosphate; disodium hydrogen ortho- ble in about 0.35 part of water,
phosphate), efflorescent in the air; slightly soluble in oil of turpentine,
soluble in 5.5 parts of water, insoluble insoluble in alcohol ; the aqueous solu-
in alcohol; an aqueous solution, is tion is rapidly decomposed by boiling,
slightly alkaline to htmus. Dose, 30 Dose, 5 to 20 grains (0.3 to 1.25 Gm.).
grains to 4 drams (2 to 15 Gm,). (See Potassii et sodii tartras, U. S. P.
Phosphoric Acid.) (Rochelle salt). Dose, 1 to 8 drams
Sodii phosphas cffervescens, U, S. P. (4 to 30 Gm.). (See Potassium.)
(effervescent sodium phosphate), con- Among the sodium preparations
taining 20 per cent, of exsiccated so- recognized in the National Formulary
dium phosphate, together with sodium are the following: —
bicarbonate, tartaric acid, and citric Soda cum cake, N. F, (soda with
acid. Dose, 2 to 8 drams (8 to 30 lime; London paste), a paste consist-
Gm,), (See Phosphoric Acid.) ing of sodium hydroxide and imslaked
Sodii phosphas cxsiccatns, U. S. P. lime in equal parts, employed as escha-
(dried sodium phosphate). Dose, 15 rotic.
grains to 2 drams (1 to 8 Gm.). (See Liquor antisepticus alkalinus, N, F.
Phosphoric Acid.) (alkaline antiseptic solution, contain-
Sodii perhoras, U. S. P. (sodium ing, among other substances, sodium
perborate) ; gives off 9 per cent, of borate, sodium benzoate, and oil of
oxygen in warm or moist air; white gaultheria. (See Salicylic Acid.)
crystalline granules or powder; soluble Liquor sodii arsenatis, Pearson, N.F.
in water. Dose, grain (0.06 Gm.). (Pearson's solution). (See Arsenic.)
Liquor sodii phosphatis compositus, Liquor hypophosphitum, N. F, (solu-
U. S, P. (compound solution of sodium tion of hypophosphites). Dose, 1
phosphate), a 100 per cent, solution of fiuidram (4 c.c). To replace the offi-
sodium (citro) phosphate, containing cial syrup of hypophosphites when
also 4 per cent, of sodium nitrate, sugar is to be avoided.
Dose, ^ to 4 fluidrams.(2 to 16 c.c). Liquor hypophosphitum compositus,
Sodii salicylas, U. S. P. (sodium N. F. (compound solution of hypo-
salicylate). Dose, 15 grains. (See phosphites). Dose, 1 fluidram (4 c.c).
Salicylic Acid.) Liquor sodii boratis compositus, N.F.
Sodii sulphas, U. S. P. (sodium sul- (Dobell's solution), containing phenol,
phate; glauber salt), rapidly efflores- 0.3 per cent.; sodium borate and bi-
SODIUM (SAJOUS).
179
carbonate, of each, 1.5 per cent., and
glycerin, 3.5 per cent., in sterile water.
Liquor sodii carbolatus, N. F. Ill
(carbolated soda solution), consisting
of phenol, 50 per cent, in water, to-
gether with sodium hydroxide, 3.5 per
cent.
Liquor sodii citratis, N. F. (solution
of sodium citrate; potio Riveri), made
from citric acid, 2 per cent., and so-
dium bicarbonate, 2.5 per cent., in
water. Dose, 2 fluidrams (8 c.c).
Liquor sodii citrotartratis cffcrvcs-
ccns, N. F. (tartrocitric lemonade).
Dose, 12 flviidounces (360 c.c).
Liquor sodii oleatis, N. F. Ill (solu-
tion of soap).
Elixir sodii hromidi, N. F. (elixir of
sodium bromide). Dose, 2 fluidrams
(8 c.c), containing 20 grains (1.3 Gm.)
of the bromide.
Elixir sodii hypophosphitis, N. F.
(elixir of sodium hypophosphite).
Dose, 1 fluidram (4 c.c).
Elixir sodii salicylatis, N. F. (elixir
of sodium salicylate). Dose, 1 fluidram
(4 c.c). (See Salicylic Acid.)
Syrupus bromidorum, N. F. (syrup
of the bromides). Dose, 1 fluidram (4
c.c).
Syrupus calcii et sodii hypophos-
phitum, N. F. (syrup of calcium and
sodium hypophosphites). Dose, 1 flui-
dram (4 c.c).
Syrupus sodii hypophosphitis, N. F.
(syrup of sodium hypophosphite).
Dose, 1 fluidram (4 c.c).
Liquor soda et nienthcc, N. F. (soda
mint solution), consisting of aromatic
spirit of ammonia, 1 part ; sodium bi-
carbonate, 5 parts, in spearmint-water,
enough to make 100 .parts. Dose, 2
fluidrams (8 c.c).
Syrupus hypophosphitum composi-
tns, N. F. (compound syrup of hypo-
phosphites), containing hypophosphites,
quinine, and strychnine. Dose, 2
fluidrams (8 c.c).
Sodii borobcncoas, N. F. (sodium
borobenzoate), a mixture of sodium
borate, 3 parts, with sodium benzoate,
4 parts. Dose, 10 to 30 grains (0.6 to
2 Gm.).
Sal Carolinum factitiiim, N. F. (ar-
tificial Carlsbad salt), an amorphous
powder consisting of sodium sulphate
(dried), 18 parts; sodium bicarbonate,
36 parts; sodium chloride, 18 parts,
and potassium sulphate, 28 parts. To
be dissolved in 200 parts of water.
Dose, 6 fluidounces (200 c c), repre-
senting an equal volume of Carlsbad
water (Sprudel). If the crystalline
preparation of the same nature be used,
1.75 parts of the salt are to be dis-
solved in 200 parts of water.
Sal Kissingcnse factitium, N. F.
(artificial Kissingen salt), consistmg of
sodium chloride, 357 parts ; sodium
bicarbonate, 107 parts; magnesium sul-
phate (anhydrous), 12 parts, and
potassium chloride, 17 parts. One and
a half parts of the salt are to be dis-
solved in 200 parts of water. Dose,
6 fluidounces, representing an equal
volume of Kissingen water (Rakoczy).
Sal Vichy anum factitium, N. F. (ar-
tificial Vichy salt), composed of so-
dium bicarbonate, 846 parts ; sodium
chloride, 77 parts, and magnesium sul-
phate (anhydrous) 80 parts, and po-
tassium carbonate, 38 parts. To be
dissolved in 200 parts of water. Dose,
6 fluidounces (200 cc), representing
an equal volume of Vichy water
(Grande Grille spring).
Pulvis satis Carolini factitii effcr-
vcsccns, N. F. (efi^ervescent artificial
Carlsbad salt). Dose, 90 grains (6
Gm.) in 6 ounces (200 c.c.) of water.
Pulvis salts Kissingensis factitii ef-
fervescens, N. F. (effervescent artifi-
180
SODIUM (SAJOUS).
cial Ki.vsmj^cii .^.iii;. lAJ^^c, «S0 grains
(5.5 (jm. ) in 6 Huidounces (2(K) cc.)
of water.
f'ulri^ salis I'ichyani fiutitii effer-
vt:sctnui, NT. F. (effervescent artilicial
Vichy salt). D<:>se, 57 grains (3.75
(im.) in 6 rtuidouncea (200 c.c.) ot
water.
f'ldrif .uiJui i u.nyam j(U:tuii effer-
vcM<-its cum lithio, M. F. (effervescent
artificial Vichy .salt witJi lithium).
Dose, 'X) grains {h (Jm,), repre.senting
14 grains (I Gno,) of artificial Vichy
salt and 5 grains (0.,? Gm,) of litliium
citrate.
PHYSrOLOCrCAL ACTION. —
Sofliunx as an element or ion exerts in
nio<lerate amounts, different from po
tassium, little or no effect upon tJie
ti.ssues of higher animals. That the
.sodium ion may exert a deleteriiitJs ac-
tion on s<jme animal cell,s is shown,
htiwever, l>y tJie (^b.se.rvation tlaat .some
ova and fish ordinarily inJiahiting .sea-
water survive longer when place<l in
distillerl water than when place^l in a
solution of .«iodium chioride {."^i-itonic
with sea-water. More concentr.ntr i
.solutions of .soflirim chloride, in ai;>..
tion to a possible ionic poi>i(inous ef-
fect of tJie kind ju.st descriJied prcxluc;
the effects characteristic of "salt ac-
tion" in general, viz., witJidrawal of
water from cells, with corresponding
shrinkage ai the latter and, where the
occasion present^*, effect-9 due to irrita-
tion, such as vomiting in the case of
the stfjmach.
According to tiie e:itpcriraents of
Miinch, exhibition for a few days of
large quantities of .sorlium chloride in
man causes at first a ^0n decrea.'ie
in excretion (especially renal), with a
corresponding gain of body weiebt ;
after a time, however, the excretions
•ncrea.se and the weiglit decrcn
Small amount.>i ol .>alt have been found
at times to les.^en the acidity of the
ga.stric juice, but the greater palatabil-
ity of f<X)d .sea.soned with salt may
counteract this by augmenting the re-
rtex ga.stric .secretion. The salivary
How is increased by salt, partly tlirough
reflex action and partly because some
of it is excreted by tiie .salivary glands.
.-Xhsorption of ins:;"ested hypotonic
.soluti<ins of .salt takes place chiefiy
fn^m the intchtine, and resultsi in a
diluted Condition of the bloxl — hy<lre-
mia — which induces diuresis. The flow
of urine is increased more by direct
.saline infusion into Uie bloo<i than by
sahne solution (or water) absijrbcd
fr<im tJie st<:)mach and b<:)web Hyper-
tonic salt Si^lution injected into the
blo(xi causes marked diuresis tii rough
absorption of water from the bcwly ti.s-
sues, hxst hypertonic salt solution in-
gested causes littie or no diuresis, as
tht salt i,s only slowly absorbed from
it, and though tending, for a time, to
increase tiie total ludk of the blood,
does not render it hydremic.
Sodium kydroxidt: (caustic .sex la),
like potassium hydroxide and calcium
oxide, is a .strong caustic, de.str<jying
i4e by abstraction of water, dissolu-
tion of albumin, and .saponification of
fats. .Similar effects arc produced by
liquor sodii hydroxidi and by .scx^la cnm
calce (N. P.).
Sodium hypochionte, official \u the
liquor sod^e chlorinatjc or I^l:>arraquc's
sM^lution, gives off chlorine and pos-
.sesses the anti.septic, deodorant, and
bleaching properties of tiie latter. It
is decidedly irrit.ating to the tissues,
but this property may be reduced,
seemingly without loss of anti.septic
power, by the addition of sufficient
Ixiric acid to neutralize the free alkali
in the preparation.
SODIHIt C5.\rOL'SK
isi
I
jikaljej wtth. the veg^fcibte vtciu^. b>
nt^ipjly obijerbed ami oxiUiitKi m. tfee
sy^ton tx> 6?cni soiiimir ct"
w-fickfit tnsoreases tire al&almitry . . . .
btocti irol crtmt. iimi erases limresij.
Ov^r dinict ■'*::"-^uti <>>£ ilkalrcce ctr-
bomttes or t ' — -ittt^ suviiam: :ic«tite
xml strnilar salH fctvi* tfee idv^nctge
©f not netdn- . ice gastnjc jotoj.
te^Bt tx> mocoos nsatibntnies* exerts a:
isQotfirag: dfect.. ami ttaais- - - ' ■;
thick nmoiSv. Tt ts cooMtv- a' - ■-
the alfciTmitr of its sofation^ c: .:j.,<s
oa sranaiin^. b«^ra-^" "'""" the toss of
carbon, dio-xide^ ,^ 'n dttote sota-
tHjtt 1s?> Esotabfil contractile organs, en-
ctoJirrg- vesijel-walls ami ciTirateil eip-t-
rftefimiL Bt canses for a t
tHate altaBis^ cner^Esevi actrvctr anu.
tooKitjr, ami ai certani p- an:
BBcreased resfetance te> asfifevea :••-,"
QXTg!e3i exdnsiott: liate- -•- : • '^"- ■
activitT c? replaced by :.,.. ._-..-^>.\:.
Expertmoits ixt dogs- have ??''
rirrtr the aQdhne carbonates, a
tereti tncemaltT. (fe not trrliaen.ce the
race €>£ gastrtc secre:- ■ They temi.
tQwever, te nacerease gastric motilrtv
hf ■vrtrtne o€ the carbon '-
T^Sfl throc^ reacttott wini cae iy — ■-
cMornr acid of the gastric imce. •" "
UE^ also m themselves-^ by '-rr-.--.- -^
:d%&t local trriratEoni.. esjsrt j. ..- jI
cannmatrve ettect. rdieving- gaseJtis
lijtonioa artti the consequent pain.
E^rvre grains i Q. J Gm. ) <:JC ^odnini W.~
carbi-^nalK. if completely utilized in the
destnictaott of the gastric aciil are
c^abfe QC aetitrafizmg- ab«:irt 154
oraKes o€ gastric ' -. ■ :.
strength. '^Trere : >: ^-^
no 2ci'l. as tn the r^.:.: , ^e-
cweei the (^estijiJii of SUV -- . ^^
so&xEo. biEaEfecajate ampJy tfissolves the
gastric macas ^soA is absocbe<l mar-
cfcxti^ied. JfeotraJicitwii t>f . -
actid has been hf'
partly or cor. . . - . . _ -.m-
trie hyperactdity . Ltovrevxar, it "■^;-'''
nevertheless*, be beieiiciaL by j
excessive irritatijon: b-v the gastrtc actd
Ett the ■
catarrh of ciie ;ai:i:ei\ :kv
others biive -' " that • - o^irt
no direct •"■ — th.e -c^., • ■•• "•*
reactic- ■ ■ ---^'^ -■-
\fiew^ -- . .-- ^
some, sue -.ire e^'^re*^ 'i '■*■
tiaxatrve etf ect. Ottce • - : ■ :
bloodL so« ■ carbonate increases the
jf the tatter, though tts r.-
excrenott readers fit tfiffrcttlt ts* ((jfecaiu
a lastitrg: rescttt bbb t&cs respect- "^
of che ortEce cs redttced ■
ir^'T-r^ """creased: whe--
- ij'cii Clvch t*; — ^''er .. ^ .. " :
■<i. sodiora: ._ . • 'ate tr^av" b
fee it arcchangeii
Scilrttni btcarfjorctte alwtEjrs strmtt-
EEfees t&e gttstric seci?etrotts^ Ehe %>-
tiT^, _...-....- iont«i .„„^ ^._ .. ■
so tfett t&ie fuotf cart [©tve t&ie si
acfti birfbce- Ifee (ssKfissbre ac&lfir?- (it
tfte c&yme ' L T&e
(ira^ ftits a ......j.^. . - ■••£ '■'■-
teJir on. tfce fctniy paiix c: -
ever m. secretary iaiSTrfEcxiaiiey- im
fr- ■'•:^st resTrfts- ar^
Qi; ..^.- . - . -. ^: --:;i3nral q£ twx?
6;ottrs before tfee nretr for a i&se of
0:5 QiL- {73 ^srams'i : tixee fcotrrs for
trwrnre fefri-s dose., lavf foar fcomrs for
I • ■ ■• ■ ■' - "— ~~ r— ■•ns-).. Vf— '
sir; , ev^Hi •' : ■
tfee nteaDs. TBae isrvx^ remfeirs t&e
stQniaid&: content alkaEiie smS. amdier
tfre stfimtttttiba of tMs tEte se ■
180 SODIUM (SAJOUS).
cial Kissingen salt). Dose, 80 grains Small amounts of salt have been found
(5.5 Gm.) in 6 fluidounces (200 c.c.) at times to lessen the acidity of the
of water. gastric juice, but the greater palatabil-
Pulzns salis Vichyani factitii effer- ity of food seasoned with salt may
vescens, N. F. (effervescent artificial counteract this Ijy augmenting the re-
Vichy salt). Dose, 57 grains (3.75 flex gastric secretion. The salivary
dm.) in 6 fluidounces (200 c.c.) of flow is increased by salt, partly through
water. reflex action and partly because some
Piilvis salis Vichyani factitii effer- of it is excreted by the salivary glands.
vcsccns cum lithio, N. F. (efifervescent Absorption of ingested hypotonic
artificial Vichy salt with lithium), solutions of salt takes place chiefly
Dos.e, 90 grains (6 Gm.), representing from the intestine, and results in a
14 grains (1 Gm.) of artificial Vichy diluted condition of the blood — hydre-
salt and 5 grains (0.3 Gm.) of lithium mia — which induces diuresis. The flow
citrate. of urine is increased more by direct
PHYSIOLOGICAL ACTION.— saline infusion into the blood than by
Sodium as an element or ion exerts in saline solution (or water) absorbed
moderate amounts, different from po- from the stomach and bowel. Hyper-
tassium, little or no effect upon the tonic salt solution injected into the
tissues of higher animals. That the blood causes marked diuresis through
sodium ion may exert a deleterious ac- absorption of water from the body tis-
tion on some animal cells is shown, sues, but hypertonic salt solution in-
however, by the observation that some gested causes little or no diuresis, as
ova and fish ordinarily inhabiting sea- the salt is only slowly absorbed from
water survive longer when placed in it, and though tending, for a time, to
distilled water than when placed in a increase the total bulk of the blood,
solution of sodium chloride isotonic does not render it hydremic,
with sea-water. More concentrated Sodium hydroxide (caustic soda),
solutions of sodium chloride, in addi- like potassium hydroxide and calcium
tion to a possible ionic poisonous ef- oxide, is a strong caustic, destroying
feet of the kind just described produce tissue by abstraction of water, dissolu-
the effects characteristic of "salt ac- tion of albumin, and saponification of
tion" in general, viz., withdrawal of fats. Similar effects are produced by
water from cells, with corresponding liquor sodii hydroxidi and by soda cum
shrinkage of the latter and, where the calce (N. R).
occasion presents, effects due to irrita- Sodium hypochlorite, official in the
tion, such as vomiting in the case of liquor sod?e chlorinatse or Labarraque's
the stomach. solution, gives off chlorine and pos-
According to the experiments of sesse? the antiseptic, deodorant, and
Miinch, exhibition for a few days of bleaching properties of the latter. It
large quantities of sodium chloride in is decidedly irritating to the tissues,
man causes at first a slight decrease but this property may be reduced,
in excretion (especially renal), with a seemingly without loss of antiseptic
corresponding gain of body weight; power, by the addition of suf^cient
after a time, however, the excretions boric acid to neutralize the free alkali
-ncrease and the weight decreases, in the preparation.
SODIUM (SAJOUS).
181
Sodium acetate, like other salts of
alkalies with the vegetable acids, is
rapidly absorbed and oxidized in the
system to form sodium carbonate,
which increases the alkalinity of the
blood and urine, and causes diuresis.
Over direct ingestion of alkaline car-
bonates or bicarbonates, sodium acetate
and similar salts have the advantage
of not neutrahzing the gastric juice.
Sodium bicarbonate, applied in solu-
tion to mucous membranes, exerts a
soothing effect, and tends to dissolve
thick mucus. It is mildly alkaline, but
the alkalinity of its solutions increases
on standing, because of the loss of
carbon dioxide. Applied in dilute solu-
tion to isolated contractile organs, in-
cluding vessel-walls and ciliated epi-
thelium, it causes for a time, like other
dilute alkalies, increased activity and
tonicity, and in certain protozoa an
increased resistance to asphyxia from
oxygen exclusion; later, the augmented
activity is replaced by depression.
Experiments in dogs have shown
that the alkaline carbonates, adminis-
tered internally, do not influence the
rate of gastric secretion. They tend,
however, to increase gastric motility
by virtue of the carbon dioxide liber-
ated through reaction with the hydro-
chloric acid of the gastric juice, and
may also in themselves, by inducing
slight local irritation, exert a mild
carminative effect, relieving gaseous
distention and the consequent pain.
Five grains (0.3 Gm.) of sodium bi-
carbonate, if completely utilized in the
destruction of the gastric acid, are
capable of neutralizing about 1^
ounces of gastric juice of 0.3 per cent,
strength. Where the stomach contains
no acid, as in the resting period be-
tween the digestion of successive meals,
sodium bicarbonate simply dissolves the
gastric mucus and is absorbed un-
changed. Neutralization of the gastric
acid has been held to reduce pancreatic
secretion, the normal stimulus to the
pancreas resulting from the entrance
of acid into the duodenum having been
partly or completely removed. In gas-
tric hyperacidity, however, it may,
nevertheless, be beneficial by allaying
excessive irritation by the gastric acid
in the duodenum, thereby relieving
catarrh of the latter. Stadelmann and
others have shown that alkalies exert
no direct influence on the secretion or
reaction of the bile, in spite of former
views to the contrary. According to
some, sodium bicarbonate exerts a mild
laxative effect. Once absorbed into the
blood, sodium bicarbonate increases the
alkalinity of the latter, though its rapid
excretion renders it difficult to obtain
a lasting result in this respect. The
acidity of the urine is reduced and its
total output increased; where enough
has been given to render the urine
alkaline, sodium bicarbonate may be
found in it unchanged.
Sodium bicarbonate always stimu-
lates the gastric secretions. In hy-
perchlorhydria it should be given in
large doses some time after meals,
so that the food can leave the stoin-
ach before the excessive acidity of
the chyme has been restored. The
drug has a remarkable soothing ac-
tion on the tardy pain of digestion,
even in secretory insufficiency. In
hypochlorhydria the best results are
obtained with an interval of two
hours before the meal for a dose of
0.5 Gm. (7.5 grains); three hours for
twice this dose, and four hours for
a dose of 5 Gm. (75 grains). Very
small doses can be given even with
the meals. The drug renders the
stomach content alkaline, and under
the stimulation of this the secretions
gradually pour out to neutralize the
alkalinity, and normal acidity is thus
184
SODIUM (SAJOUS).
acetic, citric, or tartaric acid, which
are often available in the form of
vinegar, or lemon-juice. Passage of
a stomach-tube is dangerous, as it
might penetrate the corroded gastric
wall.
Olive oil, lard, white of egg, or
milk, should be given as demulcents.
Morphine may be given to alleviate
the pain. Stimulants may be re-
quired to combat collapse ; external
heat should also be applied under
these circumstances. Later, the pas-
sage of bougies or surgical proced-
ures to overcome stenosis may be
necessary.
SODIUM BICARBONATE AND
CARBONATE.— Sodium bicarbonate
is free of caustic action, but the car-
bonate may corrode tissues when ap-
plied for some time in concentrated
solution. Giving large amounts of
the alkaline carbonates and bicar-
bonates to animals has been observed
to induce a chronic gastroenteric in-
flammation, which may prove fat-al.
Sodium bicarbonate in large doses,
such as 300 grains (20 Gm.) or more
daily, may cause an increase in body
weight, due to retention of chlorides
with resultant water retention, which
may go on to the appearance of
edema. This condition is most likely
to appear during the administration
of the bicarbonate to cachectic dia-
betics with acidosis, but it can be
produced in an experimental way in
normal individuals. L. A. Levison
(Jour. Amer. Med. Assoc, Jan. 23,
1915).
SODIUM CHLORIDE. — Serious
symptoms and frequently death have
resulted from the introduction of a
large quantity of sodium chloride into
the system. Such poisoning occurs
oftenest from the inadvertent use of
a strong salt solution instead of nor-
mal saline solution for proctoclysis or
intravenous infusion, but is reported
also to be a common method of sui-
cide in one of the provinces of China,
a pint or more of saturated salt solu-
tion being ingested for this purpose.
Combs reported a fatal case, with
crenation of the erythrocytes in fresh
blood, in a woman who received about
4 ounces (120 Gm.) of salt in a strong
solution by hypodermoclysis.
The symptoms of sodium chloride
poisoning consist of nausea, vomiting,
diarrhea, fever up to 104° F. (40° C),
delirium or coma, and fatal collapse.
In cases with diminished renal per-
meability and salt retention, as in
nephritis or eclampsia, even normal
saline solution may increase edema
and induce edema of the lungs, or the
v^omiting of fluid rich in chlorides
(Bastedo). Marked edema of the
legs from prolonged use of large
amounts of salt with the meals has
also been reported.
Case of a healthy boy of 5 years
who received an injection of strong
brine as a domestic remedy for
worms. The mother made the mis-
take of putting a pound instead of
a tablespoonful of salt in a quart of
water. In five or ten minutes the
child was taken with pain in the
head, intense thirst, and vomiting,
soon followed by severe purging. In
thirty minutes he had become un-
conscious, and one convulsion fol-
lowed another until death occurred
five hours after the injection. O. H.
Campbell (Jour. Amer. Med. Assoc.
Oct. 5. 1912).
SODIUM NITRATE. — The ni-
trates, in excessive amount, especially
if taken in concentrated form, cause
gastric pain, nausea, vomiting, and
sometimes diarrhea. Blood may be
eliminated with the vomitus and
stools. Either diuresis or oliguria
may be noted. Further symptoms
SODIUM (SAJOUS).
185
are motor weakness, mental dullness,
collapse, and . coma, terminating in
death. Dilute nitrate solutions may
be taken in large amount without
trouble, but the more concentrated
ones induce the symptoms referred to.
SODIUM SULPHATE.— Large
amounts of a strong solution of this
salt cause repeated alvine discharges,
which finally consist chiefly of mu-
cous fluid stained with bile. Serious
poisoning with it is rare.
SODIUM SULPHITE AND
THIOSULPHATE.— Although large
amounts of the sulphites have been
taken by man without the production
of poisoning, symptoms or irritation
of the alimentary tract have been
noted after even small doses. Some
of the irritation of the stomach is as-
cribed to the liberation of sulphurous
acid by the hydrochloric acid of the
gastric juice.
THERAPEUTICS. — Gastrointes-
tinal Disorders. — The alkaline salts of
sodium, especially the bicarbonate,
are used extensively in disorders of
the alimentary canal. Given in the
digestive period, the bicarbonate di-
minishes the secretion of gastric
juice, neutralizes some of the hydro-
chloric acid, and acts as a carmina-
tive by setting free carbon dioxide.
Where organic acids are present, it
may likewise neutralize them, and
by doing so lead to the opening of a
pylorus previously in spasm.
In continuous gastric hyperacidity
and in cases witli gastric fermenta-
tion and resulting "sick headache,"
preparation of the stomach for a meal
may be effected by giving a dose of
sodium bicarbonate an hour before it.
In the fermentation cases coml:)ina-
tion of calomel with it may be ad-
vantageous. For hyperchlorhydria
manifesting itself after meals, the
drug is also very eft'ective, and is
beneficial, especially when taken one
to two hours after the repast. A
combination of sodium carbonate and
magnesium oxide may be even more
grateful, the latter compound exert-
ing, in addition, a local sedative ef-
fect. Where, however, stimulation of
evacuation is particularly desired, an
efl^ervescent mixture of sodium bi-
carbonate, 30 grains (2 Gm.), with
tartaric acid, 10 grains (0.6 Gm.) —
dissolved separately in half a glass-
ful of water, then mixed — is of value.
Such a mixture may also prove
useful in the vomiting attending
acute inflammatory diseases and the
exanthemata.
The early morning acidity of hy-
peracid cases may be prevented by
the exhibition of a dose of sodium
bicarbonate the night before. Mucus
may be removed from the stomach,
preparatory to breakfast, by a dose
taken on arising. In alcoholic gas-
tritis lavage with a dilute sodium bi-
carbonate solution is useful for the
same purpose.
In gastric hyperacidity alkalies
have two indications. They may be
employed in the late pain of hyper-
acidity, but the tendency of the pa-
tient toward abuse of the drug must
not be forgotten, for excessive use
may cause gastritis. The author pre-
fers bismuth subnitrate in large doses
to the alkalies. The alkalies may
also be employed to hasten the di-
gestive process; here the so-called
Vichy cure may likewise prove bene-
ficial. The use of artificial Carlsbad
salt seems, however, of greater
value, the results being more last-
ing. Hayem (Tribune med., xli, 281,
1908).
The prolonged suppression of salt
in the diet reduces pain and vomiting
in conditions of hyperacidity, while
186
SODIUM (SAJOUS).
in other conditions in which the HCl
is deficient the use of salt increases
it and aids digestion greatly. The au-
thor's experiments on a healthy man,
following out L. Mcunicr's technique,
showed that with certain foods, as
meat, the digestion was the same
with or without salt, but with other
foods, such as milk, eggs, and car-
bohydrate foodstuffs, the digestion
was delayed from ten to twenty min-
utes when no salt was given with
them. Thus, in certain subjects and
with certain foodstuffs, the addition
of sodium chloride to the diet favors
the gastric secretion. A. Martinet
(Presse med., Apr. 1, 1908).
In children, where an antacid is re-
quired and constipation is present,
sodium bicarbonate is preferable to
lime-water.
In yeasty vomiting, especially when
sarcinse are present, sodium sulphite
is often of value in doses of from 5
to 20 grains (0.3 to 1.3 Gm.). The
vomiting due to acid fermentation of
starches and sugars may be relieved
by the same salt in doses of from 20
to 60 grains (1.3 to 4 Gm.), or by
sulphurous acid, in doses of from 5
to 60 minims (0.3 to 3.6 c.c), well
diluted).
In cases with dyspeptic pains asso-
ciated with motor insufficiency, E.
Binet recommends the use of two of
the following powders at intervals,
respectively, of one hour and half an
hour before meals, and, if necessary,
at the same intervals afer meals : —
R Sodii bicarbonatis.. gr. xij (0.75 Gm.).
Magnesii oxidi pon-
derosi gr. iv (0.25 Gm.).
Pulveris belladonH'CC
folioruni gr. % (0.01 Gm.).
Pone in chartulam no. j.
Where there is pylorospasm due to
hypersecretion, a powder should be
taken one hour after the meal and re-
peated at one and one-half-hour inter-
vals until the next meal.
In duodenal ulcer sodium bicar-
bonate may give relief when the
"hunger pain" appears.
In catarrhal jaundice, sodium bicar-
bonate, combined with rhubarb, has
been considered especially useful.
The official mixture of rhubarb and
soda may be given.
In chronic hepatic affections good
results have at times followed the use
of the solution of chlorinated soda, in
doses of from ^ to 2 drams (2 to 8
Gm.), diluted in from 4 to 8 ounces
(120 to 240 c.c.) of water. .
In constipation sodium sulphate is
not as often employed as some other
drugs in human beings, though
largely used in veterinary practice, as
it is one of the most irritant of the
saline purges, producing large, watery
stools with considerable griping. The
purgative dose is from ^ to 1 ounce
(7>4 to 30 Gm.). It should be used
with some caution if any intestinal
inflammation be present. It is one of
the constituents of Carlsbad, Hun-
yadi, and similar waters. According
to Maberly, it frequently acts as an
intestinal antiseptic in small doses.
Sodium sulphate is an intestinal
antiseptic. After observation of its
action in dysentery and infantile di-
arrhea, the writer relies almost en-
tirely on it in all septic bowel
complaints. To obtain the antiseptic
action one must avoid doses having
an aperient action. The dose should
begin with about 6 grains (0.4 Gm.)
for a baby under 6 months of age,
increasing up to 1 dram (4 Gm.) for
adults, given every six hours in one
of the flavored waters, such as fen-
nel. Children over 6 months old
seldom exhibit any aperient effects
from doses of 14 to 20 grains (0.9 to
1.3 Gm.). The writer also uses the
drug in typhoid fever; the stools,
SODIUM (SAJOUS).
187
from being loose and fetid, become
more normal in appearance and odor,
and the temperature runs a lower
course. Maberly (Lancet, Nov. 10,
1906).
For diuretic purposes, 4 Gm. (1
dram) of sodium sulphate may be
dissolved in 1 or V/2 liters (quarts)
of v^rater, to be divided into three
doses, one in the early morning, on
a fasting stomach; one in the fore-
noon, and one in the afternoon ; the
water must be sipped slowly. For a
light, non-irritating purgative effect,
5 Gm. (V/i drams) of the salt may
be dissolved in Yz or Y^ liter (quart)
of water, to be divided in two doses,
one in the early morning and one an
hour before the noon meal; it should
be taken warm. For an energetic
purgative action, 25 to 60 Gm. (6 to
15 drams) of sodium sulphate are to
be dissolved in 200 c.c. (6 ounces)
of water, sweetened if desired, or
flavored with lemon, peppermint, or
anise-seed, according to taste, to be
taken at one dose. Alfred Martinet
(Presse med., Aug. 23, 1911).
Physiological salt solution passes
through the gastrointestinal tract
without irritating it or interfering
with osmotic conditions. There is
nothing which passes along so rap-
idly. The writer has patients drink
2 glassfuls of a 0.9 per cent, solution
of sodium chloride twenty minutes
before breakfast. After nine or
twelve minutes defecation followed.
The stomach expels the solution
promptly, and reflexly sets up peris-
talsis throughout the intestinal tract.
The larger the amount ingested the
more rapid the passage. Most min-
eral waters are hypertonic and are
absorbed in the duodenum unless
large quantities are taken. After
drinking the salt solution on an
empty stomach in the morning the
writer has the patient follow it with
a cup of coffee or other appetizing
drink. In atony of the stomach, the
rapid expulsion of the physiological
salt solution makes it a valuable reg-
ulator of the bowels. Best (Med.
Klinik, July 27, 1913).
The use of sodium citrate has been
strongly recommended in the treat-
ment of digestive disorders, especially
in children, as well as in acidosis and
in pneumonia. According to Lacheny,
15 grains (1 Gm.) of the salt allay
dyspeptic pain in the stomach and 23
grains (1.5 Gm.) promptly arrest most
attacks of vomiting.
The chief uses of sodium citrate
in infant feeding are as follows: (1)
for weaning the healthy infant; (2)
for increasing the amount of milk
taken in the twenty-four hours; (3)
for correcting milk dyspepsia, and
(4) for the avoidance of scurvy. It
is not antibacterial. A good propor-
tion is 1 grain (0.065 Gm.) of sodium
citrate to the ounce (30 c.c.) of milk.
Poynton (Brit. Med. Jour., Oct. 21,
1905).
Good results obtained from the use
of sodium citrate added to milk in
infant feeding when gastric disorders,
especially vomiting, exist. When so-
dium citrate is added to milk the
coagulum is less solid and lighter.
This is due to the fact that in the
presence of sodium citrate the cal-
cium salts, especially the chloride,
which augment coagulation, are pre-
cipitated. It is usual to administer
1 to 2 Gm. (15 to 30 grains) a day
to infants. Vomiting due to hypo-
alimentation may derive as much
benefit from its use as that due to
superalimentation. The drug is su-
perior to bicarbonate of sodium in
digestive disturbances in adults, and
does not cause a secondary secretion
of acid in the stomach. Variot
(Tribune med., Oct., 1910).
Sodium citrate facilitates the diges-
tion of milk when a milk diet is be-
ing given, preventing the formation
of large, compact clots where the
fluid is drunk too quickly or in ex-
cessive amounts at one time. Many
cases of infantile dyspepsia yield
when a tablespoonful of a 10-grain
(0.65 Gm.) to the ounce (30 c.c.)
solution of sodium citrate is added
188
SODIUM (SAJOUS).
to each 4-ounce (120 c.c.) bottle of
milk.
Sodium citrate also acts as an al-
kali, is soothing in pyrosis, dimin-
ishes gaseous fermentation, and even
obviates the regurgitation of food.
Even in small doses, it is a good
laxative. In constipation in dyspep-
tics it lessens autointoxication and
obviates mechanical disturbances. In
constipation associated with hepatic
congesion, Huchard frequently ad-
vised its employment, along with
sodium sulphate and bicarbonate: —
IJ Sodii citratis,
Sodii hicarhonatis,
Sodii sulphatis.. . .aa. 3v (40 Gm.).
M. Sig. : One teaspoonful every morn-
ing in a hot infusion.
Plicque (Bull, med., May 31, 1913).
In certain conditions of malnutri-
tion, marasmus, and chronic indiges-
tion in infants and children, Le Bou-
tillier and others have recommended
subcutaneous injections of a dilute
sea-water solution.
In applying the sea-water treat-
ment in infants, the writer followed
the Robert-Simon method, diluting 83
parts of sea-water with 190 parts of
pure spring-water, filtering through
a germ-proof Berkefeld filter, and
putting it up in sterile bottles. The
usual injection sites were just below
the angle of the scapula or in the
gluteal regions, the former being
preferable. The amount injected
varied from 10 to 60 c.c. (2>4 drams
to 2 ounces), the usual dose being
15 to 30 c.c. (^ to 1 ounce), accord-
ing to age and urgency, and from
three times a week to every day for
a short time. Sometimes five or six
injections improved the condition so
much that the patient was discharged.
In other cases the treatment had to
be kept up for several months. There
is improvement in the amount of food
taken within the first two or three
weeks; this is noticeable in older
children suffering from malnutrition
or chronic indigestion. In infants.
distressing colic was invariably re-
lieved within the first two weeks.
The skin, often harsh, dry, and scaly,
cleared up entirely, whether in in-
fants or in older children. The pa-
tients who were losing weight or
stationary, as a rule, gained after the
first few treatments, sometimes as
much as an ounce a day. The sleep
of many patients was markedly im-
proved. The treatment is a useful
adjunct of other methods in the mal-
nutrition of tuberculous disease "t
that following any of the infectious
diseases, T. LeBoutillier (Jour. Amer.
Med. Assoc, Jan. 1, 1910).
In the cyclic vomiting of children,
rectal or oral administration of a 2
per cent, solution of sodium bicar-
bonate is an essential measure where
■ acidosis exists, in conjunction with
the administration of dextrose, seda-
tion of the vomiting reflex by means
of drugs, and exhibition of fluids in
copious amounts.
In cancer of the stomach the use of
sodium chlorate has, in some cases,
been followed by good results. The
initial dose recommended by Brissaud
is 2 drams (8 Gm.) daily, in divided
doses ; this is gradually increased un-
til 4 drams (16 Gm.) are taken. If
albuminuria be present or develop,
the drug is contraindicated.
In mercurial stomatitis, aphthae,
mucous patches, and ulcers of the
tonsils, sodium sulphite in 1 to 8
solution may be applied with a cot-
ton pledget, or in the form of spray.
Calomenopoulo has emphasized the
utility of sodium chlorate in mercurial
stomatitis. He also noticed that so-
dium chlorate in large doses reduced
intolerance to potassium iodide where
this drug was being taken in full
doses for syphilis.
Seatworms {Oxyuris vermicularis)
may be dislodged from the rectum by
SODIUM (SAJOUS).
189
injection of a solution of the chloride,
and, with them, the intense itching.
The injections should be given every
morning, then every two to four
evenings, with the buttocks ele-
vated or in the Knee-chest posture
until all evidence of the worms has
disappeared.
In dysentery the use of sodium ni-
trate in dram (4 Gm.) doses, freely
diluted, every three hours, has been
recommended.
Cutaneous Disorders. — In acute
eczema, when there is much serous
discharge, the following application
is efficient: Sodium carbonate, ^
dram (2 Gm.) ; water, 1 pint (500
c.c). The solution may be made
stronger in old cases where the skin
is much thickened. When the weep-
ing has ceased and mere desquama-
tion remains, the alkali ceases toi be
of use.
The pruritus of eczema, lichen,
urticaria, dermatitis, burns, and frost-
bite may be relieved by applications
of the following: Sodium bicarbonate,
3 drams (12 Gm.) ; glycerin and dis-
tilled extract of witchhazel, of each,
3 ounces (90 c.c). The itching of
urticaria and lichen will often yield
to a 1 : 100 solution of sodium car-
bonate, applied with a sponge or
mop.
Poison-ivy eruption and other
forms of pruritus may be similarly
soothed by sodium hyposulphite in
solution (1 to 16), a solution of the
bicarbonate, or by the solution of
chlorinated soda, diluted 1 to 32.
In parasitic skin diseases, espe-
cially those due to the tricophyton
fungus, as pityriasis versicolor, the
hyposulphite (1 to 8) in solution or
ointment is valuable. Startin has
recommended the following: Sodium
hyposulphite, 3 ounces (90 Gm.) ; di-
lute sulphurous acid, ^ ounce (15
c.c.) ; water, enough to make 1 pint
(500 c.c). In tinea versicolor and
pruritus vulvae Fox found the follow-
ing useful : Sodium hyposulphite, 4
drams (16 Gm.) ; glycerin, 2 drams
(8 Gm.) ; water, enough to make 6
ounces (180 c.c).
In scabies also the hyposulphite
has been used successfully. After the
morning bath apply the hyposulphite
in solution (1 to 1) to the affected
part and allow it to dry on the skin.
At night bathe with the following
lotion, which may be diluted if
found too strong: Dilute hydrochloric
acid, 4 ounces (120 c.c) ; distilled
water, 6 ounces (180 c.c.) (Ohmann-
Dumesnil).
For the removal of freckles, sun-
bum, and tan the following lotion
may be used : Sodium chloride, 2
drams (8 Gm.) ; potassium carbonate,
3 drams (12 Gm.) ; rose-water, 8
ounces (240 c.c.) ; orange-flower-
water, 2 ounces (60 c.c). The in-
flammation of sunburn may be sub-
dued by applications of sodium bicar-
bonate in solution.
In hyperidrosis of the feet and
axillae a solution of the carbonate
freely applied locally will remove the
fetor and diminish the secretion of
sweat.
In burns and scalds sodium bicar-
bonate in powder or in solution re-
lieves the pain and soreness very
promptly. It may also be applied
with advantage to insect bites.
The carbonate is used externally
when it is desirable to soften or re-
move scaly or scabby accumulations
upon the skin, as in certain forms of
eczema, plica polonica, etc.
In tuberculous ulcers and in psoria-
190
SODIUM (SAJOUS).
sis, g^ood results have at times been
secured with hypodermic injections
of diluted sca-ivatcr, as orijuinally
su.G^n;-ested by Robert-Simon and
Quinton.
Genitourinary Disorders. — Irrita-
tion of the urinary })assa£;;"es due to
an excess of acid may be allayed by
sodium bicarbonate in doses of 10 to
20 g-rains (0.6 to 1.3 Gm.), given in
a glass of water, every four hours.
In cystitis a 1 per cent, solution of
the bicarbonate may be used to wash
out the bladder when an acid condi-
tion of that viscus exists.
Some relief is afforded in gonorrhea
by injections of a 1 per cent, solution
of the bicarbonate.
In malarial hematuria sodium hy-
posulphite is given with advantage in
doses of from 10 to 30 grains (0.6 to
2.0 Gm.), every four hours. Its mode
of action is unknown.
Fischer's solution, containing 10
Gm. (150 grains) of sodium car-
bonate (crystallized) and 14 Gm. (210
grains) of sodium chloride to the liter
(quart) of water, has been used in-
travenously in amounts up to 2 liters
(quarts) for the relief of anuria in
scarlet fever, eclampsia, Asiatic chol-
era, etc. In less urgent cases of im-
paired renal function, including cases
of chronic nephritis, the sodium bicar-
bonate may be increased to 15 to 30
Gm. (225 to 450 grains) in the liter,
and the solution given per rectum by
the drop method.
Sodium chloride having long been
known as a powerful diuretic, the
writer used it as a last resort in ad-
vanced nephritis, and obtained striking
benefit after a prolonged period on a
salt-free diet. When no benefit fol-
lows the salt-free diet, a single large
amount of sodium chloride, 1 to 3
days during the week, may induce
marked diuresis and considerable clin-
ical improvcnunt. Polag (Schweizer.
mcd. Woch., i, 29, 1920).
Laryngologic and Respiratory Dis-
orders.— In asthma the use of potas-
sium nitrate in 3- or 4- grain (0.2 or
0.26 Gm.) doses has been highly
commended. The drug is probably,
in part, changed to a nitrite in the
system, and acts as such.
In pulmonary hemorrhage the ad-
ministration of dry salt is a popular
remedy.
Use of salt by the mouth or in
infusion recommended to control
hemorrhage. Salt enhances the co-
agulating power of the blood in the
living subject, though not in the test-
tube. This may be due to the mobi-
lization of thrombokinase stored up
in the tissues. In 29 cases of hem-
optysis the writer obtained excellent
results by giving 75 grains (5 Gm.)
of sodium chloride by the mouth,
coagulability being much increased
thereby for an hour to an hour and
a half. The effects become evident
in a few minutes. If the tendency
to hemorrhage returns later, the dose
of salt is repeated, or potassium bro-
mide substituted in the dose of 45
grains (3 Gm.), the bromide having,
further, a sedative action. In the most
urgent cases the use of sodium chlo-
ride and potassium bromide, in full
doses, may be combined. R. von den
Velden (Deut. med. Woch., Feb. 4,
1909).
In capillary hemorrhages, including
capillary hemoptysis, in the hemor-
rhagic diathesis, and in epistaxis and
metrorrhagia, Reverdin claims 2-grain
(0.13 Gm.) doses of sodium sulphate
every hour to be of great value. The
drug must be given by mouth or
intravenously, not hypodermically.
It is believed by him to increase the
coagulabilitv of the blood.
In acute tonsillitis, catarrhal condi-
tions, bronchitis, etc., sodium l)icar-
SODIUM (SAJOUS). 191
bonate in solution may be combined Solutions of sodium bicarbonate are
with hamamelis, belladonna, or other extensively used in catarrhal condi-
remedial agent. According to Bulk- tions to soften and remove dried
ley, coryza may be successfully secretions and thickened mucus. Do-
treated by giving 20 to 30 grains bclVs solution (sodium bicarbonate and
(1.3 to 2 Gm.) of the sodium bicar- borax, of each, 2 drams — 8 Gm. ;
bonate in 2 or 3 ounces (60 or 90 c.c.) phenol, 24 grains — 1.5 Gm. ; glycerin,
of water, every half-hour, for three 14 drams — 56 Gm. ; water, 1 pint —
doses, with a fourth dose an hour 500 c.c.) is largely used for this pur-
from the last one. Two to four pose. Pynchon has recommended the
hours are next allowed to elapse, and following as better : Sodium bicar-
the four doses are then repeated if bonate and borax, of each, 2 ounces
there seems to be necessity, as is fre- (60 Gm.) ; listerin (liquor antisepti-
quently the case. After waiting two cus, U. S. P.), 8 ounces (240 c.c);
to four hours more the same course glycerin, 1^ pints (750 c.c.) ; of this
may be taken again. To be promptly add 1 ounce (30 Gm.) to 1 pint (500
effective the measure should be begun c.c.) of water.
with the earliest indications of coryza Gynecological and Puerperal Disor-
and sneezing, when it rarely fails to ders. — Leucorrhea, when dependent
break up the cold. upon an increased secretion of the
K. E. Kellogg points out that in cervical glands, frequently yields to
hay fever marked relief from the injections of a 1 per cent, solution of
rhinitis symptoms follows the taking the bicarbonate. This secretion is
of sodium bicarbonate in 1-dram (4 strongly alkaline, and is checked on
Gm.) doses three times a day. The the general principle that alkalies
drug appears to have a desensitizing check alkaline secretions.
action on the mucous membranes. In puerperal metritis the solution
In a few cases he found it necessary of chlorinated soda (1 part to 10 or
to supplement the treatment with a 12 of water) has been used as an
nasal spray of sodium bicarbonate antiseptic injection. In the same
solution. strength it may be used as a vaginal
In affections of the throat and douche when the lochial discharge
fauces, sodium chlorate is a better becomes fetid. It is also a useful
and safer remedy than the potassium injection in simple and gonorrheal
salt. vaginitis.
In malignant forms of sore throat A hypertonic solution of 4 drams
and in diphtheria the official solution (16 Gm.) of sodium chloride and >4
^r ^1,1^,-;,,^+ A A^ rj/ A. o j^^^„ dram. (2 Gm.) of sodium citrate to
of chlormated soda (% to 2 drams — , . .r^r. n r i
_ ^ ^ . . r. the pint (500 c.c.) of water proved
2 to 8 Gm.—m water, 4 to 8 ounces— ^^^ effective vaginal douche in all
120 to 240 c.c.) has been used as a inflammatory diseases of women and
gargle. Sodium sulphite in solutiotl in septic conditions, giving better
(1 to 8) may be used as a gargle, results than the customary antiseptic
spray, or local application in similar douches. In infected puerperal le-
... T , , , 1 • sions of the genital tract healthy
conditions. It has also been used in- , ^. „ ^^^„^^a ;„ -, f«,„
granulation was secured in a tew
ternally in combination with sulphur ^ays. After clearing out the uterus
and calomel. in puerperal sepsis and douching it
192
SODIUM (SAJOUS).
with the hypertonic saline solution,
a few tablets of salt left in the uter-
ine cavity cause the flooding of any
remaining organisms with the serum
drawn out to dissolve the salt and
materially hasten recovery. All con-
ditions producing pelvic congestion
responded well to the hypertonic
douches. Enemata of water contain-
ing from 3 to 6 or 8 drams (12 to 24
or 32 Gm.) of salt to the pint (500
c.c.) proved effective in emptying
the bowel in eclampsia and other
conditions requiring a watery evacu-
ation for the removal of toxic ma-
terial. Clifford White (Lancet, Oct.
30, 1915).
Constitutional Disorders. — Acute
rheumatism, though usually best
treated with the salicylates (see
Salicylic Acid), is also amenable to
the action of the alkalies. Sodium
bicarbonate is of great service in
allaying the pain and soreness of the
joints when given internally in doses
of from 15 to 30 grains (1 to 2 Gm.)
every four hours. It may also be
used in solution as a lotion, applied
around the joints on lint or cloths.
Sodium nitrate in solution (1 to 3)
has been used externally in like man-
ner. Sodium acetate has been given
in acute rehumatism and gout, but its
value is less than that of the corre-
sponding potassium salt.
In conditions associated with acido-
sis, including diabetes mellitus, so-
dium bicarbonate or carbonate have
been extensively used. To act as a
blood alkalinizer sodium bicarbonate
should be given shortly before meals,
when no acid to neutralize it is pres-
ent in the stomach. In diabetic coma,
delayed chloroform poisoning, and
similar severe states of acidosis, doses
as large as ^ ounce (15 Gm.) of
the bicarbonate have been given by
mouth, or by the rectal drop method,
amounts up to 1% ounces (50 Gm.)
a day, in a 3 per cent, solution in
water. At times, gratifying results
have been obtained.
Sodium citrate advocated in place
of sodium bicarbonate for use in
acidosis. It is practically tasteless,
and may be added to the food or
given in water and lemon-juice. Al-
though the author has given as much
as l}/2 ounces (45 Gm.) a day, it
causes much less digestive disturb-
ance than the bicarbonate, and diar-
rhea never followed its administra-
tion. Lichtwitz (Therap. Monat.,
XXV, nu. 81, 1911).
The hypodermic use of sodium bi-
carbonate solutions has fallen into
disrepute on account of their ex-
tremely irritating properties. This is
because during sterilization this salt
is largely converted into sodium car-
bonate. The latter may be recon-
verted into sodium bicarbonate if
carbonic acid gas is allowed to
bubble through the sterilized solu-
tion. The latter is then well borne
both subcutaneously and intraven-
ously, and is indicated in diabetic
coma. A 4 per cent, solution should
be used. The writer advocates the
preparation of such solutions in
sealed flasks with a carbonic acid
atmosphere. Magnus-Levy (Med.
Klinik, S. 2001, 1914).
Vorschiitz has called attention to
the value of an alkali in whipping up
the body cells to proper metabolism
and elaboration of protective sub-
stances. A deficiency of alkali, he
asserts, may be responsible for defec-
tive antibody production. In cases
with severe septic processes, osteo-
myelitis, scarlatinal nephritis with
abscess, etc., he witnessed good ef-
fects from having the patients drink
during the day a bottle of Seltzer-
water, in which 150 to 300 grains (10
to 20 Gm.) of sodium bicarbonate had
been dissolved. Although in some
SODIUM (SAJOUS).
193
cases gastric discomfort necessitated
at times svispension of the treatment
for a day or two, some patients took
the doses mentioned for weeks with-
out disturbance, and all cases thus
treated recovered.
Surgical Disorders. — In fractures
and sprains a solution of sodium sili-
cate constitutes a valuable dressing,
as it rapidly becomes hard and im-
movable when painted over the band-
ages and thus forms an immovable
splint which is cleaner than plaster
of Paris and equally effective.
Morbid growths, warts, etc., may
be removed by applications of caustic
soda or of London paste.
Wright's solution, composed of 4
per cent, sodium chloride and 1 per
cent, sodium citrate in water, is
useful in the treatment of infected
cold more of the hot solution is
poured over the whole dressing. The
solution is contraindicated if there is
a tendency to persistent oozing of
blood from the wound, and when
protective adhesions are desirable, as
in certain abdominal wounds just
after operation. The solution should
be used only for the first thirty-six
to seventy-two hours after operation,
during the acute stage of the mflam-
mation. If used longer it leads to
maceration and indolence in healing.
L. R. G. Crandon (Annals of Surg.,
Oct., 1910).
Wright's citrated isotonic solution
(sodium citrate, 0.5; sodium chloride,
3.0; distilled water, 100) used with
great satisfaction in the treatment
of wounds. G. K. Dickinson (Med.
Rec, June 20, 1914).
Foul ulcers, sinuses, etc., may be
cleansed with liquor sodse chlorinatae,
diluted in the proportion of ^ to 4
wounds, abscesses, etc. The citrate, drams (2 to 16 c.c.) to 8 ounces (250
by precipitating the calcium salts in c.c.) of water. In military practice
the lymph, prevents coagulation and a 3^ per cent, solution of sodium hy-
insures free exit of lymph discharge, pochlorite has been extensively used
The chloride, in hypertonic solution, for checking infection in wounds,
hastens the flow of lymph by osmosis, Dakin's solution is prepared by dis-
thus antagonizing bacterial develop- solving, in 10 liters (quarts) of tap-
ment, and is itself antiseptic owing to water, 140 Gm. (4^^ ounces) of dried
its hypertonicity. sodium carbonate (or 400 Gm. — 13
In using Wright's solution for ounces — of the crystalline salt) and
drainage, the abscess is opened by a 200 Gm. (6% ounces) of good quality
calcium chloride. The mixture is well
shaken up and after half an hour the
clear liquid separated by siphonage,
filtered through cotton, and 40 Gm.
(1% ounces) of boric acid added. In
Carrel's technique of wound treat-
ment, rubber tubes surrounded by an
absorbent, spongy material are car-
ried to the bottom of the wound and
in each of its recesses, and Dakin's
solution is injected into the tubes at
one or two-hour intervals, or, better,
introduced by continuous instillation
by the drop method.
wound as small as will allow the
cavity to be wiped out, or thor-
oughly emptied by expression. The
surrounding skin is thoroughly
cleaned with 70 per cent, alcohol
and smeared with boric acid or
eucalyptus petrolatum. If the skin
tension closes the lips of the wound
a bit of rubber dam may be put in.
The wound is covered with a large
pad of gauze or of absorbent cotton
covered with gauze, dripping wet
with hot salt and sodium citrate
solution. The part is put at rest.
* Outside the dressing may Ijc applied
a hot flaxseed poultice or a hot-water
bottle. As often as the dressing gets
8—13
194
SODIUM (SAJOUS).
Intravenous infusion of 3 to 5 c.c.
(48 to 80 minims) of a 5 per cent,
salt solution practised with the best
results before operations in which
parenchymatous hemorrhage is feared
or when the blood coagulates less
readily than normal. The measure
is advised in prophylaxis or during
the operation, repeating it every half-
hour as needed. Von den Velden
(Zentralbl. f. Chir., May 21, 1910).
Instruments, especially if plated,
when boiled in a solution of sodium
carbonate or bicarbonate come out
covered with a white scum, are slip-
pery, and less quickly dried, and are
likely to turn black, especially if they
have any blood left on them. The
writer recommends, instead, the use
of sodium hydroxide, which has not
these disadvantages. About 38 grains
(2.5 Gm.) or Y^ inch of stick caustic
to a quart (liter) of water makes the
proper solution. I. M. Ileller (Jour.
Amer. Med. Assoc, Aug. 26, 1911).
CHLORIDES IN URINE.— These con-
sist chiefly of sodium chloride, with a
small amount of potassium and ammonium
chlorides. The healthy adult excretes
from 10 to 16 grams of chlorides in 24
hours. The chlorides are increased nor-
mally, by increased ingestion of salt, by
al^undant drinking of water, and by active
exercise; abnormally, in the first few days
after the crisis of acute febrile diseases,
gradually increasing as the disease abates;
in diabetes insipidus; in dropsy after
diuresis has set in. The chlorides are
decreased normally during repose; abnor-
mally, in all acute febrile conditions (espe-
cially with serous exudations) up to the
crisis, when they may disappear; in pneu-
moniia their absence always indicates a
serious condition; in diarrhea; in chronic
conditions with impaired digestion and
dropsy; during the formation of large exu-
dations; in acute and chronic diseases of
the kidnej'S with albuminuria; in chronic
diseases. A decided diminution or ab-
sence of chlorides in a febrile condition
strongly suggests pneumonia.
Test for Chlorides. — Place 2 drams of
urine in a test-tube, acidify with 10 or 12
drops of nitric acid, C. P., and carefully
add 1 drop of silver nitrate solution
(1 to 8). If the amount of chlorides be
about normal, this drop will form a whit-
ish globule, a solid white ring or one or
more compact, whitish, flocculent lumps,
and will settle to the bottom. If the chlo-
rides are diminished, there will be only
some cloudiness. (Jne may use a speci-
men of normal urine in another test-tube
as control. When the exact quantity of
chlorides is desired, one must resort to
quantitative titration, the technique of
which may be found in larger treatises on
Uranalysis.
SALINE SOLUTION.— Prepara-
tion.— As ordinarily prepared, "nor-
mal" saline solution is of 0.8 to 0.9
per cent, strength. For the prepara-
tion of a sterile solution of this type,
sterile sodium chloride may be dis-
solved in sterile water in the ratio of
1 dram (4 Gm.) of the salt to 1 pint
(roughly 500 c.c.) of water; or, the
solution may be sterilized after the
salt has been dissolved. The solution
should then be filtered into flasks, and
these plugged with non-absorbent cot-
ton and sterilized in toto.
Hypertonic sodium chloride solu-
tions are at times used, as in the
hypertonic saline treatment of Asiatic
cholera devised by Rogers, in which
1.2 or 1.6 per cent, solutions of the
salt are employed. (See Cholera.)
Physiological Action and Uses. —
Introduction of normal saline solu-
tion into the system may be of value
in a variety of ways. In hemorrhage
and in depleted states, such as that
arising in cholera, it is of assistance
to restore the blood volume to nor-
mal, thereby not only favoring better
distribution of blood to the periph-
eral parts of the body, but also im-
proving heart action by allowing the
organ to contract under more normal
mechanical conditions. In toxe.mic
states, saline solution is of value to
promote renal activity and therewith
SODIUM (SAJOUS).
195
elimination of toxic material. Where
the blood-pressure is low, a small sa-
line infusion containing a moderate
amount of epinephrin is of great
value, though unless the administra-
tion be continued the effect soon
wears off through filtration of the
solution from the vessels into the tis-
sues. (Large saline infusions under
these conditions merely favor the pro-
duction of edema.) Saline infusions
are also of value for the relief of
thirst.
Absorption of saline solution, how-
ever given, is generally rapid. In
saline hypodermoclysis a pint of solu-
tion may be absorbed within ten or
fifteen minutes, though at times
marked circulatory weakness greatly
delays the process. After hemor-
rhage, especially rapid absorption oc-
curs from the bowel.
Modes of Administration. — Among
the various routes available are: (1)
the rectal ; (2) the subcutaneous ; (3)
the intravenous ; and (4) the intra-
peritoneal.
(1) Saline enteroclysis (proctocly-
sis ; rectal infusion) is advantageous
in that the slight pain entailed in the
insertion of a needle through the skin
is avoided, and that the use of a sterile
solution is not necessary. The older
method of applying the procedure
consists merely in passing into the
rectum a pint to a quart of saline solu-
tion at 110° F. through a small cathe-
ter, twenty to thirty minutes being al-
lowed for its entrance into the bowel.
The measure may be repeated at four-
hour intervals as long as the necessity
for saline administration persists. An
improved procedure is that recom-
mended by John B. Murphy, in which
precise adjustment of the flow of
saline solution to the absorptive
power of the bowel is sought. An
excellent description of Murphy's
technique of proctoclysis, kindly
furnished us bv Dr. Richard L.
Stoddard, of Rochester, N. Y., is
subjoined : —
Cleansing enemas, to the extent of emp-
tying the intestinal tract of fecal matter,
are necessary before beginning the proc-
toclysis treatment. Thorough elimination
of all formed feces from the intestinal
tract during the preoperative preparation
is of paramount importance.
The saline solution is made by adding
1 dram (4 Gm.) each of sodium chloride
and calcium chloride to each pint (500 c.c)
of hot water. The solution must be main-
tained at a temperature per rectum of 100°
to 110° F.
The average quantity is \y2 to 2 pint3
(250 to 1000 c.c.) every two hours. The
quantity to be given depends upon the
severity of the case, the age of the pa-
tient, and the development of an edema.
The average twenty-four-hour quantity is
18 pints. In a child of 11 years (a patient
of Dr. Murphy's) 30 pints were adminis-
tered in twenty-four hours. Murphy
states that "less than 8 pints in twenty-
four hours is of very little value from a
therapeutic standpoint."
The base of the saline solution container
should be elevated sufficiently — 2, 4, or 6
inches — above the buttocks of the patient
to allow 1^ to 2 pints of the solution to
flow into the rectum in from forty to sixty
minutes. The rapidity of the tlow should
never be controlled by the use of forceps,
clamps, knots, or faucets, in connection
with the tubing. The height of the con-
tainer must always control the hydrostatic
pressure, which should average 4 to 6
inches, and not exceed 15 inches.
The patient is placed in the Fowler
position, and the proctoclysis continued
for two or three days, and sometimes five
or six days. Too much solution after the
third, fourth, or fifth day is indicated by
edema of the ankles, hands, and even the
face, and occasionally i)y threatened heart-
failure. The solution should then be dis-
continued until the circulatory equilibrium
is restored, when the treatment may be
196
SODIUM (SAJOUS).
repeated if indicated. The Fowler posi-
tion, being uncomfortable for many pa-
tients, need be used only in exceptional
cases where abdominal drainage is neces-
sary for twenty-four to forty-eighth hourg.
An excellent and comfortable substitute
for the Fowler position is to raise the
head of the bed 12 to 18 inches.
A medium-sized hard-rubber vaginal
douche tube, with several %- to %-inch
openings, makes a useful rectal tube,
which must be flexed at an obtuse angle
2 or 3 inches from its tip. The rectal
tube will cause no inconvenience if so
strapped to the thigh as not to press on
the posterior wall of the rectum. Fre-
quent changing of the rectal tube, as re-
moving and inserting, or an improper posi-
tion of the tube, or a too rapid flow of
the solution into the rectum, are each and
all very annoying to the patient, and soon
produce an irritation of both the anus and
rectum, resulting in partial or complete
evacuation of the saline solution.
When the patient strains during the act
or vomiting, coughing, or sneezing, or
wishes to expel gas or fluid, provision
should always be made for a sudden re-
turn of the fluid through the rectal tube
and rubber tubing into the saline solution.
For this important purpose, one should
use a medium-sized rectal tube with the
openings as described; avoid attempting
to control or govern the rapidity of the
flow by the use of clamps or faucets,
and also avoid overdoing the hydrostatic
pressure.
If the rectum is not in an irritated con-
dition from surgical interference, or other-
wise, success in the early administration
of large quantities of saline solution will
be had with the above technique.
In case an elaborate and electrically
heated solution container is not at hand,
an ordinary douche-can may be employed,
and may be maintained at the desired
temperature by first immersing a bath
thermometer in the saline solution, and
then surrounding the container with bot-
tles filled with boiling water, or immersing
one or two bottles in the solution. To
further retain the heat, the whole ap-
paratus, bottles and container, may be
wrapped in a warm woolen blanket. By
immersing a 16-candle-power electric-light
globe and a thermometer in the saline
solution, the desired temperature can be
more easily maintained.
For the past three years Dr. Stod-
dard has been using the Ny lander
electric saline heater, which correctly
regulates the temperature. He has
thoroughly tested the Murphy method
of proctoclysis in peritonitis, typhoid,
uremia, diphtheria, pneumonia, shock
from hemorrhage, and local and gen-
eral septicemia, and has found it of
inestimable value, especially if used
early and before the heart has been
badly affected by the intoxication.
In lobar pneumonia proctoclysis
with hot tap-water was usually fol-
lowed in a few hours by abatement
of the signs of toxemia and mental
improvement. In typhoid fever bene-
fit was also noted. In obstinate cases
of delirium tremens the mental state
rapidly cleared up. In 4 cases of
scarlet fever, 2 very severe, excellent
results were obtained. The casts and
albumin found in the urine early in
the disease disappeared before the
patients left their beds. In the inter-
current febrile, "grippal" attacks of
pulmonary tuberculosis, the comfort
of the patient was greatly increased
and the invasion apparently cut short.
In the sudden flooding of the sys-
tem with toxins from confined pus
which not rarely occurs in tuber-
culous subjects, remarkable ameliora-
tion of the symptoms may follow
saline proctoclysis. Henry Sewall
(Amer. Jour. Med. Sci., Oct., 1910).
All patients show less rectal irrita-
tion to proctoclj'sis if given a saline
enema before the operation. Patients
given water by rectum absorb nearly
400 c.c. more in the twenty-four
hours than do patients given salt
solution, the average for the former
being 2444 c.c, and for the latter
2041 c.c. Patients given salt solution
by rectum require nearly twice as
much water by mouth to relieve
thirst — 696 c.c. in the first twenty-
four hours, as against 332 c.c. The
SODIUM (SAJOUS).
197
amount of urine is practically the
same in the two classes of cases. In
drainage cases more fluid may be
taken by rectum than in laparotomies
closed without drainage. Proctocly-
sis should be employed more fre-
quently, and in all classes of cases
in which it is possible. Care should
be taken to prevent "water-logging"
of the system, this applying to both
salt and water. In peritonitis cases
with drainage, the patient can take
four or five times as much fluid by
rectum as in other conditions. H. H.
Trout (Jour. Amer. Med. Assoc,
May 4, 1912).
A new device which consists in
placing a two-quart heating bag near
the patient's rectum, through which
the salt solution pipe passes as in a
hot-water bath, prevents the great
loss of heat from the tube, as in
other methods. In this method the
temperature of the saline as it enters
the rectum at first, when the heating
bag has just been filled, is about 108°
F., from which it drops gradually in
an hour and a half to 98°, when the
heating bag is refilled at 140° F. and
the rectal temperature returns to
108° F. G. H. Tuttle (Inter. Jour, of
Surg., June, 1913).
Proctoclysis method applied to in-
fants in place of subcutaneous saline
injection. Tolerance was perfect,
even in the youngest. Fifty or 100
c.c. of isotonic saline solution or 4
per cent, solution of sugar is ab-
sorbed as rapidly as by subcutaneous
injection. Excellent results obtained
in children of all ages with gastro-
enteritis, cyclic vomiting, acute ali-
mentary anaphylaxis, and typhoid
fever. In some cases a little epi-
nephrin was added. The latter was
more effectual by rectum than by
mouth. Lesne (Bull, de la Soc. de
Pediat., Oct., 1913).
Saline proctoclysis by the drop
method gives in typhoid fever results
as good as, if not superior to, those
of the cold-bath treatment. In the
lung complications of typhoid fever,
dyspnea is relieved and the physical
signs of lung condensation caused to
disappear by the measure. Even in
acute, frank pneumonia, the proced-
ure at once reduces the dyspnea and
liquefies the secretions. The heart is
quieted, marked diuresis supervenes,
and the crisis ordinarily occurs on
the fifth day, though the physical
signs persist a few days longer. P.
E. Weil (Presse med., Feb. 14, 1916).
(2) Saline hypodermoclysis (sub-
cutaneous infusion), while usually
highly efficient, is somewhat painful.
Careful asepsis is required, and care
must be taken not to introduce too
much sokition in a single area, lest
the prolonged anemia of the tissues
lesuh in their devitalization and
sloughing. The method is especially
indicated where the emergency is not
such as to require intravenous infu-
sion but the rectal route is unavail-
able because the bowel is too irritable
or for some other reason.
Hypodermoclysis may be practised un-
der the breast, in the loose tissue over the
pectoral muscle, on the posterior or inner
aspects of the thighs, beneath the ab-
dominal skin, including the iliolumbar
regions, or between the scapulae. The
reservoir for the solution is usually of
glass, preferably graduated. The needle
should be long and preferably of a large
caliber, such as 1 to 2 millimeters, for
although a small hypodermic needle may
be successfully used, greater hydrostatic
pressure is then required and the solution
cools more as it descends through the
tube, necessitating an original tempera-
ture of 110° C, as against 105° C. if the
aspirating needle is used. The entire ap-
paratus should have been sterilized. Be-
fore the infusion is given, the breast, in
the case of women, is carefully disin-
fected. It is then raised, and the needle,
with the fluid flowing from it, gently in-
serted into the cellular tissue beneath the
organ. The pain of the puncture may be
avoided with ethyl chloride. Where ele-
vation of the reservoir is insufificient to
maintain the flow, or the latter stops some
1 98
SODIUM (SAJOUS).
time after, withdrawing the needle slightly
or rotating it will usually start the stream
again. If not, the fluid can be forced in
by anointing one hand and the tube with
petrolatum, and stripping the tube down-
ward between the lingsers. Seven hundred
cubic centimeters of fluid (lyi pints) can
be injected under each breast. After com-
pletion of the procedure the puncture can
be closed with rubber tissue or adhesive
plaster.
Absorption from hypodermoclysis where
the general circulation is markedly im-
paired can be hastened by the addition,
where possible, of enteroclysis, or even a
simple hot saline enema (R. C. Kemp).
Gentle local massage also hastens it.
Salt solution for therapeutic pur-
poses may be injected into the pre-
vesical space of Retzius. This space
is roomy, the connective tissue is
loose, and can easily hold one liter
(quart) of solution. The needle is
inserted just above the symphysis
pubis, and pushed along the rear wall
of the latter. In a large experience,
puncture of the bladder never oc-
curred. The author uses a fairly
large needle. One is thus able to
inject a liter of solution in eight to
nine minutes. D. Schoute (Zentralbl.
f. Chir., July 6, 1912).
For hypodermoclysis the writer
uses a large silver cannula from a
Southey tube apparatus, connected
with a large glass funnnel by means
of a tapered glass tube and a section
of Southey's rubber tubing. This is
all readily portable and readily ster-
ilized by boiling. In administering
the saline the anterior axillary fold
is grasped firmly and drawn out-
ward. The trocar with cannula is
then passed into the skin in a direc-
tion perpendicular to the chest and
pushed through the axillary fold, so
that its point emerges within the
■ axilla. The trocar is then removed
and the cannula is pushed outward
until its shoulder is flush with the
skin. The fluid emerging from this
cannula squirts in all directions. It
is absorbed so rapidly that one can
inject a quart into the tissues in
twenty minutes without any material
swelling occurring. E. M. Wood-
man (Brit. Med. Jour., Feb. 8, 1913).
(3) Intravenous saline infusion is
indicated in the more urgent emer-
gencies, e. g., after very abundant
hemorrhage; in cases of shock; where
prompt elimination of toxic material
from the blood is desired, as in de-
lirium tremens, gas poisoning, and
septicemia, and where anuria has de-
veloped, the rise in blood-pressure
attending intravenous infusion caus-
ing a resumption of renal function.
The apparatus required comprises some
.species of graduated reservoir for the
saline solution, a connecting rubber tube
with pinchcock, and a cannula for inser-
tion into the vessel. A slightly curved
cannula is to be preferred, facilitating
maintenance in the lumen of the vessel.
In emergencies the glass portion of a
medicine dropper may be substituted. As
in hypodermoclysis, the apparatus and
solution used should be sterile. The nor-
mal saline solution should be placed in
the reservoir at a temperature of 120° F.
Another useful form of apparatus com-
prises a large flask, arranged like the ordi-
nary wash bottle, with two glass tubes,
one short and the other long, entering it
through the stopper. The longer glass
tube, dipping into the contained saline
solution, is connected by tubing with the
infusion cannula, while to the other tube
a rubber pressure bulb is attached. Pres-
sure upon this bulb forces air into the
flask, and hence the saline solution into
the vein. The temperature of the solution
in the flask may be maintained by placing
it in a large jar partly filled with hot
water.
Preparation of the patient consists in
placing a constricting bandage around the
upper arm, tightly enough to obstruct the
venous return flow, thus distending and
rendering easily visible the vein to be
employed, usually the median basilic or
median cephalic at the bend of the elbow,
applying alcohol or tincture of iodine at
the latter area, and exposing the vein,
under aseptic precautions, for a distance
SODIUM (SAJOUS).
199
of about one inch. After passing two
ligatures, untied, round the vessel, a small
valve-shaped opening, the flap of vessel
raised pointing distally, is made v^^ith
pointed scissors, and the cannula, well
filled with solution and free of air-bubbles,
passed into the opening. The cannula is
now fixed in the vessel by tying the upper
ligature, the low ligature also tied to close
the vein below, and the constricting band
round the arm removed. The saline solu-
tion receptacle should be at such an alti-
tude, usually about three feet, above the
vein that the solution will run in but
slowly. The heart and blood-pressure
should be watched, care being taken not
to dilate and weaken the former or to
raise the latter excessively by infusing
too much solution. The usual amount is
1 to 3 pints (500 to 1500 c.c). In shock
injection of 1:1000 epinephrin solution
with a hypodermic syringe into the lumen
of the rubber connecting tube may be ad-
vantageous. This should be done slowly,
a few drops being given every few min-
utes until the desired rise in blood-pres-
sure has been obtained. Another good
procedure is to drop the epinephrin, ac-
cording to requirements, in a funnel into
which the saline solution is being poured
at intervals as it is consumed.
Many users of intravenous saline ther-
apy simplify the insertion of the needle
by dispensing with exposure of the vein,
the needle, with an obtuse angle point,
being merely thrust obliquely into the
distended vessel while the solution is flow-
ing. The point of the needle should not
be too sharp, to avoid inadvertent injury
to the vessel's walls after its insertion,
and should be held firmly in proper rela-
tion to the vein while the saline solution
is being run in.
(4) Intraperitoneal saline infusion
is of value at the termination of
abdominal operations attended with
marked shock, provided extension of
an intra-abdominal infection as a re-
sult is not apprehended. J. G. Clark
found that flushing- the peritoneum
with the solution greatly augmented
leucocytosis, and advocates its use
even in peritoneal infections. He
makes it a practice to leave at least 1
liter of solution in the peritoneal
cavity even after the simplest opera-
tions, not only the circulation, but
also the kidneys, skin, intestines, and
all other organs functionating better
under its influence, thirst being re-
lieved, and the virulence of infection
being decreased.
Contraindications. — Saline infu-
sions are contraindicated in many in-
stances of edema, especially where
there is retention of sodium chloride
in the system as a result of renal im-
pairment, and in pulmonary edema.
Pure salt solution often fails to bring
on diuresis in cholemic states, prob-
ably because of a prejudicial action of
the circulating bile on the kidneys.
Other Solutions. — The studies of
Jacques Loeb have shown that a
solution of pure sodium chloride in
distilled water has poisonous proper-
ties owing to the complete absence of
other salts, especially those of calcium
and potassium. As the tap-water gen-
erally employed in the preparation of
normal saline solution is likely to
contain some calcium salts, but little
of which is required to ofit'set the
poisonous influence of the sodium, no
difficulty from the use of the ordinary
normal saline solution is, as a rule,
experienced. The possibility of dan-
ger from excessive displacement by
sodium chloride of the calcium and
potassium salts known to be essential
to the vitality of the body cells is
recognized, and Thies has advised
against the use of pure normal so-
dium chloride solution, especially in
small children with disorders asso-
ciated with a considerable elimination
of salts, in inanition from pyloric
stenosis or other cause, in cachexia,
200
SPIGELIA.
in conditions entailing changes in the
kidneys or cardiovascular system, and
in febrile affections, in which elimina-
tion of salts other than those of so-
dium is augmented. Thies recom-
mends for rectal introduction a solu-
tion containing 0.6 per cent, of sodium
chloride and 0.02 per cent, each of
calcium chloride and potassium chlo-
ride, and for hypodermoclysis, one
containing 0.85 per cent, of sodium
chloride and 0.03 per cent, each of
the other salts. Among other im-
proved substitutes for normal sodium
chloride solution are : —
Dawson's solution, containing 0.8 per
cent, of sodium chloride with 0.5 per cent,
of sodium bicarbonate.
Locke's solution: Sodium chloride, 0.9
per cent.; potassium chloride, 0.042 per
cent.; calcium chloride, 0.024; sodium bi-
carbonate, 0.03, and dextrose (glucose),
0.1 in distilled water. (Schiassi would re-
duce the potassium salt to 0.0075 and the
calcium salt and bicarbonate each to 0.01.)
The Ringer-Locke solution, like the pre-
ceding, but with the nutrient dextrose
omitted.
Fleig's solution: Sodium chloride, 0.65
per cent.; potassium chloride and mag-
nesium sulphate, of each 0.03; calcium
chloride, 0.02; sodium bicarbonate, sodium
glycerophosphate, and dextrose, of each
0.1, in distilled water. Oxygen, ad satu-
randum, may with advantage be added.
H. M. Adler's solution: Sodium chloride,
0.59 per cent.; potassium and calcium
chlorides, of each 0.04; magnesium chlo-
ride, 0.025; sodium dihydrogen phosphate,
0.0126; sodium bicarbonate, 0.351, and glu-
cose, 0.15. This solution, on one occasion,
maintained rhythmic contractions of an
isolated cat's heart for twenty-one hours,
and is intended to provide a mechanism
for maintaining the reaction of the blood,
for neutralizing acids and alkalies, and for
the transport of a sufficiently large amount
of carbon dioxide.
Fischer's solution, containing 1.4 per
cent, of sodium chloride and 1 per cent,
of crystallized sodium carbonate, has been
recommended by W. M. Brown for rectal
or oral introduction in puerperal eclamp-
sia to maintain a proper circulatory vol-
ume after eliminative treatment by ca-
tharsis, hot packs, colon irrigations, or
venesection.
Fischer's solution used in a case
of vomiting of pregnancy where
other measures had failed, giving 20
grains (1.3 Gm.) of sodium bromide
dissolved in a pint (500 c.c.) of this
solution per rectum by the drop
method. A patient with chronic myo-
carditis, mitral regurgitation, and a
moderate degree of arteriosclerosis,
with general edema and vomiting,
was put on Fischer's solution per
rectum by the drop method and
passed a gallon of urine inside of
fourteen hours. Post-partum eclamp-
sia, coming on in a primipara who
failed to respond to the ordinary
treatment, was successfully treated
by venesection, followed by intraven-
ous infusion of 1^4 pints (750 c.c.) of
Fischer's solution. Southworth (Lan-
cet-Clinic, Sept. 5, 1914).
A study of antianaphylactic im-
munization with sodium chloride
showed that when a second injection
of horse serum is to be given to an
animal which 3 weeks previously had
been given a preliminary injection of
this serum, the violent anaphylactic
reaction, which is frequently lethal
within a short time, may be pre-
vented by the use of a serum which
has been diluted with 9 times its vol-
ume of isotonic sodium chloride solu-
tion. Where this is done the reaction
is of only moderate intensity, and the
animal quickly recovers. If the solu-
tion is injected before the serum a
much larger quantity of salt is re-
quired. Richet, Brodin and Saint-
Girond (Presse med., July 24, 1919).
L. T. DE M. Sajous.
Philadelphia.
SPIGELIA.— Spigelia (pink-root;
Maryland, Carolina, or Indian pink;
worm-grass, worm-weed, starbloom) is
the dried rhizome and roots of Spigelia
viarilandica (fam., Loganiaceae), growing
in thickets from Pennsylvania to Illinois
and southward. The active constituent is
SPINAL ANESTHESIA (BABCOCK).
201
apparently a volatile, crystalHzable alka-
loid, spigeline, which is soluble in both
alcohol and water. There is also present
a small amount of volatile oil, fat, wax,
tannin, and a tasteless resin.
PREPARATIONS AND DOSES.—
Sfigclia, U. S. P. (spigelia). Dose of
powder, 10 to 20 grains (0.60 to 1.30 Gm.)
to a child under 5 years of age, and from
^ to 2 drams (2 to 8 Gm.) to an adult.
Fhiidcxtractum spigelicc, U. S. P. (fluid-
extract of spigelia). Dose', 10 to 20
grains (0.60 to 1.30 c.c.) to a child of 5
years, and from Yz to 2 drams (2 to 8 c.c.)
to an adult.
The fluidextract of spigelia and senna,
formerly official, is a convenient and ac-
tive preparation, and may be given in the
same dose as the official fluidextract of
spigelia, preferably in simple syrup, or
with aromatics.
PHYSIOLOGICAL ACTION. — Spi-
gelia is a popular and efficient anthelmin-
tic against roundworms (Ascaris lumbri-
coides). It has some cathartic action, but
as this is uncertain it is usually com-
bined with senna, Epsom salt, or other
cathartic. When purgation is lacking or
tardy cerebral symptoms may present, as
vertigo, dimness of vision, strabismus,
mydriasis, and even convulsions.
POISONING BY SPIGELIA.— Toxic
doses produce a hot, dry skin and fauces,
accelerated circulation, dilated pupils, in-
ternal strabismus, exophthalmos, general
motor paralysis, drowsiness, passing into
coma and slow respiration. Death oc-
curs from paralysis of the respiratory
center.
THERAPEUTIC USES.— Spigelia is
chiefly useful as an anthelmintic against
roundworms (Ascaris lumbricoides) and
ranks as one of the best. It is always
best to administer a dose of a saline, like
magnesium citrate or sulphate, about two
hours after taking spigelia. W.
SPINAL ANESTHESIA.— In
spinal anesthesia or anal<4esia, or, bet-
ter, subarachnoid anesthesia, insensi-
bility of portions of the body is
produced by the injection of local
anesthetic drugs into the subarach-
noid space in the spinal canal. The
method may more properly be termed
a nerve-root than a spinal anesthesia,
since it is the sensory nerve-roots as
they meet the spinal cord, rather than
the cord itself, v^^hich are anesthetized.
The term lumbar anesthesia, some-
times (ised, applies definitely to an-
esthesia induced by injection in the
lumbar portion of the spinal column.
Sacral or caudal anesthesia is to be
clearly dififerentiated from the usual
type of spinal anesthesia, in that the
anesthetizing injection is made, not
into the subarachnoid space, but in
the sacral canal below and outside
the dura covering the nerve-trunks of
the Cauda equina. This procedure
will be taken up in a separate section
at the close of this article.
To J. Leonard Corning, of New
York, belongs the credit of first ap-
plying the principle of conduction
anesthesia to the structures enclosed
in the spinal canal. In 1888 spinal
(extradural) injections of cocaine
were made by him for the relief of
pain in 4 cases of spinal disease, but
it was not until 1899 that actual intra-
dural anesthesia with cocaine was
attempted by August Bier, of Bonn.
Others soon adopted the procedure,
often only to abandon it later owing
to the unpleasant and at times fatal
results attending tlie use of cocaine.
In 1904 a long step forward was
made in the substitution for cocaine
of the less toxic stovaine, discovered
by Fourneau in the preceding year.
Numerous further improvements in
the technique since that time have
done much to popularize the proced-
ure, and have reduced its disadvan-
tages as compared to other major
forms of anesthesia — practically to
the vanishing point.
202 SPINAL ANESTHESIA (BARCOCK).
PHYSIOLOGICAL ACTION.— centration of the drug used, ranging
The action of the various drugs from as little as twelve minutes to
which have been used in spinal an- two hours. After the full adult dose
esthesia is so similar that a single the average duration of analgesia is
description will answer for all. The from one to one and a half hours, the
spinal cord occupying less than one- effect beginning slowly to recede
half tlie anteroposterior and trans- from its maximum fifteen or twenty
verse diameters of the spinal canal, a minutes after the injection. Whereas
considerable space, filled with cere- 0.05 or 0.06 Gm. (}i to 1 grain) of
brospinal fluid, exists between it and stovaine in 4 per cent, solution will
the surrounding arachnoid and dura! produce an analgesia lasting about
membranes. An anesthetic drug in- ninety minutes, the effect from a 0.02
jected into this space comes in con- or 0.03 Gm. (^ to % grain) dose in
tact, not only with the spinal cord, the same concentration will persist
but with the motor and sensory only fifteen or twenty minutes,
nerve-roots, the conductive power of The abdominal walls being relaxed
which it arrests, causing anesthesia, in spinal anesthesia, the abdomen be-
motor paralysis, and sympathetic pa- comes partially scaphoid, and abdom-
ralysis in the segments involved. The inal breathing, except from the dia-
spinal cord itself is but superficially phragm, is practically abolished. The
influenced, and its columns may con- intestine is largely released from
tinue their functional activity dur- sympathetic inhibition through pa-
ing the anesthesia. The autonomic ralysis of the rami communicantes.
system, likewise, remains practically and tends, therefore, to contract, the
uninfluenced. gaseous and liquid contents of the
The action of the drug begins in a large intestine not infrequently es-
few seconds after its injection, and caping — an advantage in ileus — as the
the patient immediately notices a anal sphincters are simultaneously
paresthesia of the feet, followed very relaxed. Peristalsis is, to a slight
promptly by insensibility and almost extent, similarly stimulated in the
complete motor paralysis. The pain stomach. Where the upper dorsal or
sense is more markedly and exten- cervical segments become involved in
sively paralyzed than the tactile the anesthetic action, nausea, usually
sense; thus, if the anesthesia be not very transient, and caused probably
deep, the contact of the knife during by cerebral anemia, is frequently ex-
the incision may be felt, though no perienced. Vomiting is difficult un-
pain is experienced. Sensation is lost less the head and chest be lowered,
before the power of motion, which The eft'ect of spinal anesthesia on
may therefore persist during the an- the circulation is to produce a reduc-
algesia if a weak solution of the lion in the pulse rate and blood-pres-
anesthetic is used. With sufficient sure, which is proportionate to the
dosage, however, the patient becomes intensity of the anesthesia, and, in
completely unaware of the position or particular, to its height in the spinal
movements of the lower limbs. canal. Where only the lower spinal
The duration of the analgesia va- segments are involved these changes
ries markedly with the dose and con- are likely to be but slight, but if the
SPINAL ANESTHESIA (BABCOCK).
203
upper dorsal nerve-roots are reached
the pulse rate may drop to 40 or 30,
and the blood-pressure to zero at the
wrists. These effects, which may be
ascribed to vasomotor paralysis in the
involved segments, to absence of op-
position to cardioinhibitory vagal ac-
tivity owing to paresis of the sym-
pathetic accelerator mechanism, and
probably to other factors, begin in
about fifteen or twenty minutes after
the injection, and gradually subside
after a time. No other anesthetic in-
duces so complete a vasomotor relax-
ation^, though if the breathing is well
maintained, even a zero blood-pres-
sure at the wrist may be innocuous.
Respiration is affected, even in an-
esthesia limited to the lower dorsal
segments, in that the co-ordinate
movements of the abdominal walls
are lost, the respirations becoming
exclusively diaphragmatic. If the
action extends sufficiently high to
relax the chest walls, a sense of
weight or thoracic oppression may be
experienced, and if the fourth cervical
segments supplying the phrenics are
reached, progressive asphyxia rapidly
follows, unless efficient artificial res-
piration is instituted. The breathing
in spinal anesthesia is, on the whole,
slow and rather shallow. Cyanosis is
ominous, and necessitates immediate
inquiry into the possibility of ob-
struction to the upper respiratory
passages, to be followed by artificial
respiratory measures if no improve-
ment is obtainable in this direction.
The skin during spinal anesthesia,
unless it extends high up, remains of
normal color or becomes slightly
pale. The sweating and suffusion of
ether anesthesia are conspicious by
their absence. The urinary sphincter
is probably not relaxed, no inconti-
nence of urine having, in my experi-
ence, been observed. The uterine
contractions are weakened, but not
abolished, by the procedure. The
uterus contracts promptly after de-
livery. Hemorrhage during delivery
or curetment for miscarriage is less
than that occurring under chloroform
or ether.
TECHNIQUE.— Solutions Used.—
The numljer of the spinal segments
influenced in subarachnoid anesthesia
depends not only upon the dosage
and bulk of the injection, but also
upon the : ~2cific gravity of the solu-
tion used, and the posture of the pa-
tient after the injection. Although
the specific gravity of the cerebro-
spinal fluid is relatively constant,
ranging almost invariably between
1.0055 and 1.0065, it is impracticable
to use an anesthetic solution of ap-
proximately a like specific gravity
with the expectation that it will re-
main indefinitely at the level of its
introduction in the spinal' canal. The
slightest variations in the specific
gravity of the cerebrospinal fluid
causing the solution to rise or fall,
it is desirable to use a solution either
distinctly heavier or lighter than the
cerebrospinal fluid. An increased
specific gravity may be obtained by
adding to the solution a little glucose,
lactose, dextrin, or mannitol. Thus,
Barker injects a 5 per cent, solution
of stovaine in a 5 |)er cent, solution
of glucose, the patient lying on the
side, with shoulders and hips slightly
elevated, .\fter the injection the j^a-
tient is cautiously rolled on the ])ack,
the elevation of the shoulders and
hips being maintained witli suitable
pads or boards. The nerve-roots of
the lower dorsal region are thus
chieflv anesthetized.
204 SPINAL ANESTHESIA (BABCOCK).
Since it is often desiral)le to operate The heavy solution is intended for
with the patient in the Trendelenburg cases in which it is desirable to ele-
posture or to lower the head where vatc the head and shoulders of the
marked circulatory depression exists, i)c-iticnt during the operation.
1 have been in the hal)it of employing, Stovaine, the drug generally em-
in most instances, a solution lighter ployed, is the most powerful anesthe-
than the cerebrospinal tluid, the pa- tic and motor paralyzant of the three,
tient being quickly laid on the opcrat- though likewise the most toxic, most
ing table, with his shoulders about actively hemolytic, and the strongest
two inches lower than his hips, after protoplasmic poison. Tropacocaine is
the injection. Having experimented, somewhat less active as an anesthetic,
as anesthetic drugs, with cocaine, while novocaine, though less toxic
alypin, eucaine lactate, chloretone, and non-hemolytic, is the least effi-
stovaine, tropacocaine, and novocaine, cient of the three, and may not pro-
I have been led to discard all but the duce complete muscular relaxation
last three, the following formulas be- even if analgesia exists,
ing at present used : — Avoidance of toxic effects from this
Light Solutions type of anesthesia necessitates care-
A. Stovaine 0.08 Gm. {V4 gr). ful preparation of the solutions to be
Lactic acid 0.04 c.c. (% min.). used. These are best kept in sealed
Absolute alcohol... 0.2 c.c. (3i/< min.). ampoules, each containing 2 c.c. (32
Distilled water L8 c.c. (30 min.). minims) of solution, and should be
B. Tropacocaine 0.1 Gm. (114 gr.). prepared under aseptic precautions
Absolute alcohol... 0.2 c.c. (3/, min.). ^^^^ sterilized, not by boiling, but by
Distilled water L8 c.c. (30 min.). ■ ^ -j.^ . , ^
intermittent exposure to a tempera-
C. Novocaine 0.16 Gm. (2/. gr.). ^^^^.^ ^^^^ exceeding 65° C. (149° F.).
Absolute alcohol... 0.2 c.c. (3'/> min.). rr^i , r i i i, r i r
n- ,„ . , lo /OA • N ihe dose, for the adult, of each ot
Distilled water 1.8 c.c. (30 mm.). _ ' , '_
the solutions mentioned is 1 to IJ/2
Heavy Solution. , , , _ , . . n , , ,
.. ^ . ^^.^ ^ ,, . \ c.c. (16 to 24 minims), the larger
D. Stovaine 0.08 Gm. (1^ gr.). ^ , . , , • , , .
r ,• •, nn/1 /"/ • \ amount being used only in the robust.
Lactic acid 0.04 c.c. (7^ mm.). 5' -^
Milk sugar (lac- Children withstand relatively large
tose) 0.1 Gm. (IK' gr.). doses. Thus, 0.015 Gm. (^4 grain) of
Distilled water, to stovaine, may be given in the new-
"^^^^ 2.0 c.c. (32 min.). y^^^.^^ q Q3 q,^^ ^y^ gj.j^j„) ^^ ^ ^j^jlj
The addition of 10 per cent, of al- of 5 years of average size and robust-
cohol to the 4 per cent, stovaine solu- ness, and 0.04 Gm. {% grain) to a
tion reduces its specific gravity to child of 10.
about 0.992, causing it to ascend in Site of Injection, — The action of
the spinal canal, with the patient sit- the anesthetic drug in spinal anesthe-
ting up, at a rate approximating 10 sia is tide-like, the influence grad-
centimeters (4 inches) a minute. The ually extending upward and, less
lactic acid is added to the stovaine noticeably, downward in the suba-
solutions to retard its precipitation rachnoid space from the point of in-
by the alkaline cerebrospinal fluid, jection. The highest nerve-roots in
stovaine having the alkaloidal prop- the range of diffusion of the drug
erty of being precipitated by alkalies, having been reached, the tide of
SPINAL ANESTHESIA (BABCOCK).
205
analgesia gradually recedes toward
the spinal segments close to the point
of injection. The affected segments
farthest from this point are thus sub-
jected to the action of the drug in
its most diluted form and for the
least period of time. For prolonged
and complete analgesia it is desirable,
therefore, to inject the drug through
an interspace adjacent to the nerve-
roots corresponding to the field of
operation. In operations on the
perineum and anus, the injection is
especially efficient if made through
the third or fourth lumbar interspace,
i.e., below the third or fourth verte-
brae, respectively; in operations on
the leg, through the second or third
lumbar interspace; in those on the
lower abdomen or groin, through the
first lumbar interspace, and in those
on the stomach, gall-bladder, or liver,
through the twelfth dorsal interspace.
A minimum dose injected through
the last-named interspace, though it
may suffice for upper abdominal
work, may yield only a transient and
patchy anesthesia for operations upon
the legs or perineum.
High spinal anesthesia or analge-
sia involving the upper dorsal, the
cervical, and the cranial segments
may be produced by selecting a high
interspace, especially the seventh
cervical interspace as advocated by
Jonnesco; by injecting a large quan-
tity of a dilute anesthetic solution
after withdrawing an equal quantity
of cerel)rospinal fluid, or by causing
upward diftusion of an anesthetic
solution having a specific gravity dif-
ferent from that of the cerebrospinal
fluid. In some instances the with-
drawn cerebrospinal fluid is used as
the solvent for the anesthetic. As it
is difficult to produce analgesia with-
out motor paralysis, shock, uncon-
sciousness, respiratory and cardiac
arrest, and especially blocking of the
phrenics are not uncommon. To
avoid these dangerous effects the dos-
age must be much reduced, so that a
very brief, and at times imperfect,
analgesia is produced. JonnescO' ob-
tains an analgesia of about fifteen
minutes' duration, and attempts, but
imperfectly, to increase the safety of
the injection by the addition of
strychnine. While it is possible to
do even craniotomies under high
spinal anesthesia, the brevity of the
effect, and especially the great dan-
gers incurred, preclude its adoption
as a justifiable method of anesthesia.
Only when a drug is found capable
of arresting sensory without motor
conduction will high spinal anesthe-
sia deserve consideration.
Syringe and Needle. — A glass
syringe of the Luer type of 2 c.c.
capacity, graduated with 0.1 c.c. di-
visions, is to be given preference.
The piston of such a syringe, when
properly made, fits loosely enough to
be forced out by the pressure of the
intradural fluid — an important feature
in showing that the needle has en-
tered the subarachnoid space.
To insure delicacy of manipulation,
the needle should likewise be small
and light. It should be of iridium-
platinum or gold, to insure against
Ijreakage, and should be about 7 cm.
long and 1 mm. in diameter. The
point should be very sharp, but very
oblique, so that the length of tlie
bevelled portion shall be only about
2 mm. The needle should be pro-
vided with a well-fitting stylet, that
its lumen may not become clogged
during its introduction. It should fit
the syringe accurately.
206
SPINAL ANESTHESIA (BABCOCK).
The syringe, needle, and stylet
shciuld be wrapped in gauze and
boiled in water free from alkali for
fifteen minutes just before using.
(The addition of an alkali may de-
compose the anesthetic drug.) The
apparatus should be brought to the
operator while still very hot, not only
to insure sterility, but also in order
that the syringe may warm the an-
esthetic solution. The assistant open-
ing the ampoule for the operator
should previously have wiped the
surface of the ampoule with a bit of
gauze moistened with alcohol.
Preliminary Narcotization. — Reten-
tion of consciousness by the patient
while in the operating room being
often objectionable, it may in many
instances be obviated by the prelimi-
nary injection of narcotics. In a ro-
bust adult % grain (0.01 Gm.) of
morphine sulphate and %oo grain
(0.0006 Gm.) of scopolamine hydro-
bromide are given hypodermically.
about seventy-five minutes before the
time of operation. If in twenty min-
utes the patient answers questions
without evidence of mental confusion,
the injection is repeated, and in cer-
tain very resistant patients a third
injection of morphine, either alone or
combined with Yi-y grain (0.004 Gm.)
of apomorphine hydrochloride, if the
delirlfacient scopolamine action pre-
dominates, or of both morphine and
scopolamine if the previous injections
have produced little effect, is later
given. In patients under 30 years of
age, in whom the delirifacient scopo-
lamine action often predominates, the
initial injection may consist of y^
grain (0.016 Gm.) of morphine and
Vi5o grain (0.0004 Gm.) of atropine.
Such narcotization intensifies and
prolongs the action of spinal anesthe-
sia. Properly applied, it enables the
I-iatient to pass through the operation
oblivious of the fact that he has been
removed from liis l)ed. In shocked,
debilitated, or aged patients it should,
liowever, be employed with the
greatest care, or avoided ; likewise,
in patients w^ith marked respiratory
depression, grave renal disease, or
marked toxemia. Narcotics have
been used in about 85 per cent, of
our cases.
Consciousness may also be dulled
by the administration of ether or
other anesthetic by inhalation. Often
a minute amount of ether will divert
the mind or slightly obtund con-
sciousness during the operation.
In children, narcotics are rarely
required. After the spinal injection
the child, if properly reassured as to
the numbness and loss of power in
the legs, will often fall asleep during
the operation.
Associated Local Anesthesia. —
A\'here the operator finds it necessary
to extend his incision above the level
of the analgesia, or the operation is
so prolonged that the spinal effect in
part passes oft", a 1 per cent, solution
of novocaine in saline solution may,
with advantage, be used locally for
the skin and subcutaneous tissues,
and a 0.25 per cent, solution for the
deeper tissues. In very extensive
amputations it may be desirable to
inject a 2 per cent, novocaine solution
in the important nerve-trunks, not
only to guard against imperfect ar-
rest of conduction in the spinal nerve-
roots, but also as an aid in prolonging
the local analgesia.
Induction and Management of
Spinal Anesthesia, — Tlie patient's
back, before he is brought to the op-
crating room, is scrubbed with ace-
SPINAL ANESTHESIA (BABCOCK). 207
tone and painted with a 2.5 per cent, should be inserted close to the mid-
tincture of iodine ; a dry, sterile line, at about the vertical center of
binder is then applied. In the oper- the interspace, at right angles to the
ating room the patient is sat across body surface, and carried directly
the middle of the operating table, the forward until it is grasped by the
binder removed, and the back either dense interspinous ligament. (In the
flushed with alcohol or given a sec- dorsal region it is necessary to tilt
ond coating of dilute iodine tincture, the needle somewhat upward.) The
The assistant sees to it that the pa- grasp of the needle by the interspin-
tient is sitting squarely across the ous ligament — often cartilaginous in
table, that his hips are even, elbows its consistency — usually indicates that
parallel and at the sides,^ and the it is being passed in the proper direc-
forearms crossed in front of the body. tion. If it encounters only loose tis-
Facing the patient, he then stands on sue, it has probably deviated laterally,
a low stool and holds the patient's and should be withdrawn and reintro-
hands with his own right hand, while duced with more accurate orientation,
liis left arm encircles the back of the The stylet is now withdrawn and
patient's neck and his fist makes pres- the needle cautiously pushed forward
sure against the patient's abdomen, with short, quick strokes, a few milli-
The patient's chin is thus forced meters at a time. A cessation of re-
down on his chest and the back sistance is noted as the needle-point
arched without allowing him to lean leaves the interspinous ligament and
forward. enters the loose areolar tissue outside
The spinal interspace, through the dura, followed by slight resist-
which it is desired to inject, is ance and a snap — sometimes audible
now located. This may be done by — as the tense dura is punctured,
stretching a sterile towel between the Finally, the needle is partially rotated
iliac crests; its upper edge will cross to insure complete penetration of the
the fourth lumbar spine or interspace, dura by its point. Cerebrospinal fluid
Or, the interspace opposite the angle should now drop fairly rapidly from
formed by the last rib and the erector the needle; if it does not, the needle
spinas muscle may be noted; this is may be cautiously rotated or slightly
the first lumbar. From one of these moved until the fluid flows freely. At
known interspaces the desired space times it is necessary to reintroduce
may be ascertained. the stylet, cautiously aspirate with
The injection should be made im- the syringe, or seek another inter-
mediately before the operation, to space, the latter being usually the
avoid diffusion of the anesthetic and best plan where there is much diffi-
earlier loss of the effects. After culty with the first attempt. At
drawing the contents of the sterile times, if the needle enters directly in
ampoule into the syringe, air-bubbles the median line, a few drops of blood
and any excess of the solution beyond may flow from the venous plexus out-
the dose to be injected — usually 1.2 side the dura; this apparently does
to 1.5 c.c. (20 to 25 minims) — ex- no harm, and the blood is usually
pelled. The needle, detached from quickly followed by cerebrospinal
the syringe but containing the stylet, fluid.
208
SPINAL ANESTHESIA (HABCOCK).
Only when the fluid is running
freely should the charged syringe be
adapted to the needle. The piston is
first drawn out a short distance to
permit cerebrospinal fluid to enter
the syringe and mix with the anes-
thetic solution, as well as again to
prove that the needle has been prop-
erly introduced. If a thorough difl^u-
sion is desired, a part of the mixture
may now be injected, more cerebro-
spinal fluid drawn into the syringe,
and this process repeated two or
three times until the syringe is empty.
Not over twenty seconds, however,
should be consumed in giving the in-
jection.
Finally, the needle is quickly with-
drawn and, if a light solution has
been used, the patient at once laid
upon the table, slightly tilted with
the head down, to be maintained in
that position at least twenty minutes,
or, if a heavy solution has been in-
troduced, the head and shoulders
kept elevated. Analgesia should de-
velop in two or three minutes, and is
determined by watching the face as
the skin is pinched. If no analgesia
is present after six minutes, the in-
jection may be repeated, in the same
dosage, and, perhaps, through an-
other interspace.
During the operation the pulse and
respiration should be continuously
watched, the latter by observation of
the to and fro movements of a wisp
of cotton afiixed to the end of the
nose. Diverting conversation is often
desirable in the minority of cases in
which the patient is awake. Should
the patient exhibit evidences of nau-
sea, the head and shoulders must be
lowered by further inclination of the
table and a careful watch kept for
respiratory depression or a fall of
blood-pressure. The latter, in the
absence of respiratory arrest, need
cause little alarm, but if the respira-
tions become shallow or imperfect, a
stimulating subcutaneous injection of
4 grains (0.26 Gm.) of caffeine and
YiQ grain (0.004 Gm.) of strychnine
sulphate should be given, and the
surgeon stand ready to practise arti-
ficial respiration or an intravenous
injection of epinephrin.
After-treatment. — Sealing or dress-
ing of the point of lumbar puncture
in spinal anesthesia is unnecessary,
no signs of infection having devel-
oped in over 8000 anesthesias without
the application of an occlusive dress-
ing.
In patients who have received pre-
liminary narcotic injections, an enema
of 2 quarts of warm water, to which
may be added 2 ounces (60 Gm.) of
glucose and 3 drams (12 Gm.) of
sodium bicarbonate, should be slowly
run into the bowel immediately after
the operation, and every four hours
thereafter for the first twenty-four or
forty-eight hours the patient should
receive from 4 to 8 ounces (120 to
240 c.c.) of fluid by rectum. If the
narcosis is too prolonged or intense,
a pint (500 c.c.) of black coft'ee and
2 drams (8 Gm.) of tincture of cap-
sicum may be given with the first
enema. Constant watching, to de-
tect early and remove any cause of
obstruction in the upper air-passages,
is required in such deeply narcotized
subjects.
Spinal anesthesia does not contra-
indicate the administration of water
or bits of ice, either during or after
the operation. Such food as seems
best in the particular case may be
given without regard to the fact that
the patient has been anesthetized.
SPINAL ANESTHESIA (BABCOCK). 209
INDICATIONS AND ADVAN- resistant to many forms of treatment,
TAGES OF SPINAL ANESTHE- were thus relieved by spinal anesthe-
SIA. — Spinal anesthesia is applicable sia alone before an incision had been
in patients of all ages, from the new- made.
born to those in advanced life. It With one exception, during the
can often be used where ether is in- past twelve years, I have selected
admissible, as in patients with acute spinal anesthesia for all abdominal
pulmonary or chronic cardiovascular operations on the toxic, septic, or
disease, or is known already to have desperately sick, withholding opera-
produced dangerous symptoms. tion only from those admitted to the
Its chief value is in operations on hospital manifestly in a dying condi-
the lower abdomen and pelvis. Prob- tion. It may be employed with un-
ably no other form of anesthesia questionable advantage in abdominal
yields as great a degree of muscular surgery in preference to ether where
relaxation in these regions with as there exists an acute pulmonary or a
little danger. Intra-abdominal ma- severe cardiac, vascular, or renal dis-
nipulations are greatly facilitated by order, particularly when associated
the relaxed parietes and contracted with high blood-pressure,
intestine it affords. A shorter in- Operations on the pelvic organs
cision may be made than under other are very conveniently carried out un-
anesthetics, and the anesthetic does der spinal anesthesia. A most satis-
not add to the patient's intoxication factory relaxation of the perineal
nor impede elimination. Particularly muscles is afforded, and the relaxa-
is the procedure valuable in acute tion of the anal sphincters — last to
peritoneal infections, as from the ap- relax under ether, but among the first
pendix. In such patients no preop- to relax under spinal anesthesia — fa-
erative preparation is necessary be- cilitates operations on the lower
yond the sterilization of the skin, and, bowel. In such cases an enema
possibly, the passage of a stomach- should not be used for some hours
tube. The lowest mortality I have before the operation ; the rectum
obtained in operating on the appen- must, however, have previously been
dix — 1.8 per cent, in a series of 220 thoroughly emptied, otherwise an
consecutive and unselected cases, op- evacuation will usually occur on the
erated promptly upon admission to table.
the hospital, and irrespective of the In certain operations on the kid-
degree or duration of any associated neys, spinal anesthesia seems espe-
peritonitis — was secured with spinal cially valuable. Thus, I, have not
anesthesia. hesitated to operate on these or-
Where meteorism exists or there is gans simultaneously, nor to perform
inflammatory ileus, evacuation of the nephrolithotomy on a residual kidney
intestinal tract usually takes place after removal of the opposite organ,
while the patient is on the operating In one woman, aged about 60, for
table, and he returns to l)ed with a example, the residual kidney was
scaphoid abdomen. Three patients, opened three times for recurrent cal-
apparently with mechanical intestinal culi. From renal decapsulation per-
obstruction of some days' duration, formed under spinal anestliesia for
8—14
210 SPINAL ANESTHESIA (BABCOCK).
advanced nephritis, with or without spinal anesthesia, the heart action be-
marked anasarca, i have observed no mg maintained during the interven-
untoward effects. Spinal anesthesia tion by the intravenous use of
seems also of especial value in blad- epinephrinizcd salt solution. In a
der resection or removal for tumor, series of 14 cases of ruptured ectopic
and in prostatectomy. pregnancy, some of the "tragic" type,
In obstetrics spinal anesthesia is of which I operated by the vaginal route
value to facihtate operative delivery, under spinal anesthesia, there was no
As W. A. Steel has observed, hemor- mortaHty. J. P. Marsh, of Troy, N.
rhage is markedly lessened in these Y., has reported 4 successive and suc-
cases, and there is an immediate cessful Cesarean sections for eclamp-
soothing mental effect on the patient sia under spinal anesthesia. It is
owing to the cessation of her suffer- especially desirable for operative de-
ing. The patient, holding to the side livery in this condition, owing to the
of the bed, with the arms over her relaxation and lowering of blood-
head, is enabled herself to render aid pressure induced, without interfer-
in difffcult forceps deliveries. The ence w^ith elimination,
uterine contractions are not abolished, In labor cases with heart disease
and the placenta may be expelled spinal anesthesia relieves the patient
spontaneously. No ill effects are pro- of all cardiac strain. H. R, M. Landis
duced on the child. In private prac- has found that child-bearing may be
tice the method enables the surgeon rendered relatively safe in tubercu-
to handle emergency obstetric op- lous patients by instrumental delivery
erations without an anesthetist or under spinal anesthesia.
trained assistant. The procedure may The perineal anesthesia and mus-
be employed in version or threatened cle relaxation afforded bv spinal an-
uterine rupture. Uterine inertia is esthesia permit of immediate painless,
probably less frequent than after thorough repair work on the birth
ether. In breech or version opera- canal (Steel).
tions the after-coming head must be Curettement for retained products
extracted rapidly, or else the lower of conception is performed with much
uterine segment may contract on the less hemorrhage than when ether or
neck (Steel). chloroform is used. Reactionary hem-
In exsanguinated obstetric patients orrhage seems to be less frequent,
spinal anesthesia is frequently avail- Hematomas and hemorrhagic extrav-
able where ether or chloroform would asations in wounds are uncommon,
be contraindicated. In a case of in spite of the fact that fewer vessels
Cesarean section, reported by J. C. require ligation in operations under
Applegate, the uterus had ruptured spinal anesthesia than under ether,
sixteen hours before the operation Spinal anesthesia prevents, to a re-
and the fetus was in the abdominal markable degree, the production of
cavity. Although the patient had to shock by operative measures carried
be brought about twenty miles to the out under its influence (though it ac-
hospital, and was pulseless and ap- centuates pre-existing shock). Its
parently moribund when admitted, great rapidity of action — surgical an-
she recovered upon operation under algesia being almost invariably in-
SPINAL ANESTHESIA (BABCOCK).
211
duced within two minutes, and usu-
ally in a still shorter time — is often a
marked advantage.
Secondary nausea or vomiting
should not occur as a result of spinal
anesthesia, and the patient should
have less postoperative pain, less
headahce, less backache, and less gen-
eral discomfort than if he had re-
ceived ether (J. O. Bower). The
suffusion of the skin, drenching
sweats, and heat radiation of ether
are absent. Albuminuria does not
occur.
The repeated production of spinal
anesthesia in the same person seems
no more harmful than a single injec-
tion. One patient was subjected to
it no less than eleven times for re-
peated plastic operations for hypo-
spadias, without evidence of spinal
cord or root injury.
CONTRAINDICATIONS, —
Whereas in aneurism, threatened de-
compensation in valvular heart dis-
ease, in the excessive vascular tension
of eclampsia, in nephritis, and in ad-
vanced arteriosclerosis the vasorelax-
ation induced by spinal anesthesia
may be of protective value, the pro-
cedure should be used with care and
diminished dosage, or avoided, in
conditions of marked hypotension,
e.g., in severe shock and where great
depression or exhaustion of the spinal
centers exists. Patients nearly or
quite pulseless from traumatic shock
should not, as a rule, be subjected to
spinal anesthesia until reaction has
occurred. The low blood-pressure
induced favors cardiac arrest in cer-
tain forms of myocardial disease, as
well as in thoracotomy and other op-
erations causing sudden changes in
intrathoracic tension.
Patients with advanced peritonitis.
marked abdominal distention, and
cyanotic extremities, especially when
of the middle aged, obese type ; pa-
tients in collapse from traumatic
ileus ; patients with advanced septic
disease of the biliary system and as-
sociated marked myocardial weak-
ness, and patients greatly depressed
and toxemic, or with mechanical lim-
itation of respiratory space, as from
large serous or purulent effusions or
massive intrathoracic growths, are
not good subjects for spinal anesthe-
sia. In patients in collapse from
hemorrhage or with large fibroid tu-
mors and myocardial degeneration
the intradural injection should be
given with great caution.
Obese patients with a short, thick
chest and limited breathing apparatus
are less suited for the method than
subjects with ample breathing space.
Aged and debilitated patients should
receive relatively small doses of the
anesthetic drug.
Greatly depressed subjects, who
may be carried through an operation
with local anesthesia or a few whiffs
of ether, should not be given the
spinal injection.
Should spinal anesthesia be admin-
istered to a person with marked cir-
culatory hypotension, direct prepara-
tions for intravenous introduction of
epinephrinized saline solution should
be made before the operation, as de-
scribed in the following section.
Spinal anesthesia should not be
employed by those who have not de-
veloped a trustworthy aseptic tech-
nique or have not carefully mastered
the physiology of the method, includ-
ing an understanding of the dosage
and mode of diffusion of the drug.
Neither should the procedure be used
if the patient cannot be properly
212 SPINAL ANESTHESIA (BABCOCK).
watched for one hour after the in- tions no anesthesia resulted, probably
jcction, or if the operator is unprc- because the fluid was extradural. In
pared to meet emeri;encies. rare instances the injection must be
TECHNICAL DIFFICULTIES, repeated or another anesthetic used.
COMPLICATIONS, AND SE- Dosage.— The chief drugs used in
Q\JKL,JE. — Position of the Patient, spinal anesthesia are still under pro-
— In rare instances a patient is un- prietary control and may not have
able to breathe when recumbent. For been rigidly standardized, different
such a subject a solution of high samples of a given drug appar-
specific gravity should alone be used, ently showing variations in activity
or, better, local anesthesia substi- amounting to as much as 30 per cent,
tuted. In the ordinary case, in which At times we have found 0.04 Gm. (%
the light solution is being used, the grainj of stovaine a proper dose, and
patient should not be raised to a sit- again 0.06 Gm. (1 grain). As a 10
ting posture for one-half hour after per cent, increase in the dose may be
the injection, lest syncope be induced, dangerous, these variations in activ-
Carrying the patient about after the ity necessitate great care in the em-
injection is dangerous; without con- ployment of every new lot of the
stant watchfulness the orderly or anesthetic.
resident will lift or carry the patient Circulatory Depression. — In pa-
with the head and shoulders raised, tients nearly pulseless, before the
thus exposing the higher spinal seg- spinal injection, a needle connected
ments to the action of the anesthetic, with a funnel containing physiolog-
Breaking the Needle. — This mishap ical salt solution should be tied into
occurred in my experience upon using a convenient vein before the opera-
a very delicate, highly tempered steel tion is begun. The salt solution may
needle in a young child, the needle then be run into the vein from time
breaking when the child suddenly to time as indicated, from 1 to 10
straightened the back ; removal of the drops of 1 : 1000 epinephrin solution
fragment was soon successfully ef- being added to each 6-ounce (180
fected. I know of no instance in Gm.) funnelful if the patient becomes
which a platinum needle has broken actually pulseless at the wrist. The
beneath the skin. introduction of epinephrin should be
Lack of Anesthesia. — This may re- cut off by pinching the tubing as soon
suit not only from the use of an im- as the pulse returns, for fear of an
perfect solution, but from failure to excessive action upon the heart. For
introduce the needle properly, or weak patients, not sufficiently asthe-
from leakage of the solution outside nic to require the procedure just re-
the arachnoid. In one kyphotic ferred to, the subcutaneous injection
dwarf I failed to enter the spinal of 1 ampoule of pituitrin of 3 to 5
canal. In two other patients the minims (0.18 to 0.3 c.c.) of epine-
bony canal was entered, but no cere- phrin at the beginning of the opera-
brospinal fluid could be obtained and tion may be of value. For nervous
no very obvious analgesia followed, faintness, inhalation of aromatic spirit
In still another case, fluid was ob- of ammonia, or a few drops of ether
tained, but despite repeated injec- may be tried
SPINAL ANESTHESIA (BABCOCK). 213
Respiratory Depression. — To a Early After-effects. — Nausea and
very weak subject, 4 grains (0.26 Vomiting. — In a large series of our
Gm.) of caffeine and Yis grain (0.004 spinal anesthesia cases, 18 per cent.
Gm.) of strychnine sulphate should had slight nausea and 13 per cent.
be administered subcutaneously to an- vomited during the operation. This
ticipate respiratory depression. The is probably due to involvement of the
same injection should be given in upper dorsal nerve-roots by the an-
other cases in which the respiration esthetic, with the resulting cerebral
is observed to weaken. If the breath- anemia. The condition soon passes
ing ceases, artificial respiration should off.
be practised, most conveniently, as a Slight nausea and vomiting were
rule, by rhythmic compression of the shown by 24 per cent, of the cases
thorax, the surgeon clasping his after being returned to their beds,
fingers down over the patient's ster- This was either associated with an
num and making pressure downward intra-abdominal condition that would
and inward sixteen to twenty times produce nausea or was secondary to
a minute, a procedure which may be the use of morphine or other narcotic
aided by the hands of the assistant, drug. On the whole, our impression
placed under and below the elbows of is that spinal anesthesia does not pro-
the surgeon. The patient's arms are, duce any postoperative vomiting un-
meanwhile, extended above the head, less meningeal irritation occurs. The
Oscillations of the cotton wisp on the showing in this respect is far more
patient's nose prove the ef^cacy of favorable than that of our ether cases.
the artificial respiration, which should Headache. — Mild headache followed
be continued, if necessary, for one in 21 per cent, of our spinal anesthe-
hour or more, or until the patient can sias. Fifty per cent, of the ether
again breathe spontaneously. patients had headache, which was, as
Where obesity or an abnormal a rule, more severe than after the
intrathoracic state interferes with spinal procedure. We have recently
the thoracic compression procedure, seen no severe headaches after the
forced artificial respiration should be latter. Headache of the characteris-
tried, either with the pulmotor or tic spinal type, i.e., increased by rais-
lungmotor, if quickly available, or in ing the head from the pillow and
a sudden emergency, by the insertion associated with some stiffness of the
of a full-sized tracheal tube and di- neck muscles, indicates the use of a
rect rhythmic inflation of the lungs contaminated or deteriorated solu-
by the surgeon or assistant through tion, which should be promptly dis-
a piece of drainage-tube cut off square carded.
and held intermittently against the Backache. — Sixteen per cent, of our
external plate of the tracheal tube. spinal anesthesia cases complained of
Upon continuing artificial respira- this symptom, as against 61 per cent,
tion until depression of the respira- of the ether cases,
tory centers has passed off, the pa- Postoperative Pain. — The average
tient, perhaps pulseless, relaxed, and duration of incisural pain after spinal
pale, awakens as though miraculously anesthesia was twenty-nine hours, as
resurrected. against forty-eight hours after ether.
214 SPINAL ANESTHESIA (BABCOCK).
Albuminuria. — Despite a number of headache and pain in the l)ack of the
uranalyses, we have found no evi- neck. The period of incubation and
dence that the intradural injection the associated mening^eal irritation
irritates the kidneys. ^Fhis is corrob- sugj^est that the condition is due to
orated by the tolerance of patients the use of a solution contaminated
to repeated or extensive operations with bacteria.
on the kidneys, in spite of existing Neurotic Symptoms. — Weakness of
serious renal disorders. the legs, backache, headache, and
Remote After-effects. — Injury to various pains are frequent after ab-
Nervous Tissues. — Puncture of the dominal and especially after pelvic
spinal cord by the needle produces operations, whether ether or spinal
no symptoms, and, while it is to be anesthesia has been used. In the
avoided, is relatively harmless. Lat- neurotic, especially those with pelvic
eral deviation of the needle with in- symptoms, spinal anesthesia should
jury to a nerve-root may, however, be accordingly be employed with cau-
followed by a severe neuritis and tion. Such patients, particularly if
secondary palsy, which is rarely per- influenced by prejudiced persons, will
manent. Touching a nerve-root with often attribute all symptoms such as
the needle-point produces a lightning- the above to the intradural injection,
like pain usually radiating down the Mortality. — The safety of any an-
leg. If this occurs the needle should esthetic depends, to a considerable
be immediately withdrawn and rein- extent, upon the experience and skill
troduced. of the user. In comparing the mor-
Secondary degeneration of the tality from spinal with that from
spinal cord from the chemical- action ether anestl^esia, one should be mind-
of stovaine, as used in spinal anesthe- ful of the fact that the relatively
sia, does not, in my opinion, in the favorable ether statistics frequently
least degree occur. Experiments on quoted do not actually represent con-
dogs in this connection are entirely ditions as they obtain in the general
misleading, owing to anatomical dif- use of the drug, including its em-
ferences and the differences in the ployment by the inexperienced and
action of dilute and concentrated imperfectly trained, in sudden emer-
solutions of stovaine. gencies, under unpropitious circum-
Palsy of the abducens nerve, stances, and upon patients poorly
though met with several times in our prepared for the anesthesia. Our
earlier spinal anesthesias, has not oc- own experience with ether as admin-
curred in a series of over 4000 recent istered by internes in hospitals, and
injections. The condition is peculiar the results of inquiry into the ex-
in developing in from seven to twelve perience, personal or otherwise, of
days after the injection. Usually a several of my associates and assist-
single abducens is involved, but at ants, suggests a mortality of about 1
times the palsy is bilateral. Recov- in 500 in ether anesthesia,
ery usually follows in from a few As for spinal anesthesia, from up-
days to several months. Our cases ward of 5000 injections, including
occurred in a period during which many administered by my assistants
the anesthetic was often producing and associates, we have had 10 deaths
SPINAL ANESTHESIA (BABCOCK).
215
on the operating table, and 1 death
after operation, in which the anesthe-
sia was a factor. Three of these died
during- or after operations for large
empyemas — a condition now recog-
nized as contraindicating spinal an-
esthesia. Two patients died under
operations for gall-bladder disease
associated with peritonitis ; one of
these apparently was drowned by
profuse, regurgitant vomiting as the
operation was being completed, while
the other was obese and had a seri-
ous valvular lesion. Of the remain-
ing 5 cases of early death three were
nearly or quite pulseless before the
anesthesia had been induced, the
fourth was an infant with advanced
general miliary tuberculosis, suc-
cumbing during the search for an
intrapulmonary abscess, and the fifth
was an obese, elderly man with ex-
tensive intestinal gangrene and diffuse
peritonitis. These 5, properly to be
considered as inoperable, were in a
hopeless condition under any form of
treatment. The eleventh case, that of
an obese colored woman with a
fibroid tumor, who died from circu-
latory depression about two days
after the operation, was the only fatal
case in which the patient had been in
even a fair condition at the time of
anesthesia.
In 4 of our spinal anesthesia cases
attempts at etherization had been
made in other clinics. In each case
the operation had to be abandoned,
as the patient collapsed, and it was
evident that complete etherization
would be fatal. In each of these pa-
tients, without special preoperative
treatment, the operation was suc-
cessfully performed under spinal an-
esthesia, with subsequent recovery.
Similar results were obtained in sev-
eral additional cases in which opera-
tion had l)een refused at other clinics
on account of advanced sepsis, old
age, or other cause.
On the whole, in our experience
ether and spinal anesthesias have
proven about equally dangerous, the
former from exigencies necessitating
a profound narcosis or the participa-
tion of an imperfectly trained anes-
thetist, the latter from faulty selec-
tion of patients and, for a time,
imperfect knowledge of the action of
the anesthetic drug. These factors
favoring a high mortality in spinal
anesthesia having been eliminated,
we have had no mortality from it
during the past three years. Even if
skillfully administered, spinal anes-
thesia is probably more dangerous
than a transient and light narcosis
under ether or nitrous oxide-oxygen;
but it is safer than is a prolonged
narcosis with complete muscular re-
laxation under ether or nitrous oxide-
oxygen. Spinal anesthesia produces
the greatest degree of muscular re-
laxation with the least protoplasmic
disturbance. The method has been
repeatedly selected by my medical
associates, assistants and nurses for
operations on themselves or members
of their families.
Although relatively safe and very
effective when used skillfully, spinal
anesthesia is undoubtedly a danger-
ous as well as unreliable procedure in
the hands of those who do not under-
stand its action. Ability properly to
select patients suitable for its em-
ployment is of paramount importance.
For general, indiscriminate use ether
remains the standard anesthetic de-
spite its many drawbacks. The nov-
ice should not attempt spinal anesthe-
sia without careful investigation of
216
SPINAL ANESTHESIA (BABCOCK).
the subject, and should apply it only
in robust cases until due dexterity
and familiarity with the technique
have been acquired.
SACRAL ANESTHESIA.— In this
tyi)e of anesthesia, also termed epi-
dural aiicstlicsia by Cathelin, its orig-
inator, and extradural anesthesia by
Lawen who, in 1910, hrst reported
material success with it, an anesthetic
solution is injected through the sacral
hiatus into the pocket formed in the
sacral canal below the level of the
second sacral segment owing to the
closure of the spinal dura mater
around the nerve-trunks forming the
Cauda equina. The method has also
been termed caudal anesthesia. The
sacral pocket referred to is com-
pletely isolated by the dura from the
subarachnoid space above ; none of
the anesthetic solution, therefore,
mixes with the cerebrospinal fluid.
The areas affected in this procedure
are merely those from which sensory
nerve-fibers pass to the centers
through the sacral plexus. In the
sciatic distribution collateral innerva-
tion maintains sensibility ; the fully
anesthetized region, therefore, in-
cludes only the perineum, the anus
and lower rectum, the urethra and
penis, the lower part of the prostate,
the scrotum, but not its contents, and,
in the female, the external genitals
and vagina (P. Bull).
Novocaine is the anesthetic drug
generally used. Bull (1915) gener-
ally injects 20 c.c. (5 drams) of a 2
per cent, solution, plus epinephrin.
Lewis and Bartels (1916j use from
40 to 90 c.c. (1^ to 3 ounces) of a
mixture in equal parts of 1 per cent,
novocaine solution and 1 per cent,
potassium sulphate solution, made
with freshly distilled sterile water,
with 2 drops of 1 : 1000 epinephrin
solution added for each 30 c.c. (1
ounce) of tiie combined solution.
During the injection the patient is
placed on his right side, with head
slightly elevated and back strongly
curved. After proper local cleansing
the sacral hiatus is located, just be-
low the spinous process of the sacrum
and above the coccyx, in the midline.
Lewis and Bartels infiltrate the skin
and deeper soft tissues over the
hiatus with the anesthetic solution
before making the injection. The
needle is first held at 45° with the
skin surface, but as soon as penetra-
tion of the ligamentous membrane
covering the sacral hiatus is felt, the
syringe is carried down almost to a
level witli the body plane at that
point, and the needle made to follow
the axis of the sacral canal, into
which it is introduced for a distance
of V/i or 2 inches. If, in error, the
needle has gone up too far and passed
through the dura into cerebrospinal
fluid, numerous drops of the latter
will escape through the needle when
the trocar wire is withdrawn.
Care should always be taken, be-
fore administering the injection, to
ascertain that the needle has not
entered a vein. The injection should
be given slowly.
The method differs radically from
spinal anesthesia in the time required
for development of the analgesic ef-
fect, from eight to twenty minutes be-
ing consumed in the permeation of
the anesthetic through the dura cov-
ering the nerve-trunks. The an-
esthesia lasts for about an hour (Sie-
bert). Relaxation of the sphincters
and pelvic floor is a salient feature of
the method.
Lewis and Bartels report 13 pros-
SPINAL CORD, DISEASES OF (PRITCHARD).
217
tatectomies, 68 cystoscopies, 2 cys-
totomies, and 1 external perineal ure-
throtomy performed under caudal
anesthesia. In the cases of supra-
pubic incision local infiltration anes-
thesia at the site of incision was also
used. Three of the prostatectomies
required partial or complete ether
anesthesia in addition. Among the
68 cystoscopies there were 13 in-
stances of only partial analgesia and
5 of no analgesia (3 of these failures
due probably to faulty technique).
Bull reports imperfect anesthesia in
15.6 per cent, out of 60 cases.
Complications are uncommon and
not dangerous. The method is
deemed especially advantageous by
Lewis and Bartels in aged bladder
and prostatic cases already so re-
duced by pain, back pressure, and
toxemia as to possess no resisting
powers to stand further depletion by
other methods of anesthesia. Stoeckel
(1909) applied the procedure in 141
cases of childbirth, with distinct relief
from pain in 111 cases. A tendency
to arrest of uterine contractions when
the injection was made at the be-
ginning of labor was noted ; but
when once the contractions had well
started, there was no such effect.
Successful results were also obtained
with sacral anesthesia in 5 cases of
dysmenorrhea.
As long ago as 1901 Cathelin used
injections of normal saline solution
into the sacral canal for enuresis,
tabetic crises, etc.
Sacral anesthesia is, with difficulty,
applied in the obese, the very nerv-
ous or hysterical, and in children.
According to Suchy, it is contraindi-
cated in the alcoholic.
W. Wayne Babcock,
Philadelphia.
SPINAL CORD, DISEASES
OF. — GENERAL CONSIDERA-
TIONS.— The diseases of the spinal
cord, including the various congenital
and acquired deformities and anoma-
lies of development, together with the
primary or complicating affections of
the meninges, are more than fifty in
'number. Of this list, infantile spinal
paralysis, myelitis, and locomotor
ataxia constitute collectively prob-
ably three-fifths of all the cases.
Locomotor ataxia has been described
in a separate article ; so have multi-
ple sclerosis and the forms of menin-
gitis. Abscess of the cord is best
studied in connection with caries of
the vertebra, with which it is often
associated. The non-traumatic vas-
cular diseases of the cord — hemor-
rhage, embolus, thrombus, and aneu-
rism— are exceedingly rare, and this
is true also of tumors, though perhaps
less so. The spinal type of progres-
sive muscular atrophy has been in-
cluded among the diseases of the
muscles.
INFANTILE PARALYSIS; PO-
LIOENCEPHALOMYELITIS.
SYNONYMS.— Infantile spinal pa-
ralysis ; myelitis of the anterior
horns; acute atrophic paralysis; es-
sential paralysis of children ; West's
morning paralysis.
DEFINITION.— An infectious dis-
ease due to a minute micro-organism,
characterized by a purely motor
paralysis of flaccid type, occurring
usually in young children, the paral-
ysis being followed by rapidly de-
veloping atrophy, with degenerative
electrical reactions in the affected
muscles.
Not all children and relatively few
adults are susceptible to infantile pa-
218
SPINAL CORD, DISEASES OF (PRITCHARD).
ralysis. Young children are more
susceptible, generally speaking, than
older ones; but no age can be said
to be absolutely insusceptible. When
several children exist in a family or
in a group, one or more may be af-
fected, while the others escape or
seem to escape. The closer the fam-
ily or other groups are studied by
physicians, the more numerous it
now appears are the number of cases
among them. This means that the
term "infantile paralysis" is a mis-
nomer, since the disease arises with-
out causing any paralysis whatever,
or such slight and fleeting paralysis
as to be difficult of detection. Simon
Flexner (Public Address, New York,
July 13, 1916).
An acute, a subacute, and a chronic
form are recognized, the last com-
monly observed in adults.
Formerly our conception of the disease
was that of a pure, flaccid motor paralysis
without cranial-nerve involvement or cere-
bral implication, the lesion being constant
and limited to the giant cell of the anterior
horns. Epidemics of poliomyelitis had
been noticed, though infreqeuntly, and a
growing belief existed in the theory of
some specific micro-organism.
Between 1902 and 1908 a number of en-
demic outbreaks occurred in various sections
of this and other countries, and such varia-
tions from standard appeared in the* clinical
picture as to modify completely its inter-
pretation. Adults as well as children were
attacked, many cases proved fatal, cranial
nerves were frequently affected, sensory dis-
turbances, though temporary, were, at
times, conspicuous, and the gravest cere-
bral complications were noted. The picture,
in short, was that of involvement of the
entire motor neuron system, cortex, basal
and cord. This complex picture continued
to be the rule up to within the past two or
three years, since which time I have no-
ticed a reversion to the old classic type.
The final demonstration by Flexner and
Noguchi of an almost ultra-microscopic or-
ganism, capable of inducing the disease in
monkeys and recoverable from its victims,
establishes its etiology as one of specific
infection.
SYMPTOMS.— Trodromata are
rare, as a rule. Irritability, malaise
weakness, nausea, constipation or
diarrhea, coryza, bronchitis, tonsillitis
or restlessness may precede an at-
tack. These may disappear com-
pletely and be followed a few days
later by poliomyelitis. Bronchopneu-
monia may then develop owing to
paralysis, or, at least, paresis of the
respiratory muscles.
The disease begins abruptly, usu-
ally with some fe'ver. The tempera-
ture may be only slightly elevated (1
to 3 degrees), the range being higher
and the fever more prolonged, the
older the child. In the New York
epidemic of 1907 the temperature
ranged from 101° F. to 104° F. (38.3°
C. to 40° C), but higher tempera-
tures, 105° F. to 106° F. (40.5° C. to
41.1° C), have, though rarely, been
noted. A definite chill is also rare.
There inay be slight digestive disor-
•ders, such as vomiting and diarrhea,
slight headache, and sometimes pain
in the back and the limbs. These
general symptoms vary in intensity
with the temperature. In about one-
fourth of all cases the onset of the
disease may be marked by a convul-
sive seizure. The younger the pa-
tient and the higher the temperature,
the more likelihood is there of con-
vulsions, which, however, are rarely
repeated more than once or twice.
Some cases, however, run their
course without fever.
Headache is common, at least in
patients old enough to complain. In
the New York epideinic it was usu-
ally general or frontal, but in cases
observed by Wickman, it was occip-
ital. It is moderately severe, as a
rule, but is occasionally intense.
Prostration is marked when the on-
SPINAL CORD, DISEASES OF (PRITCHARD). 219
set is sudden, as also in many mild before the onset of paralysis. It may,
abortive cases. Albuminuria and however, be abolished on one side
anuria are occasional ; incontinence and exaggerated on the other.
rare. The bladder and rectum are After a few days — usually 2 or 3,
not involved. rarely more than 10 — the fever and
Besides the irritability observed, general disturbance subside, and not
early excitement, restlessness, anxi- until then, usually, is the true nature
ety, and mental perturbation are com- of the illness made evident by the
monly noted. This is followed, par- discovery of a flaccid motor paralysis,
ticularly in children, by a period of which may at hrst affect all of the
apathy or drowsiness, with some extremities as well as the trunk-mus-
confusion on waking. This confused cles. If suspected and sought for,
state may lapse into mild delirium of however, the paralysis may often be
short duration. Convulsions some- detected during the febrile stage,
times occur also in children as Within a week or two the general
noted above. On the whole, how- paralysis clears away, leaving a resid-
ever, the patient tends to retain ual paralysis limited to one or more
consciousness throughout the illness, limbs, or, it may be, to a single mus-
even in lethal cases, and coma is cle or group of muscles. Such groups
rare. Pain is complained of early, are invariably of muscles of asso-
particularly in the back of the neck ciated function. The lower limbs are
and spine. The pain in the face, arms, rather more frequently affected than
and legs resembles that of myalgia, the arms. A paraplegic distribution
but it may present the characteristics is common, a hemiplegic distribution
of neuritis, with hyperesthesia and exceedingly rare.
tenderness over the nerve-trunks. In perhaps one-fourth of all cases
This may persist for weeks, but, as a among children the onset is even
rule, the pains subside with or before more abrupt than as described. The
the onset of paralysis. Again, menin- child may be put to bed in apparent
gitic symptoms — stiffness of the neck good health, sleep quietly or perhaps
and spine, contraction of the spinal a little restlessly through the night,
muscles with retraction of the head — and is found the following morning
may be noted. in addition to the pain bright, cheerful, and with a hearty
in the same areas. Kernig's sign — appetite, but paralyzed in one limb,
inability to extend the leg when the or, it may be, with a paraplegia, the
thigh is flexed at right angle — is also affected limb hanging helpless and
present in some cases. inert. Such cases were descrilsed in
Both in cases which do not result the older literature as West's morn-
in paralysis and those that do, mus- ing paralysis.
cular twitchings, jerks and tremors Within 2 weeks usually, sometimes
usually occur. They may first be much earlier, the muscles paralyzed
elicited when the physical examina- begin to atrophy. The wasting some-
tion is made, or during sleep, when times progresses rapidly. If the child
they are most noticeable. At first the is fat, this atroi)hy may not be ap-
patellar reflex is exaggerated, but it parent to the eye, but palpation will
is invariably diminished or abolished at once make it evident. Not only
220
SPINAL CORD, DISEASES OF (PRITCHAKD).
does tlie limb look wasted, but it
usual 1\- presents a bluish, cyanosed
appearance, and to the touch of the
examiner it is distinctly colder than
its fellow. The deep reflexes are lost,
if affected at all.
Simultaneousl}- with the atrophy,
or it ma}' be a little later, an altera-
tion both quantitative and qualitative
may be noted in the response to both
the faradic and galvanic currents. To
the faradic current the muscular re-
sponse is at first simply diminished.
It grows more and more feeble from
day to day, and is eventually lost
completely in severe cases. To the
galvanic current the nerves involved
show at first beginning and later
more or less complete reaction of de-
generation. In making these elec-
trical tests the corresponding sound
muscles in the unaft'ected limb should
be used for comparison. Minor
changes can only be determined in
this way.
Within a few months various de-
formities from contraction and unop-
posed muscular antagonism may de-
velop. Talipes varus and -equinus,
and many other deformities are pos-
sible. Sometimes an arrest of de-
velopment occurs, one limb after a
few years being shorter than the
other, or one hand or foot smaller
than the other.
Chronic poliomyelitis is one of
the forms of progressive muscular
atrophy arid, together with the sub-
acute variety, dififers chiefly in the
mode of onset and rate of progress,
but not the nature of the paralysis.
Individual cases so varv from the
classic type in recent years as to
suggest the presence of different af-
fections. Wickman, of Stockholm,
Sweden, after a careful study of the
Scandinavian epidemic, and a clinical
study of 1025 cases, showed, how-
ever, that all the supposed disorders
were but different forms of the same
disease. An analysis of W'ickman's
paper, by Ur. W. R. Ramsey, of St.
Paul {Jour. Minnesota State Med.
^■Issoc, Dec, 1909), so ably summar-
izes this important contribution that
it is reproduced below as accurately
descriptive of the disease as we have
been seeing it in the past ten or fif-
teen years.
Poliomyelitic Form. — The sickness al-
most always begins acutely with fever
and general indisposition. The expressed
opinion of several authors, that in a great
percentage of the cases the paralysis ap-
pears without preceding initial symptoms,
is certainly incorrect and rests upon in-
sufficient observation. Sometimes the acute
symptoms are preceded by indefinite pro-
dromata. Sometimes the disease develops
in two phases with a distinct pause be-
tween, so that the patient, partially or
even completely, recovers from the initial
symptoms and then again becomes ill with
accompanying paralysis.
Among the initial symptoms are pain
and a somewhat characteristic hyperes-
thesia. Another series of initial symp-
toms are meningitic irritation, pain in the
back of the neck, and sometimes com-
plete opisthotonos. In many cases the
gastrointestinal symptoms, vomiting and
diarrhea, are so severe that the disease
assumes the stamp of an acute gastroin-
testinal catarrh. During the first days it
is not seldom that ''etention of urine is
observed, but this disappears, without ex-
ception, in a short time. Tne severity of
the onset and of the initial symptoms can-
not be dependec upon to determine the
future course of the disease.
The generally accepted opinion that the
paralysis continues for life and that it is
always attended by atrophy and the reac-
tion of degeneration, is not true; on the
contrary, there are many cases which only
show a transient paralysis of several days
to several weeks when the paralysis com-
pletely disappears.
SPINAL CORD, DISEASES OF (PRITCHARD).
221
The paralysis may involve the different
muscle groups and may sometimes limit
itself to a definite muscle group, e.g., the
muscles of the neck. Sometimes most un-
usual symptoms appear, e.g., the pupillary
symptoms and optic neuritis.
Sensibility to pressure over the nerves
and muscles appears in a considerable
number of cases. In rare cases there is
a marked interference with sensibility, or
partly a dissociated paralysis of sensation,
or sometimes a complete anesthesia as a
result of the changes in the anterior horns
of the cord. Pretty constantly appears a
diminution in the so-called electric sen-
sibility, and, indeed, in many cases one
can speak of a partial paralysis of sen-
sibility or sensation.
Concerning the tendon reflexes: The
patellar reflex comes chiefly under con-
sideration. These are by no means al-
v^fays absent. An exaggeration of these
reflexes may precede their complete dis-
appearance. Incomplete paralysis of the
leg with increase of the patellar reflex
may remain. In affections of the upper
part of the cord the patellar reflex may
be increased as an indication that the
white substance is also involved.
Landry's Form. — In another series of
cases the disease takes on an extensive
course, and, indeed, the durcrent muscle
groups may become involved, either in an
ascending or descending manner.
In case the muscles of respiration are
involved, which means an affection of the
respiratory center, the disease assumes
the form of Landry's paralysis. Since the
progress of the paralysis may be more
easily followed in adults than in children,
the erroneous reports, which are found
generally in the literature, explain the
different ages, as also the prognosis of
poliomyelitis. Landry's paralysis in a
child is generally diagnosed as poliomye-
litis, while a fatal poliomyelitis in an
adult is generally diagnosed as Landry's
paralysis.
Bulbar Form. — The bulbar and brain
forms may occur together or separately.
Most often in these forms facial paralysis
appears, but frequently also an affection
of the hypoglossus and eye muscles may
occur. Sometimes the disease takes the
form of an acute bulbar paralysis, but this
form appears to be rare. Sometimes there
exists an injury to the center of accom-
modation, and thereby an ataxia of the
cerebellar type or an exaggerated condi-
tion of the reflexes may occur.
Encephalitic Form. — Under this form
are considered all cases of cerebral
paralysis.
Ataxic Form. — This form appears as a
transient, acute ataxia, which most fre-
quently resembles the cerebellar type.
Polyneuritic Form. — When I mention
this as a separate form I do so from
purely practical grounds. During the epi-
demic many cases appeared which, when
grouped, were that of a distinct polyneu-
ritis. To this form belong, first, cases
which in a comparatively short time com-
pletely recover, especially when they are
accompanied by well-pronounced disturb-
ance of sensation, such as pain and pares-
thesia; second, cases which present such
local symptoms as pain upon pressure on
the nerves and muscles, and which inay
be regarded as an affection of the periph-
eral nerves; third, those cases under form
5 mentioned as the ataxic form. The last
two forms, 5 and 6, correspond to what
is described in the literature as acute
motor infectious neuritis. Clinically they
cannot be differentiated from this form,
but etiological!}' they are not identical.
The pathological investigations have not
been able to differentiate these forms, but
since so many cases occurred during this
epidemic of poliomyelitis, we must assume
them to be of common origin and that
the disease is really a transient poliomye-
litis. That the differential diagnosis be-
tween acute poliomyelitis and polj'neuritis
under other conditions must first be con-
sidered, is self-evident.
Meningitic Form. — As before mentioned,
in the initial stage and, indeed, not seldom
meningitic irritation appears. This may
be so severe and characteristic that one
thinks he has to do with an acute menin-
gitis. Later, however, the appearance of
the paralysis usually makes the condition
clear. The usual paral3-sis may, however,
remain absent, so that the whole course
is that of a meningitis serosa. This was
demonstrated during the epidemic, clinic-
ally as well as by autopsy.
It is then natural to conclude that at
222
SPINAL CORD, DISEASES OF (PRITCHARD).
least a part of the sporadic cases of se-
rous meningitis results from the poison of
the acute poliomyelitis.
The opinion of several investigators,
that there exists a relation between the
etiology of epidemic cerebrospinal menin-
gitis and infantile paralysis, is, in my
opinion, not sound. The difference in the
whole course of the diseases, in the in-
dividual symptoms, as well as in the an-
atomical changes, is so great that we
are justified in regarding them as two
distinct diseases.
Abortive Form. — Frequently other cases
occurred in the vicinity of the typical
cases of poliomyelitis, which, in general,
gave only the picture of a general infec-
tion, but of which the symptoms corre-
spond to the initial symptoms of the
typical ones. Such cases must be termed
abortive forms. One can, however, differ-
entiate various types of the abortive
form : —
(a) Cases which run the course of a
general infection.
(b) Cases in which there is some men-
ingitic irritation.
(c) Cases in which the painful symp-
toms are well pronounced (influenza
type).
(d) Cases in which the gastrointestinal
symptoms are especially marked.
How far anatomical changes of even
the slightest degree are present in these
abortive cases is not, with any certainty,
decided.
DIAGNOSIS.— An early diagnosis,
i.e., before the onset of paralysis,
would prove of service as regards
prophylactic measures, were any such
available.
We must accustom ourselves to
keep the possibilities of poliomyelitis
more frequently in view. Any case
of acute febrile disease, especially in
children, which is characterized by a
general hyperesthesia of the skin
with a tendency to profuse sweat-
ing, absence of leucocytosis, weak-
ness, and decrease of the muscle
tonus in certain muscle groups with
diminished tendon reflexes should
strongly arouse suspicion. Starck
(Med. Klinik, Dec. 22, 1912).
The prodromal symptoms enumer-
ated under the foregoing heading are
important in this connection: Irri-
tability and restlessness several days
before other symptoms appear ; head-
ache, vomiting, then slight spinal
rigidity with occipital headache and
backache, particularly along the
spine when any attempt at rotation
of the trunk is made; marked and
persistent asthenia; rapid and weak
pulse; hyperesthesia; pains in the
limbs with exaggerated patellar re-
flex— are suggestive in the absence of
an epidemic, and especially so when
cne prevails.
In some forms of poliomyelitis, the
brain, medulla, and pons are specially
involved, leaving the cord, for the
most part, unaffected permanently, —
really cases of polioencephalitis.
Some of these cases closely resemble
cerebrospinal meningitis. The differ-
ential points are: (1) In poliomye-
litis there is a short preliminary
period in which patient, having had
high fever, continues to be about; not
in meningitis. (2) Increasing sopor,
extending over days, in poliomyelitis;
this is quite unlike the onset of cere-
brospinal meningitis. Other cases
closely simulate tuberculous menin-
gitis. Differential points: (1) In
polioencephalitis, onset is sudden; in
tuberculous meningitis, gradual. (2)
In former affections, there occurs a
gradual diminution of the prelimi-
nary sopor, and in a week or two pa-
tient is brighter; in tuberculous men-
ingitis sopor deepens into coma.
Koplik (Amer. Jour. Med. Sci., June,
1911).
Hitherto unobserved preparalytic
symptom consisting of a peculiar
twitching, tremulous or convulsive
movement of certain groups of mus-
cles, lasting from a very few seconds
to somewhat less than a minute. The
amplitude of vibration is greater than
in a tremor, not so constant. Colliver
(Cal. State Jour. Med., Nov., 1913).
SPINAL CORD, DISEASES OF (PRITCHARD).
223
Congestion of the throat is almost
constant during the early acute stage.
It is usually limited to the faucial
mucosa and the pharynx, while the
soft palate assumes a deep red color
and often, in addition, a distinct vio-
laceous tinge. The latter, when pro-
nounced, is somewhat distinctive.
Regan (Arch, of Pediat., Dec, 1917).
Tuberculous meningitis may be
simulated. The spinal fluid in this
case may contain tubercle bacilli, and
injection of it into a guinea-pig may
facilitate differentiation. There may
be an evident primary focus, and also
choroidal tubercles. Syphilitic menin-
gitis is determined by a positive Was-
sermann. Other diseases to be ex-
cluded are gastro-intestinal disturb-'
ances, rickets, scurvy, acute arthritis,
and tuberculosis of the hip. Tum-
powsky (111. Med. Jour., Apr., 1918).
Report of experiments indicating
that the virus is regularly present in
the nasopharynx in the first days of
illness and decreases relatively quickly
as the disease progresses, except in
rare instances; and that it is unusual
for a carrier state to be developed.
Flexner and Amoss (Jour, of Exper.
Med., Apr., 1919).
In several personal cases and others
observed by colleagues in a recent
outbreak, all had at the outset a catar-
rhal inflammation of the nose and
throat and but few gastro-intestinal
signs. Abrahamson (N. Y. Med. Jour.,
April 20, 1921).
A lumbar puncture made at this
time may confirm the diagnosis by
demonstrating a shght opalescence or
milkiness in the spinal fluid with-
drawn, which opalescence indicates
the early appearance of paralytic phe-
nomena. It also contains, after a pre-
liminary fall, an excess of leucocytes,
mainly lymphocytes, tending to reach
the maximum when paralysis impends.
The value of lumbar puncture as
an aid in diagnosis between cases of
acute cerebrospinal meningitis and
acute poliomyelitis of the meningeal
type is undoubted. In the former
the fluid shows marked turbidity, fre-
quently coarse, purulent clot forma-
tion, a great excess of albumin, ab-
sence of dextrose, and the meningo-
coccus. Forbes (Lancet, Nov. 18, 1911).
Increase of pressure is the most
persistent of the changes in the spinal
fluid in poliomyelitis, and does not
disappear for several months. After
the tenth day it is present in nearly
100 per cent, of cases. Of the fluids
examined, 93 per cent, showed an in-
crease in the globulin content and 86
per cent., a pleocytosis. Lympho-
cytes predominated. Larkin and Corn-
wall (Arch, of Pediatr., Aug., 1918).
The history of the acute or febrile
stage is of import, especially in ex-
cluding cerebral meningitis and the
cerebral palsies of childhood. In polio-
myelitis there are few irritative symp-
toms. Convulsions may occur, but
the patient does not develop epilepsy
or mental enfeeblement. Epilepsy, on
the other hand, is often a part of the
symptom-picture in the cerebral pal-
sies and mental impairment in some
degree almost invariably present.
The type of the paralysis in the two
is exactly opposite. In poliomyelitis
the paralysis is flaccid, the reflexes
are lost, the muscles atrophy, the
muscles affected are functionally as-
sociated, and a monoplegia is the rule
as regards distribution. In the true
cerebral palsies the paralysis is spas-
tic in type, with exaggerated reflexes;
no wasting, although arrest of de-
velopment may result ; the paralysis
is of muscles anatomically associated ;
the distribution is usually hemiplegic,
monoplegias being rare. In cerebral
palsies, too, the cranial nerves, par-
ticularly the facial, are often afifected
and the mind is almost invariably im-
paired. Finally, there are no elec-
trical changes characteristic of the
cerebral palsies.
224
SPINAL CORD, DISEASES OF (PRITCHARD).
From other forms of myelitis infan-
tile spinal paralysis is to be distin-
guished chiefly by the frequent ab-
sence in the latter afifection of sensory
symptoms, of sphincter involvement,
of bed-sores, of spastic or semispastic
phenomena. Palsies from peripheral
neuritis due to trauma, including so-
called birth-palsies caused l)y obstet-
rical forceps or injury in delivery, are
often difficult to distinguish from
poliomyelitis. The history of injury
to the arm or shoulder and the an-
atomical distribution of the paralysis
are points of differential value. In
neuritis of this type sensor}^ disturb-
ances are not conspicuous, as a rule,
but may be present. The history as
to mode of onset and progress serves
to distinguish poliomyelitis anterior
acuta from the pure muscular atro-
phies. Differentiation from cerebro-
spinal meningitis is at times, espe-
cially in endemic outbreaks of either
disease, exceedingly difficult. Lab-
oratory methods in the bacteriolog-
ical examination are in such cases
imperative as the only accurate method
by which to determine the identity of
a given case.
ETIOLOGY. — The pathogenic
agent of poliocerebromyelitis has been
found by Flexner to be an exceed-
ingly minute organism, emulsions of
a virulent spinal cord being still in-
fective after filtration through Cham-
berland filters. That it is a living
organism is shown by the fact that
it undergoes reproduction in the body
of an inoculated animal, a small
amount of emulsion of the spinal cord
of a victim of the disease injected
into a monkey being sufficient to
cause it after a period of incubation
of 5 to 46 days. It has not been iso-
lated in pure culture.
It is not only constantly present in
the cerebrospinal system, but also in
the mucosa of the nasal cavities and
pharynx, the salivary, mesenteric,
and lymph glands after inoculation,
and also in the spinal fluid, and in
small quantity in the blood. Animals
other than the monkey, with the ex-
ception of certain breeds of rabbits,
do not appear susceptible to inocula-
tion. Monkeys that recover from the
infection show a definite immunity to-
reinoculation, while their blood-serum
deprives an emulsion of virulent
spinal cord of all pathogenic power.
The organism probably penetrates
the central nervous system after en-
tering the body by way of the naso-
pharynx or intestinal tract, or both.
The secretions of the nose and throat
are, therefore, regarded as infectious
and capable of disseminating the dis-
ease by direct contact. Hence, the
fact that the patient should be iso-
lated and kept from school at least
three weeks after convalescence. See
Prophylaxis below.
The physical properties of the virus
adapt it well for conveyance to the
nose and throat. Being contained in
their secretions, it is readily dis-
tributed by coughing, sneezing, kiss-
ing and b}^ means of fingers and
articles contaminated with these se-
cretions, as well as with the intes-
tinal discharges. Moreover, as the
virus is thrown oE from the body
mingled with the secretions, it with-
stands for a long time even the high-
est summer temperatures, complete
drying, and even the action of weak
chemicals, such as glycerin and car-
bolic acid, which destroy ordinary
bacteria.
Hence mere drying of the secre-
tions is no protection; on the con-
trary, as the dried secretions may be
converted into dust which is breathed
into the nose and throat, they be-
SPINAL CORD, DISEASES OF (PRITCHARD).
225
come a potential source of infection.
The survival of the virus in the se-
cretions is favored by weak daylight
and darkness, and hindered by bright
daylight and sunshine. It is readily
destroyed by exposure to sunlight.
Simon Flexner (Address, New York,
July 13, 1916).
Ninety per cent, of the acute cases
occur within the first decade of life
and more than half of all cases within
the first three years of life. Among
children the two sexes seem about
equally susceptible. Among- adults
it is comparatively rare in the female.
The disease is no respecter of caste
(giant cells) of the anterior horns.
This occurs as the result of an in-
flammatory myelitic process dis-
seminated more or less extensively
throughout the cord, but chiefly in
the anterior gray matter, induced by
the Flexner micro-organism, the me-
dium of invasion being the branches
of the anterior spinal artery. In the
Striimpell and Wernicke types the
cortical and basal nuclei or neurons
are involved. The cells of the lower
dorsal and midcervical segments are
most frequently afifected. The ante-
rior nerve-roots are also afifected sec-
or class, nor does it manifest any ondarily with degenerative changes.
special racial proclivities, though the
negro is comparatively exempt and
the disease is more common in cen-
ters of dense population than in rural
districts. Poliomyelitis is often a
sequel to the febrile infections of
childhood, especially scarlet fever,
measles, and diphtheria. In this re-
spect, as well as others, its etiology
and this is true of the muscles to
which the affected nerves are distrib-
uted. The atrophied muscles show
a distinct diminution in the size and
number of fibers, the normal tissue
being replaced by fat and connective
tissue.
PROGNOSIS.— To approximate
idurinof the acute febrile stage the
is quite similar to that of epidemic extent or degree and the distribution
and sporadic cerebrospinal menin- of the final more or less permanent
gitis. Poliomyelitis may also occur paralysis there is no positive guide,
as an epidemic. but the severity of the constitutional
In not a few instances trauma ap- disturbance, including temperature,
pears as the exciting cause; exposure is sometimes an index. Occasionally
to extreme cold or to excessive or after the constitutional disturbance
violent exercise may superinduce the subsides, the loss of power may re-
disease. The season has its influence, main rather widely distributed. In
many more cases occurring in sum- such instances the electrical response
mer than in winter. This is espe- affords information. If the quantita-
cially noticeable in seasons of pro-
longed excessive heat. Among adults
violent exercise, exposure, trauma.
tive response grows less or the quali-
tative change greater from day to day
in certain muscles or a limb, just in
debilitating
excesses, and syphilis proportion is there likely to be a per-
are recognized as potent factors, manent residual paralysis. In all
Heredity is not a factor. cases some permanent paralysis will
PATHOLOGY. — The essential le- remain, but it may be six months
sion in acute anterior poliomyelitis is from the onset before the limits of
a trophic destruction, more or less this paralysis can be determined. The
complete, of the larger ganglion-cells patient is handicapped physically in
8—15
226
SPINAL CORD, DISEASES OF (PRITCHARD).
after-life to a greater or less extent,
but never mentally. The prognosis
depends largely upon the ability of
the parent to carry out instructions
in faithful, patient, persistent treat-
ment. Recoveries range from 7.1 per
cent. (New York epidemic) to 19.2
per cent. (Minnesota epidemic).
In poliomyelitis proper the prog-
nosis as regards life is almost invari-
ably good. In the polioencephalitic
type a fatal result has been frequently
noted, and this is true of certain en-
demic outbreaks, a variable virulence
in the micro-organism afifording the
probable explanation.
The prognosis as to life is good in
sporadic cases; in epidemics the mor-
tality is frequently 12 per cent., and
in some may rise as high as 40 per
cent. Hochhaus (Miinch. med. Woch.,
Nov. 16, 1909).
PROPHYLAXIS. — Flexner holds
that the United States has suffered
disproportionately and more severely
than Europe in its epidemics of polio-
myelitis because the disease was
often unrecognized, and there were
no authoritative sanitary regula-
tions to enforce quarantine. Most
attention should be paid to preven-
tion. Human transmission, both by
those actively infected and those who
are about the ill, occurs frequently.
Hence there must be quarantine of
the sick and of those in attendance on
the sick. Cases of long persistence of
the active virus in the monkey are
cases of chronic bacteria carriers. A
period of isolation of three to four
weeks is necessary even in ordinary
cases. The nasal and buccal secre-
tions of those affected with polio-
myelitis must be especially well cared
for, as in them is probably the chief
source of infection, although all the
excretions must also be asepticized.
Domestic animals may serve as res-
ervoirs for the virus. Flies may
harbor the virus on their bodies or
in their viscera. Recovery from the
disease is effected by means of im-
munizing principles in the blood.
Sera obtained from animals subjected
to injections of spinal cord and brain
of monkeys containing the living
virus are relatively weak in anti-
bodies, and will be of little aid in
cases of developed poliomyelitis in
human beings. The only drug rec-
ommended is hexamethylenamine.
Once in the air the virus may be
disseminated in various ways, by di-
rect contact with clothing, by the
wind, and by water. As prophylactic
measures, washing down and oiling
the streets, antiseptic scrubbings of
rooms, spraying the nasopharynx
with hydrogen peroxide in persons
exposed, a .«trict quarantine for at
least two months, prohibition of
bathing in stagnant water in a neigh-
borhood where a case occurs, as well
as of playing around sand-heaps, and
thorough disinfection of domestic
animals are recommended. M. Neu-
staedter (Jour. Amer. Med. Assoc,
■ Sept. 7, 1912).
The writer emphasizes the need
for greater care in the prevention of
the spread of the disease by the use
of (1) dilute hydrogen peroxide or 5
per cent, menthol nasal irrigation for
those exposed; (2) disinfection of
the patient's stools and urine; and
(3) isolation of the patient for six
weeks and of other members of the
household for three weeks. G. W.
Howland (Can. Jour. Med. and Surg.,
xxxvii, 52, 1915).
Practical demonstration of the fact
that the active virus of poliomyelitis
may occur in rectal washings ob-
tained from a patient fourteen days
after the beginning of the paralysis.
Since the virus may leave the body
from the rectum, as well as from
SPINAL CORD, DISEASES OF (PRITCHARD).
227
the nose and mouth, precautions
should be taken in the care of polio-
myelitis patients to prevent infection
from feces and soiled bedding. W.
A. Sawyer (Amer. Jour. Trop. Dis.
and Prevent. Med., Sept., 1915).
The chief means by ivhicJi the secre-
tions of the nose and throat are dis-
seminated is through the act of kissing,
coughing, or sneezing. Hence during
the prevalence of an epidemic of in-
fantile paralysis, care should be exer-
cised to restrict the distribution as
far as possible through these com-
mon means. Habits of self-denial,
care and cleanliness and considera-
tion for the public welfare can be
made to go very far in limiting the
dangers from these sources.
Moreover, since the disease at-
tacks by preference young children
and infants, in whom the secretions
from the nose and mouth are wiped
away by mother or nurse, the fingers
of these persons readily become con-
taminated. Through attentions on
other children or the preparation of
food which may be contaminated, the
virus may thus be conveyed from the
sick to the healthy.
The conditions which obtain in a
household in which a mother waits
on the sick child and attends the
other children are directly contrasted
with those existing in a well-ordered
hospital; the one is a menace, the
other a protection to the community.
Moreover, in homes the practice of
carrying small children about and
comforting them is the rule, through
which not only the hands, but other
parts of the body and the clothing of
parents may become contaminated.
Flies also often collect about the
nose and mouth of patients ill of in-
fantile paralysis and feed on the se-
cretions, and they even gain access
to the discharges fronx the intestines
in homes unprotected by screens.
This fact relates to the domestic fly,
which, becoming grossly contaminated
with the virus, may deposit it on the
nose and mouth of healthy persons, or
upon food or eating utensils. To what
extent the biting stable-fly is to be
incriminated as a carrier of infection
is doubtful; but we already know
enough to wish to exclude from the
sick, and hence from menacing the
well, all objectionable household in-
sects.
Food exposed to sale may become
contaminated by flics or from fingers
whicli have been in contact with secre-
tions containing the virus; hence food
should not be exposed in shops and no
person in attendance upon a case of
infantile paralysis should be permitted
to handle food for sale to the general
public.
Protection to the public can be best
secured through the discovery and iso-
lation of those ill of the disease, and
the sanitary control of those persons
who have associated with the sick and
whose business calls them away from
home. Both these conditions can be
secured without too great interfer-
ence with the comforts and the rights
of individuals.
Where homes are not suited to the
care of the ill so that other children
in the same or adjacent families are
exposed, the parents should consent
to removal to hospital in the interest
of the sick child itself, as well as in
the interest of other children. But
this removal or care must include
not only the frankly paralyzed cases,
but also the other forms of the
disease.
In the event of doubtful diagnosis,
the aid of the laboratory is to be
sought, since even in the mildest
cases changes will be detected in the
cerebrospinal fluid removed by lum-
bar puncture. If the efifort is to be
made to control the disease by isola-
tion and segregation of the ill, then
these means must be made as inclu-
sive as possible. It is obvious that
in certain homes isolation can be
carried out as effectively as in hos-
pitals. Simon Flcxncr (Address, New
York, July 13, 1916).
TREATMENT.— No material proo--
rcss has of late been made in the
treatment of the disease.
228
SPINAL CORD, DISEASES OF (PRITCHARD).
During the febrile stage the treat-
ment is that for all forms of acute
myelitis, including absolute quiet and
rest, ice-bags or counterirritation to
the spine, laxatives, and a non-stimu-
lating, easily digested diet. To these
measures should be added, if there is
much fever, antipyretics, such as phe-
nacetin or other coal-tar derivatives.
It is customary to use ergot in Yz-
dram (2 Gm.) doses or less, with or
without bromide of potassium, and
no liarni is likely to follow its em-
ployment. The salicylate of soda has
been employed with some advantage
in epidemics of the disease, and its
use seems rational. Administration of
hexamethylenamine in full doses has
been advised throughout the acute
stage. In Flexner's experiments on
monkeys, however, the drug proved ef-
fective only very early in the course of
the inoculation, and in only a part of
the animals treated. The dose should
be 2 grains (0.13 Gm.) every six hours
for a child of 2 or 3 years of age; 3
grains (0.2 Gm.) at 6 to 10 years, and
5 grains (0.3 Gm.) for adults.
Among 11 cases treated with ad-
renalin, as recommended by Meltzer,
there were 18 deaths, of which but 5,
or 6.9 per cent., are considered fail-
ures of the adrenalin treatment. The
bottle of 1:1000 solution was first
placed in a bath of boiling water to
drive off the chloretone. Spinal punc-
ture was made between the fourth
and fifth lumbar vertebrae, intraspinal
pressure relieved, and 2 c.c. (32 min-
ims) of the adrenalin solution in-
jected. This was repeated every 6
hours day and night until the tem-
perature was normal. P. M. Lewis
(Med. Rec, Sept. 23, 1916).
In epidemics, as a measure of pro-
phylaxis, careful attention should be
given to the hygiene of the naso-
pharynx, intranasal antiseptic solu-
tions being indicated. A 1 per cent.
hydrogen dioxide solution should be
used as spray and gargle by the
patient and the members of his
family. Argyrol (25 per cent.), pro-
targol, chinosol (1 : 2000), or colloidal
silver are also available for this.
Efforts to immunize by bacterial
sera have not been as yet successfully
perfected, although Flexner's work in
this direction has seemed to promise
much for the future.
The writers deem it established for
monkeys, and probable for man, that
intraspinal injection of immune serum
in poliomyelitis is curative. Flexner
and Amoss (Jour, of Exper. Med.,
Apr., 1917).
Report of 26 cases treated with
large amounts of serum obtained from
persons recently recovered from '
poliomyelitis. Apparently the best
results were obtained in cases treated
within 30 hours. Amoss and Chesney
(Jour, of Exp. Med., 25, 581, 1917).
An immune serum of high titer was
prepared by repeated inoculation of
the horse with the coccus of anterior
poliomyelitis and used in 159 cases.
The mortality was 12 per cent., as
against 32 per cent, in the untreated.
Ten patients were treated in the pre-
paralytic stage, and all recovered
without paralysis. The serum arrests
the progress of paralysis when de-
veloping. It was given intraspinally
by the gravitj' method after with-
drawal of spinal fluid, the dose being
5 to 10 c.c. for a child. Simultane-
ously from 10 to 30 c.c. were given
intravenously. The injections were
repeated at intervals of twenty-four
hours. J. W. Nuzum and R. G. Willy
(Jour. Amer. Med. Assoc, Oct 13,
1917).
Treatment of poliomj'elitis with
immune horse serum applied in 58
cases. Altogether, 94 intravenous in-
jections were made. In no instance
was a primary toxic action noticeable,
and in only 6 was there later evidence
of serum disease. Ten patients died,
SPINAL CORD, DISEASES OF (PRITCHARD).
229
a mortality of 17 per cent. Exclud-
ing 7 already moribund, there were
but 3 deaths. Of 23 untreated pa-
tients, 9 died. Paralysis never de-
veloped when treatment was begun
before its onset. No extension of ex-
isting paralysis occurred. Rosenow
(Jour, of Infect. Dis., Apr., 1918).
The antistreptococcic serum of
Nuzum and Willy has failed to show
in the monkey neutralizing or thera-
peutic power when applied by the
writers' methods against small doses
of the virus of poliomyelitis. Under
the same conditions the serum of
monkeys recovered from experimen-
tal poliomyelitis proved neutralizing
and protective. Amossi and Eberson
(Jour, of Exper. Med., Sept., 1918).
The writer applied the therapeutic
test devised by Amoss and Eberson
to fresh samples of immune horse
serum prepared by injections of the
poliomyelitic coccus in the horse.
Three monkeys were completely pro-
tected while the fourth developed
mild symptoins and recovered com-
pletely. The control monkeys re-
ceiving normal horse serum all died.
Fresh immune horse serum protected
perfectly against infection, while
pooled immune monkey serum served
only to delay the onset of a fatal in-
fection. Nuzum (Jour, of Infect. Dis.,
Sept., 1918).
For the permanent residual paral-
ysis our most reliable therapeutic re-
sources consist of electricity, mas-
sage, and exercise of the parts through
the assistance of various mechanical
appliances to be appropriately de-
vised by the orthopedist. Both cur-
rents should be employed. In using
galvanism one electrode, a large flat
pad, should be placed over the spine
at the level affected, the other on the
limb paralyzed. Not more than 3 to
5 milliamperes should be used at first.
As the child becomes accustomed to
it, the current-strength may be grad-
ually increased. The seance should
last twenty minutes daily, and should
be followed by an application of the
faradic current to the limb itself. The
current here should be strong enough
to produce gentle contractions. If
there is no response to faradism ex-
cept with painfully strong currents,
the interrupted galvanic current may
be used in the same way. As much
as possible of the affected muscle
should be included in the circuit.
Massage should be given, prefer-
ably by one qualified for the work,
though, if an expert be not available,
simple rubbing is of at least some
service in stimulating the circulation
and local nutrition. Strychnine inter-
nally is at times of apparent value.
The amount should vary with the
age, of course, but much larger doses
than are ordinarily prescribed are in-
dicated. Such large doses may be
quite safely reached by a gradual in-
crease. Splints, braces, and other ap-
pliances serve a useful purpose in
preventing crippling contractions and
unsightly deformities. A flaccid leg
may be supported by a brace so as to
become useful in walking, which in
itself is a valuable therapeutic aid.
Velocipedes, tricycles, and other sim-
ilar machines are often of much
service.
The employment of re-educational
and developmental exercises with
muscle training, direct or vicarious,
should be much more extensively and
hopefully employed. Much more is
to be accomplished remedially by
such methods than by the prolonged
employment of fixation apparatus,
l)races, and dther su])portive devices.
Operative Treatment. — Consider-
able work in this direction has been
done in recent years. Besides efforts
to correct deformity and improve
230
SPINAL CORD, DISEASES OF (PRITCHARD).
muscular function referred to above,
tendon transplantation, insertion of
bone, insertion of periosteum, ar-
throdesis or the production of arti-
ficial ankylosis and other operations
have been employed. As these be-
lono- to the held of the orthopedic
surgeon, a recently published report
by Dr. R. Tunstall Taylor {Nczv York
Medical Journal, January 29, 1916) is
submitted : —
Tenotomy and Myotomy. — Orthopedists
daily now employ them in correcting de-
formities by severing the overactive mus-
cles and lengthening them thereby; this
overactivity is due to a paretic condition
in the antagonist or antagonistic group as
explained by Seligmiiller's theories. These
operations are of distinct benefit, in that
they not only restore the normal align-
ment in the members, but relieve the re-
maining weakened living muscular fibers
in the paretic muscle from overstrain,
which in itself is a detriment. As a rule,
some mechanical device to prevent recon-
tracture of the overstrong muscle is re-
quired in the after-treatment of all cases.
Tendon shortening by taking a tuck in
it by suture, tying, or removal of a sec-
tion has been done by various surgeons
in the past.
Tendon lengthening has been accom-
plished more often by tenotomy subcu-
taneously within the sheath, and lengthen-
ing has occurred by organization of the
plastic exudate between the severed ends.
Some few authorities prefer lengthening
the tendon by obUque section and suture
through an open' incision. Again, others
prefer to lengthen by the Bayer Z section
and then stretching. Again we find some,
instead of cutting the tendon transversely,
cut it from below upward and forward
through the width of the tendon to get
a broader surface for sewing.
Tenodesis was a procedure advocated
by Hoffa and extensively used by him, of
converting the tendons around a joint
into ligaments by sewing them above and
below a joint, to increase its stability
when flail-like and to restore proper
alignment and balance when distorted.
Gallie's recently presented operation is
akin to Hoffa's tenodesis in that he en-
deavors to secure more thorough joint
fixation by using a whole or a part of a
tendon near the ankle to produce a ten-
don fixation into the bone, which he has
grooved with a gouge to sufficient depth
to suture and bury the tendon and to
cover it with the incised and elevated
periosteum.
Extra-articular silk ligaments, chiefly to
support a flail ankle, knee, or shoulder
have been advocated by Lange and Alli-
son. The former has preferred silk liga-
ments to arthrodesis since 1903 and intro-
duces from 6 to 8 strong silk threads su-
tured to the periosteum of the scaphoid
and tibia and cuboid and fibula, having
been passed through the adipose tissue
from point to point. The upper point of
attachment is 5 cm. above the ankle-joint.
Allison uses the silk as a stirrup. With
a drill having an eyelet which he threads,
he passes the silk through the anterior
tarsal bones from side to side of the foot,
then threads a probe, which he passes
under the annular ligament up to the
crest of the tibia, where he makes an in-
cision and sutures the two ends to the
periosteum. Similarly, he threads the os
calcis and passes the ends up for suture
in the posterior aspect of the tibial perios-
teum.
Intra-articular Silk Ligaments.— Bartow
and Plummer describe artificial ligaments
of silk which are both intraosseous and
intra-articular, passed into and through
joints in the desired direction to restrict
or limit motion, to be used exclusively in
flail joints. It is especially adapted for
use at the knee, ankle, and shoulder, using
14-20 Corticelli silk. Allied somewhat,
only so far as the effect obtained is con-
cerned, is the operation of Robert Jones
for flail elbow, where we have a useful
band which is valueless when the arm
hangs at the side. He removes a dia-
mond-shaped flap of skin from the front
of the elbow, of sufficient size so that the
two equal triangles which go to make up
the diamond when approximated and su-
tured, will hold the forearm at 40 degrees
with the arm, the most useful angle.
Arthrodesis for flail joints was described
at length by Townsend and Goldthwait in
SPINAL CORD, DISEASES OF (PRITCHARD).
231
excellent articles which will be found in
the Transactions of the American Ortho-
pedic Association. This procedure, espe-
cially for the ankle, has many warm ad-
vocates, as it enables the paralytic in
many cases to do without a brace. It is
employed also at the shoulder in deltoid
paralysis and at the hip and knee rarely;
never at the hip, knee, and ankle of
the same subject. H. Augustus Wilson
strongly advocates this procedure.
Articular Transposition.— Gwilym Davis
has devised an ingenious and efficient op-
eration for paralytic talipes calcaneus in
which he makes a transverse horizontal
section through the os calcis just below
the articular surface adjacent to the as-
tragalus. He then slides the heel back
and the tibia, fibula, and astragalus for-
ward, so that the weight comes upon the
anterior portion of the os calcis, and cal-
caneus is impossible. This procedure I
have classified as "articular transposition."
His results are excellent.
Astragalectomy. — Whitman has been
the author and chief advocate of astrag-
alectomy for talipes calcaneus. After
removal he slides the tibia and fibula for-
ward, and the recurrence of calcaneus is
practically prevented as in Davis's opera-
tion. The mutilation, prevention of other
motions, and shortening of the limb are
its chief objections, but the gait se-
cured is excellent and the deformity is
corrected.
Nerve Anastomosis. — This procedure
has been successful in secondary suture
after traumatic section of nerves, and in
facial paralysis. Spitzy was successful ex-
perimentally in dogs' legs, in anastomos-
ing nerves both centrally and peripherally,
and Howell anastomosed flexor nerves
into extensor and znce versa in dogs' legs,
but neuroplasty has failed to meet expec-
tations in anterior poliomyelitis, when the
peripheral end of a paralyzed nerve was
sutured into a functioning nerve or a slip
from a functioning nerve was attached to
a paralyzed nerve. There is evidently a
general impairment in all the nerves in a
partially paralyzed extremity, and a nerve
anastomosis is like taxing an already weak
and run-down battery with more work.
Tendon Transplantation on Tendon. —
It consists in the attachment of the distal
tendon of the weakened muscle to one
still alive and functionally active, to help
restore support and use to the paralyzed
tendon, but only in rare instances have
these cases yielded results which enabled
the patient to do without artificial sup-
port. Dane's statistics of 50 cases from
the Children's Hospital, Boston, were dis-
couraging, as were reports from elsewhere
in this country and abroad.
Tendon Transplantation to Periosteum.
— Since 1899, by means of the new method
of Lange, as it is called, in contradistinc-
tion to the older method of Nicoladoni,
we suture the tendon to the periosteum
or a silk prolongation of the tendon to
the periosteum, or actually pass the ten-
don through a bony canal, or sew it to
the bone, or reduplicate it on and suture
it by Ryerson's method to itself. This
seems to have maintained the desired
muscular tension much better and to have
accomplished the aim we have in view
more satisfactorily in the writer's hands,
and, as reported, by HofTa, H. Augustus
Wilson, Dane, Le Breton, and others.
Elongation of short tendons by means
of silk sutures — preferably white subli-
mated— coated with paraffin, and giving
these a periosteal attachment, has also
yielded good results in my experience.
Auger first used silk to lengthen tendons
in 1875, to which Lange calls our atten-
tion, but Lange popularized its use.
The following operation has been con-
stantly employed by me since 1909 and
in some 300 cases of leg and foot parlysis:
The tendon must be carried straight from
the origin to the new insertion to gain
the greatest mechanical efficiency, and the
annular ligament must be employed when
possible to take up any slack in the new
order of things. The tendon is more se-
curely fixed if sutured to a notch in the
bone, retained in a fixed dressing for 4
months, and without weight bearing for
2 months.
MYELITIS.
SYNONYMS.— Inflammation of
the spinal cord ; softening of the
spinal cord.
DEFINITION.— Myelitis is an in-
flammation, localized or general, with
232
SPINAL CORD, DISEASES OF (PRITCHARD).
secondary softening or sclerosis of
the spinal cord, with irritative and
paralytic motor and sensory as well
as special symptoms, varying- in char-
acter and distribution with the locali-
zation and degree of the morbid pro-
cess at different levels or areas of the
cord. ]\Iany varieties are recognized.
The anatomical division includes the
cervical, dorsal, and lumbar varieties ;
the transverse (imperfect or com-
plete) ; the diffuse, or disseminated;
the focal ; the central ; and the mar-
ginal. The last mentioned is fre-
quently associated with and often
dependent upon a meningitis, the re-
sultant condition being known as
meningomyelitis. The etiological di-
vision includes at least three varieties
of importance : the traumatic, the
syphilitic, and the tubercular. The
terms acute, subacute, and chronic
appear in the literature, although
Striimpell and others dispute the ex-
istence of a primary chronic myelitis.
The type of all forms is acute trans-
verse myelitis.
SYMPTOMS.— The disease may
begin abruptly, subacutely, or very
gradually. When the onset is abrupt
a chill may occur, followed by fever,
the temperature ranging from 101° to
104° F. (38.3° to 40° C), occasion-
ally higher. In children the onset
may be attended with convulsions;
aside from the general malaise and
fever, the constitutional disturbance
may be slight.
The essential nervous symptoms
are usually irritative at first, although
motor and sensory paralysis may be
present from the start. These nerv-
ous symptoms vary widely with the
locality and extent of the myelitic
process, imperatively necessitating a
certain degree of familiarity with the
topographical anatomy and functional
localization of the cord. The dorsal
region is most frequently affected in
the focal disease. Among the irrita-
tive symptoms hyperalgesia and hy-
perestliesia are common. The patient
may complain, sometimes emphatic-
ally, of pain in the back and legs.
Quite often the sensation is that of
a tired aching in the limbs, as from
excessive fatigue. If up and walking
about, the legs are lifted wearily and
the patient refers to them as being
vveighted with lead. There is a sub-
jective numbness, or various pares-
thesiae may be mentioned. The blad-
der is disturbed in function. There
is retention, or the urine may dribble
involuntarily. The bowels are usu-
ally obstinately constipated ; less fre-
quently there is incontinence of feces.
Sexual power is lost or there may be
persistent priapism. A feeling as of
a band or belt encircling the hips, the
waist, or the chest may be present.
This is the so-called ccinture, or gir-
dle symptom, and is quite constant in
myelitis. The level of the ccinture
feeling is a guide to the level of the
cord-lesion. If the disease is of the
cervical cord, involving the origin of
the brachial plexus, the arms will be
affected. Pupillarj^ changes are also
frequently noted when the disease is
of the cervical cord through implica-
tion of Budge's ciliospinal center.
Case characterized by an acute as-
cending paralysis, commencing with
indications of meningitis in the form
of acute pain and spinal rigidity.
Vision was impaired on the follow-
ing day, and on the day after this
evidence of slight papillitis, more on
the right side, was observed. The
upper limit of hyperesthesia was one
inch below the nipples. On the ninth
day of illness the breathing was al-
most entirely abdominal, but the arms
SPINAL CORD, DISEASES OF (PRITCHARD).
233
could be easily moved. On the four-
teenth day marked dysphagia set in,
and the patient died while attempting
to swallow fluid. E. F. Clowes (Lan-
cet, Mar. 23, 1912).
Should the myelitis extend upward
the functions of the vagus are dis-
turbed and dyspnea, with circulatory
and vasomotor symptoms, is added
to the picture. Following- the irrita-
tive come the paralytic symptoms.
The hyperesthesia is succeeded by
anesthesia, which is characteristically
erratic in distribution. Any or all
other forms of common sensation
may be impaired or completely lost.
There may be dissociation of sensa-
tion.
The motor weakness is succeeded
by actual paralysis, which follows an
anatomical distribution, but is usu-
ally not absolute. This paralysis
may be flaccid or spastic, or first one
and later the other, with abolished or
exaggerated reflexes according to the
location of the lesion. Widespread
motor and sensoiy paralysis may fol-
low slowly a prolonged irritative
stage or it may be extensive and com-
plete in a few hours or days. Within
a few weeks or months atrophy of the
muscle, sometimes slight, sometimes
extreme, occurs. The electrical reac-
tions may remain normal, although
both quantitative and qualitative
changes have been frequently noted.
Bed-sores are exceedingly common in
severe cases, and are sometimes an
extremely dangerous symptom.
In the spastic cases decided con-
tractures may develop, the knees be-
ing flexed upon the abdomen, the
heels touching the buttocks. Clonic
or tonic spasms occurring in ex-
quisitely painful paroxysms add to
the sufferings of the patient in many
instances. In the chronic variety of
the disease the irritative symptoms
are far less prominent. The mind re-
mains unaffected in all cases except
where an insanity may be superadded
from pain and abject helplessness. It
should be remembered, too, that the
syphilis or tuberculosis or alcohol
causing a myelitis may later attack
the brain.
Case of a man of 50 with a history
of syphilis. He began to experience
pain in the spine, and after a few
days there was sudden and total
paralysis of the legs, but no flaccid
paralysis. The spine was painted
with tincture of iodine, while vigor-
ous mercurial treatment was insti-
tuted and by the fifth day the man
was taking a few steps and soon was
able to return to business. Britto
(Brazil Medico, Nov. 15, 1914).
Case of myelitis in a child of 5^^
years, who had complained of vague
pains in the chest and legs. There
was paralysis of both legs and back
with anesthesia extending from the
toes to a line drawn around the chest
just below the nipples. The tempera-
ture, previously fairly normal, rose
just before death. The heart and
lungs remained normal. There was
no history of any infectious fever,
which is the rule in these cases. The
etiology of this case is obscure. H.
T. Ashby (Brit. Jour. Child. Dis..
May, 1915).
DIAGNOSIS.— The acute disease
may occasionally closely resemble
Landry's paralysis. In the latter af-
fection the sensory symptoms are
slight ; usually there are no bladder
or rectal symptoms, na girdle sensa-
tion, and the course of the disease is.
as a rule, much more rapid. Certain
types of multiple neuritis are occa-
sionally temporarily confusing. This
is especially true of the cases of
myelitis inducing flaccid paraplegia
or diplegia. In such cases, however,
234
SPINAL CORD, DISEASES OF (PRITCHARD).
pain is much less conspicuous than
in neuritis, and in the latter the
sphincters are not involved. Bed-
sores and other trophic lesions are
rare in neuritis.
Spinal meningitis rarely exists alone,
the cerebral meninges being usually
simultaneously involved. In syph-
ilitic or tubercular spinal pachymenin-
gitis or leptomeningitis, the pain is
usually much more conspicuous and
the irritative spasms more decided.
Usually, however, the cord is soon
involved, and the differentiation is
unimportant.
Occasionally tabes is suggested.
The knee-jerks may be abolished or
greatly diminished, the genital func-
tions are involved, the sensory symp-
toms may be similar, Romberg's
symptom may be present, and there
may be an ataxic gait. The Argyll-
Robertson pupil vvrill be found want-
ing, however, as well as other ocular
and optic-nerve changes ; the pains
are different in character and degree,
and there is true motor paralysis.
The history as regards mode of
onset and rate of progress is of value
in differentiating spinal muscular atro-
phy and amyotrophic lateral sclerosis
and primary lateral sclerosis from my-
elitis. Tumor of the cord is almost
invariably complicated with myelitis
of focal type, and the symptoms are
necessarily identical in great meas-
ure. It is possible, however, to de-
termine the existence of tumor at
times by the more intense and some-
times agonizing pain, the slower rate
of progress, the narrower limitation
of symptoms, and the lessened degree
of constitutional disturbance. The
presence of tumor elsewhere, espe-
cially if malignant, is often of assist-
ance. The X-ray is of very infre-
f|ucnt value in suspected cord tumor
in my experience. Its employment is
none the less indicated as a routine
procedure in suspected cases. Spinal
hemorrhage, if at all extensive, is
usually quickly fatal from shock.
Case in which the symptoms of the
myelitis changed, showing that the
lesion had migrated. Patient was a
robust mechanical engineer of 30,
who ran a rusty nail into one toe
and a month later had to work in icy
water all one night. The motor pa-
ralysis, motor irritation, disturbances
in sensibility and in the reflexes were
at first those typical of myelitis in
the lower spinal cord, but then these
subsided and others developed indi-
cating transference of the lesion to a
region higher up. Among the most
disturbing symptoms in the later
phase were the unbearable itching
from axillae to ears, including the
arms, and also the headache. Inva-
sion of the medulla oblongata was
momentarily expected, but under in-
tramuscular injections daily of 10 c.c.
{lYi drams) camphorated oil, with
strychnine and aspirin, a marked
turn for the better was noted, and
with continued galvanization, strych-
nine injections and carbonated baths
a clinical cure followed, even the
cremaster and abdominal reflexes re-
turning. In less than three months
from the first symptoms the patient
felt entirely well. Bing (Med. Klinik,
Dec. 15, 1912).
ETIOLOGY. — The disease may
occur at any age and in either sex,
though it is most common in males
between the ages of 15 and 40 years.
Prolonged or severe exposure to cold
and dampness is a frequent and po-
tent etiological factor. Next in fre-
quency and importance, perhaps, is
trauma, including excessive physicjd
effort or exertion.
Case of myelitis first manifesting
itself two days after a severe fright
from burglars; the patient had pre-
SPINAL CORD, DISEASES OF (PRITCHARD).
235
viously suffered from an attack of
facial paralysis from which he seemed
to have perfectly recovered. The
case terminated fatally, and necropsy
showed extensive organic disease in
the lumbar cord. Cases of paralysis
from fright have usually been at-
tributed to hysteria. The patient also
suffered from perirectal infection, and
septicemia was given as the cause of
death. W. G. Spiller (Jour. Amer.
Med. Assoc, Oct. 31, 1914).
A relatively large number of cases
are due to syphilis, which may act
either directly or remotely as cause.
Even in cases where an obvious
trauma or other etiological factor is
present, a Wassermann should be
done as a matter of routine. The co-
existence of syphilis may modify both
prognosis and treatment in cases due
to other exciting causes.
Case in a girl of 17 with both gon-
orrhea and syphilis; three months
after the development of the syph-
ilitic eruption she began to have
fever, headache and paresis of the
legs, blending into total paraplegia of
the ascending type, fatal the fifteenth
day. The findings in the spinal cord
were those characteristic of acute
poliomyelitis, but the symptoms had
been more those of Landry's paral-
ysis. A tetragenus in pure cultures
was obtained from the blood and
cerebrospinal fluid, and this germ
was evidently responsible for the
syndrome observed. Catola (PoH-
clinico, Jan., Med. Sec, 1911).
Tuberculous myelitis is rare, though
spinal meningitis due to tuberculosis
with secondary complicating invasion
of the cord is not uncommon. Oc-
casionally myelitis occurs during or
immediately following (propter hoc)
the acute infectious diseases. Ar-
senic, lead, and other metallic poisons
may induce the disease.
A toxi-infectious myelitis may run
an absolutely latent course, and be
merely a necropsy surprise. In other
cases, the only sign may be exag-
geration of the foot and knee ten-
don reflexes. This was found mani-
fest in 60 of 100 typhoid patients,
also in cases of pneumonia, miliary
tuberculosis and neurasthenia. In 4
cases of the latter, after influenza,
this was the only spinal symptom. S.
Bernheim (Revue de med., Jan.,
1912).
Gross alcoholic excess is often a
most important contributing factor
and may occasionally prove the
sole cause. In a very appreciable pro-
portion of patients the etiology can-
not be positively determined. This
is especially true in subacute and
chronic myelitis.
Case of poliomyelitis in a young
woman of 18 years, in whom grad-
ually, over a period of three days,
developed symptoms of a complete
transverse myelitis involving about
the middle of the dorsal cord. Im-
provement was noticed on the sixth
day, and recovery was pactically com-
plete in about seven weeks. B. S.
Sachs (Jour. Nerv. and Mental Dis.,
Nov., 1912). ■
Case in which at operation the
cause of the compression was found
to be a vertebral sequestrum, 3 cm.
long, which had penetrated into the
spinal canal and was surrounded by
fibrous adhesions. The operation was
followed by an excellent functional
result. Mendler (Miinch. med. Woch.,
Nov. 5, 12, 19, 1912).
PATHOLOGY.— The morbid an-
atomy of myelitis varies with the
cause of the disease somewhat and to
a still greater degree with the stage
during which death occurs. In pa-
tients dying during the acute stages
the apj)earance of the cord in the
areas affected is that of an acute in-
flammatory process. Punctiform or
capillary hemorrhages are sometimes
present. The cells are swollen and
236
SPINAL CORD, DISEASES OF (PRITCHARD).
the nuclei distorted or displaced.
These changes are followed by an
increase of connective tissue, with
destruction of the nerve-cells and
nerve-fibers. The cord may be dis-
colored and swollen in appearance on
gross inspection or it may appear
shrunken. Later the vessel-walls be-
come thickened ; the nerve-tissue is
more or less completely displaced by
connective tissue; the cells disappear
and are replaced by granular and
amorphous material. The pia and
even the dura may be involved. In
some instances, especially those due
to syphilis, the entire cord for sev-
eral inches may be so softened as to
be diffluent. The nerves may par-
ticipate secondarily in the degenera-
tive process.
In most cases of acute myelitis, and
also of acute poliomyelitis, the afifec-
tion is caused, not by an inflamma-
tion, but by thrombosis of some of
the vessels of the spinal cord (where,
in the latter disease, it is not due to a
special acute degenerative process).
This conclusion is rendered obvious
by the similarity of the morbid
changes in question to those occur-
ring in the brain which are due to
thrombosis, as well as to the absence
of any reason why a primary inflam-
mation should be rare in the brain
and common in the spinal cord. Bas-
tian (Lancet, Nov. 26, 1910).
PROGNOSIS.— This varies widely
in individual instances. Myelitis due
to causes which are removable by
surgical procedure — as, for example,
compression from trauma, tumor, or
vertebral disease — may occasionally
be completely cured. Syphilitic mye-
litis ofifers a distinctly better progno-
sis than the non-syphilitic, although
even here an opinion as to the outcome
should always be extremely guarded.
Immediate danger as regards life is
greatest in myelitis due to or follow-
ing the infectious fevers, sepsis, and
severe injury. The duration of the
disease is equally indefinite; a sub-
acute myelitis may pass into a
chronic, slowly progressive form, the
gradual development of symptoms
extending over a period of many
months or years. The inflammation
may subside after a varying length of
time and be followed by a necrosis
or sclerosis which is limited by the
preceding inflammation, the patient
being left with a paralysis which re-
mains permanently stationary. The
process may stop and then start up
again, some slight additional cause
relighting the fire in a locality pre-
disposed by previous disease. The
severity of the trophic symptoms is
quite reliable as a guide in determin-
ing the immediate danger to life, deep
and extensive bed-sores being invari-
ably of ill omen. Severe bladder
symptoms are also of evil significance.
TREATMENT.— Absolute rest in
bed is essenial in all cases ; at first
counterirritation should be employed,
with extreme caution, on account of
bed-sores. A water-bed is often ad-
visable from the first to prevent this
complication. The catheter should
be employed also with extreme anti-
septic and mechanical precaution.
Pain should be relieved by opiates
when necessary, but in minimum
doses. In syphilitic myelitis the pa-
tient should be put at once upon full
and rapidly increasing doses of potas-
sium iodide. The dose to begin should
be at least 25 drops of the saturated
solution. The salt should be pure
and the vehicle should be changed
every few days — water, milk, Vichy,
Apollinaris, Giesshiibler water, or
plain carbonated water may be em-
SPINAL CORD, DISEASES OF (PRITCHARD).
237
ployed in turn. The dose should be
progressively diluted more and more,
as it is increased. Should iodism de-
velop, double the dose if less than 40
drops or grains ; if over 100, reduce
it one-half and rapidly increase to a
dose beyond that at which iodism oc-
curred.
The niaximum daily amount is
to be determined by the effect on
the disease, but it is rarely necessary
to give more than 600 or 800 grains
(40 or 53 Gm.) daily.
Mercury is superior to the iodide
only when primary syphilis has im-
mediately or at least recently pre-
ceded the myelitis, but both drugs
should be used in every case, either
alternately or in conjunction. The
immediate gain from the use of neo-
salvarsan should not be relied upon,
l)Ut should be followed up with mer-
cury promptly.
Syphilitic meningomyelitis and en-
cephalitis, or even gumma, should be
most responsive to direct medica-
tion by one of the methods of intra-
spinal or subdural introduction.
When the disease results from
trauma or is due to tumor, abscess,
or disease of the vertebrae, the ques-
tion of operative interference should
always be considered and decided
promptly in order to prevent exten-
sion and secondary softening.
Symptomatic relief may often be
obtained by appropriate operative
treatment, and this is true even in
tuberculous myelitis, where lumbar
puncture with drainage at times
greatly alleviates the patient's dis-
tress. In myelitis due to infection
there is no specific drug or plan of
treatment. Sodium salicylate, small
doses of mercury, or full doses of
iron may be given in addition to the
familiar local measures during the
acute stage. Hexamethylenamine has
come into vogue as a routine drug in
all cases due to trauma or infection.
For the chronic disease we may ex-
pect a certain amount of benefit from
galvanism and massage. (See Polio-
myelitis) . Silver, arsenic, gold, phos-
phorus, and ergot are all mentioned
as therapeutic resources, but there is
little, if any, evidence of specific bene-
fit from either. A tentative course
of treatment with potassium iodide
should be given in all chronic cases.
AMYOTROPHIC LATERAL
SCLEROSIS.
DEFINITION.— Amyotrophic lat-
eral sclerosis is a disease character-
ized essentially by the two symptoms
of spastic rigidity and muscular
atrophy.
SYMPTOMS.— The clinical his-
tory of the disease is quite constant.
It begins very insidiously. Usually
the earliest symptoms are referable to
the disease in the anterior horns, and
are similar to those of incipient pro-
gressive spinal muscular atrophy :
wasting of the thenar and hypothenar
muscles, of the interossei or of the
muscles of the arms or legs, almost
always symmetrically, with or with-
out tremor, which is rarely fibrillary,
however. The degree of wasting may
be slight, or it may be readily mis-
taken at this stage for some form of
progressive muscular atrophy.
Within a few weeks or months, or,
it may be, simultaneously, a sense of
unusual fatigue upon exertion, with
muscular stiffness and increasing
difficulty in walking or in using the
arms, due to the developing spastic
rigidity, is noted, and the patient
seeks advice. On examination, in
238
SPINAL CORD, DISEASES OF (PRITCHARD).
addition to the atrophy, which is
often more perceptible to touch than
to vision, the liml)s will be found
more or less rii^id and resistant to
passive motion, giving the examiner
a sensation as of bending a lead pipe.
The knee-jerks and other deep re-
flexes will be found markedly exag-
gerated, and often early in the dis-
ease, and always in the well-estab-
lished disease, ankle-clonus and wrist-
clonus are readily elicited. If the
bulbar nuclei are involved, there may
be wasting of the muscles of the face,
with alteration in the expression and
impairment of speech, respiration,
deglutition, and cardiac action.
A symptom of importance is the
altered electrical reaction to both the
faradic and galvanic currents. The
muscles respond more and more
feebly to faradism. Qualitative changes
with the galvanic current are present
early, and it is not uncommon to find
decided alteration of the normal polar
formula, with reaction of degenera-
tion within a few weeks or months.
In the late stages of the disease the
atrophic symptoms may dominate the
picture, the rigidity disappears, the
reflexes are lost, and the victim is
bedridden, but with unimpaired in-
telligence.
In some cases of amyotrophic lat-
eral sclerosis, the symptoms and
signs suggest nothing more than a
progressive muscular atrophy of the
Aran-Duchenne type, the sclerosis of
the anterolateral columns, character-
istic of amyotrophic lateral sclerosis,
not being manifested in any very
distinct symptoms. In the case re-
ported by the authors, there v^^as
noted, in addition to the Aran-
Duchenne syndrome, merely a slight
exaggeration of the tendon reflexes
in the four limbs, a temporarily posi-
tive Babinski, a few brief attacks of
rigidity and pain at long intervals,
and only at the last a trace of mus-
cular contracture. Yet the patient
died about twenty months after ad-
mission, and the spinal cord showed
a typical lateral sclerosis. Such a
case demonstrates the importance of
paying heed to even minor spinal
signs in the diagnosis of amyotrophic
lateral sclerosis. A. Gonnet and A.
Grimaud (Lyon med., Apr. 19, 1914).
DIAGNOSIS.— The diagnosis is a
matter of no difhculty ordinarily.
The picture is that of primary lateral
sclerosis and progressive spinal mus-
cular atrophy combined. From other
forms of myelitis and sclerosis pre-
senting one or both of these symp-
toms, this disease is distinguished by
the usual absence of sensory symp-
toms and of sphincter involvement.
ETIOLOGY.— It is not at all a
common affection, is seen oftenest
during middle adult life, and affects
males chiefly. The etiology is not
definitely understood, although trau-
matism, exposure to extreme cold,
and excessive physical exertion, if
prolonged, are probable auxiliary fac-
tors etiologically.
Two cases in which amyotrophic
sclerosis developed after an injury to
the hand in 1 case, and after a severe
strain, followed some months later
by a fall, in the other. There is only
a reasonable presumption of trauma
as an etiological factor, definite proof
being lacking. A. H. Woods (Jour.
Amer. Med. Assoc, June 24, 1911).
PATHOLOGY. — The pathology,
on the contrary, is unusually well
defined and constant. In the spinal
cord the lesions are found in the an-
terior horns and in the lateral and
anterior pyramidal columns. In the
anterior horns the lesions are prac-
tically identical with those observed
in chronic poliomyelitis. The so-
SPINAL CORD, DISEASES OF (PRITCHARD).
239
called giant cells are either atrophied
or destroyed altogether. In the motor
tracts, both lateral and anterior, there
is in all cases a well-marked sclerosis
of these fibers, extending throughout
their entire length, often into and be-
yond the pons and occasionally even
to the subcortical motor fibers of the
Rolandic area itself. If the ponto-
bulbar region is involved, the motor
nuclei show degenerative atrophy ex-
actly as do the cells of the anterior
cornua. The peripheral nerves also
imdergo degeneration, which is of
the parenchymatous type. In the
muscles the essential fibers are re-
placed by connective tissue and fat,
the alteration in color and consist-
ency being often readily apparent.
PROGNOSIS. — The prognosis is
hopeless as to cure. Early helpless-
ness is the rule, and death occurs
within a few years, though a fatal
termination may be delayed by an in-
duced or spontaneous remission or
arrest of progress.
TREATMENT.— Our therapeutic
efforts are limited by experience to
purely palliative measures. Among
these, rest, massage, electricity, and
hydrotherapy are all of value. The
victims of this disease should be con-
sidered legitimate subjects for thera-
peutic experiment.
PRIMARY LATERAL SCLE-
ROSIS.
SYNONYMS.— Spastic spinal pa-
ralysis; spastic paraplegia.
DEFINITION.— It is a disease of
gradual progressive onset assumed to
be dependent upon a primary sclero-
tic affection of the lateral pyramidal
tracts or columns, with symptoms of
motor paralysis of spastic type, ex-
aggerated reflexes, clonus, and con-
tractures.
SYMPTOMS.— Spastic spinal pa-
ralysis is always of gradual onset. It
may begin as a stiffness in walking
or in using the arms which gradually
increases and suggests a condition of
tonic spasm. The essential symptom
is spastic contracture of the muscles
of the extremities, particularly the
flexors.
The symptoms are most objectively
conspicuous in the lower limbs, and
the gait almost p'athognomonic, con-
sisting of short, jerky, spasmodic,
dragging steps, the patient being
tilted forward on tip-toe. The act of
walking will sometimes induce a
clonus causing a series of heel-taps
as the foot drags along the floor.
Clonus is nearly always present in
decided degree, and the deep reflexes
— knee, wrist, ankle, elbow, and jaw
— are invariably greatly exaggerated.
There are no sensory or trophic
symptoms, nor are the intracranial
nerves or functions involved; but the
bladder is often disturbed, the patient
exhibiting what Seguin has termed
"hasty micturition." Sexual func-
tion may be indirectly lost.
In an examination of 35 cases of
spastic paralysis, the writer found
both Babinski's and Bechterew's re-
flexes present in 57.1 per cent., Ba-
binski's alone in 25.7 per cent., Bech-
terew's alone in 11.4 per cent., and
both reflexes absent in 5.7 per cent.
In 17 cases in which both reflexes
were present, Bechterew's was pres-
ent on one side only in 6. The
cases in which Bechterew's reflex
was positive, in spite of the absence
of Babinski's, are of special interest.
Nikitin (Berl. klin. Woch., Sept. 7,
1908).
Spastic paralysis may result from
an apparent normal delivery. In some
cases interference with the dressing
or the bathing- of the infant may be
the first evidence of an existing spias-
240
SPINAL CORD, DISEASES OF (PRITCHARD).
tic paralysis. In other cases delayed
functions of sitting and walking sug-
gest it. Convulsions in infants, either
immediately after or shortly after
delivery, should make us suspicious
of cerebral injury. The possibility of
syphilis as the etiological factor
must always be remembered. Where
ophthalmoscopic examination reveals
increased intracranial pressure, and
where there is not a great amount of
interference with the mentality of
the patient, subtemporal decompres-
sion, as described by Sharpe, should
be performed. In the other cases,
and in the after-treatment of cases
operated on, massage, electricity,
manipulation, supports, tenotomies,
and muscle education usually offer
relief. J. Grossman (N. Y. Med.
Jour., Mar. 11, 1916).
DIAGNOSIS.— In spite of the
vagueness of the pathology, the clin-
ical picture is very constant and strik-
ing. Secondary lateral sclerosis from
intracranial or basilar lesions is con-
fusing only when such lesions are bi-
lateral, and the presence in such cases
of cranial-nerve involvement and of
mental impairment will at once ex-
clude the primary type. In myelitis
with spastic contractures, the pres-
ence, in addition, of sensory symp-
toms, atrophy, rectal and vesical pa-
ralysis, with bed-sores and other
trophic lesions, will readily dififeren-
tiate. In disseminated sclerosis the
patient may exhibit a typical spastic
gait, with contractures and exagger-
ated reflexes, but the additional symp-
toms of intention tremor, nystagmus,
scanning speech, oculomotor palsies,
and sensory disturbances are pe-
culiar, in their associated presence, to
multiple sclerosis alone. In amyo-
trophic lateral sclerosis the marked
and early atrophy is a distinguish-
ing symptom. In progressive spastic
ataxia, or ataxic paraplegia, the inco-
ordination is sufficient to exclude the
disease under consideration. In all
instances, primary lateral sclerosis
should be diagnosed only after most
rigid exclusion of every other possi-
bility, and particularly disseminated
sclerosis in an anomalous or atypical
form.
ETIOLOGY.— The disease afifects
adult males chiefly, usually in the de-
cade between 25 and 35. It is not
very common, and its etiology is
not at all definitely known. It oc-
curs at times in several members of
a family and in such instances doubt-
less is due to an embryonal defect.
PATHOLOGY.— The pathological
evidence in support of the assumption
that a primary sclerosis of the lateral
columns exists is so slight and in-
definite as to have led to much
skepticism. Morbid changes found
post mortem have been strikingly
inconstant. Tumor, hydromyelus,
pachymeningitis, transverse myelitis,
syringomyelitis, hydrocephalus, and
several times disseminated sclerosis
are among the many lesions which
have been observed.
Hip-joint disease in 2 cases of con-
genital spastic paralysis. The special
feature of the microscopic findings in
both cases was the primary develop-
mental defect in the cells of the
motor zone in the brain, a hypoplasia
of the ganglion cells. The pyramidal
tracts were apparently intact in the
second case. S. Miura (Jahrb. f.
Kinderheilk., July, 1912).
PROGNOSIS. — The disease may
last many years, the general health
remaining quite good. Recoveries
are unknown. The victim of the dis-
ease is sooner or later incapacitated
for any and all forms of physical
labor, though he may be able to em-
ploy the hands and arms after walk-
SPINAL CORD, DISEASES OF (PRITCHARD).
241
ing shall have become impossible.
The mind is not afifected.
TREATMENT.— Prolonged rest
is of the first importance, and will at
times result in decided amelioration
of symptoms. The motor depres-
sants— hyoscine, atropine, and coni-
um — have all been successfully em-
ployed for the temporary relief of the
spasticity. Hydrotherapy also serves
effectually the same purpose.
Trial of thiosinamine sodium sali-
cylate in a case of chronic sclerosis
of several years' standing. The con-
tractures and pain were much dimin-
ished, there was less ataxia, and the
power of walking returned. The in-
jections must be made deeply under
the skin. K. A. Grossmann (The
Hospital, Dec. 5, 1908).
Very severe and progressive case
of spastic spinal paralysis in which
there was no obtainable evidence of
acquired syphilis. Patient was al-
most absolutely helpless and bedrid-
den, and had been treated by almost
every method known. When seen, in
July, 1911, he was put on ascending
doses of potassium iodide, which
were rapidly raised to the over-
whelming dose of 1248 grains (83
Gm.) in a single day. From this
time the drug was continued in
amounts of 375 grains (25 Gm.) three
times daily, after which it was grad-
ually reduced as improvement con-
tinued. To this treatment there were
added massage, passive movements,
educational exercises, and forcible
breaking of adhesions in the joints.
On January 1, 1914, the patient was
discharged entirely cured. C. L.
Nichols (L. I. Med. Jour., Oct., 1914).
Surgical measures have been re-
sorted to for the relief of spasticity
with considerable success. In resec-
tion of the spinal roots, iirst pro-
posed in 1905 in this country by
Spiller, the technique devised by
Forster is that most employed at the
present time. The spastic contrac-
tures are either mitigated or cured,
but adjuvant measures are indispen-
sable.
Fifteen cases on record in which
resection of the nerve-roots has been
attempted, according to Forster's
technique. Two of the patients died,
both adults, one from infection and
the other from operative shock.
The other patients were remarkably
benefited, being restored to active
life after years of absolute and hope-
less immobility. F. Rose (Semaine
med., July 7, 1909).
Forster's operation consists in di-
vision of the posterior spinal roots
for severe forms of spastic weakness,
especially in cases of cerebral diple-
gia, old hemiplegias, etc. The prin-
ciple of the operation depends upon
the fact that the spasticity is due to
loss of inhibitory control from the
higher centers. The operation con-
sists essentially in the division of the
paths to the affected groups of mus-
cle, without producing either ataxia
or anesthesia. It has been proven
that anesthesia does not occur unless
three consecutive posterior roots are
divided; Forster recommends there-
fore that no more than two should
ever be divided. The selection of the
roots depends upon careful anatom-
ical study. The indications for the
operation are: (1) The presence of
such severe contracture as to make
standing and walking impossible. (2)
The occurrence of painful cramps in
the affected limbs. Thus far better
results have been obtained for affec-
tions of the lower extremity than for
the upper. The operation is prefer-
ably done in two stages. At the first
a laminectomy with proper exposure
of the dura is done. At the second
the dura is opened and the affected
posterior roots are resected. The
after-treatment is important and in-
cludes correction of deformity by
mechanical means, plastic operations
to overcome organic contractures and
exercises. Otto May (Lancet, June
3, 1911).
-16
242
SPINAL CORD, DISEASES OE (PRITCHARD).
Fourteen cases of spastic paralysis
treated liy section of posterior spinal
nerve-roots, 1^ of them of Little's
disease, while 11 were in the dorso-
luml)ar region. There were 2 deaths,
the remainint^ 12 patients being more
or less imi)roved. There was cessa-
tion of spasm in all cases imme-
diately after operation. Hunkin (Am.
Jour. Orthop. Surg., Oct., 1913).
Unilateral laminectomy, introduced
by A. S. Taylor, seems to afford
greater room for the surgical treat-
ment of all degenerated cord lesions.
The severity of surgical resection
of the spinal roots has led to the em-
ployment of other surgical measures
of a more conservative type.
Transplantation of the muscles
and tendons often proves surpris-
ingly effectual. In the moderately
serious cases improvement under op-
erative and orthopedic measures is
always notable. Redard (Annales de
med. et chir. infantiles, Oct. 1, 1913).
Three cases in which Stoffel's
method of weakening the contracted
muscle by severing certain of its
nerve-fibers was tried. Balance be-
tween the muscle and its antagonist
is restored. The patients were 3 and
12 years old, with Little's disease or
paralysis from early encephalitis. In
two of the children the results are
highly satisfactory. Bundschuh (Beit,
z. klin. Chir., Sept., 1913).
Stoffel corrects talipes equinus by
resecting a portion of the popliteal
nerve. The electrode is used in dis-
tinguishing the nerve bundles. For
contracture of the hamstring muscles,
he operates upon the sciatic nerve in
the upper thigh. For adductor spasm
one or both branches of the obturator
nerve are excised. In the upper ex-
tremity the median nerve is exposed
at the elbow and the branch to the
pronator teres and various flexor
muscles resected as desired. The
author reports 5 cases operated upon
by this method. In some a second
operation was performed, where too
little of the nerve supply had been
resected. In the lower extremity the
results seemed uniformly successful,
but resections of the median nerve
did not produce as good functional re-
sults, although the cosmetic results
were satisfactory. The author also
proposes, instead of partial nerve re-
section, a transplantation of the same
nerves into the weak opposing mus-
cles. Sharpe's cerebral decompres-
sion for spastic paralysis is on trial,
but would appear to be of value only
in recent cases in the newborn. Gill
(Ann. of Surg., 67, 529, 1918).
LANDRY'S PARALYSIS.
SYNONYM. — Acute ascending pa-
ralysis.
DEFINITION. — Landry's paral-
ysis is a rapidly progressive motor
paralysis of flaccid type, beginning in
the extremities, usually th^e legs, ex-
tending thence upward through the
trunk to the arms, and frequently to
the nerves which have their origin in
the lower pons-medulla region. In
some instances the disease may begin
above and progressively descend.
SYMPTOMS.— The disease begins
with a feeling of extreme weakness,
occasionally associated with pares-
thesia, especially numljuess, in the
legs. This is progressive, and in a
few days or even hours there is com-
plete motor paralysis of the lower
limits. Quite often the onset is at-
tended with slight or, it may be in
rare instances, decided elevation of
temperature. Paralysis of the trunk-
muscles follows, the sphincters es-
caping; and Anally the muscles of
respiration and deglutition are in-
volved, such involvement usually ter-
minating the disease fatally. This
order of invasion and progress is, in
rare instances, reversed. The motor
cranial nerves have been said to have
been affected in one or two reported
examples of the disease. Minor sen-
SPINAL CORD, DISEASES OF (PRITCHARD).
243
sory changes, particularly hyperal-
gesia or anesthesia, are not uncom-
mon, though rarely conspicuous. The
deep reflexes always, the superficial
reflexes occasionally, are abolished.
The mental faculties are, as a rule,
normal, though a muttering semide-
lirium is sometimes observed. Bed-
sores or other trophic symptoms are
rare accidents, though atrophy of the
muscles with altered electrical reac-
tions may appear in protracted cases.
In the typical disease the cycle is
completed in from ten to fifteen days.
Many of the cases which have
served to confuse the pathology of
Landry's paralysis are only cases of
acute poliomyelitis, in which the
spinal cords, could they be examined,
would reveal lesions of a distinctly
inflarnmatory character, presenting
quite a different pathological picture
from that in which Landry was un-
able to demonstrate any definite
changes. C. W. Hitchcock (Jour.
Amer. Med. Assoc, Dec. 23, 1911).
Landry's paralysis is a clinical en-
tity with varying pathological changes.
These may be primarily in the pe-
ripheral nerves, and confined to them,
or they may be myelitic only, and
again neurocellular. Poliomyelitis is
a pathological entity with varying
symptom complexes. There may be
flaccid paralyses, with muscle atro-
phy, or spastic paralysis, or cranial-
nerve involvement, also ataxias and
tremors or mixed types. Neustaedter
(Med. Rec, Sept. 11, 1915).
DIAGNOSIS. — The diagnosis is
quite free from difficulties, as a rule,
if the doctrine of an identity with
multiple neuritis be accepted. Per
contra, the rejection of this theory
renders the diagnosis between the
two often a very complex problem.
From fulminant forms of transverse
myelitis it is to be distinguished by
the involvement of bladder and rec-
tum and the more decided sensory
disturbances in the latter afifection.
In myelitis, too, the deep reflexes
are often exaggerated, there is the
cincture symptom, trophic symptoms
are of early onset and vicious prog-
ress, and the duration of acute
myelitis is more protracted. The
acute vascular lesions of the cord
— particularly hemorrhage, if prop-
erly localized — may closely simulate
symptomatically the disease under
discussion. The history of trauma,
the apoplectic onset, often with con-
vulsions, and the rapidly fatal ter-
mination are data of value. Lumbar
puncture with bacteriological exami-
nation of the serum should be a
routine procediu'e. Quite possibly,
too, intraspinal medication may prove
efl^ective.
Landry's ascending paralysis can be
distinguished readily from polyneu-
ritis and poliomyelitis by the absence
in long-continued cases of muscular
atrophies, reactions of degeneration,
and sensory symptoms of paralysis.
The typical cases depend on intoxica-
tion. The toxin seems to leave the
sensitive neurone intact and to af-
fect exclusively the motor function
without impairing the structure. Bol-
ten (Berl. klin. Woch., Jan. 16, 1911).
ETIOLOGY.— It is a disease of
early or middle adult life affecting
males chiefly. It is not very com-
mon. The etiology is not clearly un-
derstood, but there is a growing una-
nimity of opinion to the effect that
the disease is due to a toxic infection.
It may follow the infectious fevers.
In at least one case seen by the writer,
which termin-ated fatally on the
eleventh day, gross alcoholism was
the cause. Neither •climate, season,
nor heredity is an etiological factor.
Case of Landry's paralysis in a
man, 46 years of age, indicating low-
244
SPINAL CORD, DISEASES OF (PRITCHARD).
ered resistance as the preliminary
necessity in the development of the
disease, with psychic depression.
While no specific organism was likely
to be proved the cause of Landry's
paralysis, it seemed that some con-
dition of toxicity springing out of un-
wonted virulence of some one of
the bacterial flora native to the body
and operating under the auspices of
lowered resistance would be settled
upon as the cause of this insidious,
creeping death. E. M. Hummel (N.
Y. Med. Jour., May 31, 1913).
PATHOLOGY.— The pathology is
as yet an unsolved problem, though
the solution seems happily not far
distant. Autopsies are often nega-
tive. Inconstant and widely varying
lesions were reported or no determin-
able lesions whatever could be found,
the latter result being the rule until
within recent years. The theory of
a profound and fulminant molecular
disorganization of the anterior-horn
motor cell is not plausible. That of an
identity with poliomyelitis, differing
in the acuteness and severity of form
only, has been entertained and is
based upon much quasisupportive
evidence. That the disease is a pure
form of fulminant myelitis is no
longer accepted, although it is ad-
mitted that the resultant symptom-
picture may closely simulate Landry's
paralysis. The consensus of present-
day neurological belief is that the
disease is quite probably a special
form of multiple neuritis affecting the
lower motor neurons, with secondary
changes in the anterior horns and
muscles resembling or identical with
those observed in poliomyelitis.
In the case studied by the writer,
the pathological findings were those
of an interstitial neuritis, afifecting
the nerve-roots and peripheral nerve-
stems. In spite of this, no sensory
symptoms or pain on pressure oc-
curred. The motor cells were well
preserved, and the cellular changes
which were present could hardly be
regarded as' having any direct rela-
tion to the paralysis. Pfeififer (Brain,
May, 1913).
In a typical case in a 16-year-old
girl, with complete absence of fever,
ascending flaccid palsy, causing death
by finally involving the medulla, au-
topsy showed no naked-eye altera-
tions in the brain and cord. The
latter to the microscope showed se-
vere recent lesions in the ganglion
cells; more or less complete plas-
molysis and chromolysis of the cells
of the anterior horns. There were no
inflammatory changes and nowhere
any infiltrative interstitial process —
which distinguishes this form of pa-
ralysis from the epidemic infantile
type. The writer was able to inocu-
late apes with the disease, and to
transmit it from ape to ape. The
virus is filtrable and the period of
incubation varies from seven to
twenty-three days. Leschke (Berl.
klin. Woch., Apr. 27, 1914).
PROGNOSIS. — The prognosis is
grave always ; nevertheless, occa-
sional recoveries have been reported.
Should the disease not terminate
fatally within 2 or 3 weeks the pa-
tient will probably recover. In those
who recover there is no residual pa-
ralysis, the functions, of the affected
nerves being usually restored to the
normal. A special susceptibility to
subsequent attack is said to remain,
but this lacks verification. The dan-
ger to life is, of course, greater when
the heart and respiration are affected
(bulbar extrusion or "bulbous type") ;
but even in such cases recoveries are
said to have occurred.
TREATMENT.— This is empirical.
The patient should be put to bed at
once and kept absolutely quiet. The
limbs should be enveloped in lambs'
SPINAL CORD, DISEASES OF (PRITCHARD).
245
wool fleece or the hot wet pack.
Ergot in J^- or 1- dram (2 or 4 Gni.)
doses every 4 hours has been em-
ployed. Quinine in full doses with
or without sodium salicylate may
be used. Small and frequently re-
peated doses of mercury or inunctions
of mercury are indicated. In plethoric
subjects moderate venesection fol-
lowed by warm saline transfusion
suggests itself as a rational proced-
ure. Serum-therapy may prove an
aid ultimately. For the late stages
of the protracted disease potassium
iodide, strychnine, and electricity are
indicated. Oxygen has been em-
ployed with symptomatic relief in
the dyspnea from respiratory involve-
ment.
The bladder, if involved, must be
most carefully irrigated and hexa-
methylenamine given if urinary in-
fection threatens. In their ow^n case,
in which the patient recovered, the
writers gave sodium salicylate, which
was followed by potassium iodide
and mercurial inunction, in spite of
the absence of syphilis. Later, large
doses of strychnine were given, with
the faradic current and massage to
the paralyzed muscles. Three-dram
(12 Gm.) doses of fiuidextract of cas-
cara were needed in the early stages,
while later J/2-dram (2 Gm.) doses
sufficed. Hall and Hopkins (Jour.
Amer. Med. Assoc, Jan. 12, 1907).
Typical case which improved under
treatment with galvanism, hot and
cold applications to the spine, and
small doses of ergot, and was dis-
charged, walking well, early in July,
1905, after a stay of eighty-two days
in the hospital. He had a slight
relapse, possibly hysterical, in Oc-
tober. This lasted less than a week,
and he has been perfectly well ever
since. J. K. Mitchell (Jour. Amer.
Med. Assoc, Feb. 1, 1908).
Case presenting most of the symp-
tomatic manifestations of Landry's
paralysis, in which hypodermic injec-
tions of strychnine sulphate in full
doses gave unexpectedly good re-
sults. Two subcutaneous injections
of 0.005 Gm. (1/12 grain) each were
given on twelve successive days, with
the result that paralysis in the palate,
facial muscles, and limbs — especially
the upper extremities — disappeared
with considerable rapidity. Pic, Bon-
namour, and Blanc-Perducet (Lyon
med., Jan. 26, 1913).
HEREDITARY ATAXIA.
SYNONYMS.— Friedreich's ataxia,
or disease; family ataxia.
DEFINITION.— It is a distinctly,
though not necessarily a directly,
hereditary degenerative disease of the
spinal cord, affecting the posterior
and lateral columns and the bulbar
region, usually beginning in child-
hood, with symptoms of ataxia, cur-
vature of the spine, defects of speech,
talipes, choreiform movements, ver-
tigo, and ultimately paraplegia.
SYMPTOMS.— In very young chil-
dren the initial symptoms may not
be recognized, but may be interpreted
simply as indications of slow develop-
ment or unusual awkwardness. The
child stumbles and falls easily or stag-
gers in attempting to stand or walk.
The hands are used clumsily and co-
ordination appears to be learned with
unusual difficulty. In speaking, the
child drawls its words. The develop-
ment of nystagmus, of curvature, or
of talipes in some form may prove the
first obvious and unmistakable evi-
dence of the affection. The disease
is much more readily recognized
when the symptoms develop later in
life, as at 8 or 10 years of age.
Contrast with a previously normal
standard renders it conspicuous.
The gradually or rapidly increasing
ata.xia of gait and station ; the chorei-
form ataxia in using the hands; the
246
SPINAL CORD, DISEASES OF (PRITCHARD).
slow, drawling, thickened or scanning
speecli ; the nystagmus ; the club-
foot ; the hammer toe ; the curvature
of the spine, and the paraplegia are
pathognomonic when conjointly asso-
ciated in jarly life in two or more
members of the same family. Weak-
ness in the legs is present early with
the ataxia, and ends in a paraplegia.
Sensory symptoms are rare, though,
subjectively, headache and slight ach-
ing or pains in the limbs may be
present. Vertigo is not uncommon.
The sphincters are not involved until
late in the disease. The knee-jerks
are lost, as a rule. Atrophy of mus-
cles and trophic lesions of the skin
are exceedingly uncommon except
late in the advanced disease. The
electrical reactions are usually undis-
turbed. In a very few cases paresis
of the eye-muscles has been noted.
Usually some degree of impairment
mentally is present.
The sensory disturbances found in
20 typical cases of Friedreich's dis-
ease were as follows: The appre-
ciation of touch, pain and tempera-
ture were very irregularly affected in
the upper extremities, never more
than very slightly and often not at
all. When loss occurred it was al-
most always a slight distal blunting
to touch, and very rarely to pinprick,
or to heat and cold as well. In the
lower extremities these cutaneous
elements were more frequently in-
volved, and there was often some
distal hypoesthesia. Appreciation of
simultaneous contacts, and of size,
shape, and form, was most severely
affected. Saunders (Brain, Nov., 1913).
DIAGNOSIS.— There are only two
diseases which are likely to confuse
the diagnosis: disseminated sclerosis
and Huntington's chorea. In the lat-
ter the disease occurs in middle life
or later, as a rule; the mental facul-
ties are more markedly involved; the
choreiform movements are far more
active and extreme ; the speech is
jerky or explosive; and there is no
curvature, no talipes, and usually no
nystagmus. From multiple sclerosis
the distinction is sometimes impos-
sible. The family history as to di-
rect heredity is of value, but the fact
that a brother or sister is similarly
affected is less valuable since Dresch-
feld and others have reported multi-
ple sclerosis in two members of the
same family. The cranial nerves are
more frequently affected in dissemi-
nated sclerosis; the knee-jerks are
often exaggerated ; disturbances of
sensation are much more common,
which is true also of sphincteric in-
volvement. The tremor when pres-
ent in Friedreich's ataxia is less of
the intention type and more like that
of chorea. Convulsions and crises
point to multiple sclerosis. Remis-
sions do not occur in the latter, while
not uncommon in the former.
Tabes in young people as the re-
sult of a general hereditary syphilitic
taint is often confounded with Fried-
reich's ataxia. Tumor of the cere-
bellum is accompanied by pain,
vomiting, and optic neuritis. In
ataxic paraplegia the knee-jerk is
increased, the onset is later in life,
and there is no hereditary tendency.
Griffith (Brit. Med. Jour., Mar. 9,
1907).
ETIOLOGY.— The essential pre-
disposing factor is an inherent de-
velopmental defect of the spinal cord,
especially the posterointernal and lat-
eral columns. The heredity is some-
times direct, but more frequently
indirect. Organic insanity, gross al-
coholism, syphilis, consanguinity of
marriage, epilepsy, or some other de-
generative neurosis mav constitute
SPINAL CORD, DISEASES OF (PRITCHARD).
247
the ancestral or parental taint. A
generation may be skipped, the par-
ents being apparently healthy. Tabes
is rare in the family history of this
disease. Direct inheritance of the
disease itself was found by Griffith in
33 out of 143 cases. It is somewhat
more frequent in males than females
(86 males, 57 females — Griffith's
table) and more than two-thirds of
all cases develop symptomatically
within the first decade of life (99 out
of a total of 143 — same author).
The disease seems to be more com-
mon in America than elsewhere, and
the victims are from the rural districts
rather than the cities. It is the rule
to find more than one case in a fam-
ily, and sometimes several brothers
and sisters may be afifected in suc-
cession. Three of the writer's cases
were in brothers and sisters, the
mother of whom was undeveloped,
both physically and mentally, almost
a midget in physique and with lo'W
mentality. The first obtrusive symp-
touis may follow an acute illness,
especially the infectious fevers.
Five cases of Friedreich's ataxia
occurring in two families. In one
family two sisters, aged respectively
17 and 10 years, were affected, and
in the other family the second, third
and seventh members of a family of
thirteen were affected. These 3 pa-
tients were two brothers, aged re-
spectively 29 and 18 years, and a
sister, aged 27 years. T. W. Griffith
(Brit. Med. Jour., Mar. 9, 1907).
PATHOLOGY.— The gross path-
ological anatomy has been quite sat-
isfactorily demonstrated. The extent
of the lesions may vary, however,
considerably. The cord appears di-
minished in bulk and sometimes of
eccentric contour macroscopically.
Occasionally two central canals have
been found or the one central canal
may be disproportionately large. Va-
rious other developmental anomalies
may be present. The morbid process
is that of sclerosis, which is always
well marked in the lateral pyramidal
and posterointernal columns, but
may also involve the columns of
Turck and the direct cerebellar tract.
It does not invade the gray matter,
which is usually separated from the
diseased columns by a layer of
healthy tissue. Dejerine believes the
sclerosis found in family ataxia to be
really a neurogliar sclerosis or form
of so-called gliosis, due to a develop-
mental ectodermal defect. The col-
umns of Goll and the pyramidal
tracts are afifected in varying degree
throughout their entire course. The
pathogenesis is as yet undetermined.
PROGNOSIS. — The duration of
the disease is indefinite. Death may
occur from a bedridden asthenia, but
is usually due to some intercurrent
affection. The disease may be com-
plicated with insanity.
TREATMENT.— There is little to
be done for these patients. Suspen-
sion has been tried, larg-ely in vain.
Arsenic is at times beneficial. The
Frankel method is indicated for the
ataxia. Prevention of the disease ])y
means of careful selection in mar-
riage, or, better still, celibacy among
the tainted, is much the more hope-
ful and legitimate line of action.
Should the disease appear in the first
child, further pregnancies or births
should be prevented. The idea of pre-
venting the development of the dis-
ease by withdrawing the infant from
the motlier's breast, as has been
suggested, seems far-fetched.
Cases of hereditary ataxia arc not
necessarily doomed to chronic in-
248
SPINAL CORD, DISEASES OF (PRITCHARD).
validism. The writer's patient, an
adult male, 44 years of age, traced
his illness back to the sixth year of
life, lived comfortably with the aid
of selected occupation. The patient
could plow, drive, and do most of
the lighter work about the farm.
When 30 years of age he became so
disabled that he had to use crutches,
and he then became a schoolteacher,
following this occupation until two
years ago, when the increasing ataxia
in his hands compelled him to aban-
don this work also. His general con-
dition remained good. Van Wart (N.
Y. Med. Jour., Dec. 31, 1904).
ATAXIC PARAPLEGIA.
SYNONYMS. — Progressive spas-
tic ataxia; combined posterolateral
sclerosis.
DEFINITION.— As described by
Gowers, it is a combination clinically
of ataxia and spastic paraplegia, hav-
ing an anatomical basis in lesion of
the dorsal and lateral columns. The
disease is probably not a distinct
pathological entity.
SYMPTOMS. — The clinical pic-
ture is usually clear-cut and constant.
The first symptom is ordinarily that
of constant fatigue, with more or less
unsteadiness in standing or walking.
This ataxia is especially marked in
the dark or with the eyes closed.
The sphincters may be affected at
the same time and sexual power lost
or impaired. There are no sensory
symptoms except, perhaps, a subjec-
tive aching in the legs and lumbar
region. Paretic weakness in the legs,
particularly the flexors, gradually and
progressively develops. One leg may
be more affected than the other at
first. More or less rigidity, with ex-
aggerated knee-jerks, clonus, and
contractures, develop. The patient
becomes more and more dependent
upon assistance in walking, spread-
ing the feet wide apart with eyes
fixed upon the floor. The feet are
dragged along, however, and not
brought down with unnecessary force
as in true tabes. The cranial nerves
are rarely involved, but the mind un-
dergoes degenerative deterioration,
often like that of general paresis. The
arms may, like the legs, show spastic
paralysis and inco-ordination. Tro-
phic symptoms are absent.
DIAGNOSIS.— The total absence
of pupillary changes, of sensory
symptoms, and of Westphal's symp-
tom excludes true tabes readilv. The
spasticity and exaggerated reflexes
with clonus may suggest primary lat-
eral sclerosis, but there is no ataxia
in the latter affection. Ataxia and
parapareses, with exaggerated knee-
jerks, may be present in dissemi-
nated sclerosis, but there will be, in
addition, involvement of the cranial
nerves, intention tremor, scanning
speech, nystagmus, etc. Tumor in-
volving the cerebellum may induce
symptoms of inco-ordination and
spastic paralysis; but here, again, the
addition of cranial-nerve symptoms,
especially of the optic nerve, will
clear away any temporary confusion.
ETIOLOGY.— As with most of
the degenerative spinal scleroses,
ataxic paraplegia is most common in
males during middle life, and the
causes are also similar. Gowevrs, Os-
ier, and others deny the relationship
of syphilis as a cause except in rare
instances : this is disputed by most ob-
servers. Lead and other poisons may
superinduce the disease. Heredity is
a minor factor, if it exists at all.
Under this group might be in-
cluded the so-called Putnam-Dana
variety of myelitic sclerosis of hema-
togenous origin, though in the latter
SPINAL CORD, DISEASES OF (PRITCHARD),
249
the age of incidence and the marked
preponderance of females are quite
distinctive. (See also Pernicious
Anemia.)
PATHOLOGY.— As they are de-
scribed by Gowers, the lesions con-
sist of sclerosis of the posterior and
lateral columns, which is very vari-
able in extent and position and not
strictly "systemic" in character, the
mixed zone of the lateral and the
lateral limiting layer between the
pyramidal fibers and the gray matter
being involved quite often. In the
posterior columns the sclerosis is fre-
quently more marked in the dorsal
than in the lumbar segments. Oc-
casionally a zone of sclerosis has been
found in the entire periphery of the
cord (annular sclerosis). Titrck's col-
umns may be affected. Marie does
not consider it a systemic disease.
He believes the distriljution of the
sclerosis to be dependent upon the
arterial supply through the branches
of the dorsal spinal artery, which are
involved. By many the disease is
believed to be a form of chronic mid-
dorsal myelitis, by others simply an
atypical form of tabes, and by others
still an atypical variety of multiple
sclerosis.
That ataxic paraplegia is identical
with general ascending paresis has
been maintained. The final decision,
however, is still sub judice.
PROGNOSIS. — Except in the
syphilitic cases, the prognosis is bad.
The duration is extremely variable.
Often many years elapse before the
victim succumbs. Paralytic helpless-
ness may develop, however, within a
few years and become complete.
When mental symptoms are manifest
early, the prognosis is that much
worse.
TREATMENT.— Potassium iodide
should be invariably tried. The pa-
tient is thus given the benefit of the
possibility that syphilis may be the
cause.
SYRINGOMYELIA.
DEFINITION.— The term etymo-
logically signifies a cavity (abnor-
mal) in the cord. This definition is,
however, misleading. By almost
general consent the word has been
restricted in its application to a dis-
ease characterized anatomically by
lesion usually and chiefly of the cen-
tral substance of the cord ; patho-
logically by a gliosis or gliomatosis
often dependent upon embryonal-tis-
sue persistence, with subsequent per-
verted cellular proliferation and ulti-
mate cavity-formation ; clinically by
the presence, in association, of pro-
gressive muscular atrophy, dissocia-
tion of sensation, prominent trophic
symptoms, and scoliosis.
SYMPTOMS. — The clinical pic-
ture is very variable. There is not a
function of the cord which may not
be perverted, and, on the other hand,
no 'disturbance at all may be present
or at least recognized. There is no
single pathognomonic symptom, nor
any constant grouping of symptoms.
Case of a patient, 17 years old, who
presented evidences of loss or reduc-
tion of sensibility to pain and heat
in various regions, incipient atrophy
of certain muscles of the hands, and
left scoliosis. The course of the case
confirmed the presumptive diagnosis
of syringomyelia. The writer has
observed left scoliosis also in 2 other
cases as an early symptom. Lifshitz
(Roussky Vratch, iii. No. 13, 1905).
The cavity may be so small as to
give rise to but few symptoms, but
by extension may compress or de-
stroy the posterior columns, poste-
250
SriNAL CURD, DISEASES OF (PKITCHARD).
rior gray horns, and even the crossed
pyramidal tracts. Then, again, it may
be of various irregular shapes, tlius
giving rise to most irregular symp-
tom complexes. E. P. Bernstein and
S. Horwitt (Med. Rec, Oct. 18, 1913).
In the cases in which the diagnosis
has been made durinij;- life and con-
firmed by autopsy the clinical history
has been about as follows: The pa-
tient first notices some aching and
pain in the neck, shoulders, and arms,
with paresthesia in the hands and
fingers. This is followed by an
atrophy which slowly affects, first,
the smaller muscles of the fingers
and hand, and which is attended
with fibrillary twitches. Analgesia
develops in varying degree in the
affected limb, and thermoanesthesia,
sometimes complete, is also present.
Tactile perception may remain either
normal or only slightly impaired, and
this combination of analgesia with
thermoanesthesia and preserved tac-
tile perception constitutes the so-
called "dissociation phenomenon" at
one time supposed pathognomonic.
Following the atrophy and sensory
disturbances, trophic lesions of the
skin, hair, nails, bones, etc., develop,
and are often quite prominent.
Herpes, bullae, ulcers, felons, and
gangrene, usually painless, are among
the skin lesions observed. Extensive
arthropathies have been noted, and
the bones may become quite brittle.
Two cases of the sacrolumbar type
occurring in a brother and sister.
The bones show a peculiarity which
is described by Tedesco: (1) a gen-
eral transparency of the bone-shad-
ows as a whole; (2) diminution and
softening of the cortical layer of the
diaphyses; and (3) rarefaction of the
spongy bone while its external form
is preserved. When the process of
atrophy is far advanced, however, the
bone gradually disappears, as the
skiagrams show. The accompanying
increased brittlcness accounts for the
occurrence of fractures. Spontane-
ous fractures, however, do not occur
as frequently as one would expect.
J. M. Clarke and E. W. II. Groves
(Brit. Med. Jour., Sept. 18, 1909).
Vasomotor symptoms — such as
sweating, edema, redness, or cyano-
tic discoloration in certain areas or a
limb — are quite common. As the dis-
ease extends from above downward,
the trunk-muscles become involved,
and scoliosis, or curvature, develops.
Extending still lower, the legs are
affected with paraplegic weakness,
the sphincters become paralyzed,
and sexual power is lost. Just as
with the upper, the first symptoms
indicating involvement of the lower
cord may be irritative — paresthesia
may precede the paraplegia. Should
the disease extend upward, bulbar
symptoms are added. The trigeminus
may be affected and facial atrophy
appear. Pupillary abnormalities have
been noted occasionally, particularly
an inequality in size and response.
The eyeball may appear protuberant
as in exophthalmic goiter, or the
globe may appear to have receded.
This condition is often associated
with facial hemiatrophy (Schulte).
Ataxia of both lower and upper ex-
tremities has been observed. The
muscular sense, however, may remain
normal.
Case of paralysis in the throat and
palate, with sensibility and reflexes
normal, in which further investiga-
tion revealed syringomyelia. There
had been no other noticeable disturb-
ances, but atrophy of the right side
of the tongue confirmed the diag-
nosis. The writer found 26 similar
cases. Throat symptoms may be the
first sign of the affection. In 9 of
the 27 cases there was atrophy of the
SPINAL CORD, DISEASES OF (PRITCHARD).
251
tongue, and there was paresis of the
palate in 17. In 3 cases the hoarse-
ness came on suddenly. Baumgarten
(Berl. klin. Woch., Aug. 23, 1909).
The symptoms are usually bilat-
eral, though they may at first and for
some time be limited to one side, and
they are often unequal in degree on
the two sides. The first symptom
may be referable to the dorsolumbar
or the bulbar segments, in which
case, of course, the order of se-
quence would be reversed. This is
the basis for the so-called bulbar and
paraplegic types.
Case in which the disease began
at the age of 5; the patient is now 16.
Pain in the back of the head and
the curving of the spine were to-
gether the earliest signs. (One of
Guillain's cases which went to au-
topsy commenced with the same
pain.) These disappeared in the
girl's case. Gradually at the age of
6 the left arm began to be afifected.
The lower extremities were attacked
at about 10 years of age, and the
right arm has only shown involve-
ment for three years. For the last
year there has been slight difficulty
in micturition, frequency being in-
creased. G. W. Rowland (Can.
Pract. and Rev., Aug., 1909).
In certain cases trophic symptoms
predominate, due, it has been thought,
to a complicating neuritis. Morvan's
disease is assumed by many to be
essentially identical with this form of
syringomyelia. The identity has not
yet been proved.
Case of Morvan's type of syringo-
myelia in a lad aged 17 years. A
marked stoop, due to weakness of
shoulder and back muscles, a well-
developed scoliosis to the left, arms
abnormal, right hand and arm atro-
phied, with loss of muscular power.
The left hand had lost the distal
phalanges from thumb and first and
second fingers, was reddish, swollen.
and slightly edematous; shoulder-
muscles paralyzed on left side, and
the limb practically useless; no dis-
sociation of sensation, but complete
anesthesia over an area beginning
from a line passing between the
mastoid processes behind and from
the notch in the thyroid cartilage to
the mastoid processes in front, down
to a line passing from the level of
the third rib, in front, to the sixth
dorsal spine, and including both
arms. H. V. Wildman, Jr. (Med.
Rec, Oct. 17, 1914).
DIAGNOSIS. — With our present
knowledge, or rather lack of it, an
inaccurate diagnosis in syringomyelia
is not a serious reflection upon in-
dividual skill. In the dififerential
'diagnosis of the disease, tumor and
hemorrhage of the cord, myelitis,
pachymeningitis, particularly cervi-
calis hypertrophica, progressive mus-
cular atrophy, and tabes dorsalis are
chief in importance.
Case of tabes with syringomyelia.
Some have held that the association
of the two processes is not merely a
coincidence, but that one stands to
the other in the relation of cause and
effect; others have expressed them-
selves guardedly. Spiller (Jour. Med.
Research, Mar., 1908).
In tumor all irritative symptoms —
such as pain, spasm, etc. — are usually
far more pronounced, the symptoms
are more definitely localized and uni-
lateral, and the rate of progress is
more rapid. Tumor elsewhere, espe-
cially if malignant, is significant. In
cord hemorrhage or embolism the
onset is abrupt and apoplectiform in
nature and the symptoms are rapidly
destructive. From myelitis the diag-
nosis may be, at times, difficult. The
more widely distributed symptoms
and the more extensive involvement
of all forms of sensation, with the
relative infrequency of true trophic
252
SPINAL CORD, DISEASES OF (PRITCHARD).
symptoms in myelitis, should prove
sufficient data.
The muscular atrophy is often late
in myelitis and is more rapid after
once beginning. From cervical pachy-
meningitis the differential diagnosis
is at times impossible during life. It
is only when tabes dorsalis begins
with extensive and vicious trophic
symptoms or when it presents the
symptom of dissociated sensation
that temporary hesitancy occurs. In
leprosy we may have analgesia and
trophic lesions, but there is no
atrophy, scoliosis, or dissociated sen-
sation.
Case of dislocation of the first
row of phalanges on the metacarpals
which proved to have been due to
syringomyelia. This causes extensive
trophic alterations in the upper ex-
tremities, as does tabes dorsalis in
the lower limbs. The arthropathies
which result bear a certain resem-
blance to arthritis deformans, the
analgesia, however, contributing to
aggravate the state of afifairs. In the
neuropathic arthropathies we usually
see destruction of the articulating
structures, but the dislocations may
exceptionally occur without this pre-
requisite, especially in the shoulder-
joints. Joachimsthal (Berl. klin.
Woch., Aug. 12, 1912).
ETIOLOGY.— The disease is com-
paratively rare. More cases have
been reported ainong males than fe-
males, in many instances recognized
first between the ages of 25 and 35
years. The essential causative factor
is an inherent predisposition dating
back to embryonal life. Syringomy-
elia is not directly hereditary, nor is
it a "family" disease. No adequate
explanation is offered for the cause of
the underlying developmental defect.
The exciting cause is most often
trauma.
Secondary infection is doubtless
occasionally responsible. Prolonged
exposure to severe cold and damp-
ness, physical overexertion, toxemias,
malnutrition, and anemia are causes
to which individual cases have been
ascribed. Alcoholism may act as an
indirect etiological factor. The clin-
ical association of syringomyelia with
acromegaly suggests a fundamental
teratological origin.
PATHOLOGY. — Cavities of the
cord may exist as congenital dou-
bling, diverticula, or other anomalies
of the central canal, or they may be
secondary to acute lesions, such as
abscess, hemorrhage, tumor, etc. Sim-
ple dilatation, more or less extreme,
of the normal canal may occur (hy-
dromycUa) , which often is unattended
by any symptoms whatever.
In a personal case the pathological
process completely isolated the pos-
terior columns from the rest of the
spinal cord from the first cervical to
the eleventh thoracic segments, in-
clusive. There was perfect preserva-
tion of tactile sensibility and loss of
pain and temperature sensibility.
There was very diagrammatically
demonstrated the lower limit of the
trigeminal area. The cavitj' forma-
tion in the gliomatous tissue was
most marked on the right side.
The case shows that with total cut-
ting off of all the afferent pathways
of the cord with the exception of the
posterior columns tactile sensation is
quite unimpaired. A. R. Allen (Jour.
Xerv. and Mental Dis., Jan., 1911).
In some instances hydromyelia
gives rise to symptoms identical with
syringomyelia, but the essential path-
ological basis of the latter disease is
a slow central gliosis: In the embryo
the central canal is relatively large.
It closes by gradual approximation of
its walls posteriorly, which, uniting,
SPINAL CORD, DISEASES OF (PRITCHARD).
253
form the normal posterior septum.
The anterior walls remain separate,
forming the normal central canal. In-
terruption or perversion of the nor-
mal development results in the for-
mation of a cavity. Such interruption
may be localized to one or more seg-
ments or extend for some distance.
The cell-elements remain of the
embryonal or glia type. They are
distributed irregularly in the cavity-
walls, sometimes occurring as nests
resting upon a basement material.
These ependymal and periependymal
cells and neurogliar or basement tis-
sue, later in life, through the stimulus
of trauma, infection or some other
exciting cause, begin to undergo pro-
liferation, forming gliomatous masses.
The proliferation extends from cen-
ter toward periphery and also longi-
tudinally, usually in the posterior
areas of the cord first. The most
common locality affected is the cer-
vical cord. This new gliomatous
tissue, from low vitality, hemorrhage
or other vascular lesion, breaks down
aJid a cavity results.
Recent advances in the pathology
of syringomyelia bear especially upon
the hyperplasia of connective tissue
associated with the gliosis. In a per-
sonal case, evident proliferation of
connective tissue was present at all
levels of the lesion; the blood-vessels
throughout were very numerous with
much thickened adventitia; curiously,
there were also striated muscle-libers
in various spots between the fourth
cervical and the eleventh dorsal seg-
ments. This was ascribed to defect
in embryonic development. Andre-
Thomas and Quercy (Nouvelle Icon,
de la Salpetriere, xxv, 5, 1913).
The gliosis may not always end in
cavity-formation, Ijut may remain as
a tumor or as simple glia hyperplasia,
which, however, destroys the normal
motor and sensory cell-bodies and
their axis-cylinders quite as effect-
ually as the breaking--down. The
tendency to cavity-formation is said
to be proportionate to the excess of
cellular over basement tissue in the
gliosis. Secondarily atrophy of the
muscles and various forms of periph-
eral neuritis are among the patho-
logical findings.
PROGNOSIS.— There is no cure
for the disease ; hence an unfavorable
prognosis must be given as regards
recovery. The disease may progress
very slowly, however, and a duration
of twenty or more years is said to be
not uncommon. Spontaneous remis-
sions may occur which may last
through several years.
TREATMENT. — Gliomatosis of
the cord is unamenable to curative
or even palliative treatment. Potas-
sium iodide has occasionally proved to
be of service in gliomatous tumors of
the brain and should be tried faith-
fully. Silver nitrate, gold salts, ar-
senic, and iodine are theoretically in-
dicated. Electricity has been almost
invariably disappointing, except as a
tonic. Change of climate, rest, and
tonics offer the best prospect for a
temporary arrest of the disease.
Radium has been recommended by
Raymond Touchard and other au-
thorities. The applications were made
daily to the vertebral column at vari-
ous levels, alternating to the right or
left of the spinous processes. The ex-
posures were increased from 10 min-
utes to over one hour. X-rays have
also been advocated.
The use of the X-rays entirely
changes the clinical history of the
disease, causes considerable improve-
ment, which lasts for some time, and
wholly changes the prognosis. E.
254 SPINAL CORD AND NERVES, INJURIES AND SURGERY OF.
Beaujard and J. Lhermitte (Semaine
med., Apr. 24. 1907).
Details of a case of syringomyelia.
In a workman of 51, the Rontgen
rays arrested the morbid process and
seemed to allow restitution of the
functions of the nerve-tract involved.
The effect is evidently due to direct
local action on the pathological pro-
cess in the spinal cord. There was
restoration of the functions of the
hands and fingers. The improvement
has persisted to date, nearly two
years, and the patient has gained
over 25 pounds in weight. I. Holm-
gren and O. Wiman (Nordiskt Med.
Arkiv, xli, Int. Med., No. 3, 1909).
W. B. Pritchard,
New York.
SPINAL CORD & NERVES,
INJURIES AND SURGERY OF.
— The spinal column, as outer and pro-
tective covering of the spinal cord, being
primarily injured in traumatisms of this
region, such as gunshot and punctured
wounds, and sprains and dislocations, the
lesions suffered by the cord proper are
reviewed in the article on the Spine, Dis-
eases AND Injuries of, which follows the
present section. Lesions of the cord,
which complicate fractures of the spinal
column, are treated in the fourth volume
in the article on Fractures and Disloca-
tions, page 759.
As regards operations on the spinal
cord, laminectomy, which affords access
to the cord, is also 'treated in the article
on the Spine, which follows the present
one, while the operations on the spinal
cord indicated in certain diseases of that
organ, such as resection of nerve-roots in
primary lateral sclerosis, are treated un-
der the headings of these diseases in the
article on Spinal Cord, Diseases of, pre-
ceding the present section.
NERVES, INJURIES OF.
SUBCUTANEOUS NERVE INJUR-
IES.— By these are meant injuries of
nerve in which the skin has not been
penetrated.
Concussion. — A blow on the elbow, a
fall in which the subject alights violently
on his hands and other similar sources of
violence to the surface may sufficiently jar
a nerve-trunk, or, at least, its terminal
fibers, to awaken functional disturbances;
these are sometimes accompanied by se-
vere pain and shock. As a rule, if there
is no lesion of continuity of the medullary
sheaths or of the axis-clydinders due to
laceration of the perineural tissues, the
disturbance awakened is transitory.
Contusion. — Pressure paralysis — contu-
sion of a nerve — should mean the lesions
that direct traumatism produces. As gen-
erally interpreted, however, it denotes the
symptoms of pressure upon a nerve how-
ever awakened. "Pressure palsy" form is
frequently experienced by everyone when,
during sleep, for example, a limb is held
in an abnormal position. Numbness is
followed by tingling when the position
of the limb is changed to normal. This
temporarj^ palsy is the mildest form of
nerve "contusion." Surgical anesthesia is
responsible, however, for paralyses which
may last weeks when care is not taken
to prevent a limb from hanging over the
table, thus allowing its edge to exert
pressure upon one or more nerves. An
Esmarch bandage, too tightly or improp-
erly applied, or left in place, may do like-
wise; indeed, permanent paralysis of the
radial, ulnar and external popliteal have
been provoked in this manner.
Nerves which pass over or are in close
proximity to bones are most exposed to
pressure, hence the frequent paralysis due
to contusion of the sciatic when reduc-
tions of dislocations of the hip, especially
those of the traumatic and congenital
type, are attempted. Callus, produced in
the course of bone repair after fractures,
scar tissue, projecting bone, or spicules of
the latter, osteoma, infiltration, etc., are
as many causes of pressure paralysis
which may be accompanied by, more or
less, severe neuralgia.
Stretching and Laceration. — Stretching
of a nerve sufficiently to produce lacera-
tion occurs in the course of accidents or
operative procedures in which undue trac-
tion is exerted either directly upon a limb
or through malposition of the bones in
the course of dislocation, as, for instance,
in shoulder dislocation. Laceration of
nerves may complicate fractures of the
SPINAL CORD AND NERVES, INJURIES AND SURGERY OF.
255
base of the skull and thus give rise to
disturbances of vision, paralysis of one-
half of the face, etc. In general, the
symptoms of laceration are disturbances
of sensation or motion, or of both these
functions, sufficient to give rise to the
reaction of degeneration.
Displacement. — Displacement of a nerve
may occur when, as a result of excessive
flexion of a limb, the groove over which
the nerve passes fails to hold it in posi-
tion. The ulnar, for instance, may be
displaced by forcible flexion of the arm
when the medial epicondyle is shallow.
In some subjects such a displacement oc-
curs whenever the forearm is flexed, with-
out causing discomfort. Displacements of
the ulnar and external popliteal may also
occur in fractures of the medial epicon-
dyle of the humerus and of the head of
the fibula. Under these conditions, con-
tusion and inflammation, with consider-
able pain, throughout the area of distribu-
tion of the nerve, and also sensory and
motor disturbances may follow.
TREATMENT.— The treatment de-
pends, of course, upon the nature of the
condition present. In uncomplicated con-
tusions and lacerations the measures should
be conservative, immobilization of the
part in a cast to prevent traction on the
injured nerve. If the reaction of degen-
eration is present, weak galvanism, the
cathode over the seat of injury and the
anode on the plexus of the system ener-
vating the part, should be begun after the
acute phenomena have subsided. Resump-
tion of function follows after from 4 to 6
weeks in simple cases.
When the injury involves the whole
nerve transversely, as indicated by the
failure to improve, operation should be
resorted to as soon as possible, as time
compromises the issue increasingly. Ex-
posure of the nerve will then reveal some
of the conditions described, i.e., it will be
compressed by or imbedded in a mass of
scar tissue or callus. Neurolysis and,
preferably, Babcock's nerve dissociation
should then be resorted to. This proced-
ure has for its purpose to relieve nerves
of compression by adhesions, fibrous cica-
tricial tissue, callus, bone infiltration, etc.,
which give rise to painful or paralytic
affections.
By the term dissociation the writer
means isolation of the affected part
of the nerve through an incision
freely opening its sheath, disassociat-
ing its component fibers and isolat-
ing the nerve from later fibrous com-
pression. It is intended to permit
the escape of exudate from within
the nerve-sheath, to reduce pressure
upon individual nerve-fibers, to free
axis-cylinders which have become
useless through entanglement of sev-
ered tissue, to facilitate the formation
of new nerve-paths, and to stimulate
desirable changes in the nerve-trunk.
The sheath of the nerve is divided
well beyond the limits of lesion; the
nerve-trunk, lifted upon one or two
fingers, is held taut. The nerve-fibers
are then carefully separated from
each other by means of a small
sharp tenotome, transforming the
structure from a round cord to a
flat, ribbon-like band of separated
fibers. If cicatricial tissue is en-
countered in the nerve-trunk the sep-
aration of the fibers is prolonged
along staight lines, dividing the scar
into multiple parallel threads of tis-
sue. The nerve, previously imbedded
in cicatricial or fibrous tissue, should
be removed from this area, or at
least isolated from future cicatricial
adhesions by the interposition of adi-
pose tissue, strips of which can usu-
ally be secured from beneath the
skin.
Out of 7 cases in which the nerve-
fibers had been partially or thor-
oughly disassociated by the writer, in
only 1 was there detected an increase
of paralysis immediately following
the operation, while in several there
was almost immediate increase of
function in the affected nerve-field.
Babcock (Annals of Surg., Nov.,
1907).
When compression is due to cicatricial
tissue, the latter is exposed and the nerve
isolated from it by dissection. The
filjrous tissue is then removed, and the
nerve surrounded with Cargile membrane
to prevent invasion of surrounding tissues
during the healing process. A bony cal-
256 SPINAL CORD AND NERVES, INJURIES AND SURGERY OF.
lus may be reached, if necessary, through
the muscular phmes. The nerve is iso-
lated and the bony mass removed, a pro-
cedure which sometimes requires the aid
of the chisel. Here, again, Cargile mem-
brane should be employed to protect the
nerve during the healing process.
The nerve may be foimd severed and
the intruding mass of callus or scar tis-
sue prevent union of its ends. In that
case, the nerve should be treated as de-
scribed under the next heading.
OPEN NERVE INJURIES.— By these
are meant injuries, whether exercised by
cutting or pointed instruments, bullets,
etc., in which the skin has been pene-
trated.
Effects of Nerve Division. — When a
nerve has been severed its vasomotor
functions cease; the vessels it supplies be-
ing thus allowed to dilate, more blood is
admitted into the area to which the ves-
sels are distributed. The temperature of
this area is, therefore, raised. But this
rise is only temporary; the continued
vasodilatation due to loss of vasomotor
control soon interferes with the z'is a tergo
motion of the blood and, the local circu-
lation being slowed and poorly oxygen-
ized, the parts become blue and cold, and
lose their functional activity. Muscles
lose their motor power at once, and soon
begin to degenerate, atrophy and shorten,
and finally develop the reactions of de-
generation. If the nerve contains sensory
fibers, complete anesthesia to pain, touch
and temperature follows, unless the part
be supplied by another nerve in addition
to that severed. Yet, pressure with a
blunt object may be felt in the analgesic
area; this is because motor branches of a
mixed nerve send st.isory branches — deep
sensibility nerves — throughout muscles
and tendons, which may leave the nerve
above the point of section.
The trophic changes which may arise in
the paralyzed parts are numerous: the
skin may be the seat of eruptions and
ulcers, or become glossy; the hair falling
out, the nails becoming furrowed, brittle
and even shed; the deeper tissues may be
the seat of painless felons or abscesses,
or, as is the case with muscles, atrophy;
the joints may become inflamed — a con-
dition which may lead to ankylosis.
Finall}', dry gangrene is a formidable
complication which not infrequently fol-
lows division of large nerves.
The effects of abolition of the func-
tions of the severed nerve continue until
its regeneration occurs, if at all. The
nearer the two ends of the severed nerve
remain the greater are the chances of
early union; hence the curative effects of
nerve suture, in which these two ends
are held in apposition. In the absence of
suture, the abolition of function may l)e
permanent. When, however, proximity of
the two ends is such as to permit union,
sensation may return in from 6 weeks to
as many months. Motor power is slower
to return than sensation, and takes from
3 months to 3 or 4 years, but seldom be-
fore 6 months. Anastomosis with ad-
jacent nerves probably accounts for the
exceptional cases in which very early re-
sumption of sensation and motion has
occurred.
Process of Repair. — After complete
division of a nerve the entire peripheral
or distal end degenerates. The proximal
or body end, however, degenerates only
in the portion immediately adjacent to the
seat of injury, and tends rapidly to re-
generate. This is accomplished through
the formation, just above the site of in-
jury, of an enlargement or bulb composed
of imbedded and very small nerve-fibers.
These new fibers infiltrate the granulations
formed from the cells of the sheath of
Schwann and project themselves until
they reach the distal end of the nerve,
which they penetrate to its terminal fila-
ments, thus re-establishing function. Ac-
cording to some histologists incompletely
developed elements are also formed in the
distal segment of the cut nerve, which
meet those from the proximal segment.
The central stump of a nerve long
retains its capacity to sprout new
fibers, and consequently it is of lit-
tle moment when the nerve is su-
tured during the first 4 or 6 months
after the injury. The prognosis de-
pends more on the location and ex-
tent of the injury, the peripheral
nerves having a greater proliferating
power than those more centrally lo-
cated. The general health is an im-
portant factor in the outcome. Spiel-
SPINAL CORD AND NERVES, INJURIES AND SURGERY OF. 257
meyer (Miinch. nied. Woch., Jan. 19,
1915).
SYMPTOMS.— As we have seen, the
symptoms following division of a nerve
consist in loss of function, motor, vaso-
motor, and trophic. If complete section
occurs the abolition of function is imme-
diate; if it is incomplete, pain and pares-
thesia may appear.
The anatomical position of the wound
governs, of course, the nature of the mor-
bid phenomena awakened. After complete
section these consist of absence of re-
flexes, flaccid paralysis, soon followed by
muscular atrophy. If, for instance, one
or more cords of the brachial plexus are
severed, motor paralysis and anesthesia
appear throughout the area supplied by
the severed cord, whether this be through
the ulnar, median, subscapular, circumflex
or other nerves supplied by the plexus.
These symptoms are the same as if the
nerve itself had been severed. Thus, in-
volving as it may do, the circumflex, we
would have paralysis of the deltoid and,
as a result, inal)ility to raise the arm to
a right angle with the body. If the outer
cord of the brachial plexus is severed, the
musculospiral nerve will be involved; we
shall then have paralysis of the biceps and
of the brachialis anticus, which means
paralysis of the forearm flexors, etc. Yet
we must not lose sight of the fact that
this same cord of the brachial plexus gives
origin to the external ".nterior thoracic
and median, and that the resulting paral-
yses are added to those due to involve-
ment of the musculospiral. The great mul-
tiplicity of nerves renders necessary an
intimate knowledge of their distribution.
In so far as their surgical treatment is
concerned, the measures indicated, as we
shall see, apply to all nerves. When de-
generation takes place in antagonistic
muscles, these gradually contract, produc-
ing deformities.
The sensory disturbances are not as
widespread, because the terminals of sen-
sory nerves anastomose freely, as a rule,
with those of adjacent nerves, while cu-
taneous sensory fields overlap one an-
other. The tendency, moreover, is for
the anastomotic l^ranches to take up the
work of the cut nerves. Hence, the rapid
reduction of the area of sensory disturb-
ances and the fact that it is only when
large trunks, which give off many im-
portant nerves are cut, that extensive or
permanent sensory disorders follow.
It is not only the muscular and cutane-
ous functions (the skin being subject to
disorders such as eczema, herpes zoster,
ulcers, etc.), that suffer, but likewise the
bones. During growth the development
of osseous tissue in the parts supplied by
the severed nerve may cease, and atrophy
even follow, the morbid process being
aggravated by serous infusion of the
joints. Vasomotor disturbances, such as
redness, cyanosis, and cutaneous hypo-
thermia have already been mentioned.
The reaction of both nerve and muscle
to electricity should be determined when
injury to a nerve is suspected. That of
a divided nerve and of the muscles it sup-
plies to the faradic or galvanic current
decreases gradually in intensity and rapid-
ity, disappearing completely in about 12
days. But there soon ensues a difference
between the two currents, the degenerat-
ing muscle then showing increased reac-
tion to the galvanic current, and also the
reaction of degeneration, in which the
A. C. C. is greater than the C. C. C. This
reaction may increase in intensity a few
weeks, then remain stationary months, or
even a year or more, when atrophy of the
muscles has reached completion. The re-
action of degeneration is important in the
treatment of such injuries.
Those cases should be treated con-
servatively in which the motor and
sensory disturbances are slight and
in which electrical exainination re-
veals only a slight decrease in elec-
trical excitability or a partial reac-
tion of degeneration. In such cases
there is an improvement in function
in 3 or 4 weeks, although complete
recovery may take 8 weeks, or even
3 months. Another class of cases in
which operation should be resorted to
are those in which there is complete
motor paralysis and complete re-
action of degeneration. Operation
is also indicated when there is severe
and long-continued pain. This com-
plication is quite frequent. S. Auer-
bach (Deut. med. Woch., xli, 254,
1915).
8—17
258 SPINAL CORD AND NERVES, INJURIES AND SURGERY OF.
TREATMENT.— Important in this con-
nection are the conditions that may re-
tard regeneration. Infection tends greatly
to delay the progress of the process of
repair. Destruction of a long segment of
the nerve, the interposition between its
cut ends of a tendon, muscle, bone, for-
eign body, or, later, of scar tissue, or dis-
placement of the cut ends out of their
normal line, are all features which tend
to prevent their union and, therefore, re-
sumption of function.
Any of the conditions that may be pres-
ent having been corrected as far as pos-
sible, and the wound and neighboring
area having been carefully sterilized, a
constrictor bandage is applied and the
ends of the divided nerve are sought
and sutured.
In gunshot wounds, especially if due to
a small projectile, the nerve may not be
found completely divided. Expectant
treatment is then indicated, since in all
likelihood recovery will occur in a short
time. If, however, after a few weeks func-
tion fails to return, the nerve should be
exposed and the ends united with aid of
one of the measures described below.
Often after minor hand injuries the
patient develops pain and skin ten-
derness, usually some time after the
injury, and rarely directly after the
trauma. Very good results are ob-
tained in operating these cases by
excising the scar tissue and in this
way freeing the nerve. Occasionally
excision of the involved portion of
the nerve is necessary, with approxi-
mation of the ends. In 1 case in
which there was an edematous con-
/ dition of the nerve the sheath was
simply incised, which resulted in a
diminution of its size. Usually after
any work on these nerves they were
covered with subcutaneous fat before
the wound was sutured. These op-
erations are easy. H. Neuhof, Amer.
Jour. Surg., xxix, 143, 1915).
Nerve Suture or Neurorrhaphy. — The
term primary suture is used when the two
ends of the cut nerve are approximated
and sutured immediately or soon after the
injury. The wound being asepticized and
an Esmarch bandage applied, the ragged
ends of the nerve are exposed, and all
bruised tissue is removed. Two or three
catgut sutures are then passed through
both the nerve and the sheath, and tied.
Unless too long a segment has been de-
stroyed, stretching of each end may be
resorted to, if necessary. The Esmarch
bandage is then removed, the bleeding
arrested, the wound is dressed aseptic-
ally; the limb is then placed, relaxed, on
a splint. After the wound is healed the
splint is removed and massage friction,
electricity and the douche are used to en-
courage the restoration of function. This
may take weeks or months, sensation re-
turning before motion.
The ultimate outcome of a sutur-
ing operation on a nerve can be fore-
seen in many cases by applying irri-
tation to the nerve below the suture.
Some sensation is felt in the para-
lyzed region if the conductibility in
the nerve has been restored even in
the slightest measure. It is thus
possible to determine the outcome
weeks before actual restitution oc-
curs. Hoffmann (Med. Klinik, Mar.
28, 1915).
When the ends are united a considerable
time after the injury, secondary suture is
resorted to. The chances are against its
success, however, if the operation is done
after more than 3 years have elapsed since
the injury was received. The trifacial will
frequently reproduce itself after the re-
moval of segments an inch in length, while
the median or ulnar tends obstinately to
resist reunion.
Study of 287 reported cases of in-
jury of nerves requiring surgical
treatment in which 340 operations
were performed. The sensibility and
the motor functioning are less reliable
criteria than restoration of the earn-
ing capacity. This was restored in
72 per cent, of the cases, partially
restored in 15 per cent., and results
unknown in 13 per cent. The pro-
portion of successes was larger with
secondary than with primary suture.
Oberndorfifer (Centralbl. f. d. Grenz-
geb. d. Med. u. Chir., June 5, 1908).
In military nerve wounds the nerve
is damaged much more than is the
SPINAL CORD AND NERVES, INJURIES AND SURGERY OF. 259
case usually in the injuries in civil
life. The writer has sutured the
nerve in 23 cases and released it from
pressure of scar tissue in 13 others.
Operation must be delayed until all
inflammation is past, and the wounded
must be informed that a complete
success cannot be assured. Huis-
mans, Steinthal, Dopfner and Sauter
(Miinch. med. Woch., Apr. 13, 1915).
When a nerve is partially or
wholly divided in a bullet wound,
loss of function is marked and per-
manent, and may even tend to in-
crease. In these cases it is useless
to expect spontaneous regeneration.
The sooner nerve suture is per-
formed the easier it is and the
greater likelihood of an early cure.
R. A. Stoney and H. Meade (Brit.
Med. Jour., July 3, 1915).
The region being rendered aseptic and
bloodless, an incision is made over the
line of the nerve, the length of the in-
cision varying with the position of the
nerve, the hiatus between its ends, the
interposition of scar tissue, callus, etc.,
any of which conditions may demand ex-
tension of the incision later. The proxi-
mal or body end should be sought first,
since its bulbous end will facilitate its
identification, and perhaps prove sensi-
tive. This will point, besides, to the
atrophied distal end which, owing to its
tenuity, may be difficult to find. Should
this prove to be the case, the incision
should be extended to the nerve-trunk in
its anatomical position, from which the
atrophied nerve may then be traced to
the site of injury.
The two ends being now available, a
piece of the bulbar or proximal end is
cut off and the extremity of the lower or
distal end likewise. They are then ap-
proximated and sutured with catgut. As
the sutures readily cut their way out, they
should not be inserted too near the ends,
while several should be used. Moreover,
several sutures should be passed before
any is tied, to prevent any one cutting its
way out while another is being inserted.
The wound is then treated in the same
manner as after primary suture. Sensa-
tion sometimes returns after a few days,
but, as a rule, it only does so weeks or
even months later.
Case of a soldier with fracture of
the ulna and complete motor and
sensory paralysis of the median
nerve; an operation to restore the
continuity of the nerve was per-
formed 2 months after admission.
Three cm. of the nerve-trunk were
sacrificed. On the fourth day power
in the flexor muscles had returned,
though sensation was still absent.
Motor power thereafter progressively
increased and sensation soon re-
turned. Salva Mercade (Bull, de
I'Acad. de Med., Feb. 2. 1915).
It is not always possible to approximate
the ends of the severed nerve in order to
suture them. Bridging of the interval is
then necessary. Numerous strands of
chromicized catgut, along which the nerve-
fibers readily grow, may be used to con-
nect the widely separated ends. This is
also termed suture a distance, and is the
simplest and most successful method.
Results may appear only slowly,
and require the aid of massage, pas-
sive motion, electricity, etc., to bring
them about. The chances are against
success in bridging gaps of more
than 4 centimeters, though a few
successful cases have been reported.
In such cases, shortening the gap by
bone resection, or lateral implanta-
tion of both nerve-ends into a neigh-
boring motor trunk, may be advis-
able. A certain amount of deformity
with muscle power in a limb is much
to be preferred to complete and per-
manent paralysis. Taylor (Jour.
Amer. Med. Assoc, Mar, 28, 1908).
Neuroplasty, devised by Letievant, may
also be resorted to. This consists in split-
ting a nerve lengthwise a distance % inch
longer than the gap between the nerve-
ends, and detaching by cutting one of
the halves of the nerve in such a way as
to form a flap which, by being turned
back, will extend it. The free end of this
flap is then sutured to the opposite nerve-
end. If the gap is long, both ends may
be treated in the same manner, the ends
of the flaps meeting half-way between the
nerve-ends.
260
SPINAL CORD AND NERVES, INJURIES AND SURGERY OF.
In secondary nerve suture fine cat-
gut should be used to unite the nerve-
ends, plain if there is no tension,
lightly chromicized in cases in which
any tension falls on the junction.
Non-absorbable materials should be
avoided; they give rise in many cases
to symptoms months after suture,
causing relapse and seriously inter-
fering with complete recovery. After
wounds in the region of the wrist
the deep fascia should always be su-
tured carefully. If this is not done
the tendons may become adherent to
the skin, and often, if the wound is
extensive, a hernia of tendons forms,
which is a source of weakness un-
til remedied by operation. Sherren
(Brit. Med. Jour., Jan. 15, 1910).
In nerve-grafting, anastomosis or im-
plantation, a method also devised by
Letievant, the distal end of the nerve is
sutured to some adjacent normal nerve,
after the latter has been vivified, or in-
serted in some slit in the latter. The nor-
mal nerve thus takes up the functions of
the injured nerve in addition to its own.
Both the upper and lower ends of the cut
nerve may thus be grafted into a healthy
nerve, the segment of the latter betw^een
the grafted ends serving as bridge.
Sections of nerves from a freshly am-
putated leg or from an animal have also
been used for bridging purposes.
Case in which there had been com-
plete section of the median nerve
with a hiatus of 3 inches between
the ends. Attempts to unite them
with strands of catgut proved futile.
About 3 weeks after the accident the
wound was reopened and the sciatic
nerve of a small dog w^as grafted on
the freshened ends of the median
nerve. Twelve months after the op-
eration the patient was able to bend
and grip anything wnth the last 3
fingers of the hand; the arm was
strong and could be moved very
freely. The sensory functions were
only partiall}' restored. Stirling (In-
tercol. Med. Jour, of Austral., Mar.,
1907).
Tubulization. — Union ot the sutured
nerve-ends or grafts may be interfered
with by scar tissue formed in the ad-
jacent structures during the process of
repair. To prevent this various means,
known under the general term tubuliza-
tion, have been tried. A solid cylinder
of decalcified bone or of absorbable mag-
nesium may be made to contain the su-
tured ends; gelatin, silver-foil, and cargile
membrane have also been tried.
Trials in a personal case indicated
that bridging by tubules or loop
stitches is unsatisfactory, and that
implantation or direct suture by
forced joint positions are the more
desirable methods. Steinthal (Beitr.
z. klin. chir., xcvi, 295, 1915).
Murphy employed a mixture of equal
parts of the paraffin and oil of sesame,
which may be pressed out into thin sheets
and may be wrapped around the sutured
nerves. If available, neighboring fascia,
fat or even muscle, may be used as pro-
tective covering. Finally, as suggested by
Oellis, shortening of a limb by resecting
a piece of its bone or bones may be re-
sorted to, in order to permit approxima-
tion of the ends of the nerve.
Two cases of bullet injury of
nerves leaving persistent pain in the
calf in 1 case and anesthesia and pa-
ralysis of part of the hand in the
other. In both the nerves involved
were found imbedded in cicatricial
tissue. Treatment was restricted to
mobilizing the nerve and moving it
over to a region where it lay between
layers of sound muscle, apart from
the injured region. The pains sub-
sided in less than 2 weeks, and in 6
months function was almost normal.
Hashimoto and Tokuoka (Archiv f.
klin. Chir., Ixxxii, nu. 1, 1907).
Six months after injury in a per-
sonal case the nerve was exposed and
found to be severed above where it
divides into the radial and interos-
seous; the ends were not widely
separated and were caught in the
scar tissues of the wound; each end
showed a bulb formation of the
nerve and scar tissues. These were
excised and the nerve-terminals su-
tured together with fine catgut in an
absorbable tube prepared from the
SPINAL CORD AND NERVES, INJURIES AND SURGERY OF.
261
artery of a cow after Foramitti's
method, slightly rnoditied. The wound
was closed without drainage and a
cast was applied with the arm at
right angles. The arm and hand
were perfectly normal at the end of
a year. Torrance (N. Y. Med. Jour.,
June 17, 1911).
Early exploratory incision and re-
pair advocated in nerve trunk injury.
To prevent nerve adhesions at the
site of repair, fascia and fat are alone
useful, with the latter the favorite.
End-to-end suture or tubulization
gives better repair tlian lateral im-
plantation. The scar must be excised
to normal axis cylinders as indicated
by a granular surface on the nerve-
end liefore repair is done. Three fine
silk sutures are used to approximate
the ends, and then a free fat trans-
plant is placed around the line of
union. This is stitched to complete
the tubular form and then fixed by
suture to adjacent tissues. D. D.
Lewis (Surg. Clinics, 1, 103, 1917).
Neurolysis combined with a cap-
sulectomy of spindle-shaped neu-
romas has been followed by recovery
in most, and improvement in all,
cases in which this has been done;
exsection of a spindle-shaped neu-
roma is not justified unless failure
has resulted from a neurolysis cap-
sulectomy. Nerve transplantations
and doul)le lateral implantations of
the ulnar into the median in the fore-
arm, have been followed with some
measure of success; but recovery is
slow and uncertain.
Axis cylinders, judged by Tinel's
sign, grow at the average rate of 2
mm. a day.
Perineural scar tissue constricting
young axis cylinders is the most im-
portant factor in hindering recovery.
Joyce (Brit. Jour, of Surg., Jan., 1919).
Peripheral Nerve Injuries.— These are
mainly met in the upper extremities, and
chiefly in the clavicular region, thus in-
volving the brachial plexus. Not infre-
quently the cranial nerves, especially the
facial nerve, are injured. Injury to the
nerve-roots is very i^are. The pain is
often very severe. When any movement
causes stretching of the nerve it is apt
also to be of long duration.
Intraneural injection of alcohol
used in 21 cases of painful neuralgia
following gunshot wounds of nerves,
recovery resulting in each case.
About 3 to 4 centimeters above the
seat of the wound a fine hypodermic
needle is introduced and about 1 to 2
c.c. (16 to 32 minims) of 60 per cent,
sterilized alcohol — or even 80 per
cent., if the neuralgia is of long stand-
ing— injected. Sicard (Lancet, Feb.
9, 1918).
Every case of paralysis from nerve
injury should have an appropriate
splint applied and continuously used
until disappearance of the paralysis.
It should prevent overstretching of
the paralyzed muscles and deformity
due to contractures, and allow harm-
less movement of the part and treat-
ment without removal of the splint.
M. Langworthy (Amer. Jour, of
Orthop. Surg., 16, 445, 1918).
Report of results detained in 358
cases of nerve wounds treated sur-
gically. Resection and suture is the
method of choice, yielding success-
ful results in 88 per cent. When re-
section is so extensive as to prevent
approximation of the 2 ends, even
with the limb flexed, it should be
done in 2 stages.
At the first operation the largest
possible section of nerve should be re-
moved and the diseased ends sutured
together.
Some months later, after the nerve
has become stretched, further resec-
tion and suture of healthy nerve ends
can be effected. In still more exten-
sive loss of nerve tissue, nerve graft-
ing should be performed, either with
the aid of 2 fragments from the mus-
culo-cutaneous side by side, or a
piece of nerve from an amputated
limb. Delageniere (Presse med., Oct.
17, 1918).
It is not very often that infantry mis-
siles lodge in or near the nerve. As in
case of the brain the shots which graze
are very deceptive, as they frequently re-
262 SPINAL CORD AND NERVES, INJURIES AND SURGERY OF.
suit in deposit of particles in the nerves.
When a foreign body is lodged in or
near a nerve the indication, of course, is
to remove it.
In subcutaneous nerve injuries op-
eration should be resorted to if, after
the first effects of the trauma upon
the soft parts have passed away, no
improvement in motility has oc-
curred, and also if neuralgic symp-
toms or a degenerative reaction en-
sue. The procedures consist in para-
neurotomy, division of the nerve-
sheath, nerve-suture, and imbedment.
In cases of paralysis occurring intra
partum, which usually involves the
brachial plexus, early intervention is
also indicated, especially in the pres-
ence of a degeneration reaction.
Borchard (Beitr. z. klin. Chin, Bd.
91, Hft. 3, 1914).
Injury of the vagus is liable to
slow the pulse and the respiration.
Severing the vagus nerve on one side
does not cause any threatening symp-
toms on the part of the heart or
lungs. But irritation of the nerve is
liable to induce extremely severe
symptoms, possibly complete arrest
of heart and lung action. In some
cases there are also more or less
dyspnea and spasmodic coughing.
When severe symptoms develop, the
writer advocates vagotomy. The
only drawback is the permanent pa-
ralysis of the vocal cord. The vagus
nerve sometimes stands traction,
compression, etc., but it is more
liable to respond with serious symp-
toms. If cautiously and gently ma-
nipulated it will stand a great deal,
especially if treated with cocaine be-
forehand. Zesas (Centralbl. f. d.
Grenzgeb. d. Med. u. Chir., Mar.,
1915).
As regards operative indications an im-
portant feature is that it is rare to have
a nerve severed; also that a shot pene-
trating near a nerve may cause paralysis
without direct injury to it, because it is
imbedded in a bloody, gelatinous exudate,
which also infiltrates it. The principal in-
dication for operation lies in the necessity
for freeing the nerve from a scar.
The indication for operation upon a
nerve because of pain is not clear and
decision is difficult. One should operate
in such cases only when other means of
treatment fail. Unfortunately in war one
sees at times ischemic paralysis of the
nerves due to the use of the Esmarch
bandage, which may be left on from 10
hours to 3 days. The prognosis in these
cases is hopeless.
The beneficial effects of nerve-suture
often are not manifest for as long as 8
months. The results of neurolysis become
evident sooner, function often being re-
stored after 2 months.
Among 502 wounded soldiers ob-
served by the writer, 52 presented
injuries of nerve-trunks or centers,
and of these 27 showed wounds of
the nerves in the extremities. Where
paralysis alone exists, without pain,
the writer does not operate until the
wound has entirely healed, in order
that the intervention may be con-
ducted under aseptic conditions. In
painful cases, however, experience
has shown that, where the distress
cannot be relieved by medical means,
an operation is justified, not only
because of the pain itself, but on ac-
count of the danger that increasing
injury will be done to the nerve
through contraction of cicatricial tis-
sue. Extensive removal of any su-
perficial cicatricial tissue, together
with the deep-lying indurated mass,
was effected. Once exposed, the
nerve was carefully freed from ad-
herent cicatricial remnants, being
meanwhile kept moist with normal
saline solution.
The most important feature of the
operative technique is the inter-
position between the nerve and the
surrounding injured tissues of layers
of normal muscular tissue taken in
so far as possible from the surround-
ing muscles. These layers are su-
tured to the tissues which would
otherwise be in contact with the
nerve, and preserve the latter from
subsequent cicatricial compression.
Walther (Bull, de I'Acad. de Med.,
Nov. 10, 1914).
SPINAL CORD AND NERVES, INJURIES AND SURGERY OF.
263
Besides the liberation of a nerve
from surrounding cicatricial tissue,
injection of 2 c.c. (32 minims) of
normal saline solution containing
0.005 Gm. (M2 grain) each of cocaine
and stovaine into the nerve-trunk for
4 to 6 cm. is recommended. Where a
nerve, upon exposure, is apparently
normal, being thus merely in a state
of inhibition or stupor, injection into
the nerve-trunk of 1 to 2 c.c. (32
minims) of a 1:100 solution of
chemically pure methylene blue in
normal saline solution prepared with
distilled water is advised. Sicard,
Imbert, Jourdan and Gastaud (Bull,
de I'Acad. de Med., Feb. 16, 1915).
In operating on nerves injured by
a bullet or fragment of a shell the
nerve should not be separated from
its bed until the last minute, as the
stumps must be guarded against
twisting. This would prevent coap-
tation of the fiber tracts. Stretching
of the stumps to bring them into con-
tact should be done before the ends
are freshened. It is usually neces-
sary to pass the needle through some
of the nerve-tissue itself to obtain a
stout hold. When this is the case,
the sensory tracts should be se-
lected, carefully avoiding touching
the motor tracts. Stoffel (Miinch.
med. Woch., Feb., 1915).
In nerve suture the writer found it
feasible, by using fine silk and the
finest needles obtainal^le, to suture
the perineum without injury to the
axis cylinder fibers. Frouin (Presse
med.. Jan. 8, 1917).
Tinel's sign of distal tingling on
percussion depends upon the fact that
the percussion of young axis cylin-
ders leads to tingling in the skin
areas corresponding to their ultimate
distribution. The formation of new
axis cylinders in the proximal end of
a divided nerve becomes evident by
the above sign in from four to six
weeks. W. M. Macdonald (Brit.
Med. Jour., July 6, 1918).
Experiments showed that direct
nerve suture exposes the limb to seri-
ous trophic distur1)ances of the mus-
cles and skin. These are obviated by
interposition of a short dead nerve
transplant. The indirect suturing is
done with 2 or 3 silk threads passed
through the neurilemma. The dead
transplants are obtained aseptically
from calf fetuses 50 to 60 centimeters
long, easily procurable at slaughter
houses. They are fixed in 50 per
cent, alcohol and kept in sealed tubes.
Only 4 threads are used to hold
them in place. These transplants
remain at least a few weeks before
absorption. Such treatment is prac-
ticable only in recent nerve in-
juries. Nageotte (Paris med., July
20, 1918).
Nerve suture should be so per-
formed as to prevent improper dis-
tribution of fibers. This can be done
by careful observation of the oval
contour of the nerve and correct ap-
proximation of the 2 ends. Reforma-
tion of scar tissue is prevented by
accurately bringing together the neu-
ral sheaths. When the gap is too
great for direct suture, one should
insert a homogeneous graft taken
from a mixed nerve of equal or larger
size than the injured one, e.g., from
amputations or amputation stumps
requiring a secondary operation. E.
W. Fisher (Brit. Med. Jour., Apr. 26,
1919).
The following operative procedures, not
already referred to, are sometimes indi-
cated:— •
Nerve Stretching or Neurectasy. — This
operation has been employed in many
nervous disorders, but particularly in the
various forms of neuralgia, including that
of such large nerves as the components of
the brachial plexus and the sciatic. In per-
forming it the nerve is exposed, and iso-
lated by a blunt dissection. It is then
grasped by suitable tractors or with the
thumb and finger, and stretched from both
directions, central and peripheral, until
the nerve is plainly elongated. The con-
ductivity of the nerve is lessened, and it
is separated from any cicatricial or other
tissue which may compress it.
The best results are obtained in sciatica,
and in supraorbital neuralgia. Tlie sciatic
nerve will stand a pull v.^hich will raise
the limb from the table, but jerking should
264 SPINAL CORD AND NERVES, INJURIES AND SURGERY OF
be carefully avoided, while the traction,
which may last from 3 to 5 minutes, is
exerted.
Nerve Extraction or Avulsion. — This
method, devised I)y Thiersch in 1889, is
more effective than neurectomy in the
treatment of trifacial neuralgia and tic
douloureux, and is less serious than op-
erations about or removal of the Gas-
serian ganglion. Under general anesthe-
sia the painful nerve-trunk is exposed,
then grasped with blunt forceps, and
slowly twisted round the forceps in such
a way as to pull the nerve out of its bed
and its connections. Segments of the
nerve, from 5 to 8 inches in length, may
be readily removed by this procedure.
Even here, however, regeneration of the
nerve may occur from previously inacces-
sible fibers. When the nerve issues from a
foramen, such as the supraorbital, the lat-
ter may be plugged with bone grafts
(Kanavel), silver screws (Mayo), amal-
gam, gold- or silver- foil, etc., to prevent
regeneration.
Neurotomy. — This consists in dividing
the painful nerve, and was largely done at
one time in the treatment of neuralgia and
tic douloureux. Unfortunately, the relief
is but temporary, the average freedom
from pain, according to a review of 43
cases by Putnam and Waterman, being
but 10 months. In some instances only a
few weeks' relief was afforded.
Neurectomy. — This operation consists
in exposing the painful nerve in neuralgia
or tic douloureux, etc., and removing
either by cutting or extraction of segment
of the nerve. As ably described by
Urban Maes, of New Orleans (Surg.
Gynec. and Obst., Oct., 1915), the operation
is carried out in the following manner in
the regions specified: —
The supraorbital branch of the first
division is best reached by a curvilinear
incision in the eyebrow. The skin, fascia,
and fibers of the orbicularis are divided.
The nerve lies between the two layers of
periosteum near the junction of the mid-
dle and inner thirds of the orbital ridge
where a notch may be felt. After expo-
sure of the nerve, which should be care-
fully separated from its accompanying
vessel, it may be avulsed by the method
of Thiersch.
The second or superior maxillary divi-
sion is the ijranch most freciuently af-
fected, according to Spiller. It makes its
appearance in the face at the infraorbital
foramen, which is in a vertical line with
the supraorbital notch, just below the
margin of the orbit. In this region it may
be exposed on the face and avulsed or
subjected to an injection of 1 to 2 per
cent, osmic acid or 80 per cent, alcohol.
The failure of this operation caused
Kocher to devise a method of resection
at the foramen rotundum, which is de-
scribed in his book, which is a thorough
treatise on the surgery of the trigeminus.
The incision is in the same curvilinear line
as for the peripheral operation, but is
carried farther back, at the same time
avoiding injury to the fibers of the facial
and being well above Steno's duct. All
structures attached to the malar bone are
pushed aside with a periosteotome, up to
and including the floor of the orbit. The
chisel is then used to cut into the spheno-
maxillary fissure and to open the antrum.
This opens the infraorbital canal. The
frontomalar articulation is divided with a
chisel, and finally the malar-zygomatic ar-
ticulation. The malar bone is then dis-
located outward and upward where the
nerve can be followed and avulsed up to
the foramen rotundum, care being taken
not to injure the accompanying artery.
The malar bone is then replaced. There
is some risk of infection in this operation,
and, as already noted, the antrum is
opened.
For division of the trunk of the inferior
maxillary after its exit from the foramen
ovale, either Kocher's or Kronlein's op-
eration may be used. In Kocher's opera-
tion a curvilinear incision with its con-
vexity downward is made from just behind
the frontomalar articulation to the root
of the zygoma. This incision includes all
structures and divides the temporal ves-
sels and a branch of the facial nerve to
the occipitofrontalis. Retracting the edges
of the incision exposes the zygoma, which
is divided but left attached on its under
surface. After removing the underlying
fat, the posterior border of the temporal
muscle is drawn forward, exposing the
periosteum along the pterygoid ridge.
This periosteum is divided and elevated
SPINAL CORD AND NERVES, INJURIES AND SURGERY OF. 265
from the bone along with the soft parts
so as to avoid the internal maxillary ar-
tery. This dissection is carried back until
the base of the pterygoid process is seen,
and just posterior and to the mesial side
of this process we find the foramen ovale
at a depth of about 3 cm. from the root
of the zygoma. The trunk is then divided
or avulsed according to the method of
Thiersch.
The inferior dental branch of the third
division may be reached by any one of
three routes, although the intrabuccal
method is accompanied by too much risk
of infection to make it practical. In or-
der to avoid a visible scar the incision is
made just around the angle of the in-
ferior maxilla, through all structures to
the bone. With a periosteotome the tis-
sues are elevated from the under surface
of the ascending portion of the ramus
until the foramen is reached, which is
identified by the spine of Spix. The nerve
can then be caught with a hook and
avulsed. Another method is to approach
the nerve by trephining the jaw just op-
posite the foramen, which is located just
in the center of the irregular quadrilateral
formed by the ascending portions of the
ramus. A skin incision is made down to
the masseter, which is separated in the
direction of its fibers. A small trephine
is used to perforate the bone, and the
nerve avulsed, avoiding the accompanying
artery.
Even this operation may be followed by
recurrences. The more radical operation
described under the next heading may
then be resorted to, but only after all
other measures have been tried.
Removal of the Gasserian Ganglion or
of Its Sensory Root. — This operation, first
proposed Ijy J. Ewing Mears, is classed
bj^ Deaver among the "relatively safe"
operations, "while for efficacy there are
few superiors," though acknowledging
that his mortality had been higher than
that given by Frazier and Keen, viz., Z.l
per cent., in a total of 230 cases. Spiller
has shown, however, that removal of the
ganglion was not necessary, division of
its sensory root being sufucient. Frazier
describes the operation as follows: —
The essential feature of this operation
is the division or avulsion of the sensory
root exclusively without interfering with
the ganglion itself. The approach to the
ganglion is made through an opening
somewhat posterior to that employed by
other surgeons. The center of this open-
ing is about on a line with the point at
which the sensory root passes into the
ganglion.
Under nitrous oxide-ether anesthesia,
preceded by the administration of a hy-
podermic injection of morphine (grain %
— 0.01 Gm.) and atropine sulphate (grain
%00 — 0.00065 Gm.), with the patient in a
vertical posture, a horseshoe-shaped in-
cision is made, beginning about the mid-
dle of the zygoma and terminating behind
and a little below the helix of the ear.
The musculocutaneous flap, purposely
made a little larger than the opening in
the skull, is reflected, the skull opened,
and the opening, with a diameter not ex-
ceeding 3 cm., enlarged as far as the in-
fratemporal crest. The dura is separated
from the base of the skull with a blunt
instrument, such as the handle of a
scalpel, as far as the foramen spinosum,
where the middle meningeal artery is
ligated and divided distal to the ligature.
The dura propria is incised directly over
the mandibular division and dissected
from the superior surface of the ganglion
backward and inward until the sensory
root is exposed. If the motor root can be
recognized, it should be isolated. The
sensory root is then picked up with a
blunt hook, grasped with forceps, and
either divided or avulsed. Hemorrhage is
controlled by strips of gauze not more
than 1 cm. in width, introduced at either
side so as not to interfere with continua-
tion of the operation. As soon as the
sensory root has been divided the anes-
thetic is discontinued. When the reflexes
have returned, the conjunctival reflexes
should be tested in order to assure the
operator that no fibers of the sensory
root remain undivided. The musculocu-
taneous flap is closed with tier sutures
and a small narrow strip of rubber tissue
introduced in the posterior angle of the
wound. It is almost always necessary to
provide for the escape of blood, inasmuch
as only exceptionally will the field be en-
tirely dry when the operation is concluded.
(This is accomplished by a rubber-tissue
266
SPINE, DISEASES AND INJURIES OF (SAYRE).
drain.) The rubber tissue is removed
within 24 or 48 hours. This operation is
now preferred, because it is less likely to
involve the fibers of the facial, which
brings on ocular complications of a seri-
ous nature, while the small opening made
reduces the likelihood of hernia.
Removal of the Cervical Sympathetic.
— This operation has been advocated by
Jonnesco and others in the treatment of
exophthalmic goiter, epilepsy, and other
disorders, but, in view of recent progress,
is not to be recommended. S.
SPINAL MENINGITIS. See
Meningitis.
SPINAL PARALYSIS, INFAN-
TILE. See Spinal Cord, Diseases
of: Infantile Paralysis.
SPINAL PARALYSIS, SPAS-
TIC. See Spinal Cord: Primary
Lateral Sclerosis.
SPINE, DISEASES AND IN-
JURIES OF.— TUBERCULOSIS
OF THE SPINE.— (Pott's disease;
spondylitis). — Tuberculosis of the
vertebrae makes up nearly all the
cases classed under the head of Pott's
disease, so called because of the ver^'
elaborate account given of it by Per-
cival Pott over a hundred years ago.
The subject of Bone Tuberculosis
has already been discussed (see vol-
ume ii), under the head of Hip-joint
Disease (see volume vi) and, under
the head of Arthritis, Tuberculous
(see volume vi). What was then
said of the growth of tubercle in the
femur and joints also applies to tu-
berculosis of the spine.
SYMPTOMS AND DIAGNOSIS.
— As a -rule, the primary focus of
disease in the cancellous tissue of the
body of a vertebra spreads slowly
until the intervertebral cartilages
connecting this vertebra with its fel-
lows are involved. It is rare for the
disease to remain confined to a single
vertebra. It more usually involves
several contiguous vertebrae, or there
may be present several spots of in-
flammation, at different locations in
the spine, some of which may appear
months or even years after the pri-
mary infection. The vertebral body
is gradually destroyed, and usually,
unless support is applied to the spine,
the superincumbent weight of the
body crushes together the softened
vertebrae, causing an angle in the
spinal column, with a protrusion of
the spinous processes. As a rule, the
erosion has been toward the front of
the bodies of the vertebrae, and the
angle takes an anteroposterior posi-
tion accordingly.- But it occasionally
happens that a marked bend to one
side takes the place of the ordinary
anteroposterior deviation. It occa-
sionally happens also, that large
amounts of the cancellous tissue are
destroyed, even the entire bodies of
two or three vertebrae, without the
occurrence of deformity, as enough
inflammation has occurred to cause
proliferation of bone between the
transverse processes, the vertebrae
becoming firmly ankylosed in a
straight position.
Sometimes the seat of the disease
is in a costovertebral articulation.
This point must be borne in mind in
making a diagnosis before excluding
vertebral tuberculosis. Very rarely
the focus of disease is found in the
transverse arch or in the spinous
process of a vertebra.
Abscess formation often accom-
panies vertebral tuberculosis. The
abscess may extend into the vertebral
canal, giving rise to paralysis. It may
also point anteriorly, and may cause
such pressure on the trachea or bi-
SPINE, DISEASES AND INJURIES OF (SAYRE).
267
furcation of the bronchi as to impede
respiration. It may rupture into a
bronchus and the pus be expectorated
or it may cause suffocation ; it may
set up a pleurisy; or it may perforate
the bladder or the rectum ; but usu-
ally such abscesses, if in the dorso-
lumbar region, burrow a tract along-
the course of the psoas muscles, and
point either below Poupart's ligament
or above the posterior iliac spines.
In the cervical spine these ab-
scesses at times burrow until they
penetrate the mediastinum, with most
disastrous consequences, or may rup-
ture into the pharynx, the pus setting
up an intestinal tuberculosis.
A diagnosis must be made between
spinal tuberculosis, syphilis, and rick-
ets, and this may be very difficult. If
the child be under 2 years of age, and
have several foci of disease in the
spine, several other joints involved,
or show evidences of syphilis else-
where, or the parents be known to be
syphilitic, it should receive anti-
syphilitic treatment in addition to
protection for its spine. A nega-
tive Wassermann reaction does not
necessarily exclude syphilis.
If evidences of rickets show them-
selves in large epiphyses, beaded ribs,
open fontanelles, abnormal sweating
about the head, the spinal curvature
is probably rachitic. Benefit will fol-
low changing the diet and adminis-
tering phosphorus and codliver oil.
The necessity for supporting the
spine is, however, as great as if
tuberculosis were present ; but the
chances are that it will be required
for only a short time.
Many tuberculous cases do not
prove fatal, and, if adequate mechani-
cal support is applied before the oc-
currence of a deformity, the latter
should be largely prevented. Abso-
lute rest of the inflamed area and the
building-up of the patient's nutrition
are the two essentials of treatment.
A certain percentage under the best
of care does not improve, but develops
abscesses and amyloid changes in the
viscera, or develops pulmonary or
meningeal tuberculosis, especially the
latter.
Lumbar Pott's disease, with begiuuing psoas
abscess, simulating lateral curvature of the
spine in the position patient holds her body.
(R. H. Sayre.)
Early diagnosis is important, as the
disease precedes the deformity for
some time, and. as elsewhere, is more
easily prevented than cured. Pain,
muscular spasm, and slight elevation
of temperature are the three diag-
nostic points to be noted. The pain
is referred to the distal extremity of
the nerves which pass from the spine
at the point of inflammation, and the
symptoms, as a result, vary. In the
268
SPINE, DISEASES AND INJURIES OF (SAYRE).
first and second cervical vertebrae oc-
cipital headache may be noted, and
the condition may resemble torticollis.
In torticollis, however, the face looks
upward and away from the con-
tracted muscles, while in cervical
tuberculosis the face, though turned
to one side, is more often directed
downward. In torticollis pain is not
present, and the muscular spasm,
pathognomonic of joint inflammation,
does not exist : simply a chronic con-
tracture of certain muscles. Fever of
99° or 993^° F. (37.2° or 37.5° C.)
will also probably be found associa-
ated with tuberculosis.
One symptom which is pathogno-
monic of inflammation in the first and
second cervical vertebr?e is pain, or
sometimes a sense of impending death
on being placed recumbent. The pa-
tient may be unable to lie down to
sleep for weeks at a time, until ade-
quate support is applied. The ana-
tomical construction of the first and
second vertebrae accounts for this
peculiarity. While recumbent, the
weight of the head presses the body
of the atlas back against the odontoid
process of the axis, while in the up-
right or slightly anteflexed position
the latter is freed from pressure. Re-
cumbency gives relief when the dis-
ease is in any other portion of the
spine.
With this particular location a
prognosis must always be reserved,
as there is possibility of entire erosion
of the odontoid process or rupture of
the check ligaments and consequent
fatal pressure on the cord, — unless
ankylosis of the vertebrae has oc-
curred previous to the odontoid
destruction.
A little lower in the neck the dis-
ease causes dyspnea and a kind of
breathing, somewhat resembling the
noise of croup or whooping-cough,
while at the dorsocervical junction
the disease at times produces auscul-
tatory sounds which exactly resemble
a general bronchitis, and which disap-
pear when traction is made upon the
head, to reappear again the moment it
is relaxed. In the majority of cases
of upper dorsal disease there is a
peculiar grunting respiration which is
pathog'nomonic, and once heard can-
not be mistaken.
When the disease is situated in the
dorsal region, pain may be referred
to the front part of the chest or pit
of the stomach, and the diagnosis of
indigestion made in consequence,
while, when it is a little lower in the
spine, the child is often treated for
worms and colic. Here also, pain
may be referred to the bladder, per-
ineum, or the rectum. In the lower
lumbar region hip disease may be
suspected, the pain being referred to
the inner side of the thigh and to the
knee. At times, sharp contraction of
the abdominal muscles may be noted,
before the appearance of a knuckle in
the spine, giving the appearance of a
string tied tightlv around the bellv.
Pain is rarely felt at the point of
disease, except when of long stand-
ing, and this pain is usually elicited
by blows and jars or sudden twisting
of the spine, and not by direct pres-
sure ; often, if the patient be laid face
downward and pressvire made on the
knuckle, relief will be given, due to
removal of pressure from the inflamed
surfaces.
The gait is characteristic. There
is a careful, apprehensive tread, the
ankles, knees, and hips being flexed to
avoid jarring the spine; and the pa-
tient steps upon the toes. On bending
SPINE, DISEASES AND INJURIES OF (SAYRE).
269
to pick up an object a child with
Pott's disease will flex the ankles,
knees, and hips, and squat down,
and in walking around a room it
wull frequently support itself by the
table, chairs, etc., taking- care not
to release its grasp of one until it has
secure hold of another. If compelled
to walk by itself, it may support its
trunk by placing both hands on
its thighs and stiffening the arms,
thus relieving the spine of pressure.
Usually these patients find that rid-
ing in street-cars or on rough pave-
ments causes pain, and that they are
obliged to place their hands on the
seat of the carriage, thus supporting
the body. If the disease is high up
in the spine, the head is frequently
supported by the . fingers, and on
looking- to either side the entire bodv
is rotated, and not simply the neck.
When the disease is in the dorsal re-
g-ion the child often w^alks with the
head thrown back, the face looking
tow^ard the sky, to relieve the front
part of the vertebral bodies from
pressure, and a mistaken diagnosis of
cervical disease be made in conse-
quence.
The diagnosis is simple in the pres-
ence of deformity, but long before
this symptoms are present which,
properly interpreted, permit a correct
diagnosis. It is important that the
patient's trunk be stripped, and the
attitude noted. The patient should
bend forward and backward and to
both sides, the occurrence of spasm
in any of the muscles of the trunk
being carefully noted. Marked ten-
derness to pressure along the entire
spine, without muscular spasm or de-
formity is a pretty sure indication of
the so-called "hysterical" spine. It
spasm be found on any manipulation
of the spine, any pain on bending or
on concussion, with pains referred to
the anterior part of the body, com-
bined with a one degree fever, the
condition is almost certainly an in-
flammation of the spine, even with-
out any deformity.
In such cases, one should examine
the costovertebral articulations, tak-
ing the ribs one by one and pressing
their heads against the vertebrae to
detect any inflammation. In doubt-
ful cases if there is fever, inflamma-
tion is probable in the spine, which
should be protected accordingly until
time shall have cleared up the diag-
nosis.
ETIOLOGY.— An injury can fre-
quently be traced as the exciting
cause. The customarv gradual on-
set, however, causes observers fre-
quently to overlook the connection
between the traumatism and the
disease.
TREATMENT.— The treatment
should consist of physiological rest
of the inflamed vertebrae. /;/ children
under 5 years of age, this is best se-
cured by recumbency in a wire
cuirass comfortably padded and
made to fit the shape of the entire
child. The legs and the body are
bandaged to hold it firmly in position ;
traction is then made upon its head
by means of a leathern head-support,
which passes under the chin and occi-
put, and is attached to a cross-bar
which is suspended from an upright
fastened to the cuirass. Without this
traction, a knuckle is very sure to de-
velop from reflex muscular spasm,
in spite of the recumbent position.
If the disease is in the uf'pcr dor-
sal region, the shoulders should be
held 1)\- the attachment suggested by
Dr. Whitman, which consists of tw^o
270
SPINE, DISEASES AND INJURIES OF (SAYRE).
hard-rubber caps which fit the heads
of the humeri and which are con-
nected together by a steel rod passing
across the front of the chest; the
straps pass above and below the
shoulders from buttons on the rub-
])er caps to the back part of the
cuirass, and the shoulders are thus
held thrown well backward.
The use of straps passing around
the shoulders to hold the latter back
is decidedly less efficacious than the
Whitman apparatus, which controls
better the movement of the vertebrae.
In the cuirass the child may be
taken out in a large baby carriage,
and receive the benefits -of sunshine
and fresh air. The bandages should
be removed every day, and the child's
skin kept in proper condition. Every
few days, if need be, the child may
be removed from the cuirass, by roll-
ing it on its stomach, and washed
with water and a little alcohol. This
is preferable to recumbency in a cot,
with traction on the head with weight
and pulley, as in the cuirass the child
may enjoy the benefits of outdoor life
and be carried up and down stairs.
The invalid child should pass most of
its time recumbent. If simultaneous
disease of the knee or hip is present
with spinal tuberculosis, the cuirass
is also the proper treatment. The
Bradford frame of gaspipe over which
is stretched a canvas cover is pre-
ferred by many to the cuirass, but
in the writer's opinion gives much
less quiet to the spine, especially if
the disease is dorsolumbar.
// the child be larger, and the pelvis
enough developed, apparatus may be
applied to allow the child to walk.
If the disease is in the cervical re-
gion, a jury-mast should be applied,
which may be fastened to either a
plaster jacket or to a steel back-brace.
If the latter is used, it must receive
support cither from the shoulders of
the child or from the crests of the
ilia, the latter being the best point
from which to make upward traction.
// tJie disease is in the first or sec-
ond cervical vertebra, the head must
be held absolutely rigid with a metal
head-support fastened in position by
a brow-band and connected to a
body-brace by a rod having universal
joints at the occiput and seventh cer-
vical vertebra, in order that the ap-
paratus may be adjusted to the head
in its position of distortion and grad-
ually altered as the subsidence of in-
flammation permits.
If the head is not turned far from
a straight line, simple uprights of
iron bent to fit the shape of the neck
and head may suffice, the ordinary
jury-mast being used for this pur-
pose. If it is not practicable to ob-
tain such an apparatus, plaster-of-
Paris bandages enveloping the head,
neck, and trunk, like a suit of armor,
may be used with success. In fact,
I believe the plaster of Paris simpler
and better.
In the loiver cervical vertebra: ro-
tation may be permitted.
// the disease is in the upper dorsal
vertebrce, any apparatus used must
sustain the weight of the head,
whether it be an anteroposterior steel
brace or a plaster jacket.
IVith the disease in the dorsal re-
gion, the spine may be supported with
the anteroposterior steel brace,
A spinal brace should be made of
steel so tempered as to be capable of
being bent by a large pair of monkey
wrenches, and should be accurately
fitted so as to support the entire
spine. There should be two back-
SPINE, DISEASES AND INJURIES OF (SAYRE).
271
bars, one lying on each side of the
spinous processes, and connected by
cross-rods so curved as not to press
on the spine. There should also be
a pelvic belt, with padded bands at-
tached, which pass over the iliac
crests in order that the weight of the
head may be transmitted down here.
Control of the head is obtained by a
metal rod passing from the back-bars
of the brace over the top of the head,
and supplied with a cross-bar from
which depends a leathern head-
support passing under the chin and
occiput. From the back-bar project
other bars which pass behind the
scapulae and project a trifle over the
shoulder, and from these straps pass
i-i front of the shoulders and under
the axillae, and fasten again to buckles
on the back-bars. The reason these
bars project above the shoulders is
to prevent the straps from crowding
the shoulders down, as they are only
intended to force them back. As the
straps by themselves would slip into
the fold between the humerus and the
chest, they are kept from so doing
by fastening them to two concave
rubber caps which rest against the
front of each humerus and are con-
nected by a curved metal bar, ac-
cording to Dr. Whitman's suggestion,
which keeps them apart. A linen
apron with straps to the back-bars
keeps the entire apparatus in place.
It should be fitted with great care.
The patient should be prone and the
spinal outline taken with a strip of
flexible lead or other metal and the
back-bars then properly bent with
wrenches. The bars may require to
be twisted sidewise as well as in an
anteroposterior direction and should
be so adjusted that zvhen the patient
is upright the entire spine is thoroughly
supported. This is difficult in case of
decided deformity. The fitting of
such apparatus should be done by the
physician himself in his office ; upon
the perfection of support will depend
the benefit derived.
In many cases the improving posi-
tion requires straightening of the
back-bars from time to time.
In my experience better results are
obtained from the use of the plaster-
cf-Paris jacket than from any other
means of support except in cervical
and high-dorsal cases, where a steel
brace is preferable.
The Plaster-of-Paris Jacket.—
Cross-barred muslin or crinoline
should be the material used in mak-
ing the bandages. This muslin
should be carefully washed to get rid
of the superfluous sizing before being
torn into strips from three to four
inches in width and three yards in
length. "Phelps hospital crinoline"
does not, however, require washing.
The selvage is to be torn off. These
strips are drawn through a tray filled
with freshly ground plaster of Paris,
and enough rubbed into the muslin
to fill all the meshes. The bandages
are then rolled moderately tight and
laid in an air-tight tin until required.
The patient should have the body
covered with a tightly fitting knitted
or woven shirt, without sleeves, tied
tightly over the shoulders and drawn
down and securely pinned over a
folded towel in the perineum with a
safety-pin. If the patient is a fe-
male, pads of proper thickness should
be placed over the mammre and under
the shirt, which pads are to be re-
moved when plaster sets. Another
towel, the "dinner pad," also to be
removed after the plaster sets, is
placed inside the shirt, thus provid-
272
SPINE, DISEASES AND INJURIES OF (SAYRE).
ing space for the expansion of the
stomach. If the patient has just
partaken of a hearty meal, this dinner
pad may be omitted. A felt pad
should be placed along the spine, be-
ing pinned to the top edge of the
shirt, and felt pads placed so as to
protect the iliac crests on each side.
These pads are left in the jacket.
The patient, now being prepared, is
placed in the suspension apparatus,
V, hich consists of a pair of padded
straps, which pass under the axillae,
and a leathern head-piece which
passes under the chin and occiput, all
of which are suspended from an iron
rod, which, in turn, hangs from a
compound pulley suspended from the
ceiling, door, etc. In patients' houses
a folding tripod of wood is very con-
venient. Traction is now made on
the head and arms evenly, the straps
being lengthened or shortened until
the pressure is evenly distributed.
Traction is now made very slowly
and gently, and only carried to the
point of giving the patient perfect
comfort, and never beyond that point.
In some cases the heels will be
slightly raised from the floor before
this point is reached ; as the sen-
sations of the patient are the only
guide as to the amount of traction
needed, an anesthetic should under
no circumstances ever be given. If
it is a young child, watch carefully
the expression of its countenance ;
and when it is changed from pain to
pleasure, there always stop, and im-
mediately apply the plaster bandages
with great care and accuracy, press-
ing them into all the irregularities
and covering the entire trunk from
the pelvis to the top of the sternum.
If the patient is kept suspended in
this position till the plaster is set, it
will retain the body in perfect com-
fort.
In appl}ing the bandages one of
them should be placed on end in a
basin or pail of tepid water. When
bubbling ceases, the bandage is
ready. Do not add salt to the water,
as it renders the plaster brittle.
.Squeeze out the superfluous water
before applying it, and place another
roll, end up, in the water, which will
be ready for use by the time the first
one is applied.
It is not a bad plan to immerse the
bandages while wrapped in thin Jap-
anese paper napkins. The bandages
are then one by one laid in a dry
basin to drain while the preceding
bandage is being applied. In this
way much less plaster is left in the
bottom of the pail to be gotten rid of.
The patient being suspended, the
jacket is applied by the surgeon,
standing or sitting at the back of the
patient, while an assistant sits in
front, steadying the patient by his
knees and rubbing and smoothing the
bandages which are being applied.
Begin at the waist, taking one or
two turns around the smallest part of
the body, and then going down in a
spiral form, each layer overlapping
the other half or two-thirds of the
width of the bandage until reaching
the trochanters ; then, having taken
one or two turns around the pelvis,
reverse the bandage and gradually
proceed in the same spiral manner
upward until the body is covered.
This process is repeated till the
jacket is sufficiently thick to support
the body, the number of bandages de-
pending on the size of the patient.
In cases where the disease is in the
loiver dorsal or lumbar vertebra" this
is all that is required. // the disease
SPINE, DISEASES AND INJURIES OF (SAYRE).
273
is at the middorsaJ or cervical! vcrte-
brce, it then liecomes necessary to add
the jury-mast to the jacket in order
to take off the weight of the head.
In many instances great advantage
is derived from the addition of Whit-
man's shoulder brace to keep the
chest well expanded, and press the
shoulders back into the jacket.
Several modifications have been
made in the application of plaster
bandages, as Davies's hammock, in
which the patient was suspended, face
downward, while traction was made
on the head and heels by an assistant.
Goldthwaite, of Boston, has advocated
traction by a windlass, with the pa-
tient lying on the back, the most
prominent part of the curvature being
supported by a little upright, the
weight of the patient's head and
shoulders tending to correct the de-
formity. Goldthwaite thus claims
great improvement in curvature of
the spine in various cases, and in
properly selected cases this position
is preferable to vertical suspension.
Taylor, of Baltimore, applies plas-
ter jackets, the patient being fastened
to a bicycle saddle, while pressure is
made against the kyphos and the ster-
num by means of arms which project
from the apparatus, while traction is
made on the head, upward and back-
ward, by means of a pulley.
In the great majority of cases the
jacket can be applied while the pa-
tient is suspended vertically ; where
there is paralysis, where the heart is
too weak to allow the patient to re-
main upright, or in excessively fat
and feeble people, Davies's hammock,
with holes cut to allow projection of
the head and feet, or Goldthwaite's
apparatus is to be preferred, traction
being made at both ends of the body
to the point of comfort while the
jacket is being applied.
Management of Abscess. — Opin-
ions differ widely as to the proper
mode of procedure. If the patient is
doing well, with a temperature below
100° F. {27.7° C.), appetite and diges-
tion good, it is wise not to interfere,
especially if the disease is between
the first and twelfth dorsal vertebrae,
as the chances for the removal of all
tuberculous material and disease foci
do not warrant the risk of a mixed
infection. // the abscess Jms ap-
proached near the surface and seems
about to burst, it is wisest, in most
instances, to cleanse the skin thor-
oughly, and apply an antiseptic
dressing. When the abscess dis-
charges, this dressing should be
changed as frequently as required,
care being taken to prevent infection
of the wound at such times.
The patient should take much
more rest when abscesses are pres-
ent, as they increase in size much
more rapidly if children run about.
// the abscess has become infected
1^'itJi pus organisms, a free incision
should be made, either in front or in
back, or both, according to the situa-
tion of the abscess, and the abscess
cavity freely laid open and washed
out with hot Thiersch solution. If
conditions permit, the abscess cavity
should be explored and all carious
bone removed. In dorsal disease it
may be necessary to resect the head
of a rib in order to secure sufficient
space to thoroughly explore the spine.
Great care should be taken to push
the pleura in front of the finger,
and not tear it in approaching the
vertebra.
There must be short and direct
drainage to the initial point of in-
8—18
274
SPINE, DISEASES AND INJURIES OF (SAYRE).
flammation ; otherwise these abscesses
are apt to form sinuses which run for
years, become secondarily infected
and finally set up amyloid degenera-
tion of the liver and kidneys.
/;/ the upper cervical vcrtebrce an
abscess may point in the back part
of the pharynx, and the question may
arise whether to open it through the
pharyngeal wall or from the outside
of the neck. There are many objec-
tions to the former procedure.
In case the abscess is increasing in
size and in danger of rupturing into
the mouth or of burrowing down the
neck, it is better to open it from the
outside of the neck. Unless the ab-
scess points elsewhere, it can be well
approached by an, incision behind the
sternomastoid, blunt dissection, push-
ing aside the muscles of the neck.
After the abscess has been thor-
oughly evacuated any carious bone
that can be reached should be re-
moved and the cavity packed.
In case the abscess presses on the
spinal cord and causes paralysis, a
question of operation for the relief of
pressure comes in ; but this is of very
doubtful value. The pressure on the
cord will probably diminish in a few
months' time, restoration of function
therefore taking place. If the laminae
were to be removed fior the purpose
of exposing the abscess, there would
be nothing left to support the spine.
Operating on these abscesses is alto-
gether different from removal of the
laminae in cases of fracture, and
should not be undertaken until time
has shown all chance of improvement
in other ways to be improbable.
Very exceptionally, paraplegia in
spinal tuberculosis is caused by the
narrozmng of the spinal canal in con-
sequence of the collapse of the bodies
of the I'crtebrcc. In these cases lami-
nectomy is advisable. All cases of
laminectomy should have the spine
supported and protected by a plaster-
of-Paris corset for months, just as
if the operation had not ])een done.
The technique of laminectomy is
discussed under Fractures of the
Spine (this article).
Forcible reduction of the deformity
was revived by Calot, but the results
very soon proved disastrous. The
patient is anesthetized, placed face
downward on a firm table, and trac-
tion made on the head and feet either
by assistants or by compound pulleys.
Pressure is then made on the prom-
inent boss until the spine is forced
straight. The patient is then en-
veloped in a plaster-of-Paris jacket,
which extends upward so as to in-
clude the neck and head. A number
of cases of sudden death and more of
death following soon after the oper-
ation have been reported. There is
danger of rupturing abscesses or of
re-exciting inflammation by tearing
apart old adhesions. That nature
can fill the resulting large gaps be-
tween the vertebral bodies with new
bone has still to be shown, and
time will be necessary before this
method can be approved except in
unusual cases. Gradual reduction
by suspension or by horizontal trac-
tion supplemented by backward bend-
ing of the spine without the use of an
anesthetic is more feasible and, which-
ever method is adopted, the spine
must be held in the corrected posi-
tion until it can be so maintained by
the patient, i.e., until the disease is
cured, sometimes a matter of years.
Hibbs's Operation. — This aims to
ankylose the posterior part of the dis-
eased vertebrae with each other and
SPINE, DISEASES AND INJURIES OF (SAYRE).
275
with the healthy skin above and be-
low. A longitudinal incision is made
directly over the spinous processes
through skin, supraspinous ligament,
and periosteum, to the tips of the
spinous processes. The periosteum is
split over both the upper and lower
borders of the spinous processes and
the laminse and stripped back from
them to the base of the transverse
processes. The spinous processes are
then transposed after partial traction
so that they make contact with fresh
bone, the base of each with its own
base and the tips with the base of
the next below. The adjacent edges
of the laminse being absolutely free
from periosteum, a small piece of
bone is elevated from the edges
of the laminse and placed across the
space between them, its free end in
contact with the base bone of the
lamina next below it. The lateral
walls of periosteum and the split
supraspinous ligament are brought
together over these processes by in-
terrupted chromic catgut sutures.
The skin wound is closed by silk and
a steel brace applied with the space
between the uprights increased some-
what at the site of the wound so as
not to make pressure on it. Rest in
bed is absolute from four to eight
weeks. During the next four weeks
sitting up in bed is permitted. At the
end of the twelfth week walking is al-
lowed. The brace is continued for
another month, when it is removed
for a part of each day, then gradu-
ally left off entirely. In children un-
der 5 it should be worn six months.
Albee's Bone Grafts. — Albee has
tried to cut short the time of treat-
ment by transplanting a graft of bone
secured from the crest of the tibia
and long enough to go from the sound
vertebra above to the sound vertebra
below the point of disease. It is im-
portant that this bgne splint should
include periosteum and bone-marrow,
and be thick enough to stand some
strain. An incision is made to one
side of the spine and a skin-flap of
sufficient size to include a couple of
vertebrae above and below the dis-
eased area turned back. Either spinal
process is then split longitudinally
for about one inch from its tip and
on one side, but so as to fracture it,
leaving a g"ap between the two pieces.
The bone-graft is then taken from the
shin, preferably by a circular saw
operated by electricity and devised by
Albee, inserted into the splits, and
held by kangaroo tendon or chromic
gut. If the kyphos is so marked that
the graft cannot be bent, it is partly
cut by the saw at several places on its
lower border and then bent. The skin
wound is then closed. After oper-
ation Albee advises long recumbency
on a convex gaspipe frame, so as to
hold the correction.
In properly selected cases both
these operations are of undoubted
value, but a warning must be given
not to expect to change the time of
treatment of bone tuberculosis from
three years to three months and to
operate in every case.
In 33 cases of tuberculosis operated
at the Mayo clinic by the Albee
method and 6 by the Hibbs method,
the patients on the whole did very
well. The operation, while of great
value, should be considered only an
aid to treatment. All the patients
had been requested to wear the brace
one year after cessation of all symp-
toms, and all hygienic measures for
tuberculous subjects were carried out.
Ijut 2 are going without braces; 1 is
cured and the other much improved.
Most of those examined after 1 year
276
SPINE, DISEASES AXD INJURIES OF (SAYRE).
do not show absolute fixation on flex-
ion of the spine. But all show lack
of muscular spasm and are nearly
well. Henderson (St. Paul Med.
Jour., Oct., 1914).
Success of l»f)ne transplantation by
Albee's operation depends on the
proper implantation of the bone
splint. Essential is a careful protec-
tive after-treatment. Even a period
of six months is much shorter than
the average duration under non-oper-
ative methods. Jacol:)s (Jour. Amer.
Med. Assoc, Jan. 30, 1915).
SCOLIOSIS, OR ROTARY LAT-
ERAL CURVATURE.
This is a most insidious disease,
which offers some of the most diffi-
cult problems of orthopedic surgery.
ETIOLOGY.— The age at which
it appears is usually said to be be-
tween 12 and 14, but in most in-
stances the deformity begins in very
early life, though on account of the
absence of pain it is not detected
until well-marked bone changes have
taken place. In early adolescent life,
moreover, deformities that have re-
mained quiescent for several years
quickly assume marked proportions
due to the rapid increase in stature.
Coincident with this may be "adoles-
cent rickets," a disease well recog-
nized on the continent of Europe.
The softened condition of the bones
then present is responsible, in my
opinion, for the rapid progress made
by some lateral curvatures. Some
observers record instances of lateral
curvature noticed at birth. The
writer has since then seen such cases,
all of which have been complicated
by anomalies in the development of
the skeleton.
The next most frequent cause of
scoliosis is anterior poliomyelitis, and
many such cases are unrecognized
because the extremities have re-
covered so as not to be noticeably
deficient. In some cases of anterior
poliomyelitis certain trunk-muscles
have been damaged to such an ex-
tent as to impair the equilibrium be-
tween the two halves of the body, and
so constitute a constant force work-
ing steadily toward the distortion of
the thorax, which is only overcome
with the utmost difficulty.
In some cases scoliosis arises after
a severe pneumonia, usually with
pleurisy, especially if purulent, the
restriction of the movements of the
thorax on the affected side being re-
sponsible. A number of cases under
observation have convinced the
writer that the German view, that
rotation of the spine fails to accom-
pan}^ this variety of scoliosis, is
erroneous.
Inequality in the length of the legs,
owing to fracture, congenital dislo-
cation, hip disease, and so forth, at
times produces a scoliosis, but, un-
less the leg shortening is due to a
paralysis, such scoliosis can usually
be almost entirely removed by means
of a thick sole on the patient's shoe.
In very rare instances scoliosis fol-
lows traumatism, as in one of my
cases, where a difficult delivery fol-
lowing a transverse presentation
caused separation of the ribs from the
sternum, and later on in life a most
exaggerated rotary lateral curvature.
Sometimes scoliosis which pro-
gresses rapidly during adolescence is
caused by ovarian neuralgia, which
sets up reflex contraction of muscles
causing a deformity that rapidly sub-
sides on relief of the pain. In rare
cases hysterical contractions may
produce a deformity closely resem-
bling scoliosis.
SPINE, DISEASES AND INJURIES OF (SAYRE).
277
There is a class of scoliotics in
which, apparently, none of these
etiological conditions is present. But
the number of such cases grows
smaller the more closely we study
them, and it is my opinion that
rickets or some central nervous le-
sion, analogous to anterior poliomye-
litis, is the true cause of these "idio-
pathic" cases.
Congenital Scoliosis. — The writer di-
vides such, defects into 5 classes: 1.
Developmental hindrances such as
diminished amniotic fluid, the inter-
pressure of twins, etc. 2. Skeletal
malformations, such as spina bifida,
and those due to defective development
or union of the three pulmonary ele-
ments of which each half of the sym-
metrical bilateral trunk is constituted.
3. Variations from the normal, such
as cervical ribs, defective develop-
ment of the lower lumbar vertebra
and sacrum. 4. Bilateral asymmetry
of congenital origin. 5. Defects due
to improper secondary development,
the fetal chest and its high sternum;
perpendicular ribs; chicken breast,
etc. All these fundamental defects
tend to develop or augment as
growth proceeds. Bohm (Berliner
klin. Woch., Oct. 20, 1913).
Diagnosis. — Ln no disease is early
diagnosis more important than in
scoliosis. The clothing should be re-
moved as far as the great trochanters,
the skirts being pinned round the
hips. Time should be allowed to
elapse for the patient to become ac-
customed to her strange surround-
ings, as, at first, she may hold herself
more erect than usual. In the vast
majority of cases the dorsal convex-
ity is right-sided. Normally a plumb
line from the nape of the neck should
pass midway between the scapulae
and through the intergluteal fold,
striking the floor midway between
the feet. If there is anv deviation
from this line, the patient's attitude
is not correct. In the ordinary
scoliosis the. right scapula is far-
ther from the median line than the
left, the right hand hangs farther
away from the hips than the left, and
there is a larger space between the
right elbow and the waist than on
the opposite side. Quite often the
shoulder on the side of the dorsal con-
cavity is found lowered. The hips
very often show an apparent difi^er-
ence in height, the hip on the side
of the concavity appearing to be de-
cidedly the higher. This diiYerence
is usually only apparent, and due to
the sharp deviation of the trunk from
the midline. Inspection from the
front will often show the inequality
of the hips to a greater extent than
when viewed from the back. The
breast on the side of dorsal convexity
is almost always smaller than its fel-
low. There is also, usually, a differ-
ence in their distance from the um-
bilicus, the one on the side of the
dorsal convexity being higher up.
Many cases show a flattening of the
plantar arch, and, at times, have very
pronounced flat-foot. This calls for
treatment, as it is impossible to pre-
serve an erect carriage of the trunk
if the feet upon which it rests are not
in good condition.
The patient should now bend for-
ward, keeping the legs straight, and
letting the hands hang. In this posi-
tion the ribs are better exposed to
view than when the patient is upright,
and small amounts of rotation of the
spine can thus be made out.
Lateral deviation may occin- in
Pott's disease, and at times the de-
formity so closely resembles a true
scoliosis as to deceive even those of
large experience. Muscular spasm.
278
SPINE, DISEASES AND INJURIES OF (SAYRE).
with pain on movement or with ele-
vation of temperature, should cause a
provisional diagnosis of spinal tuber-
culosis. Rest and protection of tlie
spine should be tried and gymnastics
prohibited.
Lateral curvature of spine, with marked
rotation. (7?. H. Sayre.)
Records should be kept of the con-
dition of the patient to judge of the
progress of a case. The age, weight,
height, circumference of the chest,
and length of the limbs certainly
should be noted. A photograph also
should be taken with both front and
rear views and, at times, a profile.
With the patient lying i)rone upon the
floor fjr some hard surface, the con-
tour of the back should be taken at
various points, by means of a flexible
lead tape, and the tracing transferred
to a permanent record. In taking
later tracings or photographs, one
must reproduce as nearly as possible
the original conditions. Otherwise
there is great danger of the physician
deceiving himself in regard to the
progress of the case.
The apparatus of Beely, of Berlin,
and the Zander machine for taking
diagrams of the thorax are very use-
ful methods of recording the results.
Pathology. — Probably the early
changes are in the intervertebral
disks, which become compressed on
one side, and so destroy the erect
spinal posture. Compensating curves
occur in the opposite direction at
those points of the spine remote from
the original curvature, in order to re-
store, as far as possible, the equilib-
rium of the trunk. From the fact
that the spinous processes are united
by the interspinous ligaments, lateral
flexion of the spine is always accom-
panied by more or less rotation of the
vertebrae on themselves, and this is
the most difficult factor with which
we are called upon to deal.
In the more advanced cases of
scoliosis the deformity involves the
entire vertebras. The bodies of the
vertebrae show unequal development
of their two component halves, and
the spinous processes bend to one
side or the other, according to the
curve. The bodies are often wedge-
shaped, one side being twice the
height of the other, and not infre-
quently large osteophytes are thrown
out which at times firmly join several
SPINE, DISEASES AND INJURIES OF (SAYRE).
279
vertebrae together, producing an anky-
losis or encroaching on the interverte-
bral foramina, causing painful neu-
ralgias.
In these cases the ribs also par-
ticipate, their angles on the side of the
convexity being accentuated, while
the ribs themselves often droop so far
toward the pelvis as to pass inside of
its brim. The ribs may occasionally
overlap each other, giving rise to
great pain, and even to periostitis.
Not infrequently these bone
changes extend to the pelvis itself,
and in many cases the typical rachitic
pelvis is readily distinguished.
The rotation of the front part of
the body of the vertebrse is toward
the side on which the convexity
exists, and may be so great that a
line through the spine and body
of a cervical vertebra may be paral-
lel with one through the fifth lum-
bar, and yet at right angles to one
through the middorsal region.
Skiagraphs of the spine are now
often taken in incipient scoliosis, and
many skeletal anomalies have thus
been discovered, which often are the
real fundamental cause of the de-
formity, by throwing the l)ody
slightly out of balance early in life.
Treatment. — This consists, first, in
removing any defect which predis-
poses toward a scoliosis. If the case
be one due to paralysis, and the pa-
tient is unable to hold the body up-
right, artificial means must be em-
ployed to maintain it in an erect
position. The same is true in some
rachitic cases. The most important
point in treatment is to detect the
lateral curvature very early and to
prevent bony deformity, rather than
to remove the latter after it has
become marked.
If the patient is distorted to any
appreciable extent, force must be
used to press the bones back toward
the straight line as far as possible.
In doing this, both longitudinal trac-
tion and rotation are necessary. The
Lateral curvature of spine, with marked
rotation. (R. IT. Sayrc.)
most convenient method of employing
longitudinal traction is for the patient
to suspend herself partially by means
of a head-collar fastened to a cross-
bar and hanging from a beam by a
compound pulley, the end of the
pulley-rope being held by the patient,
280
SPINE, DISEASES AND INJURIES OF (SAYRE).
who, keeping her arms extended to
their fullest extent, lifts herself by
deg^rees, hand over hand, until her
heels are clear of the floor, thus sus-
pending- almost the entire weight of
the body on her head and arms. The
Palm of hand against projecting ribs and hand
of hollow side across top of head. Endeavors
to bulge out hollow side. (R. H. Sayrc)
hips should now be grasped, either in
a clamp or between the surgeon's
knees, and the trunk twisted around
its longitudinal axis, so as to reduce
the deformity. In some cases the pa-
tient is laid prone on a firm couch.
The surgeon then presses with great
force on the projecting ribs, endeavor-
ino- to force them toward the normal.
The pressure is directed so as to ro-
tate the vertebrae around the longitu-
dinal axis in the proper direction,
mere lateral pressure against the side
tending to increase rather than de-
crease the angular rib deformity.
If the patient bends forward, plac-
ing the hands on the knees as if play-
ing leap-frog, it will be found that the
hollow side can be straightened by
these voluntary efforts of the patient.
These efforts, however, last but a
minute fraction of the day.
Abbott's Method. — Abbott, of Port-
land, Me., has taken advantage of the
increased mobility of the spinal col-
umn when in this flexed position to
applv constant force by means of a
plaster-of-Paris jacket.
The patient is placed in a position
of marked flexion, and by means of
bandages passing around the trvmk
the thorax is untwisted as far as pos-
sible, and the plaster-of-Paris jacket
applied in this position. Thick felt
pads are applied outside the skin-
fitting shirt, at all points liable to
have undue pressure exerted on them,
and when the jacket is hard a window
is cut out over the concave ribs. An-
other slit is then cut in front and pads
pulled between the jacket and the
patient, so as to make still more
pressure on the front of the thorax.
The patient's efforts at respiration
thus cause the hollow ribs to bulge
out through the window cut in the
jacket, and his efforts to get away
from the pressure in the front tend to
rotate the spine on its long axis all
the day long instead of during the
few minutes devoted to exercise by
the former method.
SPINE, DISEASES AND INJURIES OF (SAYRE).
281
Abbott applies his jacket with the
patient suspended, back down, in a
sort of hammock, the feet being
fastened to a pulley high above the
head and suspended from a frame.
The arms are twisted so as to rotate
the spine and untwist the curve.
Others apply the jacket with the pa-
tient seated and bent forward with
the hands holding the sides of an up-
right frame. The principle is always
corrected, but overcorrected, and a
deformity on the opposite side
caused.
After this has taken place a remov-
able corset should be made which the
patient wears all the time, removing
it morning and night for the purpose
of exercising. Later on, the corset
may be removed at nigiit.
A case is not cured until the patient
can voluntarily hold the spine straight
Method of making pressure on projecting ribs to correct rotation in lateral
curvature of the spine. (R. H. Sayrc.)
to secure marked flexion, of the spine,
and in this position seek to unrotate
the vertebrae, making pressure against
projecting points and cutting win-
dows through which the concave ribs
may project in response to pressure
from within the thorax.
Such a corrective jacket should be
renewed in six weeks, the padding
being changed once or twice a week,
according to the amount of change.
Efforts are made to untwist the
spine until the deformity is not only
without support, and until the twisted
bones have become straight, as other-
wise the spine will relapse when sup-
l)ort is removed.
Report of Committee of the Ameri-
can Orthopedic Association to in-
vestigate the results of tlic treatment
of scoliosis by the newer methods:
1. Overcorrection of the deformity is
apparently possible I13' means of Ab-
bott's method in cases of moderate
severity and perhaps occasionally in
severe cases. 2. If sufficient overcor-
rection is not secured or is not main-
tained long enough, partial or com-
282
SPINE, DISEASES AND INJURIES OF (SAYRE).
plete relapse usually follows rather
rapidlj'. 3. The period of retention
in overcorrection necessary for a
cure is longer than formerly claimed.
4. Abbott's method has apparently
given better results in his own hands
than in others. Freiberg, Silver, and
standing, hands on hips, patient endeavors to
bulge out the hollow side and simultaneously
to untwist the rotation. {R. H. Sayre.)
Osgood (Trans. Amer. Orthop. As-
soc, 1913).
Since many cases of scoliosis occur
in persons distinctly rachitic or show-
ing symptoms of hypothyroidism,
thyroid extract was tried, with pro-
nounced success. It may be used
also in other cases, and likewise ex-
tracts from other endocrine glands.
Properly fitted braces .should be used,
and supplemented by exaggerated body
flexion over a curved frame and rotary
traction. Peckham (Jour. Am. Med.
As.soc., Oct. 13, 1917).
In ordinary cases, where a plaster
jacket is necessary, it is most readily
applied in the upright position.
In applying plaster-of-Paris ban-
dages in cases of lateral curvatuyc, a
shirt of double length is used, pads
are placed inside the shirt over the
mammae and outside the shirt over
the iliac crests, and a strip of tin two
inches wide is placed next the skin
from sternum to pubes, on which to
cut the plaster; the patient suspends
herself, pulling on the free end of the
rope which passes from the head-
swing over the pulley, while she keeps
the arms outstretched, the upper hand
being on the concave side. The sur-
geon, sitting behind, applies ban-
dages as in Pott's disease. When the
plaster is set, which should be the
case by the time the corset is fin-
ished, it is split open down the front
and removed while the patient is still
suspended. A thin slice is then taken
from each edge of the slit and the cor-
set held together with a roller ban-
dage and dried. When dry, the next
day, it is put on the patient while
again self-suspended, and fastened
with a roller bandage; then trimmed
out under the arms and above the
thighs until comfortable, and re-
moved. The extra length of shirt is
then reversed over the jacket and
sewed to itself, covering in all the
plaster, and lacings are sewed on in
front. The latter are sewed through
and through the plaster of Paris, a
shoemaker's awl being used to make
the holes. If the patient is very
heavy it is well to reinforce the edges
SPINE, DISEASES AND INJURIES OF (SAYRE).
283
of the corset under the leather which
holds the hooks.
Plaster-of-Paris jackets should not
be covered with shellac or varnish,
as it renders them impervious and
makes them hot and unhealthy.
If the case is very badly deformed,
it is expedient to put padding inside
of the shirt when it is reversed, in
order to make the corset as sym-
metrical as possible, and thus avoid
the necessity of padding the clothes.
The corset having been made while
the patient is stretched out, it should
always be applied to the patient in
this position. For this purpose, the
patient is provided with a pulley-
wheel and head-swing at home, by
which she can suspend herself in the
morning, while the corset is applied
by some member of the family, and
retained in position by lacings joining
the hooks on the front of the jacket.
The lacing should pass first around
the two central hooks at the waist,
and then run down to the bottom, be
reversed, and pass up again to the top.
It is a mistake to cut a corset down
in two places ; neither should it be
made so stiff as to be unremovable
unless thus cut.
If support is to be used, a plaster-
of-Paris jacket is the most useful, in
my experience. The various forms of
elastic supporting braces fail to ac-
complish their purpose.
If a patient requires a permanent
support on account of z'cry marked
deformity or paralysis, a wood jacket
is lighter, though hotter, than one
made of plaster of Paris. The wire
corset is cooler than the wood, but
not so light, and both require much
more time and trouble tO' make. The
same is also true of the aluminum
corset, while celluloid forms a very
pretty support, but one so hot as
rarely to be .endured.
The key to success in all cases of
lateral curvature, however, lies in de-
veloping the patient's own ability to
hold the body in as improved a posi-
After forcible correction with plaster-oi-Paris
jacket and gymnastics. (R. II. Sayre.)
tiun as possiljle. To be effective,
exercise must be so carried on that
the patient learns instinctively to
help herself at all times during the
twenty-four hours, and not merely to
preserve an erect carriage while in the
doctor's office. Any system which
284
SPINE, DISEASES AND INJURIES ()¥ (SAYRE).
fails to arouse the patient's desire to
improve as far as possi])le by con-
stant effort will fall short in its
results.
The following set of exercises will
be found useful for most cases : —
While self-suspension, in the man-
After forcible correction with plaster-of-Paris
jacket and gymnastics. (R. II. Sayre.)
ner indicated, is a most useful pro-
cedure, it is not practicable for a long
period of time; and it is wise to sup-
plement it by suspension by means of
a weight and pulley attached to a
chin-piece, which is fastened to the
patient's head while she lies on her
back on an inclined plane which is
slightly convex.
In correcting the rotation the pa-
tient sliould be placed face down-
ward up(jn the floor or a firm table
covered with a thick rug, while the
physician makes strong pressure upon
the projecting scapula, pushing in a
direction forward and away from the
central line of the body, so as to ro-
tate the vertebrae toward the median
line. In some cases the patient is al-
lowed to lie for half an hour in this
position with a sand-bag weighing
twenty or thirty pounds resting upon
the shoulder if it can be placed so
that the weight is exerted properly.
In beginning the exercises a mat
or thick shawl is laid on the floor and
the patient lies prone, the arms at
right angles with the trunk, palms
down, face turned to the convex side,
and the back as straight as possible.
The patient supinates the hands,
throws the scapulae well back, raises
the hands from the floor and lifts the
trunk, while the surgeon holds the
feet down. This is repeated three
times ; later on it can be done oftener.
The patient should breathe naturally
during the exercises. If necessary,
to secure this make her count aloud.
With the hands behind the head,
the patient raises the elbows from the
floor, and raises the trunk as before,
the feet being held by the surgeon.
With the hands behind the head
and the elbows raised, the body is
swayed toward the convex side, the
patient trying to "pucker in" the
bulging ribs and not to bend in the
lumbar concavity. The feet are fixed.
With the arm on the side of the
convexity under the body, the other
arm over the head, the heels fixed, the
patient raises the trunk from the floor.
Sometimes the arm on the side of
the concavity is put on the opposite
buttock, while the patient raises the
SPINE, DISEASES AND INJURIES OF (SAYRE).
285
trunk. Sometimes the arm on the
convex side is put on the buttock, and
in cases of marked lordosis, with
great stooping- of the shoulders, both
hands are put on the buttocks while
the patient raises the trunk.
The patient now lies on the back,
arms at the sides, palms up, and lifts
first one foot in the air, while the
surgeon makes resistance ; repeated
five times. The same is done with the
other foot, and then with both. The
feet are next separated and then
brought together once more while the
surgeon resists. Each leg then de-
scribes a circle, first from within out,
then from without in.
If there is special weakness at the
ankles, with a tendency to flat-foot,
the patient flexes the foot and extends
it against resistance, and turns the
sole of the foot toward its neighbor,
the surgeon resisting; and it is then
forcibly everted again by the surgeon,
the patient resisting.
The patient now lifts the arms from
the sides, passing perpendicularly to
the floor until they are stretched as
far beyond the head as possible, and
then, going at right angles to the
trunk and parallel with the floor, re-
turns them to the sides, palms up.
When the heels are held, the pa-
tient rises to the sitting position,
hands at the sides; then she rises
from the floor with the hands behind
the head and the elbows at right
angles to the trunk.
The patient now stands with the
heels together, toes turned slightly
out, hands behind the head, elbows at
right angles to the trunk ; then rises
on tip-toe, bends the knees and hips,
keeping the back as straight and erect
as possible, and rises up once more.
With the arm on the concave side
above the head, the arm on the con-
vex side at right angles to the body,
she rises on tip-toe, bends the hips,
knees, and ankles, so as to squat,
then rises and stands. All this time
care must be taken to push the body
as straight as possible, and grad-
ually to educate the patient to hold
it so without wrigg-ling.
Let the patient practise walking in
these positions, both on the flat-foot
and tip-toe, and also stepping high, as
if walking upstairs. With the palm of
the patient's hand on the convex side
against the ribs, pushing them in, the
other hand on the concave side, she
pushes a slight weight up in the air,
while the body swings so as to
straighten out the curves.
The surgeon should sit behind the
patient, fix her thighs with his knees,
while she holds both arms above the
head and bows toward the floor, keep-
ing her knees stifle while the surgeon
keeps her ribs as straight as possible
with his hands.
With the arm on the concave side
across the top of the head, and the
arm on the convex side around in
front of the abdomen, the patient
bends to the convex side through the
ribs and not through the waist.
The patient sitting with the back
toward the surgeon, the latter pushes
one hand against the most projecting
part of the convexity, and, with the
other hand passed under the shoulder
of the concave side, straightens out
the curve as much as possible, the
hand on the "bulge" acting as
fulcrum.
The patient sits on a stool in front
of the surgeon, who fixes the pelvis
with his knees. The patient then
twists the projecting shoulder to the
front while the surgeon holds the el-
286
SPINE, DISEASES AND INJURIES OF (SAYRE).
bows, which are at rig-ht angles to the
trunk, the hands being behind the
head, and makes resistance. In the
same position the patient swings for-
ward and back, swinging through the
liips, keeping the back stiff and not
bending in the waist.
The patient pushes in the ribs on
the convex side with the hand, and
pushes up with the hand on the con-
cave side, the same as when stand-
incf. She also lifts the arm on the
concave side up at right angles with
the body while holding a weight.
In cases of round shoulders, wind-
mill motions of both arms and to-and-
fro movements of the head against
resistance are advisable.
The patient lies prone on the
couch, all the body above the waist
projecting from it, while the surgeon
holds the heels. With the hands be-
hind the head, the elbows thrown
back, the body is bent toward the
floor, then raised up ; later on, re-
sistance is made by the surgeon.
The patient lies on the concave side
and rises up laterally. The patient
lies with the convexity on the edge
of the couch, and hands off as far and
as long as possible.
The patient stands bent forward as
if playing leap-frog, her hands on a
chair, wdiile the surgeon, with one
hand under the shoulder on the con-
vex side and one hand on the project-
ing ribs, corrects the rotation. It is
advisable to steady the patient with
the knee while doing this.
SPONDYLITIS DEFORMANS;
BECHTEREW'S DISEASE.
This condition is an osteoarthritis
of the spine, due to ankylosis of the
vertebrae. It is due to osteophytic
formations usually located on the
edges of the latter, but it may affect
any part of the vertebrae and involve
the heads of the ribs connected with
them. It may occur at any age.
Symptoms. — It usually begins by
tenderness of the spine, followed by
severe and persistent pain due to in-
flammation and often to pressure
upon the nerve-roots. This is fol-
lowed, in most cases, by bending of
the spinal column anteriorly, but the
curvature may also be lateral and re-
main ankylosed in this position, the
pain continuing if the nerve-roots are
compressed. When the entire spine
is involved, cervicodorsal kyphosis
results, the head being projected for-
ward and held in stiflly in that posi-
tion and the lumbar spine being also
rigid.
Treatment. — If recognized early
this condition may be greatly bene-
fited by treatment for Arthritis De-
formans (see sixth volume, p. 109).
Personal case in a man of 46 years
with ankylosis of the whole spine,
both hips, the right knee, both should-
ers and the right elbow. There are
but 35 or 40 cases on record. They
appear to be due to chronic infection.
Baths, electricity, and potassium
iodide might be tried. VVenzel
(Miinch. med. Woch., May 12, 1914).
SPINAL LOCALIZATION.
It must be recollected that spinal
nerves do not issue from the spinal
canal directly opposite the segment
from which they arise, but lower
down> the distance below becoming
greater the lower down the spine the
injury is located.
We judge of the location of a cord
injury first by the motor paralysis;
second, by the cutaneous anesthesia ;
.and, third, by the reflexes.
In the accompanying table from
Keen are shown the various spinal
SPINE, DISEASES AND INJURIES OF (SAYRE).
287
segments, the muscles innervated by
each, and the part of the body sup-
plied by sensation, as well as the re-
flexes (next page).
TUMORS OF THE SPINAL
CORD.
These tumors may be extradural or
intradural. There have been reported
lipoma, osteoma, fibroma, sarcoma,
myxoma, psammoma, carcinoma, tu-
bercle, parasitic cysts, callus from old
fracture, and connective-tissue forma-
tions. Gummata are usually capable
of removal by constitutional treat-
ment. Carcinoma is usually second-
ary and inoperable.
SYMPTOMS. — These vary with
the location of the tumor; they are
pain, motor paralysis, and sensory
paralysis.
Pain is usually the earliest symp-
tom and is often mistaken for rheu-
matism, but should be differentiated
from this by not afifecting various
joints, and by its gradual onset.
Muscular spasm is frequent, together
with anesthesia on the side opposite
the tumor, while hyperesthesia exists
on the same side, with ataxia, motor
paralysis, and exaggerated reflexes on
account of the fact that the motor and
sensory fibers of the cord cross at dif-
ferent levels. The pain is referred to
a level below the tumor, and care
should be taken to explore the cord
higher up than the tumor was sup-
posed to exist in case it is not dis-
covered at this point. There is apt to
be rigidity of the spine partly from
pain and partly from muscle-spasm.
Paralysis may be caused by pres-
sure simply or from myelitis, hemor-
rhage into the cord, or infiltration of
the tumor, and is usually gradual in
its onset. Motor paralysis progresses
from above downward, while the pa-
ralysis of sensation begins at the feet
and ascends. The reflexes are exag-
gerated at the outset and diminish
later on. Retention and incontinence
of urine occur, with cystitis, rectal
paralysis, bed-sores, and the usual
chain of cord symptoms.
DIAGNOSIS.— This is based on
cord involvement with the exclusion
of other cord diseases, the site being
diagnosticated by means of the symp-
toms exhibited by various parts of the
body, keeping always in mind the pos-
sibility of the tumor being multiple.
TREATMENT.— Except in the
case of gummata, the prognosis is
fatal without operation, and the lat-
ter should thereforei be undertaken
unless the condition of the patient is
such as to render it hopeless.
SACROCOCCYGEAL AND SA-
CROANAL TUMORS.
This region is occasionally thei seat
of dermoids ; but these growths may
also form between the sacrum and
the rectum. Again, the cutaneous
structures sometimes fail to coalesce
in the sacral, or coccygeal region and
a post-anal dimple or sinus, the latter
lined with skin and sometimes glands
and hairs, is formed. Such a sinus
may suppurate or become blocked up
and form a dermoid cyst. The sacro-
coccygeal region may also be the seat
of hydatid cysts, lipomata, and tera-
tomata. Cysts, both unilocular and
multilocular, may also develop be-
tween the sacrum and the rectum
from remnants of the post-anal gut
and neurenteric canal. They arc
readily detected by digital palpation.
Treatment. — Sacrococcygeal der-
moids, lipomata, and hydatids should
1)e extirpated ; teratoniata likewise if
288
SPIXE. DISEASES AND INJURIES OF (SAYRE).
Localization of the Functions of the Segments of the Spinal Cord. (Keen.)
SEGMENT.
Second
and
third
Cervical.
muscles.
Fourth
Cervical.
Fifth
Cervical.
Sixth
Cervical.
Seventh
Cervical.
Eighth
Cervical.
i
First
Dorsal.
Stcrnomastoid.
Trapezius.
Scaleni and neck.
Diaphragm.
Diaphragm.
Deltoid.
Biceps.
Coracobrachialis.
Supinator longus.
Rhomboid.
Supraspinatus and infra-
spinatus.
Deltoid.
Biceps.
Coracobrachialis.
Brachialis anticus.
Supinator longus.
Supinator brevis.
Deep muscles of shoul-
der-blade.
Rhomboid.
Teres minor.
Pectoralis (clavicular
part).
Serratus magnus.
Biceps.
Brachialis anticus.
Subscapular.
Pectoralis (clavicular
part).
Serratus magnus.
. Triceps.
Extensors of wrist and
fingers.
. Pronators.
Triceps (long head).
Extensors of wrist and
fingers.
Pronators of wrist.
Flexors of wrist.
Subscapular.
Pectoralis (costal part).
Serratus magnus.
Latissimus dorsi.
Teres major.
Triceps (long head).
Flexors of wrist and
fingers.
Intrinsic hand-muscles.
Extensors of thumb.
Intrinsic hand-muscles.
Thenar and hypothenar
muscles.
reflex.
Hypochondrhim? (third
to fourth cervical).
Sudden inspiration
produced by sudden
pressure beneath the
lower border of ribs.
Pupillary (fourth cervi-
cal to second dorsal).
Dilatation of the pupil
produced by irritation
of the neck.
Scapular (fifth cervical
to first dorsal). Irri-
tation of skin over tlie
scapula produces con-
traction of scapular
muscles.
Supinator longus (fourth
to fifth cervical). Tap-
ping the tendon of the
supinator longus pro-
duces flexion of fore-
arm.
Triceps (sixth to seventh
cervical). Tapping el-
bow-tendon produces
extension of forearm.
Posterior wrist (sixth
to eighth cervical).
Tapping tendons causes
extension of hand.
Anterior wrist (seventh
to eighth cervical).
Tapping anterior ten-
don causes flexion of
hand.
Palmar (seventh cervical
to first dorsal). Strok-
ing palm causes clos-
ure of fingers.
sensation.
Back of neck and of
head to vertex. (Oc-
cipitalis major and
minor, auricularis mag-
nus, supcrficialis colli,
and supraclavicular.)
Neck. Shoulder, ante-
rior surface. Outer
arm. (Supraclavicular
circumflex, musculo-
cutaneous, or external
cutaneous.)
Back of shoulder and
arm. Outer side of
arm and forearm to
wrist. (Supraclavicu-
lar circumflex, musculo-
cutaneous, or external
cutaneous, internal cu-
taneous, radial.)
Outer side and front of
forearm. Back of
hand, radial distribu-
tion. (Chiefly mus-
culocutaneous, or ex-
ternal cutaneous, inter-
nal cutaneous.)
Radial distribution in
hand. Median distri-
bution in palm, thumb,
index, and one-half
middle finger. (Mus-
culocutaneous, or ex-
ternal cutaneous, inter-
nal cutaneous, radial,
median.)
Ulnar area of hand,
back, and palm. In-
ner border of forearm.
(Internal cutaneous,
ulnar. )
Chiefly inner side of
forearm and arm to
near axilla. (Chiefly
internal cutaneous and
nerve of Wrisberg or
lesser internal cuta-
neous.)
SPINE, DISEASES AND INJURIES OF (SAYRE).
289
Localization of the Functions^ of the Segments of the Spinal Cord. (Concluded.)
SEGMENT. MUSCLES. REFLEX.
Second
Dorsal.
I
SENSATION.
Inner side of arm near
and in axilla. (Inter-
costohumeral.)
Second
to
twelfth
Dorsal.
Muscles of back and ab-
domen.
Erectores spina.
Epigastric (fourth to
seventh dorsal). Tick-
ling mammary region
causes retraction of the
epigastrium.
Abdo)iiinal (seventh to
eleventh dorsal).
Stroking side of ab-
domen causes retrac-
tion of belly.
Skin of chest and abdo-
men in bands running
around and downward,
corresponding to spinal
nerves upper gluteal
region. (Intercostals
and dorsal posterior
nerves.)
First
Lumbar.
Second
Lumbar.
I Ilio-psoas.
-{ Rectus.
I Sartorius.
I
f
Ilio-psoas.
Sartorius.
Quadriceps femoris.
Cremasteric (first to
third lumbar). Strok-
ing inner side of thigh
causes retraction of
testicle.
Skin over groin and
front of scrotum. (Ilio-
hypogastric, ilioingui-
nal.)
Outer side of thigh.
(Genitocrural, exter-
nal cutaneous.)
Third
Lumbar.
Quadriceps femoris.
Anterior pairt of biceps.
Inward rotators of thigh.
^ Abductors of thigh.
Patellar (third to fourth
lumbar). Striking pa-
tellar tendon causes
extension of leg.
Front of thigh. (Middle
cutaneous, internal cu-
taneous, long saphe-
nous, obturator.)
Fourth
Lumbar.
f Abductors of thigh.
I Adductors of thigh.
-! Flexors of knee,
j Tibialis "anticus.
t Peroneus longus.
Gluteal (fourth to fifth
lumbar ) . Stroking
buttock causes dim-
pling in fold of but-
tock.
Inner side of thigh, leg,
and foot. (Internal
cutaneous, long saphe-
nous, obturator.)
Fifth
Lumbar.
Outward rotators of
thigh.
Flexors of knee.
Flexors of ankle.
Peronei.
Extensors of toes.
Achilles tendon (fifth
lumbar to first sacral).
Overextension causes
rapid flexion of ankle,
called ankle-clonus.
Back and outer side of
leg; dorsum of foot.
(External popliteal, ex-
ternal saphenous, mus-
culocutaneous, plan-
tar.)
First
and
second
Sacral.
Flexors of ankle.
Extensors of ankle.
I Long flexor of toes.
Intrinsic foot-
L
muscles.
Plantar (fifth lumbar to
second sacral). Tick-
ling sole of foot causes
flexion of toes and re-
traction of leg.
Back and outer side of
leg, sole, dorsum of
foot. (Same as fifth
lumbar.)
Third,
fourth,
and
fifth
Sacral.
f Gluteus maximus.
I Perineal.
J Muscles of bladder, rec-
tum, and external geni-
tals.
Vesical centers.
Anal centers.
Back of thighs, anus,
perineum, external
genitals. (Small sci-
atic, pudic, inferior
hemorrhoidal, inferior
pudic.)
Fifth
Sacral
and
Coccyg-
eal.
r
I
-j Coccygeus muscte.
8—19
Skin about the aims and
coccyx. (Coccygeal.)
290
SPINE, DISEASES AND INJURIES OF (SAYRE).
possible. A postanal dimple should
only be removed if it causes trouble.
Some anosacral cysts can l)e removed
throug-h the rectal wall, but others
require a preliminary osteoplastic re-
section of a portion of the sacrum.
CONGENITAL DEFORMITIES
OF THE SPINE.
MYELOCELE OR RACHISCHI-
SIS. — Myelocele .is the result of de-
ficient formation of the vertebral
arches. The medullary plates fail to
coalesce and the cord is rudimentary.
The central canal not having formed,
the endothelium which should line it
is exposed. Only a part of the cord
may be involved — partial rachischisis.
These subjects are either stillborn or
die a few days after birth.
SPINA BIFIDA.— Spina bifida is a
congenital malformation of the spine
analogous to and often associated
with harelip, cleft palate, and bifid
uvula, which is due to defective de-
velopment of the ovum. A vertebra
develops from four primary centers :
two for the body, which made their
appearance at the eighth week, and
one for each lamina, appearing at
the sixth week. If the laminae fail to
unite in the median line, the cord
and its membranes may protrude,
forming a tumor on the back. Veiy
rarely there is failure of union of the
two halves of the body of a vertebra,
an interior spina bifida resulting.
The gap caused by the failure of
the laminae to unite may be small and
confined to one vertebra, or may in-
volve almost the entire width of the
laminae and extend the entire length
of the spinal column.
Now and then there is a defect in
one or more vertebrae without pro-
trusion of the membranes or cord,
— spina bifida occulta, — with no tumor
to be seen. The existence of this
condition should be suspected in per-
sons with cong-enital disturbances of
function of the lower limbs, espe-
cially with imperfect sphincter con-
trol. If there is a hairy patch on the
spine, the probabilities of a spina
bifida occulta are much increased.
In the ordinary spina bifida the
contents of the spinal canal form a
tumor in the median line of the back
which may vary in size from a hardly
appreciable button to a mass as large
as a foot-ball. At times there is a
constricted base and pedicle; or, the
tumor may lie flat on the back. This
tumor may be covered with tough,
thick skin ; but usually from, internal
pressure it is changed to a thin,
translucent envelope through which
the contents of the sac are visible.
The fluid filling the sac is the same in
character as the cerebrospinal fluid.
Often spina bifida is associated with
hydrocephalus ; upon pressure on the
tumor a sense of fullness may be
communicated to the fingers held
against the anterior fontanelle. The
child's head may also swell when it
is laid down and the spinal tumor
grow larger when the child is placed
upright.
There are three recognized classes
of spina bifida. If the cord mem-
branes alone protrude, the tumor is
called a meningocele. Should both
the membranes and the cord, with
its appertaining nerves, protrude, we
have a meningomyelocele. Should the
central canal of the cord become dis-
tended with fluid and push before
it both membranes and cord, we have
a syringomyelocele, or a condition
known as syringomyelia.
It is by no means easy to recognize
SPINE, DISEASES AND INJURIES OF (SAYRE). 291
the kind of tumor present except in vulsions, viz., iodine, gr. x (0.65
the rare cases where the sac is so Gm.) ; potassium iodide, gr. xxx (2
thin that the outlines of the nerves Gm.) ; and glycerin, {%] (30 c.c).
can be made out. Failure to see With an hypodermic needle passed
these, however, by no means proves through the healthy skin into the sac
that they are absent; but if there is a half-dram (2 c.c.) or so of fluid is
marked involvement of the sphinc- drawn off and an equal amount of the
ters, with paralysis and atrophy of iodoglycerin fluid injected. Pressure
the lower extremities, it is almost is applied during the operation to
certain that the case is a meningo- prevent, if possible, the fluid from
myelocele, entering the spinal canal. The punc-
Prognosis. — This varies. At times ture is then covered with collodion
the tumor is small and the general and cotton and gentle pressure made
condition good ; at others there is a on the sac. In a few days, if all
large defect, the tumor is enormous, symptoms of irritation have subsided,
the lower extremities are paralyzed, the injection may be repeated. Bet-
there is little or no sphincter control, ter results have apparently attended
and frequently intelligence is almost the injection of Morton's fluid than
lacking. Some of these very bad any other method of treatment. On
cases fortunately die soon after birth, the other hand, in consequence of
Treatment. — If the tumor is small greater familiarity with radical oper-
and covered by strong skin, it may ation and knowledge of how to avoid
in time diminish in size, and nothing suppuration the recent statistics of
be required but protection from trau- excision show great improvement,
matism by a shield of metal or eel- and there is no question that in many
luloid. If the skin is thin, painting it cases this is the procedure to be pre-
frequently with tannin collodion ferred and in some the only possible
serves to thicken and toughen it. one.
In case the child does not improve Technique of Excision of the Sac.
in the control of its muscles, or if — The child is placed with the head
the skin covering the sac grows so lower than the tumor to avoid the too
thin as to threaten rupture, operative sudden escape of cerebrospinal fluid,
interference should be tried. This Incisions are made to include the
may consist either in aspirating the skin covering the sac. If the latter
fluid and injecting something to cause have a small pedicle it may be ligated.
contraction of the sac or in excising If the sac have a wide base it should
the sac and closing the gap as well as be opened and removed, enough of it
possible. being left to cover the opening with-
in 1848 Brainard, of Chicago, re- out tension. If nerve-fibers on the
ported a series of cases in which he inside of the sac can be separated
had successfullv injected a watery from the sac with ease they should
solution of iodine and potassium be so separated and returned to the
iodide. Later on Morton advocated spinal canal. If, however, they are
the use of an injection less apt than too intimately adherent, no effort
either water or alcohol to ])crmeate should be made to save them. After
the cerebrospinal fluid and cause con- closing the membranes efforts should
292
SPINE, DISEASES AND INJURIES OF (SAYRE).
be made to close the gap in the
bones. To effect this, the periosteum
from the side of the canal has been
dissected up and brought across as a
flap and stitched to a similar flap of
periosteum raised from the opposite
side of the spinal canal. Flaps of
bone have been chiseled from the
ilium or sacrum when the defect is
Spina bifida and hydrocephalus.
low down or from the transverse pro-
cesses when it is higher up, and these
flaps turned over, like hinges, and
sewed to others taken in a similar
manner from the opposite side, the
periosteal surfaces being turned to-
ward the cord.
In the dorsal region flaps have been
taken from the adjacent ribs and
pushed through the erector-spin?e
muscles and sutured to flaps from the
other side. Portions of the scapula of
the rabbit have been employed to
cover the gap in the bone and flaps of
the periosteum of a rabbit's scapula
have been sewed to the periosteum
on the edges of the gap. Plates of
celluloid have been used. At times
the gap is so extensive that no efforts
to repair it are made, and in any case
the operation is completed by joining
Club-foot, associated with hydrocephalus
and spina bifida.
skin flaps in the median line. If the
tumor has had a very broad base and
the skin has been very thin it may be
necessary to slide the skin from both
sides of the trunk in order to make
the flaps meet.
The effort should be made, as far
as possible, to sew together the
various tissues covering the spinal
canal, each to its fellow in their own
proper relation. The causes of mor-
tality in the past have been shock
SPINE, DISEASES AND INJURIES OF (SAYRE).
293
and convulsions due to loss of cere-
brospinal fluid, the patient's head
not having been kept lowered, and
septic meningitis from faulty tech-
nique.
In hydrocephalus it has been pro-
posed to drain off the cerebrospinal
fluid by tapping through the spinal
column instead of by way of the orbit
or anterior fontanelle. The needle
should be introduced in the median
line between the sacrum and the last
lumbar veretebra. It may, however,
be introduced between the fourth and
fifth or third and fourth lumbar
vertebrae — not higher.
This same treatment has been tried
in cases that seemed to be tuberculous
meningitis, survival following.
Parkin proposes to trephine the oc-
cipital bone and so gain access to the
subarachnoid space and by aspiration
relieve the intracranial pressure. The
prognosis without operation is so
universally fatal that the occasional
successes that have followed these
procedures render them worthy of
trial.
WOUNDS AND INJURIES OF
THE SPINE.
GUNSHOT AND PUNCTURED
WOUNDS.— Bullet wounds of the
spine are not necessarily fatal, and
whether or not the l:)ullet should be
removed will depend largely upon its
location. The X-ray here serves use-
fully, pictures being taken in two
diameters of the body, or, preferably,
with copper points superimposed on
the trunk, so that the actual distance
of the bullet from the surface of the
body may be accurately determined.
An accessible bullet should be re-
moved. It may, however, he so
placed as to make such a proceeding
most hazardous, and, unless the
wound of entrance is already in-
fected, it is well, in such cases, not
to interfere. In any surgical interfer-
ence, the strictest cleanliness must,
of course, be observed. Girdner's
telephonic probe may be used in ex-
ploring for the bullet.
The concussion of modern high-
velocity projectiles causes, at times, a
temporary paralysis, even when the
wound is insignificant. But this soon
passes off if the cord is uninjured.
// the cord is compressed by frag-
ments of bone or blood, or the bidlet,
it should be freed from pressure by
operation. // the bidlet has passed
through the body but injured the cord
in transit, it is proper to operate if the
symptoms do not improve in a few
days, as they may be due to pressure
that could be relieved by operation.
Stab wounds of the spine are unim-
portant unless the blade passes be-
tween vertebrae, when it may divide
the spinal cord or cause hemorrhage,
either fatal in itself or causing such
secondary compression of the cord as
to induce paralysis. In the latter
case it is possible for the hemorrhage
to cease spontaneously, and, later, for
the effused blood to be absorbed, and
paralysis gradually diminish. A fea-
ture emphasized by the European
War is, if the spinal cord is involved,
to avoid infection of the bladder and
bed-sores.
The European War has afforded
vast opportunities for the study of in-
juries of the nervous system, such
constituting about one-sixth of all
severe wounds. The brain is repre-
sented by about 25 per cent., the
spinal cord 10 per cent., and the
peripheral nervous system about 65
per cent., in the total of nervous
injuries. Spinal cord injuries offer
294
SPINE, DISEASES AND INJURIES OF (SAYRE).
but little opportunity for operative
work. Where there is complete sec-
tion of the cord the prognosis is ab-
solutely unfavorable; partial cord in-
juries offer certain chances without
operation. Lewandowsky (Berlin,
klin. Woch., vol. li, p. 1929, 1914).
In traumatic cases, removal of de-
pressed bone or metal will do noth-
ing to restore the portion of cord
destroyed. Operation should there-
fore not be undertaken until there is
evidence that the lesion is incom-
plete, but when such evidence exists,
it should not be delayed. Operations
to repair an injured cord, either by
suture or grafting, are inadvisable.
Wide exposure is essential. With ex-
tradural lesion and an apparently
normal dura and cord, if there is no
septic extradural focus, it is better to
examine the cord. In operating for
root pains, a sufficient number of roots
must be divided. A. J. Walton (Lan-
cet, Feb. 15, 1919).
// a portion of the blade has been
broken off and left imbedded in the
tissues, it should be searched for and
removed, provided it is causing irrita-
tion and can be removed with safety.
Meningomyelorrhaphy. — The ef-
fects of complete transverse destruc-
tion of the spinal cord by a projectile
or otherwise may be mitigated by ex-
posing the cord, removing the injured
tissues by a transverse section of
both segments and joining the latter
by means of sutures passed through
both cord and membranes. In a case
reported by Stewart and Harte in
which Ya of an inch of cord was re-
sected, life was saved and the cord
recovered partly its functions. In a
series of 43 cases, collected by
Haynes, this operation reduced the
mortality from 69>^ to.42j^ per cent.
SPRAIN AND DISLOCATION.
— The vertebral column may be
sprained like any other joint. If se-
vere, a tearing ofif of small bundles of
muscle may accompany the injury.
Much more seriously is to be consid-
ered the injury that may simultane-
ously be inflicted upon the spinal
contents.
Symptoms. — These depend upon
the damage done. There may be an
external hematoma, which may not
show itself for several days. If there
has been a spinal hemorrhage it may
either be in connection with the mem-
branes, either extradural or subdural,
(hematorrhachis) or in the substance
of the cord itself (hematomyelia).
If the hemorrhage is extradural it
is less apt to cause paraplegia. Hem-
orrhage of either variety may be so
extensive as to pass from one end of
the cord to the other.
If the paraplegia does not come on
for some hours and the line of anes-
thesia mounts higher rapidly, it is
very probable that hemorrhage is the
cause. Browning has suggested the
use of an aspirator needle in the
diagnosis.
Hematomyelia may constitute either
a "destroying" or a "compressing"
lesion. If the former, there will, of
course, be permanent paralysis. If
the latter, there will be paralysis and
anesthesia, more or less complete, be-
low the level of the injury, with re-
tention of urine and feces, and prob-
ably priapism, which subside as the
blood is absorbed.
If a diagnosis of hematorrhaehis
can be made out and no improvement
occurs after a sufficient length of time
has been given for the blood-clot to
be absorbed, it would be good surgery
to open the spine for the purpose
of removing the compressing clot.
Iodide of potassium internally is sup-
posed to favor its absorption.
SPINE, DISEASES AND INJURIES OF (SAYRE). 295
Certain symptoms so often follow disability after trauma, with some de-
railway injuries that the term rail- parture from the ordinary shape of
zvay spine has been used in describ- the spine. The surgeon's manipula-
ing them, and some have concluded tions must be very guarded, as it is
that the prompt recovery that at times quite possible to injure the already
follows the awarding of damages by compressed cord so severely that per-
a jury is proof that the patient was manent paralysis will ensue. If pos-
feigning disease ; but the same symp- sible, an X-ray apparatus should be
toms in many instances are found used for an exact diagnosis, which is
when no one is held responsible for perfectly easy in the cervical and
the injury and the question of dam- fairly so in the lumbar regions, while
ages does not come into consideration, skiagraphs of the thorax are unsatis-
In some of the cases in which death factory, except in children or very
has followed the shock, an autopsy thin adults. Large experience in the
has failed to reveal any gross lesions interpretation of normal skiagraphs
of the brain or cord. In other cases is necessary to comprehend properly
hemorrhage is found, and in others a pathological one.
still there is a traumatic neuritis. Treatment. — Efforts should be
Some of these cases are incapable made I)y manipulation to replace the
of muscular exertion, and even have dislocated vertebrae, and experience
little control of the bladder, but when alone can guide the surgeon as to just
suspended and fitted with a snug how these manipulations should be
plaster-of-Paris corset can do a fair made. In case pressure upon the cord
amount of work. Many require sup- is urgent enough to demand it, the
port for the spine for years, though vertebra should be exposed, by in-
eventually able to dispense with it. cision and the rongeur, to effect re-
As with other sprains, the mistake duction. If operative interference be-
is often made of regarding slight comes necessary, it should not be de-
cases as of trivial importance. If re- layed, in order to minimize the dura-
covery does not promptly take place tion of cord compression, and also to
in mild cases, the spine should be formulate a definite prognosis. If no
protected by support until all pain damage has been done to the cord, if
has ceased, or the patient may be left the patient be free from pain, and the
with a weak back for the balance of deformity slight, it will be unwise to
his life. The plaster-of-Paris jacket endeavor to replace the vertebrae, as
is the most efifective apparatus. Any- not infrequently they become anky-
thing which will immobilize the losed in their new position, with com-
parts, and allow the trunk to move fort to the patient and safety to life,
as a solid mass, will answer the while cfiforts to restore them to their
purpose. original situation may result disas-
DISLOCATION OF A VERTEBRA trously.
is infrequent and usually is accom- Bed-sores. — These are among the
panied by fracture, more or less ex- most distressing results that follow
tensive. It is most often cervical, damage of the cord. They dififer
next lumbar, and very seldom dorsal, from ordinary bed-sores, due to pres-
The diagnosis is based on sudden sure by bony prominences. They
296
SPINE, DISEASES AND INJURIES OF (SAYRE).
may form inside of twenty-four hdurs,
and usually first make their ajjpear-
ance as erythematous patches. These
then turn into blebs, which burn,
leavini;;^ a raw sore, which sloughs
very deeply, perhaps down to the
bone. If one side only of the cord
has been injured the bed-sores will
form on the opposite side.
Treatment. — -This consists in the
removal of all pressure, keeping the
skin absolutely clean, washing the
surface with alcohol and alum several
times a day, and, after being thor-
oughly dried, dusting it with lycopo-
dium, talcum, or boric acid powder.
Retention of urine is another con-
stant accompaniment of cord-lesions,
from paralysis of the bladder. This
is accompanied by incontinence of
urine, and the patient lies in a pool
of decomposing urine unless constant
care is exercised to keep him dry.
Part of the urine being retained,
it becomes decomposed and soon
sets up disturbances in the kidney.
If great care is not exercised to keep
all catheters scrupulously clean, this
is sure to follow from urine infection.
SACROILIAC DISEASE. — The
diagnosis of this is based chiefly upon
the position of the patient, who bends
to the opposite side in order to relieve
the affected joint, the weight being
largely borne on the opposite leg.
Difficulty in bending or twisting the
body is frequently experienced, and
pain extends down the thigh, in the
course of the great sciatic nerve.
Careful local examinations will show
tenderness on pressure over the sa-
croiliac joint, and if the two ilia are
pressed together, so as to crowed them
against the sacrum, pain will be pro-
duced. The same pain may be pro-
duced by crowding the head of the
femur into the acetabulum, as pres-
sure will thus be transferred to the
hip-joint, but hip-joint disease can be
excluded by the production of pain
when the iliac crests are crowded
together.
Fever is usually but slight : per-
haps half a degree. The disease is
likely to be mistaken for lumbago and
sciatica, but the position as described
above is typical.
In addition to inflammation, tuber-
culous or other, of the sacroiliac joint,
this joint, and also the sacrolumbar
joint, is subject to sprains wdiich give
rise to the same deformity as chronic
inflammation, but which often arise
suddenly and without fever. A skia-
graph may show a change in the rela-
tions of the sacrum, ilium, and last
lumbar vertebra, but to get a clear
idea of the condition a stereoscopic
skiagraph is essential.
In some cases the slipped bone can
be replaced by manipulation without
an anesthetic; in others, anesthesia is
essential, and a firm girdle around the
pelvis is then required to retain this
position. Adhesive plaster passed
around the pelvis below the iliac crest
is best, but as it irritates the skin if
worn a long time, recourse must gen-
erally be had to a webbing belt with
perineal straps. A large pad over the
sacrum is usually required in addi-
tion.
Treatment. — In tuberculosis, if the
pain is extremely acute, the patient
may be put to bed, with traction ap-
plied in the long axis of the thigh, and
also at right angles to it, in order to
relieve joint pressure. If the pain
does not rapidly subside, the actual
cautery should be applied, burning
very deeply along the line of the joint.
The weight of the patient in walking
SPINE, DISEASES AND INJURIES OF (SAYRE). 297
should be borne on the sound leg, and removal of the laminae of the vertebrae,
an elevation of from four to six The entire back should be prepared
inches should be applied to this shoe, for operation with great care. If pos-
in order that the foot of the affected sible, the operating table should be
side may swing clear of the ground, provided with a hot-water plate or
The she© of the affected side may other means of keeping the patient
have half a pound of lead, or more, warm to lessen the shock, which is
according to the comfort of the pa- often severe, and means should be at
tient, fastened to the sole, to produce hand for subcutaneous injection of
traction on this joint. salt solution in addition to the or-
// suppuration takes place, remove dinary stimulants. A large number of
all tuberculous foci, being careful hemostatic forceps will be required,
that no pockets remain inside of the In many cases the primary spinal
pelvis to cause infection. The older condition has interfered more or less
writers assumed that suppuration in with the function of respiration, and,
sacroiliac disease was necessarily as the patient is of necessity placed
fatal, but modern results prove this prone or semiprone, the anesthetist
erroneous. must pay more than usual attention
At times it is extremely difficult to to the condition of the patient,
differentiate between sacroiliac and Many surgeons advise making a
sacrolumbar tuberculosis. In the lat- single median incision, long enough
ter the plaster-of-Paris jacket gives to include five or six vertebrae. The
prompt relief, and in sacroiliac disease muscles are then retracted to such an
it is of general use if continued down extent as to uncover the laminae on
the leg to the ankle as a spicti. one side. A short cutting knife should
DISORDERS OF THE COCCYX, be used to free the muscles from the
— The coccyx rarely suft'ers from dis- bone, for, if a dull instrument is used,
ease, except as the result of a trau- the tissue is apt to be so badly lacer-
matism, when it may undergo necro- ated that necrosis follows,
sis and require removal. Hemorrhage is apt tO' be very pro-
Coccygodynia, so called, at times fuse at this stage. The operator
demands the removal of the coccyx, should, however, proceed rapidly to
performed through a longitudinal in- complete the incision and stop the
cision over it. But the great major- bleeding by pressure of compresses
ity of cases suffer because of some wrung out in water as hot as can be
other disturbance, — either hemor- borne by the hand. The wound
roids, a misplaced uterus, or an ex- should be tightly packed while the
hausted nervous system, — and such laminae on the other side of the
cases must be very carefully excluded spine are being exposed. The second
before the diagnosis of coccygodynia wound is then packed and the bleed-
is made ; otherwise, although the bone ing checked in the first. Hydrogen
be removed, the ]iain will continue. dioxide at this stage is of use as an
LAMINECTOMY. — Access to the hemostatic. The interspinous liga-
spinal canal for the purpose of reliev- ment is cut through. In the dorsal
ing pressure or for any other ])ur- region the incision must be made in
pose is almost always obtained by a slanting direction, owing to the
298
SPLEEN, DISEASES OF (SAJOUS).
overlapping of the upper over the
lower vertebrae. With a rongeur or
rib-cutter the laminae are then cut
through and removed.
Some surgeons prefer making an
osteoplastic resection, using an 11
or U incision. Some of them use
Hey's saw or a chisel to divide the
lamina. Care must be had to make
the cut through the laminae at a sharp
angle, otherwise it will not enter the
spinal canal. The interspinous liga-
ment of the vertebrae at the cross-cut
is now divided, and the flap with the
spinous processes and arches attached
reflected upward and laterally, other-
wise the spinous processes will meet
and prevent lifting the flap.
A layer of adipose tissue is now
met with ; this should be divided in
the median line and pushed aside,
when the dura w'ill be brought into
view. Bleeding can be controlled by
pressure, hot water, and hydrogen
dioxide. The cord should pulsate.
If it does not, the absence of pulsa-
tion may point to adhesions, swelling
of the cord, or pressure by bone or
fluid. If relief from bone-pressure
is being sought, it often is not enough
to remove the laminae, as the pres-
sure may be caused by encroachment
on the anterior surface of the spinal
canal. To reach this the spinal cord
may be drawn to one side by an
aneurism needle or other blunt hook,
the extremities of the patient's trunk
being meanwhile supported on sand-
bags, making the spine concave pos-
teriorly, so as to relax tension on the
cord. Should it be necessary to
divide any nerve-roots in order to
move the cord far enough to one side,
these nerves should later be sutured.
If the dura is distended with blood,
its color will be purplish ; yellow, if
pus be present. A tumor can usually
be recognized by touch.
If the trouble has not been satis-
factorily remedied, the dura should
now be opened. If a tumor be pres-
ent, it should be removed if possible,
but it may inflltrate the cord so as
to be inoi)erable. Blood-clots, frag-
ments of bone, etc., should, of course,
be removed when the cord is lacer-
ated. Efforts to suture the cord have
so far been disappointing. The dura
should be closed with fine sutures un-
less for some reason pressure on the
cord is not desired. The skin incision
may or may not be drained, the de-
pendent position of the cut favoring
the escape of fluid. If a drainage-tube
is employed, it should be removed in
twenty-four hours. A plaster-of-Paris
bandage outside all the dressings is
advisable in almost all cases — cer-
tainly in those for Pott's disease and
in fracture. _, ^^ ^
R, H. Sayre,
New York.
SPINE, DISLOCATION OF.
See Dislocations.
SPIRILLOSIS. See Relapsing
Fever.
SPIRIT OF MINDERERUS.
See Ammonium.
SPLANCHNOPTOSIS. See In-
testines : \"isceroptosis.
SPLEEN, DISEASES OF.—
FUNCTIONS OF THE SPLEEN.—
To establish the diseases of an organ
on a satisfactory clinical basis its
functions should be known. Unfor-
tunately such is not the case with the
spleen. Many functions have been
attributed to it, but none can be said
to have been clearly established.
At the present writing the following
deductions seem warranted: —
SPLEEN, DISEASES OF (SAJOUS).
299
1. The spleen is a contractile organ, the
rhythmic systolic and diastolic movements
of which are prolonged, the cycle lasting
about one minute. This process is prob-
ably concerned with digestion since the
organ begins to enlarge when this func-
tion begins and continues to do so five
hours, when it gradually recedes, resum-
ing its normal size in about seven hours.
[My own view in this connection is that
in keeping with the experimental studies
of Herzen, Lepine, Gachet, and Pachon,
the spleen produces an internal secretion
which converts the pancreatic trypsinogen
into trypsin. The latter taking part in
digestion and the defensive reactions of
the body, we have an explanation of the
next function attributed to the organ. S.]
2. It participates, through its internal
secretion, in the defensive functions of the
body against certain infections: anthrax
(Bardach), Trypanosoma brucci (Bradford
and Plummer), syphilis, etc., in com-
mon with other lymphatic glands. This
function, however, is but an auxiliary one,
judging from the comparatively harmless
effects of splenectomy, and the fact that,
after this operation, the general lymphatic
glands take up its functions, while new
hemolymph-glands are being developed.
The functions of the spleen are to
remove bacteria and certain toxic
agents from the blood, to conserve
the food values of the broken-down
blood-corpuscles, and to send their
remnants to the liver for utilization.
The gland has no important internal
secretion and is not essential to life.
It is not an obsolete organ, however,
as often suggested. W. J. Mayo
(Jour. Amer. Med. Assoc, March 4,
1916).
[The prevailing impression that removal
of spleen is comparatively harmless is
based on the fact that splenectomy is
performed in diseases in which the organ
has undergone sufficient change to render
it virtually functionless and after the gen-
eral lymphatic system has assumed its
functions. When, however, the operation
is performed where the organ is normal,
as, for instance, after rupture, marked
constitutional disturbances may be en-
countered. Among these may be men-
tioned: Extreme anemia, emaciation, daily
rise of temperature and increased fre-
quency of pulse, attacks of fainting, head-
ache, drowsiness, great thirst, severe grip-
ing pains in the abdomen and pains in
the arms and legs; marked enlargement
of the lymphatic glands, which may be
permanent;' great diminution of the red
blood-corpuscles, and considerable leuco-
cytosis. S.]
3. It serves to break down worn-out red
corpuscles by means of a ferment and to
prepare the constituents and contents of
these cells (globulin, hemoglobin, etc.)
for physiological processes elsewhere, the
pancreas, liver, blood, etc., including the
elaboration of bile, hemoglobin, new cor-
puscles, etc. This probably applies also
to worn-out leucocytes and particularly
phagocytes.
There can be no question that in
the spleen a large number of cells
undergo their final disintegration
after the action of hemolytic poisons,
and that the hemoglobin there liber-
ated passes by the portal system di-
rectly to the liver. When the spleen
is removed, this disintegration occurs
in other organs, notably, in the
lymph-nodes and bone-marrow, and
the hemoglobin from these organs
passes not into the portal but into
the general circulation, from which it
reaches the liver more gradually and
in a more dilute form. Austin and
Pepper (Jour. Exper. Med., Dec,
1915).
Its functions are probably more im-
portant in childhood than after middle
life, when it begins to atrophy as do the
thymus, tonsils, etc., until old age, when
it is reduced in normal subjects to a small,
shrivelled, though vascular, remnant.
ANOMALIES.— Tlie spleen may
vary in size irrespective of any dis-
ease. Small spleens have been met
which weij:yhed less than one ounce,
and congenital absence of the spleen
has, though rarely, been noted. Large
spleens are, as a rule, met in in-
fants, but often in conjunction with
some teratological defect. Accessory
300
SPLEEN, DISEASES OF (SAJOUS).
spleens, splenicuH, are common, espe-
cially in the peritoneal folds about the
hilum, but they may; be widely scat-
tered in the abdomen.
Malformations of the spleen are
common. Its lower edge is often the
seat of deep indentations. It may be
rounded or elongated. Its anterior
margin may present several notches,
or a single deep one almost dividing
the spleen into two parts. The notch
may be near the lower end or even
on the posterior border. Long proc-
esses may be given off from the main
body. Occasionally the spleen is rep-
resented by a number of small masses
scattered about the peritoneum or
clustered into masses like bunches of
grapes. They may become imbedded
in the spleen itself. They are sup-
posed to be more common in early
life.
Malposition of the spleen is occa-
sionally observed, the organ being
located in other parts of the abdom-
inal cavity, even on the right side,
the liver being then transposed to the
left side.
MOVABLE OR WANDERING
SPLEEN. — This condition, also
termed floating spleen, dislocated
spleen, and splenoptosis, is uncom-
monly met with, and, in most in-
stances, in women. It may be due to
relaxation and elongation of the sus-
pensory ligament which connects it
with the diaphragm' because of in-
creased weight with or without en-
largement of the organ itself, or to
traction upon it by neighboring
organs, the stomach, kidney, colon,
pregnant uterus, etc. The condition
may occur in conjunction with gen-
eral enteroptosis and, though rarely,
as a result of traumatisms. Malaria,
syphilis, and other diseases which
cause splenic enlargement may occur
as etiological factors.
Symptoms. — These, as a rule, are
slight and variable, as the organ may
migrate into any part of the abdomen
and be extremely mobile, especially in
women who have borne several chil-
dren. Often the symptoms consist of
a dragging sensation on one side of
the abdomen, with backache, recur-
rent headaches, digestive disorders,
lassitude, and insomnia. Direct in-
terference with neighboring organs
through pressure may cause jaundice,
ascites, intestinal obstruction ; renal,
uterine, and cystic disorders.
Torsion or twisting of the pedicle
may bring on alarming phenomena
quite suddenly if the torsion is com-
plete. These may include sudden
enlargement of the organ and severe
local pain, marked pallor, with ane-
mia, fever, uncontrollable vomiting,
marked shock, and collapse. When
the torsion is incomplete the symp-
toms are less acute. In some cases
the torsion may lead to rupture of the
supporting ligaments. The peri-
splenic tissues may become inflamed
and cause considerable local pain.
The writer studied the records of
79 cases of torsion of a wandering
spleen to which he adds 1 of his own,
all in women. He knows of only 3
cases in men. In 13 cases the spleen
was removed during a pregnancy or
after delivery, and all the women re-
covered but 1, who died on the sixth
day.
On the other hand, 4 of the 13
women died who required splenec-
tomy for rupture or other injury of
the spleen, during a pregnancy. The
greatest damage from a wandering
spleen occurs when it is in direct con-
tact with the genital organs and ad-
hesions develop or it pushes them
out of place. Montuoro (Zeitchr. f.
Geburts. u. Gynakol., Aug. 23, 1913).
SPLEEN, DISEASES OF (SAJOUS).
301
Diagnosis. — This, as a rule, is not
difficult provided it is borne in mind
that the organ may be found in any
part of the abdomen, and that it some-
times becomes adherent to another
organ. The misplaced spleen is usu-
ally close to the surface and its out-
line, with its sharp, indented edge and
l)ulsating artery at the hilus, can usu-
ally be discerned by palpation. This,
coupled with the absence of dullness
where the organ should normally be,
and the possibility of causing the
displaced organ to glide back to this
normal position, added to the general
symptoms, usually establishes the
diagnosis.
Case of dislocated spleen in a girl
of 17 who entered the hospital with
severe pain in the right lower abdo-
men and local symptoms suggesting
an appendicular abscess with matting
and adhesions of the omentum and
bowel. Constitutional symptoms de-
veloping, the abdomen was opened
and a huge, engorged, bleeding spleen
was found. It was replaced in the
normal situation. The conservative
method in this case appears to have
been right, for after thirteen months
the organ had shrunk to half its
original dimensions, was fixed, and
situated midway between its normal
position and the umbilicus. Black-
burn (Austral. Med. Gazette, Dec,
1907).
The conditions for which it may be
mistaken are hydronephrosis, mov-
able kidney and abdominal tumors,
particularly when these are sessile.
In some cases, cystoscopic examina-
tion is required. Extra-uterine preg-
nancy, ovarian and uterine tumors,
and fecal accumulation may also be
simulated.
Treatment. — In mild cases, treat-
ment of the causative disease, if any,
and the use of suitable bandage after
replacement of the organ will often
suffice. In severe cases, operative
measures are indicated. Splenectomy
is to be preferred to splenopexy. The
former operation cause? slight if any
changes in the normal blood-picture,
according to Fowler, and the mortal-
ity is low. Leukemia and marked
disease of the organ preclude opera-
tive intervention.
Series of 9 cases in which a dis-
placed spleen was removed on ac-
count of severe symptoms. In one
of these, the patient, a woman aged
42 years, suffered from an enlarged
spleen with a twisted pedicle. The
organ on removal weighed 1200
grams. In another case, the spleen
occupied the entire abdomen. It
weighed on removal 2000 grams.
The patient recovered. A still larger
spleen was removed from a woman
aged 30 years, the organ weighing
2200 grams. Recovery followed.
The other patients were also women,
aged 30, 45, 32, 20, and 25 years.
Zhilinskaja (Roussky Vratch, July
11, 1915). ■
ACUTE HYPEREMIA or CON-
GESTIVE ENLARGEMENT OF
THE SPLEEN.— This condition is
also designated as acute splenic tu-
mor. This term is misleading and
should be dropped.
The condition occurs in acute tox-
emias of various kinds, particularly
those attending typhoid and typhus
fever, septicemia, pyemia, ulcerative
endocarditis, glanders, anthrax, abor-
tion due to sepsis, etc., and less fre-
quently as a result of intoxication by
drugs, the coal-tar derivatives in par-
ticular. Acute splenic hyperemia may
also follow traumatisms, or occur as
a result of temporary pressure by
adjoining swollen structures, or of
obstruction by emboli. It may attend
practically any infection, but not to a
302 SPLEEN, DISEASES OF (SAJOUS).
sufficient degree to be recognized ABSCESS OF THE SPLEEN or
clinically. In yellow fever, for exam- ACUTE SUPPURATIVE SPLEN-
ple, the spleen is said never to be- ITIS, — This condition may occur as a
come enlarged, though probably hy- result of infection of the spleen by
peremic. The enlargement due to neighboring ulcerative processes, em-
acute infections is usually moderate pyenia, peritonitis, etc., but as a rule
and tends to disappear with the cause it is caused by septic emboli, such as
of the toxemia. While in chronic en- those formed in, ulcerative pericar-
largement of the spleen the organ is ditis, pulmonary abscess, etc. It may
usually hard, in the acute form it re- occur also as a complication of splenic
mains soft and flabby. congestion in the course of typhoid,
SYMPTOMS. — These depend malarial and other infectious fevers,
upon a great variety of conditions, It has been attributed to cold, exhaus-
causal and local, which may include tion, traumatism, etc., but these fac-
displacement, torsion, abscess, rup- tors act by weakening the defensive
ture, embolism, perisplenitis, etc. En- reaction of the tissues. The size of
largement of the spleen and pain in the abscess varies from a small aggre-
the splenic region are leading symp- gate of pus to an enormous accumu-
toms, but the latter may be absent, lation sufficient to suggest ascites,
though tenderness on pressure and a Those due to emboli, however, tend
sensation of weight are usual. The to be small.
splenic tumor may be accompanied by When an abscess penetrates the
pulsation of the organ, sometimes so capsule perisplenitis is developed, but
marked as to be discernible on in- the resulting adhesions may wall it
spection. This may occur in both the ofif ; if they fail to do so, however, and
acute and chronic forms, especially pus is evacuated into the abdominal
when blood-pressure is high and there cavity, fatal peritonitis develops. An
is a concomitant valvular disorder. embolic abscess is usually fatal while
TREATMENT. — The causal fac- a non-embolic abscess may, if evacu-
tor naturally demands primary atten- ated, end in recovery.
tion. The splenic congestion being SYMPTOMS. — Pain in the splenic
usually attended with high blood- region, aggravated and extended when
pressure, hypodermoclysis or in chil- neighboring structures such as the
dren proctoclysis may be tried, to re- pleura, diaphragm, etc., are involved ;
duce the viscidity of the blood by tenderness over the splenic area and
increasing its osmotic power. The the usual symptoms indicating a sup-
iodides sometimes prove effective, purative process — chills, fever, nau-
whatever be the cause, in reducing sea, vomiting, prostration, more or
splenic enlargement when it persists less marked leucocytosis — constitute
during convalescence. Strapping of the picture usually obtained. Enlarge-
the splenic region to prevent free ment of the spleen may usually be de-
motion of the organ, dry or wet cup- tected, even if the abscess be small;
ping over it or applications of cold if it is large fluctuation may some-
compresses tend to inhibit the hyper- times be elicited, while the onset of
emia. Purgation, using saline cathar- a non-embolic abscess may be grad-
tics, acts in the same direction. ual and the symptoms develop pro-
SPLEEN, DISEASES OF (SAJOUS). 303
gressively. In embolic abscess, how- spleen is then sutured to the ab-
ever, the onset is sudden. Involve- dominal wall in such a way as to pre-
ment of neighboring structures is vent carefully all access of fluids to
common, and gives rise to dyspnea, the abdominal cavity. The abscess is
cough, and expectoration of pus and then opened and drained. In some
blood, for instance, if the abscess cases the spleen is found to be ad-
open into the pleura and lung; pleu- herent to the wall. In extensive ab-
ritic pain if the former alone be in- scesses, or such as are not amenable
vaded, etc. The stomach, intestine, to this procedure, splenectomy is in-
diaphragm, perisplenic tissues, and dicated, having given a low mortality
pancreas may be involved. The X- (G. B. Johnston). When operative
rays are sometimes helpful to locate procedures cannot be resorted to,
the abscess and exploratory puncture strapping of the splenic area to limit
is advocated by some, but this is at ' movement and if possible the iodides
best a dangerous procedure owing to to favor absorption may prove useful,
the danger of favoring rupture of the
abscess. RUPTURE OF THE SPLEEN.
The course of the case depends Although traumatisms may cause
upon the nature of the causative dis- rupture of the spleen, malarial disease
order. If this be an ulcerative endo- of the organ is by far its most fre-
carditis, a pyemia, etc., and an em- quent cause. Then come in the order
bolus be the direct cause, the chances oi frequency according to Berger's
of recovery are at best very remote, statistics (1902) pregnancy (usually
This applies also to an abscess which where the spleen was already dis-
causes pleurisy, peritonitis, nephritis, eased), typhoid fever, leukemia, syph-
etc. If it open, however, into the ilis, alcoholic cirrhosis, tuberculosis,
stomach or intestinal canal, the pos- hemophilia, and capsular varices. To
sibility of recovery is greater, but these have been added by other ob-
prompt evacuation tends to insure it. servers : typhus, anemia, eclampsia.
Case of primary abscess. The relapsing fever, infarct, abscess, and
symptoms were low fever, headache aneurism. Splenomegaly does not al-
and pain under the seventh rib, radi- ways exist. It may occur spontane-
ating to the shoulder. In the course ously, but a strain, as in the course of
of two months increasing fever and ^n eclamptic paroxysm, causing trac-
chills compelled intervention and ,• ,, i ^i i '^ ji
, ,, . . , tion on the capsule, through adhe-
rapid recovery followed resection of . . , . ,
•- , •, ^- r sions formed m the course of a con-
two ribs to permit evacuation of pus • ^i a, ^w i
between the lobes of the lung, after comitant perisplenitis, may also cause
evacuation of the pus in the spleen, it. One or more ruptures may occur.
Belloni and Moschini (Gazz. d. Os- The resulting hemorrhage is occa-
ped. e. d. Clin., Feb. 1, 1910). sionally encapsulated by splenic ad-
TREATMENT.— The condition of hesions, but, as a rule, the blood is
the patient and the nature of the dis- liberated into the abdominal cavity,
ease warranting it, the abscess should usually in large quantity.
be reached and evacuated. This is SYMPTOMS. — Although unusual
best done by laparotomy at the outer discomfort may precede the rupture,
edge of the left rectus muscle. The the first symptom is severe abdominal
304
SPLEEN, DISEASES OF (SAJOUS).
pain, soon followed by symptoms of
severe shock, pallor, faintness, cold-
ness of the extremities, etc. If the
hcmorrhaf^e be very severe, the pa-
tient may die within the hour. Tlie
acute symptoms may be deferred 3 or
4 days, but, as a rule, a febrile reaction
with signs of peritonitis occurs, which
soon ends in death. Muscular rigid-
ity in the left hypochondriac region
is an early symptom. Percussion
over the spleen may indicate reduc-
tion owing to ischemic collapse. The
accumulating blood-mass in the ab-
domen may also elicit dullness over
an increasingly large area, which
mass, as shown by Ballance, does not
shift when the patient is moved. The
history of the case, moreover, and the
suddenness of the onset of shock and
pain, point clearly to the nature of
the complication.
TREATMENT.— Immediate lapa-
rotomy is indicated. The bleeding
area should then be sought, compress-
ing the pedicle if necessary to check
the bleeding while this is being done.
Splenectomy has given the best re-
sults (66 per cent, recoveries in 150
cases collected by G. B. Johnston).
If, however, the tear is small and the
organ is in good condition, the open-
ing may be closed with a catgut
suture and the suture line covered
with omentum. Forcipressure by
suitable forceps may be used to ap-
proximate torn edges, thus allowing
them to be pared and sutured. Very
small tears sometimes warrant the
use of the tampon.
SPLENOMEGALY, OR CHRONIC
ENLARGED SPLEEN.
That chronic enlargement of the
spleen is but a symptom of many dis-
orders is well shown by the following
list of causal factors published by
Osier in 190<S:—
1. In children, disturbances of metab-
olism and chronic intestinal infections:
rickets, amyloid disease, and a large, ill-
defined group of intestinal disorders, par-
ticularly in the tropics; the pseudoleu-
kemia infantum. 2. Infections: sj'philis,
malaria, kala-azar, and other forms of
tropical splenomegaly, Hodgkin's disease
and tuberculosis. 3. Primary disorders of
the blood-forming organs: leukemia, per-
nicious anemia, chlorosis, hemachroma-
tosis; polycythemic splenomegaly. 4. Cir-
rhosis of the liver: syphilitic, alcoholic,
hypertrophic of Hanot. 5. Hereditary and
family forms of splenomegaly: (a) with
congenital acholuric icterus; (b) with con-
stitutional disturbances, dwarfing, etc. 6.
New growths and parasites: sarcoma,
primitive endothelioma of Gaucher, echin-
ococcus, and the schistosoma\ of Japan.
7. Splenomegaly not correlated with any
of the above or with any known cause:
Banti's disease, with its three stages of
(a) simple enlargement, (b) splenomegaly
with anemia, (c) splenomegaly with ane-
mia, jaundice and ascites.
In recent years, however, the tend-
ency has been to individualize several
syndromes out of the series, viz.,
splenic anemia, which includes Banti's
disease as a terminal stage ; Gaucher's
splenomegaly, tropical febrile spleno-
megaly (kala-azar), and polycythemic
splenomegaly. These disorders (ex-
cepting Kala-azar, already treated
in vol. vi, page 174) are reviewed be-
low. We shall consider, in the pres-
ent connection, therefore, only splenic
enlargements which occur in general
disorders.
Syphilitic Splenomegaly. — Where,
as in children, a history of lues is
difftcult to trace, Hutchinson teeth,
interstitial keratitis, persistent cracks
at the corners of the mouth and other
familiar signs will serve, with a posi-
tive Wassermann, to establish the
cause of the enlarged spleen. Al-
SPLEEN, DISEASES OF (SAJOUS).
305
though, as a rule, the latter is not
very large, in rare instances it fills
the entire left side of the abdominal
cavity. Stunted growth and infantil-
ism are common in splenomegaly due
to inherited syphilis. In acquired
syphilis the splenic enlargement may
be due to gummata, dififuse cirrhosis,
or perisplenitis. Profound anemia
may be present and the picture of
splenic anemia (q. z'.), with its hemor-
rhages, hepatic cirrhosis, etc., predom-
inate. Syphilitic splenomegaly often
complicates syphilitic cirrhosis of the
liver. Leucopenia is usual in ac-
quired syphilis, while in the inherited
In young children the spleen is
especially active, and all general in-
fections attack it; all pathologic con-
ditions of the blood affect it more
than other organs, and as it is such a
vascular organ, any insufficiency in
the circulation is felt most severely
here. In the case of a much debilita-
ted boy of 7, observed by the writer,
an enormous enlargement of the
spleen was traced by exclusion to
either tuberculosis or inherited syphi-
lis. Test treatment being resorted to,
the swelling disappeared after the
second injection of neo-arsphenamin,
plus X-ray exposures of the spleen.
Lesne (Medecine, Aug., 1920).
Malarial Splenomegaly (Ague
form the proportion of leucocytes is, Cake). — The spleen becomes acutely
as a rule, normal.
Tuberculous Splenomegaly. — The
spleen may be the seat of primary
tuberculosis. This is sometimes fol-
lowed by general hyperplasia of the
lymphatic tissues, being then often
mistaken for a lymphadenoma. The
course may be acute or chronic.
There is a sensation of oppression and
more or less pain or at least tender-
ness on the left side of the abdomen,
and in sufficiently advanced cases
respiratory disturbances, at times
with cyanosis, fever with afternoon
exacerbation and asthenia.
Gastrointestinal disturbances are
common and sometimes indicate the
simultaneous presence of tuberculous
peritonitis.
The blood-picture is not character-
istic. While the erythrocytes may
be reduced in some, in others a dis-
tinct polycythemia may be present.
The spleen shows tuberculous nod-
ules and caseous masses with areas
of fibrosis. Tuberculous splenomeg-
congested during a malarial parox-
ysm. While this enlargement sub-
sides after each attack, repetition
entails a disposition to the permanent
form. At first soft and pulpy, the
parenchyma finally becomes firm
with prominent trabeculse. The pig-
mentation is sufficient in some speci-
mens to constitute a true local mela-
nosis. The intercommunicating- Ivm-
phoid spaces and vessels may become
obstructed with these products of
broken-down hemoglobin, constitut-
ing veritable thrombi. The spleen
may then attain immense size and
even extend down to the ilium. Its
weight may reach 10 pounds or more.
Malarial splenomegaly is the most
prolific cause of rupture of the organ,
93 of 132 cases being of malarial
origin, with but 1 traceable to syph-
ilis and 1 to tuberculosis. The his-
tory of the case and examination of
the blood for the Plasmodium remove
diagnostic doubts.
Thrombotic Splenomegaly. — En-
aly not uncommonly complicates largement of the spleen may also be
general tuberculosis, especially the caused by thrombosis of the splenic
miliary form. vein.
8—20
This may be due to degen-
306
SPLEEN, DISEASES OF (SAJOUS).
erative processes of the latter or its
radicles, in the course of chronic de-
generative diseases, pressure of dis-
eased neighboring- organs, tumors,
traumatisms, displacement of the
spleen capable of causing torsion of
the vein, etc. While at first passive
congestion and localized hemor-
rhages may occur, fibrosis follows.
Besides' the splenic enlargement there
are usually gastric and other hemor-
rhages, thus causing a syndrome re-
sembling greatly that of splenic ane-
mia {q. zk). The blood changes are
less marked, however, and the gen-
eral phenomena less acute.
The first sign of infarcts in 2 cases
was a sudden excruciating pain in the
region of the organ afifected, strictly
localized, not radiating, persisting for
some time unmodified without essen-
tial remissions, but gradually sub-
siding in the course of a few days.
An infarct in the spleen or kidney
may occur with severe symptoms
suggesting ileus or peritonitis, prob-
ably of reflex origin (collapse, vomit-
ing, retention of feces and urine).
These symptoms may be accom-
panied by slight temperature and
possibly also by moderate leucocy-
tosis. Head's zones of hyperalgesia
on the skin are sometimes noted, and
their location on the right or' left
side may sometimes have diagnostic
importance to determine whether the
left kidney or the spleen is affected.
Enlargement of the spleen and fric-
tion in the splenic region point to
this organ. Riebold (Deut. Arch. f.
klin. Med., Bd. Ixxxiv, no. 5 u. 6,
1905).
Amyloid Spleen. — When amyloid
occurs — as a result of tuberculosis,
syphilis, chronic suppurative proc-
esses, especially those of the joints,
or rarely from carcinoma, malaria,
gout, alcoholism, etc. — it is only when
the organ is greatly enlarged that the
condition may be recognized. Its
edge, which may then be palpated,
feels smooth but hard and, unlike vir-
tually all other splenomegalies, is not
sensitive to pressure. What pain is
experienced is due to the weight of
the organ and to perisplenitis. What
anemia may be present may de due to
interference with the hematopoietic
functions of the organ, but in most
instances it is due to the causative
disorder. Rarely, primary amyloid
spleen has been witnessed.
Miscellaneous Forms of Splenomeg-
aly.— Besides the foregoing varieties
of splenomegaly, others are occasion-
ally encountered in which therapeutic
measures often prove helpful.
To the various disorders of the
blood, besides splenic anemia and
polycythemia to which special sec-
tions are devoted below, the spleno-
meduUary or myeloid form of leu-
kemia may be added. Such cases are
characterized by very great enlarge-
ment of the spleen, the organ often
reaching below and beyond the um-
bilicus. This causes abdominal dis-
comfort and pain in the splenic area,
often duei to perisplenitis, and to ad-
herence of the enlarged organ to
various viscera, including the stom-
ach. It is easily identified by the very
marked leucocytosis and the other
symptoms of leukemia. In pseudo-
leukemia or Hodgkin's disease, the
spleen is enlarged in a majority of
cases, but not to the extent observed
in leukemia. Hence the fact that the
enlargement is '^eldom associated
with pain. Repeated blood examina-
tions here reveal a progressive sec-
ondary anemia. The enlargement of
the lymph-glands serves to distin-
guish it from pernicious anemia, an-
other blood disorder in which the
spleen may be enlarged. Here, how-
SPLEEN, DISEASES OF (SAJOUS). 307
ever, the condition is one of hyper- echinococcus cysts may involve the
plasia with exacerbation of hemolytic spleen (see Tumors, at the end of this
activity as illustrated by the beneficial article), to the extent of about 3 per
effects of splenectomy, viz., a post- cent, of all cases. Cysts in this loca-
operative rise of the erythrocyte tion may attain a large size and
count. Here the characteristic varia- occur as primary growths in over
tions in size and shape of these cells one-half of the cases. In such the
and the other signs of pernicious ane- diagnosis cannot be made certain,
mia will be found. Closely allied to unless an exploratory laparotomy be
this blood disorder is lone recently de- made, by puncture of the spleen, a
scribed by Banti under the name of dangerous procedure in that it may
hemolytic, splenomegaly in which hy- entail fatal toxemia, peritonitis, es-
perplasia of the organ also enhances cape of hydatids in the peritoneal cav-
its hemolytic activity, probably under ity or rupture, the latter occurring at
the influence of some undetermined times spontaneously,
poison. It is characterized by a Splenomegaly is often associated
rapidly progressive anemia, jaundice with hepatic disorders. In cirrhosis
without clay-colored stools, urobili- of the liver it is commonly present,
nuria and bilirubinuria, and a special but the hepatic symptoms usually
hemopoietic reaction of the bone- predominate. It may be mistaken
niiarrow, indicated by the presence for the cirrhotic stage of splenic
in the blood of normoblasts, myelo- anemia, or Banti's disease, in which
cytes, polychromatophilous erythro- ascites, jaundice, anemia, and hemor-
cytes, and erythrocytes with baso- rhage are also prominent symptoms,
phile granulations. The importance A history of alcoholism, the tardy
of recognizing this condition lies in initiation of hemorrhages, and of the
the fact that permanent cure may be splenomegaly will indicate the true
obtained by means of splenectomy. condition present. In Hanot's hyper-
The parasitic splenomegaly, that of trophic cirrhosis of the liver, the fre-
hookworm disease, also requires men- quently accompanying hemorrhages,
tion. The profound anemia with jaundice, fever, and leucocytosis may
sometimes greatly enlarged spleen, suggest splenic anemia. But the
and the dropsy may mislead the ob- large,, hard and smooth liver, the per-
server into a diagnosis of splenic sistence of jaundice instead of! the
anemia, thus causing him to deprive mottled pigmentation, and the promi-
the patient of thymol. The discovery nence of the hepatic symptoms point
of the parasite in the stools and eo- to the presence of Hanot's cirrhosis,
sinophilia always suggesting a para- The hepatic cirrhosis with spleno-
sitic disease, will, however, reveal megaly of childhood, with anemia or
the true identity of the case. Ascar- jaundice, and gastric hemorrhages, is
ides may also be attended with mod- differentiated with difficulty from
erate enlargement of the spleen, splenic anemia. In fact, it is probable
Eosinophilia and examination of the that most cases described as such are
stools of the suspected cases, children, advanced cases of the latter disease
as a rule, will reveal the cause. It is to in which the Banti syndrome predom-
be remembered also that hydatid or inates. In hemochromatosis, charac-
308 SPLEEN, DISEASES OF (SAJOUS).
terized by the presence in the skin — or enlarc^cment of the spleen due to
and deeper organs of hematin, an the blood-s^-hmds or internal secretory
iron-laden constituent of hemoglobin, glands. Thus, rachitis, now known
the skin assumes a bronze hue, and to be intimately connected with defi-
enlargement of the spleen is com- ciency of the thymus and of the thy-
monly observed. This, however, oc- roid apparatus owing to their in-
curs concomitantlv with hypertrophy fluence on calcium metabolism, is fre-
of the liver, the whole process leading quently attended with marked en-
ultimately to sclerosis of both organs, largement of the spleen. Dwarfing is
and also of the pancreas. In ad- not uncommonly associated with this
vanced cases glycosuria points to the condition and, precisely as we see
disease present, but earlier, the slow stunted growth of hypothyroid and
progress, bronzing, hepatic enlarge- hypothymic origin, so is there a family
ment, the absence of hemorrhages, form of splenomegaly with dwarfing,
and of the Addisonian asthenia point TREATMENT.— The multiplicity
to the true nature of the disease. of causes of splenomegaly indicates
Closely allied with the above dis- the treatment to be adopted in each
orders are some which might be form, viz., elimination of the causal
grouped under the term obstructive factor. In primary tuberculosis of the
splenomegaly, since any of them spleen, splenectomy has given 56 per
by causing portal obstruction can, cent, of recoveries, while death, ac-
whether the disturbance be cardiac, cording to Winternitz, invariably fol-
pulmonary, vascular, etc., induce pas- lows without it. Tuberculin, however,
sive congestion with distention of the may prove useful early in the case. In
spleen — sufficient at times, where the svphilis neosalvarsan, salvarsan, mer-
organ is the seat of degenerative le- cury, or the iodides should be tried,
sions, to cause rupture. This read- but where the morbid phenomena
ily explains the indurative inflamma- assume those of splenic anemia
tory splenomegaly which occurs when splenectomy is also indicated. On the
the organ fails to undergo resolution whole this operation is indicated
after acute enlargement of the spleen where threatening symptoms, such as
attending acute infections, intoxica- repeated gastric hemorrhages, intense
tions, etc. During this pre-sclerotic hemolysis, etc., persist notwithstand-
stage it may be the seat of focal Jng faithful effort to control the cause
hemorrhages and necrosis, while in- w'ith drugs, unless leukemia or amy-
farcts likewise are not uncommon, joid spleen be present.
Abscesses may be formed, there being Jn chronic inflammation, the X-rays
a marked tendency to accumulation of tg^d to reduce the splenic enlarge-
bacteria in the organ. Perisplenitis ment. The treatment of the vari-
(treated separately below) is a com- ^^s causative diseases mentioned is
mon complication of the resulting g-Jven under their respective headings
splenic inflammation. throughout the present work.
Finally, another group which will
command increasing attention is one SPLENIC ANEMIA.
which might be classified under the This disease is now generally re-
head of hemadenogenic splenomegaly garded as embodying various dis-
SPLEEN, DISEASES OF (SAJOUS).
309
orders which, though g-iven individual
names, are but stages of it. These are
primary splenomegaly, which repre-
sents the initial stage of splenic ane-
mia, and Banti's disease or splenomeg-
aly with hepatic cirrhosis, deemed to
be its terminal stage.
Splenic anemia is characterized by
marked chronicity and progressive
enlargement of the spleen, secondary
anemia and, in some cases, terminal
hepatic cirrhosis. It shows a predilec-
tion for males (about 60 per cent.)
and for the third and fourth decade
of life.
There exists a peculiar susceptibil-
ity of the spleen in children, not onlj'
to become enlarged but also to
undergo histological changes. It is
liable to enlarge with acute and
chronic infectious diseases, with cer-
tain affections of the liver, and with
twelve different diseases of the blood-
producing apparatus. Its patholog-
ical conditions are more acute in
children than in adults. Brinchmann
(Norsk. Mag. f, Laegevidenskaben,
Dec, 1915).
The morbid process in the spleen
consists of hyperplasia followed by
fibrosis affecting the pulp reticulum,
its Malpighian bodies especially, and "
the capsule. The liver is at first the
seat of passive congestion followed
later by atrophic interlobular cirrhosis
with calcification affecting mainly the
portal veins, which vessels may be-
come obstructed by thrombosis. That
hemolysis is a factor of the morbid
process is suggested by the formation
of new hemolymph-nodes and de-
posits of blood-pigment, with com-
pensatory proliferation of erythro-
blastic tissue.
A pathological study of 18 spleens
from patients upon whom positive
clinical diagnoses of splenic anemia
had been made showed in each spleen
a hyperplasia of one or more of the
constituent tissue elements. In 2
spleens the lymphoid tissue was so
overgrown as to suggest lymphoma
in one and lymphosarcoma in the
other. In 3 spleens the proliferation
of the endothelium of the venous
sinuses was most predominant. In
13 spleens the process was chronic
and diffuse. While any case of pri-
mary splenomegaly ma; begin as an
overgrowth of the lymphoid tissue or
of the endothelium, a secondary over-
growth of the stroma of the gland
will later appear, accompanied by
degeneration of the lymphoid or en-
dothelial elements. As the connec-
tive tissue begins to undergo over-
growth, the spleen may be reduced
in size, the roughness of the exterior
being an index to the development
of connective tissue within it. The
histopathological picture presented in
all 3 types of spleens from cases of
primary splenic anemia harmonizes
with the hypothesis of a slowly
acting local toxin. L. B. Wilson
(Surg. Gyn. and Obst, March, 1913).
In a case observed by the writers,
the lymphatic glands in the abdomen
had undergone a hyperplasia similar
to that in the spleen. Blood was
present in the lymph-sinuses of these
lymphatic glands to a variable ex-
tent, but its amount bore no relation
to the endothelial hypertrophy or
fibrous tissue of the gland. These
hemolymph-glands probably repre-
sent blood-organs sui generis in which
the same pathological changes had
occurred as in the other blood-organ,
the spleen. Collins and Kiddel (Brit.
Med. Jour., May 29, 1915).
Although some form of toxemia un-
doubtedly underlies the disease, its
actual cause is still to be determined.
It will probably be found due to vari-
ous forms of intoxication. Various
bacteria, syphilis, malaria, and other
infections have been incriminated.
SYMPTOMS. — The only detect-
able symptom at first is an enlarge-
ment of the spleen. This increases
310 SPLEEN, DISEASES OF (SAJOUS).
insidiously and very slowly without the gastrointestinal passive hyper-
giving- rise to other morbid phenom- emia, nausea, vomiting, diarrhea, etc.,
ena, even the blood-picture remaining alternating with constipation, but
normal. After a few years anemia de- they are apt to occur only in advanced
velops, though showing no character- cases. This applies also to the pres-
istic picture. When the morbid proc- ence of al])umin and granular casts in
ess is advanced, the red corpuscles the urine, and to fever, seldom attain-
are reduced one-third or perhaps one- ing more than 100° F., observed
half, but the hemoglobin percentage toward the decline of day. As the
shows greater decline — down at times case becomes far advanced it may
to one-fourth. The leucocytes may assume the hectic type, when marked
also show considerable reduction in asthenia is added. Death may be due
some cases, while in a minority there to cardiac syncope following a severe
may be' a leucocytosis. A relative hemorrhage or independently of such,
lymphocytosis has been observed by As a rule, however, the patient is car-
some, but a differential count afifords ried ofT by an intercurrent disease,
nothing characteristic. The anemia is When the Banti stage of splenic
chlorotic in type. anemia begins the symptoms are:
Another important feature is the P progressive increase or reduction
.1 , ^ . , , , in size of the spleen and change in
tendency to gastric hemorrhages and •, . ^ ro\ .u ■ u
, . Its consistency; (2) the vems become
hematemesis. It occurs in about one- more conspicuous, especially in the
half of the cases and is often profuse. upper part of the abdomen;, (3)
While recurring at long intervals at symptoms of insufficiency on the part
first, the hemorrhages, which are due ""^ ^^^ '>^^^' defective bile production
, . ^- • ,1 • and also urobilinuria, uroerythrinuria,
to passive congestion in the gastric , -,. , • • u ^ • ^ ^ ^
^ ° ° bihrubmuria, cholemia and clay-col-
mucosa, rupture of esophageal veins, ^red stools; defective transformation
and occasionally to erosions, become of urea, causing hypoazoturia; defec-
more frequent, particularly when the tive sugar metabolism, causing ali-
hepatic cirrhosis is advanced. Epi- mentary glycosuria and levulosuria;
.•111- , .1 .-1 defective antitoxic action, increasing
staxis, bleeding at the gums, retinal , . ,^ . ' , , .
, , , the urotoxic coemcient and defective
hemorrhages, ecchvmoses, etc.. mav ^■ • ^- r ^u i ui t-u
f3 , v,v.v, y ^ v,o, vtv,., _; elimination of methylene blue. There
also appear at this time. are the following accessory signs: (1)
Pigmentation of the skin, SUgges- a tendency to hemorrhages; (2) pain
tive of Addison's disease in its early in the liver region; (3) gastrointes-
stages, and most marked in the tis- ^^"^1 disturbances, dyspepsia, etc.;
sues exposed to light, is probably ,^4) edema in the legs^ Rummo
^ . r ?■ f- •. (Polichnico, March 15, 1908).
an expression of this proclivity to
hemorrhage. Jaundice may precede DIAGNOSIS. — While percussion
it or accompany it, owing to hepatic readily indicates the presence of an
cirrhosis. Ascites and edema of the enlarged spleen, it is necessary to as-
ankles are occasional symptoms, as certain also the nature of the morbid
are also cardiac phenomena such process that is present. In pernicious
as hemic murmurs, palpitations, etc., anemia, the spleen is enlarged, but
which are due to the existing anemia, never to the same degree and the
Among the general phenomena ob- blood changes are characteristic; this
served are digestive disorders due to applies to leukemia and to Hodgkin's
SPLEEN, DISEASES OF (SAJOUS). 311
disease in addition to the enlarged advanced ; it has proven effective,
lymphatic glands in the latter. Con- however, even after the Banti symp-
genital hemolytic jaundice differs toms, hepatic cirrhosis, and ascites
from splenic anemia in that it appears had developed. The operative mor-
early in life, shows -urobilin and uro- tality at the Mayo clinic has been 11.1
bilinogen in the, urine, and marked per cent. It is influenced, of course,
staining peculiarities of the red cor- by the condition of the patient. Be-
puscles. Amyloid spleen is distin- fore development of cirrhosis and
guished by the history of syphilis, ascites, the mortality was but 13.4
suppuration, or tuberculosis with per cent, in 82 cases, while during
amyloid disease in other organs. Late that advanced stage it was 56.2 per
in the history of the case hepatic cir- cent, in 16 cases, according to Rod-
rhosis may be taken for it, but the man and Willard (1913). Blake
greatly enlarged spleen and the his- (1915) recommends the operation in
tory of the case permit differentia- either stage under the following- con-
tion. ditions : 1. In adults, when the diag-
T RE AT ME NT. — Medical treat- nosis is agreed on by a good physi-
ment sometimes proves of temporary cian and a competent surgeon. 2.
benefit. Arsenic is especially useful When the condition of the patient is
if hemolysis is active, the case ap- sufficiently good to withstand what
proximating, in some instances, one of may be a serious operation ; or trans-
pernicious anemia. Salvarsan or neo- fusions, when a poor condition can be
salvarsan may also prove useful in sufficiently improved. 3. In chil-
such cases. Iron is indicated when dren, only after a thorough trial of all
the erythrocyte count is to any degree possible medical methods of treat-
lowered. Fresh air, sunshine, and ment, including fresh air, sunshine,
liberal diet are important. Accord- careful nursing, liberal and appro-
ing to Rummo, thorium X causes a priate diet, as well as the judicious
marked reduction of the spleen, an in- use of drugs. In a large majority of
crease of red corpuscles, and in small cases, a high white blood-count, or a
doses polynuclear leucocytosis ; large considerable recurring or continuous
doses cause leucopenia. Mild appli- fever are contraindications,
cations of X-rays over the splenic Good results in 4 cases of advanced
reg-ion are given twice a week at the Banti's disease and 1 of malarial
same time. Benzol and olive oil, splenic enlarg'ement with ascites by
^^.,,^1 ^.^^^ „4-;^ r, u • • VI combining- Talma's operation (omen-
equal proportions, begmnmg with a ^ . , , ^,
, .. , .„ • • /n r /- N • topexy) with splenectomy. The
daily dose of 8 minims (0.5 Gm.) m- , • ^u 1 1 i • ^ r.
-^ ^ -' changes in the blood-picture after
creased according to the patient's age operation were the same as those ob-
and resistance to 30 minims (2 Gm.) served after splenectomy for other
and given while the X-rays and tho- splenic affections, viz., the hemo-
rium are used, have procured good globin rose nearly to normal; the
results. The blood should be' ex- '■^^-"" ^°""t exceeded slightly the
, , ., normal, then gradually returned to
amined daily. . ... ^ . . , ,
. . the condition existing before in-
Splenectomy is the only curative <-^,.,.»„f:,.„ ^„.i ^ r w i 4. •
f^ J J tervention, and a slight leucocytosis,
measure available, provided it is re- with pronounced eosinophilia, per-
sorted to before the case is too far sisted. Febrile complications of ob-
3i:
SPLEEN, DISEASES OF (SAJOUS).
scure causation may follow the oper-
ation. In thrombotic forms of spleno-
megaly, primary or secondary, medi-
cal treatment should alone be employed ;
3 patients treated by splenectomy
succumbed. Tansini and Morone
(Rev. do Chirurgie, Aug., 1913).
Recent observations have tended to
show that the anemia which follows
splenectomy is best prevented by the
use of uncooked foods.
The anemia which develops after
splenectomy is most marked in
animals on a mixed table-scrap diet
of meat, bread, cereals, and vege-
tables, which is essentially a cooked
diet. Further studies did not support
the view that the anemia is due to
lack of iron in the food. A diet of
raw meat, as contrasted with cooked
meat, shows a more severe anemia in
animals on the cooked diet and sug-
gests the possibility that heat alters
some substances which, in the ab-
sence of the spleen, the body cannot
utilize. Pearce, Austin, and Pepper
(Jour, of Exper. Med., Dec, 1915).
GAUCHER'S SPLENOMEGALY.
This uncommon disease is charac-
terized by the presence in the spleen
and subsequently the liver, lymph-
glands and bone-marrow of large,
rounded or polygonal cells with small
nuclei arising probably from the en-
dothelium, and accumulations of iron-
laden pigment. The spleen is greatly
enlarged, owing to the development of
these cells in dilated alveolar spaces
and venous sinuses throughout the
pulp. The liver may also be greatly
enlarged and show the same cells in
the lobules and interlobular connec-
tive tissue, the masses of iron pig-
ment accumulating around the ves-
sels and in the capsule. The abdomi-
nal and thoracic deep-seated lymph-
nodes present the same characteristic
and the bone-marrow likewise in
cases of long duration.
Gaucher considered the condition a
primary epithelioma of the spleen,
but, as emphasized by Wilson at the
Mayo clinic, it fails to show the at-
tributes of malignancy, but rather of
a form of hyperplasia resembling that
observed in the thyroid, which leads
to a secondary increase of the stroma,
degeneration of the parenchyma, and
finally fibrosis. This interpretation
serves to eliminate the gloomy prog-
nosis of malignancy and substitutes
for it a comparatively favorable one,
as experience has shown, where
splenectomy can be resorted to.
The cause of Gaucher's spleno-
megaly is unknown, but its familial
occurrence suggests a predisposition
to some toxic or virus capable -of irri-
tating the follicles of the hemato-
poietic system.
SYMPTOMS.— The disease is usu-
ally recognized by a great enlarge-
ment of the spleen traceable to early
life and its slow development, cases
having been known to reach the
fourth decade in which the process
had started during childhood. The
liver, which enlarges after the spleen,
may also attain large proportions.
Another peculiarity is its tendency to
occur in several members of a family,
but in the same generation and pref-
erably in girls (85 per cent.). There
is a marked tendency to epistaxis,
bleeding at the gums, etc.
History of a family, 4 members of
which suffer from the Gaucher spleen.
Father and mother are both living
and well; there is no tuberculosis in
the family; nor could any luetic his-
tory be obtained, while a Wassermann
reaction of mother proved negative.
The mother has given birth to 4
children, and has had no miscarriages
or stillbirths. Of the patients, Anna,
the oldest child, is 11 years old.
SPLEEN, DISEASES OF (SAJOUS).
313
Lily died in 1909 at the age of 8;
Freda is 9 years old, and Max, the
youngest, is 4 years old. Reuben
(Amer. Jour, of Dis. of Child., Jan. 3,
1912).
There is a yellowish or brownish
discoloration of the skin, especially
where it is exposed to light ; the face,
neck, and hands, and particularly
around the nose. According to
Charles Herrman, there may also be
wedge-shaped thickening of the con-
junctiva on either side of the cornea.
Secondary phenomena such as sen-
sations of weight and pressure, gas-
tric and intestinal distress, malnutri-
tion, etc., may appear.
The blood-picture is not character-
istic. There is a relatively slight ane-
mia and a progressive decrease of the
hemoglobin percentage as the case
progresses. Leucopenia is always
present with relative decrease of the
polynuclears.
Case of primary splenomegaly of
the Gaucher type in an infant 11
months old. The child had never
thrived and weighed only 11 pounds.
There was idiopathic enlargement of
the spleen, liver, and lymph-glands,
and a peculiar yellowish pigmenta-
tion of the skin of the exposed parts.
The blood-picture was normal until
a few days before death, when it
assumed the appearance characteris-
tic of lymphatic leukemia. Mason,
Knox, and Wahl (Med. Record, Oct.
3, 1914).
TREATMENT.— All forms of
treatment, including the prolonged
use of X-rays, have failed. Splenec-
tomy alone has afforded cures — evi-
dence in favor of the non-malignancy
of the disease. According to Erd-
mann and Moorhead (Amer. Jour.
Med. Sci., Feb., 1914), the best cases
for operative interference are those
showing a practically normal blood-
picture with a hemoglobin percentage
of 50 or more. Enlargements of the
liver and glands are not contraindica-
tions if the general condition of the
patient is good. The blood-picture
soon returns to normal after the op-
eration. The operative mortality is
relatively low in appropriate cases.
SPLENOMEGALIC POLYCY-
THEMIA, or ERYTHREMIA.
This disease, wrongly termed
"Vaquez's" and "Osier's" disease,
since these authors only aided to
make it known by their writings,
was first described by Rendu and
Widal in 1892. It is characterized by
a peculiar mottled redness of the
skin, with cyanosis, enlargement of
the spleen, and striking increase of
the blood-cells, both red and white.
SYMPTOMS.— The skin is brick
red tinged with violet, the latter be-
ing due to cyanosis, especially notice-
able at the lips, nails, buccal mucosa,
and tongue. Hemorrhages from the
nose, gums, stomach, intestines, skin,
and genito-urinary tract are common.
There is also enlargement of the
spleen, sometimes considerable. The
red cells may reach nearly three
times the usual number, while the
hemoglobin may attain 200 per cent.
In most cases there is a marked leu-
cocytosis, particularly of the poly-
nuclear neutrophile variety. Greatly
increased viscosity of the blood is
another notable feature of the disease.
Among general symptoms are my-
asthenia and neurasthenia, headache,
vertigo, and cerebral congestion, at
times leading to apoplexy ; neuralgia
and spasmodic muscular disorders.
Circulatory disorders with high blood-
pressure are usual. Gastrointestinal
and respiratory disorders are also wit-
314
SPLEEN, DISEASES OF (SAJOUS).
nessed, particularly dyspnea due to
pulmonary edema, though late in the
history of the case. Edema of the
extremities with dilatation of the
heart, enlargement of the liver, and
bronzing may then coincide with
drowsiness or a semicomatose state
which may end in death. Although
a few cases reported have run their
course in a few months, the patient
may live six years or more.
ETIOLOGY AND PATHOL-
OGY . — Splenomegalic polycythemia
occurs in both sexes about equally
and seldom before the fourth decade.
Formerly attributed to tuberculosis
of the spleen, it is now thought to be
due to violent stimulation by some un-
determined toxic of the blood-forming
organs, as shown by the presence of
normoblasts, megaloblasts, and mye-
locytes in the blood, and the intense
erythroblastic and leucoblastic con-
gestion of the bone-marrow and
spleen.
[It has been suggested by Saundby that
the disorder might primarily be a neurosis
associated with spasm of the arterioles
and peripheral congestion. Such a condi-
tion might well produce the observed
typical congestion of the blood-forming
organs, but this form of vasomotor is so
common an occurrence, while polycythe-
mia is a relatively rare disease, that this
interpretation of the process can hardly
hold. S.]
The writer has collected reports on
179 cases of which 149 appeared to
be instances of true polycythemia,
the remainder being open to doubt.
The condition must be diflferentiated
from the relative increase in the red-
cell count accompanying acute diar-
rhea, dysentery, etc., in which the
volume of the blood is decreased, as
well as from erythrocytosis, or sec-
ondary absolute polycythemia, typic-
ally seen in congenital heart disease,
particularly pulmonary stenosis, in
chronic heart and lung diseases, and
in certain individuals residing at
great altitudes. It is marked, per-
sistent, absolute, and of unknown
origin. Lucas (Archives of Int. Med.,
Dec, 1912).
TREATMENT.— This has not ad-
vanced beyond symptomatic meas-
ures, of which repeated venesections
to reduce the volume of erythrocytes
and other blood-cells have been found
the most efficient.
[As it is the proportion of blood-cells to
the volume of plasma which should be re-
duced, I would suggest saline solution in-
travenously after each bleeding as an ad-
ditional measure which would tend also to
reduce the abnormal viscidity of the
blood, and therefore its excessive activat-
ing influence on hematopoietic organs, in-
cluding the bone-marrow and spleen. S.]
The X-rays will serve to reduce
the volume of the spleen but also the
blood-count. Splenectomy is contra-
indicated, since the spleen is but a
partial factor in the morbid process ;
it has, in fact, afforded bad results.
PERISPLENITIS; CAPSULITIS;
CAPSULAR SPLENITIS.
This is an inflammation, acute or
chronic, of the capsule and peritoneal
covering of the, spleen, Avhich may
occur as an extension of any disease
affecting the spleen) itself or the
•organs immediately surrounding it.
Part or all of the capsule may be in-
volved. It may be simply inflamed,
or it may produce a fibrinous or puru-
lent exudate, become thickened. Ad-
hesions may develop.
SYMPTOMS.— Discomfort or pain
in the splenic area, radiating in vari-
ous directions and aggravated by
breathing, pressure, lying on the cor-
responding side and motion, and the
splenic friction sound on ausculta-
tion, represent the array of symp-
SPLEEN, DISEASES OF (SAJOUS). 315
toms added to those of the causative stance or vascular tumors. Dermoid
disease. It is readily confounded cyst of the spleen is very rare,
with inflammatory disorders of the Parasitic cysts are those most com-
pleura, but the absence of cough and monly met with. Hydatid or echino-
dyspnea usually facilitates the diag- coccus cyst occurs in the spleen in
nosis. Occasionally involvement of about 3.5 per cent, -of all cases. It is
the diaphragm adds respiratory symp- generally unilocular, and may develop
toms rendering recognition difficult. in any part of the organ or in the ad-
TREATMENT.— Besides measures joining tissues and attain large size,
addressed to the causative condition, Of the malignant tumors, sarcoma,
strapping of the splenic, area is indi- though rare, is that most usually met
cated, with absolute rest in bed. De- with. It consists as a rule of nodules
rivative purgatives are- also useful. If which project more or less from the
an accumulation of pus or an effusion enlarged organ. Occasionally the
can be detected, and absorption fail to spleen becomes the seat of a meta-
occur under the use of potassium static sarcoma. Carcinoma of the
iodide, laparotomy should be resorted spleen is exceedingly rare — likewise
to, the incision being made at the metastatic carcinoma,
outer edge of the left rectus and the SYMPTOMS. — In benign growths
spleen sutured to the abdjominal mus- of sufficient size, particularly splenic
cles unless it be found already adher- cysts, the symptoms are those of a
ent. The morbid area is then opened slowly growing tumor in the left
and drained. If done with due care hypochondrium. Pressure symptoms,
this procedure is fraught with no dan- or symptoms due to the mechanical
ger of complications. weight of the mass, may develop,
viz., indigestion, flatulence, at times
TUMORS OF THE SPLEEN. nausea and vomiting as the result of
Primary tumors of the spleen are pressure on the stomach, and consti-
infrequent. Of the benign growths pation, from pressure on the bowel,
fibroma, which occurs rarely, is seldom A sense of soreness may also be
discovered clinically. Lymphangio- noted over the mass, while pain,
ma and angioma cavernosum may, from mechanical traction, referred
however, attain large size, especially toward the left axilla and shoulder,
the latter. is also frequently in evidence. There
Cysts of various kinds are not un- is always present a sense of dis-
common. The simple cysts may be comfort. Objective symptoms are
divided into hemorrhagic cysts, usu- those of any large mass. The site
f.lly due to traumatism and traction of occurrence, the fact that the
upon the friable tissue of the organ, tumor dullness is confluent with
and infections ; lymph-cysts due to the splenic dullness, the direct con-
accumulation of albuminous fluid, nection frequently found with the
and serous cysts, when the content spleen by palpation, and the moving
is non-albuminous and of low specific of the mass with respiration, all point
gravity. The two latter forms are de- to the spleen as the site of the origin
generative products of the Malpighian of the tumor. The cystic character
bodies, broken-down splenic sub- of a tumor is readilv recognized by
316
SQUILL.
the waves of fluctuation easily elic-
ited. (J. H. Musser, Jr.) Lymphan-
giomata and angiomata sometimes
give rise to palpable pulsations.
Hydatid or echinococcus cysts may
sometimes be identified by tlie hy-
datid fremitus and by the simulta-
neous presence of a hydatid cyst of
the liver. Diagnostic puncture of the
cyst places the diagnosis on a sound
basis, since the fluid obtained may
contain booklets, etc. ; but the danger
of peritoneal invasion by the latter,
of secondary peritonitis, etc., render
this procedure hazardous.
Sarcoma of the spleen develops
rapidly. This feature, the nodules,
radiating pain and tenderness, and the
cachexia may facilitate recognition.
Carcinoma is of slower development
and is more likely to accompany a
malignant growth elsewhere and to
show involvement of other lymphatic
structures. The lobulated character
of the spleen and its hardness, if it is
large enough to be palpated, the en-
larged lymphatic glands and cachexia
aid in establishing a diagnosis.
TREATMENT.— As a source of
comfort pending operation, adhesive
plaster strips, to prevent the harm-
ful effects of motion of the enlarged
spleen on other organs and to reduce
the danger of torsion, may be em-
ployed when the growth is not large.
When its dimensions are such, how-
ever, as to produce active symptoms
an abdominal bandage to support the
abdomen is preferable.
Where possible, surgical removal of
the growth should be practised. In
sarcoma it is contraindicated, but
in benign growths splenectomy has
proved uniformly curative, partic-
ularly in cysts. Other procedures
such as incision, drainage, and mar-
supialization present greater dangers.
A bUxxl-cyst may be sutured to the
incision in the abdomen and drained.
The incisions to reach the spleen
number 28: (1) simple laparotomy in-
cisions (23); (2) thoracolaparotomy;
and (3) transdiaphragmatic laparo-
tomy. The external rectus incision,
due to the severe trauma caused and
poor exposure, is not recommended.
It is lower than the spleen and further
exposure injures the costal arch. In-
cisions along the border of the ribs
are better, also the modifications of
the laparotomy incisions in which an
oblique incision toward the left is
made in addition. Still better ap-
proach is offered by resection or
bending of the cartilaginous costal
arch. Ssoson-Jaroschewitsch (Xautschn.
Med., 4, 1920).
C. E. DE M. Satous,
Philadelphia.
SPLEEN, INJURIES OF. See
Abdominal Injuries.
SQUILL (Scilla, U. S. P.; Squills) is
the bulb of Urginea maritima or Urginea
scilla (fam., Liliaceae), deprived of its dry,
membranaceous outer scales, cut into thin
slices, and carefully dried, the inner por-
tions being rejected (being the youngest
growth and deficient in activity). The
active principles of squill are glucosides,
three having been isolated by Merck, the
last two of which are poisonous: Scillin
(pale-yellow crystals, sparingly soluble in
water, more freely soluble in alcohol and
hot ether); scillipicrin (amorphous, yellow
to yellowish-red, bitter, and hygroscopic
powder, soluble in water) ; and scillitoxin
or scillain (brownish amorphous powder,
soluble in alcohol, but insoluble in water
and ether). Squill also contains a little
volatile oil, sugar (about 22 per cent.), the
peculiar mucilage sinistrin, and a large
amount of calcium oxalate.
PREPARATIONS AND DOSES.— The
official preparations are: —
Scilla, U. S. P. (the crude drug). Dose,
1 to 5 grains.
Acetum scillce, U. S. P. (vinegar of
squill; used for the preparation of syrup
of squill, and rarely used by itself). Dose,
SQUILL.
317
15 minims (1 c.c); best administered in
an aromatic draught.
Fluidextractum scillcc, U. S. P. (fluidex-
tract of squill). Dose, 2 to 3 minims
(0.10 to 0.20 c.c).
Syrupus scillce, U. S. P. (syrup of squill;
45 per cent, acetum scillse). Dose, J^ to
1 dram (2 to 4 c.c).
Syrupus scills compositns. U. S. P.
(Coxe's Hive Syrup; 8 per cent, each
fluidextracts squill and senega, and 0.2 per
cent, tartar emetic). Dose, 20 to 30
minims (1.3 to 2 c.c) in adults.
Tinctura scillcc, U. S. P. (10 per cent,
squill). Dose, 10 to 30 minims (0.6 to
2 c.c). This preparation fully represents
the diuretic and expectorant qualities of
squill. The official acetic acid prepara-
tions are not so uniformly dependable.
(E. M. Houghton.)
Valuable unofficial preparations are: —
Mistura pectoralis, Stokes, N. F.
(Stokes's Expectorant). Dose, 1 dram (4
c.c.) representing 1 grain (0.06 Gm.) am-
monium carbonate, 2 grains (0.12 Gm.)
each senega and squill, and 10 minims
(0.6 c.c.) camphorated tincture of opium
in syrup of Tolu.
Syrupus chondri compositus, N. F. Ill
(Irish moss syrup). Dose, 2 drams (8
c.c.) representing % grain (0.008 Gm.)
ipecac, 2 grains (0.13 Gm.) each squill and
senega, S^A minims (0.2 c.c.) camphorated
tinct. opium, in mucilage of Irish moss.
PHYSIOLOGICAL ACTION.— Squill
possesses emetic and stimulating expec-
torant and diuretic properties. Its physi-
ological action as an expectorant has not
been satisfactorily explained; its use is in
large measure empirical. It apparently
stimulates the bronchial mucous mem-
brane, causing free and thinner secretion.
As a diuretic, it appears to be effective by
toning the kidney up through its irritant
action; it does not, apparently, stimulate
the secretory epithelia of the renal organs.
Squill is eliminated by the bowels, kid-
neys, and bronchial mucous membrane.
Poisoning by Squill. — In toxic doses it
produces violent irritation and inflamma-
tion of the gastrointestinal and genito-
urinary tracts, giving rise to nausea,
vomiting, abdominal pain and purging,
strangury and hematuria. There is a
marked fall in body temperature; the cir-
culation becomes enfeebled; dullness,
stupor and convulsions follow, and not
infrequently death. Death has followed
the injection of 24 grains (0.6 Gm.).
TREATMENT OF POISONING.—
The treatment of poisoning by squill is
similar to that of digitalis poisoning.
(See Digitalis, Poisoning by, vol. iv, page
136.)
THERAPEUTIC USES.— Squill is a
useful expectorant in subacute bronchitis,
when the sputum is tenacious, and raised
with difficulty, or when the tonus of the
bronchia is lowered and the sputa are very
profuse (bronchorrhea). In chronic bron-
chitis squill is often advantageous, com-
bined with other stimulating expectorants,
as in Stokes's expectorant. Squill should
never be given when fever and acute
bronchial inflammation are present.
As a diuretic it is frequently given in
dropsical conditions, whether the result of
chronic renal disease or of the renal con-
gestion following chronic cardiac disease,
and in chronic pleurisy and pericarditis
with effusion. If the kidneys are the seat
of acute inflammation, squill is contrain-
dicated. Niemeyer's pill is an efficient
diuretic, containing 1 grain (0.06 Gm.)
each of squill, digitalis and calomel.
Squill is frequently used as an emetic
in spasmodic croup, seldom alone, but in
the form of the compound syrup which
contains tartar emetic; it is too depressing
for general use as an emetic. In whoop-
ing-cough it is serviceable. W.
SQUINT. See Strabismus.
ST. ANTHONY'S DANCE.
See Chorea.
ST. ANTHONY'S FIRE. See
Erysipelas.
ST. VITUS'S DANCE. See
Chorea.
STAPHYLORRAPHY. See
Surgical Anaplasty, or Plastic Sur-
gery: Cleft Palate.
STATUS LYMPHATICUS. See
Thymus Gland and Lymphatic Sys-
tem, Diseases of.
318
STERILIZATION AND DISINFECTION.
STERILIZATION AND DIS-
INFECTION.—The term sterilization
refers to the process of rendering sub-
stances or articles absolutely free of live
micro-organisms. Disinfection, though for
practical purposes largely synonymous to
sterilization, refers exclusively to the
destruction of those organisms which are
pathogenic.
Sterilization and disinfection may be di-
vided into 3 forms: thermal, mechanical
and chemical. These will be taken up
in the order given.
THERMAL STERILIZATION.— This
consists in the application of heat, and is
the most eflfectual of all types of sterili-
zation, though not always applicable.
Dry heat includes actual combustion or
burning, which can be carried out only in
the case of worthless rags or infective dis-
charges that are small in amount; the use
of hot air, which is suitable for glassware
and other articles that will stand a rela-
tively high degree of heat, and the use
of the thermocautery, appropriate for
asepticizing infected tissues of the human
body, such as the margins of openings
surgically produced in the intestine for
anastomotic purposes, the appendiceal
stump, etc. Sterilization by hot air is
usually carried out in a "hot air" or "dry
wall" sterilizer, consisting of a metallic
chamber provided with woven wire shelves
and heated by burners beneath. Small
objects may be readily sterilized in the
kitchen oven. Heating to a temperature
of 150° C. (302° F.) for one hour destroys
. all bacteria and their spores. Most fabrics,
however, are injured by a temperature
exceeding 110° C. (230° F.).
Moist heat, consisting in the application
of steam to the articles to be sterilized,
is far more satisfactory than dry heat,
possessing greater penetrating power and
acting more rapidly. Bacteria in the
vegetative stage are immediately killed
on exposure to steam, and most varieties
of spores within a few minutes. Clothing,
bedding, and the various muslin, cotton,
or linen articles used in the practice of
surgery, including gowns, caps, masks,
towels, sheets, blankets, gauze sponges
and pads, compresses, absorbent cotton,
and dressing materials are best disinfected
by steam, though the latter injures silk
and shrinks woolen fabrics, and ruins
leather and fur, oilcloth, and objects
made of impure rubber or wood, as-
sembled with glue or coated with varnish.
Steam may be employed either as stream-
ing steam or steam under pressure. The
former sterilizes in one-half to one hour
and has the same disinfecting power as
boiling water. It may often be applied
without any special apparatus, any rough
structure, not necessarily air-tight, serv-
ing as receptacle for the objects to be
sterilized. The steam should be admitted
at the top, in order the better to expel
the heavier air at the bottom and secure
penetration of the contained articles. In
the laboratory small objects may conve-
niently be disinfected in the Arnold steam
sterilizer.
Steam under pressure acts more power-
fully than streaming steam, and is the
favorite procedure in the routine sterili-
zation of clothing, bedding, and surgical
materials. Steam at a pressure of 15
pounds to the square inch sterilizes with
certainty in twenty minutes, its actual
temperature at such a pressure being
120° C. (248° F.). The smaller forms of
apparatus for applying steam under pres-
sure are known as autoclaves or digestors,
and the larger forms as steam disinfect-
ing chambers. The former consist of a
strong metallic cylinder provided with a
removable lid which can be fastened on
tightly with screw bolts, a thermometer,
safety valve, pressure gage, and stopcock
for allowing escape of the air. Water is
placed in the bottom of the receptable
and heat applied, generating steam. When
the air has been thoroughly removed by
steam escaping through the stopcock, the
latter is closed and the pressure in the
apparatus rises, the overheated steam
actively sterilizing the contained articles.
Where fluids are sterilized in the auto-
clave, the latter must be allowed to cool
before being opened, lest the fluids boil
over or their receptacles burst.
The larger steam disinfecting chambers
are usually rectangular or cylindrical in
shape, and may be employed either with
steam under pressure or streaming steam,
with formaldehyde gas or formaldehyde
and dry heat, or with combinations of
STERILIZATION AND DISINFECTION.
319
these agencies, either without or with a
vacuum. The chamber comprises an inner
and an outer shell, forming a steam jacket
into which steam is passed before the ob-
jects in the central chamber are exposed
to the steam, thus heating these objects
and preventing condensation of the steam
on them (and the consequent wetting)
when disinfection is begun. An attach-
ment known as the ejector is provided
which when in use rapidly creates a
partial vacuum in the central chamber
and favors penetration of the steam into
the interstices of fabrics and remote cor-
ners, to replace the air withdrawn by
it. The best forms of steam disinfecting
cylinders open at both ends, in order that
the infected material, introduced at one
end, may be removed at the other with
less risk of reinfection. In well-equipped
disinfecting establishments a dividing wall
passes across the disinfecting cylinders to
separate completely the receiving end and
attendants who prepare the material for
treatment from the discharging end,
where the disinfected material is aired,
dried and repacked by other attendants.
Light cars with trays are provided to
facilitate introduction into and removal
from the apparatus. Densely packed
bundles of rags, cotton, hair, etc., must
be loosened before their introduction to
insure disinfection throughout.
Intermittent, discontinuous, or fractional
sterilization consists in exposure of the
materials to be sterilized to steam (with-
out extra pressure) for 15 minutes on
each of three successive days. Prolonged
application of heat, or the use of heat at
a temperature exceeding 1(X)° C, is thus
avoided.
Boiling water, left in contact for one
hour, will kill all pathogenic micro-organ-
isms, excepting possibly the spores of
tetanus and anthrax. In fact, the germs
of typhoid fever, cholera, dysentery, pneu-
monia, tuberculosis, plague, diphtheria,
erysipelas, and practically all the non-
spore-forming organisms, are destroyed
at once by boiling and likewise by ex-
posure to 60° C. (140° F.) for 20 minutes
(Rosenau). Boiling water is eminently
suitable for the disinfection of table and
kitchen ware, urinals, and cuspidors, and
most kinds of fabrics. Cleansing with
boiling water, especially if mercury bi-
chloride or phenol be dissolved in it,
efficiently disinfects walls and floors,
metal objects, beds, etc. When oily or
organic matters are disinfected with it,
admixture with a strongly alkaline soap,
lye, or borax is of advantage to augment
its penetrating power. In the operative
room boiling is employed especially for
the sterilization of metal instruments, a
special tank such as the Schimmelbusch
sterilizer, heated by gas-burners beneath,
being generally employed. Sterilization
is effected by boiling for 10 minutes in a
1 per cent, solution of sodium carbonate,
the latter serving to prevent rusting and
injury to cutting edges. Removal from
the sterilizer may be accomplished with
a perforated tray and long hooks, or, in
the case of single instruments, with for-
ceps. Knives are boiled for 2 minutes
only in racks designed to maintain their
edges uppermost; needles for 3 minutes
in an open metal box, and scissors and
cutting forceps for 5 minutes. The lid
of the sterilizer should be in place dur-
ing the process. Boiling is also employed
frequently in the sterilization of rubber
articles and in that of Pagenstecher
thread, linen thread, silk, silkworm gut,
horsehair, and silver wire. Rubber drain-
age-tubes may be boiled for one-half to
one hour in 1 per cent sodium carbonate
solution, rubber dam likewise in saline
solution, rubber tissue and gloves for five
minutes only and finger-cots for one
minute. Sterilization of water itself is
readily efifected by boiling, either with the
aid of as simple an apparatus as an al-
cohol lamp and spoon or can, or with
special apparatus ranging from the more
inexpensive types to the large water ster-
ilizers used in hospitals or for other
purposes.
Sterilization of solutions of drugs or
other substances unfavorably modified by
l)oiling may be effected by repeated (in-
termittent) exposure to a temperature of
65° C. (149° F.). Pasteurization, which, as
applied to inilk, consists in heating once
to 60° C. (.140° F.) for 20 minutes, or
better — to provide a factor of safety — to
65° C. (149° F.) for 30 or 45 minutes, is
a fairly trustworthy procedure for render-
ing milk or other fluids free of pathogenic
320
STERILIZATION AND DISINFECTION.
germs, but a process of disinfection and
not of sterilization, since a small propor-
tion of the non-pathogenic organisms, in-
cluding the lactic acid bacteria, remain
undestroyed by the degree of heat applied.
Sunlight, the idtra-violct rays, and elec-
tricity may, for convenience, also be con-
sidered under the heading of thermal
disinfection. The first named possesses
distinct germicidal properties, though its
variability and uncertainty are disadvan-
tages. The blue-violet and ultra-violet
rays are alone active, the yellow and red
rays having practically no germicidal
power. Even dififused light has an anti-
septic action. Tubercle bacilli are less
easily killed by sunlight than the cholera
and plague organisms. The ultra-violet
rays, as supplied by the Cooper-Hewitt
mercury-vapor lamp, are strongly ger-
micidal, and are being availed of for the
sterilization of water, milk, etc., even
upon a large scale, as in purifying a muni-
cipal water-supply. Thresh and Bealle
showed that these rays would, in clear
water, kill many bacteria in 5 to 20 sec-
onds and even resistant spores in 30 to
60 seconds. Electrical currents, except
in so far as heat is liberated, have but
little germicidal power, and the Rontgen
rays none.
MECHANICAL STERILIZATION.—
The mechanical cleansing constitutes a
method of sterilization which, though in-
efficient in itself, acts as an important
preparatory influence or mordant for the
subsequent application of chemical disin-
fectants. Under this heading belongs,
e.g., the preliminary scrubbing of the
hands with green soap and water in the
preparation of the surgeon for operative
procedures. The process is so bound up
with chemical disinfection as to be more
profitably taken up when the occasion
presents under the next heading.
CHEMICAL STERILIZATION.— The
mode of action of the various disinfect-
ants, including, in particular, mercury
bichloride (see Mercury and Wounds),
carbolic acid (see Phenol), creolin (see
Cresols), hydrogen peroxide (see Hy-
drogen dioxide), potassium permanganate
(see Manganese), alcohol (see Alcohol),
formaldehyde (see Formaldehyde), boric
acid (see Boric acid), iodine (see Iodine),
and iodoform (see Iodoform), has already
been taken up. Reference to chemical dis-
infection will here be limited, therefore,
to a comparison of these various agents
and an account of their mode of practical
application for various purposes.
The careful tests reported in 1910 by
Post and Nicoll showed that the Bacillus
iyfyJwsus could be destroyed in one minute
by the following agents: Argyrol, 10 per
cent.; protargol, 10 per cent.; silver ni-
trate, 1 per cent.; mercury bichloride,
1:500; mercury biniodide, 1:1000; phenol,
5 per cent.; trikresol, 1 per cent.; iodine
tincture, undiluted, 7 per cent.; official
formaldehyde solution, undiluted; alcohol,
SO or 70 per cent.; tincture of green soap
and hydrogen dioxide, undiluted. The fol-
lowing preparations proved ineffectual:
Silver nitrate, 1:1000; phenol, 1 per
cent.; trikresol, 0.3 per cent.; lysol,
1.5 per cent.; creolin, 1 per cent.;
formaldehyde solution, 1 per cent.; al-
cohol, 20 or 30 per cent.; potassium per-
manganate, 1:1000; copper sulphate, 1 per
cent.; boric acid, saturated (1:18) solu-
tion; potassium chlorate, saturated (6.6
per cent.) solution; glycerin, undiluted,
and distilled water. With the streptococ-
cus, gonococcus, and pneumonia the results
were, with few exceptions, similar, though
failures to disinfect were somewhat more
frequent in the case of these organisms
than with the typhoid bacillus, i.e., stronger
solutions were generally required. Among
the salient items of knowledge gained
from studies of this kind have been the
importance of organic matter, e.g., blood-
serum, in interfering with the action of
germicides, and the marked inefficiency
of such preparations as liquor antisepti-
cus, U. S. P., listerine, alkalol, and gly-
cothymoline in destroying bacterial life.
Practical Uses of Chemical Disinfectants.
— Disinfection of the Surgeon's Hands. —
The procedure generally followed consists
in first scrubbing the hands vigorously
for 5 minutes with soap and a brush in
hot running water. The nails are then
cleared of foreign material and the scrub-
bing repeated for 5 minutes more. The
latter should be rinsed off frequently.
The hands are then rinsed in 1:3000 mer-
cury bichloride solution, or Harrington's
solution followed by sterile water and the
STERILIZATION AND DISINFECTION.
321
sterile gloves either put on wet in the
antiseptic solution or after drying the
hands with a sterile towel. Where it is
desired to operate without gloves, the
hands may be dipped in a bichloride-per-
manganate solution (potassium perman-
ganate, 1 ounce; bichloride, 7^ grains;
hot sterile water, 1 quart), rinsed in cold
1:3000 or 1:4000 bichloride solution in 50
per cent, alcohol every 5 minutes during
the operation, and after the operation
treated with a hot saturated solution of
oxalic acid to remove the remaining per-
manganate, followed by warm water and
a cold ammonia solution (ammonia, 1
ounce, water 2 quarts). To disinfect the
hands after septic operations a small quan-
tity of chlorinated lime and of sodium car-
bonate may be rubbed into the skin with
water for a few minutes, then rinsed of¥
with warm water.
For the general practitioner Kolle
(1907) and Tavel have endorsed Schum-
berg's procedure of scrubbing the hands
thoroughly with a mixture of 2 parts of
alcohol to 1 of ether, to which 0.5 per
cent, of nitric acid has been added. This
mixture, besides disinfecting directly,
shrivels up the skin and confines the
germs in its crevices for several hours; it
produces no irritation of the skin, even
upon repeated use. Heusner, for skin dis-
infection, has recommended the use of a
solution of 1 part of iodine in a mixture
of 750 parts of benzine and 250 parts of
liquid petrolatum. E. McDonald (1915)
asserts that a solution of commercial
acetone, 40 parts; denatured alcohol, 60
parts, and pyxol, 2 parts, will completely
sterilize the hands in 30 seconds. Mc-
Mullen has used McDonald's solution,
after scrubbing with green soap, water,
and alcohol with success.
DisUifection of the Operative Field. — On
the afternoon of the day preceding that
on which the operation is to be performed
the skin of the operative field should be
shaved, then washed thoroughly with soap
and warm water, rinsed with cold water,
then rubbed with alcohol and mercury
bichloride 1:5000, and thoroughly dried.
Over areas of thick skin such as the
elbow, knee, and sole of the foot boro-
salicylic compresses (salicylic acid, 15
grains, and boric acid, 90 grains to the
pint) should be applied and renewed every
four hours, the loosened epithelium being
removed by sponging with alcohol. If
the preparation has been thorough, paint-
ing the operative field and surrounding
area with tincture of iodine is alone neces-
sary at the time of the operation. If not,
the parts should be scrubbed for 3 minutes
with soap, hot water, and sterile gauze,
the skin sponged carefully with Harring-
ton's solution (water, 30; alcohol, 60;
hydrochloric acid, 6; mercury bichloride,
enough to make a 1:1250 solution) and
dried with ether, and the area finally
painted with tincture of iodine, beginning
at the line of incision (Fowler). Whiting
(1914) recommends an iodine tincture
made with 70 per cent, alcohol.
Sterilization of Surgical Paraphernalia. —
Rubber goods, after sterilization by heat,
may be kept sterile in 50 per cent, alcohol
or a 1:40 or 1:20 solution of phenol.
Glass instruments such as drainage-tubes,
syringes, nozzles, droppers, and medicine
glasses may be kept, after boiling, in a
1 : 1000 bichloride solution. Filiform
bougies should be washed, without boiling,
wnth soap and water and placed in 1:40
phenol shortly before use, then rinsed
with sterile water. Tourniquets and rubber
bandages may be washed with soap and
water and rinsed in 1 : 100 phenol. Hand-
brushes may be sterilized by boiling for
ten minutes in 10 per cent, potassium bi-
chromate solution, then kept in jars con-
taining a 10 per cent, bichromate solution
in 1:1000 mercury bichloride. Catgut is
sterilized by boiling for 1 hour in alcohol
on each of 3 successive days, or by boil-
ing- in cumol. It may also be sterilized
(Bartlett method) by heating gradually in
asbestos to 220° F. in the course of 2
hours, placing it in an asbestos-lined
kettle containing liquid albolene, allowing
it to remain there until cleared (usually
in a few hours), and finally heating gradu-
ally on a sand-bath to 320° F., which tem-
perature is maintained for one hour.
Silkzvorni gut and horsehair, after steriliza-
tion by boiling, may he preserved, respec-
tively, in a 1 : 30 phenol solution and
1:1000 solution of mercury bichloride in
alcohol.
Disinfection of Bed and Body Clothing. —
Such articles, after con (.not willi cases of
21
Z22
STERILIZATION AND DISINFECTION.
communicable disease, if not disinfected
by heat, may be immersed in phenol, 5
per cent.; formaldehyde, 10 per cent., or
mercury bichloride, 1 : 1000. If soiled with
discharges, they should previously have
been heated under antiseptic precautions
with 3 per cent, soft soap, to 50° C. for
three hours and two days< later boiled for
half an hour in water containing 1:3000
of petroleum and 1:120 of soft soap
(Rosenau).
Disinfection of Bath Water. — Water used
in bathing a patient and contaminated by
his secretions may be disinfected by mix-
ing with the bath water ^ pound of
chlorinated lime and allowing it to stand
half an hour (McClintic).
Disinfection of Feces,' Uri)i£, and Sputum.
— The following methods may be used:
(1) Add a 5 per cent, solution of crude
carbolic acid to an equal bulk of excreta,
mix thoroughly, and allow to stand one
or two hours; (2) similar employment of
a 10 per cent, formaldehyde^ solution; (3)
add an equal quantity of freshly prepared
milk of l/me containing 1 part of freshly
slaked lime to 4 parts of water, and al-
low to stand at least 2 hours (the reaction
of the mixture of lime and excreta must
be alkaline if success is to be attained);
(4) add an equal amount of a 3 per cent,
solution of chlorinated lime, mix thor-
oughly, and allow to stand for 2 hours.
In the disinfection of feces and urine,
in the absence of chemicals, a bucket of
boiling water added to a stool, which is
then covered and allowed to stand until
cool, will destroy practically all bacteria
except the spore bearers (Hasseltine).
Arnould (1914) has recommended the use
of copper sulphate, 6 or 7 grains to one
liter of stools, combined with the addition
of sulphuric acid, 5 per cent., for the
destruction of typhoid and cholera organ-
isms. In the disinfection of privies, cess-
pools, etc., lime and chlorinated lime are
commonly used.
Disinfection of the Sickroom. — This is
usually best effected with formaldehyde
gas, though in the case of yellow fever,
malaria, and plague insecticide agents
must be especially employed. Articles
such as bedding, carpets or rugs, and up-
holstered furniture, if left in the room
during the infective period, should prefer-
ably be left in place until a preliminary
gas disinfection has been performed, then
removed for sterilization by steam. Ob-
jects to be removed from the room for
disinfection should be wrapped in" a sheet
or bag wet with mercury bichloride solu-
tion. Before disinfection of the room, the
latter should be rendered gas-tight, all
cracks and crevices being sealed by past-
ing paper aver them, and hearths or flues
likewise closed off. The articles remain-
ing in the room should be arranged so
that the disinfecting gas will gain access
to all surfaces possible. Of the various
methods of generating formaldehyde gas
for disinfection, Rosenau considers
most reliable the permanganate-formalin
method. This involves the use of 10
ounces (300 c.c.) of commercial formalde-
hyde solution and 5 ounces (150 grams)
of potassium permanganate for every 1000
cubic feet of air space. The formalin is
poured over the permanganate, previously
placed in a deep bucket or basin, separated
from the flooring (owing to the heat
evolved) by a board. Formic acid and
heat are set free in the ensuing chemical
reaction, the heat, in turn, liberating
formaldehyde gas. Proper formaldehyde
disinfection requires a temperature of 65°
F., or higher, and a humidity of 65 per
cent, at the beginning of the process
(Hasseltine). A control test should pref-
erably be established to determine the
efficiency of the disinfection; this is done
by exposure in the room of a strip of
(sterile) filter-paper touched with a drop
of a broth culture of B. prodigiosus or other
harmless organism, and inoculating broth
with the filter-paper at the close of the
process. Spraying formaldehyde solution
is a simple and useful procedure for dis-
infecting closets, cabinets, wardrobes, and
bureau drawers, but is not satisfactory in
larger rooms. The formalin must be
sprayed directly upon the articles to dis-
infect. In disinfecting small rooms a
sheet may advantageously be hung across
the room and sprinkled freely with for-
malin. The room should be kept closed
not less than 8 hours. The formaldehyde
disinfection should preferably be followed
by thorough mechanical cleansing, sun-
ning, and airing.
Purification of a room without a gaseous
STILLINGIA.
323
disinfectant may be carried out by remov-
ing all the movable articles in the room
one by one for disinfection outside and
mopping the surfaces in the room with
1 : 1000 mercury bichloride solution or one
of the alkaline cresols. It is believed by
many that the results after thorough me-
chanical cleansing compare favorably with
those obtained by gaseous disinfection.
The walls should be carefully brushed with
the suction brush of a vacuum cleaner and
the floors and woodwork thoroughly
scrubbed with hot water and soap or a
disinfectant solution.
For rooms in which fumigation against
diseases transmitted by insects or rats is
indicated, sulphur dioxide should prefer-
ably be used. The room to be fumigated
should be tightly sealed and all fabrics
and metallic objects which are apt to be
injured by the gas removed. The gas is
usually set free by burning sulphur, of
which at least 2 pounds for every 1000
cubic feet of space should be used, or 5
pounds where a germicidal action (surface
disinfection only) is desired. The sulphur
is best burned in large, flat, iron pots,
each placed in a tub of water, and the
latter, in turn on a table or box. It is
best ignited by making a little hollow in
the middle of the sulphur, pouring in
some alcohol, and igniting the latter. In
destroying vermin an exposure of 2 to 12
hours is sufficient; for a germicidal effect,
6 to 24 hours. The gas may also be lib-
erated from liquid sulphur dioxide, which
is marketed in cans, and is merely poured
into a washbowl or iron pot. Two pounds
of the liquid are equivalent to one pound
of sulphur. The germicidal action of sul-
phur dioxide is favored by moisture.
Sulphur dioxide is applicable to the dis-
infection of stables, outhouses, freight-
cars, the holds of ships, etc. Hydrocyanic
acid gas is available for similar purposes
(see Hydrocyanic Acid).
Disinfection of Passenger Cars. — Where
contamination with the virus of a trans-
missible disease is known to have oc-
curred, the car should be disinfected
precisely like a room. Prophylactic dis-
infection consists in treatment with for-
maldehyde gas, followed by removal of
carpets and seats for vacuum treatment
and several hours' exposure to sunshine.
and by mopping or scrubbing of the floor
with a disinfectant solution.
Disinfection of Books. — Books handled
by persons suffering from contagious dis-
eases may be disinfected by placing 2 or
3 drops of commercial formaldehyde solu-
tion on every second page (taking care
to distribute the drops well), laying the
books in a closed box in which more
solution has been sprinkled, and leaving
the box in a warm place for at least 24
hours. Larger numbers of books may be
disinfected while standing widely open on
wire trays in special chambers. After in-
stitution of a partial vacuum, a high per-
centage of formaldehyde, together with a
temperature of 80° C, is applied for 12
hours (Rosenau). Books merely exposed
in a sickroom, without having been
handled, require no disinfection save sur-
face exposure to formaldehyde gas. S.
STILLINGIA. -Stillingia (Queen's
root or delight, yaw-root, silver-leaf) is
the dried root of Stillingia sylvatica (fam.,
Euphorbiaceae). The activity of stillingia
is due to a volatile oil (3 to 4 per cent),
a fixed oil, a resin known as sylvacrol;
tannin is present to the extent of 10 or 12
per cent., and a small amount of gum and
starch. The volatile oil has a strong and
unpleasant odor. The fixed oil is soluble
in ether, and is as acrid as the resin syl-
vacrol, which can be extracted by alcohol
or chloroform.
PREPARATIONS AND DOSES.— The
official preparations are: —
Stillingia, U. S. P. (the crude drug).
Dose, ]/2-l dram (2 to 4 Gm.) in decoction.
FluidextractiDn stillingice (fluidextract of
stillingia). Dose, J^-1 dram (2 to 4 c.c).
Syrupus stillingiae compositus, N. F.
(compound syrup of stillingia). Dose, 1
dram (4 c.c). Contains stillingia, coryda-
lis, iris, sambucus, chimaphila, coriander,
and xanthoxylum.
PHYSIOLOGICAL ACTION.— In
small doses, frequently repeated, it is be-
lieved to stimulate the various secretions,
acting as an alterative. It is also regarded
as a stimulant to the heart and circulation.
In large doses, stillingia is a strong
irritant to the gastrointestinal tract, pro-
ducing nausea and vomiting, and violent
catharsis.
SXGStACH, CAHCR^ "^ -?^HFUS5:».
--.s, all active ai
-s sir - ''■ sypiiiiis
-m-riTTir liver disorders, m
5kin -' jaundice,
.-;-,- - disordered
_-ficieat action at' die
\ has tjcen nrnch use
- ('X. F/' is a=-": .
-mm ioHiffp r jypnuis,
iirnnir riieamatism, ere. W.
e a
ress, j^'
■s.. J.I severe. =
c cancer. The
-red papers of St.
inic, pp. 149,
ry of gastric
11.4- jears
%>cz;
■ones, ave-"'""'
STOKES --\D. VMS DISE
i CTT
: ::. -- - ,: .:e SDecinic..
imined nd per cent, showed, nicers
with liases free h' cancer, while about
40 ner cent, showed them to he tmi-
cancerans.
These stadstics are somewhat
higher than those re - : :n atfaer
STOM.\CH, CASCESL OF.- pans
Reiiaoie recent s'
— X of the ->Li iii.L
lie
iaa lU^er than
t'l :
ie. ac
to Smithies, over one-half i
deaths occmred throu^tiout the • -
lized world in the same period.
ETTGLOGY. — The disease occurs
with the greatest fre berveen
the a-. • "
advancia :ii ^t::
cai -'^•^■■•elial p. u.c ii
err.. .:c rests, in .. "^i-
cal. thermic, traaTnrt--r i-r.d -ti- ■ - -.^
irritants, do not e
aomena. of gastric cancer. An a:
tempt has been made Co iraolicate
occupation, a^ tobaccc. trau-
matisra, diet, her but none at
these factors has yieided a sansnic-
tc-T— ■'—■\ Sex i- ' -■ ip-
pr :..,:u..:ely three .u....^;- u.-- j.-c-i '"
everv 'emnle.
ter
in. the pre-ex:.
SYMPTQMATOLQG-Y
DIAGMOStS. — ' lastrtc cardnorau
IS .
■ne
Ae other
Xi3
ms dne. an. the
- t tile chseas^
. .'!'--, «anac:ii-
:i : r. and.
-ne
- -le
i^nc—
TV
U:.,T
cmoma rs e: .
fies active st-.
-Approximately r-r per cert of aH
cases of gastric car - eriteti
upon at the Mayo " iccordin^
-r- ■. naiib._ .. n:-
. • . 2 with gastric
.ctirn. meed distnrbances
in " ty and secretion can accur
varymg^ with the Iccancn of tie
-n-miir
An impi^rrant question i& the pr i -
Terr " --y TtnfrmMi
; — . . ■ tC' bear,
ie c. X. ■ v.;i ^. ;. ,.; i must be
borne in Carcincma must be
-ecognizc^ re emaciancn. aneiffii,
weakness, tumor, and 'nchexia ap^
pear: ni the preseicy ese symp-
toms the case ns already inuperabfe.
Secondly, the very tirst sta^ at cat-
STOMACH, CANCER OF (REHFUSS).
325
cer, represented merely by an iso-
lated group of aberrant cells, can
hardly be diagnosed, because radio-
logically it will not deform the image
and physiologically it will not inter-
fere with function. Therefore, when
we witness an .actual disturbance, the
disease is already advanced.
The patient does not CQnsult the
physician until definite symptoms are
present, and yet definite symptoms
often spell disaster. How, then, are
we to cope with the condition? By
educating the public to the frequency,
danger, and necessity of early diag-
nosis, and then bv submittinc: anv
persistent gastric condition which ap-
pears during the "cancer" age to
all diagnostic methods available.
The means at our disposal are: (1)
history and clinical examination ; (2)
laboratory diagnosis, bacteriological,
serological and chemical; (3) X-rays.
Graham (collected papers, St. Mary's
Hosp., Mayo Clinic, 1913) recognizes
three types of history in gastric car-
cinoma: First, a long precancerous
history, often years in duration,
clearly an ulcer history (40-42 per
cent.) ; second, those who for months
or years past had gastric symptoms,
but who for months or years have
had freedom from discomfort; third,
those whose trouble came as a thief
in the night or who have seemed to
leap from health to grave disease, —
the latter, 58 per cent, less than two
years. As histories are better studied
group 3 decreases and groups 1 and
2 increase proportionately.
The symptoms vary with the to-
pography and nature of the growth.
Again, the course varies according
to whether the patient has been pre-
viously in perfect health or whether
the growth is engrafted on the ulcer.
Pain is almost constant, usually
dull, boring and continuous. As a
rule, it is not intense, but shows ex-
acerbations after the taking of food.
Occasionally, food relieves it. It is
often described as "burning," "sore-
ness," "aching," with a feeling of
fullness and discomfort. A few cases,
up to an advanced stage, show no
definite pain.
Vomiting appears as the disease
progresses. In pyloric cancer it may
occur early and yield a rancid, foul
material. In the ulcer carcinomato-
sum type all the signs of gastric
dilatation with hypersecretion may
be present.
Gas is ejected in many cases along
with bitter or sour eructations, al-
though often the symptom is simply
a troublesome aerophagia.
Anorexia occurs rather early, and
may later be associated with nausea.
Soon all desire for food is lost, par-
ticularly for meats. Yet in medio-
gastric carcinomata and in non-ob-
structive neoplasms, the appetite,
considering the gravity of the lesion,
is often good.
In a number of cases emaciation,
loss of weight and anemia occur be-
fore any localizing symptoms become
apparent ; in another group gastric
symptoms will dominate the picture ;
while in the course of a chronic-ulcer
history the heartburn and burning
may abate and the pain become al-
most constant, with, probably a grad-
ual change in the gastric chemis-
try, with sudden or gradual loss of
weight. While constipation is more
frequent, diarrhea may occur, with
foul, putrid stools and signs of sec-
ondary intestinal infection. . Again,
vomiting may be the first symptom
witnessed.
324
STOMACH, CANCER OF (REHFUSS).
THERAPEUTIC USES.— Stillingia was
formerly employed as an active alterative,
but evidences of its virtues are lacking.
It has been used, especially in the South-
ern States, as an alterative in syphilis,
scrofula, chronic liver disorders, and
chronic skin affections. In jaundice,
hemorrhoids, constipation, and disordered
digestion from insufficient action of the
liver, stillingia has been much used. The
compound syrup (N. F.) is used as ve-
hicle for potassium iodide in syphilis,
chronic rheumatism, etc. W.
STOKES -ADAMS DISEASE.
See Heart and Pericardium : Heart-
block.
STOMACH, CANCER OF.-
Reliable recent statistics shovv^ that
carcinoma of the stomach is on the
increase. In 1913 over 75,000 deaths
were attributable to this cause in the
United States alone, while, according
to Smithies, over one-half million
deaths occurred throughout the civi-
lized world in the same period.
ETIOLOGY.— The disease occurs
with the greatest frequency between
the ages of 40 and 70. The theories
advanced in explanation of the atypi-
cal epithelial proliferation, based on
embryonic rests, infection, chemi-
cal, thermic, traumatic, and infectious
irritants, do not explain all the phe-
nomena of gastric cancer. An at-
tempt has been made to implicate
occupation, alcohol, tobacco, trau-
matism, diet, heredity, but none of
these factors has yielded a satisfac-
tory clue. Sex incidence shows ap-
proximately three males afflicted to
every female.
The frequency with which car-
cinoma is engrafted upon ulcer justi-
fies active study in this direction.
Approximately 60 per cent, of all
cases of gastric carcinoma operated
upon at the Mayo Clinic, according
to Wilson (collected papers of St.
Mary's Hosp., Mayo Clinic, pp. 149,
1913) gave a long history of gastric
distress, i.e., averaging 11.4 years
prior to a short history (average six
months) of severe symptoms due to
gastric cancer. The remaining 40 per
cent, gave short histories, averaging
seven months. Of the specimens ex-
amined 60 per cent, showed ulcers
with bases free of cancer, while about
40 per cent, showed them to be uni-
formly cancerous.
These statistics are somewhat
higher than those reported in other
parts of the country, and higher than
my own. MacCarty believes that
the cancer cell in the stomach comes
from the intraglandular hyperplastic
cells of the mucosa and represents a
terminal malignancy in the pre-exist-
ing hyperplasia.
SYMPTOMATOLOGY AND
DIAGNOSIS.— Gastric carcinoma
is attended b)" symptoms due, on the
one hand, to the effect of the disease
per se, namely, weakness, emacia-
tion, cachexia, loss of weight, and,
on the other, to the specific action on
the gastric walls, namely, epigastric
tumor, loss of appetite, nausea, vomit-
ing, and interference with gastric
function. Pronounced disturbances
in motility and secretion can occur,
varying with the location of the
tumor.
An important question is the prob-
lem of early diagnosis. Every method
available must be brought tO' bear.
Several fundamental points must be
borne in mind. Carcinoma must be
recognized before emaciation, anemia,
weakness, tumor, and cachexia ap-
pear ; in the presence of these symp-
toms the case is already inoperable.
Secondly, the very first stage of can-
STOMACH, CANCER OF (REHFUSS). 325
cer, represented merely by an iso- Pain is almost constant, usually
lated group of aberrant cells, can dull, boring and continuous. As a
hardly be diagnosed, because radio- rule, it is not intense, but shows ex-
logically it will not deform the image acerbations after the taking of food,
and physiologically it will not inter- Occasionally, food relieves it. It is
fere with function. Therefore, when often described as "burning," "sore-
we witness an .actual disturbance, the ness," "aching," with a feeling of
disease is already advanced. fullness and discomfort. A few cases,
The patient does not consult the up to an advanced stage, show no
physician until definite symptoms are definite pain.
present, and yet definite symptoms Vomiting appears as the disease
often spell disaster. How, then, are progresses. In pyloric cancer it may
we to cope with the condition? By occur early and yield a rancid, foul
educating the public to the frequency, material. In the ulcer carcinomato-
danger, and necessity of early diag- sum type all the signs of gastric
nosis, and then by submitting any dilatation with hypersecretion may
persistent gastric condition which ap- be present.
pears during the "cancer" age to Gas is ejected in many cases along
all diagnostic methods available. with bitter or sour eructations, al-
The means at our disposal are: (1) though often the symptom is simply
history and clinical examination ; (2) a troublesome aerophagia.
laboratory diagnosis, bacteriological, Anorexia occurs rather early, and
serological and chemical; (3) X-rays, may later be associated with nausea.
Graham (collected papers, St. Mary's Soon all desire for food is lost, par-
Hosp., Mayo Clinic, 1913) recognizes ticularly for meats. Yet in medio-
three types of history in gastric car- gastric carcinomata and in non-ob-
cinoma: First, a long precancerous structive neoplasms, the appetite,
history, often years in duration, considering the gravity of the lesion,
clearly an ulcer history (40-42 per is often good.
cent.) ; second, those who for months In a number of cases emaciation,
or years past had gastric symptoms, loss of w^eight and anemia occur be-
but who for months or years have fore any localizing symptoms become
had freedom from discomfort; third, apparent; in another group gastric
those whose trouble came as a thief symptoms will dominate the picture ;
in the night or who have seemed to while in the course of a chronic-ulcer
leap from health to grave disease, — history the heartburn and burning
the latter, 58 per cent, less than two may abate and the pain become al-
years. As histories are better studied most constant, with, probably a grad-
group 3 decreases and groups 1 and ual change in the gastric chemis-
2 increase proportionately. try, with sudden or gradual loss of
The symptoms vary with the to- weight. While constipation is more
pography and nature of the growth, frequent, diarrhea may occur, with
Again, the course varies according foul, putrid stools and signs of see-
to whether the patient has been pre- ondary intestinal infection. . Again,
viously in perfect health or whether vomiting may be the first symptom
the growth is engrafted on the ulcer, witnessed.
328
STOMACH, CANCER OF (REHFUSS).
Many methods have been devised
to show neoplasm by gastric an-
alysis : — •
(1) Deviation in acid and ferments.
(2) Presence of organic acids.
(3) Increase in nitrogen or protein:
Nitrogen content. (Salomon:
Deut. nied. Woch., xcvii, p.
499, 1909.)
Albumin content. (Wolflf and
Junghans : P>erl. klin. Woch.,
nu. 22, 1912.)
Fractional protein content.
(Clarke and Rehfuss: Jour.
Amer. Med. Assoc, Ixiv, 1737,
1915.)
(4) Glycyltryptophan. (Neubauer and
Fischer : Deut. Archiv f . klin.
Med., xcvii, p. 499, 1909.)
(5) Tryptophan. (Weinstein, Sanford
and Rosenblooin: Jour. Amer.
Med. Assoc, Iv, p. 1085, 1910.)
(6) Amino-acids. (Barlocco: Berl. klin.
Woch., xlvii, p. 1536, 1910.)
Salomon showed that the wash
water after a special technique in
non-carcinomatous cases contained
from 0 to 16 mg. of nitrogen per 100
c.c, while that of carcinoma yielded
from 10 to 70 mg. Smithies believes
that the Wolff-Junghans reaction is
of decided value, but its value is very
much enhanced when the fractional
technique given here is followed
(Tour. Amer. Med. Assoc, Ixiv, p.
1737, 1915) :—
Specimens are collected by means of the
fractional tube at fifteen-minute intervals.
One c.c. of the filtered juice is diluted with
9 c.c. of water; 5 c.c. of this is again added
to 5 c.c. of distilled water, and the dilutions
are kept up until a series is obtained repre-
senting 1:10, 1:20, 1:40, 1:80, 1:160,
1 : 320, 1 : 640 or more. Then they are
stratified with approximately 1 c.c. of the
Wolfif phosphotungstic acid reagent.
Readings are immediately made and the
tube giving a ring at greatest dilution
recorded.
The glycyltryptophan and trypto-
phan tests, in the light of recent
communications from our la1)oratory
(Spencer, Meyer, Rehfuss, and Hawk:
Amer. Jour, of Physiol., 1916) and
others, seem valueless.
lilood is found in about 75 per cent,
of cases, by tlic fractional technique
in a larger proportion, and with about
equal frequency in tlie stools.
Lactic acid found regularly in the
stomach in 35 cases of gastric can-
cer. Sarcinai were observed in 3. In
a case of renal carcinoma there was
considerable lactic acid in the sound
stomach. The symptoms had long
pointed to this organ; a simple gas-
tric ulcer was found. Rodella (Cor-
resp. f. schweiz. Aerzte, June 1, 1918).
The Abdcrlialdcn reaction cannot be
depended upon for diagnosis. Von Dungern
(Munch, med. Woch., xxvi, 1380,1913) em-
ployed the method of complement deviation;
Waelli (Mitt. a. d. Grenzgeb. d. Med. u.
Chir., xxv, 184, 1912) the antitrypsin reaction,
which has been further elaborated by Roux
and Savignac (Archives des mal. de I'App.
Digest., vi, 453, 1912), etc,; but none of these
has been satisfactory. The anapliylactic re-
action of Ransohoff (Jour. Amer. Med.
Assoc, Ivii, 103, 1911; Ixi, 8, 1913), the
vieiostagmin reaction of Ascoli (Miinch.
med. Woch., Ivii, 63, 1910), the hemolytic
test of Kelling (Archiv f. Verdauungk.,
xviii, 164, 329, 1912), the cytolytic test of
Freund and Kaminer (Biochem. Zeitsch.,
xxvi, 312, 1910; xliv, 470, 1913), the hemo-
lytic reactions of Crile, Fischel, Frankel, the
skin reaction of Elsberg. Neuhof, and Geist
have all been recommended, but none of
them has proven to be specific or infallible.
The estimation of colloidal nitrogen, neu-
tral sulphur, and the determination of the
oxyproteic acids have been suggested as
urinary tests, but the same criticism, namely,
their non-specificity, renders them unfit as
diagnostic tests.
X-ray Examination. — By means of
careful fluoroscopic and serial radi-
ography it has been possible to deter-
mine gastric neoplasm in its incip-
iency. This method reveals the form,
size, and position of the organ, and.
STOMACH, CANCER OF (REHFUSS).
329
as Beclere was accustomed to say,
g^ives a "moulage" or cast of it.
Carcinoma interferes with gastric
peristalsis, causes "defects" in the
gastric image, and frequently can pro-
duce shrinkage or fixation of the
whole organ. In advanced carcinoma
the picture is characteristic by its
moth-eaten appearance in the medul-
lary and adenocarcinomatous types or
its shrinkage and irregular canaliza-
tion in the scirrhous types. Early
carcinoma may produce merely a
persistent pocket or "filling defect"
in the image, which is with difficulty
distinguished from ulcer or spasm.
The possibility of defects due to ex-
tragastric pressure or adhesions must
be constantly borne in mind. Achylia
with advanced scirrhous cancer and
complete narrowing of the pyloius
and antrum, will frequently produce
the picture of patulous pylorus and
rapid evacuation, while the opposite
form, a large stenosing carcinoma of
the antrum or pylorus due to medul-
lary or adenocarcinoma will be found
accompanied by gastric dilatation.
The combined fluoroscopic and plate
method is of the greatest value and
when the former is combined with
manual palpation under the screen
much can be elicited. The visualiza-
tion of the palpable tumor and the
coincidence of the filling defect with
it are convincing findings.
TREATMENT.— The treatment
alone offering positive cure is sur-
gical removal. Surgery itself has its
limitations, but tlic gravest danger of
all is late diagnosis. This is due pri-
marily to consulting the physician
only after the disease has been fully
developed, secondarily to the phy-
sician who fails to insist on a thor-
ough study of the case.
Operation gives no hope of suc-
cessful completion if (1) the tumor
crowds well up in the cardia ; (2)
if the cardia is obstructed; (3) if
the growth is diffuse and the organ
shrunken ; (4) if there is extensive
glandular involvement; (5) if there is
involvement of other organs, as the
pancreas, liver, or colon ; (6) if foci,
such as the rectal shelf and ovaries,
be transplanted, and (7) extreme
cachexia must be considered (Gra-
ham). There is prospect of a 5-year
cure in 25 per cent, and a three-year
cure in 41 per cent. (Mayo). Sur-
gery's chief contribution is thus pro-
longation in life, although cures are
also met with. The operative mor-
tality of a resection is about 10 per
cent.
Medically in inoperable cases,
where motility is still intact, the
problem before us is essentially one
of a proper diet and measures to pre-
vent, as far as possible, infection of
the ulcerated neoplasm while trying
to relieve symptoms. The diet should
he highly nutritious, finelv divided,
and, as far as possible, predigested.
Vegetables, in puree form, finely
chopped meats, souffles, peptonized
milk, starchy foods which have been
dextrinized, and an avoidance of all
coarse, irritating foods and of all but
finely emulsified fats — as we want
foods which rapidly leave the stom-
ach— are the proper dietetic measures.
Gastric lavage and the use of anti-
septics and alkaline cleansing agents
locally are often of much value, while
instillation of silver salts will often
help control secondary infection.
The use of tlie Coley toxins or the
split protein vaccine of Vaughn (N.
Y. Med. Jour., Oct. 15, 1910) sug-
gests itself, as well as the various
330
STOMACH, DISEASES OF (BASSLER).
forms of colloidal therapy, but as yet
no satisfactory treatment has been
devised. Radium locally and deep X-
ray therapy confer little beneht. The
greatest good comes from attention
to details care of the mouth and
throat, regulation of the diet, preven-
tion of intestinal infection, and insur-
ance of regular bowel evacuation.
Lavage and bitter tonics for ano-
rexia ; orthoform, anesthesin, spirits
of chloroform for pain, or even the
use of analgesics in suppostory form ;
cerium oxalate, sodium bicarbonate,
bismuth subcarbonate, magnesium
oxide for burning and discomfort;
mineral oil, cascara, phenolphthalein,
extract of belladonna and magnesia
as laxatives, or colonic irrigations for
obstinate constipation, are all in or-
der. If stenosis occurs, surgical re-
lief is indicated.
Martin E. Rehfuss,
Philadelphia.
STOMACH, DISEASES OF.-
GASTRIC NEUROSES.— Syno-
nyms.— Nervous Dyspepsia, Dyspep-
sia, Indigestion, Flatulency, Weak
Stomach, etc.
General Considerations. — True neu-
rosis of the digestive canal occurs
chiefly in subjects between the 20th
and 40th years of life and with about
equal frequency in the two sexes.
Its general causes are disorders due
to abnormal nutritive states of the
nervous system, and developing, e.g.,
from insufficient food, low vitality,
physical or mental overwork, or a
general abnormal catabolism. Added
to these are toxic causes and instabil-
ity of the psychic make-up.
NEUROTIC SECRETORY CON-
DITIONS.
HYPERACIDITY. — Hyperacidity
is a symptom of some form of irrita-
tive disorder. This may be an ulcer,
Reichmann's disease, etc. But some-
times the condition is a pure neurosis.
Etiology. — Hyperacidity is found
in the young and middle-aged, less
often in the old. The following fac-
tors are important in its production.
First : Indiscretions in diet, e.g., the
use of irritating, excessively bulky
foods, large meals, the abuse of
alcohol, tea and coffee, and particu-
larly that of tobacco; hasty eating;
drinking of excessively hot or cold
fluids or carbonated beverages, par-
ticularly with the meals ; eating of
foods too highly seasoned or with
essential oils, and the use of an ex-
cessive amount of candy. Second :
Disturbances of the gastric secretory
apparatus due to mental strain, over-
work, anxiety, worry, hysteria, neu-
rasthenia, melancholia, and psychic
conditions. Any sudden mental shock
may bring on low or absent secretion
or motility, and when mental strain
is long continued, the opposite may
occur in the secretion, the motility
at the same time remaining normal
or even being depressed.
As to whether primary myasthenia
or atonic states of the stomach should
be considered causes of hyperacidity,
I have doubts. But there is a form
of hyperacidity secondary to chronic
constipation, and likewise there are
symptomatic hyperacidities due to
open, more or less healed, or irrita-
tive scars from acute or chronic
ulcer ; early gastric cancer, chole-
lithiasis, pancreatic or renal calculi,
acute hepatitis, a mild degree of acute
gastritis, gastritis acida, chlorosis,
etc.
Symptoms. — Whatever the cause,
the symptoms are, as a rule, the same :
STOMACH, DISEASES OF (BASSLER). 331
Eructations of acid gas or regurgita- empty stomach two hours after a
tions of acid food or fluid (sometimes simple test meal, and an alkaline or
termed pyrosis), heartburn, pain and neutral stomach when it is empty of
burning in the stomach and cardiac food, are other features of hyper-
region, severe stomach pressure, dis- acidity.
tress one or more hours after meals In the digestive form, while there
(relieved by foods or alkalies, made may be no food in the stomach be-
worse by starches), attacks of nausea, tween meals, a little fluid content of
and perhaps occasional vomiting dur- an acid nature may continue from
ing the height of gastric digestion, one meal to the next. The morning
the return burning the throat and empty stomach in these cases is usu-
benumbing the teeth as it passes ally neutral or has only the slightest
over them, thirst or an excessive flow acidity. During the attacks the mu-
of saliva, constipation, anorexia, ma- cus content may be elevated slightly,
laise, headache, loss of weight and but, as a rule, it is normal, and often
strength, and finally the development below normal.
of neurasthenic states. The neurotic Prognosis. — Upon removal of the
form is usually abrupt in onset, and cause at least 90 per cent, of these
relief on taking foods or alkalies, or cases become symptom-free,
when the stomach is empty, is Treatment. — The main indications
marked. Where there is a dietetic or are to control the hyperesthesia of
neurological cause, recurring attacks, the stomach and to give sufficient
with intervals of relief, may be food to maintain an equilibrium ; or,
present. In the secondary forms, on if necessary, cause an addition in
the other hand, with the exception nutrition. Combining the free acid-
of duodenal ulcer, this history of ity by proteins is really unimportant,
intermission is not common. Use simple fluid or semisolid foods,
Diagnosis. — This is made from the hyperesthesia being thus minimized,
symptoms, the discovery of a cause, and a high caloric value in small
and the analysis of test meals. The bulks maintained. Small meals of
physical examination is usually nega- about equal size and strictly regular,
tive, though mild anemia may be ob- frequent feeding should be ordered,
served. In some, however, there is Eggs, fresh milk and cream, well-
epigastric tenderness. Diminution in cooked cereals, bread and crackers,
the chlorides and increase in indican together with a considerable quantity
are frequently observed in the urine, of butter, soft vegetables, minced
Considering only the neurotic and meat, etc., answer to good purpose,
dietetic types, the bulk of return After a few weeks additions to the
from an Ewald meal is increased, diet can l)e made, and at this time
The total amount may be as high as lime-water or alkaline drinks such
120 c.c, with a high acidity, usually as Vichy, Congress Hathorne, or
above 30° of combined HCl. A nor- Carlsbad may answer,
mal stomach should not give an acid- Hygienic, physical and hydropathic
ity above 30°, and a total return not measures should not be neglected,
above 90 c.c). Poor digestion of the The overworked should be ordered to
starch content of the test meal, an rest, and those who have been under
332
STOMACH, DISEASES OF (BASSLER).
a mental strain sent to the country,
seashore, or mountains. Out-door
life and physical exercise are most
beneficial. Walking to the place of
business and home again, with an
additional walk in the evenings, ren-
ders this possible to the business
man. With women, less carriage and
car riding, fewer social functions and
theaters, and more exercise and open-
air life, are important factors in the
treatment. Gastric lavage is malprac-
tice. In patients susceptible to it,
electricity is helpful for a short time,
and, the condition persisting, intra-
gastric galvanism with the positive
pole internal; or, if results are not
thus obtained, the negative pole in-
ternal, is helpful. When atony or
marked constipation exists, the fara-
dic current with slow interruptions
or the sinusoidal current is best em-
ployed. In neurasthenia high fre-
quency to the spine has served a
good purpose. The morning cold
plunge or sponge bath, or the morn-
ing rub vi^ith a cold wet towel, are
serviceable, and a hot douche before
retiring may relieve the insomnia.
For a long time the alkalies have
been used to control the subjective
distress. Positive and almost imme-
diate benefit comes from their use,
and no harm follows their use for
long periods. As a rule they should
be administered after taking food,
when symptoms develop (from one
to three hours after meals).
For hyperchlorhydria : —
B Magnesii oxidi,
Bismuthi subcarbonatis,
Sodii bicarbonatis,
Sodii carboiiatis exsiccati,
Sacchari lactis aa Siiss (10 Gm.).
Fiat pulvis.
Sig. : Take 3^ teaspoonful in water one,
two, or three hours after meals.
When constipation exists : —
R Magnesii oxidi 'Siiss (10 Gm.).
Misturcc rlici et sod<e. Svij (200 Gm.).
M. Sig. : Take a tablespoonful (as re-
quired in time) after meals, in water.
Or, when a powder or mixture is
not desired : —
IJ Magnesii oxidi,
Bismuthi subcarbonatis,
Pulveris rliei aa Svj (24 Gm.).
Fiant tabellse no. l.
Sig.: Take 1 of 2 tablets (as required in
time) after meals.
The second drug of importance,
which is of particular value in a per-
sistent case, is belladonna or atropine.
This drug effectually inhibits gastric
secretion, but its unpleasant physio-
logical effects may require discon-
tinuance. Tablets or pills of extract
of belladonna }i grain (0.016 Gm.) or
atropine sulphate ^/oo grain (0.00065
Gm.) may be taken after meals, or
one of these may be added to any of
the foregoing alkaline combinations.
Nerve sedatives such as the bro-
mides, valerianates and sumbul are
most valuable to control the hyper-
esthesia commonly present in these
cases. Its symptoms are most pro-
nounced when irritation from free
hydrochloric acid takes place ; hence
the importance of a suitable diet. A
useful prescription is the following : —
B Sodii bromidi,
TincturcB Valeriana",
Fl. ext. sumbul aa 3iv (16 c.c).
Syrupi q. s. 5iij (90 c.c.).
M. Sig. : Take a teaspoonful, after meals,
in water.
Olive oil and other hydrocarbons
have been highly recommended, the
former especially by Cohnheim. Its
use in tablespoonful quantities, swal-
lowed before meals, is sufficient. The
oil coats the interior of the stomach
STOMACH, DISEASES OF (BASSLER). 333
and inhibits the secretion of acid. In constant finding in chronic gastritis,
those not nauseated by it, its use is in early cancer, and in febrile condi-
worth while, particularly since it is a tions in general. In persons past the
good reconstructive in the under- 50th year of life there is a marked
nourished, and may keep the bowels tendency to diminution of gastric se-
regular. Addition of salt to the olive cretions. Some people, moreover,
oil should not be allowed. have always had a subacidity or ab-
A morning dose of Carlsbad salts sence of HCl without ever experi-
in a glass of warm water is an excel- encing any symptoms therefrom,
lent measure. This neutralizes the Symptoms. — These vary greatly,
acidity present and also moves the Epigastric pressure before and after
bowels, and when given well-diluted meals, but usually more marked after
in water it acts as an internal lavage them, with fullness, eructations, ano-
of the stomach. The Carlsbad salts rexia, diarrhea, intestinal disturb -
can also be used in small doses — 15 ances, occasionally nausea, head-
grains (1 Gm.) — in Vichy after aches, and great nervousness are the
meals. most common.
SUBACIDITY AND ANACID- Diagnosis.— The chief factor in
ITY. — In subacidity there is a low se- diagnosis is test-meal analysis. In
cretion of hydrochloric acid, with or subacidity the dimethylamidoazo so-
without a lowering of the enzyme lution or paper shows only a faint red-
content. In anacidity hydrochloric dish tinge ; the Ginsburg test is also
acid is absent, but the enzymes pres- low. In anacidity or nervous achylia,
ent. In achylia neither is present, abnormal organic acids, such as lac-
Etiology. — In instances of pro- tic, acetic, and butyric are met with,
longed anxiety, worry or suspense No case of nervous achylia should be
the secretory functions of the stom- diagnosed on the Topfer method
ach are usually inhibited or absent, alone. The Hayem-Winter method
and but very rarely run hyperacid, of estimating total chlorides and the
The effects of these emotions must tests for the enzymotic power must
be taken into consideration and not also be applied. Further, the dimi-
too much significance attached to test nution or absence of HCl and enzyme
meals removed under these condi- must not be noted at every examina-
tions (or on the first day of men- tion of test meals (and several should
struation). There is, however, a neu- be extracted); if they are, one is
rotic subacidity in which the acid and probably dealing with a more serious
also often the other constituents of state of affairs.
the gastric secretion are lessened in a Prognosis. — This depends upon the
more continuous way. While some removal of the causative condition,
of these cases are psychic or mental, which is usually possible. Where
most of them are due to debility the condition is of long standing the
from long-standing unhygienic condi- treatment may require some months,
tions, anemia, neurasthenia, hysteria, Treatment. — In the acute nervous
Graves's disease, tabes dorsalis, and cases the removal of the cause, seda-
long-standing diarrhea from any tive symptomatic treatment, and gen-
cause. Subacidity is also a most eral directions regarding diet, state of
334
STOMACH, DISEASES OF (BASSLER).
health, etc., answer all purposes. A
change of environment is often suffi-
cient. When the condition persists,
it may be necessary to allow only
enough proteins as will combine with
the hydrochloric acid present, or, in
its absence, a less amount, in finely
divided form — just enough to main-
tain nutrition. Important are the
use of foods that are finely divided
and the liberal employment of well-
cooked carbohydrates. When the
ability to digest meat is deficient,
substitution of brains, sweetbreads,
etc., may answer. Milk, as a rule,
is not very well borne. Of the
liquids, broths, such as rice, chicken
and barley, as well as albuminous
drinks and raw or soft-boiled eggs,
are recommended. Peas, beans, and
lentils in puree form or broths are
useful. Potatoes, rice, tapioca, sago,
and farina, w^ell-cooked in water or
dilute milk, are well borne ; like-
wise, any of the breads, rolls, simple
cake, or crackers, and a little butter.
Intragastric faradism may be used
when gastric motility is impaired.
The drug treatment comprises sub-
stitution therapy and also an attempt
to improve secretion.
Permanent results may be obtained
in achylia by lavage of the stomach,
its disinfection if need be, and the
giving at intervals of fifteen to thirty
minutes of 60 c.c. (2 ounces) of 0.25
per cent, hydrochloric acid for sev-
eral hours. After several such treat-
ments a full meal is taken and fol-
lowed at once by another fractional
instillation of acid. Parathyroid ex-
tract also serves in obscure cases.
M. E. Rehfuss (Jour. Amer. Med.
Assoc, Oct. 20, 1917).
Meat, broths, extracts, gelatin and
peptones stimulate the gastric secre-
tion, and in the neurotic forms of the
acute type this property may be
remedially utilized. In the more
l)ersistent type these substances arc
irritating-, and small amounts of
alcohol in the form of Byrrh wine
and Dubonnet before meals answer
better. Bitter tonics may be used.
In other instances dilute hydrochloric
acid answers best, though in the per-
sistent case its use may prove irritat-
ing. Where this is the case, one may
either resort to dietetic means, or dis-
regard the deficiency of secretion and
render the gastric digestion alkaline,
'Considering the organ as a part of the
intestine and confining its function to
that of a receptacle for food. In such
instances the following serves well : —
B. Pancreafiui Siiss (10 Gm.).
Sodii bicarbonatis Sv (20 Gm.).
Fiant pulveres no. xx.
Sig. : Take 1, after meals, in water.
For anorexia there is no better
treatment than insisting upon taking
sufficient quantities of food, together
with the use of tincture of nux
vomica, 15 minims (1 c.c), well di-
luted before meals. In anemia high
feeding should be kept up, and in the
non-acid tolerant cases the non-as-
tringent forms of iron given, and in
the acid-tolerant cases the stronger
forms of iron. Of the latter, the
tincture of ferric chloride is most
effective, particularly when kidney
complications exist : —
R Tincturs nucis vomiccB. 3ij (8 c.c).
Tinctura: fcrri chlorid.. 'Siiss (10 c.c).
Syrupi Biij (90 c.c).
M. Sig.: Take 1 teaspoonful well di-
luted in water one-half hour after meals.
Rhubarb or cascara may be used in
constipation. Flushings, either by
rectum or after appendicostomy, are
preferable in cases of gastro-enteric
atrophy with marked secondary or
pernicious anemia. When no atony
STOMACH, DISEASES OF (BASSLER).
335
exists, the use of the sodium chloride
waters, such as Kissingen, Weis-
baden, and Homburg, is sometimes
of value.
HETEROCHYLIA. — This term
applies to an alternating state of
secretion occurring chiefly in "nerv-
ous dyspepsia." At different times
within a short period the stomach
analyses show a subacidity and hy-
peracidity, or, more commonly, an-
acidity and hyperacidity. The con-
dition is of nervous origin, the vagus
or sympathetic innervation being
mainly affected. Among the symp-
toms are anorexia and a sense of
weight and fullness in the stomach
when the acid is low or absent, and
eructations when it is high. It may
be impossible to tell if a low or high
level of secretion exists at the time.
The elements of myasthenia, neuras-
thenia, and hysteria are marked in
these cases.
Treatment. — This is mainly hy-
gienic and climatic, with high protein
feedings. One should remember that
the gastric condition is secondary,
not primary.
GASTROMYXORRHEA. — The
increase of mucous flow may occur at
intervals (intermittent gastromyxor-
rhea), or, much more frequently, be
constant (continuous gastromyxor-
rhea). The condition is more com-
mon than is supposed.
Etiology. — Kiittner believes that in
the acutd form there is some connec-
tion between disorder of the nose and
that of the stomach. The chronic
form may accompany subacidity or
anacidity, or various organic diseases,
or may exist independently. It is as-
sumed that the mucus is derived
mainly from the glands of the pyloric
region.
Symptoms. — In the intermittent
cases a short prodrome of headache,
nausea, and anorexia, usually in the
mornings for one or two days, is
noted. An attack of severe intract-
able vomiting follows, the vomitus
consisting of large amounts of tough,
slimy mucus, finally mixed with bile
and intestinal juices. As a rule no
pain is present, but prostration may
be marked. Such an attack may last
from a few hours to several days,
ending suddenly. In the chronic
form subjective symptoms are usu-
ally absent or insignificant.
Diagnosis. — This is possible only
by aspiration of the fasting stomach
during an attack. Care must be
taken to distinguish mucus swal-
lowed from that of the stomach.
Treatment. — In the acute form,
during a paroxysm, thorough lavage
of the stomach with an alkaline solu-
tion may terminate the symptoms at
once. Later on it is useless. A hy-
podermic injection of morphine, as
well as external applications of heat,
may be called for. Interval treat-
ment consists in gradually ascending
doses of nux vomica until physiolog-
ical effects are produced, then con-
tinued for some time at a smaller
dose. Should paroxysms be frequent,
belladonna in fair-sized doses during
the day, or one rather large dose at
bedtime, is helpful. Tonics and hy-
gienic and climatic measures may be
indicated.
In the continuous cases no treat-
ment is more efficient than morning
and evening lavage with an alkaline
fluid, followed l)y a solution of fluid-
extract of hydrastis. Nux ^•omica
and l^elladonna may also be used, but
the effort should be made to diagnose
a more primary pathological state
336
STOMACH, DISEASES OF (BASSLER).
(e.g., chronic g-astritis), to which the
treatment should subsequently corre-
spond as well as to the general
condition.
NEUROTIC SENSORY DIS-
TURBANCES.
HYPERESTHESIA GASTRICA.
— Here the gastric mucosa is hyper-
sensitive even to normal stomach
contents. The simplest forms of food
or drink will often cause distress,
though normal secretion and motility
be present. In many instances, par-
ticularly in the Semitic races, distress
is more or less continuous, though
intensified by food. The condition
accompanies practically all of the
primary stomach disorders and many
of the secondary disorders as well.
It may be looked upon merely as a
symptom. In neurotics subacidity
may be present, or the stomach se-
cretir)n may vary.
Etiology. — As a primary affection
hyperesthesia is found in cases of
long-standing dietetic indiscretion,
neurasthenia, and hysteria, anemia,
general debility and mental strain, in
sexual excesses, and after the use of
stimulating fluids and narcotic drugs.
It is found oftener in females than
males, the disproportion being great-
est in the younger adult years.
Symptoms. — ]\Iild pain (severe
pains are gastralgic), fullness, and
weight or pressure appear imme-
diately after or are made worse upon
taking food or drink. Nausea or even
vomiting may take place at the height
of the distress. The very cold and
strong or carbonated drinks, may
cause more distress than solid foods.
The patient fears to partake of suffi-
cient food, thus may lose weight and
become anemic. Symptoms of hy-
perchlorhydria may be present,
Diagnosis. — Test meals may be
negati\e, and the diagnosis is made
from the symptoms, history, and re-
lief through proper treatment. In
persistent cases all local and general
•conditions must be excluded before
diagnosing a primary hyperesthesia.
Treatment. — According to many
the patient should be put to bed and
a milk or egg-albumin diet ordered.
I agree with this for the severe cases
and with Rosenheim, to an extent,
for the anemic ones. In general,
however, among patients intelligent
enough and with strength of purpose
enough to follow directions, only a
small proportion need go to bed.
According to the history of dietetic
causes obtained, abuse, habits, etc.,
must be stopped. The diet is essen-
tially that described under hyper-
chlorhydria. In a few cases, even
with great and persistent dietetic
care, the symptoms do- not abate. In
such, pathological QDnditions of the
stomach or other organs must be
persistently searched for. Especially
confusing is an underlying obscure
form of myasthenia or neurasthenia.
There are cases with subacidity of
the stomach which, nevertheless, do
best on the alkalies. In some instances
a little experimenting is necessary to
determine whether an acid or alkaline
treatment is wisest. High caloric
foods and iron are always in order
in the anemic and undernourished.
Drugs answering best to control dis-
tress are the bromides, and it is not
unusual to have to employ one of
these salts in large doses for weeks
at a time : —
B Sodii hromidi ... 3iiss-vj (10-24 Gm).
Aqucc mcnth. pip. 5viij (240 c.c).
M. Sig. : Take a tablespoonful in water
after jneals.
STOMACH, DISEASES OF (BASSLER).
ZZ7
Or:—
I^ Sodii bromidi,
Tinctura valcriance . .aa. Siiss (10 c.c.)-
Aquce chloroformi fSiij (90 c.c).
M. Sig. : Take a tablespoonful in water
after meals.
Or, when constipation exists : —
IJ Tinctura rhci,
Tincturcc Valeriana ..aa 'Siiss (10 c.c.).
M. Sig. : Take 20 drops in water after
meals.
Useful also in any of these cases
are the hygienic and hydrothera-
peutic measures, cold compresses to
the abdomen, galvanism, occasion-
asked, and even then may be
denied altogether. In, a few months,
suffering from pain or spasm is ex-
treme. The pain is situated in the
epigastric and left and right lower
chest and hypochondriac regions.
From this the pain may radiate into
the left chest, left shoulder, back or
general abdomen, and may be so in-
tense as to cause weakness and col-
lapse. The patient is usually anxious
and in an attitude afifording- the
greatest relief. Usually the stomach
region is tympanitic. There may be
tenderness and a sense of relief on
ally the use of nux vomica in small steady pressure. The attack lasts
doses, belladonna, and a sojourn in
the country away from work.
GASTRALGIA NERVOSA.— This
is an intense form of gastric hyperes-
thesia in which the paroxisms are
periodic or spasmodic. They soon
subside, an interval of complete
from a few minutes tO' several hours.
Diagnosis. — This is based on the
history, symptoms, type of individ-
ual, and brief seizures. In recur-
ring cases, ulcer, hypersecretion, gas-
tromyxorrhea, cardial or pyloric
spasm, biliary or renal colic, inter-
health following. There is a question costal neuralgia and herpes zoster of
as to whether giastralgia is an entity; the lower left dorsal nerves, and
yet it comprises about 2 per cent, of angina abdominis must be excluded,
all the cases of neurosis. Treatment, — The treatment is that
Etiology. — It is probably due to a of hyperesthesia gastrica together
sensory disturbance of the gastric with, imless a true neurosis, care of
vagus terminal branches. The most the underlying condition. During the
frequent causes are excessive indulg- attack, hypodermic injection of mor-
ence in tobacco, irregular eating, too phine with atropine may be neces-
free use of cheap soda-water, drink- sary. Hot compresses may be ap-
ing of iced fluids in excess, and the plied, and in the less severe cases the
use of very stimulating foods and bromide mixtures already mentioned
fluids. may sufiice. Chloral hydrate by
Symptoms. — The attacks of pain mouth or rectum answers well when
or spasm appear quite suddenly, al- the seizure is prolonged. Foods and
though they may be preceded for a drinks should be withheld. Strych-
few hours or days by anorexia, head- nine for a few days may be necessary
ache or backache, vertigo, fullness to strengthen the patient. In the true
and weight in the stomach, slight neurotic form, treatment in the inter-
precordial or gastric pain, nausea, val is most important. Tobacco and
and perhaps vomiting. In the ma- alcohol must be interdicted, regular
jority of cases the history is not ob- eating habits advised, and the taking
tained unless definite questions are of cold drinks, soda water, tea, coffee,
8—22
338 STOMACH, DISEASES OF (BASSLER).
and strongly stimulating foods, be Symptoms. — General neurasthenic
stopped, (icncral tonics, good food, states are characterized by a morbid
regular living, a loni^ period of rest irritability and fatij^ue of the physical
in bed each day, fresh air, outdoor and psychical processes accompanied
exercise, massage, and hydrothera- by various sensory disturbances, in-
peutic measures arc in order. When eluding such symptoms as depres-
there is an underlying cause recovery sion, morbid thoughts^ lack of power
is slow. of attention, fullness and throbbing
in the head, occipital headaches, in-
NEURASTHENIA GASTRICA. somnia, pains and tender areas along
POLYSYMPTOMATIC NEURO- the spine, nocturnal emissions, dread
SIS OR NERVOUS DYSPEPSIA, of impotence, hot and cold flashes,
— This condition is a mixed neurosis localized sweatings, transient blue-
in which the sensory, secretory, and ness, cardiac pains, and irregular,
motor nervous mechanisms of the rapid, or slow heart action,
stomach, either in combination or al- Among gastrointestinal symptoms
ternately, play a part. The disturb- the chief are those of the sensory
ance is essentially a neurasthenia af- group coming on after meals, viz.,
fecting chiefly the stomach, and with weight, fullness, ill-defined gastric,
it commonly the small intestine (gas- sternal, or back pains, burning or
troenteric neurasthenia). Strictly cold feeling in the stomach, and an
speaking, this type of disorder ex- empty sensation in the stomach even
eludes the true sensory neuroses and after a large repast. As a rule, these
the high and low secretory and motor are not dependent upon the quality
conditions already described. It is or quantity of food ingested, but
only as one views the patients from rather upon the state of the emotions
a neurasthenic standpoint, and after and the body as a whole. Sometimes
a large number of gastric analyses, the most digestible foods cause dis-
that these cases of true neurasthenia tress, while the most indigestible are
gastrica can be distinguished. borne without discomfort. To the
Etiology. — Any of the factors that above list of symptoms may be added
chronically deplete the general tone heartburn, eructations of inodorous
of the body — constitutional diseases, and tasteless gas, sitophobia, diges-
unhygienic conditions, dietetic errors, tive vertigo, and the intestinal symp-
or other factors — may so affect gas- toms of distention, abnormal sensa-
tric digestion as to cause neuras- tions, flatulency, and constipation.
thenic variations in its function, i.e.. There may be thin, long stools at one
variations sensory, secretory, and time and normally shaped stools at
motor, not necessarily coexisting, but another. The appetite is usually
at least all present at different times capricious. Examination of the ab-
within a short period (within seven domen is often negative, but tender
days). Neurasthenia gastrica com- zones may be noted, as well as gas
prises only about 10 or 15 per cent, distentions in the cecum, colon or
of the cases of functional gastric dis- sigmoid. Chronic excessive putrefac-
order. It is commoner in the male tion in the intestines is a common
sex than in the female. factor.
STOMACH, DISEASES OF (BASSLER). 339
Diagnosis. — This is based on the general strength built up, and treat-
incongruity and inconsistency of the ment continued long enough. The
gastrointestinal symptoms, and the milder forms yield readily to treat-
frequent combination of cerebro- ment, most of them requiring about
spinal and vasomotor disturbances a year of observation when in the
with them, on the variable course of cities, and possibly half that time in
the illness during observation, on the sanatorium treatment in the country,
length of time required for recovery. Many patients, handicapped from
and on the stomach analyses. The birth with a weak, nervous system,
greater the gastrointestinal symp- only do well when no especial de-
toms, and the fewer, relatively, those mands are made upon them. Phleg-
of the general system, the more cer- matic individuals with more or less
tain it is to be a case of true neuras- visceroptosis may continue over long
thenia gastrica. To establish the periods in fair health, but may easily
diagnosis practically every other gas- progress on a downward path, lose
trie condition must be excluded. The flesh and strength rapidly, and have
cases of ulcer, gastritis, prolapse ; a relapses on the least provocation. All
constantly high, low, or absent secre- of these cases require strong persua-
tion ; increased or absent mucus ; sion to have them carry out the essen-
atony, or hypersensitiveness, must all tials of treatment. The confidence of
be relegated to pathological states the patient must be gained, and as-
other than neurasthenia, although in surance given that he will later get
the latter any or all of these condi- well.
tions may be present only for a short Treatment. — In all cases present-
time. In so far as gastric analyses ing some other ailments these should
are concerned, a more or less con- receive first attention. The patient
stant variation in gastric secretion, must be made to> feel that hygienic
motility, and sensation, is alone diag- measures are all-important. Change
nostic. Cases in which gastrointes- of climate, entire relief from business
tinal or corporeal symptoms are in- and perhaps social life, abundant
tense and persistent, but numerous food, outdoor exercise, fresh air, but
analyses prove normal, are seldom not too much sunshine, regular liv-
those of clean-cut neurasthenia. A ing, sufficient sleep, and hydrothe-
diagnostic feature of general neuras- rapic measures are essential. Gen-
thenia is the observation that, even if eral body massage and electricity in
there is a variation in the amounts of any form are valuable adjuncts. No
hydrochloric acid secreted at different attempts at dieting are indicated; in
times, the ferments are more often fact, the rule should be to give large
present in about constantly even amounts of high caloric foods, irre-
amounts. The secretion of enzyme spective of the symptoms. Tea, coffee,
is much more independent of general alcohol, and the stimulating foods
conditions than that of the acid, and should be interdicted, but the taking
when it is influenced, this is to be of supplemental meals should be en-
taken as evidence of a local condition, couraged. The gastric douche may
Prognosis. — This, as a rule, is good be employed, but no direct benefit to
if the exciting cause can be removed, the stomach comes from lavage un-
340
STOMACH, DISEASES OF (BASSLER).
less g-astric hypomotility exists. The
ferruginous or arsenical waters may
l)e taken when indicated, or iron may
be given. The bromides are neces-
sary at first to control the symptoms,
but valerian and nux vomica bring
about the Ijest results in the end.
Nux vomica, combined with the elixir
of gentian with tincture of iron chlo-
ride (elixir gentianae cum tinctura
ferri chloridi, N. F. ; dose, 1 fluidram
— 4 c.c), taken diluted l)efore meals,
answers best for the anorexia. The
bowels may be kept open by dietetic
means, cascara, phenolphthalein, or
enemas, but the purgative waters
should not be used. There should be
taken each day at least 4 glassfuls of
Avater (1 warm before breakfast) ;
fruits, morning and evening; the lib-
eral use of honey, butter, and olive oil
or fresh cream should be encouraged ;
a dish of stewed prunes, sweetened
with lactose, should be eaten before
retiring; the use of bran gems at
meals instead of bread, rolls, or cake,
should be advised. Agar-agar may
be taken with milk or cream and
sugar, with or in place of the morn-
ing- cereal. Habit-forming drugs
should not, as a rule, be employed in
neurasthenia. A prescription of value
is, however, the following: —
B Fluidextracti coccc,
Tiuct. nitcis voiiiicw. .a.a f3ij (8 c.c).
Ac. pliosphorici dil fSvj (24 c.c).
Syrupi singiberis fSiss (45 c.c).
Aq. menth. pip..q. s. ad fSvj (180 c.c).
Ft. mist. Sig. : Tablespoonful in water
after meals.
BULIMIA. — This is characterized
by an abnormal feeling of hunger. It
may be the only manifestation of a
primary neurotic condition, or be
associated with dilatation of the
stomach, neurasthenia, hysteria, tape-
worm, pancreatic and intestinal af-
fections, brain tumors, Basedow's
disease, pulmonary tuberculosis, dia-
betes, syphilis, etc. It is probably
due to contractions of the muscularis
of the pyloric region. Neurotic bu-
limia may occur in periodical attacks,
at times accompanied by faintness,
tinnitus, vertigo, headache, trem-
bling, and cold extremities. As a
rule secretion and motility are nor-
mal. Treatment for the neurotic con-
dition, small meals at hourly inter-
vals and large doses of bromides, are
helpful. In persistent cases, a pri-
mary cause other than neurosis
should be carefully sought.
PAROREXIA. — This designates
perversions of appetite, and includes
( 1) pica, a desire for articles of a non-
food character, such as coal, ashes,
earth, chalk, insects, etc. ; (2) mala-
cia, for special or pungent foods, such
as vinegar, mustard, sauces, catsup,
green fruits, etc. ; (3) allotriophagia,
a desire for disgusting or harmful
foods, such as urine, feces, glass,
needles, pins, knife-blades, etc. Pica
and malacia are often observed in the
same individual in neurasthenia, and
allotriophagia is noted in hysteria,
idiocv, and lunacv. Malacia is often
met with in chlorotic girls and preg-
nant women.
POLYPHAGIA.— In this condition
excessive amounts of food are re-
quired to satisfy the hung-er. It is
found mostly in chronically dilated
or large stomachs, viz., in certain fe-
males of the very slim type. It dif-
fers from bulimia, in that there is
satiety after the meal. It may be
primary (neurotic) or symptomatic,
paroxysmal or permanent, and the
treatment for the neurotic form is as
for bulimia.
STOMACH, DISEASES OF (BASSLER),
341
AKORIA. — This is a term used to
distinguish a slight disturbance from
bulimia and polyphagia, in that the
appetite may not be increased and
mav even be diminished. It is
treated in the same manner.
GASTRALGOKENOSIS.— This is
a neurosis characterized by the ap-
pearance of pain in the stomach when
it is empty, and its disappearance as
soon as food is taken. It occurs
oftenest in hyperacidity and hyperse-
cretion. It is probably an expression
of hyperesthesia, and relief is easily
procured. Thorough purging is
advisable.
ANOREXIA NERVOSA. — (See
under the heading, Anorexia Ner-
vosa, vol. ii).
NAUSEA NERVOSA.— A purely
functional form of nausea, occurring
in neurasthenia, hysteria, psychasthe-
nia, debilitated states, etc. When
associated with neurasthenia or hys-
teria it is very intractable, and isola-
tion is advisable. In other nervous
cases, in which the condition is less
pronounced, the patients should be
encouraged to eat or drink as they
please, the nausea being controlled
with general sedative drugs. Bitter
tonics as well as general tonics
should also be given. Where vertigo,
trembling, and vasomotor disturb-
ances coexist, persistency, full con-
trol of the patient, and complete
confidence on his part are likewise
essential to success.
SITOPHOBIA. — A condition of
hyperesthesia, associated with the
fear of food, and in which, if the con-
dition continues, dyspej^tic symptoms
greatly increase after the taking of
the smallest amounts of food. It is
a .symptom of gastric hyperesthesia
and is similarly treated. The patient
should make every effort to take
nourishment, even though it pro-
duces distress. Sometimes a rest in
bed is helpful. When there is an as-
sociated hyperchlorhydria this should
be treated with alkalies and diet.
DISTURBANCES OF GASTRIC
MOTILITY. — These may be di-
vided into 3 groups : Those of slight
degree, mostly functional in type
(myasthenia gastrica), those of more
marked extent in which peristaltic
power is distinctly deficient {gastric
atony), and those in which the power
of the organ is markedly assailed to
the extent of enlargement {gastric
dilatation).
MYASTHENIA GASTRICA
AND GASTRIC ATONY.— Myas-
thenia gastrica (hypomotility) is
present when there is a slight delay
in the exit of foods. The stomach
is usually normal in size, but may
be slightly enlarged, though no dif-
ference in the thickness of the walls
is to be observed. Gastric atony is
usually accompanied with secretory
deficiencv as well, and the organ is
considerably enlarged and the walls
distinctly thinned. Atony will be de-
scribed under Secondary Ectasia.
Etiology. — Alechanical stretching
stimulates smooth muscle, \\nien an
organ with walls of smooth muscle is
flaccid and toneless, distention calls
forth no response, and this is true in
the atonic stomach and colon. In
general body weakness the secondary
nervous system may be unable to
maintain tonus. Acute mental states
have a powerful influence on motility
and secretion, and general debilitv
acts similarly in a more chronic way.
Added to these causes are: Habitual
consumption of indig-estible foods or
fluids ; excessive gas collection in the
342 STOMACH, DISEASES OF (BASSLER).
stomach, such as is met with in neu- Oppler bacilli, lactic acid, and blood,
rotic disturbances, gastritis, malig- The fluid contains a normal total
nant diseases, and states of reduced amount (not relative proportion of a
acid and enzymotic secretion ; con- small amount of filtrate) of hydro-
genital structural and vital deficien- chloric acid and enzyme, and perhaps
cies, and primary diseases, such as a hyperacidity in the early stages,
gastric ulcer, perigastric adhesions, For the methods of test-meal
splanchnoptosia, chronic gastritis, analysis and estimation of gastric
chronic constipation, and states of motility the reader is referred to the
excessive intestinal fermentation. Index-Supplement volume.
Symptoms and Diagnosis. — In The X-ray method of diagnosis is
myasthenia gastrica there are no of no value in myasthenia, and of
definite symptoms or signs. The questionable value in atony. The
diagnosis may be made with reason- best way to investigate gastric evac-
able certainty in those who have had uation here is by test-meal examina-
digestive disturbances following a tion. In the X-ray procedure the
long period of mental strain, and who fluid bismuth mixture leaves the
show a low state of gastric secretion ; stomach more readily than food, and
in dietetic cases which have for years one is often misled. The subjective
gone on with improper methods of symptoms are : Loss of appetite or
feeding and gradually developed di- a feeling of satiety from the small-
gestive symptoms ; in those in whom est amount of food ; distress in
hyperesthesia and excessive secretions the stomach after meals, lasting for
are excluded, in whom test-meals and from one to four hours ; greater dis-
motility tests show only slight re- tress on taking fluids than solid
tardation or are negative ; in cases in foods ; pyrosis, nausea, regurgitation,
which gas collection in the stomach but rarely continued vomiting; belch-
has long existed, with the tests for ing of either tasteless or odorless gas
primary conditions negative ; and in or that tainted with the taste of foods
those in which dyspeptic disturb- taken hours previously ; constipation,
ances accompany constitutional dis- headache, vertigo, nervous symptoms
orders or disorders of the central of various kinds, palpitation of the
nervous system, intestine, gall-blad- heart and indefinite cardiac pains,
der, generative organs, or heart. difficult breathing, and, in the forms
The diagnosis of true primary secondary to nervous or constitu-
atony is much more definite. Here tional disorders, sometimes a raven-
one can take advantage of the meal ous appetite. Gastric vertigo (vertige
analyses, and figure on the solid and stomacal) is often a distinctive fea-
fluid returns. A moderate degree of ture. In myasthenia gastrica the
stagnation or retardation is observed, physical examination of the stomach
The returns from the Ewald meal is generally negative. In atonic ecta-
show larger quantities of solid and sia it is enlarged and lax, the greater
fluid contents than normal, not sep- curvature in the prone position reach-
arating into the characteristic three ing to the umbilicus or below in the
layers seen in secondary ectasia, and males and always below in the fe-
free of yeast spores, sarcinre, Boas- males. The shape as well as the size
STOMACH, DISEASES OF (BASSLER).
343
of the organ should be mapped out,
so that an atony will not be diag-
nosed g-astroptosia ; however, more or
less atony is generally present with
the latter. On inflation, the stomach
can easily be mapped out by per-
cussion or auscultatory percussion.
Splashing or succussion sounds are
most valuable to diagnosis, partic-
ularly when present some hours after
a full meal. Water may be given and
the splash noted, but it is only when
the splash is loud and easily pro-
duced that the sign is of any value.
If the abdominal wall is very thin and
relaxed, the borders of the stomach
may be indistinctly palpable or visi-
ble. Gastrodiaphany may be em-
ployed, but the X-ray-bismuth or
hourly X-ray-food methods answer
better. These patients are usually
poorly nourished, and when young
are anemic.
Atonic ectasia must be differen-
tiated from secondary ectasia, gas-
troptosia, certain nervous disorders
of the stomach, neurasthenia, mega-
logastria, and chronic gastritis.
Prognosis. — Simple myasthenia
usually corrects itself when the local
and general conditions of the body
are improved. Atonic ectasia is es-
sentially chronic, though its course
depends largely upon a sustained
treatment, the recuperative power,
and the results of treatment of an
underlying condition when present.
Often the most gratifying results are
obtained where gastroptosia coexists.
Atony may pass into definite relaxa-
tion, but this is rare. When it does
occur, the prognosis is bad.
Treatment. — Where constitutional
and infectious diseases are contribu-
tory, close supervision is required in
convalescence. Injudicious and rapid
eating, poor mastication ; excessive
use of fluids, tea, cofifee, alcohol, and
tobacco ; incorrect modes of life, and
the habitual use of purgatives, must
be corrected. The patients require
a general mixed diet and superali-
mentation by frequent or supple-
mental feedings. Not much attention
need be given to the status of secre-
tion unless this is markedly hyper-
acid. In this event, the diet for ex-
cessive secretion should be instituted.
When the symptoms are relieved, the
diet should be as dry as possible, only
such fluid being allowed as will
allay the thirst. The best foods are
the various meats, poultry, game,
fish, eggs, cream, butter, peas, beans,
lentils, and well-cooked, mashed or
strained vegetables. If milk is well
borne, four glassfuls a day should
be allowed, re-enforced with fresh
cream. The cereals can be taken, but
fruits, berries, and green vegetables
are not safe. Cocoa or chocolate
made with milk should be substituted
for other beverages, and all gaseous
or alcoholic fluids should be avoided.
Olive oil may be employed, and foods
suggested for constipation often serve
well. The simple cheeses may be
taken, but never the pungent forms.
The caloric value of the day's diet
should always be above 2500, and
later in the treatment preferably
close to 3500 calories. The food
should be cut very fine and well
chewed. The diet is essentially that
for gastroptosia.
Lavage should never be practised
unless there is a definite indication
for its use, such as chronic gastritis.
If apparatus and technique are good,
gastric douching may be of benefit,
but collection of water in the stomach
must be guarded against; either cold
344
STOMACH, DISEASES OF (RASSLER).
or quite warm water may be used.
Intragastric faradism with slow vi-
brations, or the sinusoidal currents,
are valuable adjuncts. The external
electrode method may also be used.
When distress is marked the galvanic
current is the best to tone up the
muscle-walls. An apparatus deliver-
ing faradic and galvanic currents at
once answers to good purpose.
Seances should last from ten to fif-
teen minutes; the faradic current
should be used to tolerance and
stronger on the back than the front,
and the galvanic current at from 10
to 25 milliamperes. From 15 to 20
treatments, at the rate of two or three
a week, are sufficient. After this, in
cases with constipation, the colon
may be treated with the currents, or
electric vibration or massage added
to the routine. Good hygiene and a
strengthening regime are advisable.
In some cases systematic exercise
benefits, e.g., games such as hand-
ball, squash, boxing, fencing, tennis,
and golf. The morning sponge or
cold rub is serviceable. Patients
should not do too much brainwork
or be too much confined indoors.
Women who have primary atony and
become pregnant should be watched
very closely, kept in bed three or four
weeks after labor, nourished very
well, bandaged properly, exercised to
strengthen the abdominal muscles,
and watched during lactation. AMien
patients can afford it, a midsummer
and midwinter vacation is advisable.
Strychnine or nux vomica should
be given throughout the treatment
and in the largest doses tolerated.
Belladonna or the oils can be used
for hypersecretion, but not sodium
bicarbonate. The bowels are kept
open by the diet, enemata, cascara,
or phenolphthalein. Anemia is best
treated ]>} dietetic means and non-
astringent forms of iron. Valerian is
of service when the neurotic symp-
toms are marked. It is best not to
use the bromides. A good prescrip-
tion when the atony is accompanied
by anorexia and neurosis is : —
IJ Tuicturcr uucis vomicce,
Tinctiirce Valeriana,
Fluidcxtracti conduran-
go aa 3iiss (10 c.c).
M. Sig. : Take H teaspoonful (30 drops)
in water after meals.
SECONDARY GASTRIC DILA-
TATION.— This condition is due to
mechanical obstruction in the pyloric
region. There is an acute dilatation
of extreme degree that results in rare
cases from the drinking of large
amounts of fluids, but this is only a
temporary condition. Postoperative
gastric dilatation will be described in
the next section.
Etiology. — The degree of stagna-
tion produced in mechanical obstruc-
tion is never seen in extreme primary
atony, even when the musculature is
degenerated or when it has been
penetrated by advanced malignant
disease. The pylorus or the pyloric
region distal and proximal to it may
be constricted from within or with-
out. Among the internal causes of
constriction are the cicatrices of more
or less healed ulcers; malignant dis-
ease; continued pylorospasm; hyper-
trophic pyloric stenosis; foreign bod-
ies, such as rosin balls, hair balls,
cherry or peach stones ; pedunculated
benign tumors, and kinking of the
prolapsed organ at the duodenal an-
chorage. Among the external causes
may be mentioned perigastric bands
stretching across or drawing upon
the organ, as may be seen after ulcei,
STOMACH, DISEASES OF (BASSLER).
345
gastritis, and cholelithiasis; omental
adhesions from appendicitis, liver,
and infective gall-bladder conditions ;
pancreatic cysts pressing upon the
duodenum ; movable kidney, partic-
ularly after unsuccessful anchorage
operations; floating spleen pressing
upon the duodenum ; dermoids, and
enlarged glands or masses belovv^ an
indurated ulcer, generally in the pos-
terior wall away from the pylorus.
Symptoms. — The symptoms are
those mentioned under gastric atony,
with added malnutrition and other
variable manifestations. The feature
of the symptoms is that they are
more intense. Vomiting, particularly
that of the collective or stagnant
type, is a feature. Pains are more
complained of in secondary ectasia
than in the primary forms. Tetany
or choreiform movements may exist.
There is loss of weight, thoug"h
where there is still a fair channel of
exit nutrition may be called good,
particularly after a liquid diet rich in
proteins. Even in malignant condi-
tions, where stagnation is not marked,
an increase in weight may be accom-
plished in this way.
Diagnosis. — When emaciation is
distinct and stenosis is marked, in-
spection often discloses peristaltic
waves in the stomach running from
the costal margin on the left to the
median line. Percussion usually
shows an enlargement of the organ,
in which splashing sounds may be
elicited. The X-ray shows a large,
globular stomach, with stagnation.
Examination of the stomach con-
tents yields most important results.
Examination of the vomitus may or
may not. In slight degrees hourly
mixed test-meal analyses are essen-
tial. In severe grades the large.
dark-gray or brown achylic return,
with lactic acid, blood, pus, and long-
retained food particles, is significant.
A fluid separating into three layers on
standing is characteristic of malig-
nant disease. The vomitus may be
very fetid, and considerable subjec-
tive relief generally follows. In
lesser degrees of stenosis, partic-
ularly when non-malignant, the hy-
drochloric acid may be normal in
quantity, and the meals show an in-
creased amount of bacteria yielding
a more than 2 per cent, gas result
(Ewald meal) in the fermentation
tests. Five hours after a mixed meal,
quantities of red meat-fibers, etc., are
obtained. In high degrees of stenosis
the morning return, after a mixed
meal given the night before, usually
contains some food. The simple test-
ing method of Mayo is valuable in
this connection. An acid return with
food, with or without blood (occult
or macroscopic) or mucus, and free
of lactic acid and the lactic acid
formers, argues in favor of benign
stenosis ; likewise the presence of
many sarcinas. Yeast fungi may be
found in either benign or malignant
stenosis.
In high degrees of stenosis the
urine is diminished in quantity.
Some claim an output of 1000 to 1500
cubic centimeters for the mildest
cases ; 500 to 1000 cubic centimeters
for the intermediate, and under 500
cubic centimeters . for the severer
grades. The urine may be alkaline in
ulcer and acid in cancer. Phospha-
turia or albuminuria may exist, and
acetone and diacetic acid be present.
Acetone urines are more common in
ulcer than cancer. The blood usually
shows an anemia.
The dift'erential diagnosis rests be-
346 STOMACH, DISEASES OF (BASSLER).
tween atonic ectasia and gastric pro- come on acutely after the taking of
lapse, neurasthenia gastrica, and gas- improper foods, prompt vomiting,
trie crises; the esophageal conditions, lavage, or withdrawal by means of
and the various stenoses. Often, in a stomach-tube will relieve them,
the slight or medium grades, all one When such attacks are frequent,
can conclude is that a degree of surgical treatment is indicated. Re-
permanent stenosis exists, and that it pose in the dorsal recumbent or left-
is necessary for surgery to find out sided position after meals is help-
its precise character and source. ful. The bowels should be moved
Prognosis. — In the early stages of by enemata. Olive oil before meals
secondary ectasia one should guard will occasionally give good results,
against a definite prognosis. These When the medical treatment proves
cases should be carefully analyzed of little value, plyoroplasty, pylorect-
and closely watched, and resort made omy, partial gastrectomy, or gastro-
to surgery when improvement does enterostomy offer brilliant results in
not occur or is not sustained. The the non-malignant forms of stenosis
minor and medium grades of a benign of gastric origin, and in a few of the
nature are often most amenable to malignant ones,
medical treatment ; the severe forms
demand surgery. Pylorospasm, gas- ^CUTE POSTOPERATIVE DILA-
troptosia, and small perigastric adhe- TATION OF THE STOMACH
sions are essentially medical condi- ^^D DUODENUM.
tions. Marked cicatricial conditions ETIOLOGY.— This is still much a
after ulcer, hypertrophic gastritis matter of conjecture. The condition
with distinct retention, large foreign may be due to mechanical obstruc-
bodies, pedunculated growths, bands, tion of the duodenum by the root of
cysts, etc., generally require surgical the mesentery and the superior mes-
intervention. enteric vessels, caused by a sinking
Treatment.— The dietetic treatment of the empty intestines into the true
consists essentially of that mentioned pelvis, or may be a functional dis-
under the early treatment of hyper- turbance due to injury to the nervous
chlorhydria, together with that given apparatus either by traumatism or
under Atonic Ectasia, excepting that the effects of anesthetics or toxins,
the foods must always be given in I am inclined to the latter view,
fluid, semifluid, or finely commi- SYMPTOMS AND DIAGNOSIS.
nuted forms. All foods that give — Three-fourths of all cases follow
distress, ferment, or on aspiration are operations on patients between 10
found to have remained in the stom- and 40 years of age. No type of op-
ach too long must be changed in form erative case is especially prone or ex-
or discontinued. Best results are ob- empt, nor is either sex.
tained from frequent small meals, The definite gastric symptoms may
about six in a day. Occasional lavage be most acute ; yet markedly dilated
assists materially, and stretching the stomachs in serious cases may exist
pylorus by the Einhorn apparatus without vomiting, pain, tenderness,
may be tried in carefully selected thirst, or scanty urine — all character-
cases. When symptoms of distress istic symptoms. The onset of the
STOMACH, DISEASES OF (.I^ASSLER). 347
attack, when severe, is generally sud- perature drops, and the abdomen be-
den. The postoperative course ap- comes distended. The right upper
pears normal for a few days, or even abdominal quadrant may be slig-htly
two weeks. Suddenly gastric disten- prominent. Succussion sounds are
tion occurs, with profuse and persist- more regularly present, but the pain
ent vomiting of large amounts of may not be very definite. As vomit-
fluid ; epigastric and umbilical pain, ing may not occur, dependence must
steady or colicky ; epigastric tender- be placed upon the stomach-tube for
ness, and symptoms of collapse, diagnosis. In these cases death usu-
Muscular rigidity is usually absent, ally occurs within a few days.
The abdomen swells, due to gastric The most favorable cases are those
enlargement; the right hypochon- in which the paralysis is incom-
drium becomes prominent and the plete. These are about evenly di-
left flattened, and the general gastric vided between the postoperative and
tympany on the upper left side shows mixed cases, such as bccur in typhoid
an enlarged organ, the lower border fever, pneumonia, etc. The onset
being below the umbilicus. The may be slower and more indistinct,
transverse measurement of the organ and the abdominal examination vir-
is also increased. Epigastric tym- tually negative. The diagnosis is
pany is usually also observed. On suggested by a sudden obscure un-
passing a stomach-tube, the size of favorable turn in the case during
the organ quickly diminishes. The convalescence. Early resort to the
stomach may be so distended with tube saves most of these cases. In
gas that succussion sounds may not my opinion, in these patients the in-
be distinguishable. Visible peristal- testines may be mainly affected; gen-
tic waves may occur, and are most eral gaseous distention and obstinate
common in the moderate grades un- constipation are then diagnostic,
treated for several days. In these, a Among other symptoms that may
tube should be passed at once, the be noted in acute gastric dilatation
return revealing an unaccountably are : Scanty urine, subnormal tem-
large collection of fluid, at first yel- perature, general muscular cramps,
low, then yellowish green or green tetany, hiccough, and delirium. The
when regurgitation from the upper dififerential diagnosis must particu-
part of the small intestine is present, larly be made from peritonitis, ileus,
and finally brown with solid particles intestinal obstruction, and perforation,
and a fecal odor when the condition PROGNOSIS. — About 70 per cent,
had existed for some hours. of severe cases with typical symp-
A treacherous type of the condition toms are soon fatal. In the prog-
with the symptoms absent or slight nosis much reliance should be placed
is seen where anorexia and fermen- upon the general condition and the
tation or intestinal flatulency have diminution of return througii the
been continuously present. Sud- tube. When bile and an absence of
denly, for no assignable reason, the gastric enzyme are constantly noted,
countenance becomes dusky or pallid, the prognosis continues grave ; when
the face "pinched," and the pulse the bile recedes and stomach acids
more rapid and thready. The tem- appear, the outlook is favorable.
348
STOMACH, DISEASES OF (BASSLER).
Should there develop a fecal odor
or a return of fecal substance itself
intestinal obstruction should be
th(>U.ii;ht of.
TREATMENT.— All foods and
fluids should at once be withheld by
mouth, stimulation practised, and
later rectal feeding instituted. In
tinuous drainage of the stomach is
a useful and comfortable means to
accomplish this, as well as to medi-
cate and later on to feed the patient.
Thirst should he combated by proc-
toclysis or hypodermoclysis. Iveclal
feedings should be kept uj) until tlie
gastric condition has almost cleared.
Patient with author's continuous drainage stomach-tube in use.
the severe cases wnth sudden onset,
enemas of cofifee or other stimulants
are first in order. In every case the
stomach should at once be emptied,
preferably by lavage with plain warm
water. This should be repeated sev-
eral times in twenty-four hours — in
severe cases, about every three hours.
Once every hour or two is not too
frequent in the beginning. The lav-
age should be kept up for several
davs. The author's method of con-
The bowels should be moved by
enema, preferably of saline solution.
Hot turpentine stupes may be used
to relieve the distention. The best
purgative is a single dose of trituratio
elaterini, ^ grain (0.03 Gm.) by
mouth, supported by strychnine in-
jections. An efficient means to move
the bowels and cause discharge of
gas is an enema of 1 ounce (30 Gm.)
of pulverized alum in a pint of water.
Atropine and strychnine should be
STOMACH, DISEASES OF (BASSLER).
349
given hypodermically ; the former to
relieve possible pylorospasm and con-
trol secretion, the latter to overcome
the paralysis. The strychnine should
be pushed at first — about %o grain
(0.003 Gm.) hypodermically every two
or three hours. Giving eserine is
malpractice. Lately I have employed
hormonal in 11 cases, along v^ith
other measures, and all recovered. In
2 of the last cases I have used it in,
how^ever, no benefit was derived. It
is given in }4-ounce (15 c.c.) doses
by deep injection into the gluteals.
The next most important item of
treatment is the postural method.
The half-sitting position, and lying
flat with the head of the bed blocked
up, have been advised for the dilata-
tion which accompanies pneumonia.
These postures relieve pressure in
the lower thorax, and thus also the
embarrassed heart and dyspnea. In
the postoperative cases these pos-
tures might increase duodenal ob-
struction, and elevation of the foot
end of the bed has therefore been ad-
vised. Others have favored the side
position, usually the right, to encour-
age drainage of the stomach, and
some, notably Schnitzler, the prone
position (abdomen down). Tight
bandaging of the lower abdomen or
the use of the Rose bandage, together
with the half-sitting position, might
serve to good purpose, but many
patients have a laparotomy wound.
Of late I have been advising a com-
bination of the two dorsal positions,
carried out by blocking up the head
of the bed and placing a number of
hard i)illnws under the thorax and
head. Two wide boards are next
placed in the bed, one extremity rest-
ing over the elevated foot end and
the other just under the buttocks.
The patient is placed so that the back
is bent in the lumbar region, the
thorax and head on one side and the
hips and lower extremities on the
other, being thus elevated at the same
time.
Upon subsidence of symptoms
milk should be given by mouth in
small amounts, preferably pepton-
ized. Later on, the quantity at each
feeding can be increased, up to ^
glassful, followed by raw eggs in
milk, bouillon, strained gruels, rice,
farina, and finally the more solid
foods. The diet during convalesence
must be carefully watched, fatal re-
sults having followed too early use of
uncooked fruits, meats, etc. Opera-
tions have been performed to drain
or evacuate the stomach, or relieve
the duodenojejunal kink, but these
cases do better without operation
than with it.
In ileus, fecal material is obtained
from the stomach only after several
days, and always in small amounts.
When, after an operation, symptoms
of ileus appear and the returns from
the stomach show increasing fecal
material, the actual condition is an
intestinal obstruction, and for this
the indications are to operate at once,
withholding food in the mean time
and keeping the stomach washed out
to minimize the toxic factor.
G A STROPOLY ASTHENIA.
— This condition, not described else-
where, was met with by me in 4
cases in the course of a winter, and
is characterized by atony, apparently
with hypermotility at the beginning
and deficient power at the end of
digestion.
Symptoms and Etiology. — At first,
ra])id emptying of tiie st(Mnach takes
place, due to excessive peristalsis ;
350
STOMACH, DISEASES OF (BASSLER).
later a retardation of food exit oc-
curs, yet the acti\e peristalsis con-
tinues.
The third stage presents the usual
picture of a moderate degree of stag-
nation, running live, six, to eight
hours after the meal, yet late after
the ingestion of food vigorous peris-
taltic waves are still present, though
the food is stagnant. Careful test-
meal analyses and X-ray work sug-
gest that the condition is of extra-
gastric origin, being probably due to
an irregularity of hormone secretion
(secretin), with its influence on relax-
ation of the pylorus.
Diagnosis. — This can only be made
with the X-ray. A considerable
amount of the bismuth meal escapes
within five or ten minutes into the
small intestine, some, perhaps, being
as far down as the upper ileum. Ob-
serving at intervals after this, evacua-
tion of the stomach is noticed to have
ceased, although the wild peristaltic
waves continue up to six, seven, or
eight hours afterward. At this late
time. 15 to 40 per cent, of the bis-
muth meal is still in the stomach,
while that which had escaped is well
on in the ileocecal region.
The acidity in these stomachs var-
ies. Test-meal analyses do not per-
mit of differentiating the condition
from pylorospasm, which it closely
simulates. The latter,, however, va-
ries at different times, while the
motor phenomena of gastropolyas-
thenia are identical at each examina-
tion of the stomach.
Prognosis. — Under proper treat-
ment the condition is controlled in
from one to three months. Care
must be taken after that, however,
that the diet is suitable, as there is
always danger of recurrence.
Treatment. — The subject being usu-
all}- anemic, debilitated, and nervous,
a morning cold bath or shower, cjr a
rub with a coarse towel soaked in
cold water, is beneficial. Rest, rather
than exercise, is of value. It may be
necessary to keep the patient in bed
two or three weeks. Arsenic and or-
ganic iron preparations are useful.
After a time, general massage, with
electricity, is of some help.
The diet should be semifluid for
the first two or three weeks, consist-
ing of milk, fresh cream, eggs, well-
boiled cereals, bread, and butter, to
be taken at short intervals during the
day, — at least 3000 calories during
the twenty-four hours. Later on,
bland semisolid and solid foods may
be given. Stimulating foods had best
be withheld for months. Nux vomica
in ascending doses is often beneficial.
Of much value to relieve the distress
quickly is secretin, given as an ex-
tract of scrapings of the duodenal
mucous membrane, either in a solu-
tion, powder, or elixir.
CARDIOSPASM. — Normally
by cardial contraction, solids and
fluids are momentarily delayed in
their passage into the stomach. Ab-
normally, this spasm may be so pro-
nounced that entrance of food is
obstructed.
Etiology. — Cardiospasm may be
neurotic or secondary to disease in
the lower gullet, — ulcer or carcinoma,
— to disease of the stomach, or to dis-
ease of one or both lungs, usually the
least affected and most often the left.
Neurotic, primary cardiospasm is
due, in my opinion, to a contraction
of the crura of the diaphragm, usually
the left. The condition occurs at any
age, and, in the majority of instances,
in females.
Cardiospasm with Moderate and Uniform Dilatation of the Esophagus.
X-ray by Author.
Same case, taken one-half hour after dilatation of the cardia. show-
ins? that there was no delay in the transit of bismuth for it to give a
delinite shadow of the esophagus. X-ray by Author.
STOMACH, DISEASES OF (BASSLER). 35I
Symptoms. — At first the spasm is resenting the contracted cardial open-
not sulificient to interfere seriously ing- is seen. It is rarely more than
with the passage of food. At this half an inch long, and differs from
time there is discomfort and a slight the tail noted in malignant disease,
degree of pain, some choking sensa- Differential diagnosis is from or-
tion, etc. When esophageal peris- ganic strictures. Use of the esoph-
talsis is no longer able to overcome agoscope may be necessary. In or-
the resistance, food accumulates in ganic strictures there is usually the
the gullet and regurgitation takes history of an ulcer or some form of
place. Dilatation of the esophagus trauma, usually mechanical. Careful
soon becomes marked, and there is sounding with the bougie usually
no regurgitation after meals, but at shows these higher in the gullet,
irregular intervals. In the more pro- mostly in the upper third. Strictures
nounced cases there is a substernal of malignant disease; are met with
sense of oppression and considerable later in life, give a more distinct his-
pain, perhaps with dyspnea and a tory of progressive dysphagia, do not
slight increase of the heart's action have the regurgitation or retention,
during the times of stress. bleed freely on instrumentation, and
Most patients complain distinctly show a characteristic X-ray picture,
of a burning, tight, and pressure sen- Prognosis, — This is good provided
sation extending, perhaps, to the proper treatment is instituted,
lower sternum, together with pains Treatment. — In some of the minor
radiating to the back. When dilata- forms attention to the nervous sys-
tion exists relief is felt when the gul- tem and general nutrition is alone
let is emptied. Absence of hydro- required. The food should be high
chloric acid and gastric enzyme and in caloric value, and general in char-
persistence of the food in the forms acter, irritating and bulky foods and
sw'allowed point to esophageal regur- drinks being eliminated. Baths, suffi-
gitations. Even in the benign cases cient rest, regular exercise, and fresh
blood may be present, though if this air, and general tonics should be or-
is marked malignant disease or ulcer- dered. The bowels should be moved,
ation must be thought of. The sec- and any esophageal or gastric condi-
ond swallowing sound is absent or tion found suitably treated,
much delayed, and the sign of Re- When stenosis is marked, mechani-
widzoff absent. Loss of weight is cal measures are essential. Bougies
noticeal)le in the majority of cases. do not usually suffice. Of the vari-
Diagnosis. — This is confirmed by ous forms of dilating instruments,
obstruction to the pa£:3age of the the Plummer dilating apparatus,
bougie or tube. With the patient Avhile uncomfortable to the patient,
in the dorsolateral position, left side is very efificient. A modified form of
down, it can be noted with the X-ray this consists in using a 20 French
that a swallowed bismuth mixture is esophageal sound, at the lower end
retained in the gullet. Radiographs of which is fastened a cundum re-
show a markedly dilated gullet in- enforced with silk. To the uj^per end
capable of peristaltic waves. At its is attached a length of soft tubing,
lower end, a distinct constriction rep- A syringe of about l.'^O c.c. capacity
352
STOMACH, DISEASES OF (BASSLER).
is used to dilate the bag. Water may
be used instead of air. Sippy's dilat-
ing apparatus also answers.
A majority of cases is entirely
cured after one dilatation, providing
a Plummer or Sippy apparatus is em-
ployed. In the weaker forms of di-
lating methods several dilatations
are necessary.
GASTROSPASM (Pseudo Hour-
glass Contraction). — This is probably
an unusual form of hypermotility.
Characteristic is a history of cramps
in the stomach with a tightening sen-
sation in the sternal region and chest,
and vague pains in the upper abdo-
men, chest, and back. Regurgita-
tions of fluid from the stomach, when
present, are not noticeably acid. The
spasms may come on after meals. As
a rule they begin gradually, a final,
most severe one, accompanied by
nausea, terminating the attack.
Diagnosis. — Distinction from hy-
permotility and hypersensation can
be made only by fluoroscopic exami-
nation. The peristaltic waves are
deep and active, giving the stomach
an ampullar shape, and, perhaps, even
a contracted distal feature, suggest-
ing an hour-glass stomach.
Treatment. — This consists of a
bland diet, bromides, valerian, hot
compresses to the epigastrium, and
codeine and chloral in small doses
some time before meals. The general
condition should be attended to. All
irritating foods and fluids, together
with tobacco, should be stopped.
After a few days recovery occurs.
PYLOROSPASM. — Neurotic py-
lorospasm is rare, though pyloro-
spasm accompanies many gastric
conditions as a complication.
Etiology. — The condition is usu-
ally due to some form of irritation.
As a neurosis it may occur at any
age, most often in early life. Most
apparent cases are due to hyperesthe-
sia of the stomach, hypersecretion,
gastric or duodenal ulcer, gall-blad-
der disease, cancer at the pylorus,
and reflex irritation from disease in
other abdominal organs.
Symptoms. — At the height of di-
gestion the pylorus suddenly con-
tracts. There is intense pain in the
epigastrium, radiating from the me-
dian line, with eructations, nausea,
and perhaps vomiting, and general
symptoms of distress. In almost
every case a history of these attacks
is obtainable, coming on with long in-
tervals, which finally become shorter
and shorter, until, perhaps, almost
continuous. Vomiting of foods that
had remained in the stomach for
some hours may take place. Sharply
localized tenderness, corresponding
to the pylorus, can be elicited, and
perhaps a firm pylorus felt. The gen-
eral abdomen may be retracted, and
gastric tympany is usually pro-
nounced. In the interval a less dis-
tinctly localized pyloric tenderness is
noted.
Diagnosis. — This is made by the
X-ray, the tightened pylorus being
observed, together with the condition
of retention. If distinct benefit does
not follow an intelligent course of
treatment, other causes should be
carefullv sought.
Treatment.^ — Any primary condi-
tion found requires treatment. In
the attack a hypodermic injection of
morphine and atropine may be given.
The diet should be bland, — about that
used in hyperchlorhydria. Olive oil
before meals answers in some cases;
if not, belladonna or atropine after
meals aids materially. Occasionally
STOMACH, DISEASES OF (BASSLER).
353
the bromides in larg^e doses are use- pie meal at the usual time shows a
ful. A formula of value is : — very small amount with a correspond-
IJ Codeincc sulphatis .. gr. ij (0.13 Gm.). ingty low hydrochloric acid content,
Tincturcc belladonna:
foliorum f'3j (4.0 c.c.)-
Strontii broiiiidi .... Sij (60.0 Gm.).
Syrnpi adjnvantis fSviij (240.0 c.c).
M. Sig. : Take a tablespoonful in a little
water every four hours.
When the pain is not severe, hot
applications or mustard plaster to the
epigastrium may suffice. Intragas-
tric galvanism also helps, and, even
more, sedatives. Einhorn's apparatus
for stretching the pylorus is of value
m mfants only. pyloric incontinence, primary atony,
These measures failing, exploratory ^[^^^^. neurotic states of the gastro-
operation should be done. If ulcer, gnteron, and the benign intestinal or
gall-bladder disease, etc., are not accessory organ conditions. In long-
found, a pyloroplasty of the Ferguson standing ulcer cases a delay in the
type will cure the case. This opera- ^^j^ ^f ^^^^^ generally exists.
or, indeed, the stomach may be empty.
Examination at the forty-five-, thirty-
and fifteen- minute intervals shows
significant gradations in quantity, the
largest return being at the fifteen-
minute interval. If a mixed meal is
used, the stomach is generally empty
in two or three hours' time. The
X-ray shows an increased peristaltic
activity with the formation, usually,
of three or more ampullae.
Diagnosis. — This is made from
tion has practically no mortality, and
can be done in a very few minutes.
NERVOUS HYPERMOTILITY.
— Hypermotility not infrequently oc-
curs as a neurosis, not necessarily
Prognosis. — In all neurotic cases
the prognosis for complete recovery
is good, relapses not occurring if the
necessary indications are observed.
Treatment. — Simply cooked solid
accompanied by spasm of the orifices foods, free from condiments, are indi-
or even by gastrospasm. cated. Soups, broths, tea, coft'ee,
Etiology. — The condition is, as a alcohol, and. tobacco should be inter-
rule, found in those who habitually
partake of large amounts of strong
soups, cofifee, condiments, and rich
foods.
Symptoms. — These include ano-
rexia, tlatulence and stomach disten-
dicted. In severe cases assumption of
the left lateral position after meals
may be desirable. Lavage, douching,
or electricity should never be em-
ployed.
The bromides, giv^en in large doses.
tion after meals, hypersensitiveness or codeine, are useful. Acids usually
to the richer forms of food, and not increase the symptoms, and nux
so much to the simple or to foods in vomica does not benefit them. Olive
small quantities, postprandial eructa- oil may be given temporarily. Where
tions, and looseness of the bowels constipation exists, simple enemata
with gas distention. In some cases are alone indicated. Anemia indi-
only anorexia and a disturbed sensa- cates ferruginous foods or non-as-
tion in the moulli are noted, and the tringent forms of iron, (icneral hy-
intestinal symptoms predominate, gienic measures or a sojourn in the
slightly or not at all relieved bv thor- country are best to control an undcr-
ough purging. The return of a sim- lying neurosis.
8—23
354
STOMACH, DISEASES OF (BASSLER).
REGURGITATIONS. — Only
small quantities are brought up at a
time ; the stomach is never emptied
l)y the process. Mild degrees (eruc-
tations) may occur in hyperchlorhy-
dria, hypersecretion, and chronic g-as-
tritis. The neurotic type, generally
neurasthenic or hysterical, with nor-
mal secretion and motility, is found in
not more than 3 per cent, of the cases
of distinct gastric neurosis.
Symptoms, — As a rule the onset is
gradual, the regurgitations being
easily suppressed in the beginning.
Certain foods seem to intensify the
condition ; likewise neurasthenia or
debilitated states. The history usu-
ally includes rapid eating, and chronic
pharyngitis is commonly observed.
At length debility may be occasioned.
' Prognosis, — This is almost always
good, and usually depends upon the
results obtained in the treatment of
neurasthenia.
Treatment. — The general condition
requires first attention, then the neu-
rasthenia and hysteria. The patient
must be made to suppress the re-
gurgitations by voluntary control.
Slow eating and thorough mastica-
tion should be insisted upon. When
the spells are on, freedom from work
and continued rest should be advised.
I In severe cases the rest cure with
isolation may be necessary. Intra-
gastric faradism is valuable in some
instances. The best drugs are strych-
nine and the bromides.
Ti. Strychnines sulphatis gr. ss (0.03 Gm.).
Sodii bromidi '3v (20.0 Gm.).
Elixiris phosphori .. fSij (60.0 c.c).
Aqua: q. s. ad fBviij (240.0 c.c).
M. Sig. : Take a tablespoonful, followed
by water, fifteen minutes after meals.
MERYCISM. — In merycism,
'•chewing the cud," or rumination.
foods arc regurgitated into the
moutii, then reswallowed, perhaps
with previous mastication, or pri-
marily ejected. The condition is an
acquired one, usually from imitation,
and spells mental unbalance or de-
ficiency. It is also seen in the hys-
terical, and may follow mental shock.
Symptoms, — Merycism may occur
in periodical attacks or continue dur-
ing the whole of life. It begins as a
voluntary, pleasurable process, but
later is involuntary. The regurgita-
tion continues after a meal until the
foods become unpleasant to the taste.
If anacidity exists, rumination may
continue during the day as long as
there is food in the stomach
The prognosis is good if the pa-
tients are anxious to control the
condition. Relapses may occur after
some mental strain or shock.
Treatment, — The patient must gain
control of the habit; further treat-
ment is unnecessary in some patients.
AVhen this cannot be done an abso-
lutely fluid diet should be ordered for
a few weeks, to be followed by slow
eating and thorough mastication. Al-
kalies should be used in hyperacidity,
and mineral acids in low or absent
acidity. The eating of ice daily after
meals has been recommended by
Koerner. Strychnine and quinine
after meals are helpful, giving an un-
pleasant taste to the foods. The bro-
mides and valerianates serve well.
Intragastric electricity may be effi-
cient in some cases. In neurasthenia
and hysteria, with poor general
health, the hygienic, hydropathic,
high-feeding, and psychotherapeutic
treatments are necessary. After the
rumination is controlled a sojourn in
the country for several months is of
value, particularly when some friend
STOMACH, DISEASES OF (BASSLER).
355
is present who quickly expresses dis-
gust when the symptom is noticed.
ERUCTATIO NERVOSA (Aero-
phagia). — This is characterized by
attacks of noisy belching of odorless,
tasteless gas. It is found in neuras-
thenia or hysteria, or a result of
mental strain or shock. The gases
are derived from the bowels, or con-
sist of air previously swallowed
(aerophagia). The condition may
accompany atony or prolapse of the
stomach. The Oser theory of air
aspiration, during inspiration, into
the stomach, is probably correct.
Symptoms. — The condition persists
from a few hours to several days.
The patient emits a succession of loud
eructative explosions, each manifesta-
tion, perhaps, being accompanied by
a distressed expression in the face.
The attacks are absent during sleep
or when the patient's attention is
engrossed by some outside matter.
The stomach may be very tympanitic.
Diagnosis. — States of fermentation
such as accompany gastritis, malig-
nant disease, etc., must be eliminated
by test-meal analysis and the X-rays.
Treatment . — The patient must
make an effort to control the symp-
toms. When this is difficult measures
for treating the neurasthenia or hys-
teria are essential. In the long-stand-
ing cases the rest cure is required.
Electricity to the gullet (faradism) is
sometimes useful. The diet should
be bland. Large doses of bromides
answer well quickly to control the
symptoms, valerian serving best for
continued treatment. Prolapse or
gastric atony must be corrected.
SINGULTUS GASTRICA NER-
VOSA (Hiccough). — This is rarely
met with in a functional nervous
form, along with hyperesthesia gas-
trica. Attention was drawn to this
form by the writer in 1910. In it
continuous hiccough lasting weeks or
months, without any return of gas-
tric contents at any time may be
seen. It usually occurs in well-nour-
ished young females. Study of two
cases showed entire absence of the
symptoms of hysteria ; and competent
neurologists, ophthalmologists, gyn-
ecologists, and others, considered
these patients normal. In the not ■
uncommon true cases of hysteria in
which hiccough is a feature, hysteric
manifestations and the appearance of
the case render the diagnosis easy.
Where doubt exists, local and per-
sistent gastric symptoms and a rela-
tivelv good health are diagnosticalh^
helpful. (See Hiccough, vol. v, page
532.)
VOMITUS NERVOSUS. — Nerv-
ous vomiting may occur as a direct
or reflex neurosis affecting the vomit-
ing center in the medulla, or may be
reflex from affections of the stomach,
diaphragm, esophagus, or pharynx.
It is not uncommon, and is more fre-
quent in females, constituting about
3 per cent, of the gastric! neuroses.
Varieties. — The forms of neurotic
vomiting: (1) Cerebrospinal or cen-
tral, as in meningitis, encephalitis,
apoplexy, abscess, cerebral tumors,
brain anemia and hyperemia, concus-
sion, intoxication (ether, tobacco,
etc.), autointoxications (constipation,
indicanuria), septicemia, tabes dor-
salis, and transverse myelitis. (2)
Functional nervous vomiting, as in
the poorly nourished, anemic, and
sufferers from mental or physical
strain, neurasthenia, and hysteria. (3)
Reflex vomiting accompanying vari-
ous affections of the stomacli. eye,
pharynx, larynx, middle ear, lungs,
356 STOMACH, DISEASES OF (BASSLER).
intestines, liver, gall-bladder, kidneys, Treatment. — One should remove
and generative organs. the cause and build up general tone.
The instances of so-called idio- The psycliic form re(iuires merely
pathic vomiting (vomitus nervosus) brief sedative treatment for the
are further divided into (1) psychic vomiting.
vomiting, due to fright, shock, or a In periodical and reflex vomiting
sudden mishap; (2) juvenile vomit- absolute rest should be secured with
ing, occurring in school-children from a single hypodermic injection of
overwork; (3) juvenile periodic morphine or a few opium supposi-
vomiting, occurring in the infant, and tories. A mustard plaster to the epi-
generally passing off after the third gastrium and cold applications to the
year; (4) periodic vomiting of the head are useful. If vomiting persists,
adult (von Ley den), preceded by oral, or, better, rectal use of bromides
nausea, gastralgic pain, and head- and, perhaps, also chloral hydrate in
ache; and (5) the single attack and solution, is efl:'ective. The swallow-
persistent nervous form in adults ing of pieces of ice over which a little
(mostly females), obscure in cause or brandy has been poured afifords some
due to evident general conditions. relief. Acetylsalicylic acid is often
Symptoms. — The distinguishing of service to relieve general distress,
features of the vomiting are the ease On recovery the precise cause should
with which it takes place, the fact be sought and treated, or, if it cannot
that it is independent of the quality be found, a sojourn in the country
and quantity of food^ and the absence and hydropathic procedures advised,
of nausea. When the symptoms are intense food
In some patients only the fluid should be withheld for a few hours,
ingesta are ejected. Usually the spell and in the interval high caloric
is quickly over, and soon after the feedings maintained,
patient may again take food. In Persistent cases may be divided
marked cases the skin is dry and the into those that improve on ambula-
urine scanty. In the periodical form tory treatment and those that do not.
the patient is distressedly ill, and, the The mode of life, etc., must be looked
vomiting continuing, mucus and bile into and corrected, according to indi-
may be ejected. There may be much cations. Mental excitement, worry,
abdominal pain, vertigo, weak pulse, anxiety, suspense, late hours, trying
and marked constipation. Loss of work, etc., must be avoided. The
weight, nervousness, and anemia may patient should be told that vomiting
be noted in established cases. is not important or serious, and that
Diagnosis. — This is made from the he should always make a direct efifort
history, general neurotic symptoms, to control it. Special dieting serves
the absence of any positive findings no distinct purpose, though frequent
in gastric analyses, reflex causes of small meals may be advisable. Bro-
the vomiting in other organs, the in- mides and valerian should be taken
efficiency of the usual antiemetic regularly in large doses. When the
remedies, and the almost magical re- vomiting is controlled they should be
suits from bromides, valerian, and continued in reduced dosage for some
hygienic measures. weeks. Hydrotherapy is of benefit,
STOMACH, DISEASES OF (BASSLER).
357
and electricity may be of psychic
value. In the more extreme cases a
rest cure may be essential. Feeding
by gavage for a period may be help-
ful. Faradism is most efficient in the
bedridden cases. After the bromides,
tonics should be given for a period.
A change of occupation is often ef-
fective.
PNEUMATOSIS.— In these cases
the stomach is distended with air,
expulsion of which seems impossible.
Many correspond to the so-called
asthma dyspepticum of Henoch, and
may be modified forms of aero-
phagia. Other instances are seen in
cardiospasm, pylorospasm, atony, dil-
atation, prolapse, and neurotic con-
ditions. The condition may be
periodical or continuous, is more
common in males, and is not unusual
in individuals of the intellectual type.
Symptoms and Diagnosis. — The
epigastrium is protuberant, and the
stomach tensely tympanitic. There
may be a constant effort to belch
without result, a sensation of disten-
tion, dyspnea, anxiety, and perhaps
collapse. In the continuous form the
distention is not so marked. Gastric
analysis may show a normal, high,
or low acidity.
The diagnosis is made from the
history, by exclusion of other gastric
conditions in which distention is com-
mon, and from cardiac affections.
Treatment. — Prompt passage of
the tube is indicated. This may have
to be repeated. In continued cases
the tube may not be required. If a
tube is not at hand, the attack may be
relieved with an injection of mor-
phine (Ewald). Ten dro])s of Hoff-
man's anodyne, spirit of peppermint,
or chloroform spirit in sweetened hot
water, or 5 drops of turpentine on a
lump of sugar, may give relief. The
routine of treatment comprises that
for the underlying neurosis, neuras-
thenia, or hysteria ; for these states
strychnine or nux vomica should be
given. Physostigmine and cannabis
indica, to guard against recurrence,
are not as efficient as bromides,
codeine, and valerianates.
PERISTALTIC UNREST.— This
condition was first described by
Kussmaul as a neurosis.
Symptoms. — The most important
symptom is the noting of violent
visible movements in a stomach free
of pyloric obstruction. The waves
run downward from the costal mar-
gin toward the median line, and seem
to be more active than is the rule in
pyloric obstruction, in which they are
about six in number to the minute.
There are often like, though less evi-
dent, movements in the intestine,
together with more or less loud
rumbling and crampy sensations.
Eructations, nausea, anorexia, sink-
injj sensations in the stomach, con-
stipation, diarrhea, and symptoms of
neurasthenia may also be noted.
Diagnosis . — The stomach mav
empty itself too quickly or normally.
Fluoroscopy with bismuth shows its
wild gyrations. The test-meals may
show any degree of gastric secre-
tion at the time, but more or less
variation in later examinations. Py-
loric stenosis must be excluded; this
is easily done with the stomach-tube.
X-rays, and by observation of the
case. Clinical distinction from gas-
tros'pasm is not important; in gastro-
spasm the history is more suggestive
and j)eristalsis discernible only with
the X-ray.
Treatment. — If a marked or mod
crate true pyloric stenosis is believed
358
STOMACH, DISEASES OF (BASSLER).
present the case is an operable one.
If not, the neurasthenia must ))e
treated accordine^ to its deg-rees. Ex-
tensive outdoor exercise at regular
hours is of value in the moderate
cases. Retiring early and hydro-
therapy are also efficient. Occasion-
ally intragastric faradism or stomach
lavage, with rather cool water, an-
swers well. The diet should be bland ;
small meals at rei^ular intervals are
best. General tonics, or hematinics
in the anemic, should be given. For
the gastric symptoms large doses of
bromides and valerian should be
given an hour or so before meals, and
the tonics after. Belladonna and co-
deine may also be used in selected
cases. The bowels must be kept
open.
ANTIPERISTALTIC UNREST.
— Cases of this condition are prob-
ably identical with peristaltic unrest.
They must be differentiated from
pyloric or intestinal stenosis and con-
ditions of abdominal prolapse. Small
antiperistaltic waves seen with the
X-ray running from the pyloric re-
gion toward the fundus are indicative
of pyloric obstruction. The treatment
outlined in peristaltic unrest also an-
swers in these cases.
PYLORIC INCONTINENCE.—
This may arise through pyloric neo-
I-lasm or by traction of internal scars
or external adhesions. The condition
is usually part of a general atony.
That it may be neurotic in type is
doubtful.
Symptoms and Diagnosis. — There
is vague gastric distress, w'ith con-
stipation, insomnia, abdominal disten-
tion, and neurasthenic manifestations.
The diagnosis is suggested by find-
ing an empty stomach soon after
eating, with bile present in the full
as well as the empty organ. On in-
flation it is said that the air rushes
into the intestine, causing a prompt
general tympany, the stomach tym-
pany soon disappearing. I agree with
Ewald and Einhorn in that this is
a fallacious method of examination.
Four cases of rapid evacuation and
constant presence of bile in the stom-
ach were found by me to be actually
mstances of hypermotility of the ex-
ternally invisible form. One should
be careful in making the diagnosis of
pyloric incontinence from only mod-
erate inflation and test-meal extrac-
tions, without further examination.
Treatment. — The use of finely sub-
divided solid foods, frequent small
meals, intragastric faradism, strych-
nine, postural treatment, and meas-
ures for neurasthenia are advised.
DUODENAL REGURGITA-
TIONS DUE TO FATTY FOODS.
— Hitherto the cases in which fats or
oils have been considered contrain-
dicated have been those of so-called
"fat intolerance," with poor fat diges-
tion and absorption. The author has
called attention, however, to a stom-
ach condition in which fat foods and
the native oils are actually harmful.
Symptoms. — There occurs a sharp
attack of acute gastric pains, radiat-
ing to the l)ack, paroxysmal, lasting
several minutes to several hours, and
sometimes for days. They may be
severe enough to incapacitate the pa-
tient, though when they disappear —
often suddenly — he is as well as ever.
The gastric distress is independent
of meals. Occasionally nausea is as-
sociated, but not vomiting. The con-
dition occurs in the middle-aged.
The physical examination of the
stomach and abdomen is negative.
The gastric analyses show a large
STOMACH, DISEASES OF (BASSLER).
359
return after an Ewald meal, which is
deeply bile-stained, contains much
floating fat, fatty acids, pancreatic
juice, hydrochloric acid, and perhaps
mucus from gastric irritation. The
empty stomach, aspirated, even in
the morning, shows a large accumula-
tion of duodenal secretions, fat and
fatty acids, etc. The accumulation is
less when the patient is pain free or
has been on a fat-free diet.
In the production of the condition
it is probable that the fats directly af-
fect the pyloric mucosa and muscle,
thereby causing local relaxation or
otherwise permitting of regurgitation
from the bowel.
The pains are due to accumulation
of regurgitated juice, resulting in the
formation of fatty acids from the oils
and fats, and these with the bile irri-
tating the stomach.
Diagnosis. — The condition must be
differentiated from those instances of
test-meal extractions, in which a lit-
tle bile is noted in the, stomach from
gastrosuccorrhea (in which pains are
not so severe, little or no duodenal
secretions are present, the mucus
content lower, and the hydrochloric
acid higher), and pylorospasm. The
best means of dififerentiation is gas-
tric analyses, together with aspira-
tion from the fasting stomach.
Treatment. — These cases rapidly
recover under a fat-free diet —
skimmed milk, white of eggs, carbo-
hydrates, green vegetables, salads,
boiled meats, etc.
ACUTE GASTRITIS.— The limits
of the various types of acute gastritis,
both pathologically and clinically, are
very elastic, and, further, one has
difficulty in feeling sure that what
looks like acute gastritis may not be
an exacerbation of chronic gastritis.
ACUTE CATARRHAL GAS-
TRITIS (Simple Gastritis, Acute
Indigestion) . — Etiology. — The predis-
posing causes include the acute
fevers ; the metabolic disorders ; low
nutritive states, such as debility, ane-
mia, and the blood dyscrasias; and
chronic congestion of the stomach
due to heart, liver, or kidney disease.
The exciting cause is overeating, eat-
ing when physically tired, or when
mentally depressed or excited ; un-
suitable food; foods unripe, improp-
erly cooked, or tainted, e.g., ptomaine-
bearing ice-cream, tish, and meats ;
alcoholic overindulgence ; taking a
large amount of very hot or very cold
fluid ; and irritating drugs, such as
quinine, metallic salts, acids and
alkalies, iodides, and salicylates.
Trauma of the upper abdomen may
rarely precipitate an acute gastritis.
The male sex is that more fre-
quently affected. The condition oc-
curs at all ages. Most cases are seen
in the summer and fall, due prob-
ably to unripe or overripe fruit, ex-
cessive use of ice-water and alcoholic
fluids, or food tainted during hot
weather.
Pathology. — The mucous mem-
brane is swollen and flat, or may be
mottled. Usually tenacious mucus
clings to the surface. Submucous
hemorrhages may be observed, and
small erosions are not uncommon in
the pyloric region. The histological
changes in the mucosa are usually
marked, sometimes out of all propor-
tion to the intensity of the symptoms.
The gastric cells are swollen, and the
interglandular substance may be in-
jected with polynuclear leucocytes.
Portions of the columnar epithelium
may be absent. Many of the acids as
well as the central cells do not show
360 STOMACH, DISEASES OF (BASSLER).
nuclei, displaying merely a loose gran- tongue is coated. Herpes, urticaria,
ular protoplasm. The upper i)ortions or erythema may appear, especially
of the gland tubules may be miss- when tainted tish and shelllish have
ing. Bacteria are commonly found, been responsible. The urine is high
usually the B. lactis acrogcncs, B. coli colored. Excess of indican is the
communis, B. protcus vulgaris, O'idiiim rule when vomiting has not occurred
albicans, and streptococci. and the bowels remain constipated.
Symptoms. — These vary greatly in Fever, present in about half the cases,
severity. The onset is usually acute, may reach 105° F. (40.6° C), and
following a manifest indiscretion in be preceded or accompanied with a
diet. Fleaviness or fullness in the chill or chilly sensations. The catar-
epigastrium is experienced. After ihal inflammation may extend to the
ejection of gases, brief relief is ob- duodenum and, obstructing the gall-
tained, which may be followed by duct, lead to jaundice.
distress greater than before. Distinct In gastritis due to toxic foods,
nausea may be present and, in those vomiting is incessant and prostration
who vomit easily, the stomach con- marked, with small, rapid pulse,
tents may be ejected, after which the clammy skin, a blanched counte-
relief of symptoms is marked. In the nance, and apathy,
milder cases the gastric distress runs Generally an attack of gastritis
along for an hour or two, and then, lasts from one to four days. If neg-
without vomiting, gradually subsides, lected or frequently repeated, it may
In the severe forms acute pains pass gradually into the subacute or
may occur, radiating to the hypo- chronic form. In ptomaine-poison-
chondriac and sternal regions. There ing, where prostration is marked, the
may be severe headache, a moderate patient is apt to die. The same is
rise in temperature, anorexia, regur- true in acute gastritis occurring in
gitation of sour or bitter gastric middle-aged or old persons late in the
contents, marked thirst, cardiac pal- course of long-standing disease. A
pitation, giddiness, frequent vomit- few cases in children also end fatally,
ing, restlessness, and profuse sweat- Diagnosis. — This is readily made
ing. when a cause is apparent and acute
If the vomiting continues when the gastric distress and fever are present,
stomach has been emptied of food, Absence or marked reduction of hy-
the vomitus consists of saliva, mu- drochloric acid in the vomitus, the
cus, bile, and even blood. Ejected presence of organic acids, and the un-
foods show absence of digestion. To- digested food, are significant. Slowly
gether with the lactic and butyric developing febrile forms with slight
acids found, acetic acid is sometimes gastric symptoms may be temporarily
easily recognizable in those who have confounded with incipient typhoid
drunk alcohol. Hydrochloric acid is fever; the rapid course and the ab-
generally absent. The abdomen ap- sence of typhoid symptoms and
pears bloated and the stomach W'idal reaction soon remove doubt.
markedly tympanitic and tender. Many infectious diseases begin
Constipation usually exists, though with a history of acute gastritis,
diarrhea may follow the attack. The Therefore in all cases with high
STOMACH, DISEASES OF (BASSLER).
361
fever, when the cause is obscure, one
should be guarded until the time for
pathognomonic symptoms of other
diseases has passed. The tempera-
ture in acute gastritis rises sharply
and then falls uninterruptedly to
normal. Herpes labialis speaks in
favor of acute gastritis, though it may
■also occur in malaria and pneumonia.
Acute exacerbations of chronic
gall-bladder and duct disease, or
cholelithiasis, not causing much pain
or any icterus, may be mistaken for
acute gastritis.
Treatment. — If spontaneous vomit-
ing does not occur, and the stomach
is distended with gas and food, it
should be emptied, especially when
distress persists, and in ptomaine
cases. Gastric lavage is the best pro-
cedure. A hypodermic injection of
apomorphine, V20 grain (0.003 Gm.),
may be given in sthenic cases. In
mild cases 1 or 2 glassfuls of hot
water may relieve the distress, either
by promoting vomiting or washing
the stomach contents into the intes-
tines. A little table salt or English
mustard added to the water should
be the only emetic measure applied
per OS. EAvald and Boas, however,
recommended the following: —
IJ Pulv. ipecacuanhce. gr. xxiij (1.5 Gm.).
Antijiwnii et potas-
sii tartratis gr. % (0.05 Gm.).
Pone in chartnlam no. j.
Sig. : To be taken at once or in divided
doses.
To children syrup of ipecac may be
given in a teaspoonful dose, or, bet-
ter, 20 drops every 10 minutes until
vomiting occurs..
All food should be withheld for
some time. Later, fluids such as
strained barley, rice- or albumin-
water, or weak tea, may ])e employed.
Solid foods should not be allowed
until che demand for them is rather
insistent. About the third day, thin
soups, soft-boiled eggs, toast, bread
and butter, oysters, etc., may be
given, and, if well borne, supple-
mented by meats on the next day.
Ordinary diet may then be resumed.
Marked local distress calls for a
mustard plaster on the epigastrium,
immediately followed by an ice-bag.
Turpentine fomentations may be used
for distention in the subacute stage.
A purgative should be given after the
stomach has become tolerant — pref-
erably calomel, never oil or salines.
Ewald's plan of giving calomel in two
doses of 6 grains (0.4 Gin.) each, one
hour apart, is far preferable to the
giving of small divided doses. Laxa-
tive measures had best be withheld
until about thirty-six hours after the
beginning of the attack.
Antipyretic drugs should not be
given in acute gastritis. For pain and
general distress, a small dose of mor-
phine, or, better, codeine, given hypo-
dermically, is helpful, but counter-
irritation and hydropathic measures
should first be tried. The following
suppositories are useful : —
1} CodeincE sulphatis .. gr. v (0.3 Gm.).
Extracti belladonncc
foUorum gr. ss (0.03 Gm).
Olei theobromatis ... q. s.
Fiant suppositoria no. x.
Sig. : One every hour until relieved, then
discontinue.
For vomiting, which persists after
evacuation of the stomach, bismuth
or cerium oxalate are of use, e.g.: —
B Bismuthi subnitratis ... Siss (6 Gm.).
Ccrii oxalatis '3ss (2 Gm.) .
Peppermint-sugar 3j (4 Gm. ) .
Pone in chartulas no. x.
Sig.: Take 1 powder every hour until
vomiting is controlled.
362
STOMACH, DISEASES OF (BASSLER).
A little brandy or cracked ice in-
ternally, or a mustard plaster to the
gastric region, sometimes controls the
vomiting sufficiently.
Symptoms of hyperacidity, or pyro-
sis with thirst, indicate use of the
alkalies. Lime-water on ice may be
employed, or the following: —
IJ Magnesii oxidi,
Sodii bicarboiiatis,
Bismuthi subcarboiiatis,
Peppermint-sugar ...aa 3ij (8 Gm.).
Fac in pulverem.
Sjg. : Take Yz teaspoonful in water every
three hours.
For pronounced prostration, the
usual sustaining measures should
be applied. In ptomaine-poisoning
cases gastric lavage and an enema
are indicated; if the patient is seen
somewhat late, croton oil or colonic
enemata, should follow the lavage.
Such cases not infrequently go into
extreme collapse and imperatively
require hypodermic injections of
strychnine, nitroglycerin, ether, cam-
phor, whisky, or the hypodermic
preparations of digitalis. These may
be used in rapid succession without
danger of overstimulation.
For the anorexia, aversion to food,
and physical weakness that may per-
sist after acute gastritis, the follow-
ing tonic is useful : —
IJ Strychnina sulphatis. gr. % (0.05 Gm.).
Ac. hydrochlorici dil. Sj 30.0 c.c.).
Elixiris gentiana, q.
s. ad 5iv (120.0 c.c).
Fiat mist.
Sig. : Take 1 teaspoonful in Yz glassful of
water before meals, through a glass tube.
ACUTE SUPPURATIVE GAS-
TRITIS (Phlegmonous Gastritis,
Gastric Abscess) . — Etiology. — This
may be primary or occur as a com-
plication of other gastric affections,
such as stomach cancer and the gas-
tric involvement of typhoid fever,
puerperal fever, pyemia, variola, an-
thrax, severe exanthemata, and artic-
ular rehumatism. As a primary af-
fection the disease is rare, and occurs
either in the diffuse infiltrative or the
rather localized form of gastric ab-
scess. The condition is generally fatal.
It, is usually met with in laborers in
late middle life and of the alcoholic
type. It is caused by entrance into the
submucosa of a virulent organism,
usually the Streptococcus pyogenes,
sometimes the staphylococcus, colon
bacillus or pneumococcus.
Pathology. — In the diffuse form
the pyloric region is mostly involved,
being swollen, boggy, and pale yel-
low. The stomach-wall shows a
marked infiltration with pus-cells,
leucocytes, serum, fibrin, micrococci,
endothelial cells, lymphocytes, and
eosinophilic leucocytes. This infiltra-
tion usually extends throughout the
interglandular tissue, causing small
ulcerations through which the pus
wells up. The muscularis shows fatty
degeneration, and the peritoneum may
be raised from it by inflammatory
exudate. Areas of congestion in the
gastric region, a collection of cloudy
fluid in the peritoneal cavity, con-
gestion of the pancreas, pus in the
pleural and pericardial sacs, pneu-
monia, nephritis, and purulent menin-
gitis are other possible accompani-
ments.
Symptoms. — Intense burning pain
in the gastric region, not increased
by pressure or change of position, is
suddenly experienced. With it come
extreme thirst, a dry tongue, and an
obstinate fever of 103° F. to 105° F.
(39.5° to 41° C), sometimes preceded
by a chill. The pulse becomes small,
rapid, then irregular. Restlessness
STOMACH, DISEASES OF (BASSLER).
363
and distress are soon followed by de-
lirium. Retching- is generally pres-
ent. The vomitus, where vomiting
occurs, consists mainly of mucus and
bile^ with pus-cells, many bacteria of
one type, and blood-cells. Constipa-
tion is soon followed by diarrhea. In
a few hours prostration and coma
ensue. Perforation may occur, or the
case runs a subacute course for one
or two weeks. If a large abscess oc-
curs, it may be palpable externally.
Diagnosis. — The presence in the
vomitus of numerous bacteria of the
same type is a good diagnostic indica-
tion. If rupture of an abscess into
the stomach occurs, pus is easily seen
in the gastric contents or vomitus.
Where it is absent, the diagnosis
rests upon the bacteria, pain, vomit-
ing, meteorism, fever, diarrhea, and
general phenomena of serious illness.
According to Ewald, the condition
may closely mimic abscess of the
spleen or left hepatic lobe. When
localized swelling is noted, aspira-
tion, or, better, an exploratory incis-
ion, may be justified; where physical
signs are indefinite or fever lacking,
the diagnosis cannot be made during
life.
Treatment. — Lavage of the stom-
ach with a 1 : 10,000 corrosive subli-
mate solution or one made from Yi
ounce (15 Gm.) of boric acid to a quart
(liter) of water is an appropriate
measure. Opium in large doses may
be used, together with ice-cold appli-
cations to the abdomen, and, when
collapse occurs, strychnine, ether,
camphor, etc. Iced champagne or
brandy may be of some benefit.
Should localized abscesses occur,
drainage is in order. Recovery is
rarely reported, though localized ab-
scesses, rupturing into the stomach,
might drain sufficiently to permit of
spontaneous recovery.
INFECTIOUS GASTRITIS.—
This is due to non-pyogenic bacteria,
worms or fungi. The diphtheria and
anthrax bacilli, the favus, thrush, and
yeast fungi, and animal parasites such
as the larvae of diptera (maggots)
may be responsible, rarely ascarides
and tapeworms.
The symptoms are those of severe
acute gastritis with fever, lasting one
or two weeks. The condition may be
mistaken for typhoid fever.
The treatment is chiefly expectant.
Lavage and small doses of calomel
are generally of benefit. If intestinal
worms in the stomach are suspected,
their removal should be secured.
TOXIC GASTRITIS.— Etiology.
— This is an intense form of gastritis
produced by poisons such as phenol,
potassium cyanide, mercury bichlo-
ride, arsenic, antimony, chloroform,
oxalic acid, the mineral acids, and
the caustic alkalies in strong solu-
tions. Strong solutions of alcohol
and ammonia and croton oil may also
be included.
Pathology. — Non-corrosive poisons
cause intense hyperemia and tume-
faction with desquamative changes
in the glandularis. The mucosa be-
comes swollen, superficially necrotic,
and hemorrhagic in spots. Corrosive
substances cause a more general ne-
crosis, possibly with perforation.
Symptoms. — Intense burning pain,
epigastric, sternal, and oral, usually
soon follows ingestion of the poison.
Marked tenderness in the stomach
region develops. Incessant vomiting
soon begins and, by increasing the
pain, may cause syncope. The vomi-
tus contains mucus, l)lood, and some-
times shreds of mucosa. Thirst is
364 STOMACH, DISEASES OF (BASSLER).
great, and a thin, bloody diarrhea is drams (8 Gm.) of magnesia in water,
often noted. Dysphag-ia is common, followed by 15 minims (1 c.c.) of
Severe general symptoms follow, ferric chloride and 12 grains (0.8
which may end in collapse, llema- Gm.) of ferrous sulphate in aqueous
togenous jaundice, petechia, albumi- solution. Iodine: starch-water. Mer-
nuria, and hematuria may be noted, curial salts : white of egg and flour.
The temperature may reach to 104" Oxalic acid : lime or magnesia. Phos-
F. (40° C.), and life be spared long phorus: magnesium sulphate. The
enough for a fatal nephritis to de- use of olive oil or molten vaselin in
velop. Death may follow in a few the stomach, after neutralization and
hours or a few days from collapse, lavage, diminishes the effect of the
or later from perforation peritonitis, corrosive poisons, except phosphorus.
Stenosis of the esophagus, cardia, or Morphine may be used to control
pylorus, or atrophy of the oral and the pain and general distress, bismuth
gastric mucosa may ensue with sub- and cracked ice to allay irritation,
sequent inanition. and an ice-bag externally in peri-
Diagnosis. — This is usually made tonitis. Oral feeding should not be
by cross-examination of the patient permitted until recovery is well estab-
or by the history obtained from those lished, nutrition being meanwhile
nearby. Gastric symptoms and ex- maintained by rectal enemata alone,
amination of the mouth, throat, or Prostration and collapse indicate
vomitus, are also helpful. Chemical the ordinary prompt stimulation,
examination of the gastric contents CHRONIC GASTRITIS.— This is
Js
b
and urine may be necessary. a condition due to organic gastric
Treatment. — It is necessary first to changes, the term not necessarily ap-
ascertain the poison taken. If the plying to any gastric case simply be-
case is seen early, the stomach cause it runs a chronic or subacute
should be washed out with warm course. The misleading and inac-
water containing some demulcent curate terms "catarrh of the stomach"
and a little of the appropriate anti- and "chronic dyspepsia," sometimes
dote. In cases seen later, siphon- used as synonyms for chronic gas-
age of the stomach is preferable, to tritis, should be abandoned,
reduce the chances of perforation. A Varieties. — Severe cases of chronic
soft tube is safer and more satisfac- gastritis may, for clinical and tliera-
tory than the Kussmaul pump. peutic purposes, be divided into two
Antidotes. — Caustic alkalies : dilute types — the sthenic and asthenic. The
vegetable acids, lemon- and lime- former are those associated with in-
juice, or vinegar. Antimony : tannin creased secretion of hydrochloric acid
in demulcent drinks. Arsenic : ses- and gastric enzymes, and sometimes
quioxide of iron, made by adding increased motility; the latter, those
carbonate of sodium to tincture of in which these functions are dimin-
ferric chloride, or dialyzed iron, ished or absent. Pathologically, there
Phenol : alcohol, solution of mag- are three main types : Simple chronic
nesium or sodium sulphate, dilute gastritis, in which the glandular ele-
sulphuric acid, or saccharated solu- ments are mostly affected ; the hyper-
tion of lime. Hydrocyanic acid : 2 trophic or sclerosing form, where in
STOMACH, DISEASES OF (BASSLER).
365
addition the connective tissue and
musculature are proliferated {benign
cirrhosis of the stomach), and the
atrophic form, showing loss of epithe-
lium, destruction of the glands, and
sometimes more or less growth of
connective tissue. Primary and sec-
ondary types of chronic gastritis are
also distinguished. The former are
due to unsuitable foods, alcohol,
tobacco, abuse of purgatives, etc.
The latter are the result of acute
gastritis plus continued indiscretion,
or represent complications of other
gastric or general affections.
Etiology. — Chronic gastritis is a
common disease, occurring in all sta-
tions and ages of life, and oftener in
men than in women. In primary
cases it is caused by continued
dietetic errors, including the use of
foods defective in quality or prepara-
tion, rapid eating, alcohol, etc. Tea,
coffee, and tobacco in excess are
additional factors, and likewise over-
indulgence in carbohydrates and fats.
Two or more causes often coexist.
Rapid eating and overeating, con-
tinued use of overseasoned foods, and
the alcoholic or iced drinks are the
most common causes. Among those
using the lighter wines at their meals
chronic gastritis is not as common as
in those who take whisky or liqueurs,
carbonated wines such as champagne,
sparkling Moselle, or alcoholic fluids
containing much carbohydrate, such
as beer and ale. Moderate alcohol
drinking is often associated with
dietetic error, and the condition is
common in persons well nourished
and leading a steady, regular life in
other respects.
Among other conditions that may
directly start a chronic gastritis are
an incompletely resolved acute gas-
tritis, typhoid fever, and an unhealthy
oral condition.
As a secondai"y disorder chronic
gastritis occurs in gastric cancer,
ulcer, atony, and long-standing neu-
rotic secretory and motor disturb-
ances. It also accompanies anemia,
chlorosis, leukemia, chronic tubercu-
losis, Addison's and Bright's diseases,
gout, nephritis, diabetes, syphilis, and
amyloid disease. Again, it may re-
sult from chronic engorgement, as in
liepatic cirrhosis, chronic heart and
some chronic lung affections, and
Banti's disease. It may accompany
or result from almost any subacute
or chronic disorder causing debility.
PATHOLOGY.— In simple chronic
gastritis, the stomach is usually
slightly enlarged, the mucosa gray,
in parts reddish, and mucus covered.
At the pyloric end, usually most af-
fected, the mucosa may be found
rough and mammillated. While usu-
ally thickened, it may be thin and
firm. Microscopic study shows a par-
enchymatous and interstitial inflam-
mation of the glandularis and, in
long-standing cases, infiltration of the
submucosa, and perhaps some hyper-
trophy or atrophy of the muscularis.
The cells typically show mucoid and
also usually fatty degeneration. In
true simple chronic gastritis only the
upper cells of the tubules may be
affected. The veins are usually en-
larged, and small areas of hemor-
rhage may be noted near the pylorus.
Hypertrophic and sclerosing gastritis
represent more advanced conditions.
Hypertrophic changes in the con-
nective tissue about and below the
glands may cause the mucosa to be
thrown up in ridges, locally or more
diffusely. When the submucosa is
involved, as is usual, the glandu-
366 STOMACH, DISEASES OF (BASSLER).
laris becomes more lirmly fixed to stomach may show all the patholog-
the inner muscular coat. The result- ical changes al)ove described.
in<r interference with circulation in SYMPTOMS. — The initial symp-
digestion, together with the more or toms of chronic gastritis are not well
less complete destruction of the gland marked, and the condition is usually
cells, causes absence or decrease of ignored at first. Later, there is a.
gastric-juice secretion in these cases, sensation of pressure in the gastric
In still more advanced conditions, region after meals, with general op-
sclerotic thinning of all the gastric pression. Dizziness, cardiac palpita-
coats may ensue (phthisis ventriculi tion, and shortness of breath (asthma
or complete atrophic gastritis), or an dyspepticum) may be experienced,
enormous thickening may occur, due These may be relieved by belching,
to hypertrophy of the muscularis though local distress tends to persist
(cirrhosis ventriculi). Reduction in through gastric digestion. Sometimes
size of the organ occurs, often coupled the distress and pain continue when
with hyperplastic stenosis of the py- the organ is empty, with slight ten-
lorus. The hypertrophic types of late derness on pressure over the stomach,
gastritis are, in my experience, less The tongue is coated, and a bad
common than the atrophic form, in taste in the mouth is experienced,
which the organ remains normal in especially after meals or in the morn-
size or is somewhat dilated. ing. The tongue may be red on the
Atrophic gastritis may either ter- tip and margin, with a triangular
minate a simple chronic gastritis coating on the dorsum, or may be
or begin as such. The stomach has soft, pale and flabby throughout,
lost its function of secretion (other showing serrations from the teeth,
than mucus), but usually retains and with a thin, furry coating. The
sensation and some motility. The breath may be obnoxious, especially
condition appears to me to be due to when the teeth are carious. Faucial
a gastritis originally more definitely and oral catarrh is common, the latter
confined to the glands, with rela- rendering the breath more offensive
tively less early involvement of the and foods tasteless. Among other
submucous and muscular tissues, conditions observed are pharyngitis,
The mucous surface is smooth and postnasal catarrh, and stomatitis,
grayish in complete cases. Areas of Secondary throat involvement results
hypertrophy, hemorrhage, or small in the so-called "stomach cough."
ulcerations ("chronic catarrhal ul- The appetite is fitful in most cases,
cers") may be observed. More or less anorexia is usually but
There is marked destruction of the not always present. Freak selection
gland cells, which are in process of of foods is common. Piquant, salty,
mucoid and fatty degeneration, witli or acid foods may be sought. Satiety
final detachment from the basement from just a few mouthfuls of food or
membrane and disappearance, leaving drink is a common symptom. Thirst,
empty spaces. Tn advanced cases the however, may be increased; also the
gland tubles are lost, irregular, cyst- salivary and pharyngeal secretions.
like formations alone remaining. In severe gastritis especially, nau-
Dififerent portions of the same sea is an early and frequent symp-
STOMACH, DISEASES OF (BASSLER).
367
torn. It usually comes on after the
taking of food, and is relieved by
voiiiiting. Burning may be experi-
enced under the sternum (pyrosis),
due to increased hydrochloric or or-
ganic acids, together with eructations
of sour gas or fluid. Distinct flatu-
lency suggests gastric atony or co-
existing marked neurotic disturbance.
Vomiting of the entire stomach con-
tents, except in atrophic gastritis, is
rarely observed. Regurgitation of
smaller amounts is often met with
before or after breakfast. In alco-
holic cases, retching and ejection of
mucus, bile, and saliva are common
motning symptoms. Enteritis or a
functional hepatic disturbance may
be induced.
Early cases seem well nourished.
Later, nutrition and health inevitably
suffer, even if, as is frequently not
the case, sufficient food is being
taken. In the atrophic cases a mod-
erate degree of progressive anemia
results.
Constipation from atony is usual,
and in advanced cases is obstinate.
Diarrhea may, however, occur, par-
ticularly in heavy drinkers of beer or
ale, or those having much intestinal
fermentation and putrefaction. Al-
ternate constipation and secondary
diarrhea are occasionally met with.
The urine is usually rich in urates
and phosphates, indican is commonly
present, and albumin, casts, and cells
may be found in long-standing cases.
Gastric analyses are necessary to
determine the type of gastritis pres-
ent, the precise treatment to be in-
stituted, the prognosis and the re-
sults obtained from treatment. Much
definite information is derived. l'^)r
the methods of examining the gastric
contents and the findings to be ex-
pected in chronic gastritis, the reader
is referred to the Index-Supplement
volume.
COMPLICATIONS. — The com-
monest complication is chronic duo-
denitis and diminished pancreatic
secretion. Attacks of catarrhal jaun-
dice from occlusion of the common
bile-duct or extension higher up in the
biliary passages may then occur.
Anemia and debility are often pres-
ent, later inanition and emaciation.
An intense general neurotic condition
usually accompanies the atrophic
cases, and at times chronic nephritis.
DIAGNOSIS.— This is reached
from the symptoms and the chronic
course of the disease. The primary
and secondary forms usually are easily
dilTerentiated by the absence or pres-
ence of well-marked causative disease
in other organs ; yet, when heart,
lung, or kidney disease exists, it
should not be overlooked that a sec-
ondary gastritis may be engrafted on
a primary. In atrophic cases the
poor general health, nervous disturb-
ance, anemia, and nephritis are of
diagnostic importance.
Among gastric disorders, the clini-
cal pictures of ulcer, carcinoma, and
the neuroses should be kept in mind,
always remembering that chronic
gastritis may ensue from any of
them, or, on the other hand, precede
without being their cause. When
ulcer or cancer is strongly suspected,
the diagnosis of the more serious
condition should always be made.
Gastric Neuroses. — Frequent test-
meals will usually diff^erentiate the
true neuroses from gastritis. The
presence of much mucus, gastric epi-
thelial and gland cells, leucocytes,
and low states of hydrochloric acid
and pro-enzyme secretion suggest
368
STOMACH, DISEASES OF (BASSLER).
chronic gastritis. In the distinction
from depressive neuroses more re-
liance should be j)laccd on free or-
ganic elements and (juantities of mu-
cus than on low secretory functions.
Gastric Ulcer, — In ulcer the pain
is more acute and sharply localized,
and is increased on taking foods
(particularly the coarser varieties).
Hemorrhage and vomilus containing
much hydrochloric acid are not seen
in clironic gastritis. The test-meal
usually shows excess of secretions
and hypermotility. In chronic ulcer
there is more difficulty ; secretion
may be low, including even mucus. A
history of acute ulcer and the greater
diffusion, intensity and frequency of
the pains are important. The X-rays
and fecal examinations may also help.
Gastric Cancer. — Differentiation,
though difficult, may be possible from
a series of test-meals, and X-ray and
fecal examinations. When a tumor
is palpable, the gastric contents are
characteristic, and the general and
other local symptoms of cancer exist,
differentiation is easy. Hypertrophic
gastritis, with presence of a tumor,
occasions much difficulty. The slow
onset and the small, smooth, round,
movable tumor, always of about the
same size, would suggest a benign
condition. Bleeding is rare, and
there is absence of collective vomit-
ing, the organ being shrunken. As
surgical treatment is indicated in
hypertrophic gastritis with pyloric
stenosis as well as in early cancer,
this distinction is unimportant.
Amyloid degeneration of the stom-
ach is always secondary to long-
standing suppurations, or, more
rarely, leukemia, lead-poisoning, and
gout, and may manifest itself as a
chronic gastritis, with complete sup-
pression of secretions. This, with
the history of other disease, and if
amyloid disease is known to exist in
the li\ er, spleen, or kidneys, warrants
an assumption of gastric amyloid.
PROGNOSIS.— The average case
of chronic gastritis is curable. In the
more advanced cases, the progress of
the disease can be stayed and the
subjective symptoms relieved. Com-
pletely atrophic cases, however, are
absolutely incurable, though benefit
may accrue from careful medical at-
tention. Thq weaker the gastric se-
cretory functions, the more serious
the case; the amount of mucus pres-
ent is of less prognostic significance.
Patients who, after treatment, again
become indifferent to matters of
proper eating and drinking, are very
liable to relapses. The secondary
cases improve if the causative disease
can be benefited.
TREATMENT. — Prophylaxis in-
volves correction of hasty eating and
overeating, excessive use of iced
drinks, abuse of alcohol and tobacco
(particularly chewingj, and bad con-
dition, insufficient number, and faulty
alignment of the teeth.
Report of 72 cases of soldier's gas-
tritis with hj'perchlorhydria (among
135 instances of dyspepsia in sol-
diers), due to repeated functional
hyperstimulation. Recuperation is
favored by a non-irritating diet, milk,
potatoes, and sugar. Sugar solutions
soothe and supply calories. Reduction
of gastric secretion is favored by the
highly sweetened diet. Emptying the
stomach and rinsing it with weak
solutions of sodium bicarbonate is
effectual; likewise the ingestion of an
alkaline solution, with phosphates,
sulphates, and sodium citrate, half an
hour before meals, A suspension of
bismuth subcarbonate, taken fasting,
is of service. Loeper and Verpy
(Ann. de med., Mar.-Apr., 1918).
STOMACH, DISEASES OF (BASSLER). 369
Lavage of the stomach, coupled oxalate, or the insoluble and bland
with dietetic treatment, forms a valu- magnesia compounds may be given,
able therapeutic combination. It For the removal of adherent mucus
benefits by removal of free and adher- in lavage a solution of 3 tablespoon-
ing mucus, as well as of irritating, fuls of sodium bicarbonate or 2
stagnant food, and by stimulation of ounces (60 Gm.) of lime-water in
glandular activity. It also prevents 2000 c.c. (2 quarts) of warm water
intestinal involvement. Removal of may be advantageously used, fol-
mucus is facilitated by allowing the lowed, for its astringent and stimu-
water to run in under some pressure, lating effect when much mucus is
— a beneficial procedure when atony being secreted, by a 1 : 1000 solution
is not present. The Leube-Rosenthal of silver nitrate. To avoid argyrism,
method is^ best. In an empty stom- the stomach should be empty after
ach the gastric spray douche may be using the latter, and the measure
used with advantage. When primary should not be kept up for more than
atony exists, hand siphonage is a dozen or so washings. As the
safer, introducing only small amounts mucus appears to lessen, one may use
of liuid at a time. When the residual with the alkaline water, or alone, a
lavage water is from 500 to 1000 weak solution of tincture of Hydrastis
c.c, (1 to 2 pints) marked gastric (30 to 2000), or of the fluidextract
atony or relaxation of the pyloric of Hydrastis (4 or 8 to 2000). To
sphincter is indicated (permitting the stimulate acid secretion late in the
escape of the water into the intes- treatment a 12 to 2000 hydrochloric
tines). In the first condition, the acid solution, always freshly made,
water stretches the stomach and is should be used. Employment of 2000
injurious; in the second, the sudden c.c. (2 quarts) quantities is always
influx may be beneficial for a short advisable, as most cases cannot be
time, but in the end injures the washed clean with less. Addition of
intestines. antiseptics, such as salicylic acid, is
When residual water is due to gas- unnecessary. When atrophy of the
trie atony, preliminary intragastric glandularis is complete, no direct
faradism will so strengthen the organ benefit ever accrues from lavage,
that lavage without excess of residual The diet is to be based on the gas-
water becomes possible. trie chemical functions, and be free
Lavage should be practised in the of irritating foods. Until the symp-
morning, before food has been taken, toms abate somewhat a bland, fluid
Rarely, when mucous secretion is or semisolid diet should be given,
high, a second late evening washing consisting, c.g.^ of milk, kumyss,
may be essential. In mild cases, or matzoon, rice, farina, sago, soft eggs,
when benefit from lavage is estab- thin soups, mashed potatoes or soft
lished, every other or every third day vegetables in puree or cream, spinach,
is sufficient. Brief gastric rest is de- scraped or finely chopped meats, not
siral)le after lavage, which may be very fresh bread, toast, butter and
•done an hour or two before the even- cocoa, etc. In a week or two more
ing meal, or at 9 or 10 p.m. After solid articles should be added. Meats,
such a lavage a bismuth salt, cerium rough vegetables, and fiber-bearing
8-L'l
370
STOMACH. DISEASES OF (BASSLER).
cereals, such as oats, should be re-
sumed with caution, and severely
limited in amount. Stimulants, highly
seasoned food, pork, new veal, corned
or smoked meats, lobster, salads,
pickles, cabbage, cucumbers, too hot
or too cold drinks, and strong tea
should not be used. Coffee, except
at breakfast, should be interdicted.
In normal or increased acidity the
protein-bearing foods may be al-
lowed, but if acidity is low, only
fish, eggs, and milk should be used,
carbohydrates and cereals being in-
creased both to spare proteins and
because of their better digestion. In
severe cases, only fluid or finely sub-
divided foods should be allowed. In
constipated cases, the soft green
vegetables, fresh fruits, honey and
buttermilk, etc., are of service.
If gastric atony exists, four or five
small meals a day are best. If not,
the usual three meals should be
taken. The teeth should be looked
after and insistence placed upon
thorough chew'ing and complete in-
salivation. Disturbing thoughts at
the table should be avoided, and for
this purpose congenial company is
helpful. Habitually overfed patients
should stop eating when satiety oc-
curs, or should take a fair amount on
their plate before beginning, and stop
when this is consumed. Alcoholic
■drinks and bitters in any form had
best be forbidden. \\'hen the gen-
eral health fails, more food should be
allow^ed.
In slight and moderate cases three
fair-sized and about equal meals a
day should be taken at regular inter-
vals, not too hurriedly, and avoiding
mixtures of many foods. To be in-
terdicted are: Foods having pits,
seeds or skins; nuts in any form;
anything highly spiced; soups and
coffee ; oatmeal, tough meats and
poultry ; rough vegetables, such as
cabbage, cauliflower, sprouts, etc. ;
stews, hashes, and made-up dishes,
and foods and drinks that are too
hot or too cold. To be taken are :
Consomme, bouillon (very small
amounts) ; eggs in any form (two at
a time may be eaten twice a day) ;
fish, fresh, and always boiled or
baked ; beef, lamb, mutton, chicken,
or game, in moderate amounts, only
once a day or in small amounts twice
a day. Meat at one meal and fish at
another is a good practice. Meats
must be roasted or broiled (chopped
raw beef may be eaten with a little
salt), always finely divided, cutting
the fibers crosswise, and well masti-
cated. Breads, rolls, and plain cake,
when not too fresh, are always allow^-
able, and also plain fresh butter in
large amount. The best vegetables
are peas, beans, mashed potatoes, or
baked sweet potatoes. Any of the
salads can be eaten w^ith a little
vinegar, salt to taste, and olive oil
of good quality. Desserts made of
the cereals, butter, milk, or cream
can be used, but no fruits or berries,
pastries, or pies. The best beverage
is plain cold water, taken after meals.
A "must not take" diet list serves
best after the course of treatment,
e.g., foods to be avoided are : One-
or tW'O- minute cooked breakfast
foods ; the rough vegetables — cab-
bage, sprouts, cauliflower, artichokes,
asparagus, beets, celery, corn, cucum-
bers, kohl-rabi, onions, and tomatoes ;
foods which contain pits, seeds, skins,
or nuts ; canned and smoked beef or
fish ; lobster, crabs, shrimps ; cheese
of any kind, excepting Philadelphia
or Neufchatel ; excess of pastries,
STOMACH, DISEASES OF (BASSLER).
371
especially those cooked in melted fat,
such as doughnuts, fritters, etc.; very
sweet foods, such as jams, etc. ; fruit,
cherries, cranberries, figs, grapes,
muskmelons ; much coffee, strong
tea, alcoholic and malt beverages.
Mineral waters are of much value
to stimulate glandular activity or
neutralize acid. For the former pur-
pose, saline and carbonated waters
are of most service, e.g., Kissingen
(Rakoczy), Kochbrunnen, Homburg,
Fachingen, Sedan, or Saratoga (Con-
gress). When the acid content is
high, alkaline waters are useful, e.g.,
Vichy Celestins, Wiesbaden (Koch-
brunnen), Victoria-Brunnen, St. Gal-
niier, and Saratoga (Hawthorn). In
anemia and atony: Levico (mild),
Mitterbad, Orezza, Schwalbacher, or
Stahlbrunnen may be used. In consti-
pation : Carlsbad, Villacabras, Pluto,
or Mt. Clemens Bitter Water, —
though it is better to move the
bowels by dietetic and hygienic
means, or by small enemata of olive
oil instilled each night or saline
enemata during the day. The saline
waters should be drunk before and
the alkaline and ferruginous during
or after the meal. The aperient
waters should be taken before break-
fast. Nervous or debilitated patients
should not receive them.
A morning cold sponge bath is of
much service in depressed and phleg-
matic cases. Plain water at about
60° F. may be used, though the ad-
dition of sea- or table- salt, 1 pound to
10 gallons of water, increases the
tonic action. Patients sensitive to
cold react more quickly and are
more exhilarated by the salt baths,
which may therefore be used in con-
ditions of low general vitality. Sprays
at below 60° F., with patient stand-
ing in a few inches of warm water,
somewhat mitigate the shock. A cold
rub with water and a thick towel is
to be preferred in the case of very
sensitive and nervous persons. Warm
baths of ten or fifteen minutes' dura-
tion may be used in insomnia and
agitated states. The spinal hot
sponge bath, lasting fifteen to twenty
minutes, is valuable to induce sleep.
Outdoor exercise is of much value,
e.g., walking in outlying districts of
the city, horseback riding, and row-
ing. In the home, light dumb-bells
or wall exercises may be availed of,
or the patient may go through the
United States military setting-up ex-
ercises for ten minutes each morning
and evening. One must insist on
these exercises, or patients will soon
become very indifferent to them. To
obviate this, a daily visit to a well-
equipped gymnasium, where com-
panionship during exercise is readily
obtainable, is of service. When there
is visceral prolapse, abdominal exer-
cises are of value; likewise, sports
such as tennis. If atony is marked,
a belt or corset may afford relief.
Sthenic forms of chronic gastritis
may require special care of the nerv-
ous system. The patient should se-
cure ten or more hours' sleep daily.
Where weight, strength, and vitality
have become reduced, a "food and
rest cure" may be necessary.
Electric treatment comes next in
imjiortance to lavage and dietetics.
The faradic current, with rather slow
interruptions, is most beneficial, often
ameliorating the subjective symptoms
and gastric motor tone. The gal-
vanic current may be used in acid
gastritis without atony. The intra-
gastric method is much preferable to
the percutaneous. The course of
372 STOMACH, DISEASES OF (BASSLER).
treatment should last two or three IJ Macjncsn oxidi 3iiss (10 Gm.).
months,— at the start, treatments Bismuthi subuitniiis. . -^v {2Q Gm.).
^.11.1 .1 • J Acituc dcstillatcc Svi (180 c. c).
every other day, then every thud, _ ■• ^ '
r Ji 1 . i-1 1- r • M. Sig. : Take 1 taljlcspooiiful a half-
every fourth day, etc., until relief is , , , , , , , ,., , „
•^ ^ -^ hour before meals. Lal)el Shake.
permanent. In nervous cases a
marked psychic and general stimulat- Or, in gastritis acida : —
ing effect is often produced by the IJ Magncsii o.vidi 5iiss (10 Gm.).
faradic current. In these cases the Bismnthi subnitratis.. Sv (20 Gm.).
spinal and neck regions should be Misturcv rlwi et sodcv. 5vj (180 cc.).
treated with the external electrode. ^- f^^'" ^'''^'' ^ tablespoonful one-half
T . , 1 , 1 1 • 1 or one hour after meals. Label "Shake."
in cases with relaxed abdominal
walls, and when atonic or atrophic When mucous secretion is copious,
constipation exists, the general ab- I first wash out the stomach with
domen should be treated. 2000 cc. (2 quarts) of an alkaline
Under proper dieting, lavage, etc., solution, then follow this immediately
there need be little resort to drug with 1000 cc. (1 quart) of a 1:1000
treatment. In some instances, how- silver nitrate solution. By the use of
ever, hydrochloric acid may be indi- an irrigating stand iKilding a 2000-c.c.
cated to meet the secretory shortage (2 quarts) and a 1000-c.c (1 quart)
and stimulate the glands. I doubt, glass irrigator, side by side, with
however, the necessity of giving it short tubes from each glass jar, this
generally in 40- or 60- drop doses, is rapidly done. When the alkaline
Give 10 to 20 drops of the dilute acid solution has been run through the
in a glassful of water, one-fourth of stomach, the tube from that jar is
the amount being taken at half-hour slipped off the Y-tube, and that from
intervals after the meal. Addition of the silver solution put on instead,
pepsin is valueless. Its administra- In atrophic gastritis, when acids
tion along with predigested foods are not well borne, foods suitable for
should be discouraged. intestinal digestion should be advised
Bismuth salts are direct mechani- and the stomach kept alkaline for
cal sedatives to the irritated mucosa, this purpose. Sodium bicarbonate,
The subnitrate is best for ordinary magnesium oxide, and dried sodium
cases, but the subcarbonate has the carbonate may thus be used with the
advantage of alkalinity for acid gas- meals, which should be frequent,
tritis. Doses of 15 to 30 grains (1 small, and fully subdivided. Pan-
to 2 Gm.) should be used, and the creatin, with the alkalies, is of value,
subnitrate should always be taken The treatment of special symptoms
before meals or when the stomach is in chronic gastritis is as follows : For
empty. The taking of one 45-grain anorexia : Lavage, nux vomica, con-
(3 Gm.) dose of bismuth subnitrate durango, gentian, and orexin. For
before breakfast or at bedtime is an nausea and vomiting: Careful diet
excellent practice. and lavage, hot applications to the
When constipation is marked or abdomen, cerium oxalate, and chloral
follows the use of bismuth, the latter hydrate, 2^ j grains (0.15 Gm.), in
should not be continued except in chloroform-water, 1 fluidram (4 Gm.).
some instances as follows : — For pain : Liquid diet or brief ab-
STOMACH, DISEASES OF (BASSLER).
373
stinence from food, lavage, hot appli-
cations, galvanism, and bromides.
For deficient gastric juice: Lavage
and diet, dilute hydrochloric acid, nux
vomica, gentian, and general tonic
measures. For motor insufficiency :
Electricity, hydrotherapy, frequent
small meals, nux vomica or strych-
nine in rather large doses. For psy-
cliic depression : Electricity, cold
sponge and surf baths, general tonics,
high caloric feeding, and a sojourn
in the country, or in a well-ordained
sanitarium for digestive diseases. For
constipation : Proper diet, electricity,
exercise, going to stool regularly
whether the bowels move or not,
compound licorice powder, cascara
sagrada, or rhubarb, rectal enemas of
salt water, and avoidance of strong
purgative pills or tablets, except oc-
casionally for cleansing the Ijowels.
Surgical Treatment. — In well-es-
tablished hypertrophic stenosis, caus-
ing retention, and witli the organ
much contracted, pylorectomy is in
order. If a pyloroplastic operation
(particularly the Finney) can ])c per-
formed, it serves the purpose better,
but as the organ may be markedly
contracted to the left and away from
the duodenum, a pylorectomy may be
the only operation possible. Unfortu-
nately, the gastric tissues are in such
poor condition for union that the
mortality is higli ; these patien.ts,
moreover, are mostly alcoholic and
cannot stand the operative shock.
Ordinary gastroenterostomy should
not be performed, these stomachs
continuing to thicken after the opera-
tion, and thereby closing the com-
munication, and also because the of-
fending pylorus is not removed.
GASTRIC AND DUODENAL
ULCER. — It is now recognized that
ulcers of the stomach and duodenum
should be described together, since
the first part of the duodenum, in
which 90 per cent, of the duodenal
ulcers are found, is embryologically
and physiologically identical with the
stomach. The comJMned statistics of
59,450 autopsies of various series
showed evidences of healed or un-
healed ulcer in 4.4 per cent, of in-
stances. The disease is said to occur
more frequently in women than in
men ; some even claim a ratio of 3 to
1, but in my experience there is no
difiference between the sexes.
ETIOLOGY.— Some believe that a
local devitalization of the mucosa
may take place, its specific immunity
being lost, and autoingestion cause
the production of an ulcer. Trauma'
has long been believed to be a cause,
and there is no doubt that a break in
the mucous membrane can take place
from a violent blow upon the upper
abdomen. Probably an occasional
case of gastritis results in such local
conditions present as miglit cause an
ulcer. A high content of gastric juice,
combined with a low secretion of pro-
tective mucus, can apparently at
times cause an ulcer. Gastric ex-
foliation is much more common than
is ordinarily supposed, and in cases
of high IICI secretion more exfolia-
tion takes place than normal. .\r-
teriosclerosis is common in ulcers of
those be3'ond middle age, and tliis,
with localized bacterial infection, may
lead to thrombosis, loss of local vital-
ity, and autodigestion. Experiments
seeming-ly prove that certain bacteria
injected into the free circulation pro-
duce ulcer.
PATHOLOGY.— Tlie characteris-
tic ulcer is funnel-shai)ed or crater-
like, (|uite deep, circular or oval,
374
STOMACH, DISEASES OF (BASSLER).
irregular, linear or terraced, and
superficial in form. The acute ulcer
is usually soft witli rounded cdij;"cs ;
the chronic and irritated, rii^id, partic-
ularly at the edges, from round-cell
infiltration and hemorrhages and con-
nective- or scar- tissue. The base is
often smooth and covered with green-
ish or brownish tough mucus, though
small superficial ulcers often show no
such deposit. The simple ulcers vary
in size from 1 to 4 centimeters.
I recognize twelve difTerent special
forms of ulcers.
SYMPTOMS.— In simple ulcer
these are often characteristic enough
to make a diagnosis possible. In
atypical cases, i.e., those in which
pain, hematemesis, vomiting, exces-
sive secretion, gastralgia, etc., are
masked or lacking, diagnosis requires
most careful study. Lastly, in a mi-
nority of cases, diagnosis is impos-
sible by medical means.
Pain in gastric ulcer is a prominent
symptom. It may be burning, bor-
ing, cutting, tearing, or a constant
dull ache. Its character changes
from taking food or drink and even
with posture. Its paroxysmal occur-
rence is, however, constant in the his-
tory of a typical acute ulcer case. It
is due to irritation of the ulcer and
to consequent (or normal) contrac-
tions. It occurs either immediately
after the taking of food or after its
saturation with hydrochloric acid.
Often in pyloric or duodenal ulcer, it
begins two to four hours after food.
It is usually localized in a small area
in the pit of the stomach near the
median line. In duodenal ulcer espe-
cially it may be referred to the right
side.
During the paroxysm the pain ex-
tends through the body and may
even radiate up the back and chest.
Vomiting and retching, gastric dis-
tention, pylorospasm, and the taking
of coarse foods or irritating drinks,
increase the pain, and usually some
degree of pressure on the abdomen
affords relief. If there be hyperacid-
ity, taking milk or eggs often relieves
the gastralgia.
Two spots of tenderness usually
exist in sim]~)le ulcer. The epigastric
is found in about 80 per cent, of cases,
both in about 30 per cent., and the
dorsal alone in rare instances. The
dorsal pain is elicited, on deep pres-
sure, at the level of the tenth to the
twelfth dorsal vertebrae, alongside the
vertebrse, in a lateral expansion about
2 or 3 centimeters square.
Vomiting occurs in about 70 per
cent, of cases, usually with gastric
pain or distress. It may come on
whenever foods or drinks are taken,
or only at intervals of several days or
more. It is usually intensified by the
ingestion of much food, though per-
haps relieved by small amounts.
When pyloric stenosis, organic or
spasmodic, exists, the contents may
display evidences of retention.
Blood is present in the vomitus in
probably one-third of all cases, and
when in visible amounts is strongly
significant of ulcer. It is usually ar-
terial, and may be copious or more of
an oozing. After a frank hemorrhage
the feces are reddish, dark brown, or
black ; if the quantity of blood be
moderate or small, blood tests are
required to detect it.
Free acid and free secretion are
usually found. It is necessary to ex-
amine a test-meal, and not vomitus.
Careful use of a stomach-tube is usu-
ally permissible. Sometimes gastric
secretion is normal, or perhaps even
STOMACH, DISEASES OF (BASSLER).
375
subnormal. Mucus in flakes or
masses is not unusual.
Among the general symptoms may
be noted weakness and emaciation,
anemia, regurgitation of acid and gas,
certain nervous phenomena, thirst,
constipation, nausea, and faintness.
Perforation occurs, early or late, in
about 5 per cent, of all ulcer cases,
and may be the first symptom of
ulcer noted. Two types are recog-
nized : those associated with acute
ulcer and those occurring after more
or less cicatrization has taken place.
Usually there are no premonitory
signs, though in a few cases localized
pain precedes. Perforation- of the un-
protected anterior gastric surface in
the pyloric reg"ion causes extrava-
sation into the free perineal cavity.
Perforations of the lesser curvature
open into the lesser peritoneal cav-
ity and those of the posterior wall
(duodenum included) in the cellular
tissue behind, perhaps to the ascend-
ing colon or kidney. Less common
ruptures are through the diaphragm
and pericardium, causing such condi-
tions as pneumopericarditis, pneu-
mothorax, pyopneumothorax, or me-
diastinal involvement with external
emphysema. An encapsulated sub-
phrenic abscess is sometimes pro-
duced. Among the possible results
of perforation are abscess of the liver,
chronic hepatitis, pylephlebitis, septic
cholecystitis or gall-duct obstruction,
left-sided cellulitis, perisplenitis, left
renal involvement, and intestinal fistu-
las. In the latter instance there may
be severe diarrhea, bloody or purulent
feces, and fecal vomiting. When the
renal pelvis is entered there is usually
pyuria. Rarely an external fistula is
produced. Tn favorable cases the in-
fection becomes localized. A chronic
course may ensue, and later an exit
be formed in the renal pelvis, intes-
tinal canal, vagina, or abdominal wall.
Perforation into the free peritoneal
cavity is by far the most frequent
occurrence. If in the anterior gas-
tric wall, perforation sets up a gen-
eral peritonitis more commonly and
rapidly than do ulcers of the duo-
denum and those elsewhere in the
stomach. The gastric contents are
more infective than the duodenal ;
Showing the location of gastric ulcers as noted
la cases of perforation.
the duodenum, moreover, is tightly
moored in its upper part, small, deeply
set, and more protected by adjacent
structures than the stomach.
Moynihan has classified cases of
perforation into acute, subacute and
chronic. In acute cases the onset is
sudden, the peritoneum freely en-
tered, and the symptoms severe and
general from the beginning.
In the subacute cases the onset is
less sudden or severe, the opening
small in size, the stomach empty;
adhesions have formed, or the omen-
tum or transverse colon and meso-
376
STOMACH, DISEASES OF (BASSLER).
colon prevent extension. Localized
peritonitis or abscess formation has
previously been present. The symp-
toms .are: increased pain, rather
sharply localized ; moderate fever, and
a suggestive white blood-cell count.
In the chronic cases, protective ad-
hesions have first formed, and the
symptoms are ephemeral or those of
abscess. Later, general peritonitis
may develop. Extensive adhesions
are common, especially with the liver,
pancreas, colon, small intestine, and
omentum.
In a few cases of ulcer, perforation
may occur very late, due to autodi-
gestion of the center of an old scar,
gradual attrition, marginal erosions,
or malignant degeneration.
Perforation usually causes sudden
^gonizing pain, with' extreme tender-
ness in the upper abdomen. Soon
the pain spreads across the abdomen.
Deep breathing causes it, suggesting
pleurisy. At first the abdomen is flat,
tense, and fixed. Later it distends,
though still rigid ; finally, when peri-
tonitis exists, a softening is noted.
Liver dullness is absent in about one-
fourth of the cases, diminished in one-
half, and not affected in the others.
Stomach percussion is neither pos-
sible nor advisable. Collapse and
prostration soon supervene. The
pulse is usually accelerated, but at
first may be down to 30 or, for a time,
normal. The temperature soon rises,
as a rule not above 102° F., or be-
comes subnormal. The slower the
onset, the higher it is. The face is
pale and anxious.
The great majority of neglected
cases finally display marked disten-
tion, obliteration of liver dullness,
vomiting, singultus, cold skin, facies
Hippocratica, a small running pulse.
unconsciousness, and Cheyne-Stokes
respiration, followed by death.
It is in subacute perforation cases
that the internist is very liable to
delay transferring the case to a
surgeon until too late. The early
symptoms are mistaken for those of
perigastritis or lymphangitis from the
ulcer, or are vague or absent until
local or general peritonitis has en-
sued. Here the internist shoulders a
great responsibility. At the least sus-
picion, a blood-count should at once
be made, and repeated every few
hours. If the leucocytosis steadily
increases, the neutrophiles showing a
relative increase and the eosinophiles
perhaps diminishing or disappear-
ing, immediate surgical intervention
should be insisted upon.
Sudden abdominal pain, usually
after a strain, as in vomiting, def-
ecation, bodily exercise after a
heavy meal, trauma, etc., followed by
the symptoms already enumerated,
should suggest the possibility of
perforation.
The few cases of pseudoperforation
reported do not justify hesitancy as
to surgical intervention.
Whenever, in cases of gastric ulcer,
the respiration rate rises perceptibly,
the chest should be examined for
fluid or gas in the pleura. Chills and
a septic temperature should draw at-
tention to such conditions as hepatic,
subphrenic, or mediastinal abscess, or
infection in the lung, pleura, or
general system.
Special Features of Duodenal Ul-
cer.— Experience in the operating
room shows that duodenal ulcer is
about twice as frequent as gastric.
Most duodenal ulcers occur in the
first portion of the duodenum, within
three-fourths inch of the pyloric
Gastric Ulcer. Arrow pointing to ulcer of posterior wall near pylorus.
Case proven by operation. X-ray by Author.
Gastric Ulcer Directly at Pylorus, Causing Deformity of Pylorus,
Retention and Globulation of Stomach. Case proven by operation.
X-ray by Author.
J
STOMACH, DISEASES OF (BASSLER).
377
sphincter, and are chronic in type.
From a clinical standpoint, what has
been stated regarding gastric ulcer is
also true of duodenal ulcer. Clinic-
ally and surgically their differentia-
tion is not of much import. The
term "pyloric ulcer" seems best.
In duodenal ulcer the pain is usu-
ally not so acute as in gastric ulcer,
more burning and boring in charac-
ter, and commonly median or slightly
to the right. But it may be excru-
ciating, and may even be felt near the
right costal margin, though rarely
down as far as the gall-bladder. Re-
missions of pain, often without ap-
parent reason, are frequent. The
pains occur usually from one to three
hours after ingestion of food, and are
relieved temporarily by the taking of
food or alkalies. Characteristic, in
my experience, is pain beginning
about 2 o'clock in the afternoon, be-
coming worse until almost midnight,
then disappearing. Another type of
pain occurs between 2 and 4 o'clock
in the morning. Tenderness may be
confined to the right side along the
course of the duodenum, with perhaps
a referred pain in the back. Vomiting
is rare. The vomitus seldom contains
blood. Copious hemorrhage into the
stomach with ejection may occur, or
the same take place intO' the bowel,
with melena. An ulcer case without
blood in the test-meal analysis, but
blood in the feces, is likely to be duo-
denal. Incorporated blood in the stool
is always suspicious of ulcer high in
the intestine. Melena, when present,
is important. Constant bleeding gen-
erally causes pallor, reactionary fever,
weakness, and loss of weight. About
one-half of all gastric and duodenal
ulcer cases at some time show
blood in iItc feces.
Jaundice has often been observed
from obstruction of the common bile-
duct or coincidence of ulcer with
cholelithiasis. If pain is persistent,
often not enough food is taken to
maintain weight. This is important
in differentiating between ulcer and
gall-bladder disease ; in the latter the
patients eat well and maintain good
nutrition.
Duodenal ulcers are liable to per-
foration mostly in the anterior wall.
Those in the second part, anteriorly,
lead directly into the peritoneal cav-
ity, while those on the posterior sur-
face are extraperitoneal.
DIAGNOSIS.— When the classical
symptoms are present, which occurs
in about 1 out of 4 cases of ulcer,
diagnosis is easy. By close attention
and study about 2 of the remaining
3 cases can be diagnosed. Special
technique and laboratory tests here
offer substantial aid. In the remain-
ing, fourth case diagnosis is impos-
sible unless complications develop.
For X-ray diagnosis an ulcer must
be large enough or have caused adhe-
sions sufficient to produce an irreg-
ularity of the contour of the stomach
or duodenum. When the symptoms
are not distinctive, the X-ray should
be used.
Einhorn's method consists in swal-
lowing a "duodenal bucket" attached
to a lono- silk thread. The bucket is
ingested in the evening and removed
in the morning before breakfast. The
ulcer causes a brown or dirty black
stain on the string, and by meas-
uring the distance from the teeth
its site can be approximately deter-
mined. I have employed, with good
results (see plate opposite next page),
a BP) split shot, fastened to about 100
centimeters (38 inches) of No. 8
378
STOMACH, DISEASES OF (BASSLER).
braided silk. The shot is inclosed
in a 5-gTain capsule, the cord passing
through a small hole in one end, and
a knot is tied on the string 75 centi-
meters (28 inches) from the capsule.
A number of these are kept on hand,
each one wound around a card and
placed in an envelope bearing the
following instructions : —
"For several hours before beginning this
test no medicine should be taken, and for
supper no meat is allowed, the meal prefer-
ably consisting of milk, eggs, bread and but-
ter. At bedtime you are to swallow the cap-
sule and thread until the knot is at the teeth.
The end of the string is then made into a
loop and fastened to the nightgown with a
safety pin or tied around one ear, so that
the knot remains in place — the shot remain-
ing in the stomach all night. On awakening,
pull the string slowly and steadily and hang
it up to dry, being careful not to allow any-
thing to touch it while wet. When dry place
it in a clean envelope and mail it to me or
leave it at my office."
A number of my cases have been
most easily diagnosed by this string
test, some showing none of the car-
dinal symptoms of ulcer,— partic-
ularly the latent cases. The test is
not objected to by patients. It may
also be used to trace progress under
treatment.
The string method is not of value,
however, in ulcers of the fundus and
greater curvature. For these Einhorn
has devised a bag covered with gauze,
wdiich is introduced into the stomach
in a collapsed condition and then in-
flated. After a half-hour the bag is
allowed to collapse and withdrawn.
If ulcers are present, brownish areas
are noted in the gauze. The method
is only applicable in patients accus-
tomed to the stomach-tube.
DIFFERENTIAL DIAGNOSIS.
— Gastralgia. — Mere the pain is inde-
pendent of food, is usually a burn-
ing, and relieved by pressure or
heat, though not by vomiting. There
is commonly eructation of odorless
and tasteless gas, and perhaps saliva-
tion. No blood appears in the test-
meal. No fever is present. Hysteri-
cal and neurasthenic symptoms are
common. There is no definite area of
sharp pain, but rather a diffuse ten-
derness in the epigastrium. Epigas-
tric pulsation may be noted when
prolapse or atony exists. During the
attack constipation is the rule, and
afterward the passage may be fluid,
contcJning mucus but no blood.
The condition soon subsides, possibly
without treatment. Some hyperes-
thesia may persist for some time,
generally subsiding under bromides.
Carcinoma. — tiere debility and
emaciation often precede the other
signs. Pain is more constant, less
severe, less dependent on food, and
often nocturnal. Anorexia is fre-
quent, and the taste insipid, com-
monly with aversion to meats. The
appetite may improve under lavage.
Fetid eructations are frequent. Di-
gestion is insufficient, stagnation of
foods common, and the chemism in
late cases shows absence of hydro-
chloric acid and the presence of
blood, Boas-Oppler bacilli, lactic acid,
and pieces of cancer tissue. Vomit-
ing gives less relief than in ulcer, and
is often of the "coffee grounds" type.
Cachexia is marked, and the skin
sallow, brown, dry, or flaccid. The
patients are usually aged. A tumor
may be palpable. Perforation occurs
only after prolonged illness and, when
into the colon, lientery may occur.
The X-rays are of diagnostic value.
Hyperchlorhydria and Gastrosuc-
corrhea. — In these conditions there is
absence of distinct pain and tender-
^
Results of the string test in different conditions. No. 1, Normal ; the bile-stained
lower end usually stains the string for a distance of about IS cm. (6 inches) from the
shot, gradually fading out on the way upward. No. 2, Esophageal ulcer, the blood-stain
corresponding to above the cardia. In esophageal carcinoma, because of the stenosis, the
shot and strmg may remain in the gullet and a considerable extent of the lower end of
the string be blood-stained: in this instance the lower end of the string would not be bile-
stained. No. 3, Gastric ulcer, the blood-stain corresponding to the lesser curvature of the
stomach near the pylorus, but at the upper end of the bile-stain. No. 4, Duodenal ulcer;
the blood-stain is small in area, and the bile-stain extends beyond it, showing that the
bleeding is beyond the pylorus in location. No. 5, Gastric carcinoma, showing that consid-
erable hemorrhage was taking place, staining the string throughout the stomach. Some of
the cases show a blood-stam small in extent, and, if the pylorus permits the passing of the
shot, a bile-stained end; the string then would resemble that of gastric ulcer. Other cases
show a general blackish-green staining of the string, which displays the presence of blood
by the chemical tests. No. 6, Gastroptosia, showing that a long, attenuated stomach took
up the distance of string, permitting but a small extent of it to get into the duodenum.
(Bassler.)
STOMACH, DISEASES OF (BASSLER). 379
ness. Vomiting is ' rare and usually trie or duodenal ulcer. It may occur
follows an error of diet. Distress is in gastric or general neuroses, chole-
worst one to three hours after meals cystitis, gall-stones, appendicitis, and
(hyperchlorhydria) or in the early tuberculosis of the abdominal viscera,
morning (gastrosuccorrhea), though The diagnosis of uncomplicated py-
actual pain is rare. High hydrochlo- lorospasm is usually made by exclu-
ric acid content, low conversion of sion of all organic disease and from
starches, and an abundant return are attacks of pyloric pain with stag-
the main diagnostic features. There nation. The attack usually occurs at
is belching of acid gas or regurgita- the height of digestion. Later gas-
tion of acid fluid, with postprandial trie dilatation ensues, and food is
pyrosis. These conditions usually vomited late after ingestion. The
respond to proper treatment; if not, contracted pylorus may be felt as a
latent ulcer, underlying gastritis, small, round, tender mass, disappear-
cholelithiasis, chronic appendicitis, or ing in the intervals between seizures,
a nervous disorder should be sus- Chronic gastrosuccorrhea or tetany
pected. may exist. Blood is absent. Lactic
Hemorrhagic and Other Forms of acid may be present, but Boas-Oppler
Gastritis. — Differentiation is difficult bacilli are rare.
and usually impossible. Its impor- Appendicitis. — Mistaken diagnoses
tance is so slight that surgery is of perforating acute gastric or duo-
especially prone to failure in dealing denal ulcer for appendicitis, and z'icc
with excessive hemorrhage from the versa, are numerous. Appendicitis
stomach. Thus it is advisable to con- and erosions and ulcers of the stom-
tinue medical treatment. If the case ach are frequentl}^ associated. Payr
entirely recovers and subsequent ex- observed that "in a certain number
aminations are negative, one should of cases of appendicitis, usually of
consider the possibility of hemor- moderate severity, there appear,
rhagic gasritis as having existed. shortly after the first attack, various
In ruptured varix of the stomach, gastric symptoms closely resembling
in which bleeding may be difficult to those of gastric ulcer. There is pain,
control, the classical symptoms of occurring sliortly after the taking of
acute ulcer are usually lacking. food ; hyperacidity ; vomiting, fre-
In ordinary acute gastritis, and quently bloody in character, and,
sometimes in the hemorrhagic form, usually later, phenomena suggestive
there is the history of the cause, fol- of pyloric stenosis. These symptoms
lowed- by acute vomiting of the food generally abate after a short time,
and possibly later of mucus and bile. He ascribes these gastric disturb-
The pain is less acute and more ances to emboli derived from throm-
diffuse. In chronic gastritis the bosed veins of the omentum and
cause and the analyses are important, appendix.
When blood or eroded pieces of the In differentiating severe appendi-
glandularis are found the diagnosis citis from perforating ulcer the situa-
of secondary ulcer should be made. tion of the onset of pain is most im-
Pylorospasm is a misleading con- portant. Rigidity, local tenderness,
dition when not accompanying gas- and swelling, whether belov/ the um-
380 STOMACH, DISEASES OF (BASSLER).
bilical level or above it, are £,aiidinj^ cases arc apt to be ruddy and well-
points. If the abdomen distends, dif- nourished, while those of ulcer often
ferential diagnosis is neither possible show anemia and poor nutrition,
nor important. The al^domen should There have usually been long inter-
immediately be explored in both its vals between the paroxysms of pain,
upper and lower zones through an with a much better digestion than is
incision. 'I'he differential diagnosis seen in ulcer cases. Gastric analyses
can in every instance be made more rarely show blood. Hyperacidity is
surely and safelv bv tlie surgeon. common. Duodenal or srastric ulcer
Hyperemesis of Pregnancy. — The may coexist with gall-stones. • In
history and local examination are most of these cases the diagnosis of
here all important. No pain is pres- gall-stones is the easier to make,
ent, and the characteristic symp If a chill with fever, hepatic en-
toms of ulcer are absent. The same largement, and a swollen, tender, and
applies to vicarious menstruation, palpable gall-bladder are noted, the
and to conditions in which blood is diagnosis of gall-stones is suggested,
swallowed and vomited or enters and this is confirmed if stones are
from or through the gullet. found in the feces in succeeding days.
Uremia. — Here the low urinary In hepatic colic pain may occur in
output and the uranalysis are diag- the epigastrium, but it quickly radi-
nostic. Headache, sleeplessness, pa- ates to the right costal margin,
ralysis, amaurosis, convulsions, mania, around to the back, and beneath the
delirium, coma, increased arterial right scapula. It is more colicky in
tension, and dyspnea are significant character, coming on more suddenly
symptoms. General muscular spasm and ceasing more abruptly. The
and fever may be present. Where pain and the suffering are more acute,
consciousness persists examination of and are usually independent of food.
the abdomen is negative, but late in The patient often feels chilly, sweats
the case distention without rigidity profusely, is nauseated and vomits,
may be observed. The vomiting may and usually there is a slight rise in
be incessant and, if a uremic ulcer temperature, with jaundice following
exists, blood may occur in the vomi- in about 50 per cent, of the cases,
tus or feces. In my experience, the The right side of the abdomen is
vomitus has usually been gastric rigid and tender, especially during
juice, especially during fever. inspiration. The history of attacks
Biliary Conditions. — In gall-stones, of hepatic colic, the absence of ulcer
when tenderness is elicited only by findings, and the limitation of pain
deep pressure in the Ijiliary triangle, and tenderness to the biliary triangle,
and there is jaundice, with bile particularly when the abdomen is pal-
in the urine and the character- pated from behind, are the main
istic pains, the diagnosis is easy. But points in differentiating the chronic
when the pains are constant, espe- gall-bladder conditions.
cially after food, coupled with vomit- Renal Colic.— In nephrolithiasis the
ing which affords relief, and the signs urine is strongly acid and contains
just mentioned are lacking, time and blood, usually enough to give it a
care are usually required. Gall-stone smoky tint. Small calculi may be
STOMACH, DISEASES OF (BASSLER).
381
passed or detected in the pelvis or
ureter with the X-rays. The intensity
of the pain in the back, radiating
downward (usually only one side),
and the absence of pain and tender-
ness anteriorly are significant. Ab-
dominal examination is negative, or
the entire abdomen may be board-like
during ureteral colic.
Arteriosclerosis. — Chronic abdom-
inal pains may occur in sclerosis of
the splanchnic vessels. The symp-
toms peculiar to ulcer are absent, and
the gastric contents commonly achy-
lic. Palpable vessels are firm and
arterial tension persistently high.
Much urine may be voided, often of
low specific gravity, and with a little
albumin, and granular casts. Intes-
tinal putrefaction is common.
Spinal and Other Diseases. —
Among other conditions that have
been mistaken for gastric ulcer are :
Tabes with gastric crises, myelitis
with pains as a prominent feature,
movable kidney, lead colic, enteralgia,
herpes zoster, intercostal neuralgia,
and diaphragmatic and basal pleuri-
sies. Careful examination will gen-
erally clear up doubts.
Post-ulcer conditions that may re-
quire differentiation include perigas-
tritis, pyloric obstruction due to
cicatrices, hour-glass contraction, and
carcinomatous degeneration. All of
these conditions are best examined
for with the X-rays. Other possible
conditions are persistent excess of
secretion, irritalde stomach, erosions
of vessels, and tetany.
Advantages of the fractional test
meal descril)ecl. In .L;all-l)Iadder dis-
ease the secretory response is ])rompt
with hit^h acidity, and tlie emptying
time occurs at or near the high point.
In duodenal ulcer there is a prompt
gastric response, high acidity, and
delayed emptying time. In gastric
ulcer, not affecting the pylorus, there
is a weak and delayed response, mod-
erate acidity, and early emptying
time. Gastric carcinoma presents
two types of curve, the first showing
the presence of acid and a delayed
emptying time, and the second show-
ing the absence of acid and an early
emptying time. Horner (Jour. Amer.
Med. Assoc, Dec. 8, 1917).
PROGNOSIS.— Acute ulcers (in-
cluding erosions) are curable 'by medi-
cal means or recover without especial
treatment in at least 95 per cent, of
cases. The mortality from all kinds
of ulcer variously given as between
10 and 20 per cent, pertains only to
the most serious cases. In the com-
plications and sequels in serious
cases, on the other hand, the results
accruing from medical treatment up
to the time of operation are poor, par-
ticularly because they comprise the
small percentage of the easily diag-
nosed ulcers that do not recover.
A case which has been diagnosed
as ulcer by medical means, and in
which a restoration to health has con-
tinued for one year, is logically a
cured case ; A-et, in a very small per-
centage of these cases, surgical meas-
ures may at some subsequent time
be indicated.
The result of acute ulcer is scar
formation. The chronic ulcers, how-
ever, usually remain more or less open
or become thickened. Malignant de-
generation, if it occurs, progresses to
a fatal ending, unless operated upon
in time. Unless overwhelming, inter-
mittent hemorrhages are acute and
likely not to cause death ; the con-
tinuous forms are chronic and usually
require surgical intervention. Ulcers
giving distinct symjjtoms, properly
treated, tend toward complete recov-
382
STOMACH, DISEASES OF (BASSLER).
ery in at least 75 per cent, of cases ;
those that do not are always surgical.
The prognosis of acute ulcer de-
pends upon the depth, extent, loca-
tion, and character of the lesion,
and willingness of the patient to fol-
low orders for some months. In the
severer cases it is wise to be conser-
vative and always watchful.
PROPHYLAXIS.— Excess of se-
cretion is the most important feature
in this connection. The treatment for
it should be that outlined in hyper-
secretion. (See Hyperacidity, given
earlier in this article.) In addition,
any anemia should be corrected by
a full diet and hematinic tonics, and
debility by high caloric feeding and
extra meals of a liquid albuminous
character. Hygienic measures often
offer substantial aid.
TREATMENT.— The ulcer patient
should be put to bed, and the strictest
discipline as to complete rest, dieting,
medicinal treatment and hygiene in-
sisted upon. Even in erosions, at
least three weeks in bed should be
insisted upon, and preferably four.
With such discipline, general results
are better and the dangers of hemor-
rhage and perforation are minimized.
After this, the transition from rest in
bed to walking about should extend
over two weeks. In a case free of
symptoms, a return to the ordinary
fare can then be begun.
Diet. — Coarse vegetables and ce-
reals, highly seasoned foods, made-
up dishes, hashes, salted and pre-
served meats and fish, and meat
soups should be excluded. Preserved
fruits, pickles, fresh berries, or vege-
tables with seeds, and also nuts, are
dangerous. Alcoholic beverages, as
well as tea and coffee, should be in-
terdicted. Among the useful foods
are gruels, milk soups and purees,
and other foods , cooked with milk.
The best fluids are water, milk,
Vichy, and cocoa. White bread is
permissible. Tender beef, lamb,
chicken or fowl and fresh fish may
be taken once a day, but must be
roasted or broiled, finely cut up, and
thoroughly masticated. Eggs in any
form, with but little salt, may be
taken ad libitum. Cereals and vege-
tables should be well-cooked, and
potatoes and other tuberous vege-
tables mashed.
The evening meal should be of
fluid, semifluid or finely comminuted
foods, with little seasoning, and
small in amount. Supplemental fluid
albuminous meals should be given
between dinner and supper, and be-
fore retiring. Very hot or cold foods
should be avoided. In the first month
or two of mixed diet, rest for one or
two hours after meals should be in-
sisted upon, and also the avoidance
of all business and irritating topics
of conversation. If hyperacidity then
persists or recurs, bismuth subcar-
bonate, the mineral alkalies, plain
Vichy water, and the oils or atropine
should be given. The bowels should
be moved only with Carlsbad salts,
magnesium hydrate, or by enema. If
circumstances permit, a sojourn in
the country or a course at Carlsbad,
Vichy, or Ems should be advised.
Beginning two months after the con-
clusion of active treatment and at
regular intervals during the first year,
gastric analyses should be made and
the feces examined for blood. If acid-
ity increases, or blood appears in the
stomach contents or feces, or gastric
distress ensues, the case should be
more rigidly treated, and perhaps
again put to bed for a week or two.
STOMACH, DISEASES OF (BASSLER).
383
If gall-stones or appendicitis is pres-
ent, operation should be insisted on.
One patient may do best on early,
rather generous feeding as recom-
mended by Lenhartz, and another be-
come distinctly worse until complete
gastric rest has been afforded for sev-
eral days, as practised by von Leube.
The results seem to depend upon the
gastric and pyloric spasm, the age of
the ulcer, the amount of bleeding and
vomiting, and the general excitablity'
of the organ. As a rule, it is best to
adopt von Leube's method for the
first few days, and when the symp-
toms abate, Lenhartz's method until
the end of the fourth week of treat-
ment. Less severe cases occur in
which the Lenhartz method should
be used from the outset, and likewise
more severe cases in which the Leube
method is required for a considerable
period. The patient's general condi-
tion should be taken into account in
deciding on treatment. If oral feed-
ing or a fuller fare is long delayed
after the use of the nutritive enemas,
a distention of the stomach, with sud-
den increase in acidity, may occur and
may precipitate vomiting and prevent
healing of the ulcer. On the other
hand, the Lenhartz feeding is likely
to increase or maintain the excessive
acidity of the gastric juice, and
though cure of the ulcer is obtained,
a high level of gastric secretion re-
mains which, to some extent, favors
recurrence.
The dietetic treatment of von
Leube and von Ziemssen is based on
rest in bed, and feeding by the rec-
tum or with food which will burden
the stomach as little as possible.
Ewald's modification is descril)ed by
him as follows: "For the first three
days absolutely no food is to be ad-
ministered by mouth, but a nutritive
enema is given three times daily ;
subsequently, besides the enemata,
milk or flour and milk soup, in tea-
spoonful doses, or a bland pigeon or
chicken broth. To the milk, on ac-
count of its fine floccular coagulation,
some pegnin is added. If this diet is
well borne, it is added to as herein-
after described; otherwise, absolute
rectal nutrition is again instituted.
If no pain follows the careful admin-
istration of milk, one may permit
somewhat larger quantities (up to
about 180 cubic centimeters), legu-
minous flour soup, then legumes ;
later pappy food made of chest-
nuts, sago, tapioca, Kufeke's flour,
hygiama, and other preparations,
and later small quantities of meat.
Among nutritive substances cows'
milk takes first place. . . . The
patient, however, must drink it very
slowly and lukewarm. To prevent
flocculent coagulation of the milk and
the resulting irritation of the ulcera-
tive surfaces, I now add pegnin
(labferment), which produces a very
fine flocculent coagulation. Besides
pigeon or veal soups, the yolk of an
egg and beaten-up egg-albumin, pul-
verized meat, or leguminous soups
may perhaps be given. We must
limit ourselves to these foods until
the severe symptoms have disap-
peared. In the third week food richer
than this, both quantitatively and
qualitatively, is permissible, and one
should then carefully try food of
somewhat greater consistence, such
as scraped raw ham, raw or very soft-
boiled eggs, scraped venison or
breasts of fowl, and rolls or zwieback
softened in cocoa ; but milk is always
preferable, and one should always be
ready to return to a simpler diet as
384
STOMACH, DISEASES OF (BASSLER).
soon as the symptoms, or even pains,
appear." The diet of Ewald may be
considered as a conservative and
rational combination of w^ell-tried
methods. Arguing for its use in
preference to that advised by Len-
hartz, he reports having had but 4.8
per cent, of hemorrhage, whereas,
Lenhartz, in 20 cases, had 6.4 per
cent.
Lenhartz's dietetic treatment is
based on the fact that hyperchlor-
hydria, chlorosis and anemia fre-
quently develop in the course of
ulcer. Even in severe cases he per-
mits from the start concentrated
foods rich in albumin. In general,
the Lenhartz diet is the best to em-
ploy— simply because the average
case is not severe enough to call for
complete gastric rest.
In the Lenhartz plan of feeding.
food is administered in small quanti-
ties at one-iiour intervals. Slow mas-
tication and slow eating are insisted
upon, the patient being fed with tea-
spoonful amounts, and not allowed to
feed himself during the first two
weeks of the cure. Three or four
weeks' rest in bed is imposed. An
ice-bag is applied to the epigastrium
to relieve the pain, and bismuth sub-
nitrate given internally for hemor-
rhage. Milk and beaten-up raw eggs
are placed in tumblers surrounded
with cracked ice and kept at the bed-
side. The feeding spoon is also kept
iced. The eggs and milk are admin-
istered in alternate feedings, granu-
lated sugar being added to the former
on the third day. The raw, scraped
beef, boiled rice, and zwieback are
prepared in the usual manner. The
diet routine is as follows : —
Day. Eggs.
1. 2 drams per dose.
Total, 2 eggs.
2. 3 drams per dose.
Total, 3 eggs.
3. y2 oz. per dose.
Total, 4 eggs.
4. 5 drams per dose.
Total, 5 eggs.
5. 6 drams per dose.
Total, 6 eggs.
6. 7 drams per dose.
Total, 7 eggs.
7. 4 drams per dose.
Total, 4 eggs.
Also, 1 soft-boiled
egg every four hours.
8. As above.
9. Do.
10. Do.
Milk.
4 drams per dose.
. Total, 6 ozs.
6 drams per dose.
Total, 10 ozs.
1 oz. per dose.
Total, 13 ozs.
1^ ozs. per dose.
Total, 1 pint.
14 drams per dose.
Total, 19 ozs.
2 ozs. per dose,
Total, 22 ozs.
2 ozs. per dose.
Total, 25 ozs.
2J^ ozs. per dose.
Total, 28 ozs.
3 ozs. per dose.
Total, 1 quart.
Do.
Sugar.
Scraped Beef.
20 grams added to
eggs.
Do.
30 grams.
40 grams.
40 grams.
Do.
Do.
Do.
36 grams in 3 doses.
70 grams with boil-
ed rice.
100 grams in 3 doses.
Do.
Beef, same ; rice, 200
grams; zwieback, 40
grams in 2 portions.
Do.
11-14. Add chopped cooked chicken, 50 grams; or ham, 50 grams, and butter 20 grams.
Interval of feeding made two hours. Milk given in 6 oz. doses with Yz oz. of
raw egg. Butter increased to 40 grams, and chicken or ham as above.
STOMACH, DISEASES OF (BASSLER).
385
Among 295 cases of g-astric ulcer
treated by Lenhartz 262 had had a
hemorrhag'e before the beginning of
treatment, and in 33 the stools con-
tained blood; his total mortality,
however, was 2.3 per cent., and only
18 cases had hemorrhage after the
treatment was begun. Von Leube,
replying to Lenhartz, reported that
fully 90 per cent, of 627 patients were
cured by his own method ; 8.5 per
cent, improved under it, and only 1
per cent, did not, while the mortality
from hemorrhage was 0.3 per cent.
To check the tendency to hemor-
rhage, von L.eube insists on keeping
tlie stomach absolutely at rest. The
patient is kept in bed and receives a
single dose of 30 drops of a 1 : 1000
solution of adrenalin, supplemented
by bismuth, an ice-bag over the stom-
ach, and an injection of morphine to
keep the stomach quiet (never for its
pain-reducing properties). Food by
the mouth is entirely abstained from,
even milk. When the stool shows no
more blood, and other signs also in-
dicate cessation of the hemorrhage —
usually in two or three days — he
cautiously commences a liquid diet.
The patients may lose weight at first,
but more than make it up in the sec-
ond week. The combination of abso-
lute rest in bed, one glass of tepid
Carlsbad water twice a day, fasting,
hot flaxseed poultices renewed every
ten or fifteen minutes for twelve
hours (a wet linen cloth being sub-
stituted at night), and the special diet
referred to is held to be indispensable.
A more recent addition to treat-
ment is the duodenal method of ali-
mentation, 'i'he (iross, Oeffle, or Ein-
horn tube is used. The food is deliv-
ered in the ui)])er digestive tract with-
out coming in contact with the ulcer-
8—25
bearing area. It is evident, however,
that the cures by this method are not
as many as by the methods of Len-
hartz and von Leube. After a rather
consistent use of the duodenal method
I have abandoned it for the reason
that, however little acid there may be
in the stomach, it is not bound by
protein foods present in the organ.
Moreover, delivering a quantity of
fluid in the duodenum through the
tube reflexly excites a higher acidity
in the stomach. Fluoroscopic obser-
vations showed that the tube, draw-
ing taut against the lesser curvature,
increases gastric motility.
Medicinal Treatment. — The drue
most generally used is bismuth sub-
nitrate, as mechanical sedative. Bis-
muth subgallate should be used in
hemorrhage, and the subcarbonate in
high acidity. By the use of bismuth
pain is lessened, and vomiting and
hemorrhage controlled ; in a few days
the stomach becomes more tolerant.
Best results are obtained when the
dose is large and taken into the
empty organ. At least 30 grains (2
Gm.) should be given, either in
plain boiled or barley water. Some
recommend only one large dose in
the morning, but, since in the aver-
age case the organ is quite emptied
of bismuth in four to six hours, it is
best to give it in doses of 2 to 4 Gm.
(30 to 60 grains), at about the inter-
vals mentioned. The occasional con-
stipating effect may be minimized by
adding magnesia oxidi (as below),
suspending the bismuth in olive oil,
giving Carlsbad salts eacli morning,
of using enemas.
IJ Bismuthi subgallatls, vcl subcarhouatis,
vel subnitratis,
Maciucsii oxidi aa 3x (40 Gm.).
Fiant pulveres no. x.
Sig-. : 1 every five hmirs in harlcy-water.
386
STOMACH, DISEASES OF (BASSLER).
To avoid nitrite poisoning, which
may occur when the subnitrate is
used continuously in large doses, it
is best to employ the subcarbonate or
subgallate from the first, or substitute
one of these for it after a few days.
The bismuth should be given steadily
for two weeks, then in smaller doses
as long as indicated.
Olive oil may be a valuable adjunct
to relieve pain, vomiting and pyloric
spasm. It may be given in 1- or 2-
ounce (30 to 60 c.c.) quantities, and
is a good vehicle for bismuth. Where
olive oil by mouth induces nausea, it
may be run down through the stom-
ach-tube, but not in the early days
of treatment.
At the end of the first w^eek, plain
Carlsbad water or Vichy may be
given, one wineglassful at a time,
and preferably at room temperature.
Carlsbad salts may be used for con-
stipation, but other salts often cause
acute distress. The dose of Carlsbad
salts is a teaspoonful in a glass of
warm water, drunk slowly early in
the morning.
Of greaf: value in ulcer is bella-
donna, or atropine, — preferably the
former. Controlling both secretions
and motility, it can be given either
with the Lenhartz treatment or when
no food is given by mouth. It should
be given steadily until its "physiolog-
ical effects" are obtained. These are
usually induced by 8-minim (0.5 c.c.)
doses of the tincture, given at three-
or four- hour intervals, in about two
days. The dose should then be re-
duced to about one-third, and this
amount continued as long as the pa-
tient remains in bed, avoiding a re-
turn of the "physiological effects."
In acute gastric ulcer with marked
vomiting of sanguineous acid fluid or
intense boring pain after feeding, the
results are often striking.
The chief drugs used as astringents
to promote healing are silver nitrate
and ferric chloride. The former also
advised as antacid, is given in pill
form, 14 to >4 grain (0.015 to 0.03
Gm.) at a dose, or in solution with a
little sodium bicarbonate — ~yz to 15
grains (0.5 to 1.0 Gm.). Boas used
silver nitrate in solution, 4 grains to
4 ounces (0.25 Gm. to 120 c.c).
Duodenal alimentation proved ex-
tremely successful in gastric ulcer.
The writers introduce the tube into
the duodenum at night and feed with
150 Gm. (5 ounces) of tepid milk
daily, then 200 Gm. (7 ounces).
Yolks of eggs are given, up to 4 a
day. After every feeding a saline
injection is administered. Relief of
the pain is the first effect obtained.
Pages and Ibanez (Vida Nueva. .Xpr.,
1918).
In von Leube's method, during the
patient's ten-day stay in bed, the epi-
gastrium is washed with alcohol and
mercury bichloride solution, boric
ointment next applied on a thin cloth,
and over this a hot flaxseed poultice
renewed every fifteen minutes for ten
hours during the day, and a wet com-
press during the night. After the
tenth day, a flannel abdominal binder
is worn during the day, and for three
weeks a simple cold compress at
night. During convalescence, the pa-
tient is required to rest completely
for two hours after meals. Contrain-
dications for poulticing are menstrua-
tion and recent hemorrhage (within
three months) ; in recent hemorrhage
an ice-bag is substituted. One pint
(500 c.c.) of Carlsbad water is drunk
slowly in the morning for one month,
and alkaline waters during the day.
Bismuth and sodium bicarbonate may
be used. In the first ten days the
\
STOMACH, DISEASES OF (BASSLER). 3g7
diet consists of boiled milk, Leube's Anemia may be treated with albu-
meat solution, arid soft, unsweetened minate of iron, as Ewald suggests, by
zwieback. In the next week, rice or adding 1 fluidram (4 c.c.) of a 2 per
sago soups, boiled with milk or white cent, solution of iron sesquichloride
of egg, and soft-boiled or raw eggs to 2 fluidounces (60 c.c.j of albumin-
are used. Later on tender meats are water. One or two teaspoonfuls of
given, and after the fifth week a care- Liq. ferri albuminati (N. F.), or Liq.
ful ordinary diet. Constipation is ferri peptonati cum mangano (N. F.),
treated by enemata of tepid water or may be given three times daily in a
Carlsbad salts, or, after the eleventh little water. In the late treatment : —
day, by 1 dram (4 Gm.) of a powder IJ Arseui tr'wxidi gr. ss (0.03 Gm.).
consisting of powdered rhubarb, 8 Perri sulphatis Sij (8.0 Gm.).
parts; sodium sulphate, 6 parts, and ^^^«^-^" carbonatis . 3j (4.0 Gm.).
sodium bicarbonate, 3- parts. ^'^"t P''"'^ "°- ^^^ (^°^t^-
f, . , _, . „ Sig. : Take 1 pill three tmies a day.
Special Treatment of Symptoms. —
Pain, if severe, may rarely require ^o^ gastric hyperacidity, bismuth
morphine in the first couple of days ; subcarbonate, belladonna, and the
usually, belladonna, with or without mineral alkalies and alkaline mineral
codeine, is sufficient. Chloral hy- waters are used. Though separate
drate, as a sedative and antiseptic, "se of these is generally advisable,
would seem too irritating, even in 2- the following may be employed :—
to 5- grain (0.13 to 0.31 Gm.) doses. ^ Belladonna pulveris ... 3ss (2 Gm.).
Orthoform or anesthesin may be Sodii carbonatis 5j (30 Gm.).
T T 11 1 Magnesii oxidi 3x (40 Gm.).
given in severe cases. Usually, how- ^^^^. ^^^^^^.^ ^^^ ^15 ^^^_
ever, rest and diet having been m- p^^^ .^ ^^^^^^^^^ ^^ ^^^
stituted, a wet compress over the sig. : Take 1 powder in water every four
abdomen is sufficient to control the hours.
pain. A so-called "sweat bandage" q^.^ ^j^^ following formula of Stock-
may be used : A large soft towel is ^^^y^ ^^^^ 1^^ ^^^^^ ._
soaked in cold water, wrung out, j^ Cerii oxalatis Siiss (10 Gm.).
folded lengthwise, and wrapped round Bismuthi subcarb 3v (20 Gm.).
the patient's waist; over it rubber Magnesii earbonatis .. '3x (40 Gm.).
sheeting or oiled silk is placed, and Fac pulverem.
then a dry towel to bind these in Sig,: Take H teaspoonful every four
place. This bandage is changed two ho"i's-
or three times in twenty-four hours. Abundant hemorrhage may require
An ice-bag or flaxseed poultice over a hypodermic of morphine. In less
the epigastrium may be substituted. severe forms, adrenalin chloride solu-
Vomiting, for which bismuth, bella- tion, 1 to 1000 (10 to 20 drops), three
donna, ice, and opium suppositories or four times a day, may be eiTective.
are recommended, usually subsides Bismuth subgallate, absolute rest and
after a few days of routine treatment, quiet, and the sucking of small pieces
When it is more severe, a]iply a of ice may answer. Fwald practises
mustard plaster to the epigastrium, ice- water lavage, and others recom-
immediately followed by an ice-bag mend gelatin-water; death from hem-
when the skin is well reddened. orrhage occurs in only about 3 per
388
STOMACH, DISEASES OF (BASSLER).
cent, of cases. If the pulse is very
small, anemic murmurs appear, or
cerebral anemia occurs, normal saline
infusion at body temperature, at least
1 quart (liter) at a time, deep into
the subclavicular region or under the
breast in the female is indicated ; in
a few cases, direct transfusion of
blood is necessary ; when the patient
shows constitutional efifects from con-
stant, moderate bleeding, Murphy's
continuous proctoclysis.
Gastric lavage is imperative if there
is much fermentation — usually when
stenosis or marked atony exists.
Kaufmann advises lavage in acute
hemorrhage, claiming that gastric
contraction occurs upon evacuation.
Perigastritis usually demands pro-
longation of the treatment in bed, and
possil)ly opium suppositories, or co-
caine internally, to relieve pain, e.g.,
B Opii pulveris gr. xxv (1.6 Gm.).
Bismufhi subiiitratis 5J (30.0 Gm.).
Ci'ctcc p rcc para tec.. . 3vj (24.0 Gm.).
Sodii bicarbonatis.. 5J (30.0 Gm.).
Pone in chartulas no. xxx.
Sig.: Take 1 powder every four hours.
Sippy's treatment consists essen-
tially in accurately protecting the
ulcer from the gastric juice until
healing can take place.
The vast majority of gastric, and
more particularly duodenal, ulcers
now treated surgically can be readily
and more quickly cured by this
method. The digestive action of the
gastric juice is rendered inert from
7 A.M. to 10.30 P.M. In addition, if an
excessive night secretion is detected,
this is removed until the irritability
of the gastric glands has subsided, by
aspiration 2 or 3 times each night, if
necessary. Usually after 3 or 4 days
this night secretion then disappears.
Subsequently the normal quantity
(about 10 c.c.) of gastric juice in the
stomach at night is left undisturbed.
Neutralization of the acid is ac-
complished by frequent feedings and
by alkalies in regulated quantities.
The patient remains in bed for from
3 to 4 weeks. Three ounces of equal
parts milk and cream are given every
hour from 7 a.m. until 7 p.m. After
2 or 3 days soft eggs and well-cooked
cereals are gradually added, until
after 10 days the following is being
given: 3 ounces of milk and cream
every hour; 3 soft eggs, 1 at a time,
and 9 ounces of a cereal, 3 ounces at
1 feeding. Cream soups, vegetable
purees and other soft foods may be
substituted now and then, as desired.
The total bulk at 1 feeding should
not exceed 6 ounces. Jellies, mar-
malades, custards, creams, etc., are
permissible. Preliminarj'^ starvation
is unnecessary. In addition to giving
an alkaline powder midway between
feedings, the powders are continued
every half hour after the last feeding,
until 10 P.M. Gastric ulcer with stag-
nation is usually controlled by feed-
ing every hour and giving a powder
of 10 grains (0.6 Gm.) each of heavy
calcined magnesia and sodium bicar-
bonate, alternating with a powder of
10 grains (0.6 Gm.) of bismuth sub-
carbonate, and 20 or 30 grains (1.3 or
2.0 Gm.) of sodium bicarbonate, mid-
way between feedings. Cases with
stagnation of food and secretion
longer than 2 months usually require
more of the alkalies. Sippy (Jour.
Amer. Med. Assoc, May 15, 1915).
Surgical Treatment. — The ratio of
failures of medical -treatment in ulcer
has been reported all the way from
less than 1 per cent, up to 22 per
cent. Even in the best hands, failure
occurs, particularly in perforations,
the sequels, and chronic ulcer. Sur-
gical interference, on the other hand,
shows a most gratifying increase
of successes each succeeding year.
Moynihan's series of 251 gastroen-
terostomies, etc., for simple chronic
gastric or duodenal ulcers, mortality
3.5 per cent., and Mayo Robson's
STOMACH, DISEASES OF (BASSLER). 3^9
210 gastroenterostomies, etc., with a when the patient is returned to bed.
mortality of 3.8 per cent., may be (For technique see this vohime, page
taken as the latest authentic figures. 195.) Passing the tube between two
Among average surgeons future hot-water bags at the side of the bed
years will show a lower rate of mor- is sufficient for keeping the fluid
tality than to-day exists (5 to 20 per warm.
cent.). Thus it seems logical for the Hour-glass contraction requires
internist to refer to the surgeon those surgical treatment. A communica-
cases which do not progress under tion can be formed between the
careful medical treatment. two sacs by means of gastroplasty
In cases of copious hemorrhage, and gastrogastrostomy, gastroenter-
surgery often fails. Von Leube found ostomy being added if indicated,
uncontrollable hemorrhage the cause When the contraction is in the py-
of death in only 1 per cent, of his loric region and partial, the ideal
cases of ulcer, and surgery, even at operation is partial gastrectomy.
best, cannot offer better results than The average mortality of the opera-
this. Thus, surgery is indicated only tions for hour-glass stomach is about
for a continuation of recurrent hem- 17 per cent,
orrhage after careful treatment. Where gastric atony develops as a
Perforation, on the other hand, al- post-ulcer condition secondary to py-
ways requires surgical procedure, the loric stenosis, a special diet consist-
percentage of recoveries from medi- ing of fluids, semisolid foods, and the
cal treatment being only about 5 per solid foods in finely comminuted
cent., while that of surgery, when in- form should be given at first. The
stituted early enough, is over 65 per meals should be small and frequent,
cent. In favorable cases, a gastro- If relief does not follow : partial gas-
enterostomy should follow the clos- trectomy and gastroenterostomy,
ure of the perforation, for by it rest Incessant pains from old perigas-
of the stomach is permitted, and trie adhesions may be temporized
the secretion becomes more nearly with by medical measures and the
normal. If the general condition of use of potassium iodide or syrup of
the patient is not good, gastroenter- hydriodic acid. When these fail,
ostomy should not be done. and debility, anemia, etc., increase,
A diagnosis of perforation of the surgical treatment is indicated,
upper abdomen having been made, In persistent gastrosuccorrhea and
the patient should be kept with hyperesthesia or gastralgia following
shoulders down and hips raised until ulcer, operation should be withheld
the operation. No food is to be until thorough medical treatment,
allowed, and peristaltic rest should be with strict regime and X-rays have
secured by application of cold to the been tried. A return to the rest
upper abdomen, and perhaps the use treatment for two weeks or so is
of opiates before operation. If shock sometimes desirable. Partial gas-
is severe, intravenous saline infusion trectomy is the operation of first
is of value. The operation should be choice, and gastroenterostomy the
as brief as possible. Murphy advises second. The same considerations ap-
continuous warm saline proctoclysis ply in cases of recurrent bleeding.
390
STOMACH, DISEASES OF (BASSLER),
True chronic ulcer is generally a
surgical cnnditidn. Special dieting,
bismuth, belladonna, rest, the X-rays,
and the tonics prcjving a failure,
mixed treatment will occasionally
give surprising results. As a rule,
because of adhesions and engorge-
ment, the only feasible operation is
gastroenterostomy.
In duodenal ulcer all surgeons, and
most internists, now favor operative
treatment. Yet good grounds exist
against immediate surgical treatment
for all cases. Accepting Mayo's fig-
ures of 401 duodenal to 201 gastric
ulcers operated upon among 621
cases, duodenal ulcer is met with
twice as often from the surgical
standpoint as gastric ulcer. From
autopsy findings I am inclined to be-
lieve that many times more ulcers
occur in the stomach than in the
duodenum, and that the majority of
these heal. Further, I believe that at
least one-fourth of the duodenal ul-
cers heal under medical means, i.e.,
three weeks of bed and diet treat-
ment, and about six months of
careful dieting. Therefore, in un-
perforated duodenal ulcer, however
long its previous course, I apply
medical treatment first. In most
cases, about a week of this removes
the symptoms. After the third week
I place them on my regular diet for
reducing excessive secretion, and con-
tinue this for about six months, mak-
ing fecal examinations for blood, etc.
Before the patient goes to bed, it
should be explained to him that sur-
gical intervention may be necessary
at any time. If he prefers the opera-
tive risk to prolonged medical treat-
ment, he is operated upon at once.
After the bed treatment, I again men-
tion the possibility that operation
may later be required. After six
months, if all has been well, regular
foods are allowed. Should the symp-
toms not subside during the bed
treatment, or the bleeding continue
after the first week, or there be a
return of the pain, or if there is ame-
lioration only of the local symptoms,
operation is advised at once, prefer-
ably posterior gastroenterostomy.
Carcinomatous change is always a
surgical condition. Excision of the
diseased area, adhesions, and en-
larged lymph-glands is necessary.
When results from medical treat-
ment are poor, the patient should be
assured that nothing can be done by
internal means, and the advisability
and lack of danger of an exploratory
incision dwelt upon. Only thus is it
possible to get the majority of pa-
tients to consent to operation.
A number of cases of gastroenter-
ostomy later develop enterocolitis.
To obviate this, it is important to
maintain the diet for hyperacidity for
some weeks or months, then, to ad-
vise the following : All foods are to
be fresh and cleanly cooked and
served, and no foods eaten that have
been standing cooked some hours.
The mouth should be cleansed with
plain warm water, preferably with a
little sodium bicarbonate dissolved
in it, before and after meals, and,
when possible, at other times. Four
meals a day, moderate in amounts,
or three meals a day with small sup-
plemental meals between them and
before retiring, are advisable. Thor-
ough cooking, fine comminution of
the foods, with complete mastica-
tion and slow eating, are necessary.
Food should not be eaten during
fatigue. Rest in a reclining position
one hour after the main meals is de-
STOMACH, DISEASES OF (BASSLER).
391
sirable. No condiments should be
allowed, and the use of salt restricted.
Food should be soft or semisolid.
Where hemorrhages occur in ulcer,
direct surgical attack of the ulcer is
necessary, gastroenterostomy failing
to protect. Among 2875 cases oper-
ated on for duodenal ulcer at the
Mayo Clinic, the mortality was 1.6
per cent. About 20 per cent, of these
had had hemorrhage before operation,
and 12.7 per cent, after operation.
Among 863 cases of gastric ulcer the
operative mortality was somewhat
over 3 per cent., and 8 per cent, had
gross hemorrhages after operation.
Only 2 patients, however, died from
hemorrhages after operation. The
other symptoms were almost always
completely relieved by gastroenter-
ostomy, but not the bleeding. Ex-
cision combined with gastroenteros-
tomy gave the desired protection
against hemorrhage. The actual cau-
tery is the safest and surest method
of removing the ulcer in most in-
stances. Balfour (Amer. Med. Assoc;
N. Y. Med. Jour., June 28, 1919).
SYPHILIS OF THE STOMACH.
Judging- from experience in i)ost-
mortems on syphilitic individuals gas-
tric syphilis would seem to be a very
rare affection, though of late years
the frequency of authentic cases has
been constantly on the increase. It
is probably met with in about 1
per cent, of autopsies on syphilitics.
PATHOLOGY .—The disease
manifests itself in three ways, viz. :
diffuse syphilitic gastritis, syphilitic
ulcer, and gumma. To these may be
added the sequels, perigastric adhe-
sions or pyloric thickenings causing
stenosis. A combination of the three
lesions is often met with.
Diffuse syphilitic gastritis, essen-
tially clironic, is commonly an accom-
paniment of syphilis of other ab-
dominal organs or of gastric gum-
mata. Syphilitic lesions usually co-
exist in the liver, spleen and pan-
creas. The diffuse condition does
not differ histologically from ordinary
chronic gastritis, in which profuse
round-cell infiltration exists.
There are many reasons for believ-
ing that gastric ulcers of syphilitic
origin do occur, probably by rupture
of gummata or round-cell invasion
about and in the walls of the blood-
vessels, stopping the blood-supply.
Gummata, single and of large size,
or coalescing, to form deposits pal-
pable from without, are no doubt
very rare. Gummata are often situ-
ated in the pyloric region or along
the lesser curvature, and are seen as
reddish swellings or flattened eleva-
tions in the sul^mucosa. The mucosa
is thickened, soft, glistening, and yel-
lowish, with small ulcerations.
SYMPTOMS AND DIAGNOSIS.
— The diagnosis is based on the his-
tory, late syphilitic manifestations,
the Wassermann test, and the results
of specific therapy. The clinical pic-
ture does not differ especially from
those of non-specific gastric affec-
tions. The condition may occur
early in congenital syphilis, along
with saddle nose, prominent forehead,
lines about the mouth, Hutchinson
teeth, interstitial keratitis, etc. If
there is a history of many abortions,
hydramnios, or marasmic, short-lived
infants, it may be diagnosed or, at
least, suspected. In the acquired
form thorough treatment over years
does not always cure the condition.
There may be an achylic gastric
content with much mucus ; dilatation
of the organ, with stagnation ; a long-
standing gastric ulcer in respect of
which alcoholism, chlorosis, arterio-
sclerosis, tuberculosis, and other
Z^)2 STOMACH, DISEASES OF (BASSLER).
causes can be eliminated, and which which the drug should be continued
has not bled nor recovered under ul- at about the first-mentioned quantity
cer treatment; a long-standing-, small, or loss. Tlie insoluble mercury salts
irregular, movable pyloric growth, or (calomel or biniodide) are best given
an unaccountable, chronically en- independently. Dietetic, tonic and
larged spleen with ascites. hygienic measures arc also in order.
There is one type of case which Instead of mercury and iodide, sal-
closely simulates malignant disease, varsan or neosalvarsan, may be em-
There may be most severe gastric ployed, preferably intravenously,
pain, uninfluenced by ingestion of
food and worse at night. Debility TUBERCULOSIS OF THE
and anemia may be pronounced. The olUMACH.
stomach usually shows retention and This is usually secondary to pul-
absence of hydrochloric acid and monary disease, resulting from con-
pepsin. The epigastrium is usually stant swallowing of infected sputum,
very tender, and after some months yet cases of primary gastric tuber-
a pyloric tumor is noted. Chronicity culosis are also reported,
is a distinguishing feature, some ETIOLOGY. — Tuberculous ulcers
cases being ill four to eighteen years, of the stomach are comparatively
TREATMENT. — If the diagnosis rare, being found in about 2.Z per
is doubtful or the "therapeutic test" cent, of autopsies upon tuberculous
merely to be tried, smaller amounts patients. Presumably, many of the
of mercury and iodides may suffice at bacteria are destroyed by the gastric
first. The protiodide and bichloride juice. Motor insufficiency and chronic
of mercury may be given by mouth gastric catarrh, particularly gastritis
for a short time, but when benefit is granulosa, in which there is an in-
being derived they should be given crease in the lymphoid follicles, are
by injection or inunction. Hypo- among the most important predispos-
dermic use of 10 to 30 minims (0.6 ing factors.
to 1.8 c.c.) of a 0.4 per cent, mercury PATHOLOGY. — Five varieties of
biniodide solution in olive oil, or 10 gastric tuberculosis are described:
minims of a 10 per cent, mercury (a) The ulcer, sometimes single, often
salicylate solution in albolene, every multiple, small, irregular, elevated,
third or fourth day, is efficient. By somewhat undermined, with indu-
mouth, calomel, 1 grain (0.065 Gm.), rated margins and rough base, and in
with powdered opium, % grain (0.02 which tubercles may be noted ; rarely
Gm.), three times a day is of value. it erodes a large vessel. (6) Miliary
Internal syphilis in adults being tuberculosis, hematogenous in origin,
mostly late tertiary, the iodides manifest as millet-seed formations
should be given, in doses of between on the peritoneal surface or along the
30 and 60 grains (2 and 4 Gm.) daily, vessels, (r) Solitary tubercles, rare,
at mealtimes. When, in a gastric probably due to local infection from
case, benefit is being derived, the sputum, {d) Tumor-like masses, gen-
daily amount should be gradually erally near the pylorus, usually due to
increased to 150 grains (10 Gm.), or large tuberculous deposits, perhaps
more, until the symptoms abate, after adenomatous. As the pylorus is rela-
STOMACH, DISEASES OF (BASSLER).
393
tively rich in lymphoid tissues,
probably a number of cases of in-
explicable stenosis are tuberculous
in origin, (c) Tuberculous cicatricial
pyloric stenosis from more or less
healed lesions or contraction of re-'
suiting- perigastric bands (Martin).
A number of the small tuberculous
ulcers usually coexist on the lesser
curvature and posterior wall, being
flat, with a floor composed of yellow
or gray tubercles, and a thickened
submucosa. Scrapings show bacilli,
and giant cells are occasionally met
with in the underlying tissues. Less
often larg-e single ulcers of the in-
dolent type are seen. In addition, the
ileum, colon, spleen, and pancreas
may be similarly affected. Where
tubercles exist on the peritoneal sur-
face, adhesions with the mesentery
and omentum are common.
SYMPTOMS AND DIAGNOSIS.
— There are no distinctive symptoms
of gastric tuberculosis, excepting pos-
s\])\y the chronicity of its course. Like
the syphilitic ulcers, tuberculous ul-
cers are not so liable to hemorrhage
as the simple, malignant, or chronic
forms. If there be evidence of tuber-
culous disease in parts of the body
other than the abdomen, tuberculous
gastric disease should be thought of.
Pain is often severe. If pyloric sten-
osis exists and a tumor is palpable,
one must think of local tuberculosis
as well as malignant disease. Pri-
mary gastric atony may follow infec-
tious diseases, such as typhoid fever
and tuberculosis. Most instances of
dilated stomach in these diseases
must be considered due to toxemia
and subnutrition rather than local
gastric disease.
Tubercle bacilli in the stomach are
not diagnostic, as in lung tubercu-
losis they are swallowed. Signifi-
cant, however, may be a persistent,
slight, unaccountable fever, with its
highest point about 4 p.m. ; steady
loss in weight, cough, hemoptysis,
dyspnea, pleurisy, sputum, and physi-
cal signs.
In ulcers of the stomach or in-
testines which fail to heal, the
tuberculin test ofifers the only possi-
bility of diagnosis. Koch's tuber-
culin, standardized, in ascending
doses of 0.001, 0.003, 0.005, 0.008 and
0.01 c.c, well diluted, should be
given. The temperature reaction
(37.8° C. or 100° F. or more) should
be watched for from eight to twenty
hours after the injection, and at in-
tervals for seventy-two hours after-
ward. The von Pirquet or ophthal-
mic tests may .also be employed.
TREATMENT.— Persons with
lung tuberculosis should be warned
against swallowing sputum, and ad-
vice given to cleanse the mouth and
fauces thoroughly before eating and
drinking. The active treatment con-
sists in applying the usual antituber-
culous hygiene and diet. Careful
therapeutic use of tuberculin seems
justifiable. It should only be em-
ployed, however, in the afebrile cases
and when the state of general nutri-
tion permits. The dose should be be-
gun at 0.0001, or, better, 0.00001 c.c.
of the O. T. preparation, given every
third day, and gradually increased
until the limit of tolerance is reached
The B. F. tuberculin has been ad-
vised for the febrile cases. The
treatment should be continued for at
least three months, along with the
hygienic-dietetic treatment.
In any persistent gastric ulcer case
with Wassermann test negative and
tuberculin test positive, if the general
394
STOMACH, DISEASES OF (BASSLER).
medical treatment of tuberculosis
proves a failure, providing the gen-
eral condition warrants surgical pro-
cedure, an operation should be per-
formed. If an ulcer be found,
excision is the procedure of choice.
PSEUDOMEMBRANOUS GAS-
TRITIS.
In diphtheria, anthrax, typhus,
and pneumonia, a pseudomembranous
gastritis may rarely occur. Diagnosis
is impossible unless the membranes
are vomited or removed by lavage.
Several instances of what appeared
to be true diphtheritic gastritis have
been reported. These always accom-
panied faucial or nasal diphtheria.
BENIGN TUMORS OF THE
STOMACH.
These tumors are rare, most pal-
pable growths being carcinomatous.
Among the benign are adenoma,
papilloma, myoma and fibromyoma,
lipoma, myxoma, lymphadenoma,
polypi, and retention cysts, to which
may be added gastroliths and foreign
bodies, the thickenings of the pylorus
(hypertrophic stenosis), and divertic-
ulum of the stomach.
PATHOLOGY.— Adenomata, as a
rule, occur as small, white, translu-
cent, irregular growths of tubular
structure, and papillomata as wart-
like or pedunculated growths of a
finer consistence. Adenomata may
closelv simulate adenocarcinoma.
Myomata and Fibromyomata. —
The myomata develop in the mus-
cular layer. They are often numer-
ous and of small size, forming slight
elevations of the mucous membrane,
but may be single, large, and perhaps
pedunculated. The fibromyomata are
larger, up to the size of a pigeon's
es:^:. As a rule, the overlvintr mucous
mem])rane is normal.
Lipomata. — Small lipomata are oc-
casionally seen in the sul)mucous
coat, forming projections covered
with attenuated mucous membrane.
More rarely the tumor separates the
muscular fibers, forming small hernias
under the serosa. Orth has observed
pedunculated lipomata growing from
the serosa, and a large tumor of this
kind may cause digestive disturljance.
Myxomata are seen as small, jelly-
like deposits containing much mucin,
usually in the form of myxolipoma,
myxofibroma, and myxoadenoma.
Their cut surface is pale grayish or
reddish white in color. There is gen-
erally a thin- capsule. These grow
from the connective tissue in the sub-
mucous or intermuscular tissue. They
enlarge slowly, and rarely attain con-
siderable size in the stomach, though
when mixed with sarcoma-cells they
may grow very rapidly. In some in-
stances they are pedunculated (mu-
cous polypi), and may be numerous
in the pyloric region. Their forma-
tion has been attributed to chronic
gastritis. Submucous myxoma is not
very rare, occurring generally in mid-'
die life, and often in the male sex.
Lymphadenomata, because of their
association with sarcoma, are the
chief benign tumors. The benign
form (lymphoma) is seen as small,
scattered nodules, grayish-white and
soft, yielding a milky-white juice.
They are often found in the internal
organs in Hodgkin's disease. They
are often found in the internal or-
gans in Hodgkin's disease. They
develop in the mucosa and submu-
cosa, project into tlie lumen, and
commonly ulcerate, possibly with re-
sulting fatal hemorrhage. At times
STOMACH, DISEASES OF (BASSLER).
395
lymphomata become malignant, in-
filtrating nearby structures, involving-
the lymphatics, and infecting distant
parts. These are lymphadenomata.
Retention cysts are met with in the
polypoid forms of chronic gastritis
(gastritis ^polyposa). Gastric dermoid
cyst and multilocular lymphangioma
are very rare. Most gastric cysts are
myxomatous.
Gastroliths and foreign bodies are
very rare. They are most often seen
in the insane, but may be met with
in instances of vicious habits, such as
continued swallowing of hair, fiber,
or unusual solid articles, and very
rarely in form of collections of vege-
table detritus. These may almost
fill the cavity of the organ.
A few cases of diverticulum of the
stomach are on record, being usu-
ally met with on the distal side of
some contracting cicatrix or perigas-
tric band. They may be large, and
are always free of external adhesions.
Hypertrophy of the pylorus occurs
in two clinical types: the acquired
hypertrophic stenosis of the pylorus
accompanying a hypertrophic gas-
tritis, and the congenital type. Un-
less the obstruction is removed, the
consequences may be, and generally
are, as serious as those of pyloric
stenosis due to malignant disease.
The thickening of tissue is greatest
at the pylorus, though the entire
stomach may be smaller from general
involvement. The pyloric wall may
be 2 or 3 centimeters in thickness.
The disease occurs chiefly in persons
between 20 and 40 years of age, and
in males somewhat oftener than in
females. Chronic alcoholism is a
prominent factor in most cases. The
glandular coat is commonly much
ulcerated in the pyloric region.
SYMPTOMS AND DIAGNOSIS.
— Where benign tumors are of small
or moderate size, the diagnosis is
usually made only after death. AMiere
they are large, an epigastric tumor
may be palpable. In large pedun-
culated growths, the pylorus may act
as a ball valve. Here the growth
may cause a secondary atony of the
stomach, the extraction of mixed
meals seven, eight, or nine hours after
their ingestion affording evidence of
stagnation. Gastric secretion is not
disturbed, or a high acidity may
exist.
Hematemesis with occult l)lood in
the stools may be observed in lym-
phadenoma. Saline gastric instilla-
tions may yield pus-cells and in-
creased bacterial flora : the eas
product may be over 2 per cent.
Of the foreign bodies, "hair balls"
are most common. A soft, movable
mass may be discovered. Emesis and
excessive eructations are common. A
history of chronic digestive disturb-
ance is the rule. In these cases the
gastroscope is of value, both for
diagnosis and removal. It may also
well serve similarly in pedunculated
tumors. Cases of persistent ingestion
of needles have been reported in
which needles were found in various
parts of the abdomen, even travelling
to the extremities. Large quantities
of metallic articles are sometimes ac-
cumulated in the stomach. Where
the habit of swallowing such bodies
has existed for some time, it is often
fatal.
In hypertrophic stenosis the his-
tory is that of chronic gastritis, and
a subchlorhydric, anachlorhydric, or
achylic condition is the rule. A
small, hard, globular mass (thickened
pylorus) may be palpable in the mid-
396
STOVAINE.
line above the umbilicus, or the entire
stomach may feel stiff and unyield-
ing. Fullness, pressure, pain, pyro-
sis, and eructations are generally
present, with rather steady vomiting
as the case advances. The appetite
may not be disturbed. Small amounts
of blood are usually found in the
test-meal and fecal examinations, and
the X-rays, showing a small, trian-
gular stomach, are valuable in diag-
nosis. Differentiation from stricture
due to carcinoma or ulcer requires
exhaustive examination. These cases
advance slowly; stagnation may not
occur until very late.
In the diverticula cases a history
of severe epigastric pain after eating,
followed by vomiting of a very bitter
substance with immediate relief, and
a disinclination to take solid foods,
are present when the sac is in the
pyloric region. Physical examination
is usually negative, but the X-rays
would be helpful.
TREATMENT. — Small benign
growths causing no symptoms re-
quire no special treatment. In the
case of larger pedunculated growths
or foreign bodies producing symp-
toms and not situated in the in-
accessible pyloric region or lesser
curvature, removal through a gastro-
scope may be attempted. When such
removal is impossible, the growth is
in the gastric wall, or hypertrophic
stenosis exists, laparotomy is in or-
der. The danger of recurrence being
very slight, the organ can be at once
closed. In growths in the stomach-
wall more or less removal of gastric
tissue is necessary, and a gastroen-
terostomy may be required.
In moderate cases of hypertrophic
stenosis palliative treatment answers,
the patient abstaining from alcohol.
irritating and hard foods, and to-
bacco, and using milk, soft eggs,
purees, etc., when there is HCl secre-
tion, or chiefly well-cooked, soft car-
bohydrates and pancreatin when there
is not. Regular stomach lavage with
hydrastis solution or dilute hydro-
chloric acid is of value, particularly
when gastric retention exists. In the
more severe cases, when emaciation
is progressive and stagnation exists,
medical treatment failing, operation
should be advised. Where only the
pylorus is thickened, pylorectomy
and pyloroplasty are ideal ; if the
entire stomach, a; free gastroenter-
ostomy should be performed. .Should
the organ be contracted so high as
to preclude a posterior gastroenter-
ostomy, pylorectomy or the Finney
operation may alone be possible. In
high-degree stenosis, the operation
should not be postponed a single day.
After the stenosis has been relieved,
the case requires the additional die-
tetic, medicinal, and mechanical treat-
ments described under Chronic Gas-
tritis.
In cases of gastric diverticulum
the sac should be excised, and the
two lateral portions of normal stom-
ach-wall brought together.
Anthony Bassler,
New York.
STOMACH, INJURIES AND
SURGICAL DISEASES OF. See
Abdomen, Surgery of: Abdominal
Injuries.
STOMATITIS. See Mouth, Dis-
eases OF.
STOVAINE. —Stovaine, an unoffi-
cial local anesthetic and substitute for
cocaine, is chemically benzoylethyldimeth-
ylaminopropanol hydrochloride: CH3CH2C
(C0H5COO) . (CH3)CH2[N(CH3)2] . HCl.
It is closely related chemically to alypin.
STOVAINE.
397
It was first made synthetically in 1903 by
Fourneau, a French chemist, and named
in his honor, the English translation of
fourneau — a stove — being utilized as a
more euphonious basis than the French
word in coining the new term, stovaine.
Stovaine crystallizes in small scales. It
is very soluble in water and methyl alco-
hol, less freely in absolute ethyl alcohol,
of which 5 parts are required to dissolve
it. Aqueous solutions of stovaine are
faintly acid to litmus. When in solution
the drug is decomposed by alkalies, even
if very dilute, and is precipitated by the
alkaloidal reagents in general. The drug
is held to be stable on moderate heating,
so that solutions of it may be sterilized
at 115° C. The experience of W. Wayne
Babcock with it in spinal anesthesia, how-
ever, has afforded evidence to the effect
that, even at 100° C, the stability of the
drug is not absolutely complete, and that,
to avoid possible unpleasant after-efifects
in this delicate form of anesthesia, solu-
tions of the drug should be sterilized only
by the intermittent method, at tempera-
tures not exceeding 65° C. (149° F.).
Where the drug is used in small amount
in ordinary local anesthesia, such care in
sterilization is, perhaps, unnecessary.
PHYSIOLOGICAL ACTION, — Like
cocaine, stovaine is capable of acting not
only locally, but on the central nervous
system. Large doses of stovaine, admin-
istered subcutaneously in animals, at
times induce a general analgesia without
other nervous effects, but more frequently
such manifestations as motor inco-ordina-
tion, tonic and clonic spasms, and paral-
ysis of the extremities, followed, at times
after a period of coma, by respiratory
paralysis and death. The toxicity of
stovaine is, however, two or three times
less than that of cocaine. According to
Braun, the lethal doses of cocaine and
stovaine per kilogram of body weight
when injected subcutaneously in dogs are
0.05 to 0.07 Gm. and 0.15 Gm., respect-
ively; according to B. Wiki, the corre-
sponding figures in guinea-pigs are 0.045
and 0.11 Gm., respectively. Stovaine in
moderate dosage tends to excite the
heart-muscle; the blood-vessels are at
first dilated, but the resulting tendency
to reduction of blood-pressure is of short
duration, the pressure soon returning to
normal. As compared to the action of
cocaine this vasodilator property is an
advantage, the tendency to syncope due
to vasoconstriction so often noted with
cocaine being absent with stovaine.
Locally, stovaine exerts an anesthetic
action practically equivalent to that of
cocaine, i.e., solutions of the two drugs of
like percentage produce nearly equal ef-
fects. Stovaine differs from cocaine in
being a local vasodilator rather than a
vasoconstrictor. This vasodilator effect is
not; sufficient, however, to cause any un-
usual amount of bleeding in operations
under stovaine anesthesia, and may, in
fact, be advantageous in that no trouble-
some secondary oozing, as sometimes wit-
nessed after cocaine, need be anticipated
(Gambini-Botto).
POISONING.— Stovaine is a far safer
drug, from the standpoint of constitu-
tional effects, than cocaine. Reclus, among
100 cases in which it was used for local
anesthesia, observed slight pallor and pre-
cordial oppression in but one instance. A
dose of 3 grains (0.2 Gm.) may be used
without risk, and theoretically, one might
use as much as 7>^ or 9 grains (0.5
or 0.6 Gm.) (Kendirdjy), though such
amounts are not in practice required.
Stovaine is, however, undoubtedly dis-
advantageous, in that it acts unfavorably,
especially in the more concentrated solu-
tions, such as 2 to 10 per cent., on the
vitality of the tissue cells with which it
is brought in contact. Instances of local
necrosis after its use in local anesthesia
have been reported, and Sinclair asserts
that it interferes with the processes of
tissue repair. With 1 per cent, or weaker
solutions, the chances of unfavorable ef-
fects of this kind are, it would seem, very
slight, but the drug does, in general, cause
a more or less persistent tissue hyperemia
which is not met with after cocaine or
other cocaine substitutes, such as beta
eucaine and, in particular, novocaine.
THERAPEUTICS.— Aside from its use
in spinal anesthesia, which has already
been considered (see Spinal Anesthesia),
stovaine is, by most observers, held in-
ferior to some other local anesthetic
drugs — especially novocaine — on account
of the irritant effects referred to in the
398
STRABISMUS (JACKSON).
preceding section. That the drug may be
used, however, wihout anticipating any
special difficulty from this source — e.g.,
where novocaine is not available — was
illustrated in its extensive employment in
the few years following its discovery, be-
fore the introduction of novocaine. Gam-
bini-Botto performed al)out 200 operations
under ^ per cent, stovaine local anesthe-
sia, including 79 operations for hernia, 24
for hydrocele, 18 for varicocele, 6 for
varicose veins, 4 for anal fissure, etc.
Arnezzi (1905) used stovaine or stovaine-
epinephrin in 44 cases with satisfactory
results, and Reclus, the most eminent
French pioneer in local anesthesia, used
stovaine for a time in preference to co-
caine, though eventually abandoning it in
favor of novocaine. The writer took part
in the removal of a lipoma from the
shoulder of a female patient under sto-
vaine, and a perfect anesthesia was se-
cured with this drug. Stovaine may also
be used with good results in Yz, Ya, or 1
per cent, solution in such operations as
the removal of a wen, or other cutaneous
or subcutaneous tumor, the excision of a
lupus nodule or chancroid lesion, the ex-
traction of a foreign body, the opening
of an abscess, etc. Conduction, i.e., nerve-
trunk, anesthesia with stovaine may be
usefully applied in operations for ingrown
toe-nail, hammer-toe, paronychia, phalan-
geal dislocation, foreign bodies in the
fingers, exostoses under the nails, and cir-
cumcision. To procure local vasocon-
striction during the operation, epinephrin
may be added to the stov^aine solution.
Arnezzi used 1 minim (0.06 c.c.) of 1 : 1000
epinephrin solution to every 3 c.c. (48
minims) of J^ per cent, stovaine, and
Blondeau, 4 drops of epinephrin to every
2 c.c. (32 minims) of 1 per cent, stovaine.
The methods of inducing local anesthesia
with stovaine are identical with those fol-
lowed in using other similar drugs (see
Cocaine and Novocaine).
In dental practice a 1 or 1^ per cent,
solution of stovaine, with a little epine-
phrin added, may be applied to the sur-
face of the gums, then injected into the
latter in a plane parallel with the lateral
surfaces of the teeth. In ophthalmology
1 to 4 per cent, solutions have been used
for instillation and a 1 per cent, solution
for subconjunctival injection. Instillation
of 5 drops of a 4 per cent, solution induces
some blepharospasm, smarting, lachryma-
tion, and slight conjunctival congestion,
followed in 2 or 3 minutes by anesthesia
equivalent to that induced by cocaine
and permitting of cauterization of corneal
ulcers, extirpation of chalazia, pterygia,
or small epitheliomata, operations for
trichiasis, and muscle transplantations
(Scrini). The anesthesia, after 2 or 3
applications, generally lasts for about
half an hour (Stephenson). After 1 ap-
plication it remains complete for 8 to
10 minutes, then gradually diminishes
(Scrini). Mydriasis is less marked than
with cocaine. Accommodation and the
light and convergence reflexes are not
affected. In the deeper operations sub-
conjunctival injection is, of course, re-
quired to secure anesthesia of all the
tissues operated upon. A 1 per cent, solu-
tion may be instilled to relieve discomfort
in blepharitis, conjunctivitis, phlyctenular
ophthalmia, iritis, and episcleritis.
Stovaine may also be used in nose,
throat, and ear operations, in the same
manner as cocaine. D. McKenzie used it
in 5 to 20 per cent, solutions, and found
a 10 per cent, solution strong enough for
most cases. In 57 cases there were no
complaints or toxic phenomena. When
the application of the drug exceeded 20
minutes in duration slight ulceration was
produced which, however, readily healed.
S.
STRABISMUS. — Squint ; hetero-
Iropia.
DEFINITION.— The condition in
which both eyes do not look toward
the same point ; but when one eye
fixes a certain point the other is
turned elsewhere.
SYMPTOMS.— The false position
of the eye that is not turned toward
the object looked at is usually noticed
on casual inspection, and constitutes
a very disagreeable deformity. This
eye is called the deviating eye. The
one which is normally directed is the
fi.ving eye. The symptom of deform-
STRABISMUS (JACKSON).
399
ity may, however, prove misleading.
The direction an eye is looking is
judged by the direction the cornea is
turned. In some eyes the visual axis
pierces the cornea so far from its
center that the eye appears to deviate
when in reality it is properly directed ;
and such an eye might really deviate
when it appeared straight.
The lack of correspondence between
the eyes prevents true binocular vision,
if that function has already been de-
veloped; or prevents its development.
If the patient has previously possessed
normal binocular vision the deviation
causes diplopia or double vision. This
diplopia is distinguished from monoc-
ular diplopia by the fact that the cov-
ering of either eye removes it.
The image seen by the fixing eye is
called the "true image," it being re-
ferred to the true position of the
object. The image seen by the de-
viating eye is called the "false image,"
it being referred, in the consciousness
of the patient, to a direction different
from the real direction of the object.
The relation of this diplopia to the
deviation of the eye may be under-
stood from tlie illustration here given.
The visual axis R-T is properly di-
rected toward T, the object looked at;
but the other visual axis L-D deviates
toward D. In the eye L, therefore,
the image of T falls at t, on the nasal
or inner portion of the retina ; and it
is referred or projected in the direc-
tion f-F as another object at F, the
point / in the fixing eye corresponding
to the point t in the deviating eye.
The direction of the false image is
always the opposite of the direction
in which the eye deviates. Thus, when
the eye deviates upward the false
image appears lielow. When the eyes
are crossed we have homonymous
diplopia; and, when the eyes diverge.
crossed diplopia.
Diplopia disappears when the stra-
bismus is corrected, or when one eye
is closed. It may also disappear
through extreme deviation, causing the
image in the deviating eye to fall on
the extreme peripheiy of the retina,
which is comparatively insensitive. Or
it may disappear from habitually dis-
regarding the false image, especially
in early life. While, therefore, the
presence of binocular diplopia proves
strabismus. (Edward Jackson.)
the presence of strabismus, its absence
does not prove that the eyes are
properly directed.
ETIOLOGY.— The normal direct-
ing of the eyes depends on an ex-
tremely delicate system of reflex
actions, which requires sufficiently good
vision in both eyes and a central co-
ordinating mechanism. The power of
accurately co-ordinating the eye move-
ments normally develops after birth.
Arrest in its development may cause
strabismus. Practical blindness of one
eye, especially when it depends on
some lesion of the cornea that causes
distortion of the retinal images or the
diffusion of unfocused light within
400 STRABISMUS (JACKSON).
the eye, is very likely to cause that causing inability to move the eye in
eye to deviate. certain directions, it is called paralytic.
Errors of refraction are a common Where the scjuint is due, not to in-
cause of strabismus. Hyperopia of ability to move the eye, but to a false
rather high degree, 2 D. or upward, co-ordination of the movements, so
compels excessive effort of accommo- that while the two eyes move freely
dation, and so brings about excessive in all directions they still keep their
convergence. Myopia of very high false relation to each other (as always
degree, 10 D. or more, is attended too convergent or too divergent or
with elongation of the eyeball that one turned too high for the other)
makes it difficult to turn it in its the condition is called concomitant or
socket. This leads to divergent squint comitant strabismus.
through giving up of the effort to turn When the eyes converge too much
the eyes in, so strongly as would be it is internal or convergent strabismus.
necessary to fix both eyes upon an When they diverge, or do not converge
object so close to them. Difference of enough for near seeing, it is external
refraction between the two eyes, mak- or divergent strabismus. When one
ing it difficult or impossible for both eye turns higher than the other it is
to focus the object at the same time, vertical strabismus. When it is always
also causes strabismus. Paralysis of the same eye that deviates it is monoc-
one or more of the muscles that turn ular or monolatcral strabismus. When
the eye disables it for certain move- it is sometimes one eye, sometimes the
ments and so causes strabismus. More other, that deviates, it is alternating
rarely spasm of one or more of these strabismus. When a comitant devia-
muscles is the cause of a deviation. tion is always present, it is called
Strabismus from lack of develop- constant, although it may vary much
ment of the co-ordinating mechanism, in degree; if sometimes absent it is
hyperopia, or difference of refraction called intermittent or periodic.
between the two eyes develops in early Paralytic strabismus only appears
childhood, when it is also most likely when the affected muscles are called
to arise from practical blindness of on to perform their function. It is
one eye. From myopia it occurs a divided into varieties corresponding to
few years later, as the myopia usually the muscles affected, and usually spoken
develops during the period of school- of as paralyses of those muscles ; as
life. From paralysis of the third, paralysis of the internal rectus, pa-
fourth or sixth nerves, or ocular mus- ralysis of the interior oblique. Fa-
des, it may develop at any time of ralysis of all the muscles supplied by
life. Syphilis and rheumatism are the a certain nerve-trunk may also be
most common causes of these palsies, designated, according to the nerve
But acute infectious diseases, espe- affected, as abducens paralysis, oculo-
cially diphtheria, injuries, and chronic motor paralysis, fourth-nerve paralysis.
diseases — as diabetes and Bright's dis- Paralysis of all the extraocular mus-
ease — also cause them. Spasm of the cles, ophthalmoplegia externa, causes
muscles is ai)t to be hysterical. some kind of squint whenever an at-
VARIETIES. — When strabismus tempt is made to look out of the
is due to paralysis of certain muscles, direction in which the affected eye is
STRABISMUS (JACKSON).
401
turned. If both eyes are affected the
strabismus is usually constant.
Latent strabismus, also called hcter-
ophoria, muscular insufficiency, or im-
balance, or dynamic squint, is that
condition in which a tendency to stra-
bismus exists, but is overcome by a
special effort of the appropriate mus-
cles, in order to avoid diplopia and
preserve binocular vision. The insuffi-
ciency may be of any one or more of
the muscles, shown only or chiefly
when the particular muscle is called
into action : a sort of latent paralytic
strabismus. Or it may be found to
be about the same, whatever the direc-
tion in which the eyes are turned, a
latent comitant strabismus. To the
latter variety the term heterophoria
(from the Greek eTepo<;, different
and ^0/305, tending) may be applied.
The varieties of heterophoria are eso-
phoria, tending inward, latent con-
vergent strabismus; exophoria, tending
outward, latent divergent strabismus;
and hyperphoria, tending upward, or
latent vertical strabismus. The latter
may be right or left according to the
eye which tends to turn above its fel-
low. Orthophoria, right tending, or
muscular balance, is the normal condi-
tion, the absence of hetejophoria.
DIAGNOSIS.— In a case of ap-
parent strabismus we must first de-
termine whether the apparent deviation
is real. This is done by having the
patient fix his gaze steadily upon some
distant object; and then, while watch-
ing his eyes, covering first one and then
the other, so that he is compelled to
fix with them alternately. He will fix
with the uncovered eye. Then on
shifting the cover, if the other eye was
also properly directed while it was
covered, no movement will occur. But
if the covered eye was deviating, it
will have to move in order to fix the
point looked at, and the eye which
previously fixed will deviate; and these
movements will be repeated, every time
the cover is shifted. The extent of
such movements indicates the amount
of the deviation, and the direction
shows the variety of strabismus.
The degree of lateral squint may be
measured along the lower lid in milli-
meters of change in the direction of
the eye from the deviating to the fixing
l)osition. But it is more accurately
measured by the angle of deviation.
This may be ascertained by placing
the deviating eye at the center of the
arc of a perimeter, and directing the
gaze toward a distant point in the axis
of that arc. Then finding the point
of the arc toward which the deviating
eye is turned, we read off the angle
of deviation. The point toward which
the deviating eye is turned is ascer-
tained by moving a candle-flame along
the arc, until the surgeon's eye behind
the flame sees its reflection in the cen-
ter of the pupil of the deviating eye.
Priestley Smith's method is applicable
without a perimeter. In it the surgeon
reflects light on the deviating eye with
a mirror held at his own eye one
meter from the patient, and has the
patient look at his finger, which is
moved at a distance of one meter from
the deviating eye until the corneal re-
flex from that eye appears at the
center of the pupil. The distance
from the surgeon's eye to his finger is
then the measure of the strabismus. It
may be measured on a scale of tan-
gents showing the degrees of squint,
or each centimeter corresponds to
about one centrad or four-sevenths of
a degree. When there is diplopia the
.'unoiinl of squint may also 1)0 meas-
ured by the distance of the false image
8— 2G
40^
STRABISMUS (JACKSON).
from the true image, or the strength
of the prism required to bring them
together.
To discriminate bctxvccn paralytic
and comitant strabismus, we must note
if the deviation of the squinting eye
or the separation of the true and false
images is confined to a part of the
field of fixation, or is greater in some
parts than in others. To ascertain
which muscle or muscles are paralyzed,
note the direction in which the eyes
must be turned in order to produce
the greatest deviation, or widest sep-
aration of the two images, this being
the direction in wdiich the paralyzed
muscle is most needed to turn the eye.
The false image, belonging to the eye
which cannot be normally turned, al-
ways appears farthest in the direction
the eyes are turned. Thus, on look-
ing up, the false image appears higher
than the true image ; on looking to the
right the false image appears the far-
ther to the right. By alternately cov-
ering the eyes we can find to which
eye the false image belongs, and so the
exact muscle or muscles afifected.
Diplopia is the rule in paralytic stra-
bismus, unless one eye be blind or cov-
ered by a drooping lid ; but it is the
exception in comitant strabismus.
To recognise latent squint we must
interrupt binocular vision. To secure
binocular vision the strabismus is ren-
dered latent, and when the effort nec-
essary to prevent strabismus no longer
secures binocular vision, it is given up,
and the eyes are allowed to deviate.
Binocular vision is prevented by cov-
ering one eye. When this is done the
covered eye deviates. But on remov-
ing the covering the eye quickly turns
to the position of true fixation. The
deviation of the eye under cover may
be so slow as to be with difficulty
noticeable; but the quick "recovery"
when the cover is removed is very
apparent.
By shifting the cover quickly from
one eye to the other the eyes may be
made to deviate and "recover" alter-
nately. By so shifting the cover back
and forth while the patient gazes at
a distant lamp-flame, he will see the
lamp-flame appear to jump back and
forth from one position to another
as the cover is shifted. The direction
in which the eyes deviate and "re-
cover" and the direction in which the
flame appears to jump will tell the
variety of latent strabismus present.
Binocular vision may be prevented
by making the image received in one
eye so unlike the other that there will
be little or no tendency to fuse them.
This may be done by placing before
one eye a dark-blue or purple glass.
On looking at a distant flame the pa-
tient then sees two: one of the natural
color, the other blue or pink. In
orthophoria these appear superim-
posed; but with heterophoria they ap-
pear separated. The direction in which
they are removed from one another
indicates the kind and the distance the
amount of latent strabismus.
Binocular vision may also be pre-
vented by use of a prism which so
displaces the image formed in one eye
that it cannot be fused with the image
formed in the other eye. Thus, in the
"Graefe test" a prism of 8 or 10
centrads is held wath its base up be-
fore one eye, and the gaze fixed upon
a dot in the center of a blank card.
To the eye before which the prism is
held the dot appears displaced down-
ward. In orthophoria it appears di-
rectly below the true image. In
esophoria the lower dot appears below
and toward the side of the eye that
STRABISMUS (JACKSON). 403
sees through the prism; in exophoria treatment; and in a much larger per-"^
downward and toward the opposite centage of cases may be permanently
side. The phorometers of Stevens cured by the wearing of glasses, and
and others are mostly based on this proper orthoptic exercises. Comitant
principle. strabismus in adults, if intermittent,
The Maddox rod-test is really one may be cured by correcting lenses ;
in which one image is so distorted as but if constant will generally require
to prevent its fusion with that of the an operation. All cases of comitant
other eye. A very strong cylinder, squint are capable of relative cure by
either a piece of a small glass rod or operations judiciously chosen and
a concave cylinder of similar strength, skillfully performed, except such as
is placed before one eye. Seen through suffer from diplopia when the image
this, a point of light appears as a long is thrown on the fovea of the de-
streak. The other eye being left un- viating eye. The exactness and
covered, the streak appears in ortho- permanence of the cure depend on
phoria to pass through the point of the possibility of establishing true
light. But in hetcrophoria the streak binocular vision.
appears to pass to one side of the point Paralytic strabismus may be cured
of light. The side on which it appears by cure of the paralysis causing it.
to pass indicates the variety of latent If the paralysis be weW marked, re-
squint, and the distance of the streak covery will probably require at least
from the light, or the strength of prism six weeks. Complete paralysis that
required to cause it to pass through has lasted many months without de-
the light, shows the amount or degree cided improvement is likely to be
of the tendency to deviation. permanent. After incomplete recov-
The method of measuring the ery^ from paralysis of one of the eye-
amount of strabismus by prisms is muscles, operative treatment may
apphcable in all cases of manifest or give practical relief. Strabismus due
latent squint in which the patient can to a permanent complete paralysis
recognize binocular diplopia. It con- cannot be cured ; but may be made
sists in placing before the eyes such less noticeable or troublesome by
prisms as will causa the true and false prisms or appropriate operations,
images to coincide in spite of the stra- The diplopia of comitant strabismus
bismus. Such prisms will substitute usually ceases to be annoying or dis-
binocular vision for diplopia; and will appears entirely. Diplopia from pa-
do away with all movements of devia- ralytic squint, except when it has
tion and recovery, or of apparent occurred in childhood, will commonly
movement of the point of light looked last throughout life,
at, when the cover is shifted from one TREATMENT. — In everv case of
eye to the other in rapid alternation. strabismus, any obstacle to easy
PROGNOSIS. — For apparent binocular vision, in the form of an
squint due to displacement of the error of refraction, should be re-
cornea, we can do nothing except at moved bv the constant wearing of
the cost of binocular vision. Comi- correcting lenses. All eye-work or
tant strabismus is outgrown in a few habits tending to cause or perpetuate
cases in early childhood without the strabismus should be discon-
i
i
404
STRABISMUS (JACKSON).
tinued. If due to an ocular palsy this
should be treated. If of recent
origin, orthoptic exercises should be
resorted to. If the strabismus be
constant and of long standing, and
not much influenced by the wearing
of correcting lenses, and if throwing
the image on the fovea of the deviat-
ing eye when the fixing eye is also
in use does not cause diplopia, an
operation should be done.
Correction of any error of refrac-
tion is the first step. It may be done
at a very early age. Children 2 years
old can have their correcting lenses
determined by skiascopy and will
readily and glady wear them, if they
are much needed and accurately ad-
justed. The avoidance of injurious
use of the eyes may require the use
of a mydriatic to suspend all effort
of accommodation. Or it may in-
clude, for monolateral strabismus,
the covering of the fixing eye, or the
placing of it alone under the influ-
ence of a mydriatic, to compel the
patient to use the eye he would
otherwise allow to deviate.
Orthoptic exercises include : the
viewing of special diagrams and pic-
tures through the stereoscope; the
exercise of muscles that are relatively
inefficient by placing prisms so that
they will bring the true and false
images close enough together for the
muscles to complete their fusion, in
actual squint, or so that the prism
will require special exertion to "over-
come" it in latent squint. They also
include the use of "fusion tubes,"
which are applied one to each eye
and turned so that the eyes can just
fuse the minute openings in the dis-
tal ends of the tubes. Also the em-
ployment of the "reading-bar," an
opaque bar supported above the page
in such a way that it cuts off a por-
tion of each line from one eye, and
another portion from the other eye,
compelling fixation with both eyes
for the reading of each line. The
diploscope of Remy and diaphragm
test of Harman allow letters to be
seen through an opening. By vary-
ing the distance, position or size of
the openings, they can be used for
orthoptic training. Under this head
also comes the practice of exercising
convergence, by fixing on a point that
is gradually made to approach the
eye until the requirement of conver-
gence becomes too great to be sus-
tained. Or the practice of viewing
through strong prisms, turned with
the base toward the nose, a point
which starts near the eyes, but is
slowly withdrawn until the limit of
the power of abducting the eyes is
reached.
Operations on the ocular muscles
are of three kinds : tenotomy, de-
signed to lessen the influence of an
overacting muscle ; advancement, de-
signed to increase the influence of a
muscle relatively weak or inefficient;
and lateral displacement which may
cause one muscle to perform the
function of another muscle that is
congenitally defective or paralyzed.
Tenotomy is the simplest and least
formidable operation. But it tends
to lessen the total mobility of the eye,
and if injudiciously performed may
cause the eye to deviate in the op-
posite direction. Advancement is a
more difficult and serious undertak-
ing, but it does not lessen the mobil-
ity of the eye, and is not likely to
cause a strabismus of the opposite
kind. Lateral displacement of the
insertion of the tendon of a rectus
muscle is to be planned to meet the
STRABISMUS (JACKSON).
405
%' {
-iV
■<::e 1
indications of the particular case,
after careful consideration of all the
movements that will be influenced
by it.
For tenotomy the eye is cocainized
and the conjunctiva seized over the
insertion of the muscle to be operated
upon, and incised with a snip of the
scissors. The incision may be small
— 4 or 5 millimeters (subconjunctival
method) — or large — 8 or 10 millime-
ters (open method). The subconjunc-
tival tissue is then similarly raised and
snipped through, down to the sclera.
A strabismus-hook is now introduced
beneath the tendon, and made to lift
it from the sclera. One blade of fine,
but blunt-pointed, scissors is then
slipped beneath the tendon close to
its insertion, and the tendon is di-
vided at this point by the scissors.
For a partial tenotomy a small con-
junctival incision is made over the
center of the tendon at its insertion,
after which the tendon itself is
caught up with the forceps and
snipped through. Then, through the
small central opening so made, a
small strabismus-hook is introduced
and the tendon divided on either side,
until only a thin margin remains,
which can be readily stretched with
the hook. The subsequent stretching
of these margins permits a slight re-
traction of the whole tendon. Partial
tenotomy is also done by dividing a
part of the width of the tendon at its
insertion, and, the remainder of the
fibers farther back, making two or
three cuts that each divide only a
portion of the fibers of the tendon,
but together divide all of the fibers.
To increase the efi'ect of a ten-
otomy by permitting a greater re-
traction of the divided tendon, its
lateral connections may be divided
and the tendon thus isolated from all
its attachments that indirectly con-
nect it with the eyeball. Extended
tenotomy divides, not only all the
fibers of one rectus, but also the ad-
joining fibers of the recti on either
side of it. Thus, for convergent stra-
])ismus after dividing the tendon of
the internal rectus, the nasal half or
three-fourths of the tendons of the
superior rectus and inferior rectus
may be divided, when these still hold
the eye in a position of excessive
convergence. In this way the efifect
of a tenotomy may be more than
doubled. Another measure is to keep
the eye forcibly rotated away from
the tenotomized muscle by what is
called the thread-operation. In this
a suture is inserted near the divided
muscular insertion and made fast
over a roll of adhesive plaster so as
to keep the eye in position for the
divided tendon to slip as far back as
possible.
Advancement of the ocular muscles
is done in several different ways.
The natural insertions of the recti
tendons are from 5 to 9 millimeters
back from the margin of the cornea.
The common operation is done
through a free incision parallel to
the corneal margin. The tendon is
isolated, raised from the globe, its
insertion divided, and brought for-
ward to or near the corneal margin,
where it is fixed by sutures. The
sutures may be passed through firm
scleral tissue or may only include
conjuctiva and subconjunctival tis-
sue, one passing above and another
below the cornea. The former give
the more certain and definite attach-
ment, but the latter are easier to in-
sert. When a marked deviation is to
be corrected, advancement of one
-
404
STRABISMUS (JACKSON).
tinued. If due to an ocular palsy this
should be treated. If of recent
origin, orthoptic exercises should be
resorted to. If the strabismus be
constant and of long standing, and
not much influenced by the wearing
of correcting lenses, and if throwing
the image on the fovea of the deviat-
ing eye when the fixing eye is also
in use does not cause diplopia, an
operation should be done.
Correction of any error of refrac-
tion is the first step. It may be done
at a very early age. Children 2 years
old can have their correcting lenses
determined by skiascopy and will
readily and glady wear them, if they
are much needed and accurately ad-
justed. The avoidance of injurious
use of the eyes may require the use
of a mydriatic to suspend all effort
of accommodation. Or it may in-
clude, for monolateral strabismus,
the covering of the fixing eye, or the
placing of it alone under the influ-
ence of a mydriatic, to compel the
patient to use the eye he would
otherwise allow to deviate.
Orthoptic exercises include : the
viewing of special diagrams and pic-
tures through the stereoscope ; the
exercise of muscles that are relatively
inefficient by placing prisms so that
they will bring the true and false
images close enough together for the
muscles to complete their fusion, in
actual squint, or so that the prism
will require special exertion to "over-
come" it in latent squint. They also
include the use of "fusion tubes,"
which are applied one to each eye
and turned so that the eyes can just
fuse the minute openings in the dis-
tal ends of the tubes. Also the em-
ployment of the "reading-bar," an
opaque bar supported above the page
in such a way that it cuts oflf a por-
tion of each line from one eye, and
another portion from the other eye,
compelling fixation with both eyes
for the reading of each line. The
diploscope of Remy and diaphragm
test of Harman allow letters to be
seen through an opening. By vary-
ing the distance, position or size of
the openings, they can be used for
orthoptic training. Under this head
also comes the practice of exercising
convergence, by fixing on a point that
is gradually made to approach the
eye until the requirement of conver-
gence becomes too great to be sus-
tained. Or the practice of viewing
through strong prisms, turned with
the base toward the nose, a point
which starts near the eyes, but is
slowly withdrawn until the limit of
the power of abducting the eyes is
reached.
Operations on the ocular muscles
are of three kinds : tenotomy, de-
signed to lessen the influence of an
overacting muscle; advancement, de-
signed to increase the influence of a
muscle relatively weak or inefficient ;
and lateral displacement which may
cause one muscle to perform the
function of another muscle that is
congenitally defective or paralyzed.
Tenotomy is the simplest and least
formidable operation. But it tends
to lessen the total mobility of the eye,
and if injudiciously performed may
cause the eye to deviate in the op-
posite direction. Advancement is a
more difficult and serious undertak-
ing, but it does not lessen the mobil-
ity of the eye, and is not likely to
cause a strabismus of the opposite
kind. Lateral displacement of the
insertion of the tendon of a rectus
muscle is to be planned to meet the
H'-
STRABISMUS (JACKSON).
405
r;.
^itn
y:rt.
'ttSt
indications of the particular case,
after careful consideration of all the
movements that will be influenced
by it.
For tenotomy the eye is cocainized
and the conjunctiva seized over the
insertion of the muscle to be operated
upon, and incised with a snip of the
scissors. The incision may be small
— 4 or 5 millimeters (subconjunctival
method) — or large — 8 or 10 millime-
ters (open method). The subconjunc-
tival tissue is then similarly raised and
snipped through, down to the sclera.
A strabismus-hook is now introduced
beneath the tendon, and made to lift
it from the sclera. One blade of fine,
but blunt-pointed, scissors is then
slipped beneath the tendon close to
its insertion, and the tendon is di-
vided at this point by the scissors.
For a partial tenotomy a small con-
junctival incision is made over the
center of the tendon at its insertion,
after which the tendon itself is
caug"ht up with the forceps and
snipped through. Then, through the
small central opening so made, a
small strabismus-hook is introduced
and the tendon divided on either side,
until only a thin margin remains,
which can be readily stretched with
the hook. The subsequent stretching
of these margins permits a slight re-
traction of the whole tendon. Partial
tenotomy is also done by dividing a
part of the width of the tendon at its
insertion, and, the remainder of the
fibers farther back, making two or
three cuts that each divide only a
portion of the fibers of the tendon,
but together divide all of the fibers.
To increase the efifect of a ten-
otomy by permitting a greater re-
traction of the divided tendon, its
lateral connections may be divided
and the tendon thus isolated from all
its attachments that indirectly con-
nect it with the eyeball. Extended
tenotomy divides, not only all the
fibers of one rectus, but also the ad-
joining fibers of the recti on either
side of it. Thus, for convergent stra-
bismus after dividing the tendon of
the internal rectus, the nasal half or
three-fourths of the tendons of the
superior rectus and inferior rectus
may be divided, when these still hold
the eye in a position of excessive
convergence. In this way the efifect
of a tenotomy may be more than
doubled. Another measure is to keep
the eye forcibly rotated away from
the tenotomized muscle by what is
called the thread-operation. In this
a suture is inserted near the divided
muscular insertion and made fast
over a roll of adhesive plaster so as
to keep the eye in position for the
divided tendon to slip as far back as
possible.
Advancement of the ocular muscles
is done in several different ways.
The natural insertions of the recti
tendons are from 5 to 9 millimeters
l)ack from the margin of the cornea.
The common operation is done
through a free incision parallel to
the corneal margin. The tendon is
isolated, raised from the globe, its
insertion divided, and brought for-
ward to or near the corneal margin,
where it is fixed by sutures. The
sutures may be passed through firm
scleral tissue or may only include
conjuctiva and subconjunctival tis-
sue, one passing above and another
below the cornea. The former give
the more certain and definite attach-
ment, but the latter are easier to in-
sert. When a marked deviation is to
be corrected, advancement of one
c'. *"*
406
STRAMONIUM.
muscle is accompanied by tenotomy
of its direct antagonist. Sometimes a
portion of the advanced tendon is cut
off (muscle-shortening). Sometimes
the tendon is not divided at its
insertion, but is folded upon itself,
and so shortened (tendon-tucking).
Some operators do not attempt to
isolate the tendon, but pass sutures
through the conjunction and the cap-
sule of Tenon. This is spoken of as
capsular advancement.
After-treatment. — After tenotomy
it is usually best not to bandage the
eye, or only for a day or two. After
advancement some operators keep
both eyes bandaged for a week or
more. Generally the eyes should be
brought into use together as soon as
practicable, and correcting lenses
worn constantly, and such use made
of the eyes, or such orthoptic exer-
cises resorted to, as will favor the
perfecting of binocular movements
and binocular vision.
Prisms, aside from their use as
means of securing orthoptic exercise
and training, are of value in reliev-
ing some of the consequences of
strabismus. In actual lateral squint
they are scarcely applicable, because
the squint is usually of such high de-
gree that the necessary prism would
be too thick and heavy to wear. But
for vertical strabismus, or for latent
squint, they are often of great prac-
tical service. The apex, or thin part,
of the prism is turned in the direc-
tion in which the eye turns or tends
to turn. Thus, for right hyperphoria
the prism for the right eye would be
turned with its edge up, its base
down. Turned in this way the prism
does not "correct," but rather "per-
mits" the deviation. But the prism
removes the unpleasant effects of
such a deviation, such as diplopia, or
the strain of the ocular muscles nec-
essaiy to preserve parallelism of the
visual axes. Prisms may be valuable
aids in establishing binocular vision
after an operation on the eye-muscles
or during recovery from paralysis of
one or more of the ocular muscles.
Edward Jackson,
Denver.
STRAMONIUM.-Stramonium,
U. S. p. (Thorn-, Devil's-, or Mad- apple,
Stink-weed, Jamestown or Jimson weed,
or lily, Devil's trumpet) is the dried
leaves of Datura stramonium (fam., Sol-
anaceje), containing- not less than 0.25 per
cent, of mydriatic alkaloids. The plant,
native in Asia, is exceedingly common
and abundant in the United States, in rich
ground, about barn-yards, lumber-yards,
and other waste places. The leaves should
be gathered when the plant is in full
bloom and dried carefully in the shade.
The plant is an annual, with green stem,
coarse, rank-smelling leaves, and large,
bell-shaped, white or purple flowers.
When the seeds are eaten by children
poisoning- occurs, sometimes with fatal
results. Poisoning has also occurred
through drinking an infusion of the
leaves. Its alkaloid, formerly called "da-
turine," is now known to be identical with
other solanaceous alkaloids, hyoscyamine,
or atropine, or a mixture of the two,
chiefly hyoscyamine. A little hyoscine
is also probably present. The alkaloid
occurs as colorless needles, soluble in
alcohol, ether, and chloroform. The hy-
drochloride and sulphate occur as white
crystals, soluble in water and in alcohol.
All the preparations are now made from
the leaves.
PREPARATIONS AND DOSES.—
Straiiiotiiu)ii, U. S. P. (leaves; folia '90)
Dose, 1 to 3 grains (0.06 to 0.2 Gm.).
Extractujii sirainonii, U. S. P. (solid ex-
tract). Dose, ^ to 14 grain (0.008 to
0.016 Gm.).
Fluidcxtractum straiiionii, N.. F. (fluid-
extract). Dose, 1 to 3 minims (0.06 to
0.2 c.c).
T'nictura straiiionii, U S. P. (tincture,
STRONTIUM.
407
10 per cent, of leaves, or 0.025 per cent,
alkaloids). Dose, 10 to 30 minims (0.6 to
2 c.c).
Unguentum stranionii, U. S. P. (oint-
ment, 10 per cent, of extract).
PHYSIOLOGICAL ACTION. — The
physiological action of stramonium and
its alkaloids is almost identical with that
of belladonna and atropine. Specimens
containing a small quantity of hyoscine
are slightly more sedative to the central
nervous system. In poisonous doses they
produce the same symptoms and require
the same treatment. (See Belladonna.)
THERAPEUTIC USES.— Stramonium
is a favorite remedy in spasmodic asthma;
it is used by smoking the dried leaves in
a pipe or cigarette, either alone or mixed
with cubebs, sage, and other drugs, or
inhaling the fumes of the burning leaves
or ignited powder. A very good mixture
for igniting and inhaling is one of 3 parts
of potassium nitrate, lyi parts of potas-
sium chlorate, 3 parts of broken, or pow-
dered, stramonium leaves, and 1 part of
ipecac; moisture may be added if cones
are desired, which latter must be dried
before ignition.
The ointment is used to relieve the
pain of muscular rheumatism, neuralgia,
and hemorrhoids and fissure. In the lat-
ter the ointment will relieve both the pain
and tenesmus. The ointment is a mild
anodyne application in itching and burn-
ing affections of the skin. The alkaloid
may be substituted for atropine as a
mydriatic. W.
STRONTIUM.— Strontium is an al-
kali metal having a yellow color. Like
the other alkali metals, it oxidizes quickly
on exposure to the air, and must be kept
under naphtha, benzene, or other liquid
free from, oxygen. Strontium forms salts
with the acids and with bromine, chlorine,
fluorine, etc.
PREPARATIONS AND DOSE.—
Three salts are official: —
Sirontii broiiiiduiii, U. S. P. (strontium
bromide) [SrBro], occurring in hexag-
onal, colorless crystals, very deliquescent,
and having a bitter, saline taste. It is
freely soluble in water and in alcohol.
Dose, 10 to 30 grains (0.6 to 2 Gm.); aver-
age, 15 grains (1 Gm.).
Strontii iodidum, U. S. P. (strontium
iodide) [Srl2], occurring in colorless or
faintly yellow hexagonal plates, having a
bitter, saline taste. It is freely soluble in
water and in alcohol. Dose, 5 to 30 grains
(0.3 to 2 Gm.); average, 7^ grains (0.5
Gm.).
Strontii salicylas, U. S. P. (strontium
salicylate) [ (CcH4 . OH . COO)2Sr], oc-
curring as a white, crystalline powder
soluble in 18 parts of water and in 66
parts of alcohol. Dose, 5 to 30 grains
(0.3 to 2 Gm.); average, 10 grains (0.6
Gm.).
Among the unofficial salts of strontium
more or less frequently used are: —
Strontium lactate [(CH3.CHOH.-
COO)2Sr], occurring as a white, granular
powder, with a slightly bitter taste, solu-
ble in alcohol, in 4 parts of cold and in
0.5 part of boiling water. Dose, 10 to 40
grains (0.6 to 2.5 Gm.).
Strontium nitrate [Sr(N03)2], occur-
ring in colorless crystals, soluble in 1.4
parts of water and slowly in alcohol.
Dose, 5 to 15 grains (0.3 to 1 Gm.).
Strontium peroxide, occurring as a mix-
ture of true strontium peroxide [Sr02]
and a small proportion of strontium hy-
droxide [Sr(OH)2]. It occurs as a fine,
white, tasteless powder which, on con-
tact with water, is gradually decomposed
into hydrogen peroxide and strontium
hydroxide, the former being further de-
composed Ijy the latter with liberation
of oxygen. Dilute acids decompose it to
form a solution of hydrogen peroxide.
Used externally as a dusting powder and
in ointments.
PHYSIOLOGICAL ACTION. — The
strontium salts do not, in ordinarj'
amounts, produce any distinct effect upon
the human sj'stem. In animal experi-
ments, enormous amounts of strontium
salts, continuously given, cause inflamma-
tion of the gastrointestinal mucosa. Ac-
cording to some clinical observers, stron-
tium salts in therapeutic dosage tend to
improve general body nutrition. If this
is true, the effect may be due to the pro-
duction of a mild active hyperemia in tlie
intestine, favoring proper absorption and
assimilation. II. C. Wood saw reason for
i)elicving that strontium acts as a feeble
antiseptic in the alimentary canal and acts
410
STROPHANTHUS (SAJOUS).
of bitter taste, soluble in 100 parts
of cold water, easily soluble in hot
water, soluble in 30 parts of alcohol,
slightly solul)le in ether and in chlo-
roform. Dose, ^>c() to %5 grain
(0.00025 to 0.001 Gm.).
PHYSIOLOGICAL ACTION.—
The characteristic effects of stro-
phanthus are exerted upon the cir-
culation, and are in most respects
identical with those of digitalis. The
heart muscle is strongly excited and
toned up, the rate of heart action is
slowed through central as w'ell as
peripheral vagus stimulation, and the
output of the organ is augmented
owing to the more complete filling of
the left ventricle during diastole and
emptying during systole. In the hy-
podynamic heart the force of con-
traction of both auricles and ven-
tricles is greatly increased (A. J.
Clark). As with digitalis, large doses
of strophanthus tend to impair con-
duction of the contractile impulse
from auricles to ventricles. For ad-
ditional details as to the action of
strophanthus on the heart the reader
is referred to the article on Digitalis.
Though a vasoconstrictor, like digi-
talis, strophanthus acts less strongly
in this respect than the latter drug.
Neither remedy, as a matter of fact,
exerts in ordinary therapeutic doses
a vasoconstrictor effect sufficient to
induce a general rise in blood-pres-
sure. Of greater significance is the
difference in susceptibility of the ves-
sels in different organs to the drugs.
Thus, experimentally it has been de-
termined that, with a certain dose of
strophanthus, the real vessels can be
dilated while the extensive mesenteric
vascular system is simultaneously
constricted — a condition clearly favor-
ing diuresis, which, as in the case of
digitalis, is a characteristic therapeu-
tic effect of the remedy in patients
with cardiac edema. Strophanthus
is held to be less likely than digitalis
to constrict the coronary vessels of
the heart in full doses; this has been
suggested as an advantage of the
drug over digitalis in certain cases.
A salient difference between stro-
phanthus and digitalis is that relative
to rapidity of action, the former being
far more speedily absorbed from the
alimentary tract. The eft'ect of stro-
phanthus in reducing the pulse rate
appears in half an hour, and upon in-
terrupting its administration its action
disappears more quickly than with
digitalis. The action of the drug
when taken by mouth is, however,
distinctly less certain than that of
digitalis — a difference ascribed in part
to greater susceptibility of the con-
tained strophanthin to impairment by
the digestive juices than in the case
of the digitalis glucosides.
Union of absorbed strophanthin
with the heart tissues is believed to
be much looser than that of the digi-
talis principles. Elimination of the
drug through the kidneys is more
rapid, and cumulative effects are
much less likely to occur.
Strophanthin has been shown to be
a direct stimulant of intestinal muscle
(Bastedo), and the drug is by some
believed to be more active in causing
diarrhea than digitalis. It also pos-
sesses local anesthetic properties and
acts as a mydriatic when applied to
the cornea.
In animal experiments strophan-
thus proves more toxic to the heart
than digitalis, producing cardiac ar-
rest in doses many times smaller
than does digitalis. Clinically this
difference is greatly reduced owing to
STROPHANTHUS (SAJOUS), 411
the less perfect absorption of stro- in the strength of the pulse in from
phanthus. A given dose of tincture one-half to one hour, the effects last-
of strophanthus remains, however, ing from 4 to 8 hours. The full
about twice the equivalent of an action of the drug on the heart, upon
equal amount of tincture of digitalis, repeated ingestion, is often developed
UNTOWARD EFFECTS AND in 24 to 36 hours. According to some
POISONING. — The untoward eft'ects investigators, strophanthus produces
of strophanthus are the same as with less vasoconstriction in the splanch-
DiGiTALis (g. z'.), consisting chiefly nic (abdominal) area than digitoxin
of nausea and vomiting, diarrhea, — the chief principle of digitalis,
signs of renal irritation, and changes Gottlieb and Magnus have apparently
in the rhythm of the heart. Poison- shown that, in contrast to digitoxin,
ing by massive doses, except in ex- strophanthus produces no constric-
perimental work in animals, is rare, tion of the coronary vessels — an inl-
and is characterized by excessive portant point where the production
vagus action and cardiac oppression, of cardiac hypertrophy is desired
sometimes followed by excessive car- (Hatcher).
diac irritability and increased heart Tincture of strophanthus is ap-
rate, prostration, dyspnea, and death proximately given in 10- to 16- drop
by combined circulatory arrest and (about 5 to 8 minim) doses, a medi-
respiratory failure. Corin (1908) has cine dropper being used to measure
shown that poisonous amounts of the amount into water in a tumbler,
strophanthus cause an extreme con- Where it is desired to order tea-
striction of the pulmonary blood- spoonful doses, a little glycerin, ac-
vessels. cording to Gordon Sharp, should be
The treatment of poisoning by added, to prevent precipitation and
massive doses of strophanthus con- adhesion of the active principle to the
sists chiefly in the use of emetics, sides or bottom of the bottle, e. g. : —
gastric lavage through a stomach- i^ Tincturcc strof^hanihi... f3j (4 c.c).
tube, the application of a mustard Glycerini fSij (8 c.c).
plaster to the precordium, the admin- ^1^(^ mcnthce piperita;,
istration of atropine to block cardiac ^- ^- ^^ ^^'^^ (48 c.c).
inhilMtion, and, if necessary, the use . ^- ^ig-: One teaspoonful three or four
, , , , i .• times a day.
of stimulants, external heat, and arti-
ficial respiration. An extract of strophanthus (1 in 2)
THERAPEUTICS. — The indica- is sometimes useful in doses of Ya to
tions for the use of strophanthus are 1 grain (0.015 to 0.06 Gm.) in pill
much the same as those for digitalis, form where the tincture is rejected; it
It is conceded, however, that the acts less rapidly but more persist-
cffect of strophanthus is less certain cntly than the tincture.
and less lasting, though more prompt Strophanthus will not in all cases
in onset and less cumulative, than prove as beneficial clinically as digi-
that of the more widely used drug, talis, but where digitalis has failed,
In cardiac weakness a single full dose or has had to be discontinued for any
of strophanthus will usually produce reason, it has often shown itself a
a fall in the frequency and an increase valuable substitute. Wadleigh recom-
412
STROPHANTHUS (SAJOUS).
mends strophanthus especially in car-
diac weakness in aged people, in the
vertigo of the aged due to cerebral
anemia or poor circulatory balance, in
angina pectoris, in anemia in general,
or chlorosis, when accompanied by
cardiac weakness, and in the "irri-
table heart," palpitating on slight
exertion, with precordial pain, weak,
rapid pulse, but no organic cardiac
disease.
Strophanthus has been credited,
perhaps wrongly, with diuretic prop-
erties greater than those of digitalis,
the drug being advised in preference
to the latter in pronounced anasarca
and pulmonary edema the result of
cardiac disease. In renal affections
with secondary failure of the heart,
it is also a valuable remedy.
According to Sharp (1913) stro-
phanthus has an analgesic action on
vital nerve centers, and is therefore
of particular value in the breathless-
ness and general distress experienced
in many forms of heart disease. In
such conditions it must be given in
maximum doses and repeated every
2 hours till relief is obtained.
In exophthalmic goiter, especially
with cardiac enfeeblement, strophan-
thus has been highly recommended.
Ferguson advises its use in this con-
dition in doses of 8 minims (0.5 c.c.)
of the tincture at first, later grad-
ually increased.
Because of its more prompt action
strophanthus has often been substi-
tuted for digitalis in cases of acute
heart-failure, of whatever origin. As
emphasized, however, by Hatcher,
absorption of strophanthus or stro-
phanthin when used orally is rather
uncertain. Excretion of the rem-
edy being, moreover, relatively rapid,
strophanthin may at times fail to
be present in the circulation in
sufficient amount to exert a power-
ful influence on the heart.
Hatcher considers the official dose of
strophanthin, intended for oral use, en-
tirely too small. For these reasons intra-
muscular and intravenous use of strophan-
thin has been advised and come into wide-
spread popularity. According to Hatcher
and Bailey, 0.0003 to 0.0005 Gm. (i/ooo to
^120 grain) of ouabain (gratus or "crystal-
lized" strophanthin) in sterile (boiled)
salt solution may be injected deeply into
the gluteal muscle once in 24 hours with-
out fear of abscess formation or other
untoward actions. In urgent cases, how-
ever, intravenous injection is generally
preferred.
Frankel, after practical experience
in numerous cases, highly recom-
mends repeated intravenous stro-
phanthin injections when digitalis is
not borne or has lost its effect in
chronic heart disease. He has given
as many as 85 such injections, rang-
ing in dosage from 0.00025 to 0.001
Gm. (i-^.eo to %5 grain) to a single
case of chronic valvular defect and
myocardial degeneration within a
year and a half, with excellent re-
sults. Good effects have also been
obtained in the cardiac insufficiency
of chronic nephritis with contracted
kidneys, in the hepatic type of
chronic heart disease, and in the
acute heart weakness of infectious
diseases or acute pericarditis, and in
pulmonary edema with low blood-
pressure. According to Vaquez and
Leconte, strophanthin, in urgent
cases, acts best in primary myocar-
ditis without valvular lesions. Truel-
sen holds that the first injection of
strophanthin should not exceed 0.5
mg. (^20 grain). The lower initial
dose must be employed if the injec-
tion follows digitalis medication, and
3 or 4 days be allowed to intervene.
STROPHANTHUS (SAJOUS).
413
For intravenous injection the offi-
cial type of strophanthin — amorphous
or Boehring-er strophanthin — is ob-
tainable as a sterile 1 : 1000 solution
in ampoules each containing 0.001 Gm.
(%5 grain) of the active principle. The
initial dose is often 0.0005 Gm. (^30
grain), soon increased, if well borne,
to 0.00075 and 0.001 Gm. {%r, and i/os
grain). The 0.00075-Gm. dose is often
sufficient to give brilliant results,
dyspnea rapidly subsiding, the pulse
becoming fuller, regular, diuresis set-
ting in and sleep pr'omptly following.
An increase in amplitude of the pulse
(pulse pressure) ranging from 20 to
100 per cent, is the best objective cri-
terion of the satisfactory action of
the drug (Williamson). In adminis-
tering an injection, the patient should
be placed on his back, and care should
be taken to make sure that the needle
is actually in the vein, as the gluco-
side, if it comes in contact with the
surrounding tissues, will cause much
pain and possibly thrombosis. Before
the piston is pushed home it should
be withdrawn until a drop or two of
blood enters the syringe. The injec-
tion should, furthermore, be made
slowly, the drug being so toxic to the
heart when it reaches it in excessive
concentration. In a few cases such
injections have been followed by dan-
gerous symptoms and even death, but
these untoward results are ascribed
by some to the administration of digi-
talis by mouth shortly before the -in-
travenous strophanthin therapy, sud-
den intoxication by an excess of digi-
talis bodies resulting. Care should
be taken to allow several days or,
better, a week to elapse between oral
digitalis treatment — even when in-
effective— and intravenous strophan-
thin medication. Strophanthus, in-
travenously, according to Schleiter,
has a decisive effect in all cases of
pulsus irregularis perpetuus. He also
found it beneficial in paroxysmal
tachycardia.
Gratus strophanthin (ouabain) may
be substituted for the official stro-
phanthin. According to most observ-
ers the dosage with this product
should be slightly smaller than with
the other, though according to Johan-
nessohn and Schaechtl (1914) the
intravenous dose of crystalline stro-
phanthin (Thoms) may be given in-
travenously in doses twice as large
as the other strophanthin, and is
rapidly effective when given by
mouth in doses 3 or 4 times as large.
Headache, dizziness, nausea, and
vomiting have at times followed in-
travenous injection of either type of
strophanthin.
Ouabain used from ampules contain-
ing 0.0005 Gm. (^30 grain) in a
1:4000 solution in sterile saline. The
dose injected ranged from 1 to 2 c.c.
(16 to 32 minims), intramuscularly or
intravenously. Immediate improve-
ment of blood-pressure was noted.
Reduction of a tachycardia or restora-
tion of a bradycardia toward the nor-
mal rate are favorable indications.
In cardiac hypertrophy and dilatation
a considerable reduction in the rel-
ative cardiac dullness can be ex-
pected, but this does not imply a
constant therapeutic result. Redup-
licated sounds and extrasystoles may
disappear, but cardiac murmurs are
not liable to change in character. E.
Zueblin (Med. Rec, Aug. 31, 1918).
L. T. DE M. Sajous,
Philadelphia.
STRUMA. See Goiter.
STRYCHNINE. See Nux
Vomica.
STYE. See Eyelids Diseases of :
Hordeolum.
414
SUGGESTION-THERAPY; HYPNOTHERAPY (TAYLOR).
STYPTICIN. See Cotarnine.
STYPTOL. See Cotarxixe.
SUBPHRENIC ABSCESS. See
Liver, Diseases of.
SUGGESTION-THERAPY;
PSYCHOTHERAPY; HYPNO-
THERAPY (HYPNOTISM).
—PSYCHOTHERAPY.
A cursory survey of the present
status of the question will suffice to
afford a general idea of its purpose.
First of all, it is necessary to obtain a
clear conception of the principles un-
derlying the classification of diseases
of the nervous system. Smith E.
Jelliffe and William A. White (Jour.
Amer. Med. Assoc, Mar. 11, 1916)
have recently furnished us a clear
summary of these principles : —
"For pragmatic purposes, . . . the
nervous system may be divided into
. three levels of activity: the vege-
tative or physicochemical, the sensorimotor,
and the psychic or symbolic. . . . It is
thoroughly well established that lying
back of consciousness is a much larger, a
much more important territory which fur-
nishes psychic motivation of conduct, and,
in fact, that conscious processes as they
are known to the individual are largely, if
not altogether, determined by what lies in
this region — the unconscious.
"With the help of the hypothesis of the
unconscious, ... it has come to be
recognized that the psyche has its em-
bryology and its comparative anatomy — in
short, its history — just as the body has,
and in precisely the same way as in the
care of the body this history has to be
utilized before we can understand it.
"So long as the unconscious failed to be
recognized, just so long was the gap be-
tween so-called body and so-called mind
too wide to be bridged, and so there arose
the two concepts, body and mind, which
gave origin to the necessity of defining
their relations. Consciousness covers over
and obscures the inner organs of the
psyche, just as the skin hides the inner
organs of the body from vision. But just
as a knowledge of the body first became
possible by the removal of the skin and
the revealing of the structures that lay
beneath, so a knowledge of the psychic
first became possible when the outer cov-
ering of consciousness was penetrated and
what lay at greater depth was revealed.
As soon as this was done, the wonderful
history of the psyche began to give up its
secrets, and the distinction between body
and mind began to dissolve, until now it
has come to be considered that the psyche
is the end-result in an orderly series of
progressions in which the body has used
successively more complex tools to deal
with the problems of integration and
adjustment."
There exists, in normal persons,
a direct, clear, instantaneous inter-
communication between that part of
the mind which receives impressions
and that which is conscious of them.
When the communication is normal
between the observing, the receptive,
reasoning mind and the believing,
deliberative or reflective mind, then
alone is there right control of
thinking, feeling, and doing. When
this communication is interrupted or
broken, or co-ordination is imper-
fect, then begins hesitation, doubt,
fear, depression, incompetency, or
mental anguish. Mental distress or
indecision is due not to lack of nerv-
ous activity so much as to waste,
to prodigality of effort, bad habits,
inexact methods. This whirl of in-
effective forces being, moreover, ex-
hausting, there arise asthenias or
weaknesses. The mind then sur-
renders and no longer fights; so
brain control is vitiated or lost, and
we have the condition known as
psychasthenia.
The psychopathic, neurotic, or the
psychasthenic person, then, is one in
whom confused feelings, incomplete
actions and reactions predominate.
SUGGESTION-THERAPY; HYPNOTHERAPY (TAYLOR). 415
When attempting to pursue an idea Psychasthenia, mental weakness in
the elements of decision are perceived its varied forms and causation, is
vaguely; frantic efforts are often often due to lack of correct early
made, producing exhaustion, ineffec- training, development,- or conserva-
tiveness, alarm, and despair. An un- tion, and presents a group of puzzling
controlled mind squanders uselessly and baffling phenomena. There fol-
an enormous amount of force. Force lows a host of irrepressible impulses,
must be conserved ; otherwise, dis- ideas, persistent morbid questionings,
order or disease in tissue follows, apprehensions, dift'used emotional
The will is not a fountain of force disturbances, anomalies of perception
so much as a toolholder for the lathe, or character and action, shown in
to direct and put the power where vacillations, insistent perplexities, re-
and when it will do the most good. ligious fears, obsessions, and the like.
Many ailing persons become so How to aid the sufferers?
merely because of dwindling in capa- The great desideratum is to put the
bihties for reaction to environment patient in the way of realizing ex-
and of unawareness of their latent actly the cause of wretchedness,
capabilities. They often possess acute where it may lead, and to set his feet
perceptions and clear intuitions, on the right road. This is the aim of
which, properly controlled, would psychotherapy. The individual psy-
place them above the average of chotherapeutist studies the problem,
efficiency. If their consciousness is determines, by precise methods and
allowed to become or remain inert, with full knowledge of analogous in-
passive, then will external influences stances, just what the condition ex-
turn aside the force of wholesome de- hibits and requires, and then applies
cision, mar judgment, induce doubts, the needful measures. The purpose
Psychasthenics or psychopathies lack of psychotherapy, in short, is to re-
confidence because of previous disap- duce a disorderly, inefficient inind to
pointments in determining or carry- an orderly, well-balanced, efficient one
ing out purposes ; hence fear grows, by mental training,
blunders multiply, distress or despair Psychotherapeutic Technique. —
follows. Evil temper, sullenness, de- Often enough, all that is needed for
ceit, selfishness, and all the other conspicuous success in dealing with
invalid uglinesses are the outcome of minor psychoses is the encouraging
abnormalities in volitional poise, in or explanatory word spoken in sea-
deciding what to do and what not to son. It is both easy and eminently
do. proper for clergymen to counsel hope.
Abnormal fatigability leads to by- resignation, or faith ; for a drug-clerk
persensitiveness to stimuli, induces to administer some well-tried, "sim-
emotional anomalies, confusing alter- pie" remedy; for the foreman in a
nations of sensations, vitiations of im- lumber camp to bind up an axe-cut.
pressions, elementary hallucinations. Within their limitations, any or all
It also leads to mental irritability, of these render good service, and at
distractibility, and incapacity to fix or least four times out of five the meas-
maintain the attention. Hence follow ure is sufficient zvhen the problem is
despondencies and hypochondriasis. nncomplicated.
416 SUGGESTION-THERAPY; HYPNOTHERAPY (TAYLOR).
Such persons become menaces to like a physical illness: by accurately
the community, however, when they determining its exact nature, causation,
branch out and assume the role of and type, then skillfully applying the
universal "healers." The extent to right remedies or procedures,
which overbold ignoramuses can im- The first step in psychotherapy
peril life and reason reaches its zenith is to ascertain the facts. These must
in certain modern health cults, the include first the physical states and
apostles of which, reckless of truth next the mental. Upon the physical
and denying experience, assume the states much of success may depend,
non-existence of disease as the cor- Memories being treacherous, it is de-
nerstone of their creed. sirable to place the individual in a
Even the well-meaning clergyman position of ease, and en rapport with
may be harmful. The religionist sees the examiner. The object being to
no limit to power engendered or con- learn all the essential facts he must
ceived, whether organic or mystic; become familiar with phenomena of
hence may be dangerously optimistic, mental life, both normal and abnor-
Scientists, i.e., psychologists and mal. This anamnesis is best obtained
physicians trained in the disease of by supplying the conditions needful
mind and nervous system, appreciate to secure attention, co-operation, will-
the limitations of physical and men- ingness to confide, however much
tal power and exhibit at least due of mental reservation may subcon-
caution. sciously exist. Among these condi-
A large part of human suffering is tions are monotony and limitation
well known to be due chiefly to of voluntar}'^ movement. "Any ar-
disordered states of mind. Every rangement of external circumstances
thoughtful person can recall instances tending to produce monotony and
where a series of misapprehensions, limitations of voluntary movements,
broodings, false interpretations, in- brings about a subconscious state of
exact, oversolicitous self-observations, suggestibility in which the patient's
have created painful and damaging mental life can be afifected with
impressions. ease Consciousness is then
This is due to the fact that too few vaguer than in the full waking state,
are equipped with that measure of memory is more dififused, so that ex-
robust, well-balanced mentality, con- periences apparently forgotten come
stituting judgment, which can usually in bits and scraps to the foreground
be relied upon to steer one through of consciousness. Emotional excite-
the long series of trials and perils ment becomes calmed, voluntary ac-
that come to all of us. Again, it tion passive, and suggestions meet
often happens that, owing to physical with little resistance." (Boris Sidis.)
weaknesses caused by temporary bod- How far disorders of the mind can
ily ailments, or by original or induced exist independent of impairments of
peculiarities of mind, especially by nutrition or structural changes in this
erroneous education, emotionalism, organ, is not as yet fully determined.
etc., a psychic condition is produced "While insanity has been defined
analogous to progressive mental dis- as a departure from the normal
ease. This should be treated precisely standard of thinking and feeling, no
SUGGESTION-THERAPY; HYPNOTHERAPY (TAYLOR). 417
mental conception or psychical mani- graphically classified by F. W. Lang-
festation can occur except through don thus : The keynotes of hysteria
the medium of the brain" (Sajous). (pithiatism of Babinski) are retrac-
A large number of disorders of the tion of the field of consciousness
processes of thought as well as of wholly, or in part, with suggestibil-
the body are known to yield to meas- ity a necessary causal and curative
ures directed to the mind. There is factor: the patient cannot ivill right,
much evidence to the efi'ect that by In neurasthenia there are varied mor-
means of direct or indirect appeal, bid suggestive sensations and undue
judicious explanation, direction, en- fatigability, with defective nutrition
couragement, a mind originally well and metabolism as a basis : the patient
endowed, trained and poised can, cannot feel right. Psychasthenia is
when disordered, be brought back to marked by morbid fears, anticipa-
the norm. tions, and impulsions: the patient
A mind fully aware of its own cannot think right,
needs and unreservedly desiring relief Psychotherapy is applicable in many
may be rehabilitated by reason, con- morbid conditions connected with
solation, persuasion and other suitable ^^'"i^"^ ^''^^"^ ^' ;^^]^ ^^ ^^'Jh the
stimulation or sedation from without,
nervous system. Patients liable to
benefit by psj^chotherapy are those
and when adequately trained also ^^o complain of symptoms which
from within. are out of proportion with the ob-
Commoner and more stubborn jective findings; especially is this the
mental problems arise in those who ^^^e with gastrointestinal disturb-
,.^,, r . . ances. Further, the persons who are
possess too little of primary equip- r ^- ^ . -i u
i:^ ^ J n r- fatigued and easily become ex-
ment, are lost in a maze of doubt, hausted, who find that they forget
depression, fear or terror producing their malaise and exhaustion in
misinterpretation of their status. pleasant company. Further, persons
There are also to be considered the ^ho worry and dread, who are afraid
^ 1 r . t • 1 „ 1 ^ .. they will not sleep and consequently
environmental factors which make or j ^ ci- i.. . t • • ,
1 1- f "° "°*- -'bgnt actual or imagined or-
mar mental efficiency, habits, beliefs, ^^^-^^ trouble maintains the neurop-
and conduct. athy. Thomas (Revue med. de la
Since earliest history more or less Suisse Rom., Mar., 1912).
convincing evidence has been adduced A fair proportion of individuals
that mental disorders yield to confi- are best influenced by a plain, com-
dent domination, to influences which mon-sense, sympathetic, heart-to-
sei::e and hold attention, excite wonder, heart, man-to-man conference. A
awe, reverence, hope or expectation, basis of frank camaraderie serves best
Of late years there has been a no- if the operator be qualified to exert
table recrudescence of mind cures of it and the sul)ject will lend himself
divers forms. to the task. A man or a woman of
The conditions which promise most adequate authority, experience, skill
results from psychotherapy arc the appeals strongly to one of similar
functional nervous disorders. These sex as a rule. A man can often
are disorders of which no definite exercise more masterful qualities, a
physical causes can be determined, woman usually more of sympathetic.
The functional psychoneuroses are intuitive, penetrative force. Indeed,
418
SUGGESTION-THERAPY; HYPNOTHERAPY (TAYLOR).
the special makeup, personality of
the operator exerts more influence
oftentimes than acquired qualifica-
tions, other things being- equal.
However, the best results may ])e
frequently attained by astuteness, per-
sistence, keenness of apperception and
kindly dominance. Every physician
employs suggestion more or less in
his daily work. Some are distinctly
aware of doing so, and use good
judgment. Others make the mistake
of overdoing both affirmation and
negation ; worse than all is any form
of flippancy or ridicule or upbraiding.
Feelings wounded by real or fancied
unjust treatment may, in some chil-
dren, bring on actual neurasthenia.
Psychanalysis by the Freud method
and efforts to wean the little patient
away from brooding over his injury
are the main reliance. Suggestion
can be successfully applied to chil-
dren 2 years old and upward. The
severe attitude or discipline of a
tactless schoolteacher, and apparent
or real neglect or unjust severity on
the part of a parent, are examples
of psychic trauma in such cases.
The prophylactic treatment aims to
change the disposition, making the
child less sensitive and more self-
reliant. In this respect the child is
'"hardened"; attempt is made to un-
deceive his illusions, and through a
firm but loving training accustom
him to meet difificulties and rebuffs.
The symptomatic treatment is based
on the fact that the psychical trauma
acts like a foreign body, the volun-
tary or involuntary remembrance of
which is continually calling forth the
symptoms of the condition. This is
best relieved by diverting the mind
to other things. The best method is
the so-called "awake" or "alert" sug-
gestion, by constantly holding up
before the patient the ultimate, com-
plete cure of his ailment. This is
embodied in various medicaments,
believed by the child and the mother
to have curative properties. In addi-
tion a change in environment, and
gaining the child's confidence by tact-
ful kindness, with a free discussion of
his condition and an answering of all
questions asked will have a beneficial
effect on his symptoms. Hamburger
(Wiener klin. Woch., Feb. 20, 1913).
As to artificial aids to suggestion,
in diagnosis or in treatment, -prob-
ably the most efficacious is induction
of the hypnoidal state of Boris Sidis.
This opens the doors of closed cham-
bers of the mind, and encourages sup-
pressed emotions or anxieties, to
come to the surface and be evaluated.
The writer found it possible to free
the wounded from suffering by hyp-
notic suggestion that there was no
pain or by throwing them into a
hypnotic sleep. In a number of dis-
tressing instances, the immediate re-
lief procured was most welcome. In
war conditions the men respond with
exceptional ease to hypnosis, only
about 2 per cent, being quite refrac-
tory. An artificial deep slumber can
be counted on in about 17 per cent,
of cases. Even the initial degrees of
hypnosis permit operations with
much less anesthetic than would
otherwise be required. The author's
patients included Slavs, Teutons, and
Italians. He does not advocate hyp-
nosis for major operations, but chiefly
for the sensory pangs of psychic
origin. A single hypnotic sitting may
entirely cure such pains. Podiapolsky
(Paris med., Aug. 25, 1917).
HYPNOTHERAPY ("HYPNO-
TISM").
Both sleep and hypnosis may be
said to have evolved out 'of the
primitive, undififerentiated, hypnoidal
state, essentially a subwaking rest-
state characteristic of early and lowly
organized animal life. Having be-
come useless, and possibly harmful,
in higher animals, it was eliminated,
and can only be induced under artifi-
cial conditions in but a fraction of the
SUGGESTION-THERAPY; HYPNOTHERAPY (TAYLOR). 419
human race, though still the normal operator, he or she becomes the mere
rest-state of the lower vertebrates and tool or puppet of the latter,
invertebrates. From the medicolegal standpoint
When the hypnoidal state is in- hypnosis does not deprive the sub-
duced in man, he hovers between the J^^^^ of will-power to the point of
, , . committing a crime which he would
conscious and subconscious, some- ^ -^ a ^u ■
' not commit under other circum-
what as one hovers between wakeful- stances. The hypnotized individual
ness and sleep. The subject finally is responsible for criminal deeds
falls into a subconscious condition which he may commit, and even
in which outlived experiences are flight attenuation of the responsibil-
., J A n • c-j- i. ity can be admitted only when the
easily aroused. As Boris bidis puts ■ j- -j i v . • .1 u u. r
-' individual has been in the habit of
it, "experiences long submerged and ^eing hypnotized frequently so that
forgotten rise to the full light of con- a special hypersensitiveness may have
sciousness .... in bits, in chips, developed. Babinski (Semaine med.,
in fragments, which may gradually J"^y 27, 1910).
coalesce and form a connected series Technique. — The following method
of interrelated systems of experiences will meet the needs of the physician :
apparently long dead and buried. The The patient should be given a clear
resurrected experiences then stand explanation of the nature of hypnosis,
out clear and distinct in the patient's viz., that it is nothing more than a
mind." condition into which the patient vol-
Susceptibility to hypnotization, untarily places himself by allowing
though about equal as to the sexes, his mind to follow the physician's
predominates in subjects who readily suggestion to the exclusion of every
obey, hysterics, and children, for other thought ; that he will never put
example, and in those who most him to sleep without his consent and
readily can concentrate expectant at- desire. That, after he is asleep, the
tention and confidence. The insane, suggestions made will be such as to
low-grade idiots, and some hysterics enable him to keep his mind ofif of
who are unable to exercise continuous himself or his ailments, and that
attention are not hypnotizable by there is nothing mysterious about the
ordinary means; nor is the militant process. This introductory instruc-
skeptic. tion protects the physician should
After a subject has been hypnotized any medicolegal question arise against
he is more susceptible to hypnosis, him,. A third person, if possible
and may even enter a state of pure brought in by the physician, should
subjectivity to the operator — render- be present, particularly when the pa-
ing hypnosis very dangerous when tient is a woman. Sensual hallucina-
the operator happens to be unscrupu- tions being common in them, espe-
lous. The susceptibility may become cially where hysteria exists, perfectly
such that a mere hint, or sound, or sincere, though utterly unwarranted,
flash of light, etc., may suffice to accusations may result,
bring on the condition. Inasmuch as Several methods of inducing hypno-
the hypnotized subject is highly sus- sis are available. The patient being
ceptible to suggestibility, accepting comfortably seated, that of P)raid may
unquestioningly the dictum of the be practised. This consists in re-
420 SUGGESTION-THERAPY; HYPNOTHERAPY (TAYLOR).
questing the patient to fix his eyes entailing surprise or shock should l)e
intently upon some bright object, a avoided.
button, for example, some six inches Deep hypnosis, seldom practicaljle,
from the eyes and in such a way as is unnecessary in most instances,
to cause the latter slight strain. It Charcot has divided hypnosis into
is this strain which, reflexly and three phases. In the lethargic phase,
through the intermediary of the the highest form of hypnosis, the
neural lobe of the pituitary body temperature, pulse^ and respiration
according to Sajous, produces the are not affected, though some degree
hypnotic state. What are termed of analgesia is present. The patient
"passes" — the operator standing in hears the operator's voice and re-
front of his subject and stroking sponds readily. In the cataleptic
downward repeatedly from the fore- phase, the limbs, as in catalepsy, re-
head to the knees, close to, but not tain the position, even though awk-
touching the body, are then practised, ward, in which they are set by the
Their soothing effect, though unex- operator, but if they are set in mo-
plained so far, is undoubted. Simul- tion, in rotation for instance, the
taneously, the patient is enjoined to movement will continue indefinitely,
go to sleep by some such sentence as Here the analgesia is complete. In
"Sleep is coming on; your eye- the somnambulic phase the operator
lids are getting heavy; you begin to controls absolutely the subject, who
feel drowsy ; the drowsiness is deep- hears and obeys only him, unless
ening; your arms are beginning to instructed by him to hear others,
feel numb and heavy ; my voice seems Commands are executed irrespective
farther away ; your sleep is becoming of their irrationality or moral way-
deep, soothing and restful ; you are wardness. This is so dangerous in
now sleeping deeply and cannot open its possibilities as to render the use
your eyes." Inability to open his of the somnambulic phase unwar-
eyes on being told to do so marks the ranted under any circumstance,
time when the patient, resting quietly. The patient is easily aroused when
is ready for therapeutic suggestions. hypnosis is not pushed to the som-
Several other methods have been nambulic phase. A puff of air in the
employed. Luys caused the patient face, a command to awake while
to look fixedly at small mirrors fitted stroking the head, the suggestion that
to the revolving arms of an apparatus in one-half minute he will open his
operated by clockwork. Thus, at the eyes and find himself awake and
Charite, he could hypnotize simul- feeling quite well ; raising the eyelids
taneously many patients. Bernheim and calling the patient by name are
fixed the patient's gaze with his own the best means to employ. If left to
and suggested sleep by means of himself, the patient will awake after
sentences similar to those recorded a time, varying from a few minutes
above. Pressing gently on the eye- to several hours.
balls and suggesting sleep suffices THERAPEUSIS.— Although hyp-
in sensitive subjects. Charcot some- notism has been tried and claimed all-
times employed flashes of vivid light, curative in many ills, it is only as an
loud sounds, etc., but any practice auxiliary that its use is warranted in
SULPHONAL (SAJOUS),
421
a few disorders. It should, in fact,
be avoided wherever possible, and
only considered as a means to render
psychotherapy more effective and to
afford psychic reparative rest.
The hypnoidal state has been
utilized almost from the very origin
of animal life for the repair and res-
toration of worn-out organs and im-
paired functions. We can still use
this state to bring about a greater
vigor of personal activity, a more
efficient control of reactions to stim-
ulations, a better adjustment of the
organism to the conditions of its
environment. Boris Sidis (Boston
Med. and Surg. Jour., Sept. 9, 1909).
Its use by laymen should not be
countenanced ; what harm has been
done being attributable to them, in
most instances.
It is in clearly determined hypo-
chondria where psychotherapy has
failed to impress the sufferer that
hypnotic suggestion sometimes proves
the only efficient resource. Insomnia,
where the continuous use of sopor-
ifics is contraindicated, also' finds a
potent help in it, particularly if some
inert powder is taken in a glass of
water before it is induced. It has
been recommended in hysteria, but
hysteroepilepsy has followed its use
in this disease (Van Eeden). Aphasia
(Charcot) and hysterical convulsions
have also been known to follow it.
Numbers of hysterical individuals
have been cured after they have been
hypnotized, but psychotherapy wak-
ing would have been equally effectual
in all, unless the hysterical patients
had clamored for hypnosis. Babinski
(Semaine med., July 27, 1910).
Neurasthenia is also benefited, but
only where psychogenic phenomena
tend to perpetuate the disorder after
the nervous lesions have been ade-
quately treated by classic measures.
Where unwarranted dread of death
and other phobias and obsessions fail
to yield to psychotherapy, hypnosis
has often proved effective ; also in
psychogenic impotence and enuresis.
At one time much value was at-
tributed to hypnosis as an anesthetic,
but experience has shown that it is
unreliable. t iv/r -r
J. Madison Taylor,
Philadelphia.
SULPHONAL. — Sulphonal (sul-
f onal, diethylsulphonedimethylme-
thane), officially termed Sulphonmc-
thanum, is obtained from anhydrous
acetone by anhydrous ethylmercap-
tan with a stream of dry hydro-
chloric acid gas. It is represented
chemically by the formula (CH3)2-
C(S02C2H5)2. It occurs in thick,
tasteless, odorless, colorless prisms,
soluble in 360 parts of cold and in
15 parts of boiling water, in 47 parts
of cold alcohol, and in 2 parts of
boiling alcohol, in 45 parts of ether,
and in 16 parts of chloroform. Sul-
phonal is not affected by any of the
ordinary acids (even when concen-
trated), by alkalies, or by oxidizing
agents, either in the cold or when
warm, and is a very stable com-
pound. It was introduced by E. Bau-
mann in 1886, and clinically reported
upon as a hypnotic by A. Kast in
1888. The dose of sulphonal is 10 to
45 grains (0.6 to 3 Gm.), 15 grains
(1 Gm.) being that officially men-
tioned as the average dose. Kast ad-
vised that 15 grains (1 Gm.) be con-
sidered the maximum dose in women,
and 30 to 45 grains (2 to 3 Gm.) in
men.
MODES OF ADMINISTRA-
TION.—On account of its insolubil-
ity and slow rate of absorption when
given in capsules or suspended in
422
SULPHONAL (SAJOUS).
mucilage or simple elixir, sulphonal
is preferably administered in hot
fluids, such as hot water, milk, tea,
broth, or bouillon. Its action is like-
wise to some extent accelerated by
its ingestion in some alcoholic fluid,
such as whisky or brandy, alcohol,
especially if warmed, dissolving the
drug with relative ease. Stewart
found the action of sulphonal greatly
hastened when it was completely dis-
solved in boiling water and drunk as
soon as the water cooled to a bear-
able temperature, a teaspoonful of
creme de menthe or other liqueur
being added for flavoring purposes.
Sulphonal should preferably not be
given in solid form.
PHYSIOLOGICAL ACTION.—
Sulphonmethane and its congener,
sulplionethylmethane (trional), both
induce in therapeutic doses quietude
and sleep, without any disturbance of
the heart or medullary centers. Their
action is practically limited to hypno-
sis, no effect on pain, where such
exists, being produced. They have
also been used, however, to check
nausea, as in seasickness, and in ab-
normal psychic excitation among the
insane have proven of value as active
brain sedatives. The effect of sul-
phonal on the spinal cord in doses
larger than the usual therapeutic
amounts is well illustrated in dogs, to
which the drug is administered, pro-
nounced staggering of gait and relax-
ation of the muscles soon resulting.
Absorption of sulphonal is very
slow, as long as 2 or 3, and occasion-
ally as much as 5 hours or more,
not infrequently being required for
the induction of sleep. The sleep
induced by 20-grain (1.3 Gm.) doses,
once established, tends to persist all
night. Excretion is correspondingly
slow, and the patient often remains
drowsy on the following day. Often
the single dose of the drug will in-
duce sleep on the second night, and
in a few instances even on the third.
vSulphonal and trional — which acts
more rapidly — are eliminated as ethyl
sulphonates.
The continued administration of sul-
phonal for more than three successive
days at times imparts the impression
of a cumulative action, increasing
somnolence and lassitude resulting
from the slow elimination of the drug
and its continuous action on the cen-
tral nervous system.
CONTRAINDICATIONS. — Sul-
phonal should not be given, or be
used with caution, in cases exhibit-
ing great prostration, in cases suf-
fering from gastrointestinal disturb-
ance (especially in constipation), in
old age, and in cases of severe cardiac
disease or in nephritis.
UNTOWARD EFFECTS AND
POISONING. — Unpleasant after-ef-
fects have at times followed the use
of sulphonal in ordinary therapeutic
doses. There is not infrequently
more or less cerebral heaviness and
distress the next day. Giddiness may
follow even 15-grain (1 Gm.) doses,
and after 20 grains (1.3 Gm.) or
more, headache and inco-ordination
of gait are sometimes observed.
Among other less frequently ob-
served symptoms have been tinnitus,
muscular weakness, nausea and vom-
iting, serous diarrhea, mental excite-
ment, weak pulse, cyanosis, and an
eruption, usually minutely papulous
in character, occasionally bullous,
and, according to Erbsloh, often
showing a disposition to follow the
nerve-trunks. These untoward ef-
fects, as a rule, pass off rapidly, with
SULPHONAL (SAJOUS).
423
the occasional exception of the dis-
turbance of co-ordination.
Acute sulphonal poisoning has been
met with many times, but only rarely
with fatal results. Neisser, Hirsch,
and Richmond have reported cases in
which recovery followed ingestion of
3% ounces (100 Gm.), 63^ drams (25
Gm.), and 2 drams (8 Gm), respec-
tively. Another writer reported the
case of a man who took 3 tablespoon-
fuls of sulphonal, with recovery after
five days. Gillett recorded a case of
poisoning by 1 dram (4 Gm.) of sul-
phonal taken in 3 equal doses by a
neurotic girl of 17 years, with recov-
ery. Hill reported the case of a child
of 18 months who received 34 grains
in a few hours, with recovery. On
the other hand, IMarvin has reported
a death after ingestion of 4 drams
(16 Gm.) of sulphonal in 5 doses — 2
taken one afternoon and 3 the next
morning. Hoppe-Seyler and Ritter
reported a death from 1% ounces (50
Gm.) of the drug. Pettit recorded a
death in 40 hours from 30 grains (2
Gm.) in an hysterical, melancholic
woman of 28 years; she had, how-
ever, received chloral hydrate, canna-
bis indica, potassium bromide, and
paraldehyde on the preceding day.
In cases of postinfluenzal debility
Grant observed prostration and cir-
culatory depression from single 20-
grain (1.3 Gm.) doses. Otto referred
to cases in which walking was ren-
dered difficult or impossible under
the use of 75 grains (5 Gm.) of the
drug. Sleep lasting 75 hours has
been produced by 1 dram (4 Gm.).
The symptoms of acute sulphonal
poisoning include dizziness, inco-or-
dination, heavy sleep or actual un-
consciousness, slight reddening of
the face, gastric pain and anorexia,
vomiting, diminution or loss of re-
flexes, constipation, rapid respiration,
frequent and weak pulse, cyanosis,
and analgesia of the lower extremi-
ties. Psychic excitement, hallucina-
tions, muscular twitchings, swelling
of the extremities, and an itching,
papular exanthem have also at times
been noted. In Hirsch's case ne-
phritic manifestations were noted on
the fourth day, lasting for three days.
Fever has occasionally preceded
death, which results from cardiac
failure.
A woman, aged 27, suffering from
melancholia, took 365 grains (24.4
Gm.) of sulphonal in tablets. When
first seen she was comatose. The
pulse was 80 and feeble, the respira-
tions IS, and the temperature 98° F.
(36.7° C). The corneal reflex, knee-
jerks, and radial reflex were absent.
The pupils were slightly contracted
and reacted sluggishly. The stomach
was washed out. The urine was
drawn and found clear and abundant.
By evening the corneal reflex had re-
turned. She could be aroused to
take hot coffee. Next morning cya-
nosis set in. The pulse was acceler-
ated and the temperature rose to
103.5° F. (39.7° C). There were no
physical signs of pneumonia. On
the third day she was improved. A
sweet, chloroform-like odor was no-
ticed on the breath soon after she
had taken the dose, and with the
first urine evacuated the same odor
was obtained. On the fourth and
fifth days cerebration was markedly
interfered with and the speech stac-
cato. After eight days she was men-
tally more active, and convalescence
set in. A. E. Hind (Lancet, Jan. 23,
1904).
Treatment of Acute Sulphonal Pois-
oning.— This consists of immediate
evacuation of the stomach and purg-
ing. The kidneys should be encour-
aged to act freely by ingestion of
water and saline enteroclysis. Stim-
424
SULPHONAL (SAJOUS).
ulants such as strychnine, atropine,
aromatic spirit of ammonia, digitaUs,
etc., may pro\e of distinct value. Ex-
ternal heat and artificial respiration
are also measures to be thought of
in serious cases.
Chronic sulphonal poisoning has,
in the past, proven more common
and dangerous than the acute form.
From 1888 to 1900 about 30 fatal
cases and 50 non-fatal severe cases
were reported — mostly in lunatic
asylums. The amount necessary to
cause poisoning varies greatly. Fif-
teen hundred grains in 6 years, 224
Gm. {7y2 ounces) in 205 days, 128
Gm. (4j4 ounces) in 91 days, and
similar amounts have frequently been
taken without ill effect. On the
other hand, death has occurred after
16 Gm. (4 drams) in 1 month, and
90 Gm. (3 ounces) in 3 months, and
severe poisoning after 180 Gm. (6
ounces) in 270 days, 132 Gm. (4^
ounces) in 120 days, etc. Women are*
more commonly poisoned than men,
and poor diet, age, and debility (ane-
mia), all increase the tendency. Con-
stipation especially favors poisoning
(Dietrich). Nearly all the fatal cases
have occurred in people who were
habitually constipated (Gulland).
The first symptoms of chronic sul-
phonal poisoning to appear are usu-
ally gastrointestinal — anorexia, thirst,
nausea, vomiting, and especially con-
stipation, which may be followed by
diarrhea. There may be epigastric
pain, an acetone odor of the breath,
cardiac weakness, and a skin erup-
tion. Lassitude is marked, but
drowsiness is usually not a very
prominent symptom until the final
stage is reached. After the gastro-
intestinal symptoms appear, as a
rule, nervous manifestations, such as
ataxia and, less often, paralysis of
the extremities or facial muscles, or
even localized or general convulsions.
Mental apathy and depression, with
cutaneous anesthesia, often accom-
pany the motor symptoms, in the
fatal cases passing into coma before
death. Either early or late, charac-
teristic changes appear in the urine,
which becomes scanty and dark-red
in color ("port-wine coloration"),
owing to the presence in it of the
abnormal blood-pigment hematopor-
phyrin. Certain identification of the
latter is best carried out with the
spectroscope, which reveals definite
absorption bands signifying the pres-
ence of the pigment. The urine may
or may not contain albumin, casts,
degenerated blood-corpuscles, and
much urobilin (Talley). According
to Gulland it is always intensely acid,
and contains unchanged sulphonal.
Death may be preceded by delirium
or stupor and gradually developing
motor and sensory paralysis, and
takes place usually from respiratory,
sometimes from cardiac, arrest.
Unmistakable multiple neuritis has
been reported as caused by the con-
tinued use of sulponal (Erbsloh).
A pale patient, 32 years of age, of
fair physique, had been suffering
from chronic mania for two years.
When she became acutely maniacal,
as upon previous occasions, sulphonal
was administered in 30-grain (2 Gm.)
doses daily for one week. Twenty-
eight hours after the last dose she
refused her breakfast, and vomited
shortly afterward. The skin was
cold and clammy, pupils normal,
pulse 86, of low tension and some-
what irregular. Temperature sub-
normal. The gait was unsteady, ar-
ticulation was slow, and the mental
condition clearer than it had been
for months. The urine was of a deep
port-wine color. Flaccid paralysis in
SULPHONAL (SAJOUS).
425
the legs spread rapidly upward until
the patient was barely able to turn
her head. A varying amount of an-
esthesia was present. The muscles
were tender, and shooting pains com-
plained of in the legs. Bullae ap-
peared over the body; the superficial
and deep reflexes were lost. The
bladder and rectum were emptied in-
voluntarily. The act of swallowing
became gradually more and more im-
paired, the respirations were imper-
ceptible, and speech a mere lisp.
The patient's mind remained clear
until her death on the fifth day. H.
de M. Alexander (Jour. Mental Sci.,
Oct., 1902).
Over 47 cases of hematoporphyrin-
uria from sulphonal are upon record,
also 7 cases due to trional and 2 to
veronal. Fatalities from sulphonal
have occurred without hematopor-
phyrinuria. The author's case oc-
curred in a woman of 30, apparently
suffering from the maniacal phase of
manicdepressive insanity. She had
refused all medication per os. Sul-
phonal was then mixed with the
food. She ingested some 4 Gm. (60
grains) daily for two days, then half
that daily dose for several days
more. At most not over 10 Gm. (2>^
drams) of the drug found their way
into the body. The woman now be-
came very constipated. For the first
three days following the last dose of
sulphonal no urine was voided. On
the fourth day urine of the charac-
teristic port-wine color was passed.
After this duboisine (0.005 Gm.— 142
grain) was given. On the fifth day
she collapsed, complained of abdom-
inal pressure, and died a few hours
later. At autopsy the kidneys were
found normal. The real causes of
death were doubtless the constant
agitation of nearly two weeks' dura-
tion and the defective alimentation
and fatty state of the myocardium.
Pfortner (Deut. med. Woch., July
30, 1914).
Treatment of Chronic Sulphonal
Poisoning. — The lirst care should be
to empty the bowel thoroughly. Even
croton oil may be used, to secure im-
mediate results. To promote elimi-
nation through the kidneys, saline
solution may be given by enterocly-
sis, by hypodermoclysis, or even by
intravenous infusion. Large enemata
of warm water, as well as free use
of water by the mouth, have been
advocated. Alkalies, such as sodium
bicarbonate and sodium acetate or
citrate, or magnesium carbonate,
should be given in sufficient amounts
to render the urine alkaline; this
measure controls the hematoporphy-
rinuria (Gulland). If a hypnotic is
necessary, morphine and scopolamine,
or small doses of chloral hydrate,
may be given (Wood). Stimulants
should be given as soon as cardiac
depression appears. In all but slight
cases the prognosis is relatively bad.
Giinther collected 47 cases, with a
mortality of 53 per cent. Convales-
cence is slow.
A point in the prognosis of chronic
sulphonal poisoning is the observa-
tion that all the cases that have re-
covered have had some or all of the
gastrointestinal, nephritic, respira-
tory, and circulatory symptoms, but
no nervous symptoms beyond stupor
and ataxia. The development of pa-
resis appears always to run on to
complete paralysis and death. The
predominance of constipation among
the toxic cases should put one on
the alert to keep the bowels active
during the exhibition of the drug.
Yet free purgation is not able to
eliminate the poison when once ab-
sorbed and the mischief begun.
Smith's case had diarrhea the greater
part of the twelve days between the
first signs of poisoning and death.
J. E. Talley (Amer. Jour. Med. Sci.,
Oct., 1908).
THERAPEUTICS. — Sulphonal is
a fairly reliable hypnotic, having lit-
tle or no analgesic effects, and rank-
426
SULPHUR.
ing below chloral hydrate in power
and certainty of action. It is advan-
tageous in l)eing odorless and taste-
less, and can be administered to ob-
stinate patients in food without their
knowledge.
In functional nervous insomnia it
is valuable as a hypnotic except when
the presence of advanced organic dis-
ease of the heart is the cause of the
wakefulness, in which case it is dan-
gerous. The slowness of its action
necessitates its administration about
2 hours before bedtime if an imme-
diate hypnotic action upon retiring is
desired. In such instances the more
rapidly acting trional, or veronal, are
more convenient drugs. In the class
of patients, however, who have no
difficulty in going to sleep on retir-
ing, but later lie awake for several
hours or until morning, sulphonal",
ingested at bedtime, may be more
efficient than trional, its eftects, later
in appearing, being more likely to
continue throughout the night. On
the other hand, there is less heaviness
the next day after sulphonal than
after trional. The action of sul-
phonal often lasts two nights after
use. Mairet recommends the giving
of one relatively large dose the first
night, followed by diminishing doses
on succeeding nights.
In the insomnia of insanity, sul-
phonal generally acts well, producing
sleep by night and quietness during
the day, its slow, persistent efifect at
times giving results superior to those
obtained with the more rapidly acting
drugs. Webber recommends the use
of 5-grain (0.3 Gm.) doses 3 times a
day, and if necessary, during the
night, to quiet restlessness in neuras-
thenia, hysteria, and mania. To
combat intense excitement in the in-
sane, doses of 45 to 60 grains are
sometimes required. In somewhat
less excited maniacs and agitated
melancholies 40-grain (2.5 Gm.)
doses, given in hot milk at bedtime,
act well (Sutclifife).
Some cases of persistent hiccough
have been relieved by sulphonal,
which has also proven effectual in
nocturnal seminal emissions. An-
drews found it more sedative than
opiates in a case of painful muscular
spasm after fracture of the thigh.
Shaw-MacKenzie has recommended
its use in a dose of 10 to 15 grains
(0.6 to 1 Gm.) to relieve seasickness
and carsickness, and Rosenberg cut
short a paroxysm of bronchial asth-
ma with it. Lepine has used it in
chorea.
In the night-sweats of pulmonary
tuberculosis, except in the very ad-
vanced stages, sulphonal in 15- to 30-
grain (1 to 2 Gm.) doses has been
found efficient, cough being simul-
taneously diminished.
In diabetes mellitus sulphonal
causes, like many other sedatives, a
diminution of glycosuria, which is,
however, only temporary. To pre-
vent chronic sulphonal poisoning, sul-
phonal should preferably not be given
continuously, or, if it is, frequent in-
termissions of from 4 days to a week
imposed. Care should be constantly
taken to secure proper action of the
bowels and kidneys. If such symp-
toms as nausea, vomiting, gastric
pain, etc., the drug should be
promptly withdrawn.
L. T. DE M. Sajous,
Philadelphia.
SULPHUR. — Sulphur is a non-metal-
lic, solid element found native in the
western United States, Mexico, Iceland,
and in the West Indies, but more abun-
SULPHUR.
427
dantly in Sicily and Italy, whence the
commercial supply chiefly comes. It is
an important constituent of certain native
mineral springs which furnish sulphurated
waters. When fused and cast into rolls
or cylinders it is popularly known as
brimstone. As it occurs in nature, it
forms yellow, transparent, rhombic crys-
tals. Sulphur emits a peculiar odor when
rubbed, and has a very faint taste. It is
insoluble in water, but soluble in benzin,
benzene (benzol), turpentine, ether,
chloroform, carbon disulphide, the fixed
and volatile oils, and in boiling alkaline
solutions.
PREPARATIONS AND DOSES.—
Sulphur lotmn, U. S. P. (washed sulphur),
prepared from flowers of sulphur by wash-
ing with ammonia, which frees it from
acid. It occurs as a fine, yellow powder,
odorless, tasteless, and insoluble in water.
Dose, 15 grains to 1^ drams (1 to 6 Gm.);
average 1 dram (4 Gm.).
Sulphur pr<ccipiiatum, U. S. P. (precipi-
tated sulphur, milk of sulphur, lac sul-
phuris), prepared by precipitation from a
solution of alkaline sulphide. It occurs
as a pale-yellow powder, odorless, taste-
less, and insoluble. It is soft, and not
gritty like washed sulphur, and is there-
fore preferred in the preparation of lotions
and ointments. Dose, 1 dram (4 Gm.).
Sulphur sublimatum, U. S. P. (sublimed
sulphur, flowers of sulphur, brimstone),
occurring as a fine, yellow powder, or sul-
phurous odor and faintly acid taste, in-
soluble in water. It has been preferred
for laxative purposes, as it contains free
sulphurous acid and is gritty, but it may
contain arsenic. Dose, 1 dram (4 Gm.).
Pulvis glycyrrhizcB compositus, U. S. P.
(compound licorice powder; pectoral
powder), containing 8 per cent, of washed
sulphur, 18 per cent, of senna, and ap-
propriate amounts of licorice, oil of fen-
nel, and sugar. Dose, ^ to 2 drams (2
to 8 Gm.) ; average, 1 dram (4 Gm.).
Unguentum sulphuris, U. S. P. (sulphur
ointment), containing 15 per cent, of
washed sulphur in benzoinated lard. Used
externally.
Calcii sulphidum crudum, U. S. P. (sul-
phurated lime; "calcium sulphide"). Dose,
1 grain (0.06 Gm.). (See Calcium).
Potassa sulphurata, U. S. P. (sulphurated
potash; "potassium sulphide"; liver of
sulphur; crude potassium sulphide), a
mixture of potassium salts of which the
chief are sulphides, prepared by fusing
dried potassium carbonate with sublimed
sulphur. It occurs in hard, brownish
masses of liver-brown color with a strong
odor of hydrogen sulphide and a bitter,
alkaline taste. It deteriorates gradually
on exposure to air. It is soluble in 2
parts of water. Alcohol dissolves only
the potassium sulphide, leaving the sul-
phate and thiosulphate undissolved. It is
incompatible with acids, including carbon
dioxide, and with alcohol. The sulphides
in it correspond to 12.8 per cent, of sul-
phur. Used externally.
Recognized in the National Formulary: — •
Sulphuris iodidum, N. F. (sulphur iodide),
consisting of 1 part of sulphur to 4
parts of iodine, fused in brittle, grayish-
black masses of crystalline structure, in-
soluble in water, soluble in carbondisul-
phide and in 60 parts of glycerin. Used
externally in a 10 per cent, ointment.
Ungueiituiii sulphuris compositum, N. F.
(compound sulphur ointment; Wilkin-
son's ointment; Hebra's itch ointment),
consisting of precipitated calcium carbon-
ate, 2 parts; sublimed sulphur and oil of
cade, of each 3 parts, and soft soap and
lard, of each 6 parts. Used externally.
Liquor calcis sulphuratce, N. F. (solution
of sulphurated lime; Vleminckx's solution
or lotion), a mixture of lime, 16.5 parts,
and sublimed sulphur, 2.5 parts, dissolved
in boiling water, to make 100 parts.
Sometimes used, but not officially rec-
ognized, is the following: —
Colloid sulphur, made by passing a
current of well-washed hydrogen sulphide
through sulphurous acid until the latter is
entirely decomposed and a suspended
precipitate of colloid sulphur is formed.
The resulting mixture is then dialyzed to
remove the polythionic acid by-products
preventing solution of the colloid sulphur.
The preparation is then standardized to
contain 6 grains (0.04 Gm.) of sulphur to
the ounce. Dose, ^ ounce (IS c.c.) twice
daily with meals.
PHYSIOLOGICAL ACTIO N.— Lo-
cally, sulpiiur, if in prolonged contact
with the skin, and especially if rubbed
into it either in an ointment or a suspen-
428
SULPHUR.
sion, produces stimulation and later irri-
tation, which may eventuate in actual
inflammation or dermatitis. This is due
to its conversion by the skin secretions
into sulphides. Exfoliation of the epi-
dermis is augmented by the local stimu-
lating effect of sulphur — a property fre-
quently utilized in therapeutics. Sulphur is
also a parasiticide and is mildly antiseptic.
Taken internally, sulphur may slightly
irritate the stomach if the latter be empty
at the time. It is insoluble in the acid
medium of the stomach. Entering the in-
testine, it is in part dissolved by the al-
kaline intestinal juices and absorbed, but
most of it is gradually changed by the
proteins of the alimentary tract into sul-
phates, which are then reduced to sul-
phides, including hydrogen sulphide.
Some of the latter is absorbed into
the circulation and is excreted by the
lungs, skin, kidneys, and mammary glands.
The breath may thus acquire to some
extent the characteristic odor of hydrogen
sulphide, and silver articles worn by the
patient be quickly tarnished. An increase
in the sulphates of the urine is noted.
Sulphur, ingested even in small amounts,
is held to exert a definite antiseptic action
in all parts of the intestine, owing to the
formation of hydrogen sulphide. Heffler
found that when sulphur is brought into
intimate contact with fresh intestinal
mucous membrane, hydrogen sulphide is
soon formed; boiling does not destroy
this action, which therefore occurs inde-
pendently of bacterial action. Adminis-
tered in larger amounts, sulphur increases
peristalsis without causing pain, and pro-
duces soft stools, acting as a mild
laxative. It is believed also to increase
intestinal secretion by its slight irritant
action. Sulphur is, however, without ac-
tion on the digestive enzymes. A favor-
able action upon the mucous membranes,
in particular those of the respiratory tract,
has been attributed to sulphur.
According to Brisson (1909) sulphur
preparations are rendered more active by
the presence of the agencies which ac-
celerate the liberation of sulphuric acid
(sulphates) from it, such as sodium chlo-
ride, increased temperature, electricity,
and in particular blood (horse) serum.
Fineness of mechanical subdivision is also
a favoring factor, precipitated sulphur
being more active than sublimed sulphur,
and colloidal sulphur than the first named.
UNTOWARD EFFECTS AND
POISONING.— Toxic effects consist of
nausea, diarrhea, muscular cramps in the
limbs, fever, and painful urination. In
one case recorded there was extreme
prostation, together with a sulphurous
breath, cold perspiration, abdominal pains,
and vomitin'g and purging. Long-con-
tinued administration of sulphur causes
depression (R. B. Wild).
Carbon bisulphide, liberated in the vul-
canization of rubber, produces such symp-
toms as headache, dizziness, anorexia,
insomnia, formication, nervous depression,
dyspnea, deafness, and febrile attacks,
apparently due to a direct action on
nervous tissues.
Sulphur dioxide, set free in large
amounts from factories, and used in
bleaching fabrics, causes bronchial irrita-
tion and anemia.
Hydrogen sulphide, liberated in chemi-
cal laboratories, is capable of producing
chronic poisoning characterized by depres-
sion and weakness, slow pulse, anorexia,
furred tongue, and anemia.
Illuminating gas contains sulphur com-
pounds, which, according to Haldane, are
responsible for the unpleasantness of air
vitiated by its combustion.
Treatment. — This consists in the re-
moval of the cause and, where gastroin-
testinal symptoms are acute, the use of
purgatives followed by bismuth. Remedies
to counteract nervous or circulatory de-
pression and anemia may be indicated.
Opium to allay pain and control peris-
talsis may sometimes be required.
THERAPEUTIC S.— Gastrointestinal
and Constitutional Disorders. — Sulphur
has been used as laxative chiefly in cases
of hemorrhoids, fissure at the anus, and
partial intestinal obstruction, owing to
the soft, pulpy stools it induces without,
on the other hand, producing large,
watery evacuations. It may either be
given by mouth or, most pleasantly, as
a suppositor>, to be inserted at night. If
used by mouth, washed sulphur may be
given, e.g., in a 45-grain (3 Gm.) powder
at bedtime, mixed, if desired, with syrup
or molasses; or 7j^ grains (0.5 Gm.) each
SULPHUR. 429
of sulphur and magnesium oxide may be • In lumbago and sciatica it has been ad-
given in a wafer 3 times a day after meals. vised to apply to the afifected part the
Sulphur lozenges each containing 5 grains flowers of sulphur, retained by a bandage.
(0.3 Gm.) of the drug are official in the Intravenous and intramuscular in-
British Pharmacopeia. jections of colloidal sulphur admin-
Sulphur has been recommended in 5- to istered in subacute rheumatism with
20- grain (0.3 to 1.3 Gm.) does as a stimu- prompt and complete results, even
lant to the hepatic functions, where these deformity showing retrogression,
are disordered or suspended. Perhaps A. Cawadias (Bull, de I'Acad. de med.,
greater justification attends, however, its Sept. 25, 1917).
use in small doses as an intestinal anti- The writer injects 5 c.c. (80 minims)
septic, e.g., in the diarrhea of scrofulous of a 1 per cent, solution of sulphur in
children, with offensive, watery stools, oil of sesame in psoriasis, with ex-
in intestinal indigestion and fermentation, cellent results. In syphilis, an injec-
in amebic dysentery, etc. Maillard has tion every five to eight days greatly
called attention to the role of sulphur in facilitates active mercurial treatment,
neutralizing the phenol derivatives arising In a case of gonococcic arthritis of
in the intestine from putrefactive decom- the knee, 3 injections of 1 to 2 c.c.
position of residual proteins. This influ- (16 to 32 minims) were followed by
ence and the antiseptic action of sulphur rapid disappearance of pain and func-
doubtless account in part for the benefit tional recovery. Sulphur injections
at times witnessed in affections of the are of value in facilitating mobiliza-
rheumatic type, including chronic rheu- tion of stiffened joints. L. Bory
matism, localized myalgias and neuralgias, (Bull, ct mem. de la Soc. med. des
rheumatoid arthritis, and gout. The dose hop. de Paris, Mar. 7, 1918).
given may be small and repeated 3 times Use of calx sulphurata in lead poisoning
a day, or a larger amount may be admin- has been suggested.
istered once daily to secure both the Respiratory Disorders. — Cases of
laxative and "alterative" action. chronic bronchitis are at times benefited
External use of sulphur, in the form of by sulphur. G. See recommended the fol-
baths in mineral waters containing it, has lowing combination in these cases: —
been credited with distinct remedial prop- ^ Sulphuris prcecipitati. gr. L (3 Gm.).
erties m chrome rheumatoid conditions as Extracti belladonnce
well as m syphilis and various skin affec- foUorum gr. j (0.06 Gm.).
tions. According to Brown (1911) sul- p„/.^,,,v ipecacuanhce
phur-water_ causes a manifest increase in ^^ ^^•. ^^^ ^3 3 ^^^^^^
general oxidation and tissue metabolism, c^ i,^ .- /io/^™\
. ... i>acchan gr. xx (1.2 Gm.).
the total nitrogenous output, in his ex-
periments, having been augmented by 8 ^^"^ '" ^^P'"^^' "°- -^•
per cent.; the output of phosphates, 10 ^ J^f;.' /""^ *° ^'" capsules a day as
per cent.; that of endogenous (body ^
tissue) creatinin, 13 per cent., and that of Heubner (1908) refers to a favorable
endogenous uric acid, 18 per cent. He effect of sulphur spring-water taken in-
believes the drug causes an "enormous" ternally in adults with chronic catarrhal
stimulation of the xanthin oxidase of the conditions of the pharynx and throat, and
liver. Ullmann has emphasized the value especially recommends sulphur-water in
of sulphur baths in chronic affections of the form of drink, gargle, or inhalation
the fasciae, joints, and muscles, and F. for the chronic pharyngeal catarrh of
W. Smith employed electrolytic transmis- children, associated with persistent an-
sion of sulphur from Harrowgate waters orexia and tendency to vomit after meals,
by means of the constant current through malodorous breath, constipation, anemia,
the skin of patients with rheumatism, and coating of the throat and back part of
gout, peripheral neuritis, and eczema, with the tongue with tenacious, foul mucus,
results superior tfi those obtained without One wineglassful (5 ounces — 150 Gm.) of
the electrolytic transmission. sulphur-water is ordered taken cold, be-
430
SULPHUR.
fore rising in the morning, another half an
hour later (before breakfast), and in some
cases a third on retiring; the course of
the treatment is continued for 4 to 6
weeks, and is effectual whether trouble
has been caused by adenoids, enlarged
tonsils, or other conditions.
Robin and Maillard advise the use of
colloid sulphur in severe acute or chronic
inflammations of the respiratory mucous
membrane on the ground that where
much mucus (the mucin of which con-
tains 1.4 per cent, of sulphur) is being
thrown off as a measure of defense
against bacteria there is a great strain
on the secretory structures and a general
condition of sulphur starvation. They
hold that, whereas the older forms of sul-
phur cannot be synthesized to build up
protein combinations in the body, colloid
sulphur can be utilized in the formation
of cystin, which is the sulphur-containing
component of mucus and from which are
apparently built up (A. E. Taylor) the
important sulphurated lipoids of the cen-
tral nervous system and bile.
Chlorosis. — In chlorosis, when iron is
not well borne or has failed, sulphur has
been observed at times to improve the
general condition, so that iron could be
used with success later.
CUTANEOUS DISORDERS.— In
scabies sulphur ointment is one of the
best remedies. The official ointment
should generally be diluted, to avoid skin
irritation, with an equal amount of petro-
latum; or, a mixture of 4 parts of sulphur
with 1 part of balsam of Peru may be
used. (See Scabies.)
In tinea tonsurans sulphur ointment is
efficient after clipping the hair. In ring-
worm of the crotch and armpits sulphur
mixed with talcum powder may be used.
Seborrhea, sycosis, chronic eczema, and
psoriasis are benefited by small doses of
sulphur taken internally. Inveterate
forms of eczema, psoriasis, impetigo, and
prurigo may be improved by the fumes of
burning sulphur.
For dandrufT and seborrheic dermatitis
of the scalp, Brayton advises that the
latter be cleansed once a week with tar-
soap, and, when dry, well rubbed with a
portion of the following cream the size
of the end of the thumb: —
B Sulphuris pracipitati ... 3j (4 Gm.).
Acidi salicylici 3ss (2 Gm.).
Uiigueiiti aquce rosa: ... 5j (30 Gm.).
M.
The same ointment may be used for
seborrheic dermatitis of the face or body.
Jackson's formula in the treatment of
dandruff is as follows: —
li Ccrcc alba Siijss (14 Gm.).
Pctrolati liqiiidi 3ijss (10 Gm.).
Aqua: rosa 3j (4 Gm.).
Sodii biboratis gi". xv (1 Gm.).
Sulphuris pracipitati.. Siijss (14 Gm.).
M.
In diseases of the nails, when they have
become brittle and covered with ridges
and white spots, internal use of sulphur
in small doses will frequently bring about
a healthy and polished appearance.
In skin diseases accompanied with in-
filtration the use of sulphur iodide in a 6
per cent, ointment has been advised.
In scaly skin diseases, sulphurated pot-
ash is useful, 1 to 3 ounces (30 to 90 Gm.)
being dissolved in 15 gallons of water, for
a bath.
In suppurative skin diseases, in acne,
boils, carbuncles, glandular enlargements,
etc., calx sulphurata (calcium sulphide)
in small doses is considered of value, tend-
ing to inhibit the development of fresh
lesions. It is also of use externally as a
depilatory.
Sabouraud's formula for acne is as
follows: —
3 Sulphuris pracipitati.. 3ijss (10 Gm.).
Alcoholis (90 per ct.). 3iij (12 c.c).
Aqua destillata.
Aqua rosa aa Bjss (50 c.c).
M. Sig. : Shake and apply every
evening.
In acne sulphur (precipitated) may also
be used in 1 to 4 admixture with face
powder, or in 1 to 8 admixture with rose-
water ointment.
Riecke points out that fine subdivision
of sulphur and hence the best effects from
its preparations are obtained by the use
of sulphur freshly precipitated from cal-
cium polysulphide. He recommends
thorough application of such an ointment
2 or 3 times a day in scabies, acne vul-
garis, acne rosacea of the second degree.
SULPHURIC ACID.
431
seborrhea, tinea versicolor, tinea ton-
surans, and pityriasis rubra.
An efficient preparation of sulphur is
formed by the interaction of zinc sulphate
and potassium sulphide. Brayton applies
the following lotion at night in acne vul-
garis or rosacea: —
B Ziiici siilphatis,
Potassii sidfhidi aa 3ij (8 Gm.).
Aqucc rosce Sxij (350 c.c).
M. Sig. : Shake well before applying.
Voerner, in seborrhea, acne rosacea,
eczema, and follicular processes, secures
an intense sulphur action by dissolving 1
part of potassium sulphide in 2 parts of
water, painting this upon the affected
area, previously carefully dried and freed
from fat, and as soon as the solution has
dried upon the skin, spraying on vinegar
with an atomizer. Sulphur is at once pre-
cipitated and adheres intimately to the skin.
According to O. H. Foerster, liquor
calcis sulphuratse is the most active of all
the sulphur preparations; when this is
alone in contact with the skin nascent
sulphur and hydrogen sulphide are formed.
As Insecticide. — Powdered sulphur, if
used as an insecticide must be applied
directly to the insects, and its use is
largely limited to the destruction of mites
and lice. Sulphur dioxide set free by
burning sulphur is, however, an efficient
fumigant for all insects (see Sterilization
AND Disinfection). Where a liquid insec-
ticide is applicable, bisulphide of lime is
an efficient agent (McClintic). Rosenau
suggests the preparation of this by boiling
together, for an hour or more in a little
water, equal parts of flowers of sulphur
and stone lime. Thus, 5 pounds of each
ingredient may be boiled in 3 or 4 gallons
of water until a brownish liquid is formed;
the latter may be diluted to make 100
gallons. This preparation may be sprayed
or poured into cracks or crevices contain-
ing roaches, bedbugs, lice, etc. S.
SULPHURIC ACID.-Acidumsui-
phuricum, U. S. P., is a clear, colorless,
odorless, heavy, oily, corrosive, and hy-
groscopic liquid, of a specific gravity of
1.826, miscible in all proportions with
water and alcohol with the evolution of
heat. It should be observed that in di-
luting, the acid should be added to the
water or other diluent, and not the re-
verse. It is one of the strongest of acids,
is dibasic, and forms normal and acid salts
which are generally crystallizable and
soluble in water.
PREPARATIONS AND DOSES.—
Acidum sulphuricum, U. S. P. (92.5 per
cent, absolute H2SO4). Dose, 2 to 3
minims (0.13 to 0.2 c.c), largely diluted
and taken through a glass tube or quill,
and the mouth rinsed immediately with a
mild alkaline solution.
Acidum sulphnricum aromaticum, U. S. P.
(elixir of vitriol; contains 10 per cent,
sulphuric acid with aromatics). Dose, 15
minims (1 c.c.) diluted with water,
syrups, etc.
Acidum siilphuricum dilutum, U. S. P.
(dilute sulphuric acid; contains 10 per
cent, sulphuric acid). Dose, 15 to 30
minims (1 to 2 c.c), well diluted.
Mistura sulphurica acida, N. F. (Haller's
mixture; a 25-per-cent. solution of sul-
phuric acid in alcohol). Dose, 8 minims
(0.5 c.c), well diluted.
PHYSIOLOGICAL ACTION.— When
applied locally, or taken in concentrated
form, this acid is. a strong escharotic, ab-
stracting the water from the tissues so
rapidly that they become carbonized
(black eschar). Overdoses destroy the
tissues of the alimentary canal, causing
violent gastroenteritis with severe burn-
ing pain in the mouth, esophagus, and
stomach. Collapse, followed by death,
may occur quickly. If the acid has not
caused perforation, death may come more
slowly, and in that case Stenson's duct
usually becomes occluded and inflamma-
tion of the parotid gland results. In some
cases acute nephritis with hematuria oc-
curs. If the patient recovers from the
acute condition, he usually dies later from
inanition, brought about either by stric-
ture of the esophagus or disintegration of
the gastric tubules.
TREATMENT OF POISONING.— As
there is danger of perforation of the tis-
sues, the use of the stomach-pump must
be avoided. Mild alkaline (solutions of
sodium carbonate or bicarbonate) and
demulcent drinks (barley-water, flaxseed
tea, thin gruel, diluted starch, oil, milk,
432
SULPHUROUS ACID.
white of egg) should be given freely, and
the pain relieved by opiates in sufficient
dose. The bodily temperature should be
maintained by the application of external
heat. The use of stimulants will relieve
the shock. Magnesia, lime, chalk, plaster
scraped from the wall, may be used as
antidotes, but solutions of sodium car-
bonate or bicarbonate are to be preferred.
THERAPEUTIC USES.— As an es-
charotic this acid may he employed in
the treatment of indolent ulcers, gangrene,
warts, chancres and other venereal sores.
For the destruction of superficial skin-
cancers Michel's paste, consisting of 3
parts of sulphuric acid and 1 part of finely
powdered asbestos thoroughly triturated
together, has been recommended. Simi-
lar escharotic pastes may be made by
mixing the acid with charcoal (Ricord's),
saffron (Velpeau's) or zinc sulphate
(Smith's). A liniment containing about
1 part of acid to 3 parts of olive oil is a
• decided counterirritant. An ointment con-
' taining 10 per cent, of the acid may
be used in tinea capitis. Sulphuric acid
is a chemical antidote in acute lead pois-
oning, and a prophylactic in cholera, in
doses of 5 niinims (0.3 c.c.) in a wine-
glassful of water, repeated.
Dilute sulphuric and aromatic sulphuric
acids are practically of the same strength
and adapted to the same uses. Given in-
ternally they are tonic, astringent and
refrigerant, and are useful in serous and
other diarrheas, combined with opium and
carminatives, especially in Asiatic cholera
and epidemic diarrhea in children. In the
night-sweats of phthisis aromatic sul-
phuric acid is best combined with atropine
in small doses.
In pyogenic infections — carbuncles, fu-
runcles, staphylococcic and streptococcic
infections, and also in bronchiectasis and
pulmonary tuberculosis where there is
staphylococcic infection — Reynold has
employed with success dilute sulphuric
acid, administered internally in doses
of 20 to 30 minims (1.25 to 2 c.c),
diluted with 2 ounces (60 c.c.) of water,
every four hours. Externally carbolized
petrolatum (1 in 20) was applied. Within
twenty-four hours the infiltrated area of
a carbimcle became strictly circumscribed;
then the slough softened, the pus freely
discharged, and the whole affected area
shrank, and healthy granulation-tissue
filled up the cavity until the part healed.
In infected wounds resulting from abra-
sions, punctures, or inoculation by de-
composing animal matter, treatment by
dilute sulphuric acid caused the early
symptoms of septicemia to rapidly dis-
appear, the fever to decline, and the pain
and swelling to subside. Recurrent crops
of boils and severe cases of acne yield to
internal treatment by dilute sulphuric
acid; blind boils are aborted. In tuber-
culous cases the fluctuations of tempera-
ture are influenced and the amount of
sputum is diminished.
Leo, Kuhler, and Stroll recommend the
use of dilute sulphuric acid in pruritus,
especially senile pruritus, and that form
complicating pulmonary disease.
Haller's sulphuric acid mixture is a
valuable astringent and antiscorbutic; it
is also used to dissolve quinine sulphate
in liquid mixtures.
SULPHUROUS ACID.-Acidum
sulphurosum, L'. S. P. VIII, is a colorless,
aqueous solution of sulphurous acid (gas)
containing not less than 6.4 per cent, of
absolute SO2, having the characteristic
odor of burning sulphur, and an acid,
sulphurous taste.
ACTION AND USES.— In pharmacy
and the arts it is used for bleaching
organic matter, removing fruit-stains,
for preventing putrefaction, and as a
germicide and disinfectant. It arrests
putrefaction and fermentation by destroy-
ing the germs which produce them. For
disinfecting purposes formaldehyde has
largely replaced the fumes of burning
sulphur, which contains large amounts cf
this acid, as the former is more powerful,
penetrating and persistent, and lacks the
bleaching property of the latter.
Sulphurous acid, in some form, is ex-
tensively employed in many technical op-
erations in the preparation of food — the
production of wine, the preparation of
evaporated or desiccated fruits, and in the
manufacture of molasses. There is rea-
son to believe that the use of sulphurous
acid in foods is deleterious.
The drug is rarely employed in medi-
SUMBUL.
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
433
cine, except as a topical application in
tinea versicolor, the undiluted solution be-
ing rubbed on the affected skin once or
twice daily; if it is to be applied con-
tinuously, the acid should be diluted with
three or four times its bulk of water.
Internally, in doses of from J/2 to 2
drams (2 to 8 c.c), largely diluted, sul-
phurous acid has been used to some ex-
tent in the treatment of fermentative
dyspepsia with flatulence, in urticaria, and
in hay-fever. The sulphites are more
suitable for internal use, since they give
off the gas in a nascent form in the
stomach.
SUMBUL.— Sumbul, U. S. P., or
musk root, is the dried rhizome and root
of Ferula siiinbitl, a plant of the family
Umbellifen-e, indigenous to the mountains
between Russian Turkestan and Bokhara.
PREPARATIONS AND DOSES.—
Sumbul, U. S.' P. (the root). Dose, 15 to
60 grains (1 to 4 Gm.).
Extractum sumbul. U. S. P. (solid ex-
tract). Dose, 5 grains (0.3 Gm.).
Fluidcxtractum suiiibtil, U. S. P. (fluid-
extract). Dose, 30 minims (2 c.c).
PHYSIOLOGICAL ACTION.— Sum-
bul acts -as a stimulant and antispasmodic.
In small doses it stimulates the appetite
and facilitates digestion. It is a stimulant
to the nervous system, and also a tonic.
THERAPEUTIC USES.— Sumbul is
employed as a tonic in delirium trem-
ens, hysteria, neurasthenia, chlorosis, and
amenorrhea. A resin prepared from sum-
bul is used to relieve chronic mucous dis-
charges from the lungs (bronchitis), uterus
(leucorrhea), and urethra (gleet). W.
SUNSTROKE. See Heat Ex-
haustion.
SUPRARENAL CAPSULES,
DISEASES OF. See Adrenals,
Diseases of.
SUPRARENAL ORGANO-
THERAPY. See Animal Ex-
tracts.
SURGICAL ANAPLASTY,
OR PLASTIC SURGERY. -Pias
tic surgery includes measures to correct
cleft palate, cicatricial deformities, etc.,
and' to improve cosmetic appearances.
The common feature of plastic opera-
tions is the ready and secure union of
refreshened or divided surfaces. The skin
is the main factor of these operations,
which are dependent upon its vascularity,
elasticity, and mobility.
GENERAL CONSIDERATIONS. — In
repairing defects, the neighboring skin
can be employed by merely freshening the
edges and suturing them together, mak-
ing nearby incisions to relieve the tension
(suture and tension), or by cutting more
or less definite flaps and shoving them
from one point to another (gliding flaps).
A modification of the gliding flap with
rotation is described by Croft, and may
be called the "granulation method." It is
especially useful in replacing scar-tissue
left after burns. A flap large and thick
enough is frjeed from its deeper parts (the
deep fascia), but is left attached at both
ends. A layer of rubber tissue or oiled
silk is inserted between the raised flap and
the deeper parts, and the under surface of
the flap is allowed to granulate for from
two to three weeks, when, one end being
detached, the flap is rotated into the de-
sired position and retained by sutures.
Perfect asepsis is essential in and after the
operation. Occasionally it is desirable
to use flaps with pedicles (pedunculated
flaps), obtaining them from the vicinity
("Indian method"), or from an extremity
approximated and held fast till union has
taken place ("Italian method"). Fre-
quently the skin must be extensively
undermined to increase its mobility.
The applications of plastic surgery are
exceedingly numerous. A crural ulcer,
for instance, may be covered by a pedun-
culated flap of the other leg, the cuticle of
the hand may be replaced by flaps from
the anterior or posterior surface of the
trunk, the skin being sometimes elevated
into a bridge and the hand slipped be-
neath (pocket method); defects in the
urethra and exstrophy of the bladder can
be repaired with flaps from the scrotum
etc.; neat plastic work is done in connec-
tion with cleft palate and perineal repair.
Double flaps are sometimes useful. For
instance, if a single flap is turned from
the neck into a total defect of the cheek.
8—28
434
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
the inner raw side will contract, causing
deformity. This is avoided by using two
flaps with their raw sides together: one
from the neck and one from the scalp, the
hair of the head simulating a beard. At
times one permits two flaps to grow to-
gether before placing them in position; or
the raw surface of a flap may be skin-
grafted. Flaps may be bent upon them-
selves, rendering them thicker and sup-
plying them with cuticle on both sides.
Flaps composed of skin and periosteum,
with or without bone are cut and chiseled
from adjacent parts and employed to fill
defects in bone — e.g., in the skull, or in
osteomyelitis of the tibia. Konig employs,
in rhinoplastic work, skin-periosteal-bone
flaps obtained from the forehead. Occa-
sionally one can chisel ofif a flake of bone
through a small incision, and slide it from
one spot to another by its loose areolar-
tissue connections with the skin.
GENERAL TECHNIQUE.— The pa-
tient should be in good health, and the
tissues free from disease and scarring.
Flaps used should be thick and include the
subcutaneous tissues, and their vascularity
should be assured. Complete asepsis is
of prime importance, suppuration increas-
ing cicatricial contraction, and the cutting
of sutures. Strong antiseptic solutions,
especially bichloride, must be avoided, as
they interfere with healing.
It may be preferable to cover defects by
skin-grafts rather than to attempt ex-
traordinary feats of plastic surgery.
Undue tension should be avoided, re-
laxation sutures often being useful. The
sutures should be few, and be just tight
enough to draw the parts together and no
tighter. In cutting flaps, about one-third
should be allowed for shrinkage.
Care must be used in twisting pedicles
not to cut off the vascular supply. When
possible, one should include a blood-vessel
in the pedicle. The bruising of flaps must
be avoided. A certain amount of pressure
by the dressings is often advantageous, but
it should not endanger the free circulation
of fluids. Artificial warmth is, in general,
unnecessary. Oozing must be carefully
checked, preferably without the use of
ligatures. An accumulation of blood be-
neath a flap may seriously jeopardize the
success of an operation. Hairs may be
transplanted in flaps comprising the entire
thickness of the skin, e.g., in replacing por-
tions of the bearded cheek from the scalp.
Puckers and irregularities following a
plastic operation tend to disappear. This
should he no excuse, however, for careless
or unsightly surgery. Moderate discolor-
ation of flaps, or the appearance of blis-
ters, may mean superficial necrosis and
not complete death of the flap. In plastic
surgery dry dressings are generally pref-
erable to moist ones. Pedicles should not
be cut until definite healing has taken
place and the irculation has become
thoroughly established. This may require
two or three weeks.
DEFORMITIES OF THE LIPS.
HARELIP. — This common congenital
deformity is due to the non-union of the
mesial nasal process with the superior
maxillary process. The upper lip is usu-
ally affected. A frequent complication is
alveolar or velopalatine fissure.
Varieties. — Median harelip is rare, vary-
ing in degree from a slight indenta-
tion in the vermilion border of the lip
to a complete division reaching upward
into the nasal septum; the frenuni in
this case is also split. A bilate.ral cleft,
with the middle of the lip and maxilla ab-
sent, may be mistaken for a median cleft.
Simple Unilateral Harelip. — This varies
from a notch in the mucosa to a cleft
which divides the nostril. On the cutane-
ous aspect) of the lip the mucosa is gen-
erally everted. In the more extensive
forms there is usually atrophy of the ex-
ternal border of the cleft, the nostril is
widened, and the ala nasi lowered.
Unilateral Harelip with Fissure of the
Bony Parts. — In this form there is added
a cleft in the alveolar arch, with or with-
out irregularities of the teeth.
Simple Bilateral Harelip. — Here there is
a cleft on both sides.
Complicated Bilateral Harelip. — In these
cases there may be simple alveolar fissure
on one side and a complete cleft on the
opposite side. Usually symmetry marks
those deformities, and the bony lesions
are: an alveolar fissure of both sides, with
slight protuberance of the maxilla; a deep
fissure extending between the margins of
the bony gaps, the nasal and buccal mu-
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
435
cosa being intact; a complete fissure
through the mucosa and bones, terminat-
ing at the anterior palatine foramen by
two lines converging anteroposteriorly;
and finally with palatine roof nearly al-
ways divided. Other deformities of the
face are at times present, such as con-
genital fissure of the cheek, eyelid, etc.
Single harelip occurs most frequently
on the left side (75 per cent.). It is often
traceable to heredity.
Treatment. — A fixed age at which opera-
tion should be done — the sixth week, the
third month, etc. — cannot be applied to
all cases. While one could easily stand
operation a few weeks after birth, another
would die from shock. In the simpler
cases the earlier the operation the better.
Should the child be weakly, or the fissure
be double and extend through the hard
parts, the operation should be postponed
until the second or the beginning of the
third year.
The following general technique is that
recommended by Shepherd; For children
under 1 year an anesthetic is dangerous;
for those older, chloroform is the best
anesthetic. The child should be confined
in a sheet or large towel, and held in the
arms of a strong nurse, the head being
steadied bj^ an assistant, who thrusts the
head a little forward to prevent the blood
entering the mouth. Sitting in front, the
operator should first cut through the
mucous membrane attaching the lip to the
gum, and freely separate it so that the
lips hang loosely. The edges of the cleft
are then freely pared by using a narrow-
bladed knife and transfixing the edge of
the cleft well up to the nostril; the flap
is cut free above, but below is left on
each side attached to the edge. As the
two edges of the cleft are seldom of the
same length, on the longer side the soft
parts should be more freely freshened.
Both flaps should be cut as far as the red
line of the lips. Any redundancy can be
cut ofif. The flaps should not be separated
from the edges of the cleft below until
several sutures have been placed in the
lip above and the fastened edges of the
cleft accurately adjusted near the nose.
The paring from the shorter side is then
cut away, and more or less, as occasion re-
quires, of the tissue at the red portion of
the lip removed; the flap of the long side is
then brought over and adjusted. During
operation an assistant compresses the
sides of the cleft with his fingers. Should
blood get into the mouth, it is at once
removed. Silkworm gut and horsehair
sutures are employed. Care should be
taken not to go through the lip while
suturing, but to dip down to the mucous
membrane only; the stitches should range
on each side at least one-eighth of an inch
from the edge. If the sutures seem to
pull too much, or if there is a slight un-
evenness, one should immediately take
them out and reintroduce them. After the
main sutures of silkworm gut are placed,
intermediate ones of horsehair may be
used, the lip then everted, and the mucosa
sutured. Important points in operating
are: (1) Freeing the lip from the gum.
(2) A free sacrifice of the edge of the
cleft. (3) Accurate apposition of the
parts.
In dressing, an antiseptic paint (iodo-
form, resin, oil, and alcohol) applied
over a piece of lint or cotton is used.
Cheek-straps to prevent tension are made
of diachylon plaster, and the cheek parts
cut broader than the part running across
the lip; they should interlace in the mid-
line.
Before operation it is very important
to know that the child has not been ex-
posed to any fever, measles, or scarla-
tina. Other causes of failure are inordi-
nate crying, too early removal of the
stitches, and especially infection. Silk-
worm gut is left in from six to ten days.
Should primary union not occur, one
should wait until the inflammatory action
has subsided, then freshen the edges and
bring them together.
It is well to introduce a prophylactic
suture before freshening the edges of the
cleft so that as soon as dissection is ended
the raw surfaces are brought together and
bleeding suppressed.
After-treatment and Complications. —
Firm union takes place early if the wound
is aseptic. Every alternate superficial
stitch may usually be removed on the
second or third day. The deeper sutures
should remain six days. The child's hands
and arms should be restrained, and oa-
tient prevented from turning on its face
436
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
and rubbing the lip on the pillow. Liquid
nourishment may be given three or four
hours after the operation.
Complications may usually be traced to
a weak condition of the patient or to
sepsis; death, if it occurs, is usually due
to low vitality; wound infection rarely en-
dangers life, unless bone infection occurs.
In apparent failure, remove sutures and
After the operation there is often great
difificulty in breathing through the nos-
trils, and intranasal rubber tubes or por-
tions of a large-sized catheter introduced
are often an aid. These may be withdrawn
after twenty-four hours.
In simple unilateral harelip, where there
is (inly a notch in the mucosa, Nelaton's
operation is advised. An inverted V-
Nelaton Operation for Incomplete Harelip.
Line of incision. .
apply wet dressings, and allow healing to
proceed by granulation. The danger of
pneumonia and bronchitis maj' be dimm-
ished by preventing blood and mucus from
entering the trachea with the Trendelen-
burg position, or holding the child upright
with head inclined forward. The effects of
hemorrhage and shock may be combated
with copious saline hypodermoclysis.
///
Incision Converted into a Pei-pendicular One.
Ready for suture.
shaped incision is made through the lip,
around the corner of the notch and par-
allel with its edges. The incision is con-
verted into a vertical one and its edges
are united with interrupted sutures.
In unilateral harelip with fissure of the
bony parts (alveolar process) and ad-
vancement of the intermaxillary bone the
latter is not only misplaced, but usually
Hagedorn Operation for Complete Double Harelip.
Paring and formation of flaps.
Jacobson calls attention to an infre-
quent, fatal complication: When the cleft
is large and the upper lip when restored is
tight, when it overhangs the lower, if the
nostrils are flattened and partially closed
by the operation, owing to tension of the
parts, the breathing space may be so
limited that temporary interference with
respiration may occur. In these cases,
Rose suggests that the nurse, depress the
patient's tongue at interval's, or a strip of
collodion be painted from lower lip to
chin to hold the lip open.
Parts Ready for Suture.
rotated, so as to present a prominent sharp
edge anteriorly. It should be twisted upon
its long axis and set square, so that its
sharp lateral edge will not project under
the line of sutures. It may be necessary
to forcibly separate (with bone forceps or
chisel) the bony process from its alveolar
attachment, and bring it in place by rotat-
ing it upon its long axis. If the vomer
prevents, the edge of the intermaxillary
may be resected with a chisel or rongeur,
in which case we lose an incisor tooth. As
these measures complicate the operation.
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
437
the latter should be deferred in very young
children. Finally, the cleft in the lip may
be closed by the method already men-
tioned.
In simple bilateral harelip, the double
Malgaigne or double Hagedorn operation
may be applied. The middle segment is
invariably too short to form a part of the
free border of the lip, but may be utilized
to form the middle portion. One side
may be done at a sitting, or the lateral
margins of the middle segment and the
corresponding margins of the lateral seg-
ments may be freshened and united, thus
converting it into a double incomplete
harelip, to be corrected later. If the nose
is flattened, the lateral segments of the lips
and the sides of the nose should be sep-
arated from their deep attachments.
In complicated bilateral harelip, the
projecting premaxillary prominence may
be replaced by simple fracture or by ex-
cising a wedge (Blandin) or quadrilateral
area from the nasal septum. The middle
segment may be placed very far forward,
upon or near the tip of the nose; here the
cutaneous part of the nasal septum is ab-
sent and the soft parts must be made into
the tegumentary part of the nasal septum,
and the whole lip must be formed from
the two lateral segments alone. Libera-
tion of the flaps may be necessary, by
separating them from the alveolar process
of the superior maxilla, or, in addition, an
incision may be necessary upon either
side, around the ate of the nose, known
as Dieffenbach's Wellenschnitt. As a rule,
the attempt to replace the middle seg-
ment should be made during the first,
second, or third year. If the intermaxil-
lary bone is entirely excised the four in-
cisor teeth are lost, and a plate must be
fitted. If it is simply replaced, it usually
remains rudimentary and the attached
teeth imperfect. Removal of any consider-
able part of the septum, in order to re-
place the intermaxillary portion in its nor-
mal position, will cause the tip of the nose
to be flattened downward.
HYPERTROPHY OF THE LIPS.—
This may l)e observed in healthy individ-
uals, but more frequently in strumous
children. When it disfigures the patient,
the deformity is usually corrected by
removing an elliptical piece of the mucous
membrane and submucous tissue in a
horizontal direction. Tissue removed
should represent the excess only, lest there
result undue recession.
DEFORMITIES DUE TO INJURY.
— Burns and scalds are the most prolific
causes of labial deformities, ectropion or
eversion of the lip being caused. The
lower lip is usually that involved, and
the exposure of the teeth and gums, the
interference with speech, and dribbling
produce a repulsive appearance, especially
when the injury involves the tissues of the
chin and neck; the lip may then be drawn
over the chin and the latter to the inter-
clavicular notch or even the sternum.
Treatment. — The method recommended
by Mr. Teale, of Leeds, is as follows:
Wellenschnitt for Complete Harelip. In-
cision carried around the alse of the nose in
order to liberate the segments. Formation of
flaps by incision into each segment.
"The everted lip is divided into three
parts by two vertical incisions three-
fourths of an inch long and carried down
to the bone. These incisions are so
planned that the middle portion between
them occupies one-half of the lip. From
the inner end of each incision the knife is
carried upward to a point one inch be-
yond the angle of the mouth. The two
flaps thus marked out are freely and
deeply dissected up. The lateral flaps are
now raised and united by twisted sutures
in the mesial line and supported, as on a
base, by the middle flap, to which they
are also attached by a few points of su-
ture, leaving a triangular even surface to
granulate." This operation usually gives
good results, but it must sometimes be
slightly modified to suit existing con-
ditions.
EVERTED LIP.— Where eversion is in
the median line, above or below, a single
438
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
incision at right angles to the free margin
of the lip in the median line may be made.
This is converted into an incision lying
parallel to the free margin of the lip;
sufficient inversion results to improve the
appearance. This incision is made from
the labiogingival junction to the inner
margin of the exposed portion of the lip.
A long lip may be shortened by passing
the first sutures in the median line so that
it is fixed on the connective tissue over-
lying the gum; the degree of tightness
with which this suture is tied will meas-
ure the shortening.
Where the entire lip is everted, the in-
cisions are multiple. A portion of the
sia with scissors. When it has progressed
beyond this stage, all related lymphatic
glands in their typical position must be re-
nxivcd. If the glands are not perceptibly
enlarged, they are taken out with the sur-
rounding fat, before the tumor; this se-
quence is important. As a rule, the in-
cision should be carried two-fifths of an
inch wide of all obviously affected tissue.
There were only 3 cases of local recur-
rence out of 113 operations in which this
rule was followed.
When the edges of the new lip are de-
void of mucous membrane, the mucosa
may sometimes be pulled over the defect
from within and stitched to the skin. A
Bruns Method of Restoring the Lower Lip.
Dotted lines indicate that the mucous mem-
brane is cut longer than the skin in order to
provide a mucous membrane border to the new
lip.
mucosa may be excised, but the incision
should be well inside the mouth. The por-
tion showing as a "double lip" should
never be excised.
INVERTED LIP.— The operation is
the reverse of the preceding.
EXCISION OF LABIAL CANCERS.—
A V-incision, including the mass and closed
with deep silkworm-gut sutures, is, as a
rule, alone required. The wound usually
heals in a week. The resulting small,
rounded, puckered opening, representing
the mouth, which is formed entirely by the
upper lip, regains a nearly normal appear-
ance after from six to eight months. When
the growth has progressed farther, all dis-
eased tissues — always including all en-
larged glands — should be removed.
Fricke urges that every ulcerating wart
about the lips which resists treatment
should be extirpated under local anesthe-
Flaps Turned Down and Joined to Form
New Lip. Mucous membrane is sutured over
the free margin of the new lip. The defect
upon each side of the cheek is closed by
suture.
lip of skin alone, with no internal mucous
covering, shrinks enormously on healing.
FORMATION OF THE LOWER LIP
AFTER COMPLETE EXCISION.— To
remedy a triangular defect too large for
simple suture the Dieffenbach-Jaesche
method may be used. An incision, from
each corner of the mouth, is carried out-
ward and somewhat upward into the
cheek for a distance sufficient to close
the defect in the lip, allowing one-third
for shrinkage. A second curved incision,
from the end of each of these incisions,
is then carried downward and inward to-
ward the chin, terminating near the lower
border of the jaw and under the angle of
the mouth. Stenson's duct Is avoided.
The mucosa, corresponding to that part
of the incision that passes outward from
the corners of the mouth, should be
cut upon a higher level than the skin to
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
439
form the free border of the new lower
lip. At all other points the incision
goes through on the same level. The two
flaps are now separated from the lower
jaw, avoiding injury to the fold of mu-
cous membrane reflected to the gums.
The edges of the gums are united with
interrupted silk sutures through the lip
down to the mucosa. The edges of the
mucous flaps, which were cut long, are
turned outward and sutured to the skin.
The semilunar defects on either side are
closed with sutures.
For a quadrangular defect the Brun's
method may be used. A square-cornered
flap, from either side of the face, through
the whole thickness of the cheek, is turned
down through an angle of ninety degrees.
The apposed edges of the flaps are united
and the mucous membrane sutured to the
edge of the skin to form the free margin
of the new lip, and the lateral defect on
either cheek is then closed.
As large a defect as that left after ex-
cision of three-fourths of the lower lip
may be replaced by Estlander's method.
RESTORATION OF THE UPPER
LIP. — A defect may be closed by Estlan-
der's method, the lower lip furnishing the
flap. In Dieffenbach's Wellenschnitt a
curved incision is made through the whole
thickness of the cheek around the corner
of the nose. The flaps thus marked out
are separated from the maxillje, drawn
toward the middle line, and turned down,
so that the raw edges of the original de-
fect form the free border of the new lip.
The two flaps are united and the edges
of the mucous membrane and skin sutured
along the free margin of the new lip. The
mucosa may be cut a little longer than the
skin to facilitate the union of these edges.
The defects around the side of the nose
may be sutured together after the flaps
have been united in the middle line. Small
wedge-shaped defects may be closed with
sutures, combining this, if necessary, with
detachment of the cheek by Dieffenbach's
Wellenschnitt.
MACROSTOMA (LARGE MOUTH).
— This is a deformity of the mouth due
to failure of the maxillary process to
unite with the mandibular process during
development. The mouth may be pro-
longed on one side so as almost to reach
the ear. The condition is often associ-
ated with malformation of the auricle.
Treatment. — The edges of the buccal
opening may be freshened and united,
leaving enough of the aperture to consti-
tute a normal mouth. The latter must
not be made too small, however, the pa-
tient having to undergo a gradual train-
ing in the use of the lips in speaking,
drinking, etc. In some cases a plastic
operation is required.
MICROSTOMA (CONGENITAL
ATRESIA ORIS).— This is the result of
an excessive degree of fusion between the
maxillary and mandibular processes, and
may be marked. It must be differentiated
from acquired stenosis, from cicatricial
contraction after burns, syphilitic ulcera-
tion, lupus, etc.
Treatment. — The mouth is enlarged by
incising the cheek at the angles of the
mouth and suturing the mucosa to the
skin.
CLEFT PALATE.— This condition is
the result of imperfect union, during fetal
life, of the two horizontal septa which, by
their growth, form the partition between
the nasal cavities and the mouth. When
the posterior portions of the processes fail
to coalesce, the resulting triangular slit
forms the '•cleft."
It varies from bifid uvula to complete
central division of the soft and hard
palates. In many cases of the latter kind
the margin of one of the maxillary proc-
esses is fused with the vomer. It may
be associated with harelip on one or
both sides, the intermaxillary portion, in
the latter case, carrying two or three
incisors.
The cleft interferes with voice-produc-
tion, owing to the escape of air into the
nasal cavities, and with deglutition, food
being forced into the postnasal space.
During infancy this may be dangerous, the
infant being unable to suck satisfactorily,
owing to the inability of the soft palate
to close off the naso-oral isthmus.
Treatment. — The time to operate de-
pends upon the condition of the child,
the extent of the deformity, and the de-
gree of interference with normal feeding.
In inextensive clefts the child soon adjusts
the oral tissues and finally swallows suffi-
cient food; but an early operation is
440
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
indicated to avoid imperfect enunciation
when he begins to speak. In England it
is customary to operate about the fifth or
sixth year; in America about the third.
When interference with deglutition is
marked, Mansell-Moullin recommends that
a flap be adjusted to the rul)])cr nipple
so disposed as to close the cleft, or if the
nipple be long that the opening be on
its under surface. If a soft-palate cleft is
closed before speech is learned, the result,
so far as the child is concerned, is perfect.
Closure should, therefore, occur some-
where between birth and the end of the
second year; within this age limit the
later the operation is performed the better.
When there is a complete cleft, both of the
lip and the palate, Murray advises opera-
tion on the lip when about three weeks
old, leaving the palate alone until the end
of the second year. Lip closure influences
the subsequent growth of the hard palate.
Where the hard palate is involved articu-
lation will always be somewhat defective.
Staphylorraphy. — This operation is a
somewhat tedious performance. The Rose
position is most satisfactory, the child on
its back lying on a hard mattress, wrapped
firmly in a sheet, and with a firm pillow
underneath the shoulders. The head must
be toward the light, extended, and project
a few inches beyond the table. The mouth
is kept open by means of a mouth-gag.
Both sides of the soft palate are, in turn,
seized with a tenaculum forceps and their
edges pared off with a very sharp probe-
pointed bistoury. Curved needles are
used for sutures, the best of which is silk-
worm gut. Some surgeons prefer silver
wire and use tubular needles. The needle
is introduced on either side from below,
the surures being made double on one side
and single on the other. The latter being
passed through the former, the stitches
are tied, after the pared edges have
been carefully brought in apposition. If
the parts are not under tension, the opera-
tion proper is finished; if they are, a pro-
cedure introduced by J. Mason Warren
should be resorted to: i.e., the levator and
tensor palati muscles should be divided by
pushing a tenotomy knife through the soft
palate, immediately internal to the hamu-
lar process and cutting upward until the
muscles are severed. The brisk hemor-
rhage soon stops. The head may be
turned to one side and the mouth swabbed
out with ice-water. Blood should not be
allowed to trickle into the larynx.
Finally the parts should be carefully ir-
rigated with boric acid solution. Only
tepid and liquid food should be allowed
the first few days and soft food subse-
quently until adhesion is complete. This
occurs in a healthy child at the end of a
week, when the stitches may be removed,
but it is better and often necessary to
leave them longer. When a small portion
of the wound fails to heal, it should
be stimulated with the mitigated stick.
Polaillon performs staphylorraphy in
two sittings, at an interval of twenty-four
to forty-eight hours. At the first sitting
lateral incisions are made; the mucosa is
dissected from each side and loosened
from the palatal bones; then hemorrhage
is arrested. At the second sitting, the
edges of the tissues are vivified and very
fine sutures introduced. This operation
may be done under cocaine anesthesia.
Owen detaches the mucoperiosteum
from the back of the hard palate, in or-
der to gain a slackness of tissue at the
anterior part of the cleft in the velum.
Tension is further diminished by lateral
incisions passing through the soft palate
parallel to the line of the sutures.
Uranoplasty. — If, in a case, the hard
palate alone is fissured, the old procedure
advised by J. Mason Warren is still re-
sorted to. by most surgeons. It consists
in carefully separating the mucous mem-
brane and periosteum from the bone on
both sides with the palate elevator, be-
ginning at the margin of the cleft and ex-
tending on each side toward the alveolar
process as far as needed. The vessels in
the palatine canals must be avoided. The
free flaps of membrane thus obtained are
then brought together over the opening
and sutured. When the soft palate is also
cleft, it should be cut from the horizontal
edge of the hard palate and the edges of
the fissures pared and united precisely as
in staphylorrhapy, including the section
of the palatal muscles if required. Su-
tures are then introduced, the first being
inserted at the junction of the hard and
soft palate after the flaps have been care-
fully adjusted. In cases where the fissure
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
441
is not wide, the separation of the soft
palate from the hard palate is not
required; both edges of the entire fis-
sure are pared, the membrane over
the hard palate is raised, and the
entire opening is closed by approximating
the pared edges and suturing them. Sub-
sequent measures are as in staphylorraphy.
Ferguson divides the bone on either side
of the fissure and forces each fragment
thus obtained toward the median line.
The edges of the fissure are first fresh-
ened; holes are drilled through the bony
processes near the edge and silver sutures
are passed through the openings; a strip
of bone is then cut off with a chisel or
saw from each side and pressed over to
the median line. The sutures are then
drawn together and tied. Division of the
soft palate downward is necessary. This
operation has not obtained much favor,
though it is a satisfactory one.
Berry and Legg divide their operation
into five parts: —
(1) Detachment of the mucoperiosteal
tissues of the palate from the bony palate;
(2) Detachment of the soft palate from
the posterior edge of the palate bones;
(3) Paring the margins of the cleft;
(4) Suturing the pared edges;
(5) Making, if necessary, lateral in-
cisions to relieve tension.
Arbuthnot Lane uses the flap formation
to close in the hard and soft palates by
two methods: "If the soft parts overlying
the edges of the cleft are thick and vas-
cular, a flap is cut from the mucous mem-
brane, submucous tissue and periosteum
of one side, having its attachment or base
along the free margin of the cleft. The
palatine vascular supply is divided when
the flap is being reflected inward, and it
derives its blood-supply from vessels en-
tering its attached margin. The mucous
membrane, submucous tissue and perios-
teum are raised from the opposing margin
of the cleft by an elevator, an incision
being made along the length of the edge
of the cleft. The reflected flap, with its
scanty supply of blood derived from small
vessels in its attached margin, is then
placed beneath the elevated flap, the
blood-supply of which is ample, and it is
fixed in position by a double row of
sutures. In this way two extensive raw
surfaces, well supplied with blood, and
uninfluenced by any tension whatever, are
retained in accurate apposition. If, on the
other hand, the cleft is too broad to admit
of its safe and perfect closure in this
manner, one flap, comprising all the mu-
cous membrane, submucous tissue, and
periosteum on one side, is raised, except
at the point of entry of the posterior
palatine vessels, while the soft parts on
the opposite side are raised in a flap from
which the posterior palatine supply has
been excluded, and which turns on a base
formed by the margin of the cleft. Here
is a mobile, well-vascularized flap, which
can be thrown, as a bridge in any direc-
tion, and can be superimposed on the flap
of the opposite side, the closure being
necessarily rendered complete by flaps
from the edges of a harelip."
A feature of these operations is that
much hemorrhage usually occurs. This
can be, in part, prevented, however, by
pressing upon the tissues behind the
upper incisors. The descending palatine
arteries can be plugged with a match-stick.
Jacobson and Berry operate not earlier
than the second or the beginning of the
third year for the following reasons: The
parts are larger, more easily manipulated,
and do not tear so easily; hemorrhage is
more easily controlled and better with-
stood; congenitally deformed children do
not bear operations well; the postoperative
care is easier and more satisfactory; the
liability to postoperative pulmonary infec-
tion, convulsions, and diarrhea is mini-
mized.
John B. Roberts advises operation when
the infant is only a few days old, except
in case of grave physical disability, when
the operation may be delayed a few weeks,
during which time digital compression is
applied daily. Squeezing the separated seg-
ments of the hard palate together a few
dozen times every morning and evening,
he claims, will tend to lessen the breadth
of the cleft and favor the formation of a
bony roof to the mouth by operation.
After-treatment. — The oral cavity should
be sprayed daily with a mild alkaline
antiseptic lotion. The wound should
not be inspected unless the child strug-
gles and cries. During the first week
liquid nourishment, in small quantities at
442
SURGICAL ANAPLASTY, OK I'LASTIC SURGERY.
a time, should be given, using a spoon.
To prevent the baby from crying, it should
be nursed and soothed; if the child is
older, it should be forbidden to talk. Not
earlier than the tenth day the stitches
may be removed, the patient being an-
esthetized. The crucial test of success is
improvement in speech. Elocution les-
sons should be given later to this end.
Three months after the operation the
wound should be re-examined, and if the
soft palate appears overtense, the mother
or nurse should massage the parts.
In some cases operative procedures can-
not be resorted to; obturators constructed
by dentists should then be tried.
RHINOPLASTY.— Plastic operations
are often indicated for deformities of the
nose from syphilis, lupus, or traumatism.
Indian Method. — In this procedure a
pear-shaped flap, somewhat larger than
needed to make up the soft tissues neces-
sary, is mapped out on the forehead.
The nasal edges are thereupon carefully
freshened and leveled, a regular bed be'ng
prepared for the flap. The latter is care-
fully detached with the periosteum from
the frontal bone, twisted down, and so ad-
justed as to cause a bend in the flap to
correspond with what would represent a
nasal bridge. Two hard-rubber tubes
shaped like the anterior nares should be
inserted and the flap sutured in place.
Schimmelbusch resorts to the following
operation: A three-cornered skin-and-
bone flap is taken from the middle of the
forehead. This flap is so cut out with the
knife that the smaller base is at the root
of the nose, and the broader side lies
exactly in the middle of the forehead.
With a sharp, broad chisel the anterior
surface of the frontal bone represented by
the flap is chiseled off. From the angles
of the forehead defect, large, arched in-
cisions are carried over the skull toward
the ears, and the flaps loosened and su-
tured over the forehead. In this manner
simple linear scars remain in the forehead.
The loosened flap must first be allowed
to granulate, and then it is transplanted
upon the wound surface. The bone plate
is sawed along its middle line and folded
together in the form of the nose. This
formed flap is then sutured into the fresh-
ened wound in such a way that the raw
surface stands posteriorly and the skin
surface anteriorly. The septum of the
nose is simply obtained from the skin
in the deformed nose; so that strips of
skin are taken from the sides of the de-
fect as far as the natural position ol the
septum. The tip of the nose is also
formed from the original nose. The first
week a silver wire with buttons on either
end is passed through the nose at the level
of the alc-e, and left in place until the
separation of the forehead flap. This
helps form the alae by its lateral pressure.
Transplantation of a piece of bone
from the tibia for nasal deformity is
preferred by the writer to that of the
rib. A curvilinear incision is made
between the eye-brows, with the con-
vexity downward. The periosteum
is next cut higher up than the skin
incision and loosened above, then
turned back from the nose on the
bridge below. The skin is dissected
over the nose by means of Freer's
septal dissectors and a piece of tibial
bone inserted under the skin to the
tip of the nose and the upper end in-
serted under the upper portion of the
periosteum of the forehead. Stauffer
(Penna. Med. Jour., 21, 26, 1917).
Italian Method.— A flap is taken from the
arm of the patient, over the biceps, at
a spot corresponding with the nose when
the hand is applied over the head from
the front. The flap is so shaped as to
assume that of the nose when in sifii,
allowing I/3 for shrinkage. A pedicle from
the arm is preserved to insure nutrition.
The flap is left thus about two weeks, to
enable it to become vascular and covered
with granulations underneath. At the end
of this time the nasal orifice is prepared as
for the Indian method; the forearm is
placed over the head and fastened there
by bandages, and the flap is adjusted to the
pared nasal edges and sutured. The pa-
tient must remain in this trying position
about twelve days, when the pedicle is cut
and the arrn released. The pedicle is then
trimmed and a column is either formed
with it or with a small flap taken from the
upper lip. The procedure is often success-
ful, but it is irksome, and a presentable
nose is seldom obtained.
In less marked deformities, usually of
SURGICAL ANAPLASTY, OR PLASTIC SURGERY.
443
the alse, a small flap may be obtained from
the cheek or forehead. A pedicle should
always be left to insure nutrition of the
flap. If the redundant portion is un-
sightly, it may be adjusted as soon as the
nasal flap is thoroughly nourished through
its new channels. (See Skin-grafting.)
REDUCTION OF HUMP-NOSE
(AQUILINE NOSE).— Charles C. Miller
suggests an operation 'done under infil-
trative anesthesia. The nares are thor-
oughly cleansed with gauze strips wet
with a mild antiseptic or soap solution.
The line of incision is along the free mar-
gin of the nasal bone and need not be
long (one-quarter inch), as a very narrow
chisel serves best for loosening the hump.
Care should be taken not to chisel beneath
the nasal bones, but beneath the hump,
and when it is entirely free except for the
overlying periosteum, the loosened frag-
ments are grasped with small forceps,
passed upward, and peeled from the
periosteum. Entire dependence is placed
upon an elevation of the nasal tip to give
access to the hump. Any remaining ir-
regularity felt should be smoothed with
chisel or cutting rasp. Bleeding may be
free, but is soon controlled by pressure.
STENOSIS OF THE NOSE.— In par-
tial stenosis an incision is made in the
median line of the nostril, carrying it
backward when the stenosis is posterior,
and forward when the stenosis is toward
the nasal tip. After complete division the
tissues are everted and excess trimmed off
with scissors, so that the skin alone is
left. Two skin flaps are thus formed
which are turned upward into the nose
and sutured with fine silk. Small curved
needles serve best.
Complete stenosis is treated in a sim-
ilar manner, unless distortion exists.
PARAFFIN INJECTIONS (HYDRO-
CARBON PROTHESIS).— The judicious
use of paraffin is allowable in special
cases. Unless, however, the most perfect
asepsis is maintained, infection is apt to
follow; a marked redness of the skin with
irritation of surrounding tissues may lead
to abscess and tissue necrosis. Necrosis
may also be caused by the pressure of
the injected mass on blood-vessels or by
excessive heat of the mass. Embolism is
apt to follow accidental injection into a
vein. Overcorrection of the deformity
may follow an excessive amount injected.
Unless the melting point is above the body
temperature, absorption is likely to occur.
The injection is made with a special
syringe, strong, with a screw on the piston
to allow a measured quantity of the semi-
solid mass to be forced slowly into the
tissues, able to resist the heat of steriliza-
tion and with a lumen large in proportion
to the size of the needle.
The paraffin mass consists of 1 part
parafifin to 8 parts of white vaselin; the
melting point of the mixture should be
between 105° and 110° F. (40.5°— 43.3° C).
The paraffin should flow from the needle
in a solid, worm-like stream. Care must
be taken that the flow has ceased before
withdrawing the needle. A drop of col-
lodion will seal the puncture.
In raising the nasal depression of a
saddle-nose, the needle should be inserted
quickly and the paraffin forced into the
subcutaneous tissue steadily. If the needle
becomes plugged the paraffin may be de-
posited into the forehead or into loose
tissue on either side of the. root of the
nose. The paraffin should be so molded
as to form a narrow bridge. When the
parafifin solidifies, molding is impossible.
These injections have been successfully
used to fill out hollow cheeks, and to fill
the interval between the brows when the
location was unusually low and marked
by perpendicular lines.
PLASTIC SURGERY OF THE EAR
(OTOPLASTY).
OUTSTANDING EARS.— Much can
be done in early childhood to prevent
this condition. Where a tendency to it
exists the parents should be induced, if
possible, to adjust a bandage which shall
hold the ears iirnily against the side of the
head. This bandage may be worn at night,
and if persisted in will, in most cases, cor-
rect the condition. In adult life, when the
cartilages are formed, this plan is not so
feasible.
Operations may be performed under
infiltration anesthesia. The solution used
is boiled water, or, better, normal salt
solution in each ounce (30 c.c), of which
Va to 1/4 grain (0.015 to 0.03 Gm.) of
cocaine is dissolved. This is injected along
444
SWEAT-GLANDS, DISEASES OF THE.
the line of juncture of the ear with the
cranium posteriorly. After the tissues are
infiltrated they are divided along this line,
and a crescentic flap of the skin is dis-
sected off on both sides. In slight cases
the ear may, be now held in its corrected
position by closely suturing the skin mar-
gins. When the ear resists correction and
there is tension on the sutures the carti-
lages of the ear may be divided with h
small knife through the posterior incision.
In more extreme cases a wedge-shaped
portion of the cartilage may be removed,
care being exercised so as not to puncture
the skin anteriorly. Kcdle outlines the
flap to be removed from the back of the
ear with the point of the knife, then
presses the ear against the cranium, and
so has the outline of the cranial flap
accurately made.
ABNORMALLY ENLARGED EAR
(MACROTIA).— This deformity may be
corrected by either the Kolle method or
the Parkhill method, or if the ear is ex-
cessively large, a triangular section may
be removed and the parts sutured. An-
other plan is to remove a crescent of tis-
sues combined with a small strip from the
outer margin or helix.
REPAIR OF CLEFTS AND FIS-
SURE OF THE LOBULE.— The most
common form is that produced by the
tearing out of an earring. The wounded
part should be cleansed, any lacerated
shreds of tissue removed with scissors,
and the parts sutured with catgut or silk.
When seen later, both sides of the cleft
are infiltrated, the margins denuded with
scissors or scalpel, and the parts sutured.
ENLARGED LOBULE.— This may be
corrected by first infiltrating the parts,
then, if the lobule is enlarged in all direc-
tions, operating by Joseph's method. The
incision should be carefully mapped out
before it is made, particularly if both ears
are deformed.
ELONGATED LOBULE.— If the lob-
ule is too long a vertical incision is made
parallel to the long axis of the lobule, and
after removing any excess of tissue the
line of incision is sutured in the direction
opposite to the original one, thus shorten-
ing and broadening the lobule.
SHORTENED LOBULE.— The preced-
ing operation is reversed.
ADHERENT AND UNDEVELOPED
LOBULE.— Where the lobule is nearly
normal and is merely attached by a fold
of skin, this fold may be divided, the skin
edges of the lobule united with sutures,
and the edges of cranial skin likewise.
Where the lobule is not well formed
but triangular in shape, it should be cut
free internally, and a small flap formed
along the outer margin of the lobule, the
lobule being trimmed into shape and the
small flap adjusted around it.
For the correction of protruding,
roll, or dog ea -s the writer cuts an
ellipse of skin from the back of the
ear and the neighboring mastoid
with the superficial fascia, care being
taken to expose the periosteum and
perichondrium, which are stitched to-
gether with chromic catgut. G. Sel-
fridge (Calif. St. Jour, of Med., Sept.,
1918). S. and W.
SWAMP FEVER.
Fevers.
See Malarial
SWEAT-GLANDS, DISEASES
OF THE. — Although apparently, insig-
nificant, disorders of the sweat are often
a source of considerable distress. Sudam-
ina, treated in the sixth volume, page 705,
as a separate article, owing to its impor-
tance in general febrile diseases, is one
of these; but there are, besides, functional
disorders, which merit special attention
owing to the frequency with which some
of them occur in practice.
ANHIDROSIS, or deficiency of per-
spiration, may be physiological in the
sense that some subjects never perspire
perceptibly. As a rule, however, it is a
symptom of some general disorder such
as diabetes and certain fevers; or of some
cutaneous diseases such as psoriasis,
ichthyosis, squamous eczema, etc., the
affected areas failing to sweat when the
lesions are sufficiently developed. Vari-
ous neuroses also include deficient activity
of the; sweat-glands as symptom. Hence
the localized areas showing this defect and
its incidence with scleroderma. Anhidro-
sis may also be congenital.
Treatment. — When anhidrosis can in any
way be connected with asthenia of vas-
cular or nervous origin, the underlying
SWEAT-GLANDS, DISEASES OF THE.
445
cause should be ascertained and removed.
In addition to this, stimulation of the
sweat-glands by means of pilocarpine,
along" with vascular tonics such as nux
vomica, strychnine and also well-regu-
lated exercise in the open-air and bathing
followed by light massage are often pro-
ductive of good results. The anhidrosis
accompanying cutaneous diseases is met
by measures addressed to- the latter.
HYPERIDROSIS, OR EXCESSIVE
SWEATING, also termed ephidrosis,
polydrosis, and sudatoria, is a functional
disorder of the sweat-glands due to de-
fective sympathetic or cerebrocentral in-
nervation. It may be physiological under
the influence of heat, excitement or fear.
Of occur as a result of overexertion. It
becomes pathological when it occurs in
the course of diseases such as pulmonary
tuberculosis, rheumatism, malaria, the
anemias, etc.; it is referred to under these
respective headings. The present article
will include only localized sweating as it
occurs in the axillae, upon the soles and
palms, genitalia, face, etc. Occasionally,
the hyperidrosis is unilateral and may
affect the half of the forehead and face —
often with' migraine in the corresponding
area — and, as in paraplegia, the whole
body.
While in some cases even localized hy-
peridrosis may be constant, it is, as a
rule, exaggerated by heat or warm
weather, particularly where the parts are
covered. Here, especially about the geni-
talia and in the axillae, intertrigo may de-
velop. Sweating palms are usually cold
and clammy, though the sweat produced in
some cases is such as to fill up the hollow
of the upturned hand and to run over the
edge. The axillae and where the breasts
are large enough to come into contact are
often the seat of hyperidrosis. Sweating
of the face, is most marked about the
forehead, eyelids, and nose; the scalp is
not infrequently the seat of hemidrosis,
which often leads in this region to loss of
hair. Hyperidrosis of the feet is particu-
larly annoying, since it is frequently ac-
companied by fetor — a condition studied
specifically below under Bromidrosis. The
soles may become sodden and macerated
and the skin between the toes likewise,
the feet being thus rendered tender — suffi-
ciently so in some cases to interfere with
walking.
Treatment. — The patient's general con-
dition should be carefully inquired into
and any disorder discovered corrected if
possible. The nerve centers governing
the sudatory function should then be
toned up by means of agents known to
influence them, viz., atropine, agaricin,
ergotin, or pilocarpine, the latter in small
doses. Warm followed by cold douches
and static baths are very useful to pro-
mote the activity of the sweat-glands
where, as in obese and debilitated sub-
jects, undue patency of their tulniH under-
lies the disorder. When on the hand
there is undue activity of the glands, as in
hysterical subjects, bromides and valerates
are indicated. In some cases a deficiency
in calcium underlies the trouble; calcium
phosphate is the most efficient agent to
meet this demand. Sulphur* is often pro-
ductive of good results, a teaspoonful of
precipitated sulphur being given in milk
twice daily, and once daily if too active.
For hyperidrosis of the axilLne, hands,
or feet, local baths with vinegar, an in-
fusion of walnut-leaves and alum, a quar-
ter of 1 per cent, solution of potassium
permanganate, or a mixture of a table-
spoonful of commercial formol in a quart
of water, are all effective. Subsequently
the affected parts should be bathed with
the following lotion, diluted with one or
two parts of water: —
Ti. Naphthol B 5 parts.
Glycerin 10 parts.
Alcohol 100 parts.
M. For a lotion. To be diluted.
Or the following may be used: —
IJ Thymol gr. xv (1 Gm.) .
Tannin gr. Ix.xv (5 Gm.).
Spirit of cam fhor. Svij (210 Gm.).
M. Lotion. To be applied over sensitive
area with a brush or cotton wad.
Subsequently the feet should be care-
fully dried, and powdered with talcum,
starch, dr bismuth subnitrate, or prefer-
ably with the following: —
R Salicylic acid 5j (4 Gm.).
Starch Sijj (12 Gm.).
Powdered talc .. liij (100 Gm.).
Mix thoroughly. Foot jiowdcr.
446
SWEAT-GLANDS, DISEASES OF THE.
Another efficient powder for the feet is
the following: —
IJ Bismuth subiii-
irate Sj (31 Gm.).
Sodium salicylate. Siiss (10 Gm.).
Mix thoroughly. This powder may be
dusted into the socks and shoes.
The X-rays have been used by a num-
ber of observers with encouraging results.
The writer noticed that after a
long-continued series of sittings under
X-rays the patient ceased to perspire
on the part treated. Since that time
he has had 20 cases of excessive per-
spiration to treat. Nine of these have
been qualified medical men. In every
case which has been fully treated the
rays have produced their effect on the
sweat-glands, and either entirely
stopped their action or reduced it to
less than normal. In 2 cases which
were cured by 2 sittings, both suf-
fered from the effects of too large
a dose of X-rays (pain, irritation,
blistering, and redness); since then
all others have been done by the
longer method. Six sittings, of one
pastille dose each, at intervals of one
month, give the best results, and
cause no discomfort. Pirrie (Ar-
chives of Rontgenology, Feb., 1912).
BROMIDROSIS.— This condition, also
termed fetid sweating and osmidrosis, is
characterized by a more or less strong
odor of the sweat. It may be general, as
in the negro; but often, as is the case in
some red-haired subjects, it is restricted to
the axillje and feet. When limited to the
latter, bromidrosis is vulgarly known as
stinking feet and is a source of profound
mortification to the sufferer — sufficient in
some to lead to suicide. The odor of the
sweat is not always repulsive, however,
resembling in some instances that of
flowers, violets especially. In others,
again, it resembles that emitted by goats
and even skunks.
The cause of bromidrosis, where it oc-
curs in cleanly subjects, is unknown. As
usually met, however, it is due to the too
rapid decomposition of sweat in the
clothing and particularly shoes and stock-
ings, frequent changing of the latter and
of the underwear and daily bathing pre-
venting all odor. In some subjects, how-
ever, even such precautions prove un-
availing, especially in respect to the feet.
This form has been attributed to a
micro-organism. Bacterium fa'tidum, which
develops in an acid medium such as de-
composed sweat affords. In some pa-
tients, the skin of the feet is macerated
and appears sodden, grayish, or reddish,
especially between the toes and at the
soles. Many patients are flat-footed.
Treatment. — Scrupulous cleanliness is, of
course, of primary importance. The feet
should be bathed, using tar soap, at least
twice daily, and the stockings changed
each time. If the odor persists, various
powders are useful, dusted in the stocking
and between the toes, to prevent it.
Weber recommends the following: —
IJ Pulverized talc.
Bismuth subiii-
trate aa Siss (45 Gm.).
Potassium per-
manganate gr. }i (0.016 Gm.).
Sodium salicylate. Sss (2 Gm.).
Fluids are sometimes more efficient.
The following mixture may be used to
bathe the parts morning and evening: —
IJ Zinci sulph.,
Ferri sulph. .aa Siss (45 Gm.).
Naphtholi,
Olci tliymi,
Acidl hypo-
phosph aa gr. viij (0.5 Gm.).
Aquce Sviij (250 Gm.) .
In some instances potassium perman-
ganate or boric acid in the water used to
bathe the feet suffices. Thin recommends
that cork soles (or if unavailable, several
sheets of blotting-paper), soaked in a
saturated solution of boric acid and dried,
be worn inside the shoe. Several pairs of
these soles kept washed and saturated
may be used, thus protecting the feet and
shoes efficiently. Even where blisters and
abrasions were present, Benians obtained
excellent results from applications of
glycerin well spread over the soles and
toes after bathing, before the socks were
put on. The glycerin acts by preventing
the formation of noxious products of de-
composition. Sabouraud recommends the
SWEAT-GLANDS, DISEASES OF THE. 447
use of a 4 per cent, solution of chromic R Glycerin Siiss (10 Gm.).
acid in distilled water. The lotion is ap- Perchloride of .
plied briskly by means of a plug of cot- iron 5j (31 Gm.).
ton-wool, care being taken that the liquid Essence of herga-
thoroughly penetrate between and under mot TT^xx (1.3 Gm.).
the toes. The treatment should be re- ^,,^^^„^^^„,„ _„
, , , 1 r r , ^, CHROMIDROSIS, OR COLORED
peated daily for a few days, then every oTirir'AT^ t-i , ^ ^^^ ^ ,^
1 1 ^1 .V- 1 1 .-ii c oWii.Al. — Ihe cutaneous product m this
second day, then every third day, till nn- p l m
ally an application once a week is suffi- ""f h^"" '^'^ condition is, as a rule, either
cient. Formaldehyde is another excellent 1^'"^, red, yellow, black, brown, pink, or
remed ^"^ intermediate shade, including either
^, . , , , ^ ,1 , , of these colors. It is not, however, as its
The feet should first be thoroughly _ . , ^ j r ^t
, name suggests, always secreted by the
washed with warm water and soap, ^iju^ uj ^j- j
, , , • , ^1 , 1 sweat-glands, but may be due to disorders
rinsed, and dried. Ihen the soles r ^1 t. 1 j c •
, , , . , , of the sebaceous glands or of pigmenta-
and the skin between the toes are ,. . u • • t-i
, . , , r or tion, or to chromogenic organisms. The
painted with equal parts of 35 , , , ^ / ^ u l i_
^ . , •■ , , ,,..,,, black sweat (stearrhoea or seborrhcea
per cent, formaldehyde and distilled ..,,.. ^ , .
- ^, ,.,,,. , nigricans), which may not, however, be
water, ihe solution should dry be- i i 1 1 ^ 1 ^ i-i
. . 1 rr^, • pure black but slate-like or, again, re-
fore the foot is covered, ihis treat- ui ui 1 • u j u j-i
semble black varnish and show a predilec-
ment should be repeated three days .. r ^, ,., , .
^, „ . tion for the eyelids and face, may appear
in succession, ihe eiiect is prompt jji j ^ ji --jj
, , . . . , , suddenly, as does sweat, and has coincided
and lasts for four to six weeks, when -^u u j. ■ • ^ u- ^ t^
, ,. . , , , , , with hysteria in most subjects. It
the application should be repeated. , , . ,, .. . ,
_, . ... , . 1 corresponds chemically with the brown
ihe sweating, and the fetor to which . ^ r ^1 ^- , -^v i- ni-n
. . , pigment of the retinal epithelium. Millee,
it gives rise, are often permanently , , , ,r v-v-u
,,,'.._ , -.Tr 1 however, has observed a form which yields
cured. Althoff (Deut. med. Woch., ^ ^. . . . ^
^ im^N to antiseptics, thus suggesting some
I )pf* iyi4)
■' bacillus as cause. Red and pink sweat-
In stubborn cases, which, according to ing, usually of the armpits and external
Hale, are probably of neurotic origin, and genitalia, has been traced by Stott
are not infrequently met in armies, this to a torula, which be obtained in
surgeon sends the patient with all his pure cultures, the intensity of the color
foot-gear to the hospital. Every pair of varying inversely with the temperature.
his socks is soaked for an hour in bi- Heidingsfield has attributed red chromi-
chloride solution, 1 : 2000, thoroughly rinsed drosis to some form of erythro-micro-
in hot water, and carefully washed. His coccus tetragenus infection, but on
shoes are painted, on the inside, with a weaker grounds. Of another order is
solution of 1 ounce of salicylic acid in 4 the yellowish-brown or brown "sweating."
ounces of alcohol. The feet themselves The oily and resinous character of this
are washed, dried and painted with this excretion, which is readily soluble in
solution, attention being paid to the in- chloroform, point to an anomaly of
terdigital clefts. The entire skin surface pigmentation, the sweat and sebaceous
becomes white from the decomposition of glands and the hair-follicles being normal,
the salicylic acid, after the alcohol's evap- Brown sweating of the armpits has also
oration. Clean socks are then put on and occurred after the prolonged use of coal-
next day the painting is repeated. Per- tar remedies. In blue sweating (cutaneous
manent cure, Hale says, follows 2 treat- cyanopathy) two dififerent conditions may
ments, cleanliness of feet and foot-gear probably act as cause, since in one class of
alone being necessary to maintain it. cases it is as rapidly formed as sweat
Another efficient remedy, according to while in the other the product accumu-
Legoux, is the following: The feet are lates on the skin as a bluish, greasy pow-
first bathed twice daily for several days der which does not yield readily to water,
in a weak infusion of walnut-leaves and while at once removed with ether, alco-
then anointed twice daily with tiic follow- hoi, or chloroform, in keeping with the
ing solution: — product of the sebaceous glands, or other
448
SYPHILIS (LYDSTON).
fatty materials. Blue sweating generally
occurs in neurotic women, and is apt to
be most marked before menstruation and
during obstinate constipation. The con-
dition must be differentiated from argyria,
which, as is well known, is due to the pro-
longed use of silver nitrate and from the
blue sweating sometimes caused by potas-
sium iodide. Green sweating is some-
times observed in workers in copper.
TREATMENT.— The foregoing data
point to the need of studying the cause
of the disorder in each case and of re-
moving it. Inability to remove the excre-
tion with water, its prompt removal by
alcohol or ether, will point to the nature
of the secretion. In the former case local
remedies fail; the tone to the sweat-
glands should be activated by very small
doses of pilocarpine or, if the sweating is
excessive, of atropine. Stimulation of the
skin by means of salt baths or static baths
is very helpful. Where the morbid excre-
tion is fatty it is best treated with a satu-
rated solution of sulphur in benzene.
This applies also to the parasitic forms,
but here the yellow iodide of mercury
ointment has given the best results.
TUMORS OF THE SWEAT-GLANDS.
— These organs may be the seat of tumors,
but considerable confusion still exists
concerning their pathological differentia-
tion. Some seem to spring from the coil-
gland and have been termed collectively:
spiradenoma; others from the duct, syring-
adenoma. Others, again, are cystic owing
to the presence in the sweat-coil of a cav-
ity containing a more or less viscid fluid,
cystadenoma, with local hyperplasia and
widening of the canal. The latter forms
nodules varying in size from a barley-seed
to a pea, the smaller being hard and the
larger soft. They may occur in large
numbers on various parts of the body.
Among other tumors may be mentioned
benign epithelioma, carcinoma, and adeno-
carcinoma, which, when situated on the
vulva, syringoadenoma closely resembles.
Treatment. — Surgical removal or cauter-
ization by means of galvanocautery are
the only effective methods available. S.
SYCOSIS. See Hair. Diseases of.
SYlMBLEPHARON. See Eyelids
SYNOVITIS. See Joints.
SYPHILIS.— ETIOLOGY AND
SYMPTOMS.— Syphilis is due to
the inoculation of a healthy individ-
ual with the secretion of a syi)hilitic
subject or syphilitic blood containint^
the specific org-anism. Thoui^h usu-
ally transmitted during- sexual con-
gress, it is quite often innocently con-
tracted in other ways — syphilis in-
sontium. The conditions for inocu-
lation are such that the disease may
be transmitted extragenitally with
great facility. It occurs through con-
tact of the germ with a surface from
which the epidermis has been re-
moved. The removal of the epider-
mis is essential, the syphilitic infec-
tion having no corrosive properties
per se.
Clinical experiences that appar-
ently disprove this assertion are ex-
plicable by additional factors ; if the
infection be associated with another
type of infection which possesses
specially corrosive properties, the epi-
thelium may be destroyed by the
latter, this facilitating the absorption
of the former. Uncleanliness favors
the maceration and removal of epi-
thelium. When syphilis is associated
with chancroid — the most corrosive of
the venereal infections — the absorp-
tion of the syphilitic virus is greatly
facilitated. Traumatic removal of the
epithelium facilitates entry of the
micro-organism and accounts for a
relatively speedy development of the
primary syphilitic lesion.
When adventitious local circum-
stances favor a development of ex-
treme sensitiveness and a tendency
to abrasion of the epithelium under
slight causes, the predisposition to
infection is greatly enhanced. Ex-
treme length of prepuce in the male
SYPHILIS (LYDSTON).
449
and of the labia in the female are
important predisposing- causes ; also
alcoholism, for two reasons : first,
because it tends to produce irritabil-
ity of the mucous membranes of the
sore, or some simple affection, while
any appearing later is quite likely to
prove to be true chancre.
Specific Micro-organism of Syph-
ilis.— Fessenden Otis some years
sexual organs ; second, because of its since claimed that the contagium con-
tendency to produce moral obliquity
and indifference as to the results of
sexual excess. Often individuals,
while under the influence of alcohol,
contract syphilis from sexual ex-
posure which would be abhorrent to
the patient when in his normal con-
dition.
The virus, long suspected to be
sisted of a degraded infectious cell of
very minute proportions, acting by
incorporating itself with the normal
leucocyte and its derivatives. This
view is the more striking because in
nowise inconsistent with the germ
theory. By supposing the incorpora-
tion of a specific bacillus with the
"syphilitic germinal cell" of Otis, his
a germ of some kind, now has been views were in harmony with the
positively demonstrated and accepted bacillar theoiy. Personally, as a
to be a minute organism of the pro- disciple of Otis, his theory seemed ta
tozoon type, spirillar in form. me to be the most rational and useful
Incubation Period of Syphilis. — of all in teaching syphilology. Even
After the micro-organism of syphilis today it is logical in explaining what
has entered the tissues a certain I will term, for w^ant of a better word,
period elapses before its morbid ef- the "mechanics" of syphilis,
fects become manifest. This period The discovery of the Treponema
lasts, upon the average, about twenty- pallida by Schaudin and Hoffman
one days, but varies considerably was the beginning of the end of all
from this in different cases. Fournier controversy regarding the germ origin
relates a case in which the period of syphilis. This organism has been
was seventy-five days; Guerin, one of found by different observers in every
seventy-five days; and the writer has lesion of syphilis, including even the
noted a case of seventy days. The gummata of late syphilis, and in
period may be shorter than usual ; brain and cord lesions. One of the
thus, Hammond relates one of three most striking facts regarding it is its
days, and Nott reported his case as discovery in the brain in paretic de-
developing within twenty-four hours mentia. It occurs in special abund-
after wounding his finger in operat- ance in the chancre and mucous
ing upon a syphilitic subject. Taylor patcli. It has not been found in non-
reports a case in which the initial syphilitic lesions. Monkeys have
lesion appeared upon the second day, been inoculated with syphilis, chancre
induration upon the fourth day, and induced, and tlie spirocheta found in
general symptoms during the sixth the chancre. The crucial test of pure
week. It rnay, however, be accepted, culture and inoculation has finally
as a practical rule, that true chancre dispelled all doubt as to its specificity,
does not appear before the tenth day. The physical characteristics of the
Any sore appearing prior to that time spirocheta are distinctive. It is a slen-
is probably chancroid, a "mixed" dcr, actively motile, spiral, slightly
8—29
450
SYPHILIS (LYDSTON).
refractive organism, varying from 5
to 21 microns in length, and about ^
micron in thickness. It has from 5
to 12 corkscrew-like twists. These
twists are regular in the recent speci-
men— less so as the specimen ages.
It' is to be differentiated from the
Spirocheta rcfringens and Spirocheta
buccalis (S. de)itinm), which, are larger
and wavy in outline rather than of
corkscrew shape, and are less actively
motile than is the Spirocheta pallida.
The motion of the latter may be de-
scribed as a "bending" or "twisting."
Primary Local Changes. — Syphilis
practically is constitutional from its
inception, because we have thus far
no generally reliable means of pre-
venting its systemic results. Yet,
clinically and pathologically, the dis-
ease is exclusively local during the
first few weeks. So true is this that
the recent revival of what I am free
to confess appears to be a "broken
reed" in syphilotherapy, excision of
the chancre, is not astonishing.
The first effect of the syphilitic in-
fection is a gradually increasing ac-
cumulation of leucocytes at the site
of inoculation, produced by a modi-
fication of the normal leucocytes and
connective-tissue elements through
the influence of the infection. This
probably begins immediately after in-
fection. It is, however, gradual in
its progress ; hence a certain period
elapses before changes are apparent.
The accumulated previously nor-
mal cells (the syphilized cells of
Besiadecki, Otis, et al.), according to
their theory, contained the germs of
the syphilitic infection. Under the
pernicious influence of the syphilitic
infection, the cells became larger,
more granular, and developed nu-
merous nuclei ; were infectious, and
possessed exaggerated powers of pro-
liferation and ameboid movement,
together with a marked tendency to
retrograde metamorphosis.
Taking as our point of departure
the initial lesion of syphilis, we note
a localized proliferation of the now
infected and perverted cells, and, fol-
lowing the infection in its course,
thickening of the lymphatic vessels
and enlargement of the lymphatic
glands. After a time infection-bear-
ing— i.e., spirocheta-carrying — cells,
or, perhaps, independent spirochetae —
or both — enter the receptaciilum chyli,
and finally are emptied into the cir-
culation via the thoracic duct, then
to be driven to the superficies of the
body, the central nervous system, etc.
Various secondary phenomena now
occur: General adenopathy, as a
result of (1) the proliferation of the
cells carried to them by the blood,
(2) the proliferation of their own
lymphoid and connective-tissue ele-
ments under the stimulus of the
spirochetae and their toxins, (3) an
accumulation of infected material col-
lected by the absorbents from the
superficies of the body. Engorge-
ment of the fauces and pharynx fol-
lows, due to proliferation in their
rich network of lymphatics. Mucous
patches are likely to occur, and are
quasi papules, due to a circumscribed
collection of the characteristic cells,
— constituting syphilitic granuloma in
whatever lesion it may be found.
The same description applies to the
true papule on the skin. This may
have an excessive accumulation of
cells and become a tubercle, or, from
pressure and interference with nutri-
tion of the normal tissue-elements,
plus local syphilotoxemia and their
own tendency to retrograde metamor-
SYPHILIS (LYDSTON).
451
phosis, — with or without complicat-
ing pus-infection, — there may be
formed a pustule that may break and
result in ulceration. Nodes or peri-
osteal swellings are collections of
proliferating syphilitic cells — granu-
lomata. Secondarily, bone atrophy,
hyperplasia, necrosis or caries may
result. Bone dystrophy from tro-
phoneurosis may occur (zndc author's
paper in N. Y. Med. Record, Jan. 9,
1913: "Unique Case of Syphilis of
the Cranium, Remarks on Syphilitic
Bone Dystrophy," etc.).
The foregoing are the essential
points in the pathology of active
S3^philis, as expounded by Otis, and,
with certain modifications taught by
the author, modernized by the addi-
tion of our microbial knowledge of
the disease. There are, however, many
phenomena in the course of syphilis
to which the syphiHzed cell bears no
particular relation. Those inexpli-
cable on the ground of localized cell-
accumulation and tissue-obstruction
are at once rationally explained by
the action of syphilitic toxins. The
syphilized cell may reasonably be re-
garded as a carrier of, or as a col-
laborator with, the spirocheta of
syphilis in toxin production.
The danger of permanent injury to
the tissues is proportionate to the
amount of accumulated cells, the
duration of their contact, and the
quantity and perniciousness of the
syphilotoxins. In explanation of
the foregoing Otis says, "The natural
course of the syphilitic cell is to
accumulate in and obstruct various
tissues, thereby forming neoplastic
masses similar in structure to inflam-
matory neoplasia, and finally to un-
dergo retrograde metamorphosis and
elimination, resulting eventually in
spontaneous cure of the disease."
This view is logical enough, and is
not likely to be quarreled with, save
perhaps as to the "spontaneous cure."
As to the tissue-changes at the site
of inoculation, the first manifestation
of the disease is a peculiar lesion
characterized by induration, due to
accumulation of cells in the meshes
of the connective tissue and tunica
adventitia of the vessels. The cells
in the vascular walls are either round,
spindle-shaped, or branched ; but the
bulk of the mass consists of the char-
acteristic round, multinuclear, granu-
lar cell, derived by transformation of
leucocytes or their derivatives. The
changes are similar to those of simple
dermatitis, save in the absence of
exudate, the absence of fluid prob-
ably depending on thickening and
contraction of the blood-vessels, ren-
dering it diflicult for serum to exude
from them. This would also ex-
plain the relative local anemia and
diminished nutrition. The syphilitic
infection per se has very feebly irri-
tating properties. Such as it has are
chiefly due to mechanical effects and
to a very moderate action of the
syphilotoxins. Yet, the latter, ex-
tending over many months or years,
often produces very disastrous re-
sults in various organs.
The peculiar affinity of the syph-
ilitic process for the lymphatic tissues
is evidenced throughout. The small
blood-vessels are surrounded by peri-
vascular lymph-spaces ; it has been
claimed that the tunica adventitia of
the smaller vessels is really a part
of the lymphatic system. This ar-
rangement is related to well-known
facility with which infections are
taken up from the lymphatics and
conveyed to the general circulation.
452
SYPHILIS (LYDSTON).
It also explains general lymphatic
involvement in infections that pri-
marily enter the general circulation.
The evolution of the other elements
of the local manifestations of syphilis
— i.e., primary lymphoplasia and ade-
nopathy— practically is a duplication
of the changes occurring in the initial
lesion. Within a few days after the
latter appears, the lymphatic vessels
enlarge and harden, often resembling
pieces of pencil or wire beneath the
skin or mucous membrane. The de-
gree of inflammation depends upon
the amount of secondary irritation of
the primary lesion and the presence
or absence of mixed infection. Typic-
ally, the lymphatic lesion is a hyper-
plasia rather than a true lymphitis.
The local infection travels with
slowness and deliberation. After a
time a primary adenopathy occurs.
No general involvement of the lym-
phatic glands occurs for some weeks,
apparently not until the infection
has had time to reach the general
lymphatic system via the tissue-lym-
phatics, the central lymphatic cir-
culation, and the general blood-cir-
culation.
Each involved gland would appear
to be a depot for the storing up, pro-
duction, and finally for the distribu-
tion of the infection. Each gland
undergoes a tissue-hyperplasia sim-
ilar to that of the initial lesion, and
becomes hard and woody to the
touch.
The changes at the site of infection
and in the lymphatic glands and ves-
sels first involved have been termed
the initiatory period of syphilis.
The Initial Lesion, or Chancre. —
The typical initial lesion is an indu-
ration, pure and simple. But the
facilities for mixed infection and irri-
tation are so many that a simple in-
duration, with absolutely no solution
of continuity of skin or mucous
membrane, is exceptional. Tlie
chancre may present itself in the fol-
lowing forms: (1) Simple erosion — a
superficial loss of epithelium forming
a non-suppurating open lesion. (2) A
greater or less area of ulceration,
saucer-shaped, due to irritation and
simple pus-infection. (3) A deep ul-
cerative excavation with sloping
edges. (4) Herpetiform and crustace-
ous chancre. (5) Diphtheroid or so-
called "diphtheritic" chancre. (6) An
indurated, non-secreting plaque, pap-
ule, or tubercle. The open varieties,
of course, present in typical instances
an underlying more or less character-
istic indviration. (See colored plate.)
Erosion may be said to include
about two-thirds of chancres, and
usually is situated upon the mucous
membrane, very often inside the pre-
puce in the male. In shape it is oval,
or perhaps a trifle irregular, with a
raw, polished surface of a wine-red
color and sometimes a pultaceous
thin, sanious fluid, entirely or almost
devoid of pus. These erosions are
flat, and may surmount a thin parch-
ment induration, or may cap a hard
tubercle as large as a marble. Super-
ficial saucer-shaped ulceration may
be found with the parchment variety,
but most often with the split-pea
induration. When it caps a large
mass of induration, it • is apt to be
quite deep and funnel-shaped, — the
"Hunterian chancre." This variety
sometimes is so large that it sur-
rounds the entire glans, filling the
fossa glandis and appearing like a
semicartilaginous collar shining white
beneath the quasi mucosa.
The secretion from the ulceration is
■ I
>
o
c
SYPHILIS (LYDSTON). 453
apt to be seropurulent. Herpetiform the course of the canal, at times dis-
and crustaceous chancres may occur tinctly perceptible on palpation. The
in any situation. The simple indu- type of the discharge depends on the
rated papule or tubercle is usually complicating urethritis. Symptoms
found upon the skin, the integument of stricture may occur, due to pres-
of the penis, or even upon the prepuce sure of the chancre upon the urethral
itself when it is short and dry. Ul- lumen. By means of the urethro-
ceration of this form of induration scope an ulcer often may be detected,
might occur if it were kept moist, and in a short time the primary and
The parts upon which it develops are later the general enlargement of the
perhaps not so rich in lymphatic glands and other symptoms appear,
spaces as those in which a chancre is Great caution is necessary in making
more likely to ulcerate, the collection a positive diagnosis until these con-
of cells being consequently smaller firmatory symptoms appear, unless
and necrobiosis less marked. the spirocheta can be demonstrated.
Several unusual types of chancre There is a peculiar form of chancre
have been described. French authors that may lead to grave errors in diag-
describe a variety called the "herpeti- nosis. This appears as a slight
form." This seems to be simply a erosion of a milky color, just within
lesion of herpes that becomes infected the meatus. Induration is not percep-
with syphilis and eventually indu- tible and the lesion looks not unlike
rates. In some cases the rationale of an intraurethral herpetic lesion. The
its formation is exceedingly simple, spirocheta may, or may not, be
At the time of exposure the surface demonstrable.
comes in contact with some local Varieties of Induration. — (1) The
irritant. The patient being predis- simplest form, the parchment indura-
posed to herpes, one or more vesicles tion, usually underlies ulceration, and
soon form. The chancrous indura- is sought by pinching up the lesion
tion develops in the herpetic lesion with the thumb and finger so as to
later on, at the end of the period of press lightly upon its edges without
incubation. Fournier describes a bending it. This is the commonest
form of chancre that he terms "crus- form, according to some authorities,
taceous." This, he claims, may be and certainly is so in hospital prac-
confounded with scabies. The con- tice. In private practice, however,
dition yields to sulphur, which the Hunterian chancre, or other
chancre does not. Fournier claims,, marked forms, are more frequent in
however, that expectancy is the only the writer's experience,
recourse in the differential diagnosis. (2) A variety of the parchment in-
The symptoms of urethral chancre, duration likely to escape attention
when too deep to be seen without the consists of a very superficial cell-infil-
urethroscope, consists in a discharge tration, presenting a very slight in-
coming on after the usual incubation, duration when lightly pressed upon,
thin, perhaps sanious, but sometimes In appearance it is a slightly brown-
creamy and thick. There is a pain- ish patch covered by very fine scales,
ful spot in the urethra in micturition not unlike a minute patch of psoriasis
and erection, possibly with a lump in — the "dry, scaling patch" (Otis).
454
SYPHILIS (LYDSTON).
The author would suggest as a better
term, "squamous superficial indura-
tion."
(3) The induration may be some-
what like a split pea beneath the skin,
its convex surface being capped by
ulceration. This induration is freely
movable, with a feeling like wood,
bone, or cartilage.
(4) The induration may be large
and extend beyond the ulceration
(where such exists), often attaining
the dimensions of a chestnut or al-
mond. When such an induration is
ulcerated, it is sometimes capped with
a funnel-shaped ulcer, — the Hunte-
rian chancre. Often there is a hard,
purplish mass of induration, with no
ulceration, or, at most, a very super-
ficial erosion. In many cases indura-
tion is irregular,, at times presenting
several distinct tumors, or united by
areas of less marked induration, giv-
ing, in the penis, a "choked" appear-
ance to the organ.
(5) A very superficial infiltration
may underlie a pseudomembrane of
greater or less dimensions : the "diph-
theritic chancre" already mentioned.
Diagnosis of Chancre. — (1) Known
exposure to contact with a person
with active syphilis, whether the con-
tact be sexual or otherwise. The
surgeon or obstetrician should be on
guard, especially where attendance
on a syphilitic is known to have pre-
ceded a suspicious lesion on the hand.
(2) The period of incubation. This
often is worthless — usually so when
there have been numerous exposures.
A single exposure, preceding the ap-
pearance of a sore ten days or more
warrants the suspicion of syphilis.
(3) Induration. A large, hard,
movable, insensitive, semicartilagin-
ous, anemic-looking induration is con-
clusive to the expert, but there are so
many degrees of induration of geni-
tal sores that it alone is not diag-
nostic.
(4) Discovery of spirochetse in the
chancre secretion. This is conclusive.
(5) A positive Wassermann test.
This, if of high degree, and in cases
in which previous syphilis can be ex-
cluded, is conclusive. When the re-
action is not marked, or when it
shows soon after the sore appears, the
syphilis probably antedates the sus-
pected lesion. The Wassermann test
shows nothing until after general in-
fection has occurred, i.e., on the aver-
age in about six to eight weeks.
(6) Secondary symptoms.
Loss of Tissue in Chancre. — The
ulceration in a chancre is important,
and, aside from irritation, it is ex-
plicable by the histological characters
of the lesion. The localized cell-ac-
cumulation not only presses upon the
capillaries, but actually invades their
walls. The resulting malnutrition
leads to breaking down of the super-
ficial layers of the lesion, which, be-
coming infected, form an ulcer.
The induration of chancre is vari-
able in its extent, according to the
tissues in which it is situated. When
an extensive cut or abrasion is inocu-
lated, the resulting chancre is likely
to assume the size and conformation
of the traumatic lesion.
In quite rare cases of chancre, or
apparently simple lesions followed by
constitutional syphilis, induration ap-
pears to be entirely absent. It may
be overlooked through carelessness
or its coexistence with chancroid, or
may be so slight as to escape atten-
tion. After a chancre becomes phage-
denic, induration shortly disappears.
It is a peculiar fact that typically
SYPHILIS (LYDSTON).
455
indurated chancre is rare in women.
Contagion is oftentimes spread about
while the patient is entirely uncon-
scious of her trouble. This is true,
not only of the chancre, but of the
mucous and quasi-mucous lesions.
In simple chancre the induration
most generally precedes the ulcera-
tion, but often follows it, coming on
during the first week. Primary ulcer-
ation is probably due to some irri-
tant or to simultaneous chancroidal
or purulent infection. This is the
invariable course of mixed sores, and
probably most lesions in which in-
duration follows ulceration, instead
of preceding it, are primarily either
chancroid, herpes, or simple ulcera-
tion from pus-microbes.
The induration of chancre may be
slight and may disappear so rapidly
as to be overlooked. Cases have been
observed in which, it lasted only ten
or twelve days, but the ordinary dura-
tion is one to three months, in im-
properly treated cases; in rare cases
lasting for some years. In cases of
syphilis in which there is no history
of ante'cedent chancre, the author be-
lieves that an initial lesion has ap-
peared and disappeared without hav-
ing been observed.
Secretion of Chancre. — This is
scanty and seropurulent, and remains
so throughout unless the sore be-
comes inflamed, then being profuse,
purulent, and perhaps bloody. Some
chancres exhibit a marked and per-
sistent tendency to bleed : the so-
called "hemorrhagic chancre." The
author recalls one case of this sort in
which later "transformation" into epi-
thelioma -occurred.
Many attempts at autoinoculation
have been made with syphilitic secre-
tions, thus far in vain, as a rule.
When a chancre is inflamed and
secreting profusely, its secretion —
containing toxins and pyogenic mi-
crobes— will produce a pustule if
autoinoculated. This mav be fol-
lowed by ulceration, but never by
hard chancre. When the sore is
mixed, autoinoculation is, of course,
feasible.
The secretion of a chancre, and
blood or serum drawn from it, con-
tain the Spirochcta pallida and are
virulently infectious.
Comparative Frequency of Chan-
cre and Chancroid. — Fournier finds in
private practice that the frequency of
chancre as compared with chancroid
is about three to one. Yet the statis-
tics of ten years at one of the large
Paris hospitals show that chancroid
comprised about 80 per cent, of sores.
From clinical experience the writer is
inclined to believe that these esti-
mates are fair criteria in private and
hospital practice. In hospital prac-
tice, however, patients with atypical
and possibly mixed sores often are
lost sight of after they leave the hos-
pital. Doubtless many of these
afterward develop syphilis, thus cut-
ting down the percentage of simple
chancroids.
Complications of Chancre. — (1)
First and simplest we have vegeta-
tions or papillomatous growths : the
so-called "venereal warts." These
result from local irritation combined
with heat and moisture, and are iden-
tical with vegetations occurring under
other circumstances. The writer be-
lieves that, while in no sense syph-
ilitic, they, like herpes progenitalis,
thrive best on syphilitic soil. Proper
cleanliness usually will prevent them.
(2) Inflammation of chancre, giving
rise to considerable pain and profuse
456 SYPHILIS (LYDSTON).
purulent secretion. (3) Chancre may moist locality, such as a mucous or
be complicated by chancroid, consti- quasi-mucous surface, it may lose its
tuting "mixed sore," — unless the two hardness and at the same time be-
forms of disease appear in different come transformed into a quasi-mu-
locations. (4) Chancre may be at- cous patch by becoming covered with
tacked by phagedena or gangrene. a characteristic w^iitish pellicle. At
Mixed Chancre, — When a chancre times the sore acquires the form of
becomes inoculated with chancroid, the mucous patch, yet retains its in-
its ulceration deepens and it grad- duration. The "diphtheritic" variety,
ually assumes the general characters first described by Morrow, possibly
of chancroid ; but, unless phagedena may sometimes be the mucous trans-
occurs, induration usually still per- formation just described, but the
sists. Oftener than usually is sup- author has met with a number of
posed, however, the chancroid in- cases exactly corresponding with
hibits the chancrous induration, thus, Morrow's description.
syphilis oftentimes follows an appar- Phagedenic Chancre. — Phagedena
ently typical soft sore. Slight scle- attacking chancre is likely to be of the
rosis is apt to be melted away by the gangrenous form. The pultaceous
chancroid and thus escape attention, and serpiginous varieties are rare.
When chancroid develops primarily — After phagedena once has invaded a
from typical mixed infection — it gen- chancre, induration no longer is per-
erally runs its usual course until the ceptible. If the sore be of the mixed
incubation period of syphilis has variety, the pultaceous or serpiginous
elapsed, when induration occurs. The form of phagedena is then likely,
secretion of the mixed sore contains Bassereau and Diday believe that the
the spirocheta, is autoinoculable, and type of syphilis following phagedenic
transmits either or both diseases to a chancre was exceptionally severe,
healthy person. In some cases chan- This is true in my experience, but is
croid rapidly heals, or the incubation explicable by the fact that phagedena,
period of syphilis is long, and indu- per sc, probably is due either to gen-
ration develops in the cicatrix of the eral debility or to a peculiar diathesis
chancroid after it has soundly healed, that lessens the resistance to disease.
The test for mixed chancre is: (a) Phagedena probably is due to mixed
search for the spirocheta, (&) auto- infection in which streptococci play
inoculation. By the term autoinocu- a leading role, associated with a lack
lable is meant a sore the secretion of of tissue resistance,
which, inoculated in a new situation Infectious Secretions in Syphilis
in the diseased individual, will pro- and Infection, — Inoculations with the
duce typical chancroid. secretions of chancre and of mucous
Both poisons may be contracted at patches, and also with syphilitic blood
once or either variety of genital have been made with entire success,
lesion may develop primarily and Whether the blood is infectious be-
later be inoculated with the other tween the periods of active manifes-
disease. tation of the disease has not been
Typical chancre may undergo trans- determined by experiment, but from
formations : e.g., when situated in a accidental observations made upon
SYPHILIS (LYDSTON).
457
vaccinal syphilis it probably is. The
discovery of the specific spirocheta in
the blood, and the results of the
Wassermann test in "intervals of
quiet" in syphilis, substantiate the
foregoing opinion, originally ex-
pressed by the author in 1885. The
secretions of non-syphilitic lesions
occurring upon a syphilitic are not
inoculable unless mixed with . his
blood, e.g., the secretions of gonor-
rhea and chancroid in a syphilitic
transmit only gonorrhea and chan-
croid unless they contain syphilitic
blood. Diday inoculated pus from
acne pustules produced by potassium
iodide on a syphilitic subject, but
with negative results. It probably
also is true that a vaccine-lymph de-
rived from a. syphilitic is not capable
of producing syphilis unless it con-
tains some of his blood. This, how-
ever, should make the physician no
^ess cautious, for it is easy for blood
to mix with the lymph and remain
undetected. The vaccine-scab from a
syphilitic patient always is dangerous.
Inoculations with the secretions of
tertiary lesions and with blood during
the tertiary stages are negative, with
some apparent exceptions. Presence
of the spirocheta seemingly should
throw any case out of the category of
tertiary phenomena. As to whether
the same can be said of the Wasser-
mann test appears an open question.
The relative non-transmissibility of
tertiary syphilis has been claimed as
evidence that the lesions of this
stage are not syphilitic at all, but
simply sequelae. Neither the mucus,
sweat, urine, milk, nor semen, are
inoculable', unless mixed with blond
or secretions of a lesion containing
the spirocheta. l"^ven the saliva is
innocuous unless mucous patches or
other lesions exist in the mouth, in
which case it is contagious in the
highest degree. The spirocheta must
be present, else no secretion can
transmit syphilis. Furthermore, the
spirocheta is not always readily
demonstrable.
In every method of transmission of
syphilis, save two, the general disease
always is preceded by chancre, and
the existence of the latter may be
inferred. Chancre is never present in
the case of (1) infection of the child
in utcro, and (2) infection of the
mother through the child — the latter
method still a subject of controversy.
Modes of Contagion. — Contagion
may be mediate or immediate. The
former means transmission of syph-
ilis through the medium of infected
drinking-utensils, tobacco-pipes, tow-
els, etc. Chancroid is rarely thus
transmitted, but syphilis often, be-
cause of the multiplicity of its lesions,
some apparently insignificant, yet in-
fectious. By immediate contagion is
implied direct contact of an abraded
surface with a secreting lesion or in-
fected surface or with syphilitic blood
from a non-syphilitic lesion in*a syph-
ilitic subject. The type of this mode
of contagion is, of course, infection
during sexual intercourse, but it may
occur in many other ways ; often it is
contracted in operating or examining
syphilitic subjects, or in delivering
syphilitic women. The use of rubber
gloves eliminates this danger.
Chancre often is contracted in kiss-
ing, a small, perhaps unrecognized
mucous patch on the cheek, lips, or
tongue of the diseased person inocu-
lating any slight fissure or abrasion
present about the mouth of the
healthy subject. Sources of especial
danger are unnoticed oral lesions.
458
SYPHILIS (LYDSTON).
Duration of Chancre. — The chancre
may last for only two or three weeks,
but in the majority of cases an erup-
tion appears prior to its disappear-
ance. It may last for months, espe-
cially if complicated. The indura-
tion may last for years. Under
proper treatment it usually disap-
pears promptly, unless very exten-
sive, when it may be very slow in re-
solving.
Number of Chancres. — Chancre
generally is single, but may be multi-
ple, according to the number of
points primarily inoculated. It usu-
ally is situated upon the genitals, be-
hind the corona glandis in the male
especially; but its situation varies
very greatly. Initial lesions of the
face, tongue, nipple, and fingers are
not so very rare, and many chancres
of the tonsil have been reported. The
author has met with two cases of
chancre of the eyelid. Urethral
chancre is not uncommon.
GENERAL INFECTION, CON-
STITUTIONAL, OR SECOND-
ARY SYPHILIS.
The initiatory period ends when
the infection has traversed the- lym-
phatics, entered the receptaculum
chyli, and thence passed into t-he
blood. No tissue enjoys complete
immunity from the ravages of the
disease. We will consider the vari-
ous phenomena as they appear in a
typical case.
Following the initiatory period,
with its initial sclerosis and primary
adenopathy, there is an apparent
period of incubation lasting, on an
average, forty to forty-five days, and
followed by general symptoms. Dur-
ing this so-called second stage of
incubation the syphilitic infection is
slowly traversing the lymphatics and
making its wav into the blood.
DIAGNOSIS. — Constitutional
Syphilis. — The diagnosis of constitu-
tional syphilis is established from the
lesions shortly to be described, and
by the blood test: —
Wassermann Test. — This depends
on the principle of complement fixa-
tion by union of a particular bacterial
substance Avith the antibodies of in-
fected blood. In the standard test,
the suspected serum is mixed with
extract from, the liver of a syphilitic
fetus. If syphilis be absent, com-
plete hemolysis occurs. If it be pres-
ent, hemolysis results of a degree
inverse to the intensity (activity) of
the infection. For the technique of
the Wassermann test, the reader is
referred to the fifth volume, page 385.
Sources of Fallacy. — (1) The test
fails in a certain proportion of syph-
ilit'ics'; (2) a positive reaction not
infrequently is obtained in other dis-
eases, and in presumptively healthy
persons ; (3) a mildly positive reac-
tion, when taken alone, is not con-
clusive; (4) a negative reaction
means nothing definite.
It must be admitted, despite the
foregoing sources of fallacy: (1) that
varying degrees of competency of
laboratory workers exist; (2) that
a strongly marked positive reaction
may be taken to mean syphilis.
The known fallibility of the Was-
sermann test and the inequalities of
expertness of laboratory workers
limit the usefulness of the test,
greatly to the detriment of a large
proportion of syphilitics. Thus, in
one case of a physician suiifering
from a suspicious lesion of the palate,
three or four Wassermanns and
several examinations for the spiro-
SYPHILIS (LYDSTON). 459
cheta had been made, with negative eruption may escape observation, it
results. The lesion was typically probably is constant, in some cases
syphilitic, and I so stated. Dr. Joseph lasting for some weeks, probably
Zeisler confirmed the diagnosis, from two to eight, in others only a
Later, the lesion was pronounced by few hours. In its general appearance
an eminent authority Vincenti angina, the eruption ia not very unlike meas-
Several positive Wassermanns sub- les. The spots are of a dull, rose-red
sequently were obtained. The pa- hue, and disappear on pressure when
tient was treated for a few months, recent, though later on leaving a cop-
and for two years thereafter frequent pery stain.
Wassermanns were negative. Later The syphilitic roseola is due to
they were again positive. dilation of the cutaneous capillaries,
Nognchi's Itietin test is not constant with subsequent stasis, and the exu-
in lues. It is more frequent in late Nation of leucocytes and red blood-
than recent cases. While the Was- , t-, -i i ^.t j-i +• ^,.a
, , . corpuscles. Possibly the dilation and
sermann tends to become negative . n i
under mercury, the luetin remains un- stasis are reflex phenomena due to
changed. A. Chieffi (Giorn. ital. d. local irritation by the syphilitic in-
mal. ven. e d. pelle, May 26, 1918). fection, or to the direct influence of
Lange's colloidal gold test confirms the infection upon the vascular walls ;
other tests. It is valueless unless , , , • , i *• •„ ^.i <-
... . , but a more rational explanation IS that
a satisfactory indicator is prepared. ... . ^
In tabes it may predict paresis. In ^^ ^ direct influence upon the sym-
tabes and cerebrospinal lues it may pathetic centers analogous to that
be positive where the Wassermann, produced by quinine, belladonna, etc.,
cell count and globulin are negative, and by emotions. In the previous
In general paresis it is invariably editions of this work, and in his
positive. In normal nuids it is in- r- , •,• ,, loor i
variably negative. Harvey (Calif. St. "Lectures on Syphilis, 1885, the
Jour, of Med., 16. 170, 1918). author said: "The disturbing ele-
General Adenopathy, — The infec- ment in the action of syphilis on the
tion, after entering the right heart, is sympathetic is probably a toxin or
finally disseminated throughout the toxins elaborated by the syphilitic
tissues, producing (a) toxemia and micro-organism." The discovery of
(6) cell-proliferation, the first evi- the spirocheta justified our early con-
dence of which usually consists in a elusions.
general glandular enlargement. This, Syphilitic Prodromes, — The roseola
however, may coexist with or follow may be preceded or accompanied by
the roseola. The enlarged glands malaise, headache, backache, rheu-
now encountered are reproductions of matoid pains, anorexia, nausea, pros-
the initiatory adenopathies. tration, sleeplessness, and nervous
The Roseola. — At the end of about irritability, and in some cases quite
forty to forty-five days, on the aver- sharp febrile movement, perhaps fol-
age, after the chancre, a period of lowed by perspiration. These are
"general, systemic infection and local- the symptoms of "syphilitic fever,"
ized cell-accumulation" begins. The or, as Diday more correctly terms
first evidence of general infection is them, "syphilitic prodromes." It has
usually a peculiar eruption of rose been claimed that these symptoms
spots : the roseola. Although this may depend upon so many coincident
460 SYPHILIS (LYDSTON).
disturbances that the term syphilitic congested area sublying- and super-
'fever is obviously inaccurate. This imposed upon the lesion,
observation, however, may be falla- Syphilitic Alopecia. — As a rule
cious because of faulty methods of during- the early months of the sec-
study. The various symptoms are ondary period, often coexistent with
toxemic, and, although they vary in the papular eruption — falling of the
severity, probably might be demon- hair, or alopecia, occurs, due to dis-
strated in all cases by careful inves- turbed nutrition in the hair-follicles,
tigation. The temperature, be it re- The loss of hair may be general, but
marked, rarely is studied. it usually occurs in quite characteris-
Pharyngofaucial Infiltration. — tic patches.
About the time the roseola appears, This lesion of early syphilis espe-
there is a development of inflamma- cially appeals to the writer as a
tory engorgement of the tonsils, trophoneurosis. This may be danger-
pharynx, and soft palate, usually in- ous ground, for the close association
volving the whole faucial surface, of alopecia with tangible cell-deposit
The explanation of this involvement in other situations has led to its tacit
on the basis of lymphatic engorge- acceptance as an evidence of the
ment, due to the abundance and super- action of syphilis in loco. But it is
ficiality of the lymphatic capillaries not unusual to find papules from
of the affected parts, is quite plans- which the hair has not fallen inter-
ible. That vasodilation due to the spersed with non-infiltrated alopecia,
action of syphilotoxins upon the sym- In most cases the alopecia seems to
pathetic is an associated factor, seems bear no effect relation to cell infiltra-
probable. tion. Some authors ascribe it to local
The Papular Syphilide. — After the "poisoning" of the hair-follicles,
roseola in typical syphilis appears an Syphilis of the Nails. — The nails
eruption of true papules. This may of the fingers and toes may become
occur when a roseola has not been brittle and lusterless, or from very
noticed, or coincide with it, but gen- great infiltration and nutritive dis-
erally follows it after a variable in- turbance — and perhaps secondary
terval : often some weeks or months, pus-infection — syphilitic onychia may
The papules usually are most promi- occur, presenting obstinate ulceration
nent about the borders of the hair around and beneath the nail,
upon the forehead, forming the Pustules, Vesicles, and Precocious
corona veneris, or "venereal crown," Skin-lesions. — Pustules or vesicles
but may be scantily scattered over may form during the papular stage,
the breast, back, and limbs, or thickly as may also ulcerations resembling
studded all over the body. This tertiary or late secondary lesions,
eruption lasts longer than the roseola. The latter constitute precocious syph-
occasionally remaining prominent for ilides. These lesions are due to (a)
a number of months. At first it is pressure on nutrition, (b) local tissue
of a rather bright-reddish hue, but intoxication, (c) special coincidental
this gradually fades, leaving the char- irritation, and (d) pus-infection,
acteristic coppery red color, due to Special Mucous Lesions. — These
deposition of blood-pigment in the are modifications of the syphilitic
SYPHILIS (LYDSTON). 461
papule resulting from a different sit- it may, perhaps, be justly styled
nation and surroundings. Mucous "gummous." Similar plastic nodules
patches, constantly subjected to irri- may form in the choroid at this pe-
tation from friction, heat, and mois- riod. In late syphilis the eye may be
ture, are examples. These lesions invjolved secondarily to brain lesions,
are elevated plaques of a milky or by necrosis or caries of the orbit, or
grayish color, covered with a grayish by retinal involvement, resulting in
exudate, and are not greatly unlike optic atrophy.
the primary superficial erosion some- Early Osseous Symptoms. — Bone
times seen upon the genitals. When pains, usually localized, and localized
situated in relatively moist and un- subperiosteal accumulations of cells
cleanly regions — e.g., about the anus, termed nodes frequently occur dur-
upon the scrotum, vulva, or between ing early syphilis, although more
the digits — they hypertrophy, form- characteristic later. Pain is due to
ing broad papules or excrescences intraosseous or subperiosteal pressure
more or less elevated, sometimes cov- by the dense accumulation of cells.
ered with a quasi-diphtheritic deposit, Early Nerve Involvement in Syph-
and usually discharging a foul-smell- ills. — Syphilitic toxins are prominent
ing, serous secretion. These are in early syphilitic nerve disease,
mucous tubercles, or condylomata. They apparently act (a) by direct in-
Almost typical papillomata may com- toxication of nerve-tissue ; (b) by
plicate them. induction of vasomotor changes via
Visceral Involvement. — Visceral the sympathetic ganglia or the so-
involvements are common in syphilis, called monarchic vasomotor center;
congestion characterizing the early (c) direct intoxication and irritation
secondary, diffuse infiltration the late of blood-vessels in the nervous
secondary, and distinct gummy de- system.
posit the sequelar period. Tender- Organic or functional nervous dis-
ness over the liver, spleen, and kid- turbance is caused in many ways,
neys is occasionally observed in early viz.: (1) by invading the lymphatics
syphilis. Transient albuminuria is surrounding nervous structures ; (2)
not uncommon. The author repeat- by involving the tissues round the
edly has called attention to the dan- blood-vessels supplying or draining
ger of late complications developing the part ; (3) by invading the arterial
in viscera affected in the early stages, walls ; (4) by infiltration of tissues
Early Ocular Syphilis. — During contiguous to nervous structures;
the active period an infiltration of (5) by involvement of the nerve or
cells into the iris and ciliary body brain parenchyma proper; (6) by in-
often sets up an iritis in no way dis- volving nerve-sheaths or the menin-
tinguishable from the iritis of rheu- ges. These conditions act by: (1)
matism, trauma, etc. Later the irritation; (2) pressure-innutrition,
cell accumulation sometimes forms a and occasionally degenerations; (3)
distinct nodule, or tumor, often erron- passive hyperemia and edema from
eously termed "gummy tumor of the venous obstruction ; (4) localized
iris." This is especially likely to anemia (ischemia) from arterial ob-
occur in late syphilis, in which event struction ; (5) lymphatic obstruction.
462 SYPHILIS (LYDSTON).
Any of these conditions may occur spirocheta. (5) Similarly the gon-
in both the early and the late periods, ococcus may produce lesions which
Extensive destruction from breaking persist and become permanent, in
down of the neoplasm is rare in the spite of having become non-virulent,
earlier lesions. Gumma may de- Notable examples are chronic pros-
velop early, however, from the in- tatitis and seminal vesiculitis. (6)
trinsic malignancy of the disease. The complement-fixation test and
The terms "early" and "late" ap- Wassermann test are analogous in
plied to syphilis are rather indefinite, this: viz.: they show that toxemia
it is true, but perhaps are the best may be produced long after the germ
that can be offered. Gummy lesions has lost its primary virulency. They
occur much earlier in some cases than are alike, too, in that this toxemia is
in others. absent in many cases in which ante-
LATE SYPHILIS, SEQUELAR cedent syphilis or gonorrhea is un-
OR SO-CALLED TERTIARY deniable. How else can we explain
SYPHILIS. — The Tubercular Syph- some of the vagaries of both tests?
ilide (Gummy Infiltration). — For (7) A recrudescence of activity of
over thirty years the author taught both gonococcus and spirocheta may
that the so-called tertiary lesions of occur, but the lesions long present
syphilis were "sequelar." With the still may be the results of their per-
advent of the Spirocheta pallida and nicious activity long since past, (8)
its demonstration in many of the late If the so-called tertiary lesions are
cases, and the frequency with which due alone to the spirocheta, why do
a positive Wassermann is found in not locomotor ataxia, visceral gumma,
such cases, one would be expected to and paresis occur in early syphilis?
abandon this sequelar view. The Hemiplegia occurs, it is true, but
author not only has not abandoned rarely, and usually is followed by
it, but until it has been shown that complete recovery. That the extent
the spirocheta of late syphilis has and danger of syphilitic phenomena
lost none of its pathogenic properties, are in direct ratio to their remoteness
he will feel more firmly than ever from the active period is very sug-
convinced that the typical tertiary gestive. (9) The long periods of
lesions, and especially the nerve and quiescence preceding the tertiary
brain lesions of late syphilis, are phenomena. (10) The occurrence of
sequelar. Supporting this are the fol- slow vascular changes, never mani-
lowing, viz.: (1) The spirocheta and fest until long after the secondary
its host are subject to the same bio- manifestations of the disease. Ves-
logical laws as are other organisms, sel changes leading to the cerebral
(2) The primordial controlling law is hemorrhages of late syphilis are
mutual adaptation of tissue-cell to plainly from perverted nutrition and
germ. (3) This adaptation results in of very slow development. (11) The
an increased tolerance of the host iodides resolve gummous lesions, but
and a lessened virulency of the para- are of litle or no specific value in
site. (4) Just as the gonococcus may early syphilis.
lose its virulency, yet remain indef- As to the question of treatment,
initely in the tissues, so may the it is of no importance whether or not
SYPHILIS (LYDSTON).
463
late syphilis be regarded as a period
of sequelae. Po.ssibly, however, re-
garding- it as such may lead to more
thorough and prolonged treatment
and offset pernicious confidence in
salvarsan and the Wassermann test.
The Gumma. — One of the most
frequent of the tertiary lesions, or
sequelae, is the tubercular eruption.
This has been said to be due to a
localized accumulation of morbid
cell-material or "gummy infiltration."
This gummy material is termed by
Wagner "syphiloma," and is de-
scribed by him as an infiltration of
cells indistinguishable from the nor-
mal white blood-cells or leucocytes.
He states that their morbid effects
are due to mere interference with
function and nutrition by pressure.
Baiimler also claims that the cells of
syphilomata lack specific microscopic
characters, but are identical with
those of granuloma in general.
The tubercular, or gummy, lesion
may develop in any situation, its fa-
vorite locations being the cellular tis-
sue, skin, bones, liver, testes, brain,
and kidneys, and, in children espe-
cially, the lungs.
This gummy material is a grayish-
red, homogeneous mass of greater or
less consistency, found either as a
diffused or circumscribed infiltration,
but never capsulated. When it is
superficial or when it is excessive or
involves vessels, causing localized in-
nutrition from pressure or vascular
obstruction, the whole mass is liable
to disintegrate and form an open le-
sion, or break down into pus or
puruloid material that may absorb
through fatty or granular degenera-
tion without ulceration. The longer
the active period, and consequently
the more pronounced the lymphatic
changes, the greater the liability to
severe tertiary lesions.
After removal by fatty degenera-
tion there is a tendency to recurrence.
Hence the difficulty of curing the
disease at this period. This tendency
is due to an increased injury to the
lymphatic structures already greatly
impaired by lesions of the active
period. The impairment consists in
fibrosis due to low inflammatory
action mechanically set up by the
cells. This, of course, interferes with
tissue-nutrition.
Thus, the various lesions and their
different degrees of severity in the "ter-
tiary stage of syphilis" depend upon
(1) the damage produced in the
active period and its duration ; (2) the
constitutional condition of the in-
dividual ; (3) the relative degree of
activity of the spirocheta in late
syphilis and the degree of virulency
of its toxins, and (4) the extent to
which injudicious treatment has in-
jured the patient.
Late, or Sequelar, Nerve and Brain
Syphilis. — The nervous lesions of
late syphilis are more severe, and the
prognosis much graver, than in the
case of the early nerve phenomena.
The accumulation of neoplasic ma-
terial in and about the delicate nerve-
structures, occurring in late syphilis,
is associated with and probably de-
pendent upon: (1) The local damage
inflicted in the active stage in the
form of a fibrosis with vascular and
lymphatic obstruction. (2) Perma-
nent disturbance of nutrition, from
the toxemia of early syphilis, the
effects of which are slow in develop-
ing symptoms. (3) The debilitating
effects of prolonged syphilization and
the prolonged treatment necessitated
by it. (4) Prolonged mental worry,
464
SYPHILIS (LYDSTON).
with or without alcoholic or other
excesses. (5) At times, immunity to
remedies acquired, (a) by the spiro-
cheta, (b) by the patient.
Probably the nerve and brain
lesions of this period act chiefly
throuifh mechanical and nutritional
disturl)ance, the virulence of the
spirocheta having long since become
exhausted.
Paralyses — such as hemiplegia, pa-
raplegia, and monoplegias of differ-
ent kinds — are apt to occur, and are
due either to localized deposit of
syphiloma external or internal to the
structures involved, or to diffuse in-
terstitial deposits and proliferation of
obstructive tissue. Gummy tumors
may occur in the brain proper or its
membranes, or the latter may un-
dergo a chronic thickening resem-
' bling chronic meningitis from other
causes. Gummy deposits in and
about the cerebral vessels are pro-
lific causes of paralysis. Vascular
degeneration often is the cause of
those miliary aneurisms often the
source of apoplexy and hemiplegia.
The various cranial and spinal
■nerves are likely to become involved.
This involvement may be central,
with or without coincident brain-in-
volvement, or peripheral, affecting
any part or all of the distribution of
the nerve. As with the brain, the
nerve-lesion may consist (1) of a cir-
cumscribed or diffuse gummy de-
posit; (2) of sclerotic changes pro-
duced (o) by lesions of the active
period or (b) by sequelar gummy
deposit ; (3) of destruction of normal
tissue-elements.
It is well known that gummy in-
filtration and localized deposits with
consequent paralysis occur in the
cord, but the extent of the etiological
relation of syphilis to locomotor
ataxia was long in dispute. Erb
maintained that 61 per cent, of cases
of locomotor ataxia are due to syph-
ilis. Since the discovery of the spiro-
cheta and the advent of the Wasser-
mann test, most authorities believe
that locomotor ataxia practically al-
ways is due to syphilis — ^hereditary
or acquired. In this view the author
concurs.
The prognosis of late nerve and
brain syphilis is notoriously bad, but
often more hopeful than some believe.
Syphilides. — The syphilitic skin
eruptions — "syphilides," or "syphilo-
dermata" — are many and often con-
fusing. Where papules are the es-
sential feature of the eruption it is
termed a "papular syphilide." Simi-
larly the eruption may be designated
as vesicular, pustular, tubercular,
squamous, crustaceous, or ulcerative,
or as papulopustular, papulosquam-
ous, etc., the first part of the combined
term corresponding to the feature of
the mixed eruption that is most
prominent. Ulcerative syphilides may
be designated as superficial, deep, ser-
piginous, or perforative.
The principal distinctive lesions of
syphilis that occur at various periods
during its course are macules, pap-
ules, mucous patches, mucous tu-
bercles, condylomata, vesicles, pus-
tules, bullae or blebs, rhagades or
fissures, gummy tubercles, and dif-
fuse gummy deposits and infiltra-
tions. Dependent upon some of
these lesions, different forms of deep
and superficial ulceration, attended
or followed by peculiarly formed
crusts and scars, may occur — syph-
ilitic ecthyma and rupia — ulcero-
crustaceous syphilides. Squamae or
scales may also be noted.
SYPHILIS (LYDSTON). 465
The general characteristics of the PROGNOSIS. — Baiimler claimed
syphilides are [Keyes] : (1) poly- that the infection of syphilis lasted
morphism of all lesions, including from eighteen months to three years,
the chancre ; (2) rounded form of After this, the blood and secretions
the eruptive lesions and ulcers; (3) of open lesions ceased to be conta-
lividity or "ham-color," becoming gious, and many held that, in most
coppery, then grayish, and finally cases, especially if properly treated,
white and shining as cicatrization oc- no further manifestations ever were
curs; (4) absence of pruritus and experienced. The advent of the Was-
pain excepting in hairy regions, and, sermann test has rather disturbed the
Avith respect to pain, in the bones ; severity with which we had come to
(5) symmetry, generalization, and regard the prospects of a large pro-
superficial character of the early portion of syphilitics. It is positive
eruptions, in all save precocious or in quite a porportion of supposedly
malignant cases ; (6) tendency to cured cases. This, however, has not
grouping of the later eruptions, disturbed the author's belief that a
which involve the true skin and tend large proportion of syphilitics, under
to scarring; (7) tendency to circular proper conditions, are curable. The
arrangement ; (8) scales compara- author believes that it is never safe to
tively thin, white, generally superfi- rely upon, any test, laboratory or
cial, and non-adherent ; (9) crusts clinical, to prove that any given
irregular, thick, and adherent, green- syphilitic has been cured. Eternal
ish or black from admixture of dis- vigilance and repeated periods of
organized blood ; (10) abrupt edges of treatment are the only safeguards,
both skin and mucous ulcerations, The prognosis as regards severity
which are not undermined, are slug- of syphilis varies with the habits and
gish, and bleed easily; (11) rounded, resistance of the patient and the as-
depressed appearance of cicatrices, siduity in treatment. There is no dis-
which are thin, movable, pigmented ease the duration and course of which
at times, but eventually becoming are so uncertain. One cannot state
white and shining. These scars often arbitrarily in any given case that the
are crescentic or horseshoe-shaped. disease has or has not terminated.
The term "polymorphous" is ap- This is especially true when we con.
plied to the syphilides because there sider that it may permanently modify
is no form of skin-lesion that may the patient's constitution, even though
not occur. Indeed, no single lesion no typical manifestations appear after
usually is present: a papular syph- a certain time. No method of blood-
ilide rarely is purely papular, vesicles, examination thus far suggested has
pustules, or erythematous patches ]:)roved absolutely reliable. Even the
usually being found at the same time. Wassermann test is very frequently
In addition to the foregoing lesions, fallible,
syphilitic fever, alopecia, headache, The disease may manifest itself as
osteocopic pains worse at night, anal- a series of mild secondary eruptions
gesia, anesthesia, indolent lymphitis, followed by apparent recovery, or it
iritis, sore throat, and mucous may afiford no evidence of its pres-
patches are also typical phenomena. cnce after the initial sore throat until
8—30
466
SYPHILIS (LYDSTON).
late in life, when suddenly tertiary-
lesions — i.e., sequelcT — crop out.
Curability of Syphilis. — Proof of
its curability lies in the cases of sec-
ond attacks, cited by reliable authori-
ties, and in the fact that, whatever the
possibilities of tertiary lesions, they
are not necessary^ and probably often
are sequelae. Sequelar syphilitics
may procreate healthy children. The
blood and secretions of tertiary le-
sions often seem no longer inoculable.
The germ origin of syphilitic infec-
tion being admitted, the spontaneous
tendency to cure of syphilis is almost
beyond controversy. It is part of the
life-history of the micro-organism.
The prognosis of syphilis as re-
gards the life of the patient is a mat-
ter difficult to determine. Fatal re-
sults from syphilis usually are inci-
dental to sequelar lesions of the
arterial or cerebrospinal systems or
of the viscera. They occur, as a rule,
at a period so remote from the orig-
inal infection, and the symptoms are
so obscure as regards the specificity
of their origin, that it practically is
impossible to determine the primary
cause in many cases. Even a negative
Wassermann does not disprove the
existence of syphilitic or of post-
syphilitic lesions. This much may
be said, however, namely: Active
syphilis is a disease that is essentially
benign, per se, so far as danger to life
is concerned. It is probable that, in
well-treated cases, the average lon-
gevity is not seriously diminished by
the disease, especially if the patient
is strictly observant of the rules of
personal hygiene laid down by the
careful physician. The danger to life
increases with improper treatment
and bad habits, and compounds very
rapidly after middle life, because of
arterial and visceral damage inflicted
by the active stage of the disease.
When May a Syphilitic Marry? —
Our best authorities assert that, on
the average, marriage is safe at the
end of three years. Fournier gave
these requirements: (1) Present free-
dom from symptoms. (2) Advanced
period of the disease. (3) A consid-
erable period of absolute freedom
from symptoms. (4) A mild type of
the disease. (5) Prolonged and thor-
ough treatment. (6) Negative Was-
sermanns on repeated examinations,
extending over a period of at least
a year after systematic treatment has
been suspended. In any case, the
physician should decline to assume
any responsibility. He should merely
state the facts, explain the sources of
possible danger, and allow the pa-
tient t(S decide for himself.
CONGENITAL SYPHILIS.— Ac-
quired Syphilis in Children. — Con-
genital syphilis should be differ-
entiated from infantile syphilis in
general. The course and manifesta-
tions of acquired syphilis in children
are in nowise dififerent from the same
affection in the adult. Children may
become inoculated by kissing persons
with oral or labial chancre, mucous
patches, fissures, or ulcers, or by
nursing a syphilitic mother or nurse.
Infection in vaccination must also
be remembered, although non-human-
ized virus is now almost exclusively
used, and such an accident occurs
only with virus infected by (a) han-
dling by syphilitics in the process of
manufacture, {¥) unclean hands of
the vaccinator, (c) unclean (syphi-
lized) instruments or dressings dur-
ing vaccination.
Cases of children infected through
criminal assault also have no bearing
SYPHILIS (LYDSTON). 457
upon congenital syphilis, save that sions and excoriations of the quasi-
great care is to be exercised in dif- mucous surfaces about the genitals,
ferentiation. anus, and mouth are likely to de-
The author has reported the case velop, and may form true mucous
of a boy of 6, who contracted syph- patches or even condylomata. A
ilis by sexual contact with a syph- "scalded" appearance of the anus is
ilitic girl of 13. quite characteristic. "Snuffles" de-
It is held by many that either velop after a time, and the nares be-
parent may transmit syphilis to the come so obstructed that respiration
child, but the question of a father's and nursing are interfered with and
ability to procreate a syphilitic child nutrition is still further impaired,
without first infecting the mother is Ozena may develop and lead to ne-
still sub judice. The presence of the crosis of cartilages. No symptom is
spirocheta probably is incompatible so characteristic as snuffles. Caution
with the life of the spermatozoa, is necessary in diagnosis, however.
The most plausible view is that. Many young children, especially in
while the presence of the syphilitic such climates as that of our lake-
germ is necessary in order that the region show a catarrh or coryza ex-
semen should be inoculable, its pres- ceedingly like syphilitic snuffles,
ence is unnecessary in order that the A livid macular eruption is some-
father should impress the fetus with times seen, and ulcerations may form
conditions which, while not specific- about the mucous orifices. Papular
ally syphilitic, are none the less de- and pustular lesions are not infre-
rivatives of that disease. Further quent, and sometimes quite charac-
Wassermann studies probably will teristically afl^ect the palms and soles,
show not only that congenital syph- Subcutaneous tubercular lesions may
ilis is more frequent than hitherto be seen in a few cases,
supposed, but also that the father An eruption occasionally occurs
alone is oftener responsible for the that is identical in physical character-
infection than has been believed. istics with ordinary pemphigus in the
Syphilis Hereditaria Tarda. — In a adult. This "infantile pemphigus" is
series of lectures at the Hopital an unmistakable evidence of syphilis.
Saint-Louis, Fournier called especial The bullae are sparsely distributed,
attention to late hereditary syphilis. Sometimes but one or two blebs are
He reports some interesting cases in present. It is especially apt to afifect
support of his view that the first the palms and soles. The fluid varies
manifestations of hereditary syphilis from turbid serum to pus, sometimes
may be after the period of infancy, bloody. When the cuticle ruptures,
and even in adolescence. Experience the fluid dries into a greenish crust
with the Wassermann test tends to and ulceration occurs beneath. The
confirm Fournier's opinion. author has met with a number of
Lesions of Congenital Syphilis. — If typical examples of this eruption,
not present at birth, lesions of vari- The hair and the nails are less likely
ous kinds develop from time to time, to become afifected than in the adult,
The writer has delivered children l)ut a brittle, lusterless condition of
with a well-marked roseola. Fro- the nails occasionally is noted.
468
SYPHILIS (LYDSTON).
Taylor has called especial attention
to lesions of the bones, oftenest in
Ihe diaphyso-epiphyseal junction of
the long bones. The possible de-
pendence of certain cases of rickets
upon nutritional perversion inciden-
tal to hereditary syphilis is a ques-
tion of the greatest interest and
importance.
The most important manifestations
of hereditary syphilis are the lesions
of the viscera. Any or all of the vis-
cera may be involved, the connective-
tissue changes being especially likely
in the liver, spleen, and kidneys.
The permanent teeth in congenital
syphilis are irregular, notched, and
pegged, and the conformation of the
alveolar arch is imperfect. The two
upper central incisors are "Hutchin-
son's test teeth." These are short,
vertically notched, narrow, and
rounded at their corners.
There is in the syphilitic newborn
a marked tendency to apoplectic
effusions, particularly in the brain
meninges and probably also the cord.
Interstitial keratitis practically is
pathognomonic and, if coincident
with the syphilitic teeth, puts the
diagnosis beyond doubt. The author
has had under his care a typical case
of, keratitis which did not occur until
the child was 10 years of age, there
having been no previous phenomena
of syphilis, save the typical teeth, the
significanc of which was overlooked.
TREATMENT.— A rational ther-
apy of the disease must necessarily
conform to its natural course. Our
aim should be to combat its matcries
morbi and reinforce the spontaneous
tendency to removal of its results,
until the system triumphs. The the-
ory of Ehrlich, that syphilis could be
stamped out by sterilizing the blood
with salvarsan, revived the old fallacy
of the antid(jtal treatment of syphilis,
much to the prcjfit of tyros in syph-
ilology and of commercialists in
medicine. Possibly some more ex-
perienced, not to say more conscien-
tious heads, also were turned. In
any event, mercury is still our
sheet-anchor. Slow, continuous, and
moderate use of mercury, for a period
corresponding to the maximum time
of the normal duration of the disease
as nearly as may be, zvithont at any
time producing its full physiological
effects, if it can be avoided, generally
will bring about a cure that can be
accomplished in no other way.
It is well known that mercury has
the power of inducing fatty degen-
eration and elimination of inflamma-
tory products, or "of relieving tissues
encumbered with superfluous and ob-
structive material." This condition
of the tissues is precisely what exists
in syphilis. Mercury should, there-
fore, be administered throughout the
disease, not as antidote, but to re-
move the morbid results of it as fast
as they are formed, until finally the
syphilitic impression upon the organ-
ism naturally has exhausted itself.
Rather peculiarly every method of
treatment advocated in twoi or three
centuries — with the exception of sal-
varsan— has comprised such meas-
ures as tend to produce rapid tissue-
changes, and, more especially, elimi-
nation. The sweating cure; the use
of hot baths, as at the Hot Springs of
Arkansas ; the purgation and starva-
tion cures, Boeck's method of Syph-
ilization, and the barbarous treatment
by pustulation with tartar emetic, all
these are chiefly active through their
power of inducing fatty changes in
the tissues. Hydrotherapy results in
SYPHILIS (LYDSTON).
469
increased elimination. This is espe-
cially important in view of the toxins
elaborated by the spirocheta.
The action of mercury upon the
blood is of great practical interest.
Opposite effects may be produced, ac-
cording- to: (1) the doses used, (2)
the duration of its administration,
(3) the constitutional condition of
the patient, and (4) the stage of the
disease. (See Mercury, volume vi.)
If the drug be given in a less vig-
orous fashion for a longer period,
pallor and debility may result, due
to depreciation in the red corpuscles,
defibrination of the blood-plasma,
and increased tissue-waste. A cer-
tain degree of these effects is un-
avoidable ; it should be our chief aim
to keep them within bounds, and thus
avoid permanent injury. Pallor,
wasting, debility, pustular or vesicu-
lar eruptions, "mercurial fever," and
tremors may result from it, without
occurrence of the characteristic ptya-
lism. On the other hand, small doses
of mercury, in various cachectic or
anemic conditions, particularly dur-
ing! the sequelae of syphilis, stimulate
hematogenesis, rapidly improving
the quality and quantity of the red
cells, and fibrin, thus lessening hy-
dremia. Iodine, until salvarsan came
in vogue, was regarded as second
only to mercury. The drug still is
valuable, more particularly in late
syphilis. The iodides — of which
potassium iodide is the type — act in
two ways in syphilis, viz.: firstly by
producing fatty degeneration and
elimination of morbid products, espe-
cially toxins; and, secondly, by lib-
erating, exciting to renewed activity,
and eliminating the mercury that is
stored up in the tissues, thus assist-
ing its action. The first of these is
the more important, iodides having a
powerful effect in resolving the prod-
ucts of inflammatory changes or ad-
ventitious deposits, irrespective of
their cause. The incorrectness of the
argument that iodine can cure syph-
ilis only by liberating mercury from
the tissues is shown by the beneficial
effects of the iodides in cases of late
syphilis in which mercury never has
been administered. Since the advent
of salvarsan some have held that the
iodides no longer have a place in the
therapy of syphilis. In this the
author does not agree. While their
range of usefulness is not so wide as
before salvarsan they are still of
immense value.
Treatment should begin aa soon as
the diagnosis is established. The
duration of the initial lesion is thereby
shortened, and secondary symptoms
moderated, if not prevented. To
save the patient thus from lesions
upon the body or face is desirable.
Mercury may be given (a) by the
mouth, (b) intramuscularly, (c) by
inunction, (d) by vapor, (e) intra-
venously. In many cases oral ad-
ministration must be relied upon.
The mildest and least irritating
form internally is mercurous iodide:
the green or protiodide. It is best
given in pill form, beginning with
doses of, on the average, % grain
(0.013 Gm.), thrice daily. This dose
is continued several days, then in-
creased one pill per day until the
gums become slightly tender i)r tlic
stomach and bowels disturbed. The
writer, when the gums are sligiitly
affected, gradually lessens the dose
until the patient is taking about half
the amount, i)roducing slight physio-
logical effects. This is the patient's
average dose — usually from two to
470 SYPHILIS (LYDSTON).
five pills. This generally should be necessary, ptyalism can be produced
continued — with certain intervals oi thus in twenty-four to forty-eight
rest — throughout the course of treat- hours. With the advent of salvarsan
ment. It often is well to substi- this emergency method became ob-
tute from time to time some other solete.
mercurial. Another rapid and efficacious
It is the physician's duty to tell his method is Lewin's method of hypo-
patient that if he wishes to get well dermic injection. From ^/g to %
he must take remedies for at least grain (0.004 to 0.008 Gm.) of mer-
three years, and if any doubt exists cury bichloride, in combination with
at the end of that time he would best %o grain (0.002 Gm.) of morphine
add another year, especially if he has and a small quantity of sodium chlo-
matrimonial intentions. In the case ride, is dissolved in 15 minims (0.9
of women a still longer period before c.c.) of distilled water, and injected
marriage is advisable than in men. into the muscles, preferably of the
The patient must be convinced buttock, once or twice daily ; a
that it is necessary to avoid liquor minute dose of cocaine may be added
and tobacco for an extended period, Taylor used a mixture of calomel
and that he must abstain from his and sodium chloride, 5 parts of each,
accustomed various dissipations and suspended in 50 parts of distilled
excesses. This point must be in- water. Of this fluid an ordinary hy-
sisted upon. Patients who use alco- podermic syringeful may be injected
hoi and tobacco do not tolerate treat- every eight or ten days. The hut-
ment well, and are prone to develop tocks and the back beneath the scap-
serious nervous lesions later on. The ulse are the best injection sites,
etiological relation of tobacco to can- The newer salts of mercury have
cer of the oropharyngeal cavity and almost supplanted the bichloride and
tongue in late syphilis has been the calomel for hypodermic use. The
subject of special study on the succinimide and salicylate are best,
author's part, whose belief in its im- and should be given at intervals of
portance is firmly fixed. (Amer. Jour, two or three days to a week, in doses
of Surg., Feb., 1915.) carefully adjusted to the tolerance of
In some cases mercurial inunctions the patient, deeply in the gluteal mus-
or mercury-vapor baths must be cles. For emergencies, intravenous
wholly depended upon. Both are injections of bichloride of mercury
very efficacious in obstinate skin-le- are generally quite as efficacious as
sions. The dissemination of mer- salvarsan ; further, the beneficial ef-
curous vapors over the body largely fects are more lasting. Doses of
explains the) benefit from inunctions, from }i to j^ grain (0.008 to 0.03
It formerly was sometimes neces- Gm.) dissolved in sterile plain water,
sary to bring a patient under mer- or salt solution, may be given daily
cury very rapidly : e.g., in syphilitic for several days in some cases. In-
iritis, in which a few hours' delay jections should be made very slowly,
might be fatal to the eyes. Calomel, and the efifects carefully watched.
^2 grain (0.005 Gm.) every hour, Colitis and stomatitis sometimes fol-
accomplished the desired result. If low a single dose. Were it not for
SYPHILIS (LYDSTON).
471
this danger, the author believes that
mercury intravenously might advan-
tageously replace salvarsan alto-
gether.
For females with very weak stom-
achs, and, in children, gray powder —
hydrargyrum cum creta — is excellent.
It is an almost universal custom to
use iodides only late in the disease,
chiefly in tertiary lesions; yet many
obstinate secondary lesions also yield
to the iodides. It is well to give a
few weeks' course of the iodides from
time to time, throughout the course
of mercurial treatment. A small
amount of the nascent mercuric
iodide may be added. In precocious
syphilis, with early destructive skin
and mucous lesions or nerve-changes
iodides formerly were our chief re-
liance. It is in late syphilis, however,
that they are most reliable, especially
with mercury in the "mixed treat-
ment." Gummy lesions require an
excess of the iodides ; but, in all
cases after the lesions are under con-
trol, a prolonged mild mercurial
course should be instituted. This is
the proper method of treating the
deeper lesions of the brain, spinal
cord, bones, viscera, and testicle, tu-
bercular lesions of various kinds ; the
various scaly eruptions; and the later
grouped or particularly obstinate
syphilides. Salvarsan has largely dis-
placed iodine in obstinate lesions in
all stages. It should be followed by
routine use of mercury.
New Remedies. — Sarsaparilla was
long thought to be a specific. Among
the new preparations were cascara
amarga, berberis aquifolium and stil-
lingia, alone or in combination.
Experience with these demonstrated
their unreliability. As bitter tonics
the vaunted vegetable preparations
are all more or less useful, but as
specifics they are arrant humbugs.
The only valuable addition to our
armamentarium is salvarsan, -or "606."
Having from the first leaned toward the
side of conservatism and having waited
until personal experience warranted the
formulation of conclusions, possibly what
the author hereinafter says comes with
better grace than if he had received with
open arms the new drug as a remedy des-
tined to "wipe syphilis off the map."
From careful observation the author is
convinced of the great value of salvarsan
in meeting the following indications: (1)
Prompt removal of severe genital lesions,
thus lessening, first, the danger of infect-
ing others; second, the danger of detect-
ion; third, local discomfort; fourth, de-
structive local complications. (2) The
prevention or prompt removal of disfigur-
ing skin lesions. (3) Precocious or malig-
nant syphilis and obstinate destructive
bone and cartilage lesions, especially of
the face and nose. (4) Cases resistant to
or intolerant of mercury. In this class of
cases salvarsan often is of inestimable
service. (5) Early nerve and brain and
all visceral lesions, with the exception of
renal syphilis. In late nervous lesions its
use occasionally — perhaps always — is justi-
fiable. (6) Cases of syphilitic cachexia or
anemia, which often consist of a combi-
nation of overtreatment and syphilis. (7)
Severe and rapidly destructive lesions of
the throat and obstinate lesions of the
tongue. (8) Syphilis involving the organs
of special sense, excepting the retina. (9)
Early tabes or exceptionally in late — not
terminal — cases in the hope of relieving
severe pain or sphincter trouble. (10)
Infantile syphilis.
The drug is not promising in most cases
of tabes; yet occasional early cases are
apparently benefited by it. In the au-
thor's own experience there have been
cases in which, whether psychic or not,
the beneficial results have been endur-
ing for many months, whatever the
future may show. The Wassermann test
in general is valuable in salvarsan work,
but not always necessary. In primary
syphilis it is of no service, and in later
cases where the diagnosis is clear the
472
SYPHILIS (LVDSTON).
clinical behavior of the cases often makes
the VVassermann superfluous at the time.
In certain obviously, or even probably,
tertiary conditions, w^here the Wasser-
mann reaction is negative, we should be
governed as to indications for salvarsan
by the clinical phenomena. The same is
true of obscure nervoi's manifestations
with a clear or even prol)able history of
lues, but with a negative Wassermann.
Mercury alone can cure many cases
of syphilis if persisted in, but with
arsphenamine active treatment can be
greatly shortened and in the very
early stages the disease can even be
aborted. A positive reaction in-
dicates secondary syphilis, and the
disappearance of the positive reaction
for six months after mercury has
been stopped is evidence of cure. Gib-
son (Brit. Med. Jour., Feb. 8, 1919).
Contraindications to salvarsan have been
advanced. Paresis, advanced tabes, late
degenerative brain lesions, acute febrile
disturbances, alcoholic inebriety, advanced
arteriosclerosis, and organic heart lesions
have been accepted as such. The author
would lay stress on the danger of salvar-
san in renal syphilis. That advanced nerve
and brain lesions — unless the retina is in-
volved— are a contraindication does not
appear to be a fact. In many of the
more serious brain and cord lesions there
is nothing to lose and everything to gain,
and by using moderate or even full doses
we inay occasionally do great good. In
any event the patient and his friends are
entitled to the benefit of the doubt.
In some cases salvarsan is of great diag-
nostic service, e.g., cases of suspected
malignancy, such as lesions of the tongue,
where the Wassermann test is negative
and the microscopic findings not positive.
For many destructive lesions with an ob-
scure history, an absence of spirochetse,
and a negative Wassermann, salvarsan
may be not only valuable, but imperative.
Renal sj-philis aside, the condition of
the kidney is in general most important.
Even markedly sluggish renal action is a
contraindication for the drug. When act-
ual organic renal disease is present this
applies with especial force.
In arteriosclerosis complicating syphilis,
the impaired kidney — usually a part of the
cardiovascular pathology — rather than the
vascular changes per se, renders salvarsan
dangerous. Its entrance into the circula-
tion is safe in direct ratio to the rapidity
of its elimination. The intramuscular
method is here safer than the intravenous,
the emunctories not being suddenly over-
taxed. Where emergencies are not to l)e
combated, the intramuscular method is
more eft'ective, due to the slow absorp-
tion and elimination of the drug. Obvi-
ously, uranalysis prior to the use of sal-
varsan often is a wise precaution.
Arsphenamine is generally recog-
nized as of paramount value. Its
magical efifect occurs because it has a
powerful destructive efifect upon the
spirochete. It likewise has a rooo-
rant or tonic effect. Three inunctions
of mercury per week is a valuable
auxiliary measure, particularly in the
primary and secondary stages. No
one is in an authoritative position
today to state how long the treatment
should continue. Too often the physi-
cian stops treatment after a single
series of arsphenamine injections, and
perhaps a course of mercurj', because
the Wassermann has become negative.
This usually requires later resump-
tion of treatment, with valuable time
lost. Before any patient is discharged
from observation a diagnostic spinal
puncture should be made. Scham-
berg (Penna. St. Med. Soc; Med.
Rec, Nov. 16, 1918).
It has been the author's experience that
where salvarsan alone is relied upon, and
the infection is brought under control, re-
lapses are more frequent and earlier than
where the case has been controlled by
mercury alone.
Reverting to the value of intravenous
injections of mercury, the author recently
gave to an early ataxic salvarsan intra-
venously. At the same time bichloride in
K'-grain doses was given intravenously in
a similar case. Both had typical syphilitic
histories. The Wassermann test was neg-
ative in both; spinal fluid not examined.
The result fromi salvarsan was negative.
Improvement in the mercury-treated case
was marked after the first injection and,
after three injections, astonishing.
SYPHILIS (LYDSTON).
473
Method. — In general, the intravenous
method of administering salvarsan is best
for emergencies; it is least annoying and
least painful in all cases. The intramus-
cular method sometimes apparently gives
better results where speedy action is not
indispensable. It is, however, more pain-
ful, and in expert hands not so simple.
Technique. — The author's aim has been
to simpli-'y and decommercialize the tech-
nique of the salvarsan treatment. The
smaller the bulk of menstruum within the
limits of safety, the better. Absolute asep-
sis is necessary.
For intramuscular injection, either the
lumbar portion of the erector spinse or
the glutei should be selected — preferably
the latter. For the intravenous method
any accessible vein will do, the median
basilic or median cephalic preferred. The
skin is prepared in the usual manner and
then painted with tincture of iodine. In
the intravenous method, the vessel may
be exposd by incision, if necessary — as it
very rarely is, oftener in women than in
men. Care should be taken not to apply
the tourniquet too tightly, else the ar-
terial supply will be cut off and the veins
made less prominent. A needle for the in-
travenous method should not be larger
than 21 or 22; that for the intramuscular
should be about No. 18.
For the intramuscular method the au-
thor prefers suspension of the drug in
iodized oil of sesame, 10 per cent., rub-
bing up the mixture thoroughly with mor-
tar and pestle. From 3 to 6 c.c. are in-
jected, half upon each side of the spine
or glutei. The needle should be detached
from the syringe before injecting to as-
certain whether or not a vessel has been
punctured. If so, a new puncture should
be made. Gauze, or cotton and collodion,
serves as a dressing.
The degree of local reaction from the
intramuscular method varies. Some pa-
tients are glad enough to keep quiet for
several days; others refuse to lay up for
more than a few hours. Some of the lat-
ter regret their obstinacy a day or two
later. There is occasionally a slight rise
of temperature.
Sometimes, after absence of immediate
reaction, tenderness and pain at the site of
intramuscular injection and a rise of tem-
perature, after both intramuscular and
intravenous inethods, develops later. This
pertinently suggests advisability of rest
for several days in most cases.
For the intravenous method the author
employs the neosalvarsan via a Luer
syringe, using only 10 c.c. of sterile salt
solution, mixing the dose in a mortar. A
gauze dressing completes the operation.
Local reaction following the intravenous
method means one or several of the follow-
ing: (1) Infection. (2) Injection of the
fluid into the circumvascular cellular tissue.
(3) Injection of vein wall. (4) Transfixion
of vein. (5) Too rapid injection.
Case of laryngeal syphilis which, in
spite of intensive antisyphilitic treat-
ment for years, suddenly became dan-
gerously progressive. Intravenou:^
injections of sodium iodide were be-
gun, increasing by 5 grains (0.3 Gm.),
from 30 up to 335 grains (2 to 22
Gm.). The treatment was remark-
ably well borne. Mercury and ars-
phenamine were likewise adminis-
tered to the limit. Within a few
weeks, improvement was obvious.
This patient received 125 injections,
or 26,013 grains of sodium iodide, in 8
per cent, solution. Howard (Amer.
Jour, of Syph., July, 1918).
Instead of arsphenamine, gedyl was
used intravenously in 28 cases, 0.2
Gm. being given at intervals of four
or five days. After the fourth injec-
tion the Wassermann was usually
negative and continued so. The in-
jections were then given at five- or
six- day intervals, up to 2 Gm. Re-
actions were slight. Small chancres
healed in four to eight days; phage-
denic chancres, in twenty-five to
thirty days. In cases treated from
the outset no roseola or mucous
patches developed. P. Richard (Can.
Jour, of Med. and Surg.. Sept., 1918).
Local Treatment of the Chancre. —
Important in this connection is {I) to
avoid caustics, (2) to avoid grease,
and (3) to keep the parts as dry as
possible and perfectly clean. Impor-
tant in severe chancre is the main-
tenance of rest. Movement and fric-
474
TABES DORSALIS (PRITCHARD).
tion are often responsible for serious
complications. Sexual intercourse
should, of course, be interdicted.
The only exceptions to the rule
regarding caustics are mixed sores,
with a minimum of induration, and
exulcerated sores that become slug-
gish and refuse to heal after indura-
tion has nearly or quite disappeared.
In the first instance pure carbolic
acid followed by fuming nitric acid
is admissible, but the galvanocautery,
preceded by cocaine, is better. In
sluggish ulcers stimulation with sil-
ver nitrate may be warrantable.
The old-time black and yellow
washes are serviceable, although the
part cannot be kept dry under their
use. A solution of mercuric chloride,
1 to 20,000, is very useful. A plan
recommended for the application of
the bichloride is to wash the lesion
with a weak solution of common salt.
Calomel is now sprinkled upon the
part, a small amount of nascent and
active bichloride being thus formed.
The writer has used this plan for
condylomata quite successfully. The
best absorbent for the dry treatment
is the powdered oleate or stearate of
zinc. Simple calomel is also useful.
Once the diagnosis of true chancre
is made, local treatment usually is of
but little importance. As a rule, sal-
varsan or intravenous injection of
mercury quickly causes the lesion to
disappear. q_ Frank Lydston,
Chicago.
SYRINGOMYELIA. See Spinal
Cord, Diseases of.
TABES DORSALIS.— Locomo-
tor ataxia; posterior spinal sclerosis.
DEFINITION.— Tabes dorsalis is
an organic disease of the periph-
ero-central sensory nervous system
characterized symptomatically by in-
co-ordination, sensory and trophic
disturbances; afifections of special
nerves, the optic and ocular par-
ticularly ; and involvement of the
sphincters.
VARIETIES. — The symptom-
complex, in its classical form, is ex-
ceedingly constant. But variations
occur in the clinicopathological pic-
ture which justify classification into
at least three types: the common, or
typical; the anomalous, or atypical;
and the complicated.
In the first type, or typical cases,
the symptoms point to a primary dis-
ease of the sensory neurons of certain
areas of the lower dorsal and lumbar
cord (common type). Rarely, the
primary invasion is of the upper cord
(cervical or superior tabes), and in
still others the initial symptom may
be an optic atrophy (amaurotic tabes,
initial optic-atrophy type). The pre-
dominance and persistence of pain in
certain cases has served as the basis
for a so-called neuralgic type (tabes
dolorosa, Remak), while the early de-
velopment of general or pseudopara-
plegic muscular weakness is a basis
for the "paralytic" type. True motor
paralysis is not an essential part
of tabes, however, except as a late
secondary phenomenon. Occurring
early, it indicates the existence of a
complication. Erratic extensions of
the disease into other areas of the
cord give rise to anomalous symp-
toms (see Complications, p. 488).
TABES DORSALIS (PRITCHARD).
475
SYMPTOMS.— Tabes dorsalis
may be divided into at least two
symptomatic stages : the incipient, or
preataxic, and the ataxic. The line
of demarcation is so indistinct as
scarcely to justify separate considera-
tion, and I shall therefore first de-
scribe the clinical history as a whole.
Analyzing 500 cases of tabes, pro-
gressive paralysis or cerebrospinal
syphilis, the writer found 78 cases
of the abortive type. Only 46 of
these had pronounced symptoms. In
32 there were merely reflex rigidity
of the pupil and disturbance in the
sensibility, usually in the legs. In
none was there any trace of lancinat-
ing pains. In a few there was isolated^
ataxia of the legs. He never en-
countered a case in which there were
crises alone for years without other
signs of certain tabes. P. Schuster
(Med. Klinik, May 4, 1913).
Tabes begins very insidiously, and
its early progress is usually slow.
The first subjective evidence may be
numbness or other paresthesias (ting-
ling, burning, "pins and needles,"
etc.) occurring in the extremities, or,
more frequently, attacks, occurring
paroxysmally and without warning,
of sharp stabbing pains, usually in
the legs, but without constancy as
regards distribution.
Pains are the most important in-
dication of the commencing sclerosis
and may be the only dominant or even
apparent symptom for perhaps even
ten or twelve years. A. McL. Hamil-
ton (N. Y. Med. Jour., Feb. 22, 1913).
The lightning pains of tabes enable
the physician at times to make a diag-
nosis before the other symptoms have
appeared. These pains are charac-
teristic. They stab like a knife, or
a darning-needle going in, or they
resemble the effect produced by tak-
ing up the flesh, pulling at it, and let-
ting it go. The pains come not
singly, but rapidly repeated, several oc-
curring in the course of a second or
two, followed by a lull of longer or
shorter duration. Buzzard (Lancet,
Jan. 8, 1921).
Slight diminution, or, rarely, sud-
den increase in sexual desire or power
may be noted about the same time.
Fatigue from exercise, as in walk-
ing, dancing, or the ordinary occupa-
tion, is greater in degree and occurs
more quickly than before.
Transient attacks of double vision
may be noted with or without ptosis.
The normal action of the bladder and
sometimes of the rectum may be dis-
turbed. Severe attacks of rectal neu-
ralgia sometimes occur quite early.
The knee-jerks are decidedly dimin-
ished in activity or even abolished
(Westphal's symptom). Tests of
sensation may reveal an impaired
tactile perception in the distribution
of the ulnar ner\^e (Biernacki), the
peroneal (Sarbo) or the popliteal
space (Bechterew), or over the plan-
tar surfaces of the feet.
Anesthesia in the region of the nip-
ple, usually bilateral, is referred to as
Patrick's sign.
The eyes will present the Argyll-
Robertson pupil, which consists in a
loss of the reflex to light, although
accommodation to distance is pre-
served. The pupils are often quite
early found abnormally contracted,
sometimes to the degree of "pin-
point" pupils. They may be unequal.
The palsies of eye-muscles possess
certain peculiar characteristics. One
is their transient tendency, especially
in the early stages of the disease.
A history of diplopia can often be
elicited. There is a marked disposi-
tion to recurrence. The palsy may
last only a few hours or persist for
years and the return of the muscle to
normal action even after long periods
should be recognized as a possibility
in tabetics and tend to discourage
476
TABES DORSALIS (PRITCHARD).
operation in such cases. Posey (Jour.
Amer. Med. Assoc., Apr. 16, 1910).
Atrophy of the oculomotor nerve
is one of the earliest symptoms ot
tabes but occurs seldom in syphilis.
Syphilitics with recurrent attacks do
not become tabetics. Fuchs (Wiener
khn. Woch., Apr. 4, 1912).
The writer's spinal sign consists of
a point or small area of tenderness
just to the left of the spinal column,
corresponding to the fifth dorsal in-
terspace or one at about that level.
It is always to be found on the same
side as the stomach. It may occasion-
ally extend to more than one space.
It rarely involves the other side, and
then only in minor degree. An evi-
dent wince on the part of the patient
or an expression of pain shows when
the tender spot is reached. Browning
(Med. Rec, Oct. 30, 1920).
The disease may remain practically
stationary at this stage for some time,
even for years (Gray), but sooner or
later symptoms of ataxia supervene.
Ordinarily the ataxia is first noticed
in walking at night or along a narrow
pathway or in circumventing obstruc-
tions. Previously automatic action in
walking, standing, dancing, etc., de-
mands more conscious attention.
Quite early, the patient will present
the Romberg sign, by which is meant
an inability to stand without sway-
ing or falling if the feet are placed
close together. Minor degrees of this
are sometimes shown only with the
eyes closed or by having the patient
attempt to stand on one foot. In
walking the ataxia is manifest in the
increasing difficulty with which the
patient follows, heel and toe, a chalk
line or a carpet-seam or crack along
the floor. Here, again, closing the
eyes greatly intensifies the difficulty.
Obersteiner lays stress on the im-
port of inability to walk backward.
I have for many years employed this
test in examining tabetics, and have
frequently noted with curious interest
that the patient could walk backward
with less ataxia than forward.
The gait becomes characteristic;
the feet are kept wide apart, are lifted
unnecessarily high, and are brought
down to the floor with an appearance
of unusual and unnecessary force, the
heel striking first. Charcot is quoted
as stating that he often made the
diagnosis from hearing the patient's
footfalls, before having seen him at
all. The patient will often state, in
explanation of his defective gait, that
he is losing power in the legs. At-
tempts at forced flexion or extension,
the patient resisting, will show, how-
ever, that muscular power is intact.
The ataxia may extend — in the cer-
vical cases it begins — into the upper
extremities. The pianist loses his
delicate technique, the machinist his
dexterity. Fastening a button, espe-
cially when not in the field of vision,
becomes a serious problem. If asked
to touch the tip of his nose with the
tip of his finger or to bring his out-
stretched arms together so as to touch
the tips of the right and left fore-
fingers, the eyes being closed, the pa-
tient will almost invariably fail.
Later, these symptoms are intensified
and others added, chiefly sensory.
The patient complains of a feeling of
pressure or constriction or band of
numbness round the waist, chest, or
throat.
Various disturbances of the viscera
may develop. Attacks o^ apparently
causeless vomiting, of gastric pain, of
dyspnea, of palpitation, of vesical or
rectal tenesmus occur which are
known as crises. Certain trophic al-
terations in the skin, hair, and nails
may be present, or the teeth may fall
TABES DORSALIS (PRITCHARD). 477
out gradually and painlessly. The are not appreciated. Finally, a con-
joints, especially the knees and el- dition of motor helplessness or paresis
bows, sometimes enlarge suddenly, may be superadded,
as a rule, without pain, constituting Several variations in the picture
the so-called tabetic arthropathies of may occur. The disease may begin
Charcot. The bones become easily with an initial ataxia; it may begin
friable. Abnormalities in the visual with an optic neuritis or atrophy. In
apparatus again become conspicuous, rare instances the earlier symptoms
The transient strabismus or ptosis are referable to lesions in the cervical
of the earlier stage may recur and cord, the upper extremities being
become permanent. The optic nerve first affected. Such cases are known
presents the symptoms of atrophy, as cervical and sometimes as superior
and total blindness may result, often or descending tabes, though the two
quite early in the disease. latter terms have also been applied to
All forms of common sensation be- general paresis with secondary pos-
come impaired in varying degrees and terior spinal sclerosis. Painful sen-
different localities. An analgesia de- sory phenomena are sometimes very
velops, which may be absolute, but marked, persistent, and widespread,
is more often partial and frequently The shooting, stabbing, grinding
ataxic. The patient, pricked on the pains in the legs, the rectal pains,
left leg, may refer pain to the right the trigeminal pains, the painful
(allochiria) or to both legs. This crises, may be all extreme and give
phenomenon is sometimes true, also, rise to the "neuralgic" type. If the
of tactile and temperature perception, disease develops within a year or two
Pain-conduction may be retarded or after primary syphilis, the picture
delayed. Several seconds may inter- takes on the bizarre characteristics of
vene between the actual pinprick and exudative nervous syphilis,
the patient's appreciation of it. Symptomatic Analysis. — The Re-
The muscular sense is invariably flexes. — One of the earliest — possibly
impaired in some degree and in the earliest demonstrable — symptom
nearly all of its subdivisions — posi- is a lessened patellar-tendon reflex,
tion, weight, pressure, etc. If the This diminution may be first unequal
eyes are closed the patient may not on the two sides, but later both knee-
be able to tell whether a given mus- jerks are eventually lost (Westphal's
cle or set of muscles is being flexed symptom). So constant is this.symp-
or extended, pronated or supinated, tom as to have been held pathogno-
by the examiner. If two wooden monic. It may even occasionally ex-
globes, of like size, but differing in ist in persons otherwise healthy,
weight, are placed in the hands of the Some investigator has stated that 2
patient, he cannot distinguish the per cent, of normal individuals show
heavier from the lighter. Pressing absence of knee-jerks,
unequally with the hands upon the The simplest diagnostic method is
patient's thighs or other symmetrical to have the patient "cross" the leg
parts of the body, he is unable to dis- carelessly, when, with the side of the
tinguish the inequality. Variations extended hand or a percussion-ham-
in the degree of contact heat or cold mer, a sharp tap over the tense
478
TABES DORSALIS (PRITCHARD).
patellar tendon will ordinarily demon-
strate the normal or exaggerated pres-
ence, or the loss,, of the reflex. Such
a test, however, is not final unless
practised with one of the methods of
sensory or mental reinforcement, the
simplest of which is Jendrassik's.
This consists in having the patient
grasp the hands tightly and look up
at the ceiling, or at least away from
the field of examination, as the ten-
don is struck.
While abolition of the knee-jerk is
exceedingly constant, occasional ex-
amples of the disease have shown the
reflex preserved and intact. The
explanation is found in non-involve-
ment, by the disease-process, of the
zone of entry {ivurzcll ein-tritt) of the
corresponding posterior roots. Hemi-
plegia in a tabetic patient may result
in return and even exaggeration of
the knee-jerk.
Case of tabes dorsalis suggestive
of Friedreich's ataxia. The patient
was a man, about 28 years old, who
presented ataxic gait and station, ab-
sence of knee-jerks, insignificant ocu-
lar changes, and high foot-arches.
There was no history of similar dis-
ease in the family and the Wasser-
mann reaction was negative. J. H.
Lloyd (Med. Rec, Nov. 21, 1914).
Mills, following the observations
of Babinski as to the significance of
the tendo-Achillis jerk in tabes,
thinks that this sign may prove of
value in removing the element of
doubt in cases in which the knee-jerk
is preserved, such cases usually show-
ing alteration of the Achilles-tendon
jerk.
In early tabes the cutaneous and
superficial reflexes are preserved and
may be exaggerated : a fact of some
diagnostic significance (Bechterew).
In the late disease these also are lost.
There are cases in which the knee-
jerks persist, at least for a time; in
others they return after having been
absent; in some the Argyll-Robert-
son pupil is wanting; in others it
returned after having been absent.
In some there is return of sexual
power previously wanting, especially
after treatment with testicular ex-
tract. J. K. Mitchell (Med. Rec,
May 31, 1913).
Pupillary Symptoms. — Fixed pupil-
lary contraction (spinal myosis) ; a
loss, abruptly or gradually progres-
sive, of the reflex action to light ;
accommodation to distance and in
convergence being preserved (reflex
iridoplegia, Argyll-Robertson pupil)
with loss of the sympathetic skin-
reflex, are the more constant and
characteristic pupillary abnormalities
in tabes. Both eyes are usually af-
fected and to about the same degree.
The iridoplegia may be unilateral,
however; and the two pupils may
be unequally contracted or one only
may be abnormally small. Perma-
nent mydriasis or dilatation is rare.
I have noted an inconstant irido-
plegia in two women with tabes, in
both of whom the phenomenon ap-
peared and disappeared several times.
In another patient, a physician, the
iridoplegia was unilateral for several
years, during which time loss of knee-
reflex and plantar anesthesia was also
unilateral and of the same side.
The Argyll-Robertson pupil is, per-
haps, the most constant and charac-
teristic symptom in posterior spinal
sclerosis. It is also an early symp-
tom invariably, and with abolished
knee-jerks justifies a diagnosis even
in the absence of all other symptoms.
In late tabes the action of the pupils
in accommodation is also lost.
The lesion in Argyll-Robertson
TABES DORSALIS (PRITCHARD).
479
pupil is probably in the fibers which
pass from the proximal end of the
optic nerve to the oculomotor nerve,
according to de Schweinitz, who
quotes Turner^ however, as believing
that a single lesion in the forepart of
the oculomotor nuclei in the Sylvian
gray is the cause of both myosis and
reflex iridoplegia.
The eye findings may exist years
before tabes becomes manifest in any
other way. It is necessary to detect
it and apply treatment before irrepar-
able lesions are caused. Eye exami-
nation does this by revealing the first
tendency to loss of reflex contraction
of the iris to light. Only part of the
iris at first fails to contract. Any
irregularity in the circumference of
the iris as it contracts warns of be-
ginning impairment of the light re-
flex if there is relative miosis and the
contraction of accommodation pro-
ceeds normally. By this means we
can diagnose incipient tabes with cer-
tainty when but a few of the cells
and fibers involved are affected. Behr
(Med. Klinik, Dec. 27, 1914).
Optic Atrophy. — This may occur at
any stage, though usually present
early, and is found in from 10 to 35
per cent, of cases. Bergur found it
present in 44 of 109 cases. Disturb-
ances of color-sense and contraction
of the visual field are associated.
Atrophy is usually slow, and remis-
sions may occur. Blindness ensues
in from, three to five years. The
ataxia and also the painful sensory
symptoms diminish upon the onset
of blindness, as a rule (amaurotic
tabes). The left eye is said to be
attacked oftener than the right. Usu-
ally both are involved.
Ophthalmoscopically the optic at-
rophy has the appearance of primary
degenerative atrophy in contrast to
the appearance in that form which
follows neuritis.
Ocidar-Muscle Palsies. — One of the
first symptoms in locomotor ataxia
may be an attack of double vision
with or without ptosis. Occurring
early, such attacks are usually abrupt
and of short duration, disappearing
completely in a few days or weeks.
Well-marked strabismus, most com-
monly of the variety due to sixth-
nerve involvement, may be present,
and, if early, is equally abrupt and
transient. Mobius believes that sud-
den painless ocular palsies in an adult
are almost pathognomonic of tabes.
They are certainly exceedingly sug-
gestive. Ptosis, more or less decided,
is frequently noted in the late stages.
It is usually slow in development and
remains permanent, as does also late
strabismus. Ophthalmoplegia, both
external and internal, has been infre-
quently observed.
Normally, compression of the eye-
ball is followed in two or three sec-
onds by a diminution of the rate of
the heart-beat to the extent of eight
pulsations per minute. This reflex is
abolished in tabes. The absence of
this reflex has the same significance
as the Argyll-Robertson pupil. M.
Loeper and A. Mougeot (Prog, med.;
Med. Rec, Feb. 14, 1914).
Ataxia. — The disease may manifest
itself first in, an ataxia of gait or sta-
tion (acute locomotor ataxia). But
usually various sensory and other
symptoms prominently precede the
ataxia, disturbances of co-ordination
being essentially dependent upon im-
paired centripetal or sensory impres-
sions. Loss or defect of muscular
sensibility, particularly of position-
sense, is the chief cause of the ataxic
gait and inco-ordination of upper limbs.
Romberg's symptom is probably due
to the associated involvement of both
tactile and muscular sensibility. Ley-
480
TABES DORSALIS (PRITCHARD).
den's experimental induction of this
symptom by freezing (anesthetizing)
the soles of the feet with ether-spray
demonstrates at least some participa-
tion of the tactile sense. Helpless-
ness from ataxia should be carefully
distinguished from helplessness due
to true motor paralysis or paresis.
Suspicion of tabes should be
aroused in children when they show
persistent migraine, tendency to spas-
mophilia, enuresis, simple transient
"absences" (abortive epileptiform
seizures), inability to keep up with
the class in school, tics, slight choreic
instability, visual disturbance, or
cramps in one limb. Lereboullet and
Mourzon (Paris med., Jan. 4, 1919).
Tabetic Crises. — These consist of
attacks, occurring suddenly, without
assignable cause and ending quite
abruptly, as a rule, simulating attacks
of gastric, intestinal, nephritic, vesi-
cal, or hepatic colic. Gastric crises
are most common. The patient is
suddenly seized with excruciating
gastric or abdominal pain, usually
with violent retching and vomiting.
The attack may last two or three
days or it may end after a single
paroxysm lasting a few minutes, re-
curring at varying intervals from a
week to several months. Except
from malnutrition, such attacks are
not dangerous.
Study of 42 cases of tabes with
gastric crises. The patients were all
males of 29 to 64 years. The crises
were noted five times as an initial
symptom. Severe pain was noted in
11 cases, was moderate in 9 cases,
and severe and sometimes moderate
in 22 instances. Severe attacks of
vomiting were observed in 23 in-
stances, moderate in 12, and severe
and again moderate in 7 cases. The
gastric secretion was obtained during
the crises of 35 patients; it contained
a normal amount of acid in 6 cases,
while hypcrchlorhydria existed in 13;
hypochlorhydria was present in 10,
and variable acidity in 6. The secre-
tion was secured during intervals in
36. There was normal acidity in 14,
hypcrchlorhydria in 12, and hypo-
chlorhydria in 10. Friedenwald and
Leitz (N. Y. Med. Jour., July 6, 1912).
The authors found in the post-
mortem records of the General Hos-
pital of Vienna 5 cases of ulcer and
3 of carcinoma of the stomach in 75
tabetics. All but 1 had gastric crises.
In 6 cases at operation either a fresh
or healed ulcer of the stomach was
found. From these, and rabbits in
whom bilateral vagotomy invariably
causes an ulcer of the stomach, they
conclude that the ulcer in tabetics is
due to a lesion of the vagus nerves.
Histologically, profound changes
were found in all cases examined. A.
Exner and E. Schwarzmann (Wiener
' klin. Woch., Sept. 19, 1912).
The proof of the connection be-
tween gastric disturbance and spinal
lesion often depends on signs of
which the patient is unaware — such as
faulty reflexes and cutaneous sensi-
bility, and changes in the spinal fluid;
the demonstration that active syphi-
lis exists by the Wassermann reac-
tion in the blood and spinal fluid, or
even in the latter alone, adds the last
link to the chain. W. F. Cheney
(Amer. Jour. Med. Sci., Mar., 1913).
When, however, the heart's action
or the functions of respiration are in-
volved, the danger is much greater,
fatal results having been recorded.
Both varieties, fortunately, are rare.
The symptoms in laryngeal crises
are not unlike those of laryngismus
stridulus : dry, violent cough, with
spasmodic inspiration, marked dysp-
nea, and at times unconsciousness.
Burning pains in the neck- and
shoulder- muscles sometimes occur.
In one of my patient's, subject to
laryngeal crises, a total aphonia re-
peatedly occurred, lasting from a few
TABES DORSALIS (PRITCHARD).
481
moments to several hours. This pa-
tient later developed minor epilepti-
form attacks, dyingf finally in a
"status" of such seizures.
Cardiac crises resemble attacks of
an<T;-ina pectoris. There may be ac-
stabbing, vagabond pains of loco-
motor ataxia are so distinctive in
character as to be unique. No two
patients will, perhaps, describe them
in the same way, and yet their iden-
tical character is at once evident from
tual disease of the heart of trophic descriptions. They are often worse
origin. A rapid pulse — 100 to 120 — at night and during excessive humid-
was often noted in Charcot's cases
without associated cardiac crises.
The crises of tabes possess a local-
izing pathological value quite analo-
gous to that of the aura or signal
ity presaging a storm. Tabetics are
often, indeed, quite reliable weather
prophets.
Trophic Symptoms. — Some degree
or variety of trophic disturbance is
symptom in epilepsy, pointing to an usually manifest at some time, not
invasion and irritative degeneration as complication, but essentially as a
of the vagus-nuclei or fibers, or to part of the disease. Occurring early,
fibers elsewhere physiologically re- the trophic changes are due to in-
lated to the symptoms. Crises are volvement of the peripheral tropho-
among the earlier clinical phenomena sensory fibers ; late trophic symp-
usually, but they may persist for toms may be dependent upon lesions
many years. They often ultimately of the ventral horns. Among the
disappear with the lancinating pains, trophic symptoms are superficial and
Sensory Symptoms. — The defects in
common sensations have been sufii-
ciently described. Among less fre-
quent sensory phenomena are anal-
gesia of the testicle and anesthesia
in the distribution of the fifth nerve,
especially over the mucosae of the taneous fractures ; arthropathies, with
perforating ulcerations of the skin
and other cutaneous lesions, loss of
the hair or teeth, onychia ; atrophies
of muscles, singly or in groups ; nutri-
tional disease of the bones, particu-
larly the femur, giving rise to spon-
mouth and eyelids.
In tabetic ataxia there is abnormal
perception if the skin is pressed with
the finger and pushed in various di-
rections or a fold is taken up in the
fingers and pulled up or down or
sideways. A healthy person can al-
ways tell in which direction the
movements are made, but the tabetic
is often or constantly mistaken.
Baeyer (Miinch. med. Woch., May,
1914).
Pitres found analgesia of the testi-
cle in 75 per cent, of his cases. It
varies in degree from time to time
and may disappear temporarily. Its
disappearance may coincide with a
return of sexual power. The sharj),
secondary luxations and displace-
ments ; edema ; bed-sores.
Perforating ulcers almost invari-
ably develop on the plantar surfaces
of the feet, often beneath the great
toe, and may be symmetrical. Such
ulcers may occur early. In one of
my patients such ulcers led to the dis-
covery of tabes, the discovery over-
whelming him with surprise.
Herpes is not an uncommon accom-
paniment of the severe neuralgic or
neuritic pains sometimes observed.
Baldness or anomalies in pigmenta-
tion, especially the former, are com-
mon. The teeth may all fall out ;is
a result of trifacial involvement.
8—31
482
TABES DORSALIS (PRITCHARD).
Onychia is sometimes very trouble-
some, and wounds or operations upon
the extremities, especially the feet,
may prove quite obstinate in healing.
Muscular atrophy, if extensive, is
a late incident. Extensive atrophy
occurring early indicates a probable
complication. Atrophy of single mus-
cles may occur, though seldom early,
as a result of neuritis.
Extreme widespread emaciation
has been noted. In two such cases
under my observation frequent, se-
vere gastric crises caused death.
The arthropathies and osteopathies
of tabes occur in from 5 to 10 per
cent, of cases. The knees are chiefly
affected. The smaller joints usually
escape, though Hirtz has reported a
case with radiographic illustrations,
involving the metatarsophalangeal
articulations. In some cases there
exists, without swelling or deform-
ity, a remarkable relaxation of the
muscles of the knee and other joints,
permitting extreme hyperflexion and
hyperextension. This condition has
been called "hypotonia" by Frankel,
who considers it an early symptom.
R6ntgen-ray findings show that an
extensive destructive and a prolifer-
ating process run their courses to-
gether and lead to abnormal bone
growth outside of the capsule. The
whole trouble frequently begins with
an erosion of the bone; this is often
distinctly evident in the Rontgen pic-
ture. Kriiger (Mitteil. a. d. Grenzgeb.
der Med. u. Chir., xxiv, nu. 1, 1912).
History of 23 cases of tabes in
which Charcot joints and spontane-
ous fractures were, in some, the
earliest symptoms. They often pre-
cede the ataxic gait, and are of diag-
nostic importance in tabes. Charcot
joints are frequently of traumatic
origin and often follow fractures and
lesser injuries. H. L. Taylor (Jour.
Amer. Med. Assoc, Nov. 15, 1913).
Attacks of edema in the extremi-
ties or elsewhere, usually transient
and of a type similar to angioneurotic
edema, have been noted. Bed-sores
on the sacrum, over the trochanters,
etc., ordinarily belong to the bed-
ridden stage. An emphatic protest is
made against the custom for reliev-
ing leg pain, of tightly binding a cord
or ligature around the limb. It may,
and sometimes does, effectually re-
lieve the pains, but at great risk of
inducing far more serious trophic
disturbances.
Vesical, Rectal, and Sexual Symp-
toms.— Slight incontinence or slow-
ness in micturition may first attract
attention to the possibility of tabes.
This may vary from time to time,
and is rarely extreme or particularly
annoying. In the late stages there
may be partial or total anesthesia of
the bladder, with either absolute in-
continence or retention. The urine
may be retained without discomfort
for many hours, and, unless with-
drawn by catheter, a cystitis may
develop. Catheterization should be
practised very carefully in such cases.
The initial symptoms of tabes may
be urinary incontinence, and strongly
resemble those of prostatitis and
vesical calculi. Having these possi-
bilities in mind, the surgeon should
approach every supposedly renal,
vesical and prostatic case with the
greatest possible circumspection. H.
Klussman (Pacific Med. Jour., Dec,
1911).
Tabetics are almost invariably con-
stipated, although in the advanced
disease incontinence of feces may be
present. The rectal region may be
the site of sharp, stabbing pains in
neuralgic cases. Sexual desire and
power, while invariably impaired or
abolished in the advanced disease, is
TABES DORSALIS (PRITCHARD).
483
sometimes at first exaggerated, the
patient committing the grossest ex-
cesses in sexual intercourse. Such
paroxysmal satyriasis may give way
to total temporary abolition of sexual
function. The cremasteric reflex is
said to return and the scrotal anes-
thesia to lessen with each return of
function.
Special Senses. — In addition to vis-
ion, hearing is affected in about 75
per cent, of all cases. Deafness is
rarely due to atrophy of the auditory
nerve, and sometimes to a tropho-
sclerotic condition of the middle ear
through trifacial involvement.
Taste and smell are believed to be
rarely affected, though Klippel does
not agree with this view.
They are, moreover, among the
earliest symptoms in tabes, accord-
ing to this author, who describes
a case with these symptoms, which
came to autopsy, showing marked
degenerative disease of the olfac-
tory, glossopharyngeal, and trigem-
inus nerves and their ganglia.
DIAGNOSIS.— The chief diagnos-
tic problem lies in the prompt recog-
nition of the incipient or preataxic
stage. No single symptom is path-
ognomonic, although the Argyll-Rob-
ertson pupil is considered by Mobius
and others as invariably indicative of
either locomotor ataxia or general
paresis. The conjoint association of
any two oi the four most constant
symptoms — abolished knee-jerks, Ar-
gyll-Robertson pupil, lightning pains,
and ocular palsies — is quite sugges-
tive, if not diagnostic. Coexistence
of the four symptoms is positively
diagnostic. Subsequent development
of ataxia completes the unique clin-
ical picture.
Among the diseases obscuring the
diagnosis, are ataxic paraplegia, dis-
seminated sclerosis, brain-tumors, cer-
tain forms of myelitis ; the syphilitic
meningomyelitis of Oppenheim and
others; multiple neuritis, and post-
diphtheritic paralysis.
In the ataxic paraplegia of Gowers
there is actual loss of motor function
with spasticity, the knee-jerks being
usually exaggerated with little if any
pain, no crises, no arthropathies, and
no involvement of the eye-muscles.
In multiple sclerosis there may be
ocular palsies, pains (slight) in the
lower extremities, defects of sensa-
tion, sphincteric involvement, ataxia,
and even abolished knee-jerks. The
knee-jerks are usually exaggerated,
however; the pains differ in degree
and character, and the peculiar speech,
intention-tremor, nystagmus, and
special variety of optic atrophy
(Gnauck) are distinctive.
Ataxia is common in tumor of the
cerebellum, the frontal lobes, and the
base of the brain. Optic atrophy and
ocular palsies are also frequent. At-
tacks of vomiting may simulate gas-
tric crises. The clinical picture and
history of focal palsies, headache,
hebetude, etc., in brain-tumors serve
to distinguish the two conditions
quite readily. In myelitis the ab-
sence of optic atrophy, ocular palsies,
and Argyll-Robertson pupil suffice
to eliminate confusion. In multiple
neuritis the deep reflexes are abol-
ished or diminished, there may be
much pain, and the ataxia may be
decided. The rapid atrophy and true
motor weakness, with altered electri-
cal reactions, absence of pupillary
changes, and preserved light-reflex
are diagnostic. Postdiphtheritic pa-
ralysis simulating tabes is a nuilti])le
neuritis, and the differential data are
484
TABES DORSALIS (PRITCHARD).
the same. In s3T)hilitic meningomye-
litis there is, at times, a close resem-
blance. In such cases, however,
motor as well as sensory defect is
present, the symptoms are unilateral
or at least unequal in degree on the
two sides, the Argyll-Robertson pupil
is not present, and prompt improve-
ment nearly always follows the ener-
getic use of potassium iodide and
mercury.
Cervical tabes is at times difificult
to differentiate from syringomyelia:
a fact especially emphasized by Marie.
Cervical tabes is rare, Dejerine find-
ing only 1 in series of 101 cases.
Psychical disturbances in tabes are
not quite so rare, according to Ober-
steiner, as is usually believed. One
must carefully guard against con-
founding them with a condition of
dementia paralytica combined with
ataxic symptoms.
All cases of gradually progressive
blindness — if dependent upon optic
atrophy and especially if occurring in
negroes — should excite suspicion and
lead to careful examination for other
symptoms of tabes.
Laboratory methods in the diag-
nosis of all suspected luetic diseases
of the central nervous system, includ-
ing tabes, have come into general use
as a routine procedure. A positive
Wassermann is found in about 70
per cent, of all cases. A negative
Wassermann is, however, of no sig-
nificance in the face of a clinical
diagnostic syndrome. A lymphocyte
count of 50 or more to the cubic
millimeter is considered absolutely
corroborative. Globulin reaction oc-
curs in about 90 per cent. (Noguchi).
The colloidal (gold) test of Lange is
also quite a constant finding.
Of 1000 tabetics, 8.7 per cent, had
been su1)jectcd to laparotomy under
mistaken diagnoses one or more
times, chiefly through failure to ex-
amine the nervous system. A history
of paroxysmal attacks of vomiting,
rheumatism, paresthesias, bladder
disturbances, or fractures without
physical violence should excite inter-
est to exclude tabes. Cere1)rospinal
cytodiagnosis and the spinal Wasser-
mann are of inestimable value in
doubtful cases. Nuzum (Jour. Amer.
Med. Assoc, Feb. 12, 1916).
One of the earliest pathologic
changes in tabes is a syphilitic lepto-
menmgitis of the cord on its poste-
rior aspect. This induces a multiple
symmetrical radiculitis with pain and
paresthesias; impairment of super-
ficial and deep sensibility; loss of the
Achilles reflex; increased spinal cell
count and globulin content, and a
positive spinal Wassermann. Other
very early signs of tabes are aniso-
coria, pupils of irregular contour, and
diminished hearing. Cardiovascular
disease, especially aortic, and gen-
eral glandular enlargement are very
constant early signs. Schaller (Jour.
Amer, Med. Assoc, Jan. 20, 1917).
Case of tabes from congenital syph-
ilis in a boy of 15. Under treatment
most of these subsided. Two similar
cases are also referred to. Suspicion
of tabes should be aroused in chil-
dren with persistent migraine, tend-
ency to spasmophilia, enuresis, simple
transient "absences" (abortive epilep-
tiform seizures), inability to keep up
with the class in school, tics, slight
choreic instability, visual disturbance,
or cramps in one lim.b. There was no
disorder of gait in the case reported.
Lereboullet and Mouzon (Paris med.,
Jan. 4, 1919).
ETIOLOGY.— Heredity is of very
minor importance, if, indeed, it is a
factor at all in the etiology of tabes.
The writer observed tabes in
brother and sister. All cases of this
kind are due to inherited syphilis.
We should examine carefully the
relatives of tabetic subjects for the
TABES DORSALIS (PRITCHARD).
485
stigmata of tabes incipiens. Heitz
(Paris med., Apr. 13, 1912).
The same is true of diathetic states,
although a rheumatic predisposition
may possibly favor its development.
The writer believes that functional
anomalies and disturbances of the
endocrinous glands constitute a fac-
tor of importance in explaining in-
dividual predisposition. Starkey (Med.
Record, Mar. 4, 1916).
Next to syphilis, the occupation
and habits as regards excesses, par-
ticularly physical, are most important.
Railroad employes (especially en-
gineers), soldiers, sailors, policemen,
lumbermen, drivers, and others whose
work combines exposure to wet and
cold, with severe physical exertion,
are quite numerous among the vic-
tims of tabes. Excesses in athletic
sports, in dancing, and in sexual in-
tercourse are all considered adequate
predisposing or even exciting causes
when combined with syphilis.
Traumatism to the spine by direct
violence or concussion, as from a
violent fall on the feet, has been, in
some instances, the only apparent
cause.
Three cases in which tabes had de-
veloped apparently immediately after
a trauma, liut the investigations
showed that it must have existed
before the accident. The latter did
not have even an aggravating effect
in 2 cases; in the third case the new
symptoms that developed after the
trauma were localized in the part
specially injured. This case was
further complicated by a traumatic
neurosis. There was no history of
syphilis in any case and the Wasser-
mann test was negative. Schultze
(Berl. klin. Woch., Nov. 4, 1912).
Of all the etiological factors, syph-
ilis appears most ccmstantly. Many
believe that tabes implies pre-exist-
ence of syphilis. This is, probably,
an exaggeration ; but a history or col-
lateral evidence of syphilis can be
elicited or demonstrated in more than
75 per cent, of all cases. Erb found
89 per cent, in 300 private cases. The
exact pathogenetic relationship has
been until recently vague and con-
jectural. The actual demonstration by
Noguchi and Moore (1912 and 1913)
of the spirocheta in the brain and
cord in paresis and tabes led to ac-
ceptance of the direct causative rela-
tionship of syphilis to these con- ,
ditions.
Of 151 female tabetics, 14 were un-
married women; 11 of these had a
history suspicious of syphilis, but 3
others were virgins. It was ascer-
tained, however, that one or both of
the parents of these three virgins had
had syphilis and tabes, so that the
tabes was due to an inherited taint
in each one. Mendel and Tobias
(Med. Klinik, Oct. 22, 1911).
The interval between infection and
tabes is sometimes thirty years or
more. On the other hand, I have
seen well-marked tabes in a patient
who was under energetic treatment
for cutaneous syphilis, infection
having occurred less than eighteen
months previously. Three years later
the disease was still present, though
not advancing. In 34 cases observed
by myself the average interval be-
tween infection and the first-recog-
nized symptoms of tabes was nine
and one-half years.
The factors of age and sex are of
interest. The years between 25 and
45 show, by far, the largest number
of cases. Tabes is rare in childhood.
The course of juvenile tabes is
chronic and the prognosis is good as
tt) life. The frequency of optic atro-
phy and blindness, however, should
render one very guarded in the prog-
nosis as to vision. Price and Shan-
486
TABES nORSALIS (PRITCHARD).
non (Amer. Jour. Dis. of Children,
Apr., 1912).
Infantile and juvenile tabes is the
same as tabes of adults. Some of
the symptoms, such as optic atrophy,
are more common in the juvenile
form; others, such as Romberg and
ataxia, are more rare. Another dif-
ference is that the female sex de-
cididely preponderates. H. Barkan
(Wiener klin. Woch., Mar. 13, 1913).
Case in a boy of lYz years, with
no luetic history in either parent, no
symptoms of hereditary syphilis, w^ho
had begun to have gastric crises
when 10 months old; they now occur
every three months; the marked
ataxic gait, muscular weakness, knee
and Achilles jerks are absent. The
blood exhibited a positive Wasser-
mann and spinal fluid the same; no
lymphocytosis, no globulin excess. C.
Riggs (Med. Record, July 19, 1913).
Males are more liable to the dis-
ease than females in the ratio ap-
proximately of 10 to 1. Climate
and race are unimportant factors,
though, in my personal observations,
out of 34 cases, 14 were Irish or
Irish-Americans. Exemption in the
negro is largely apparent rather than
real, the disease probably occur-
ring much oftener in the negro
than hitherto supposed, but escaping
recognition because of the anomalous
clinical form — amaurotic tabes — in
which it appears in this race. Mc-
Connell has published the records of
5 cases of tabes in pure-blooded ne-
groes— the only cases observed in
negroes in eight years' service at the
Philadelphia Polyclinic, — all of whom
exhibited the amaurotic type.
PATHOLOGY.— Ordinarily the
gross macroscopic appearances are
both conspicuous and constant. The
cord is flattened anteroposteriorly
from shrinkage in the posterior col-
umns, which are also unnaturally
gray in color. Microscopically the
nerve-tissue proper is found sparse
or almost lost in certain localities, its
p.lace having been taken by an over-
growth of connective tissue. The
area most affected is that of the
lumbar enlargement and lower dorsal
region, and the most damaged ril)ers
are those of the columns of Goll and
Ijurdach and the Spitzka-Lissauer
tract. Higher up, and as the disease
advances, similar changes are noted
in Clarke's vesicular tract. Gowers's
sensory tract in the anterolateral field
is quite often involved and sometimes
quite early. Less constantly the di-
rect cerebellar tract shows similar
changes ; implication of the crossed
pyramidal fibers or Turck's columns
occurs only as a complication.
The posterior roots and ganglia are
also involved, sometimes quite exten-
sively. If the disease has reached the
paralytic stage, the anterior gray
horns are apt to show degenerative
changes in both fibers and cells.
Destruction of nerve-elements in
the posterior horns is often seen
microscopically. From time to time
an extensive degenerative disease of
the peripheral nerve-fibers or neu-
raxons has been noted.
In tabes and general paresis, the
ferment activity of the blood-serum is
increased above normal through the
presence of an excess of proteolytic
ferments. F. H. Falls (Jour. Amer.
Med. Assoc, Jan. 1, 1916).
The exact pathogenesis of tabes is
as yet incompletely worked out, but
enough has been proved to demon-
strate that it is not a primary sclero-
sis of the posterior columns. The
recognition and acceptance of the
theory of the neuron were impor-
tant steps in establishing this fact.
TABES DORSALIS (PRITCHARD). 487
According to the newer teaching, the systemic myelopathy ; they are the
disease is a centripetal parenchymatous expression of a progressive degenera-
atrophy or degeneration of sensory tion of the posterior-root fibers ; these
neurons followed secondarily by scle- spinal cord changes in tabes occur in
rosis, due to nutritional disturbances, segments, while each diseased pos-
ivJiich, according to Marie, affect first terior root furnishes a new contingent
the ganglia on the posterioY roots. of degenerated fibers to the spinal
These ganglia are the trophic cen- cord." The initial cord-lesion is
ters for the sensory nerves and for found in the dorsal-root zone and the
the neuraxons, or axis-cylinder proc- Spitzka-Lissauer tract, due, Marie be-
esses, of the dorsal columns of the lieves, to degeneration through the
cord. The neuron of the posterior medium of the short (1) fibers. The
spinal ganglia is a flask-shaped body, degeneration in the columns of Bur-
having an axis-process, or neuraxon, dach and Clarke's columns, which is
which divides into two branches, one usually proportionate in degree to
passing to the peripher}^, forming an the duration of the disease, occurs
arborized or brush-like network of through the medium of the fibers of
distribution in the skin or muscle- the second group. The sclerosis ob-
spindles. The other branch passes, served in the columns of Goll he at-
with the posterior root, into the cord, tributes to the degeneration of the
dividing there into two branches, one long fibers of Group 3. Primary dis-
of which ascends, while the other ease of the ganglia of the dorsal
descends, in the posterior column, roots afifords the explanation for the
From both of these branches smaller peripheral neuritis, which is paren-
fibers are given ofif which terminate chymatous and not interstitial, and is
in the posterior-horn gray matter, the result of disease of the trophic
Some of these smaller fibers are short, center of the peripheral nerve in the
others quite long. Marie divides posterior ganglia. Marie, while main-
them into three sets : — taining this view, most strenuously
(1) Short fibers which pass di- admits that no evidence whatever of
rectly into the posterior horns after disease of the spinal ganglia is found
entering the cord. in some cases, but it is quite possible
(2) Fibers of medium length which to assume that very subtle and slight
run upward in the cord, some of them trophic changes at this point, al-
ending in the middle posterior horn, though unrecognizable, are sufficient
others passing into Clarke's column, to produce the changes in the distal
These fibers are contained in the fas- arborizations of the sensory neu-
ciculus cuneatus of Burdach. raxons in the muscle-plates and skin
{Z} Long fibers coming chiefly and in the cord which are farthest
from the roots of the cauda equina, removed from their nutritional cen-
passing thence the full length of the ters, which changes give rise to the
cord to the medulla and forming the lightning pains, the diminished knee-
fasciculus gracilis of Goll. jerks, pupillary changes, the vesical
Marie's theory is as follows : "The and sexual symptoms, and other sen-
changes found in the tabetic spinal sory and trophic disturbances which
cord are not the result of a primary mark the incipient stages.
488
TABES DURSALIS (i'RlTCHARD).
The studies of Dejerine, Wallen-
berg, Rousoni, Blocq, Trepinski,
Obersteiner, and Redlich, and the
observations of Sherrington, Batten,
and others, as to the relations in
health and disease of the distal nerve
arborizations to the muscular sense
and its perversions, are all distinct-
ively corroborative of this theory.
In a case of severe tabes with un-
usual motor paralysis and muscular
atrophy, autopsy showed an almost
universal degeneration of the anterior
horns and of many of the cranial
nerve-nuclei, suggesting that this is
the primary seat of the lesions. The
point of least resistance is in the sen-
sory roots, but under conditions at
present obscure the motor neurons
may fall victims to the toxin, as in the
present case, almost pari passu with
the sensory. Occasionally the atro-
phy resembles progressive muscu-
lar atrophy; in this case the only
distinguishing features lay in that the
cell changes were rather more acute
and that the affection of the cranial
nerves was unusually widely spread.
. Tooth and Howell (Proceed. Royal
Soc. of Med., Feb., 1912).
In amyotrophic tabes, a form with
a comparatively rapid and progres-
sive atrophy of the muscles due to
disease of the anterior roots, the
picture resembles that of polyneu-
ritis rather than tabes. Drey and
Malespine (Lyon med., Nov. 9, 1913).
The relationship of syphilis etiolog-
ically occurs, according to the views
of Obersteiner and Redlich, through
the presence of thickening of the pia,
from old leptomeningitis presumably^
v^hich, by compressing the dorsal-
root fibers at a point of lessened re-
sistance, leads to their degeneration.
Edinger's theory of a local invitation
to a selective action of the poison,
from functional fatigue, has also re-
ceived the support of a certain num-
ber of observers.
COMPLICATIONS. — Locomotor
ataxia often coexists with general
paresis. Either of these may appear
as the primary disease. Hemiplegia
is also not very uncommon. Through
extension of disease other areas of the
cord may be involved, and symptoms
of lateral sclerosis, progressive mus-
cular atrophy, etc., added. Phthisis,
heart disease, and nephritis are occa-
sionally found coexistent, though not
in any essential relationship.
Exophthalmic goiter, diabetes, and
coma have also been observed.
PROGNOSIS. — The disease has
been heretofore considered essentially
chronic and progressive and the prog-
nosis as regards cure extremely un-
favorable. The degree to which the
newer discoveries will modify this is
not yet fully determined. They can,
at best, affect the progn«osis favor-
ably only when the disease is recog-
nized and properly treated in its in-
cipiency. Well-established tabes will,
in all probability, remain a progres-
sive, practically incurable affection.
The duration of the disease is very
variable, sometimes extending over
twenty to thirty years. It rarely
causes deatii per se, a fatal end-
ing occurring u«sually through the
medium of some intercurrent affec-
tion, such as cystitis, pyelitis, trophic
disorders, hypostatic pneumonia or
bronchitis, or a profound asthenia.
Much symptomatic relief may be
promised from intelligent treatment;
in some cases long periods of arrest
are obtained. Co-ordination can be
materially improved and the pains
and crises relieved. Spontaneous
remissions in the disease have been
often noted, but such results are
much more positively assured from
treatment. Usually the pains tend to
TABES DORSALIS (PRITCHARD).
489
become progressively less as the dis-
ease advances, due to progressive
diminution in sensory function.
Less easy of explanation is the
sometimes marked improvement in
the ataxic and painful symptoms
which attends the onset of blindness.
The enforced rest affords a partial ex-
planation. Vicarious function is an-
other possibility. Development of
severe trophic symptoms is an omen
of evil. Pseudoparalytic or actual
paralytic helplessness may develop in
the late stages and superinduce a
fatal asthenia. Cases with well-
marked and frequently recurring cri-
ses, especially gastric, cardiac, and
respiratory, are said to run a shorter
average course. The etiological ele-
ment in individual cases does not ap-
preciably modify the prognosis. Free-
dom from want and worry, on the
other hand, are materially advan-
tageous to the victim. In my per-
sonal experience the disease has run
a far more rapid course in women
than in men.
TREATMENT.— There is no spe-
cific known to be effective in tabes,
even in cases positively due to syph-
ilis as shown by the spirocheta.
Iodide of potassium and mercury
alone or in combination have proved
equally inefficient, though, occasion-
ally, in acute cases especially, a-n
arrest of progress has been attributed,
and probably correctly, to thes'e
agents. In cases in which, by intui-
tion or good fortune, tabes has been
recognized in its very incipiency, the
prom-pt and proper administration of
either of these drugs might prove
.positively curative. The uncertainty
of diagnosis would, however, render
conclusions as to curative value at
least a problem.
There is little, if any, clinical evi-
dence to confirm the claims of the cura-
tive merits of the salts of silver and
gold, of ergot, of arsenic, or of the
oither vaunted specifics in the older
literature. A most positive exception
is found, however, in the decided
benefit at times resulting from sodium
cacodylate. This drug should be given
by mouth and not hypodermically.
The method of suspension, while
eft'ective in exceptional instances in
modifying, at least, temporarily, cer-
tain obtrusive symptoms, has not sur-
vived the test of time, and, indeed, is
often positively harmful.
Organotherapy in this disease was
equally inglorious when first intro-
duced. Ignorance as to the principles
involved, crude and imperfect phar-
maceutical methods and a consider-
able element of charlatanism were
responsible for this disrepute. Evi-
dence is now accumulating tending
to show the adjuvant value of or-
ganotherapy.
The writer tried adrenalin in 5
cases of tabetic crises. In 3 of these
the crises- were gastric, in 1 rectal,
and in the fifth laryngeal, with a
gastric complication. The dose in
the gastric crises consisted of from
4 to 6 drops of a 1 in 1(K)0 adren-
alin solution in 20 c.c. (5 drams)
of water, which was administered per
OS. In the rectal crisis, after a pre-
vious irrigation of the rectum, from
3 to 5 drops in 20 to 40 c.c. (5 to 10
drams) of water were administered
per rectum. These doses were given
three times a day. The writer thus
obtained the disappearance of pain,
nausea, and vomiting in 4 of his 5
cases. This action set in after fif-
teen to thirty minutes, and continued
for several hours. Upon giving ad-
renalin three times a day the attack
ceased entirely. Roehmer (Semaine
med., No. 2, p. 20. 1909).
490
TABES DORSAL! S (PRITCHARD).
The writer used, with favorable re-
sults, a combination of organic prod-
ucts. To prepare the- extract, pitui-
taries, thyroids, parathyroids, and
ovaries of intact sheep of unques-
tionable health, 4 years old, and
testicles from perfectly sound cocks
1/^ years old, are used. The glands
are taken out under the strictest
aseptic precautions, all fibrous tissue
being removed as far as possible, and
only the parenchymatous substance
being used. The proportions of each
organ thus treated are: • pituitary
body, 1 part; thyroid (including para-
thyroid), 2 parts; ovary, 10 parts;
testis, 10 parts. This aggregate is
reduced to a fine paste, placed in
equal weight of chemically pure glyc-
erin, allowed to macerate forty-eight
hours, and then filtered.
The extract was administered by
the intramuscular method, using an
all-glass syringe with a half-inch
needle of the finest bore. The fa-
vorite site of injection is the gluteal
region, into which the needle is
plunged for its full length. In sen-
sitive persons the part is frozen with
ethyl chloride before injecting. A
hot compress is applied after the
injection. In chronic conditions in-
jections were originally made every
second day for one week, then twice
a week, etc.; the writer now gives a
dose daily, v/ith better results. F. R.
Starkey (Prescriber, Apr., 1913).
Two indications are paramount:
the retardation in progress of the
disease and the palliation or control
of symptoms. Three measures stand
out conspicuously as having a certain
though limited value, viz., rest, elec-
tricity, and the Frankel method of
"re-education." Conjointly and in-
telligently employed, the results are
positive. The degree of rest neces-
sarily varies. In the incipient stage
pain and other sensory symptoms
should be the guide. Five or six
weeks of absolute rest in bed is ordi-
narily sufficient. The return to active
exercise should always be tentative
and gradual, and for months, or even
years, the amount of voluntary exer-
cise should be guarded.
Compensatory exercises aim to cor-
rect 4 main abnormalities in walking.
These are: (1) Hyperextension at the
knees. It may be inadvisable to try
to correct it at first. Later the pa-
tient practises slowly the movement
of sinking and rising at the knees,
watching himself carefully and avoid-
ing all jerks. Standing may also be
practised with the knees in a partially
flexed position. (2) Overaction of the
swinging leg with dorsal flexion of
the foot. Here the patient practises
walking with the leg sharply flexed
at the knee, touching the floor first
with the toe and then coming down
gradually on the whole foot. This
is to be done slowly, aiming at steadi-
ness. At the beginning of the move-
ment the foot often leaves the floor
with a little twist, and this is to be
combated. Usually the foot is best
held pointing directly forward. (3)
Lack of plantar flexion of the foot
of the supporting leg to throw the
body weight forward. Patient prac-
tises throwing the body weight for-
ward by means of careful attention
to the movements of the supporting
foot. These first three defects are
corrected by training the eyes to
watch the various movements; for
the fourth, the equilibrium sense has
to be trained. (4) Faulty position of
the hips with a corresponding faulty
position of the trunk. Correct posi-
tion may be favored at first by the
physician's pushing in against the
trochanters of the patient as he
walks. The tendency to bend for-
ward is corrected by keeping the
buttocks forward, and this may be
aided by slight pushes or taps. The
development of the equilibrium sense
may be aided by having the patient
notice that his tendency to topple
over can be overcome in a measure
by quickly pushing out his pelvis
along the line in which he feels him-
self falling. These exercises may be
TABES DORSALIS (PRITCHARD).
491
practised with the aid of the support
of another person, then with sticks,
then without sticks, and finally with
closed eyes.
In far-advanced cases the patient
cannot stand, and must be trained to.
The exercises are along similar lines,
the patient being supported. They
should be practised for short periods
with frequent intervals of rest. The
treatment must be continued six
months to' a year. It is not suitable
for all cases, the more common con-
traindications being optic atrophy, a
heart lesion, poor general physical
candition, and frequent pains or
crises. H. M. Swift (N. Y. Med.
Jour., from Boston Med. and Surg.
Jour., Jan. 21, 1915).
Any physician can train tabetics,
and the mechanical aids can be im-
provised or dispensed with entirely in
the mild cases. As the tabetic does
not feel fatigue readily, he must be
watched to stop short of fatigue, as
this would weaken the muscles. The
exercises benefit even in the severest
cases, as a rule, and decided improve-
ment can be counted on in 50 per
cent, of all cases. The exercises can
be done in bed or on the sofa at
first. Five to fifteen minutes are
usually long enough for the sitting,
but it should be repeated two or
three times a day. It may be neces-
sary to support the limb at first
or suspend it in a sling.
A straight, zigzag or spiral chalk-
mark on the floor to follow, or a
book or cigar-box to step over may
prove useful exercises. The aim
should be to train the patient in
the movements needed in daily life:
walking, climbing stairs, knocking,
writing and buttoning garments. A
late feature is inability to extend the
leg at the knee. The knees thus give
way when the tabetic tries to stand
up. The patient strives to compen-
sate this by innervation of the exten-
sors of the knee, and this generally
results in an overcorrection. The
knee is extended too far and held in
this overtension. The same occurs
in the hip-joint, shoulder, and elbow.
By thus analyzing the elements of
the movements, the patient can be
shown and taught how to correct
errors by voluntary innervation and
- utilization of the remnants of sensi-
bility. Jacobsohn (Therap. der Geg-
enwart, Oct., 1915).
Any evidence of an aggravation is
a danger-signal, demanding a return
to absolute rest. The w^riter does not
agree with Church as to the harmful
effect of rest upon the ataxia or any
other symptom. Involuntary exer-
cise by means of massage and cer-
tain mechanical appliances (Londer)
may serve a useful purpose. In the
ataxic stage the same rule should ap-
ply. I have seen the pains, ataxia,
sphincteric disturbances, and various
crises either greatly lessen in severity
or entirely disappear from prolonged
absolute rest.
Massage in combination with me-
chanical treatment acts as a seda-
tive to spasm and a tonic in the
presence of paresis. At first gen-
tle, passive movements and efifleurage
should alone be employed, in order
merely to diminish contractures and
relieve pain by displacing the blood
from the parts. Later, the massage
should be carried out so as to im-
prove the condition of the paretic
muscles; re-education is also indi-
cated in this second period. Michaud
(Lyon med., June 23, 1912).
Next in order to rest is galvanism.
Of the value of static electricity I
have no personal knowledge. Fara-
dism in my experience is often harm-
ful. Galvanism should be employed
daily. The current should not exceed
at first 5 milliamperes. The seances
should at first be limited to ten or
twenty minutes, gradually length-
ened to one or even two hours, daily.
The electrodes (Erb) should be ap-
plied to the spine, thoroughly wet,
of course ; one over the upper dorsal
492
TABES DORSALIS (PRITCHARD).
region, the other over the upper sac-
ral spine. The selection of the pole
is immaterial. Occasionally it is of
advantage, if the pains are severe or
the ataxia extreme, to apply the
electrodes one under the sole of each
foot, the current making the direct
circuit of the nerves chiefly affected.
The benefit derived by some patients
from galvanism is quite decided. I
do not believe any appreciable effect
is exerted upon the intraspinal lesion,
but that the radiculitis and associated
neuritic condition are at times modi-
fied favorably. The well-known sus-
ceptibility of tabetics to psychic ap-
peal may be a factor to some degree.
When pains are very severe, hot
sitz-baths, the cold pack, ice-coils to
the leg or an ice-bag or the cautery
to the spine, may be tried with or
without anodynes, in particular anti-
pyrin, acetanilid, acetphenetidin, as-
pirin, or codeine. Morphine should
be employed as a last resort and
given hypodermically. Thiosinamine
sometimes relieves pain in daily
doses of 0.06 to 0.10 Gm. (gr. j-iss).
After trj'ing manj- substances ap-
plied b}' spinal injection, the writers
found solution of magnesium sul-
phate efficacious in controlling tabetic
pain. Such injections produce a true
"leucocytic shower" and a sort of
therapeutic meningitis which favors
the resorption of meningitic products
and cessation of pain. Roger and
Baumel (Presse med., Aug. 7, 1912).
To relieve tabetic pains the writer
recommends the following: —
IJ Thiosinamine,
Glycerin aa 1 Gm. (15 gr. ).
Sodium salicylate . 2 Gm. (30 gr.).
Sterile dist. water.. 10 c.c. (2^ dr.).
M. Sig. : One cubic centimeter to be
injected intramuscularly daily
or on alternate days.
Mueller (Riforma Medica; Med.
Record, May 15, 1915).
Intramuscular injection of 0.5 c.c.
(8 minims) nf 1: lUUO adrenalin solu-
tion was found to cause a para-
doxical drop of 30 to 40 mm. Hg.
in the blood-pressure in cases of
tabetic gastric crisis. Complete re-
lief from the pain was simultaneously
experienced. The pressure rose again
and the pain returned in from half
an hour to fifty minutes. A similar
paradoxical lowering of pressure had
already been observed in dementia
precox, and by Xewberger in cerebral
syphilis and menstruation. Bayard
Holmes (Lancet-Clinic, Oct. 30, 1915).
In recent years, eft'orts have been
m.ade to control the crises of tabes by
blocking the nerve-roots, by dividing
the latter in the spinal canal, an op-
eration known as rhizotomy. The
actual value of this is still sub judice.
The benefits of rhizotomy may be
attained without an operation, by
blocking the nerve-roots involved.
The writer injected 100 c.c. of the
fluid in the back, between the sixth
and tenth ribs, at the emerging point
of the nerves, forcing the fluid deep
into the muscle on each side. He in-
troduced the long needle close to the
costovertebral articulation until it hit
the rib; then it was drawn back a lit-
tle, pointed upward to the upper mar-
gin of the rib and 5 c.c. of the fluid
expelled at each point. The method
differs from the epidural injection
technique; it anesthetizes the nerve-
trunks for over six hours. It can be
applied repeatedly. The same tech-
nique might prove effectual for tabetic
pains elsewhere, lancinating pains in
the arm or leg. There is sometimes
a local pain at the point of the in-
jection, about two hours later, which
he occasionally combats by subcu-
taneous injection of a small amount
of some sedative. The patient was
a man of 44 who had gastric crises
every month and finally every week
for days at a time. The attack was
arrested at once by deep anesthetic
injection; 100 c.c. were injected at this
time and three other attacks within
TABES DORSALIS (PRITCHARD).
493
the following week were likewise
aborted, but not quite so successfully,
the amounts used ranging only from
65 to 80 c.c. The crises recurred
after a month, but the patient had
left town. Konig (Jour. Amer. Med.
Assoc, from Med. Klinik, Sept. 24,
1911).
The writer tried rhizotomy for gas-
tric crises in a case of tabes in a
man of 43. The patient was at once
relieved. After five months they re-
curred in a brief and mild form, once
or twice a week, but disappeared
again during the seventh month. In
the majority of the 28 cases published
to date there has been recurrence
later of the crises in a mild form,
but the operation has often been of
life-saving importance. Zinn (Berl.
klin. Woch., Sept. 11, 1911).
For gastric crises the writer re-
sorted to Forster's method of division
within the spinal canal of the sensory
roots of the tenth, eleventh, and
twelfth dorsal spinal nerves. For four
weeks after the operation the patient
was free of trouble. Then the vomit-
ing returned, but without the girdle
sensation and without the pain. He
concluded that the vomiting was the
result of the gastric movements con-
trolled by the vagi; in some cases at
least the primary cause is involve-
ment of the vagus or its center; the
pain is secondary to the vomiting.
Exner (Deut. Zeitsch. f. Chir., ci, 576,
1911).
In gastric crises the writers tried
Franke's operation, which they con-
sider superior to that of Forster,
with satisfactory results. They pre-
fer a single vertical incision which
divides the muscular fibers in the di-
rection they run and renders easy the
exposure of the intercostal nerves.
The ventral position is good if the
lumbar region is raised by means of
a sand cushion under the abdomen.
Four months after operation the 2
patients suffer no pain, have excel-
lent digestion, have gained in weight.
L. Maire and G. Parturier (Presse
med., July 10, 1912).
The operation rhizectomy, gener-
ally called by the writer's name, has
been done to relieve tabetic crises in
44 cases; the resection was not ex-
tensive enough in some^ so that the
pains recurred later; in some other
cases crises developed in other nerve
regions; 5 of the patients died, and
no benefit was obtained in 3 cases.
Another cause for failure may be that
in certain cases the vagus is respon-
sible for the crises. Forster (Wiener
klin. Woch., June 20, 1912).
The writer reports his own experi-
ence in 1 case with Franke's tech-
nique, the tearing out of the inter-
costal nerves. In 17 published cases
gastric crises were cured seven times;
they recurred in 8 cases. In his
own case the cure has been complete
during the fifteen months to date.
The patient was a woman of 64 who
had had tabetic gastric crises during
fifteen years. The fifth, sixth, sev-
enth, eighth and ninth intercostal
nerves were taken up in turn on a
grooved sound and wound slowly on
the sound until they tore; the periph-
eral stump was then cut. The ful-
gurating pains .in arms and legs
were not modified, but the gastric
crises were abolished. Mauclaire
(Arch. gen. de chir., Nov. 25, 1913).
Sauve and Tinel method seems to
promise still better results, but it has
only been worked out experimentally
thus far. They propose the ligation
of the intercostal nerves between the
ganglion and the dura.
In the writer's case, a man of 53,
the seventh, eighth, and ninth pairs
of posterior roots were resected;
while the tenth pair was being re-
sected the pulse and respiration
stopped suddenly, but heart action
was resumed spontaneously in a few
seconds and pressure on the thorax
started respiration. This complica-
tion can be avoided by deadening the
sensibility of each nerve just before
it is cut. There was great improve-
ment and cessation of the pains dur-
ing the six weeks he was in the hos-
pital. G. Patry (Rev. med. de la
Suisse rom., xxxv, 297, 1915).
494
TABES DOKSALIS (PRl'l CHARD).
For the relief of the various crises,
symptomatic remedies are used. Full
doses of cerium oxalate usually re-
lieve vomiting-. Heart-tonics, such
as caffeine, strychnine, etc., may
be indicated in vagus involvement.
Cystitis may be treated symptomatic-
ally as an ordinary cystitis with re-
lief. A simple device which almost
invariably afifords relief and may be
magically effective in lessening noc-
turnal cystic irritability, especially in
prostatic enlargement, is that of ele-
vating the foot of the bed with two-
inch blocks of wood. The exhausting
effects of disturbed sleep are at times
corrected absolutely by this proced-
ure. Trophic lesions are occasionally
quite intractable. Strychnine in doses
of Yso to i/ie grain (0.002 to 0.004
Gm.) will at times retard the prog-
ress of an optic atrophy. Strychnine
should, however, be given always
with caution in this disease.
The advanced tabetic case which is
practically bedridden and has had all
forms of antisyphilitic treatment does
better under strychnine sulphate than
with symptomatic treatment. The
writer's patients were treated at
three-month periods with gradually
increasing doses, beginning at %o
grain (0.001 Gm.) 3 times a day, up to
% grain (0.015 Gm.) 3 times a day.
The last month they were given
% grain continuously. Osnato (Med.
Rev. of Rev., Mar., 1918).
Case of a woman with tabetic symp-
toms in whom the Wassermann re-
action became negative and the num-
ber of cells in the spinal fluid dimin-
ished, while gait and station were
much improved. The treatment con-
sisted of frequent mercurial inunction,
together with as complete evacuation
of cerebrospinal fluid as possible
about once a week or two weeks. A
number of cases of tabes, taboparesis,
and paresis were treated in the same
way, as a rule with distinct advan-
tage and without any untoward re-
sult. S. F. Gilpin (Phila. Neurol.
Soc; Med. Rec, Jan. 18, 1919).
The demonstration of the spiro-
cheta in the nervous tissues has led
to a revival in the use of mercury, to-
gether with neosalvarsan.
The cerebrospinal fluid circulates
imperfectly and there is very little
alisorption of this fluid by the cortical
or spinal cells. Hence, intraspinal
medication is unsound. The writer
obtained most satisfactory results
from intravenous arsphenamine injec-
tions given on alternate days for
three to four weeks according to tlie
sj'mptoms, followed by complete rest
or weekly or semi-weekly injections
of mercuric salicylate for four to six
weeks, and then again starting in with
the arsphenamine injections. Some
patients received 40 or SO intravenous
injections within a year or eighteen
months. B. Sachs (Arch, of Neurol,
and Psych., Mar., 1919).
Intraspinal treatment of tabes with
arsphenamine or mercury has of late
come into widespread use. The
Swift-Ellis method or autoserum-
salvarsanized serum treatment con-
stitutes one form of this type of
procedure.
Reduction of intraspinal pressure
by removal of cerebrospinal fluid in-
creases the permeability of the epen-
dyma. Applying this fact, the author
was able to demonstrate appreciable
amounts of arsenic in the spinal fluid
twenty-four hours after intravenous
injection of an organic arsenical in
25 out of 26 cases. He gives an injec-
tion of salvarsari, neosalvarsan, or
arsenobenzol and taps the spinal canal
within twenty minutes after the injec-
tion, withdrawing fluid until it comes
only drop by drop. Barbat (Jour
Anier. Med. Assoc, Jan. 19, 1918).
Sixteen cases of tabes and cerebro-
spinal syphilis, with symptoms refer-
able mainly to the urinary tract, were
subjected to intraspinal treatment
with mercurialized serum, with re-
TABES DORSALIS (PRITCHARD).
495
suits better than those usually follow-
ing other methods. The treatments
generally consisted in intraspinal in-
jection of 0.001 Gm. (%5 grain) of
mercuric chloride in normal horse
serum, diluted with normal salt solu-
tion to 30 c.c. (1 ounce). The injec-
tions were given about once weekly
for 4 doses, followed bj^ a rest of
four to eight weeks. The reactions
were never more than moderately in-
tense. The spinal Wassermann re-
action was changed from positive to
negative in 7 cases, and the degree of
fixation greatly reduced in 6 others.
Marked urinary incontinence was
cured in one case, greatly improved
in another, and not affected in a third.
Slight incontinence was cured in 3
and much relieved in 4. Increased
frequency was cured or much dimin-
ished in 8 cases, dribbling after void-
ing cured in 4 and improved in 6, and
sexual powers improved in 6 and re-
stored to normal in 2. All patients
having pains in the back and legs were
relieved, and the residual urine was
greatly reduced. Watson (Jour. Am.
Med. Assoc, Feb. 2, 1918).
Injections of mercuric chloride in-
traspinally practised in tabes. From
%o to Mo grain (0.001 to 0.0015 Gm.),
dissolved in 1 to 2 c.c. (16 to 32
minims) of distilled water, was intro-
duced into J/j ounce (15 c.c.) or more
of spinal fluid collected in a glass fun-
nel. Not until the writer combined
the intraspinal and intravenous meth-
ods of treatment did both the blood
and spinal fluid become negative to
all tests. The treatment removed the
clinical symptoms for at least a con-
siderable period. R. B. McBride
(South. Med. Jour., June, 1918).
After five years' experience with
the Swift-Ellis and Ogilvie tech-
niques, the writers take issue with a
recent critic of the results of intra-
spinal treatment of cerebrospinal
syphilis. The method is most valu-
able and not dangerous if properly
carried out. The intravenous method
often gives as good results as can be
expected from any form of treatment,
but in some cases it falls very far
short of such results, and in these the
resort to intraspinal treatment is
usually followed by good recovery.
The need for intraspinal therapy is
especially marked in those who can-
not endure intensive treatment with
mercury or with arsphenamine intra-
venously. Cummer and Dexter (Jour.
Amer. Med. Assoc, Sept. 7, 1918).
The writer's best results were ob-
.tained by the addition of arsphena-
mine in small quantities directly to
the cerebrospinal fluid. In paretics a
prolonged remission is the best that
can be accomplished. In tabes, he
has seen cases in which, clinically,
progression had been retarded for
three years. The best effects follow
combined general and intraspinal
treatment. Tredway (Penna. Med.
Soc; N. Y. Med. Jour., Mar. 8, 1919).
No final proof of the curative value
of the Swift-Ellis or other intra-
spinal methods is however, in evi-
dence (See also the article on Dioxy-
DIAMIDO-ARSENOBENZOL, Vol. II).
Swift and Ellis Method.— The
blood-serum of recently treated or
cured syphilitic has a marked tro-
phic action on the specific spirochete
and the following technique has been
devised by Swift and Ellis for bring-
ing an effective medicinal agent into
immediate contact with the diseased
process without incurring the dan-
ger of direct injection of salvarsan
into the subarachnoid space. A dose,
generally the maximum of salvarsan
or neosalvarsan, is given intraven-
ously in the usual manner. At the
end of an hour from 50 to 60 c.c. (1.7
to 2 ounces) of the patient's blood
are drawn by means of venous punc-
ture, clear serum is separated, diluted
to 40 per cent, with normal salt solu-
tion heated to 132.8° F. for half an
hour, kept cool until the following
day, then warmed to body tempera-
ture and injected into the sul)arach-
noid space 1)}'^ means of lumliar punc-
ture after the withdrawal of about IS
c.c. (^ ounce) of spinal fluid, the
amount of diluted scrum injected be-
496
TAMARIND.
TANNIC ACID (VVITHERSTINE).
ing 30 c.c. (1 ounce). After the first
few injections, if well tolerated, 40 c.c.
(1^ ounces) of a 50 per cent, serum
is usually injected. It must be in-'
jected slowly without much pressure.
After the injection the patient is
kept in bed for a day with head cov-
ered. The general rule is to give
eight or ten treatments, one every
second week and then discontinue
them for a time, repeating, if neces-
sary, and using as indices the Was-
sermann test with the blood and
spinal fluid and the cell and protein
estimations of the latter. The method
is the mos-t promising one for tabes
and paresis that has yet been devised.
W. H. Hough (Jour. Amer. Med.
Assoc, Jan. 17, 1914).
In S cases of tabes and 3 of cere-
brospinal syphilis in which a modi-
fication of the Swift and Ellis method
of treatment was applied, salvarsan,
0.6 Gm. (10 grains), was first given
intravenously, 75 to 100 c.c. {IVi to
ZVz ounces) of blood withdrawn an
hour later, serum- from this blood
soon after heated in a water bath at
56° C. for half an hour, and an intra-
spinal injection of 25 to 35 c.c. (% to
1% ounces) of the undiluted serum
given at once, spinal fluid not exceed-
ing 35 c.c. {Wk ounces) in amount
having previously been allowed to
drain off. After the injection all pil-
lows were taken away, the foot of
th*e bed was elevated, and the patient
kept on his back for at least an hour.
Treatments were repeated at seven-
to twenty- day intervals. The patients
were all relieved from pain and
showed definite improvement in lo-
comotion, in some almost to normal.
The psychic effect was also marked,
and the nutrition rapidly improved.
T. R. Boggs and R. R. Snowden
(Arch, of Internal Med., June, 1914).
William B. Pritchard,
New York.
TACHYCARDIA. See Heart :
Frequent Pulse.
TALIPES. See Orthopedic Sur-
gery.
TAMARIND.-Tamarindus, N. F.,
is the acidulous pulp of the fruit of a
semitropical and tropical tree, the Tama-
riiidus indica (fam., Leguminosae). Before
tamarinds enter commerce, the shell of
the fruit is removed, and the inner por-
tion is, in India, molded into a mass, to
which sometimes sugar is added. In
Egypt it is formed into cakes and dried
in the sun, and in the West Indies hot
syrup is poured over the pulpy mass.
Tamarinds, in the shops, form a dark-
brown soft mass, having a fruity odor and
a subacid to strongly acid and sweet
taste. Tamarinds contain a very little
malic acid, 4 to 6 per cent, of citric acid,
5.3 to 8.8 per cent, of tartaric acid, 4.7 to
6 per cent, of potassium bitartrate, 12 to
20 per cent, insoluble matter, and about
13.9 per cent, of seeds. A trace of acetic
acid, supposed to result from sugar-de-
composition, and a little tannin in the
seed coats, complete the constituents.
Tamarind is an ingredient (10 per cent.)
of confectio sennje, K. F., in which it is
combined with senna (10), cassia fistula
(16), prunes (7), figs (12), sugar (55.5),
oil of coriander (0.5), and water.
ACTION AND USES.— Tamarind is a
mild laxative and refrigerant, due to the
combination of its acids and acid salts.
It may be given in doses as large as 1
ounce (30 Gm.) with safety; larger doses
may give rise to griping. An infusion,
strained and allowed to cool, makes a
grateful draught in fevers, when the stom-
ach is in good condition. Like nearly all
similar vegetable preparations, it is mod-
erately diuretic. A tamarind whey, made
by infusing an ounce (30 Gm.) of the pulp
in a little boiling water, and adding this
to a quart of milk, may be used as a
refrigerant in fevers.
TANNIC ACID.— Acidum tan-
iiicum, U. S. P., specifically known
as gallotannic acid, is an organic
aoid obtained from nutgall (Galla,
U. S. P.), which is an excrescence
found on Oucrcns hisitanica, or dyers'
oak (fam., Ciipuliferje), caused by the
punctures and deposited ova of the
gall-wasp, or Cynips gallce tinctoricB
TANNIC ACID (WITHERSTINE).
497
(order, Hymenoptera). It is also found
in chestnut wood and bark, in pome-
granate bark, and in sumach. Tannic
acid occurs as yellowish -white or
greenish crusts or powder, without
odor or having a faint, characteristic
odor, and a strongly astringent taste.
It is very soluble in water, alcohol,
and in glycerin.
Tannic acid is incompatible with
alkalies, lime solution, alkaloids, al-
buiTLin, gelatin, starch, salts of anti-
mony, copper, iron, lead, mercury ;
compounds of iodine, bromine, chlo-
rine, nitrites (including spirit of ni-
trous ether), permanganates, chlorates,
and other oxidizing agents ; forming
insoluble compounds with alkaloids, it
has been used as an antidote in poi-
soning by alkaloids, as well as by the
metallic incompatibles named.
PREPARATIONS AND DOSES.
— The official preparations of tannic
acid are : —
Acidum tannicum, U. S. P. (tannic
acid or tannin). Dose, 3 to 10 grains
(0.2 to 0.6 Gm.).
Collodhim stypticum, N. F. (flexible
collodion containing 20 per cent, tannic
acid).
Glyceritum acidi tannici, U. S. P.
(glycerite of tannic acid, containing
20 per cent., by weight, tannic acid).
Dose, 15 minims (1 c.c).
Trochisci acidi tannici, U. S. P.
(troches containing 1 grain — 0.06 Gm.
— tannic acid). Dose, 1 or 2, three or
four times daily.
Ungnentum acidi tannici, U. S. P.
(ointment containing 20 per cent,
tannic acid).
The principal unofficial compounds
of tannic acid are : —
Tannalbin (tannin albuminate ex-
siccated, containing 50 per cent, tan-
nin). Dose, 15 to 60 grains (1 to 4
Gm.) in tablet or in powder, with
water.
Tannigen (diacetyl-tannin). Dose,
3 tD 10 grains (0.2 to 0.6 Gm.).
Tannismuth (bismuth bitannate).
Dose, 5 to 10 grains (0.3 to 0.6 Gm.).
Tannoform (tannin-formaldehyde) .
Used externally.
Tannopine (hexamethylenamine-
tannin). Dose, 15 grains (1 Gm.) ;
children, 3 to 8 grains (0.2 to 0.5
Gm.).
Glyceritum iodo-tannin carboliza-
tum (Sajous). (Carbolized glycerite
of iodo-tannin contains iodine, 2
Gm. ; tannic acid, 15 Gm. ; water, 250
c.c. ; mix, filter, and evaporate to 60
c.c, and add glycerin, 120 c.c; car-
bolic acid, liquid, 2 drops).
PHYSIOLOGICAL ACTION.—
When tannic acid is applied locally
to the skin or mucous membranes it
constricts the blood-vessels and tem-
porarily diminishes the vascularity
of the parts; its affinity for albu-
min intensifies its astringent efifect.
Taken internally it lessens secretions
and produces constipation. By unit-
ing with albumin in the stomach it is
transformed into tannalbin or tannin
albuminate ; this latter is then slowly
decomposed by the alkaline contents
of the intestines into gallic acid, and
as such is absorbed. The researches
of Rost have shown that tannic acid
given by the mouth, subcutaneously,
or otherwise, appears as gallic acid
in the urine, along with other decom-
position products of tannin ; when
given by the mouth it appears in the
feces as gallic acid ; tannic acid has,
therefore, no remote astringent ac-
tion on secretions, on blood-vessels,
or on urinary excretion. Tannic acid
is destroyed before it arrives at the
lower part of the intestine. Tannic
8—32
498
TANNIC ACIIJ (WlTIlIiRSTlNE).
acid only acts as such before it is
absorbed.
THERAPEUTIC USES.— Tannic
acid has been used locally in vari-
ous forms of hemorrhage — epistaxis,
uterine hemorrhage, passive gastric
and intestinal hemorrhage, hema-
temesis, hematuria, and in hemop-
tysis (in spray). For its local
astrinj^ent action it may be used in
relaxed mucous membranes, relaxed
uvula, aphthous stom.atitis, spongy
gums, ptyalism, and chronic pharyn-
gitis. In tonsillitis and pharyngitis
the glycerite is a good topical appli-
cation ; the glycerite may also be
used as a spray, properly diluted, in
hemoptysis. The odor of ozena and
other affections attended by fetor
may be overcome by the application
of absorbent cotton moistened in a
saturated aqueous solution of tannin
and then dried. In simple chronic
rhinitis and rhinopharyngitis, the
carbolized glycerite of iodo-tannin is
a valuable application.
In the early stage of cholera, Can-
tani used large enemeta of tannic acid
up to and beyond the ileocecal valve.
From V/i to 5 drams (6 to 20 Gm.)
of tannic acid dissolved in 4 pints (2
liters) of warm water, with the addi-
tion of 30 drops of laudanum and
V/i ounces (45 Gm.) of powdered
gum arabic are injected at suitable
intervals.
A suppository containing 2 to 5
grains (0.10 to 0.3 Gm.) of tannin has
been successfully used in prolapse of
the rectum, and in bleeding hemor-
rhoids. Tannin in solution is bene-
ficial in excoriations about the anus
and scrotum, and in anal fissure.
In vaginal leucorrhea a saturated
solution of tannic acid on cotton
makes a valuable application. The
glycerite is an excellent form for use
in cervical uterine catarrh. In uterine
carcinoma dressings of the glycerite
will moderate the discharge and allay
the odor, especially if combined with
the glycerite of phenol.
In gonorrhea, after the acute stage
is passed, tannic acid is effective. In
women a watery solution may be
used as a vaginal injection, or the
vagina may be packed with tannin.
Tender nipples and tender feet
may be hardened with a 1 per cent,
solution of tannin. A lotion of tan-
nic acid is often efficient in herpes.
It is useful in phagedenic ulcer and
alopecia circumscripta. The stinging
pain and itching of subacute eczema
is relieved by an application of the
glycerite twice daily. The ointment,
somewhat diluted, has proved bene-
ficial in pityriasis capitis (dandruff).
Impetigo and intertrigo have yielded
to the use of the ointment. Tannin
is usually an ingredient in prepara-
tions used to relieve hyperidrosis of
the hands and feet; in a 1 per cent.
solution it has been recommended in
offensive axillary sweating. In burns
tannin subdues the pain and hastens
the formation of granulations and
healing. A solution (1 to 4) of tannin
in tincture of benzoin is said to pre-
A'ent the formation of pustules in
variola.
In chronic inflammations of the
conjunctiva, especially pannus, tannin
has given good results.
A lotioij of 2 parts tannin to 10
parts alcohol painted on the gums
and around the teeth relieves almost
every kind of dental pain; it is also
the best application in Riggs's disease
(pyorrhea alveolaris), the loose teeth
tighten under its use and become
available for mastication.
TANSY.
TAR.
499
To expel threadworms (Oxyiiris
vcrmicularis) a solution may be in-
jected or suppositories used.
A 5 per cent, alcoholic solution of
tannin is a very satisfactory disin-
fectant for the hands of the surgeon.
C. Sumner Witherstine,
Philadelphia.
TANSY — Tanacetum (tansy, bitter-
buttons, parsley or scented fern) is
the dried leaves and tops of Taiiacctmii
z-ulgare (fam., Compositae). Tansy contains
about 0.5 per cent, of volatile oil, resin,
tannin, fat, sugar, gum, citric, tartaric,
and malic acids and the amaroid tanacetin,
which is yellowish white, granular, odor-
less, fusible, soluble in ether, less freely
soluble in alcohol, and sparingly soluble
in water.
PREPARATIONS AND DOSES.—
Tanacetum (leaves and tops; unofficial).
Dose, 20 to 60 gra'ns (1.30 to 4 Gm.).
Oleum tanaceti (tansy oil; unofficial).
Dose, 1 to 3 minims (0.05 to 0.2 c.c).
PHYSIOLOGICAL ACTION.— Tansy
is an aromatic, bitter tonic, and, by virtue
of its volatile oil, it is diuretic and em-
menagogue, and in poisonous doses is a
violent irritant to the stomach and intes-
tines. Many deaths have been reported
from its use.
POISONING BY TANSY. — Large
doses, y'o an ounce (15 c.c.) or more of
the oil, taken to procure abortion, cause
disturbance of the respiration, depression
of the heart-action, clonic spasms, and
death. The usual symptoms, preceding
death, are vomiting and purging, severe
abdominal pain, a rapid, feeble pulse, slow
respiration, dilated pupils, convulsions of
an epileptiform type, coma, and asphyxia.
Alarming symptoms have followed the use
of from IS to 30 minims (1 to 2 c.c.) of
the oil of tansy. Sometimes it causes
abortion.
TREATMENT OF POISONING.—
Siphon out the stomach, refilling and
emptying several times with abundance ot
water; give emetic of apomorphine hy-
drochloride hypodermically (2 to 5 minims
-0.12 to 0.3 c.c. — of 2 per cent, solution),
if throat is not severely inflamed, mus-
tard (4 drams — 15 Gm. — in 1 to 4 ounces
— 30 to 125 c.c. — water) can be used, of
zinc sulphate (20 grains — 1.3 Gm. — in 1
ounce — 30 c.c. — water), castor oil (1 ounce
— 30 c.c.) or magnesium sulphate may be
used instead. Give demulcent drinks of
flaxseed tea, barley-water, elm-bark mu-
cilage, or arrowroot pap. Allay pain with
% grain (0.015 Gm.) morphine, or 10 to
20 minims (0.6 to 1.3 c.c.) of laudanum.
THERAPEUTIC USES.— Oil of tansy
was formerly used in functional dysmenor-
rhea, amenorrhea, and ovarian neuralgia
in doses of J,2 to 1 minim (0 03 to 0.06
c.c), in pill or dropped on sugar. In con-
junction with hot drinks and hot applica-
tions it is used in amenorrhea attributed
to cold. It has some anthelmintic effects,
but its use for this purpose is not
advised. F"or domestic uses an infusion
(tansy tea) is made by steeping 1 ounce
(30 Gm.) of the leaves or tops in 1 pint
(500 c.c.) of boiling water; of this 1 to 2
ounces (30 to 60 c.c.) may be taken. W.
TAPEWORM.
Diseases Due to.
See Parasites,
TAR. — -P'-r liquida (U. S. P.), pine tar,
or tar, is an aromatic oleoresin obtained
by the destructive distillation of the wood
of Piiius palustris and of other species of
Pinus (fam., Coniferas) of Europe and
America, that coming from North Caro-
lina and Sweden being the best. It oc-
curs as a thick, blackish-brown, viscous
mass having a peculiar odor; contains oil
of turpentine, pyrocatechin, acetic acid,
acetone, creosote, phenol, xylol, methylic
acid, etc., and is blackened by wood-
smoke. It is soluble in less than its own
bulk of alcohol, ether, or chloroform, and
is slightly soluble in the volatile and fixed
oils.
Upon redistillation tar yields pyroligne-
ous acid (crude acetic acid) and an empy-
reumatic oil called oil of tar, which is
official. Oil of tar, when fresh, is almost
colorless, but with age becomes oxidized
and dark reddish-brown in color; it is a
volatile fluid, of acid reaction, has the
odor and taste of tar. and is soluble in
alcohf)!. Tiu' residue, after the distilla-
tion, is pitch (pix solida) — unofficial — a
black solid which has a shining surface
500
TAR.
on fracture, melts in boiling water, and
consists of resin and various empyreu-
matic resinous products which are collec-
tively called pyretin. Pix solida is chiefly
used in the preparation of plasters, and
is entirely different from the residue of
coal-tar, or "gas-pitch."
Burgundy pitch, recognized in the British
Pharmacopeia as Pix burgundica, is pitch
derived from the Norway spruce {Abies
excelsa). It softens and fuses at the tem-
perature of the body. Canada pitch {Pix
canadensis) is derived from the hemlock
spruce of the United States and Canada.
Both these forms of pitch are used as
plasters.
Coal-tar, produced by the distillation of
coal, varies in composition, and contains,
in addition to about 0.1 per cent, of
phenol, such bodies as sulphur, am-
moniacal compounds, aniline, pyridine,
quinones, etc.
Lysol and pixol, derivatives of tar, will
be considered in separate sections at the
close of this article.
PREPARATIONS AND DOSE.— Pi.r
llquida, U. S. P. (tar; pine-tar). Dose,
7^ grains (0.5 Gm.).
Oleum picis liquido' rectificatum, U. S. P.
(rectified tar oil). Dose, 3 minims
(0.2 c.c).
Syrupus picis liquidce, U. S. P. (syrup of
tar), consisting of tar, 5 parts; magnesium
carbonate, 10 parts; alcohol, 50 parts;
sugar, 850 parts, and water, enough to
make 1000 parts. Dose, 1 fluidram (4
c.c.) or more.
Unguentum picis liquidcB, U. S. P. (tar
ointment), consisting of 10 parts of tar
mixed with 3 parts of yellow wax and 7
parts of lard.
The following tar preparations are rec-
ognized in the N. F. for internal use:—
Elixir picis compositum, N. F. Ill (com-
pound elixir of tar), each fluidram (4 c.c.)
of which contains %o grain of morphine
sulphate, together with" wine of tar, syrup
of wild cherry, and syrup of Tolu. Dose,
1 fluidram (4 c.c).
Glyccritum picis liquidce, N. F. (glycerite
of tar), each fluidram (4 c.c.) of which
contains about 4 grains (0.25 Gm.) of tar.
Dose, 1 fluidram (4 c.c).
Mistura olei picis, K. F. (tar mixture),
each 2 fluidrams (8 c.c.) of which con-
tains about 4 minims (0.25 c.c.) of oil ot
tar, masked with licorice, peppermint,
chloroform, and sugar. Dose, 2 fluidrams
(8 c.c).
ri)iuni picis, N. F. (wine of tar), each
2 fluidrams of which contains about 5
grains (0.3 Gm.) of tar. Dose, 2 fluidrams
(8 cc).
For external use: —
Liquor picis alkalinus, N. F. (alkaline
solution of tar, "liquor carbonis deter-
gens"), consisting of tar, 2 parts; potas-
sium hydroxide, 1 part, and water, 5 parts
Unguentum picis compositum, N. F. (com-
pound tar ointment), containing oil of
tar, 4 parts, and zinc oxide and tincture
of benzoin, 2 parts each, in every 100 parts
of the ointment base.
Tar-water, unofficial, is prepared by
shaking 1 part of tar with 4 parts of water
several times in one day, then decanting
and filtering. Dose, 1 to 2 pints (500 to
1000 cc).
Liquor carbonis detergens, essentially a
solution of coal-tar in tincture of quillaja
(soap bark), is at times assimilated with
Liquor picis alkalinus, N. F., but is
preferably made, according to Stelwagon,
as follows: Coal-tar, 4 parts; strong soap-
bark tincture, 9 parts; digest for eight
days, frequently shaking and stirring, and
finally filtering. The soap-bark tincture is
made with 1 pound of soap bark to 1
gallon of 95 per cent, alcohol, allowed to
digest for a week or so.
PHYSIOLOGICAL ACTION. — Lo-
cally, tar is slightly irritating to the skin.
It acts strongly as an antiseptic in skin
diseases, and is also a valuable disinfect-
ant. It is absorbed rather readily from
the skin, and may thus cause darkening
of the urine, as if phenol had been used.
It has been credited with expectorant
properties.
Coal-tar has the property of softening
keratin. Its antiseptic action is greater
than that of phenol, and it has more pene-
trating power. It is much less active
locally than the wood-tars, but is advan-
tageous in that its odor, after local ap-
plication, soon passes off.
POISONING BY TAR.— If in pro-
longed contact locally, tar may produce a
papular, erythematous, rubeoloid, urti-
carial, or acneiform eruption; the last has
TAR.
501
been called acne picealis (tar acne) by
Hebra. Where a considerable area has
been exposed to its action, tar, through
absorption, may give rise to toxic symp-
toms similar to those of poisoning by
phenol: fever, foul tongue, eructations,
vomiting and diarrhea, epigastric pain,
tarry evacuations, and a severe headache
or sensation of heaviness or oppression;
strangury and ischuria, with darkish urine
turning almost black in color and emit-
ting, like the stools, the odor of tar.
When taken internally, tar may give rise
to erythema, vesicles, or papules, accom-
panied by severe itching. Long-continued
or large doses of tar give rise to anorexia
and indigestion, depress the heart's ac-
tion, and cause nervous exhaustion. A
fatal case has been reported by Taylor.
Large quantities of tar have, however,
sometimes been taken without apparent
ill efifect. Children and young persons, as
a rule, are most susceptible to its toxic
action.
Treatment of Poisoning. — The treat-
ment of poisoning by pix liquida is sim-
ilar to that advised for poisoning by
phenol. If the poisoning result from ex-
ternal applications, suspension of these
will cause an abatement of the symptoms,
accompanied by copious diaphoresis and
more or less diuresis.
THERAPEUTICS.— Affections of Mu-
cous Membranes. — The vapor of tar has
been used largely for inhalations in dis-
eases of the respiratory tract. In pul-
monary disorders with excessive secretion
tar, mixed with potassium carbonate (24
to 1) to neutralize the pyroligneous acid,
may be placed in a cup over a water-bath
heated by a spirit-lamp; the fumes of hot
tar-water or wine of tar may be inhaled
by means of a steam-atomizer; oil of tar
diluted with some other oil or liquid
petrolatum may be used in an atomizer,
or the vapor from heated tar may be in-
haled. Such inhalations are by many
considered of value in bronchitis, espe-
cially in the subacute and chronic stages,
and in "winter cough." in the bronchor-
rhea of phthisis they have also proven
useful. In connection with these inhala-
tions tar may be given internally in the
form of pills or capsules (2 grains — 0.13
Gm.) in milk or beer, or as tar-water (1
to 2 pints— 500 to 1000 c.c— daily), or
wine of tar (1 to 4 ounces — 30 to 120 c.c).
If administered independently of inhala-
tions, 5- to 10- grain (0.3 to 0.6 Gm.)
doses of tar may be given.
In obstinate diarrhea H. C. Wood has
recommended a mixture of tar made as
follows: Add a pint (500 c.c.) of tar to a
gallon (4 liters) of lime-water, and allow
this solution to stand a week, stirring it
every few hours. Decant the clear liquid
and percolate it through powered wild-
cherry bark, allowing 1 ounce (30 Gm.)
of the bark for each pint (500 c.c.) of the
liquid used. The dose is 2 fluidounces
(60 c.c).
External Uses. — In cutaneous disorders,
especially those in which the mucous
layer is principally involved, tar is an ef-
fective remedy. In eczema and psoriasis
the tarry preparations are most effective
when applied directly to the disease sur-
face. In eczema tar gives the best results
when applied after the subsidence of ac-
tive inflammation; the special indication
for its use is a condition of subacute in-
flammation accompanied by a dry, scaly
surface, with more or less hyperemia and
itching, and with inflammatory products
still remaining in the tissues. It is best
to begin with a mild preparation: Tar
ointment, 1 part; zinc ointment, 3 parts.
Stronger applications may be made later.
The applications of tar may be continuous
or intermittent. The drug is best avoided
in involvement of the face, as it tends to
stain the skin.
In the dry chronic eczema of children
the following is useful: Tar, 1 part; pre-
cipitated sulphur, 1 part; zinc ointment, 16
parts. Mix and apply night and morning
(Hare).
Bulkley advises the use of liquor picis
alkalinus in sluggish chronic eczema. The
same preparation, or tar in the form of
soap or ointment, may be used in the
treatment of scabies, tinea capitis, and
lepra. In eczema of a subacute or mod-
erately inflannnatory type a lotion con-
taining- 1/2 to 2 ounces (15 to 60 c.c) of
liquor carbonis detergens to the pint (500
c.c) of water is often very useful
(.Stelwagon).
I'\>r psoriasis tar may be used as a stim-
ulant in the same manner, but it is less
502
TAR.
employed than formerly, having in part
been superseded by chrysarobin.
Care should always be taken at first, in
applying tar, lest it excite dermatitis or
acne picealis. Some skins are intolerant
of it; some other remedy should then be
substituted. A mild and relatively safe
ointment for beginning tar treatment is
one consisting of 1 or 2 drams (4 to 8
c.c.) of liquor carbonis detergens mixed
with zinc ointment, enough to make 1
ounce (30 Gm.) (Stelwagon).
In prurigo tar is often valuable. A lo-
tion of >j to 2 drams (2 to 8 Gm.) of tar
to the pint (500 c.c.) often controls itch-
ing satisfactorily. One consisting of 1 to
3 drams (4 to 12 c.c.) of liquor carbonis
detergens to the half-pint (.250 c.c.) of
water may prove even more useful. In
pruritus ani a weak tar ointment will often
afford relief.
A useful application to hemorrhoids is
the following: Tar and extract of bella-
donna-leaves, of each, 45 grains (3 Gm.) ;
glycerite of starch, 1 ounce (30 Gm.).
This is to be applied morning and
evening.
Tar ointment in full strength, or at
first diluted (1 part to 3 of petrolatum),
may be of service in lichen, comedo, syco-
sis, pemphigus, lupus erythematosus, and
lupus vulgaris. Stern has observed that,
when tar is allowed to stand in a warm
place for several weeks, it separates into
two layers, the upper of which is thin,
syrupy, and devoid of irritant properties;
an ointment prepared with this is advised
when a mild eftect is desired.
Duschkow-Kessiakofif (1915) has used
tar with satisfactory results as a wound
dressing. He pours it into all the wound
recesses and then covers the wound with
gauze. A favorable germicidal effect re-
sults and frequent change of dressings is
rendered unnecessary.
LYSOL.— Lysol, introduced in 1889, is
an antiseptic preparation made by dis-
solving in fat, and subsequently saponify-
ing with caustic potash and alcohol, that
part of tar-oil which boils between 374°
and 392° F. (190° and 200° C.). It occurs
as a clear, brown, oily-looking liquid,
having a feeble, aromatic, creosote-like
odor. It contains 50 per cent, of cresols,
and is miscible with cold water, forming
a clear, soapy, frothing liquid. If it is
mixed with boiling water, or its solution
in cold water l^oiled, a cloudy mixture is
formed. Lysol is also soluble in alcohol,
chloroform, glycerin, etc. According to
McClintic, lysol is, in tests by the Rideal-
Walker method, 2.12 times as strong as
phenol in the absence of organic matter,
and 1.57 times as strong in the presence
of organic matter (as is the case in prac-
tical disinfection). With the Liquor cre-
solis compositus, U. S. P., crude carbolic
acid, creolin, and trikresol the correspond-
ing figures were 3.00 and 1.87, 2.75 and
2.63, 3.25 and 2.52, and 2.62 and 2.50,
respectively.
Poisoning by Lysol. — In spite of the
alleged low toxicity of this preparation,
numerous cases of poisoning by lysol,
either from absorption when locally used,
or from ingestion by mistake or for sui-
cidal purposes, have been reported. Most
of the cases of poisoning from local use
have followed intra-uterine irrigation in
the puerperium, the chief symptoms be-
ing slow pulse, shallow respiration, and
cyanosis. Signs of acute hemorrhagic
nephritis and of cerebral or peritoneal
irritation have also been noted. In pois-
oning by ingestion the local destructive
damage is seldom sufficient to cause
death. The symptoms include a promptly
appearing stupor, followed by cardiac and
respiratory depression, and sometimes un-
consciousness and death. The mucous
membranes may be stained grayish white
or light brown.
The treatment of poisoning by ingestion
consists in washing out the stomach until
the washings no longer smell of lysol,
administration of 1^4 pints (6(X) c.c.) of
milk (Blunienthal), a repetition of the
gastric lavage some time later, and the
use of stimulants and external heat as re-
quired. If some hours have elapsed since
the ingestion of the poison, calcined mag-
nesia should be given (Kirchberg). If
the patient survives the first grave symp-
toms, the prognosis is relatively favor-
able, and when the poisoning does not
end fatally, organic lesions are rarely left
behind.
Therapeutics. — Lysol is widely used
for disinfection of the hands and instru-
ments, particularly in obstetric and gyne-
TAR.
TARAXACUM.
503
':ological practice. The hands and fore-
arms are scrubbed for 5 minutes with a 3
per cent, solution of lysol in hot water,
the nails cleansed, and the hands then
scrubbed for 3 minutes more in fresh
solution and rinsed in sterile water. Be-
fore and after obstetric examinations a 2
per cent, solution may be used in place
of soap. A 1 per cent, solution (roughly,
1 teaspoonful to the pint) may be used
as a vaginal douche preparatory to ex-
amination in labor. For intra-uterine irri-
gation after curettage or for the patient's
own use as a cleansing vaginal douche a
0.5 per cent, solution (1 teaspoonful to
the quart of hot water) is suitable. In-
struments may be disinfected without in-
jury by cleansing with a 2 per cent, solu-
tion, then boiling for 5 minutes in a 1
per cent, solution with a little sodium
bicarbonate. Recent wounds may be
washed or irrigated with a 1 per cent,
solution in hot water, and a 2 per cent,
solution used for cleansing chronic ulcers
and irrigating abscess cavities. In disin-
fection of the walls and floors of rooms
lysol ranks with creolin, tricresol, and
may be used in 1 to 3 per cent, solution.
The preparation has also been used for
preparing fields of operation, as a lubri-
cant for the examining finger and instru-
ments (^ dram to. 2 ounces of glycerin),
on vaginal tampons (same ratio), as a
dressing for burns (^ to ^ per cent, solu-
tion), as a mouth-wash or throat spray
or gargle (Yj to 1 per cent.), in bromidrosis
of the feet (soaking in a 1 to 2 per cent,
solution), in mucous colitis (enemas of
J4 per cent, solution), in skin affections
such as erysipelas and lupus erythemato-
sus (2 or 3 per cent, solution), and inter-
nally in indigestion with abnormal fer-
mentation in doses of 1 to 5 minims (0.06
to 0.3 c.c.) after ineals. According to
some, the official Liquor cresolis com-
positus is practically identical with lysol
in its action and uses.
PIXOL. — This disinfectant is made by
dissolving 1 pound of green soap in 3
pounds of tar and slowly adding a solu-
tion of a little more than 31/2 ounces of
either potassium or sodium hydroxide dis-
solved in 3 pints of water. This makes
a syrupy fluid wliich, in 5 per cent, dilu-
tion, may be used for disinfecting linen
and the hands. Dejecta may be disin-
fected with a 10 per cent, solution, which
is said to be fatal to the pus organisms
and those of typhoid fever, cholera, and
anthrax. S.
TARAXACUM. —Taraxacum,
U. S. p. (dandelion, blow-ball, lion's
tooth; is the dried root of Taraxacum
officinale (fam., Cichoriaceae), gathered in
the autumn. It is a well-known common
perennial of America and Europe, bearing
a flower having a yellow head of flowers
on a slender peduncle, from a cluster of
radial leaves. All parts of the plant con-
tain a milky, acrid juice, which exudes
when the plant is bruised or cut. The
active principles are taraxacin and tarax-
acerin; the former is soluble in hot
water, the latter in alcohol. The root
also contains inulin, mannite, and resin.
PREPARATIONS AND DOSES.—
Taraxacum, U. S.. P. (the root). Dose, 2
drams (8 Gm.).
Extraction taraxaci, U. S. P. (solid ex-
tract). Dose, 5 to 20 grains (0.3 to 1.3
Gm.).
Fluidextractum taraxaci, U. S. P. (fluid-
extract). Dose, 1 to 8 drams (4 to 30 c.c).
Infusum taraxaci (dandelion tea — unoffi-
cial— 1 to 8 of boiling water). Dose, 1 to
2 ounces (30 to 60 c.c).
PHYSIOLOGICAL ACTION. — The
preparations of taraxacum are bitter; they
stimulate the digestive secretions and act
as a bitter tonic. It is a feeble hepatic
stimulant, somewhat laxative, and very
feebly diuretic.
THERAPEUTIC USES. — Taraxacum
was chiefly used in atonic dyspepsia and
constipation associated with torpidity of
the liver, and also in catarrhal jaundice
and hepatic congestion. It has no specific
action in hepatic disorders, but is often
combined with other remedies which are
potent. Its diuretic effect is too feeble
to be available. The fluidextract is a good
vehicle for nitrohydrochloric acid, ammo-
nium chloride, or potassiub iodide. W.
TARTAR EMETIC. See Anti-
mony.
TELANGIECTASIS. See
lli.oou-vESSELS, Tumors of.
504
TENDONS, BURS/E, AND FASCLE, DISEASES OF.
TENDONS, BURS^, AND
FASCIi^, DISEASES OF. -dis-
eases OF THE TENDONS: ACUTE
TENOSYNOVITIS.— Inflammation of a
tendon or tendon sheath, also termed
thecitis and tenosynovitis, is the result of
a traumatism, which may or may not
prove suppurative. Often, however, the
trauma gives rise to suppurative inflam-
mation, owing to the invasion of pyogenic
bacteria, the result in some cases of in-
sufficient attention to antisepsis when the
wound is dressed, carelessness on the part
of the patient, or the presence near the
injury of a suppurative process. It may
also be caused by repeated, though slight,
contusions, such as those to which the
hand is exposed in many occupations and
sports. Acute tenosynovitis may also ap-
pear as a complication of inuflenza, syph-
ilis, gonorrhea, and rheumatism.
SYMPTOMS. — In non-suppurative
cases there are pain, tenderness on pres-
sure, and swelling. A distinctive sign is
that the inflammatory roughening along
the tendon-sheath gives rise to a moist
crepitus, which tends to disappear as the
swelling increases. The suppurative cases
differ from the non-suppurative, in that the
swelling is greater, more painful and pul-
satile, dusky red, and far more tender.
The suffering may be very great. General
sepsis occurs not infrequently. The symp-
toms vary, however, with the location of
the morbid process, the two most ex-
posed areas in this connection, the palm
and fingers, giving rise to the two condi-
tions described below.
Palmar abscess may be due to repeated
contusions, and also to extension of a
tenosynovitis of the fingers, especially
when the abscess is located on the flexor
side of the little finger and the thumb,
owing to the connection of their synovial
sheaths with the general sheath common
to the tendons of the palm. The three
other fingers, as is well known, possess
separate sheaths. When suppurative in-
flammation is present in the palm, high
fever may occur, and the pain is severe in
proportion to the resistance of the over-
lying tissue. Here, again, the pus may
burrow in various directions or insinuate
itself between the metacarpals to the dor-
sum, and, passing beneath the annular
ligament, reach the tissues of the forearm
and beyond. Death has been known to
ensue in such cases from pyemic infec-
tion. The palmar lesion may, in turn, be-
come aggravated; necrosis of the carpus
may occur and dangerous hemorrhages
suddenly appear through involvement of a
large vessel in the suppurative process. A
clawed, stiff hand may result.
Felon, or Whitlow.— The term "felon"
is often applied to a superficial inflamma-
tion of the finger or toes around the nail.
This variety has been treated under
Nails, Diseases of, vol. vi. The form
considered here is that to which "felon"
more properly belongs: inflammation of
the deeper tissues, including the tendon
and its sheath of the distal phalanx. This
is usually due to traumatism. — a blow or
crush, — and develops soon after the re-
ceipt of the injury, though sometimes only
toward the end of the second day. Severe
pain, heat, throbbing, and more or less
fever betoken the presence of quite an
acute inflammatory process. The pain be-
comes extremely severe and almost un-
bearable if surgical measure-; are not re-
sorted to. If the abscess be allowed to
proceed without relief, extension toward
the hand may follow or the pus gradually
works its way toward the surface, forming
a volcano-like mass, which, upon healing,
leaves the thumb deformed — sufficiently in
some cases to impair its usefulness.
TREATMENT. — The treatment de-
pends, of course, upon, the condition pre-
sented at the time the case is seen. In its
incipient stage an acute tenosynovitis, es-
pecially in non-suppurative cases, may
sometimes be cured by rest, elevation of
the part, and application of cold com-
presses, iodine, blue ointment, ichthyol,
prolonged baths in a solution of borate of
sodium, or hot antiseptic fomentations,
especially if small doses of iodide of
potassium are given internally — with co-
pious draughts of water. Bier's hyperemia
method may also be used with advantage.
In the vast majority of cases, however,
such a favorable result is not reached, and
the inflammatory process proceeds to sup-
puration. A free incision including the
tendinous sheath, exposure of all sinuosi-
ties that appear suspicious, irrigation and
TENDONS, BURS^, AND FASCIA, DISEASES OF.
505
drainage, all performed under strict anti-
septic precautions, and dressing with hot
antiseptic fomentations, represent the only
safe procedures. Thoroughness at this
time avoids a repetition of the operation,
while the likelihood of a deformity is
greatly reduced. General anesthesia is to
be preferred.
According to Kanavel, incisions are best
made in the fingers, either upon one or
both sides of the tendon sheath over the
length of the shaft of the middle and
proximal phalanx, avoiding the joints, and
into the proximal end of the sheaths or
the lumbrical spaces to provide drainage
there. The ulnar bursa is best treated by
splitting it throughout its length, cutting
upon the ulnar side. The anterior annular
ligament should generally be cut. This is
commonly supplemented by incisions upon
the radial and ulnar sides of the forearm
above the wrist-joint, and on a level with
the flexor surface of the bones. Through-
and-through drainage is then carried out
under the flexor profundus tendons. An
ulnar incision may be sufficient. If the
pus has invaded the forearm, an ulnar in-
cision is made at the middle of the fore-
arm between the flexor carpi ulnaris and
the flexor sublimis, or between the flexor
carpi ulnaris and the ulna. Incision of the
flexor longus pollicis sheath is made from
a finger-breadth below the anterior annu-
lar ligament to the end of the sheath.
Opening may be made above the anterior
annular ligament, the upper half of which
may be cut, or drainage may be instituted
above the wrist by the lateral incision
mentioned under ulnar bursal infections.
In the after-treatment the Bier constrictor
is used for 24 to 48 hours, hot moist dress-
ings for 2 to 4 days, followed by dry
dressings, hand being held in overexten-
sion l)y splint, daily manipulation of joints
and muscles after the immediate danger of
systemic infection has ended.
In palmar abscess the danger of delay
is especially great. A free incision under
general anesthesia is imperatively de-
manded, the line followed being that of
the metacarpal bone nearest the abscess.
In doing this, however, the location of the
palmar arch should be borne in mind, and
the artery avoided. Should it accidentally
be cut, both ends should be carefully
picked up and ligated. In some cases, the
abscess opens spontaneously early in the
history of the case. The pus, however,
originates in small superficial abscesses,
which sometimes form in addition to the
deeper and greater one, and rupture early
through the pressure exerted from below.
They tend to mislead the operator by
causing him to delay the evacuation of
the main abscess. Several palmar incis-
ions and counter-openings are necessary
at times to insure through-and-through
drainage, introduce the tubes, etc. Hot
fomentations should then be applied and
the part placed in a splint. When granu-
lations appear, dry dressing should be
substituted. The danger involved not only
includes extension of the purulent process
beyond the hand, but also destruction of
the tendons of the latter, followed by
permanent flexion of the finger: the "main
en griff e."
In whitlow, or felon, the general indica-
tions are similar, but the chances of ar-
resting the inflammation promptly are
greater if the case is seen early. Any of
the general indications given above may
be resorted to. When, according to Mac-
farlan, there is as yet no pointing or def-
inite formation of pus, a wet dressing of
mercuric iodide, 1 Gm. (IS grains); potas-
sium iodide, 4 Gm. (1 dram), and water,
100 c.c. {ZYz ounces), will usually reduce
the course of the affection and frequently
abort it. This may also be effected some-
times by keeping the finger wet with al-
cohol, diluted with an equal quantity of
camphor-water. A thin bandage well
soaked with the solution is wrapped
around the finger and oiled silk is care-
fully wrapped around the whole to pre-
vent evaporation. A strong solution of
borax, or a bichloride solution 1 : 3000
may also be used in the same manner,
but phenic acid solutions should not be
employed, several cases of gangrene hav-
ing been ascribed to their use.
In superficial felons, White softens the
area with an antiseptic solution, pares of?
the cuticle with a sharp bistoury to free
the pus without infecting the deeper tis-
sues. If the suppuration is su1)cutaneous,
however, free incision is necessary, but
the tendon-sheath and periosteum should
be strictly avoided for the same reason.
506
TENDONS, BUKS/E, AND FASCIA, DISEASES OF.
The after-treatment is the same as for
palmar abscess (see preceding page). The
distal phalanx may be found necrosed;
hence the deformity left in so many cases
of whitlow.
If necrosis is present, dead portions
of the bone should be removed; but little
apprehension need be felt, since it rarely
extends beyond the epiphyseal line. In
the two lower phalanges, however, necro-
sis is of more serious import; the dead
bone must either be removed or the finger
amputated, according to the amount of
osseous tissue involved.
CHRONIC TENOSYNOVITIS, or
THECITIS, may occur as a result of the
acute form, or be caused by traumatisms,
rheumatoid arthritis, and syphilis, but in
the majority of cases it is due to tuber-
culosis of the sheath. In the latter condi-
tion nodular, more or less spindle-shaped
swelling following the long axis of a ten-
don is formed, which contains, besides
liquid, small bodies resembling rice or
melon-seeds; hence called "riziform" bod-
ies. These are either buried in the sac-
wall or float freely in its liquid, and are
found to contain, upon microscopic ex-
amination, tubercle bacilli. The local dis-
ease may assume a fungous form, and not
only destroy the tendon, but spread to
neighboring tendons and joints. Tuber-
culous towsynoz'itis usually develops near
the wrist, and much less frequently in the
tendons of the fingers, knee, and ankle. It
gives rise to but little suffering, and, as a
rule, interferes but slightly, if at all, with
the functions of the affected extremity un-
til well advanced. Its progress is, as a
rule, quite slow. It may, if the health of
the patient is materially improved, disap-
pear spontaneously, or become fungous
after penetrating the superficial tissues, as
does typical tubercular abscess. It may
occur as the complication of a joint tuber-
culosis. The rizifonn bodies facilitate
diagnosis by conveying to the finger exert-
ing pressure upon the swelling a crepita-
tion recalling the presence of gravel.
Treatment. — The noii-tubercnlous form
should be treated by rest and local ap-
plications of ichthyol. When the acute
phenomena have disappeared, the ichthyol
applications should be supplemented by
gentle massage, hot and cold douches, or
hot-air baths, the motions of the part be-
ing reduced liy strapping.
In the tuberculous form, a tendency to
relapse renders it imperative to eliminate
thoroughly the local trouble and to treat
the general dyscrasia as well. When the
sac is purely cystic — i.e., devoid of fungoid
vegetations — a small incision, followed by
washing out with saline solution and the
injection of a solution of iodoform in olive
oil or in ether, will often suffice. When
riziform bodies are present, however, more
effective means are necessary, since they
represent as many foci for tubercle bacilli.
The sheath should be laid open and its
interior surface and the tendon thoroughly
cleared with the curette. Fungoid vegeta-
tions still further complicate the case, and,
unless every vestige be removed, including
affected external tissues, sheath, and ten-
don, recurrence is sure to follow. Asepsis
is of the greatest importance, general
toxemia occurring readily through the
lymphatic system if proper precautions are
not taken. Bier's method and the X-rays
have given good results. The general
treatment should include the administra-
tion of creosote, out-of-door life, and other
measures indicated in pulmonary tuber-
culosis.
INJURIES OF TENDON: DIS-
PLACEMENT OR DISLOCATION.— A
tendon is sometimes displaced from its
normal position by a violent motion in
which its normal axis of traction is more
or less departed from, the sheath being
torn. Often it immediately returns to its
normal position, but sometimes it does
not, and local pain, with impairment of
motion, results. The displaced tendon can
usually be felt, and its normal situation be
the seat of a depression. Or it may be
felt to slip out of its groove when it con-
tracts. The peroneus brevis probably
shows the greatest predilection in this di-
rection, and comparatively often slips out
of its groove, being felt over the malleolus
when the foot is flexed and extended.
Displacement is most frequently observed
in connection with dislocations and frac-
tures, and in the latter a tendon may in-
sinuate itself between the fragments, and
thus prevent approximation and union.
Tendon dislocation is often associated
with chronic joint disease, notably rheu-
TENDONS, BURS.E, AND FASCIA, DISEASES OF.
507
matoid arthritis, which may give rise to
displacement of the long head of the
biceps.
Treatment. — By gentle manipulation
with flexion or extension of the extremity,
as required to reduce the tension upon the
tendon, restoration to its normal position
is usually obtained. Once displaced, a
tendon is liable to again leave its bed. A
suitable retentive dressing and bandage
should be so applied as to hold it in situ
until thorough repair of the torn sheath
has occurred. If this fails, and after a
few weeks the displacement recurs, the
edges of the torn sheath should be fresh-
ened and sutured to the tendon. Or, if
the tendon fails to remain in its groove,
a halter can be made by incising the peri-
osteum and suturing it over the tendon.
Passive motion is then begun after a week
has elapsed.
RUPTURE.— Under the influence of a
sudden effort the contraction of a muscle
may exceed the resistance of the fibers of
its tendon, and the latter gives way. The
tendon of the rectus femoris above and
below the patella, the tendo Achillis, the
tendon of the triceps near the olecranon,
and that of the biceps near the forearm
are those which are most exposed to this
accident. The rupture is usually com-
plete, and a cavity may readily be felt
where before the tendon was continuous,
the gap being increased by extension.
When the knee is the seat of rupture
there is marked effusion in the joint, and
the patella is drawn upward: a deformity
very readily noticed. There is a distinct
snap when the rupture occurs, immediate
loss of power in the limb, and sometimes
severe pain.
Treatment. — Approximation of the ends
by full extension of the limb, application
of retention bandages and splints, and im-
mobilization of the limb at once suggest
themselves. If these can be carried out
satisfactorily, perfect union occurs at the
end of two months, and, with a little care
tor a few weeks subsequently, perfect cure
ensues. This happy result is not always
obtained, however; in the majority of in-
stances the tendon-ends cannot be held
together by simple means, especially when
the muscle draws the proximal end away
to such a degree that traction has to be
exerted to bring its extremity down to the
lower. In such a case, therefore, it is bet-
ter to suture the ends. This is especially
important when the traction is due to the
action of large muscles, such as those of
the calf or thigh. Under careful asepsis
this can now be done without the least
danger, even at the knee. The incision
should, if possible, be made to one side
of the tendon, and not over it, to reduce
the chances of adhesion. Rupture of the
tendo Achillis is sometimes managed with
Elongation of the tendo Achillis. (Poncet.)
difficulty, or tends, if union is obtained, to
cause pes equinovarus. Poncet (see an-
nexed illustration) avoids this by cutting
the edges of the tendon zigzag fashion to
elongate it, as shown in the cut, or by
Czcrny's method, described lielow.
WOUNDS OF TENDONS.— Tendons
are susceptible to traumatisms of any kind,
but their density causes them to resist
penetration. Puncture wounds, therefore,
are seldoin met with, the point of the in-
strument being diverged in the majority
of instances. The sheath, however, is usu-
ally torn, but it quickly recovers, if pyo-
genic organisms have not been introduced.
Incised wounds are of little moment un-
less the entire tendon is cut, when, with
508
TENDONS, I'.URS^, AND FASCl/l-:, DISEASES OF.
a snap, it assumes the relations outlined
under Rupture. In the latter, however, the
solution of continuity being- subcutaneous,
pathogenic bacteria are not introduced; in
rupture due to the thrust of a knife, sword,
chisel, etc., the contrary is likely, and the
surgeon should always assume that he is
dealing with an infected wound. He will
tluis insure an early recovery in all cases.
Treatment. — Whatever be the cause of
the laceration, the ends should be stitched
with l)uried catgut sutures, care being
taken that the ends be carefully placed in
apposition, or, better still, overlapped. It
is sometimes necessary, in order to re-
cover the proximal end, to slit the sheath,
or to free it some distance from its sur-
roundings to do this. The suture holds
best when passed through transversely
about one-third inch above each free end.
In some cases, as in 'bullet wounds, much
of the tendinous substance has been car-
ried away, while the softer and more elas-
tic sheath remains, at least to a greater
extent. If the ends of this are united, so
as to form a continuous canal, a new sec-
tion of tendon will be formed if the vital-
ity of the sheath was sufficient.
Lengthening of the tendon may also be
resorted to. Either Poncet's or Czerny's
method may be resorted to. Poncet's is
described above. Czerny's consists in cut-
ting the tendon half-through some dis-
tance above the end, then longitudinally
toward the latter until near it. The por-
tion thus partly detached is then turned
down toward the other free end of tendon
and sutured to it. If too great length of
tendon has been lost, an animal tendon
may be transplanted and sutured to both
free ends. This forms the basis of a new
tendon, the animal tendon being usually
absorbed.
DISEASES OF THE BURS^.— The
bursje, or protective cushions developed in
the cellular tissue, may be normally pro-
vided, or acquired, when certain parts,
superficial or deep, are exposed to unusual
friction or pressure. These may become
inflamed through injury or overuse, con-
stituting acute bursitis, or through con-
tinued irritation, constituting chronic bur-
sitis. The bursie often become involved in
diathetic processes, rheumatism, gout, and
s.vphilis especially.
ACUTE BURSITIS.— An acute inflam-
mation of a bursa may be serous or
purulent, and, as stated, is usually due to
injury. When located superficially there
is marked swelling, redness, and local
heat. When an inflamed bursa is situated
in the deeper tissues, the swelling can only
be detected with difficulty, if at all, and
the pain, especially on motion, is severe.
General febrile symptoms often appear
when a deep bursa is involved, especially
when there is a tendency to suppuration,
this being likely to extend. The inflam-
matory process sometimes extends to a
neighboring joint, including the synovial
sac, which is easily penetrated. The diag-
nosis can usually be established by judg-
ing the effects of motion. Extreme ab-
duction or adduction of the humerus, for
instance, causes severe pain, if the in-
flamed bursa is under the deltoid; when
the bursa between the quadriceps extensor
and the femur, or that under the liga-
mentum patellae, is the seat of the inflam-
matory process, flexion of the leg upon the
thigh becomes painful, through the pres-
sure thus exerted upon the bursa.
Treatment. — Absolute rest in bed and
immobilization, by placing the extremity
in a splint and pressure, elevation of the
part, and cold or hot antiseptic fomenta-
tions, iodine, blue ointment, or ichthyol,
all afford considerable relief. If the active
symptoms persist notwithstanding these
ineasures, the sac should be aspirated if
the fluid is serous, followed by pressure;
or free opening, if pus be present, and the
purulent discharge completely evacuated,
and the interior of the sac is swabbed
with phenic acid, then packed with iodo-
form gauze. Lugol's solution mixed with
an equal quantity of glycerin and other
solutions were at times injected, but the
danger of involving the joints has caused
them to be discarded.
CHRONIC BURSITIS. — Chronic in-
flammation of a bursa is met with much
more frequently than the acute form. It
develops insidiously, is unattended by
pain, and manifests itself only by marked
swelling, which varies in density accord-
ing to the thickness of the bursal wall.
This becomes quite dense sometimes, and
conveys to the touch a feeling of hardness
suggesting bone. In some cases it may be
TENDONS, BURS^, AND FASCIA, DISEASES OF.
509
thin and the cavity be greatly distended
with fluid. The harder bursa is usually
separated into various cavities by thick,
fibrous partitions, or the interior is
studded with villous growths, which some-
times become detached and form riziform
bodies. Occasionally it undergoes calcifi-
cation.
HOUSEMAID'S KNEE.— This pop-
ular term is applied to chronic swelling of
the prepatellar bursa, as a result of con-
tinued or repeated pressure while scrub-
bing, etc. It is located immediately at the
knee, and the globular swelling projects
anteriorly when the patient is sitting. It
is usually quite large, the size of a small
orange, and, its wall being comparatively
thin, it generally fluctuates. At times it
becomes irritated through continued pres-
sure and may become slightly painful, the
limbs at the same time becoming some-
what stiff and weak at the knee. A sim-
ilar condition of the olecranon bursa is
known as miner's elbow, and another
over the tuberosity of the ischium is
termed weaver's bottom.
Treatment. — When rest and painting
with iodine, or the application of blue
ointment, or, again, iodine cataphoresis
will fail to cure, blistering will sometimes
procure it. In most cases, however, surg-
ical measures are necessary. Aspiration,
followed by light massage, is the simplest
of these; if this proves insufficient, in-
cision and packing with iodoform gauze
should be resorted to. Extirpation may
be performed if need be through a lateral
incision.
BUNION. — This consists of an enlarge-
ment of the bursa over the metatarso-
phalangeal articulation of the big toe, but
which may also present itself over other
joints of the foot. It is often due to the
pressure of ill-fitting shoes, which not
only exert pressure upon the bursa over-
lying the articulation, but also tend to
force the big toe away from its normal
line and the metatarsal extremity of the
second phalanx outwardly. The burs?e
thus finds itself pinched between the bone
and the overlying leather. Bunions may
cause but little trouble, when not com-
pressed, but, irritated in the manner out-
lined, they become inflamed and at times
exceedingly painful; the skin becomes
highly congested and tense; tumefaction
occurs, accompanied by accumulation of
fluid in the bursa; and locomotion be-
comes difficult. In some cases suppura-
tion follows; the pus may then burrow
through the bursal wall, give rise to
cellulitis, and involve the metatarsophal-
angeal joint.
Treatment. — The shape of the footwear
is of primary importance in the treatment
of the cases. The inner side of the shoe
should accommodate the bunion in such a
manner as to avoid all pressure, while the
great toe should have ample room to pro-
ject in a straight line from the foot, and
not be pushed toward its median line.
Pointed shoes are pernicious in this con-
nection. A change of footwear is some-
times sufficient to bring about recovery.
Bunion plasters, available in the shops,
are very helpful. The local treatment is
that of bursitis. Iodine painted over the
projection is advantageous. Ichthyol and
blue ointment are also effective. When
the applications become irritating, a salve
of equal parts of cosmoline and tannic
acid, as advised by Gross, is useful.
Tapping and the evacuation of pus by
incision sometimes become necessary.
These are safe procedures if done under
strict asepsis. According to Robert T.
Morris, the older operations often resulted
in stiff joint and other discomforts. A
simple operation often suffices. It con-
sists in a longitudinal incision from Y^ to
54 of an inch in length along the inner
surface of the extensor tendons; the site
of the hyperostosis is exposed, and a sharp
chisel separates the button of the bone
readily from the head of the metatarsal
bone. The open bursa can then be
trimmed out with a pair of scissors with-
out difficulty, and when the wound is su-
tured and the skin pressed against the sur-
face of the bone from which the button is
removed, it becomes quickly adherent, and
the bunion is at an end. The patient is
allowed to walk in from 10 to 12 days.
C. T. Mayo "removes the head of the
metatarsal bone and two-thirds of the hy-
pertrophy on the inner side, then turns
the bone into the joint area in front of
the bone. He sutures this bursa in place
and thus obtains a synovial membrane
which becomes satisfactorily movable."
510
TENDONS, BURS^, AND FASCIA, DISEASES OF.
GANGLION. — This name is given to a
rouiuk-d tumor usually about the size of
half of a hazel-nut, which p;enerally forms
on the back of the hand, l)ut also on the
dorsum of the foot. It may be soft and
yielding- when pressed upon, or exceed-
ingly hard, suggesting the presence of an
osteoma. It is not painful even under
pressure, and gives rise to no inconveni-
ence. When, however, as in the case of
pianists, the fingers are moved rapidly and
\\ ' h power long periods at a time, a sen-
sation of weight or stiffness is experienced
and occasionally slight pain. Some pa-
thologists consider it as a pouch-like pro-
jection of the synovial membrane of a
joint in the majority of cases, and rarely
arises from a tendon-sheath. The prevail-
ing view, however, is that it is the result
of a traumatic degeneration of connective
tissue adjoining a joint or tendon, the
alveoli of which dilate and form a cyst
which contains a thick, honey-like liquid.
Treatment. — Pressure or a sharp blow^
causes the sac to rupture, the liquid
being promptly absorbed, but this rather
unsurgical method is now generally sup-
planted by subcutaneous incision with a
small bistoury, under strict antiseptic pre-
cautions. The small incision being made,
a piece of iodoform gauze is placed over
the sac, and, pressure being exerted with
the thumb, the fluid is quickly evacuated
and dispersed. A few drops of iodine in-
jected into the ganglion sometimes causes
its absorption. Large tendinous tumors
sometimes require excision.
CONTRACTION OF TENDONS
AND FASCIA.— The subject of Coxtrac-
TURES, including Texotomv, having already
been considered in the sixth volume, page
467, only special conditions of this class
will be reviewed under the present head.
DUPUYTREN'S CONTRACTURE.—
This is an obstinate form of contraction
affecting principally the palmar fascia, pro-
longations of which, as is well known,
run by the side of the fingers, and are at-
tached to the periosteum of the first
phalanx. By contracting, these prolonga-
tions gradually cause the fingers to close
upon the palm of the hand and to remain
in this position permanently. The ring-
finger is usually that first involved, but in
the majority of cases the three fingers on
the ulnar side of the hand are contracted,
the index finger and thumb rarely. Either
hand may be affected, but occasionally
both become so flexed as to paralyze their
usefulness. It usually begins as a small,
hard mass near the metacarpophalangeal
articulation; contraction of the corre-
sponding finger begins and proceeds antil
the nails fairly dip into the tissues of the
palm.
Dupuytren's contracture has been traced
to many causes: the rheumatic and gouty
diathesis and other general condition; but
in practically all cases there is a history
of local injury of a persistent kind, such
as the continuous forcible handling of a
certain tool, the pressure of a cane-knob,
etc. Again, it is occasionally observed
after prolonged illness in which the gen-
eral vitality of the organism has been
severelj- taxed. It is rarely observed be-
fore middle age, and almost always in
men. The patient is usually possessed of
good general health.
Treatment. — The progress of the con-
traction is steady until the hand becomes
totally crippled, and the only effective
means at our disposal are surgical. Ef-
forts at extension are unavailing, but,
when this is tried, thick elevations are
seen to form in the palmar cavity and to
push its superficial tissues upward. It is
upon these bands that efforts at libera-
tion should be concentrated. A small
tenotome should be introduced at various
places under each, and the attachments of
the bands to the overlying skin so freed
as to permit of full extension of the
fingers. A splint should then be applied
and worn, not only until recovery of the
wounds, but during several days subse-
quent thereto. Then daily passive mo-
tion and massage should begin, coupled
with a mild galvanic current, until the
motions of the fingers have been com-
pletely recovered.
In some cases it is necessary to obtain
complete extension, to resort to removal
of the hardened palmar fascia. An incis-
ion is made along the length of each
hand, and the skin is carefully dissected
up from the latter. This being done, the
hard tissues constituting the band proper
are separated from their surroundings,
then cut out as completely as possible.
TENDONS, BURS^, AND FASCIA, DISEASES OF.
511
Keen's method does this most satisfac-
torily. He makes a V-shaped incision, the
apex of which is upward; raises the flap,
then dissects out the contracted tissues.
These cases need close watching, since the
danger of recurrence is always great, and
passive motion, massage, etc., should be
resumed as soon as there is the least evi-
dence that the affection is returning.
Good results have been credited to a
combination of sodium salicylate and
thiosinamine used hypodermically. Gil-
bert obtained good results from thyroid
gland in 1%-grain (0.1 Gm.) doses, t. i. d.,
given a long time. Radiimi has also been
praised.
TRIGGER-FINGER.— Two groups oi
this disorder may be recognized: the or-
ganic and the functional. The causes for
the organic variety may be found in the
tendons, fascia, muscles, or in conditions
which will tend to modify the directions
of muscular action, and the movements of
flexion and extension. The functional
class may be reflex, following local irrita-
tion, or may be a local manifestation of
certain neuropathies. Cases of this class
may arise independently of any voluntary
movements.
The disease consists of a peculiar and
sudden locking of the finger when it is
flexed or extended to a certain point. It
remains in the position acquired notwith-
standing ordinary efforts to bring it to
another position. A powerful voluntary
effort sometimes succeeds, however; but
in some cases the assistance of another
person is necessary. The disorder is usu-
ally limited to one finger, the middle
finger being that most frequently affected.
The majority of cases are observed in
females.
Treatment. — The treatment of trigger-
finger consists in the application of iodine,
electricity, massage, passive motion, and
fixation of the finger by means of a splint.
Inveterate cases have been treated by
operation, which usually consists in re-
moving whatever obstacle to free move-
ment exists.
In a personal case, the writer
painted the part with iodine, inserted
a fine bistoury in the flexure crease,
and, pressing the point down to the
tendon, drew it along for a half-inch.
Relief was instantaneous and final. A
small pad of boric gauze made pres-
sure for two days and the trouble
was cured.
The tendon is easily located by
thumb pressure at the crease, and is
not covered by nerve or vessel. Cut-
ting the tendon fibers lengthwise (if
one wished to cut deeply, which is
not necessary) would in nowise dam-
age the tendon. Robert Abbe (Med-
ical Record, March 7, 1914).
If an underlying cause, like rheumatism
or gout, is ascertainable, proper general
methods, the salicylates, colchicum, etc.,
are to be instituted. In cases accompanied
by pronounced paresthesia! phenomena,
the use of ergot may be tried.
TENDON TRANSPLANTATION.—
In the treatment of paralysis, especially
spinal paralysis in children, transplanta-
tion of tendons, first done by Duplay in
1876, is an effective procedure. One
method consists in choosing a healthy
muscle which can be spared, dividing its
tendon, and suturing the central portion
to the tendon of the paralyzed muscle. A
second operation consists in dividing the
whole or a part of the tendon of the pa-
ralyzed muscle, and suturing the periph-
eral end to the tendon of a functionally
active muscle. A third consists in split-
ting the tendon of a functionally health}-
muscle into two parts, and attaching one
part to the tendon of the paralyzed mus-
cle. A fourth proceeding is the suturing
of a split-off portion of a healthy muscle-
tendon to a properly chosen site in the
periosteum.
The success of the operation depends
upon a correct diagnosis, and on the
proper correction of the displacement.
This is better carried out by a lengthen-
ing or shortening of tendons than by sim-
ple tenotomy. Poncet's operation for the
former (illustrated on page 507) is effec-
tive; it consists in cutting into the tendon
in step shape. In dealing with broad ten-
dons two longitudinal incisions of equal
length may be made, one 1 cm. higher
than the other. From the lower end of
the second, and from the upper end of the
first, transverse incisions are made in op-
I)()site directions. Thus, the tendon is
lengthened by the sum of the two incision
512
TETANUS (BONDURANT).
lengths. The shortening operations are
either excision of a part of the tendon and
end-to-end suture, or simple division and
suturing the ends overlapping one an-
other. Tendon surgery has been greatly
advanced by a skilled combination of ten-
don transplantation with tendon length-
ening or shortening.
Guiding principles in tendon trans-
plantations: (1) perfect asepsis; (2)
attachment of the transplanted ten-
don to the bone or periosteum is al-
ways more satisfactory than attach-
ing it to another tendon or other soft
tissues; (3) the tendon must be
stretched moderately tight before be-
ing secured; (4) it must be fastened
with suture material that will main-
tain its hold for several weeks; (5)
a covering of subcutaneous tissue
should be brought over it before the
skin is sutured; (6) about six weeks
should elapse before the transplanted
tendon is allowed to function, so that
its new attachment may become suffi-
ciently strong; further, the muscle
should be systematically developed by
massage and exercises, and be care-
fully protected by mechanical means
from overstrain for several months
after the patient begins to use it.
Galloway (Surgery, Gynecol., and
Obst., Jan., 1913). S.
TETANUS. —SYNONYMS.—
Lockjaw, Trismus, and, when occur-
ring in infants. Trismus Nascentium
or Tetanus Neonatorum.
DEFINITION.— An acute or sub-
acute infectious disease caused by the
tetanus bacillus, and characterized by
violent tonic spasms with marked ex-
acerbations and remissions.
SYMPTOMS. — Following some
injury, slight or severe, and usually
ten days after — although longer peri-
ods of incubation have been noted —
the first symptoms of tetanus appear.
There are slight stiffness of the neck,
and some rigidity of the muscles of
mastication with interference with
the movements of the tongue. Often,
however, the earliest signs are twitch-
ing spasms or "rheumatic" pains in
the wounded region or extremity,
sometimes limited to one or a few
muscles; also jerking of these or
other muscles after slight pressure,
and a tremulous tongue. Violent
headache and excessive yawning are
also suggestive.
Very possibly the trigeminus pos-
sesses a special affinity for the toxin.
The muscular contractions are very
similar to those in yawning. This
act consists in a slow inspiration
accompanied by dropping of the
lo-' er jaw and followed by a short
tonic spasm of the muscles of in-
spiration. B. Beer (Wiener klin.
Woch., Apr. 8, 1915).
Chilliness may be complained of,
and the wound, if unhealed, is apt to
become tender and painful.
The symptoms appear transiently
and are slight at first. A day or so
after the infection there may be rest-
lessness, sleeplessness, distressing
dreams, difficulty in urination and
more frequent impulses, oppression
in the chest, violent headache, drawn
features, nosebleed, sweating, fatigue,
excessive yawning, vertigo, darting
pains at various points and chilliness.
Sometimes a swelling of the in-
jured limb, notwithstanding the limb
is raised, tends to suggest tetanus; it
feels hot but is not red, and the local
arterial pressure is unduly high.
There may be occasional local pains
and in a day or so the lymph-cords
appear red and the region is very
tender Single groups of muscles
may oz tonically contracted at first
painlessly. Contracture and tremor
may be noted in the injured limb,
sometimes clonic twitching; more and
more muscles gradually participate.
In a hand wound, on grasping the
forearm twitchings in the different
flexor tendons may be felt. One
of the first signs, the third day, is a
persisting pain after the involuntary
TETANUS (BONDURANT).
il3
contractions of the muscles induced
by effort; later the muscles form a
painful lump, disappearing after a
time but returning anew if the part is
touched again. The lymph-glands
were swollen in several of the writer's
cases, the inguinal glands in some
resembling the findings with syphilis.
In one the ulnar gland had to be ex-
cised under local anesthesia. Vertigo
is an especially important early sign;
also ocular symptoms and a spas-
modic cough. The pulse is generally
tense, slow and full. The hearing at
first may be unusually acute, but later
there is more or less deafness. Speech
is slow. Evler (Jour. Med. Assoc,
from Berl. klin. Woch., Sept. 21,
1910).
In 6 cases of localized tetanus, all
wounded in battle, with preventive in-
jections of antitetanic serum, the
mode of onset was the same in all
instances, pain suddenly appearing in
one limb or in the neck without evi-
dent reason, and not always in the
vicinity of the wound. Such a sud-
den apparently causeless pain in the
limb of a wounded man is held al-
ways to suggest tetanus. Total or
partial contracture of the painful
limb soon follows. A rise in tem-
perature may occur either at the out-
set or soon thereafter. Routier (Bull.
de I'Acad. de Med., Nov. 30, 1915).
The writers have determined the
incidence of tetanus in 150,(X)0 French
soldiers wounded in 1918. The rate
was 0.06 per 1000 in the army zone,
0.19 per 1000 in the intermediate zone,
and 0.30 per 1000 in the zone of the
interior. These striking results are
to be attributed to the serum treat-
ment which had been systematized,
with improvements in technique.
Sieur and Mercier (Bull, de I'Acad.
de med., Oct. 21, 1919).
A.S the disease gradually develops,
the muscles of the jaw begin to ex-
hibit marked tonic spasms — "locked
jaw." The facial muscles are also
often attacked, producing distortions
of facial expression.
Pains and twitching in the mus-
cles around a wound liable to be
infected with tetanus germs calls for
preventive injection of antitetanus
serum. Trismus is by no means the
first sign of tetanus, although it is the
first unequivocal one. Blumenthal
(Med. Klinik, Nov. 1, 1914).
The wounded are apt to ascribe to
their wound the first faint symptoms
of tetanus, so the physician must
make special inquiry for slight "rheu-
matic" pains and stiffness in the
wounded limb, fatigue in chewing,
pains around the mouth and brief
cramps in the chest muscles, like
a "stitch in the side." Schneider
(Munch, med. Woch., Jan. 5, 1915).
The head is often drawn backward
and the dorsal muscles become in-
volved, causing backward bending of
the vertebral column. As tire spasm
extends, the body may bend forward
or laterally, according to the contrac-
tions in different muscle groups. The
muscles of the hands, arms, and legs
are comparatively little affected.
In tetanus acquired in war the
muscles nearest the point of infec-
tion were the first involved. The
superficial and deep reflexes were
also found to be increased early in
the infected extremity; thus stroking
of the sole of the foot would often
throw the leg into tetany while the
opposite leg remained relaxed. Ba-
binski's reflex and ankle and patellar
clonus are at first local. A new symp-
tom was increased nervous irritability
to mechanical stimuli, as in tetany.
The ulnar phenomenon was fre-
quent, likewise tenderness at the base
of the skull behind. All these signs
were of much aid in making an early
diagnosis. C.oldscheider (Berl. klin.
Woch., Mar. 8, 1915).
Tetanus may not only be asym-
metric, but practically unilateral. A
man was wounded in the left forearm
and then gradually the entire ex-
tremity became rigid. Next there
developed unilateral left-sided spasm
8—33
514
TETANUS (BONDURANT).
of the face, and later the left half of
the neck and trunk, with slight im-
plication of the left lower extremity.
Involution occurs in the inverse
order. Harf (Berl. klin. Woch., Apr.
19, 1915).
Case of tetanus confined to a single
extremity in a man of 28 who had
sustained 3 wounds of the left thigh
from a hand grenade. A metallic
foreign body was removed on the
next day and a preventive injection
of 10 c.c. (2>^ drams) of antitetanic
serum given. Subsequent radiog-
raphy showed 7 or more foreign
bodies still imbedded in the tissues.
Ten days after the injury brief and
painful muscular contractions on the
inner aspect of the knee were ex-
perienced, recurring about every 2
minutes. Later, all the muscles in
the wounded area went into a cramp
three or four times a minute. Two
weeks after the start of the convul-
sions trismus was noted for the first
time. The peculiar picture is ascribed
to incomplete immunization, the bul-
bar centers having been protected
and the disease expending itself upon
the nerves or spinal segment of the
injured area. Courtois-Suffit and R.
Giroux (Bull, de I'Acad. de Med.,
Jan. 25, 1916).
The slightest source of irritation,
such as a light touch of hands or bed-
clothes, moving the limbs, a breath
of air, a loud sudden noise, will cause,
so soon as the attack is well estab-
lished, a severe clonic exacerbation
of spasm. The muscles of the whole
body violently contract, often with
great interference with respiration
and phonation, or with spasm of
the glottis. The exacerbation sub-
sides after a few minutes or sooner, to
be repeated under the slightest prov-
ocation. In the intervals some tonic
spasm of the muscles persists. Dur-
ing the paroxysms there is usually
profuse sweating; the pulse rate runs
up to 130 to 150; and in some cases
there is hyperpyrexia, 110° to 115° F.
(43.3° to 46.1° C.) being seen in fatal
cases just before death. There may
be retention of urine from spasm, and
in any case the secretion is scanty.
After the attack reaches its height,
pain during paroxysm is most ex-
cruciatingly intense. The mental fac-
ulties remain unimpaired throughout
the attack. Death may occur from
asphyxia or cardiac dilatation during
a paroxysm, or at later stages from
exhaustion. The attack endures from
a few days to several weeks.
Recurrence may appear in con-
valescence or after recovery under the
stimulus of other bacteria. Such
cases have been reported by Happel
(Miinch. med. Woch., July 27, 1915)
and Brandt {Zentralbl. f. inn. Med.,
Sept. 4, 1915).
DIAGNOSIS. — In typical cases
following injury no difficulty in diag-
nosis could arise. In strychnine poi-
soning the jaw muscles are not first
affected; in the intervals between the
paroxysms there is no stiffness nor
tonic spasm ; the symptoms develop
rapidly, not gradually, as in tetanus ;
and the history of the case is different.
The head tetanus of Rose, with its
well-pronounced trismus, dysphagia,
and facial paralysis, might be mis-
taken for rabies, but in the latter tris-
mus and involvement of neck- and
back- muscles are wanting.
Case of tetanus in a child of 10,
who had very badly decayed teeth,
and no other lesion allowing entrance.
Animal inoculations and culture ex-
periments showed that tetanus germs
were present in the tooth cavity.
Luckett (Med. Rec, Feb. 19, 1910).
Case of the rare head tetanus, the
7th reported in the United States, and
the 94th in literature. In all but 2
cases the affection followed a head
TETANUS (BONDURANT).
515
wound, and the tetanus bacillus was
usually found. Lymphatic absorption
being limited in this area, the result-
ing tetanus is benign. Brown (An-
nals of Surg., Apr., 1912).
Case of tetanus of the head due to
caries of a tooth, in a young man,
the tetanus developing with facial
paralysis and trismus. The reflexes
were exaggerated, but there were
no other symptoms except that the
larger muscles were slightly tender
and showed a trifle of contraction.
The mortality of head tetanus is only
2,6 per cent. Megevand (Revue med.
de la Suisse rom., Oct., 1913).
In tetany the nature of the spasm
is different, and it especially involves
the hands and feet.
In hysteria some symptoms of tet-
anus may be simulated, but the pres-
ence of other hysterical phenomena
and the history of the case should
preclude error. A bacteriological
diagnosis should be made by means
of cultures and stained preparations
from pus of the wound and from the
earth of the locality. Mice inoculated
with pus from a tetanus-infected
wound will die within a few days : a
fact which may be used in diagnosis.
ETIOLOGY. — Newborn children
are very susceptible. After the first
month of life, however, infants seem
less liable to the disease than adults,
the period of greatest danger being
from 30 to 45 years. In general,
males are more frequently affected
than are females, and the negro races
are more susceptible than are the
white. Horses, cattle, sheep, and
other animals are also attacked.
All forms of the disease are much
more common in hot countries than
in temperate climates. The disease is
often especially frequent in certain
localities (endemic tetanus), the soil
seeming peculiarly rich- in the l)acilli.
The European war has clearly
demonstrated the tellurian origin of
the disease, the soil harboring the
bacillus. Battles in some regions
proved prolific in cases of tetanus,
whereas in others no cases developed
even after shell wounds.
There were 65 cases of tetanus
among the 26,600 wounded in hos-
pitals at Cracow. This proportion of
only 0.24 per cent, the writer ascribes
to the fighting on wild, uncultivated
land, in contrast to conditions at the
Cephalic tetanus, following disease of right
upper molar. (J. Megevand.)
(Rev. med. de la Suisse rom., Oct., 1913.)
western seat of war. Arzt (Wiener
klin, Woch., Dec. 24, 1914).
Of 66,110 wounded soldiers treated
in the hospitals of Dvinsk during
the first 11 months of the war, 95
(0.134 per cent.) suffered from tet-
anus. In other regions the disease
was more common. Feinman (Rus-
sky Vratch, Sept. 26, 1915).
In almost all cases of tetanus there
is traceable trauma, and many even
doubt the possibility of the disease
without a solution of continuity of
tissue sufficient to permit entrance of
the germ.
516
TETANUS (BONDURANT).
Idiopathic cases following exposure
to cold seem, however, to occur.
Probably such cases should be attrib-
uted to presence of the bacillus in the
intestinal canal, or to some unsus-
pected avenue of infection, such as
diseased teeth, microscopic abra-
sions, etc. The wounds most favoring
tetanus are lacerated and contused
wounds, especially where nerves are
involved. Injuries of the hands or
feet are especially susceptible. The
■disease, however, may also follow
extraction of teeth, burns, frost-bite,
insignificant scratches or injuries
from splinters, needles, tacks, etc.
Vaccination has been regarded as
an occasional cause of tetanus, but
recent researches by J. Anderson, of
the U. S. Public Health Service, have
led to the conclusion that the disease
was due to contamination of the vac-
cination wound from the exterior.
Comprehensive research showing:
1. That it is difficult, if not im-
possible, to produce tetanus in sus-
ceptible animals by vaccination with
virus purposely containing large
numbers of tetanus organisms.
2. Failure to demonstrate tetanus
organisms in a large amount of vac-
cine virus specifically examined for
that purpose.
3. That from 1904 to 1913, inclu-
sive, over 31,000,000 doses of vaccine
virus were used in the United States,
yet information was obtained of only
41 authenticated cases of tetanus oc-
curring subsequent to vaccination.
Had the vaccine used during that
time in the United States been at
fault many more cases of tetanus
should have followed vaccination.
4. That in view of the large num-
ber of vaccinations (about 585,000)
done in the United States Army and
Navy and the absence from them of
a single case of tetanus following
vaccination, the cases of tetanus fol-
lowing vaccination in the country at
large were not due to infection con-
tained in the virus.
5. That the average period from
vaccination to onset of symptoms of
tetanus in 83 cases of tetanus follow-
ing vaccination was 20.7 days, while
the average mortality of 93 cases was
75.2 per cent.
Cases of tetanus occurring 15 or
20 days after vaccination probably ac-
quire their infection about the tenth
day or later after vaccination. J. F.
Anderson (U. S. Public Health Re-
ports; Reprint 289, July 16, 1915).
It may follow child-birth in women,
although of late years this puerperal
form has been much less common
than before the days of asepsis.
In the last 50 years only 2 cases of
puerperal tetanus have occurred in
Edinburgh district. It does not diflfer
from other forms, except in the
site of infection. ' The incubation is
generally given as from 7 to 10 days.
The mortality rate in acute cases is
at least 90 per cent., the majority of
cases dying before the fifth day.
Worrall (Austral. Med. Gaz., May 17,
1913).
A clean wound, of course, involves
much less danger than a dirty one.
Surgical operations in almost any
part of the body may be followed by
tetanus. As first shown by R. Matas
fecal contamination is important, any
operation involving the intestine, its
orifice, or the perianal structures af-
fording an entry to the specific or-
ganism if it happens to be present, as
is often the case in the intestine.
The injuries and surgical opera-
tions in regions exposed to fecal con-
tamination are the most liable to tet-
anic infection, the anorectal region,
perineum, female genitourinary tract,
male genitals, especially scrotum,
lower pelvic region, including but-
tocks, sacrococcygeal region, groins,
thigh, knee, upper leg (on their pos-
terior and inner surfaces especially) ;
after operations on the intestines, ar-
TETANUS (BONDURANT).
517
tificial anus, etc. There may also oc-
cur unconscious transmission of fecal
matter to distant parts of the body
by the soiled fingers of the patient
himself, or of his attendants.
In all the cases of postoperative
tetanus occurring after operations in
regions liable to fecal contact, the
patients had eaten copiously of un-
cooked vegetables within 36 hours
before the operation. Those most
contaminated with tetanus germs
and spores are celery, lettuce, chic-
ory, water-cress, cabbage, radishes,
turnips, carrots, tomatoes, and other
green vegetables, berries, and fruits
which are grown in contact with soil
and are largely consumed raw. Five
per cent, of all normal men harbor
the tetanus bacillus or its spores in
an active state in the intestinal canal;
20 per cent, among hostlers, stable-
men, dairymen, drivers, etc. (Pizzini).
R. Matas (Monthly Cyclo. and Med.
Bull., Dec, 1909).
The intestines of certain animals,
particularly herbivora, seem to offer
especially favorable conditions for
the growth of the tetanus bacillus;
such animals are "tetanus carriers."
The presence of tetanus spores in
soils, street dust, fresh vegetables,
and on clothing and the skin is un-
doubtedly due to fecal contamina
tion. Noble (Jour, of Infect. Dis.,
Mar., 1915).
A large majority of the reported
postoperative cases in the preaseptic
and early aseptic era were connected
with operations in the female pelvis.
In view of various experimental
and bacteriological data obtained,
it seems possible that some human
beings carry and excrete tetanus or-
ganisms for long periods, and are
really tetanus carriers. Their great-
est danger is to themselves, because
after operative procedures which
permit fecal contamination of the
wound, tetanus may be inaugurated.
This is particularly true of abdom-
inal operations where the gut is
bruised or roughly handled. K. Speed
(Surg., Gynec, and Obstet, Apr.,
1916).
BACTERIOLOGY. — The tetanic
bacillus growing under favorable con-
ditions is a characteristically drum-
stick-shaped organism, with a con-
siderable enlargement at one end in
wdiich a bright, round spore can be
seen. The non-spore-bearing bacilli
are long, slender, having rounded
ends, are motile, and are numerous
when temperature and other condi-
tions are unfavorable. The organism
will not grow in the presence of the
smallest amount of oxygen. It stains
readily by Gram's method, and with
ordinary watery solutions of the ani-
line colors. It is very common in
certain soils in thickly inhabited
countries ; in particular, soils which
have been manured. It is also pres-
ent in the atmosphere, especially a
dust-laden atmosphere, and has been
shown in the scrapings of the walls
and floors of hospitals in which tet-
anic cases have been treated. It is
always found in the pus or other dis-
charge from tetanus-infected wounds,
and is frequent in stools of tetanus
cases.
The organism possesses excep-
tional powers of resistance, retaining
its virulence for months in dried pus,
and surviving antiseptics, heat, etc.,
which would prove quickly fatal to
other pathogenic germs. The poisons
generated by them have been isolated
by Brieger from filtrates of several-
weeks-old cultures in the shape of
two basic substances : tetanin and
letanotoxin. Brieger and Frankel
have also isolated an intensely poi-
sonous toxalbumin.
The phenomena of tetanus are
readily produceable in lower animals
by minute portions of these toxins in-
troduced into the tissues.
The activity of the tetanus bacillus
518
TETANUS (BONDURANT).
seems enhanced when certain other
bacteria — the Bacillus acrogcncs cap-
sulatus particularly— are present.
The BaciUus acrogcncs cat'sulatus of
Welch is frequently found in the
feces of horses and in soil which
seems most often to give rise to
tetanus. Even ordinary street dirt
and dust often contains it; 3 of 4
fatal cases of tetanus were also in-
fected by this malignant organism.
In 2 it was found in the heart's blood
after death. The virulence of the
tetanus bacillus itself can be greatly
increased by the presence of other
pathogenic bacteria. M. H. Gordon
(Lancet, Oct. 31, 1914).
It is unnecessary to heat the sus-
pected material to 80° C. to kill off
other bacteria. Heating to 60° C. one
hour is ample, while it does not mod-
ify the toxicity of the tetanus bacillus.
Ninni (Annali d' Igiene, Nov., 1920).
PATHOLOGY. — The disease is
purely toxic, without typical or con-
stant morbid anatomical changes.
There is apt to be a small, slightly
suppurating wound, with some con-
gestion of adjacent parts. The nerves
in the vicinity may be inflamed, red,
and swelled, but characteristic lesions
in the nerves or nerve-centers are
wanting, although in the brain and
spinal cord minute hemorrhages, dis-
tention of capillaries, perivascular
exudation, and pigmentary or other
degenerative changes in nerv^e-cells
have been described. Tetanotoxin
gradually penetrates the axis-cylin-
ders of nerves travelling centripetally.
Hypostatic congestion of the lungs
is a frequent post-mortem finding,
and rupture of muscle-fibers from
violent contraction has been seen.
PROGNOSIS. — The prognosis is
grave, about 80 per cent, of traumatic
and 50 per cent, of the so-called
idiopathic cases proving fatal.
On the western battle front the
mortality in 351 cases of tetanus was
70 per cent., at Hamburg only 49 per
cent. This is because the latter cases
were those with a long incubation
period, while the cases observed at
the front were those in which the
attacks came on soon after the
wounds. Kiimmell (Beitr. z. klin.
Chir., xcvi, 421, 1915).
Puerperal tetanus is rarely recov-
ered from, and tetanus neonatorum is
almost always fatal.
The least dangerous cases are those
in which the spasm remains localized
in the jaw- and neck- muscles. The
prognosis is also better when the
period of incubation is prolonged.
In a series of cases the prognostic
value of the duration of incubation
was clear. In a^' cases in which this
exceeded 10 days, recovery followed.
The cardiorenal apparatus is a de-
cisive factor. A pulse rate low in
proportion to the temperature and a
pronounced diminution in the urinary
output are bad prognostic signs; like-
wise, profuse sweating, especially of
the face and head, at the onset of and
during the paroxysms. P. R. Joly
(Bull, de I'Acad. de Med., Jan. 26,
1915).
The afebrile cases ofifer a more
hopeful outlook than those with fever.
When paroxysms are frequent, se-
vere, and involve all muscles of the
trunk, recovery is scarcely to be
hoped for.
In tetanus pulmonary and cardiac
complications may cause death. Cases
with spasms of the diaphragm and
glottis have an unfavorable progno-
sis, because these manifestations can-
not be reached by treatment; epi-
gastric pain points to forthcoming
spasms of the diaphragm. Rarely
tetany is mistaken for tetanus. Next
to death from spasm of the glottis,
confluent lobular pneumonia is the
chief cause of death. It may occur
in time to be an integral part of the
TETANUS (BONDURANT).
519
disease. Pribram (Berl. klin. Woch.,
Aug. 30, 1915).
In a personal case tetanus recurred
55 days after the close of a first at-
tack of cephalic tetanus. It assumed
the paralytic type, without contrac-
ture, and there was a confusional state
suggesting cereiiral tetanus. No
serotherapy had been given after the
subsidence of the first attack. P.
Beaussart (Bull, de la Soc. Med. des
Hop., Apr. 22, 1921).
TREATMENT.— Wounds in which
contamination is probable should be
carefully cleansed and asepticized,
opening- freely under anesthesia if re-
quired until all tissues are exposed.
All detritus, dead tissues, etc., should
be removed and a 5 per cent, solution
of hydrogen peroxide injected into
every recess of the wound, the tet-
anus bacillus succumbing- to the
oxygen.
The wounded develop tetanus be-
cause tetanus bacilli are allowed to
proliferate. If we clear out the
wound with hydrogen dioxide and
potassium permanganate there will
be no tetanus. Koch (Therap.
Monats., Mar.. 1915).
Experiments on guinea-pigs, in
which after tetanus inoculation oxy-
gen was injected through a needle
into the inoculated area. Most of the
pigs so treated recovered without any
symptoms, while the controls all died.
The method is suggested as a pos-
sible means in the treatment of
human cases. H. O. Howitt and D.
H. Jones (Lancet, Apr. 10, 1915).
For the same reason, free drainage
should be insured for deep wounds
and crust formation avoided. Dried
antitetanic serum applied copiously
to the exposed surfaces is helpful.
The surrounding area should also be
asepticized, preferably with tincture
of iodine after thorough cleansing.
No strong antiseptic should be used
in the wound, as it would close
the lymph-spaces. Chlorinated lime
seems worthy of trial.
Tetanus is rare after rifle wounds,
but common after shrapnel wounds.
Infection by contact is possible;
tetanus patients should, therefore, be
isolated. They should not lie directly
on straw. Deep wounds are to be
opened, disinfected, and given free
drainage. The wounded surface
should be kept moist and free from
drying scabs. Phenol is the time-
honored local anesthetic. Carrel's
chlorinated lime and boric acid dress-
ing seems better, impermeable crusts
being less likely to form. Iodine as
a disinfectant is still disputed, but it is
non-toxic, prevents the growth of
ordinary pyogenic organisms and pro-
duces a prolonged hyperemia.
The treatment of the wound is not
so important as immediate antitoxin
injection. Aschoflf and Robertson
recommend absorbent cotton soaked
in antitoxin and dried. The cotton
becomes moistened by secretions and
the antitoxin set free. McGlannan
(N. Y. Med. Jour., Nov. 27, 1915).
The results thus far obtained by
antitoxin treatment have not been
distinctly favorable, probably because
tetanus is unsuspected until too late
for results from specific treatment.
In 1300 wound cases, prompt use of
20 units of antitoxin prevented tetanus
in all but 1 case. Although during
the war curare had been tried with
negative results, the writer attri-
butes recovery to its use in a fullv
developed case of tetanus, first seen
10 days after receipt of a severe
lacerated head wound. Chloral was
then exhibited, and incidentally a
small dose of curare, repeated until
6 mgm. C/io grain) injected. This
produced asphyxia, and the dose was
limited to 5 mgm. (^2 grain) daily
with 45 grains (3.0 Gm.) of chloral.
The spasms ceased for some hours
daily, to reappear sooner or later
with varying severity. The patient
recovered after taking 63 mgm. (1
grain) of curare in 14 days. Schocn-
520
TETAXUS (BONDURANT).
bauer (Wiener klin. Woch. Feb. 17,
1921).
A favoral)le effect is, however, often
noted, especially when the premoni-
tory symptoms are detected early.
Antitoxin should always be used,
however, as it is probably the best
single remedy now at hand.
The first thin,<i; done in tetanus
should he an intrathecal injection of
tetanus antitoxin. The fluid with-
drawn will, as a rule, not l)e more
than 20 c.c. If the serum used be of
the ordinary strength of 150 units in
1 CO., the patient will receive a dose
of some 3000 in 20 c.c. If the serum
be of higher potency — say, 800 units
to the c.c. — the patient will have re-
ceived 16,000 units. For intrathecal
injections this high potency serum, if
procurable, should by all means be
used. At the same time, 5 to 10,000
units should be injected intramus-
cularly and 3 to 5000 may also be
given subcutaneously. The intrathe-
cal injections may be repeated daily
for three to five days; the intramus-
cular and subcutaneous may be con-
tinued daily or oftener, according to
the symptoms. When there are dis-
tinct signs of abatement, the dose
may be gradually reduced, the inter-
vals lengthened, and the serum given
only subcutaneously. There is no
convincing evidence that phenol treat-
ment has anj' curative efifect. The
cessation of spasm which follows a
magnesium sulphate injection is pur-
chased at the cost of distinct risks.
Brit. War Office Committee on Tet-
.anus (Brit. Med. Jour., Nov. 11, 1916).
The writers place the methods of
administration of tetanus antitoxin in
the following order as to efficiency:
intramuscular, subcutaneous, intra-
thecal, and intravenous. The latter
should not be used, entailing a risk
of anaphylactic shock and being of
little therapeutic value. By the com-
bined subcutaneous and intramuscular
routes the daily dosage for the first
few days should not fall below 10,000
units. Leishman and Smallman (Lan-
cet, Jan. 27, 1917).
The focus of tetanic infection must
be widely opened up, curetted and
disinfected with oxidizing agents.
Crystals of sodium persulphate scat-
tered in the wound are more useful
than hydrogen peroxide solutions,
acting longer. When the first symp-
toms of tetanus appear, the authors
give 30 c.c. of the antiserum daily for
three days and when not quite certain
that all the tetanus bacilli have been
eliminated from the wound, continue
the injections further. Sodium per-
sulphate keeps well in sealed tubes.
For use, 5 Gm. (75 grains) are
dissolved in 100 c.c. (31^ ounces)
of cold, sterilized, distilled water, and
20 c.c. (5 drams) of the solution is
injected into an elbow vein morning
and night for three or more days. In
about half the cases brief vomiting
follows; this may return a few hours
later, but is often absent after the
second or third injection. Sometimes
chloral hydrate or another sedative is
added. In a case of respiratory
spasm, prompt and complete success
followed blocking of the phrenic
nerve by injection of 10 c.c. (2>4
drams) of a 1 or 2 per cent, solution
of procaine with a little adrenalin.
Berard and Lumiere (Presse med.,
Sept. 12, 1918).
The alkali persulphates are highly
destructive to the tetanic poisons. A
1.5 per cent, solution of procaine with
addition of a drop of 1: 1000 adrenalin
solution, injected into the brachial
plexus for the upper limb, at the
point of emergence of the sciatic for
the lower limb, and about the nerve-
trunks supplying the groups of con-
tractured muscles, gave very gratify-
ing results in all instances. For
prophylactic purposes the writer uses
an iodized tetanus toxin. Bazy (Lan-
cet, Oct. 19, 1918).
The former belief that amputation
of the wounded extremity would fore-
stall the disease has not been sus-
tained. Many believe also that too
active surgical measures in the wound
promote its development.
TETANUS (BONDURANT).
521
Removal of the seat of infection
by amputation is useless. Of 5 cases
thus treated even before the disease
developed, 4 died. Hochhaus (Miinch.
med. Woch., xlvi, 2253, 1914).
Fulminating case of tetanus which
developed the twenty-first day after
the shell wound. The man was re-
covering from his injury when a cor-
recting operation was undertaken,
opening up a fistula; the tetanus de-
veloped four days thereafter. The
germs must have been already in the
wound but quiescent until roused.
When he finds the knee-jerk in a
wounded limb exaggerated and grow-
ing constantly more pronounced, he
accepts this as a sign that tetanus is
already installed, although there may
be no other sign or symptoms of it.
He administers magnesium sulphate
at once in amounts sufficient to re-
duce the reflexes to normal. Heile
(Berl. klin. Woch., Feb. 15, 1915).
Baccelli's treatment by means of a
2 or 3 per cent, solution of phenol
(carbolic acid) has also given good
results, i.e., 17.36 per cent, in Italy,
where tetanus is quite common. That
as low^ a mortality has not been ob-
tained elsewhere from this method is
attributed to the fact that tetanus in
Italy is often not as severe as in
other countries. The solution may be
used in from 1- to 2- dram (4 to 8
Gm.) doses hypodermically every
two or three hours. Antitoxin and
phenol together are especially useful.
The writer is more and more satis-
fied with his method of treatment,
which has also given good results in
other hands. In 190 cases treated by
Italian and other physicians the total
mortality, according to Imperiali, was
17.36 per cent. Among 94 severe
cases there were only 2 deaths, and
among 38 of marked severity, ex-
cluding 11 in which the dose was
much too small, 5 deaths. The
amount of phenol injected often ex-
ceeded 0.1 to 0.15 Gm. (VA to lyi
grains). He ordinarily used a 2 to 3
per cent, watery solution, beginning
with 0.3 to 0.5 Gm. (5 to 8 grains) of
the acid daily to test the tolerance of
the patient, and then rapidly increas-
ing to 1.0 to 1.5 (15 to 23 grains) in
several injections. The massive
doses are only to be employed with
great care and in serious cases. G.
Baccelli (Berl. klin. Woch., nu. 23,
1911).
Phenol injections used in 5 consec-
utive cases, all recovering; 2 other
cases treated with antitoxin died; 10
minims (0.6 c.c.) of 10 per cent, solu-
tion of pure phenol in sterile water,
diluted to 30 or 40 minims (1.8 to
2.5 c.c), injected deep into the mus-
cles, at first every three hours, later
at longer intervals as improvement
appeared. The urine should be
watched for smokiness. Kintzing
(N. Y. Med. Jour., Dec. 23, 1911).
Supplementary to the usual anti-
tetanus serum treatment, the writers
recommend the copious use of phe-
nol, either by the Baccelli subcutane-
ous method or by giving salol orally,
or both. Arnd and Krumbein (Cor-
respondenzbl. f. schweizer Aerzte,
Nov. 28, 1914).
Series of 22 tetanus cases in which
Baccelli's method was applied: Twice
daily an injection of 40 to 50 c.c.
(lYs to 1% ounces) of a 2 per cent,
phenol solution was given subcutane-
ously, in the vicinity of the wound
whenever possible, otherwise in the
thigh or abdomen. The patients
thus each received 1.6 to 2 Gm. (25
to 30 grains) of phenol a day, and
in 2 the injections were continued
for nearly a month. There was local
erythema in 2 cases and an aseptic
fluid accumulation where many injec-
tions had been given in the thigh.
No signs of general intoxication,
such as dark-colored urine, were ever
noticed. Paul Sainton (Bull, de
I'Acad. de Med., Dec. 1, 1914).
Of 22 cases of tetanus treated with
chloral hydrate in doses of 20 to 28
(]m. (5 to 7 drams) per diem and
morphine in doses of 0.02 to 0.06 Gm.
522
TETANUS (BONDURANT).
(1 grain), only 6 ended favorably,
while among 13 cases in which 0.75
Gm. (12 grains) of phenol was in-
jected dail}^ round the wound, 4 were
cured. Nigay (Presse med., Jan. 21,
1915).
Captain Everidge reported a case
of tetanus complicated with mental
symptoms (Brit. Med. Jour., Mar.
25th). The writer had a verj' similar
case in a negro. Just enough chloral
hydrate was given to keep him con-
stantly under its influence. The total
amount given was considerable. As
he was recovering from the tetanus
hallucinations were very marked.
There was no rise of temperature.
He suspected the chloral and discon-
tinued it, and the symptoms grad-
ually passed off. Recovery was com-
plete a week later. In Everidge's
case the chloral dosage was large,
and in view of the writer's own case
the mental symptoms might be more
rightly attributed to this than to the
phenic acid. W. F. Law (Brit. Med.
Jour., Apr. 22, 1916).
Precautionary measures are always
in order after tetanus antitoxin to
avoid anaphylaxis. Should the case,
after recovery, contract diphtheria, an
injury suggesting the possibility of
tetanus, or be exposed to typhoid
fever, etc., and receive prophylactic
injections of their specific sera, the
possibility of anaphylaxis is to be
thought of. Indeed, it occasionally
attends the use of prophylactic injec-
tions when these are first used.
Case of a wounded man of 30 who
received an injection of 10 c.c. (2J/2
drams) of antitetanic serum, and 4
years later was given another in-
jection after being again wounded.
Two series of untoward results fol-
lowed this second injection; first, a
localized pseudophlegmonous edema,
then, 9 days after the injection,
very severe general phenomena for
3 ciays, viz., sudden attacks of cardiac
weakness, vomiting, generalized urti-
caria, extreme asthenia, scanty urine
and albuminuria. These manifesta-
tions correspond closely to experi-
mental anaphylactic shock. The
patient subsequently showed paral-
ysis of the latissimus dorsi with mus-
cular atrophy and reaction of degen-
eration. P. Thaon (La med. mod.,
Nov. 26, 1910).
Two cases of tetanus developing
after a shell injury of the upper arm.
One man was given 200 antitetanus
serum units, both intravenous and
intraspinal, repeated the next day and
followed daily with 100 units intra-
venously after the arm had been am-
putated. He was progressing favor-
ably until the fourteenth injection, fol-
lowed by severe anaphylaxis. Under
stimulants in an hour he recuperated.
The next day he developed an exan-
them. The other case showed twitch-
ing in the arm and face, but as this
subsided after intravenous injection
of 300 units, the assumption of tet-
anus seemed to have been erroneous.
Thirteen days later the symptoms re-
turned in a severe form. Injection of
300 units was followed in a few
minutes by cyanosis, a chill and tem-
perature of 40.9° C. (105.3° F.), but
the pulse kept good. After this
there were no symptoms of tetanus.
Three days later, the seventeenth day
after the first injection, 100 units
were injected intravenously again,
severe anaphylactic shock ensuing,
with total unconsciousness for half
an hour and marbling of the body,
the pulse scarcely perceptible, and
finally a chill and temperature of
40.1° C. (1(H.2° F.). By the next day
the pulse and breathing were normal
again. These cases suggest that the
tenth day is the danger line. Simon
(Jour. Amer. Med. Assoc, from
Miinch. med. Woch., Xov. 10, 1914).
Magnesium sulphate, recommended
by jMeltzer, Auer, Hanbold, and
others, when given in doses insuffi-
cient to morbidly affect the respira-
tory center, abolishes or, at least,
noticeably inhibits the spasms, and
thus tides the patient over until anti-
TETANUS (BONDURANT).
523
bodies are formed to counteract the
tetanotoxin in the nerves. It may be
administered subcutaneously or in-
traspinally.
The magnesium sulphate treatment,
in about 50 cases, has lowered the
mortality to 35 per cent. Individual
susceptibility to magnesium sulphate
varies, and the dose must be regu-
lated by actual trial in each case.
The subcutaneous method, available
to the general practitioner, requires
a most careful supervision of the pa-
tient. A slight tendency to paralysis
of the respiration must be constantly
watched for as the initial sign of
possible serious trouble. To antag-
onize the excessive action of the
magnesium salt, 1 dram (4 c.c.) of
a 5 per cent, solution of calcium
chloride may be injected repeatedly
into the muscles, as required. The
most important measure, however, is
artificial respiration, which may
prove sufficient alone, particularly if
%5 grain (0.001 Gm.) of physostig-
mine salicylate has previously been
injected. Intratracheal insufflation is
advantageous; either oxygen may be
run in from a tank or air pumped in
with bellows. Intraspinal injection
of the salt is a better procedure than
subcutaneous use, but is difficult to
apply except in hospitals, as a single
physician cannot carry it through.
Weintraub and Unger (Berl. klin.
Woch., Oct. 19, 1914).
The chief object of magnesium
sulphate is to gain time until the
body forms antibodies. Meltzer and
Auer found that the maximum dose
was 1.5 Gm. (23 grains) to 1 kg. (214
pounds) of body weight. Giving it in
fractional doses throughout the 24
hours this amount can be given on
from 6 to 18 successive days without
doing any harm. The severer the
case the larger initial dose is given,
and it may be well to» give it intra-
venously for quicker action. It is
not necessary to give the full dose
to produce complete relaxation of
the muscles; it is sufficient to depress
the centers so that the convulsions
stop, even though some stiffness per-
sists. In giving such a dose there is
practically no danger of producing
paralysis of respiration, hyperex-
citability of the nerve-centers being
overcome sooner than their capacity
for reaction to physiological stimuli.
The sulphate is excreted very rapidly,
most rapidly after intravenous injec-
tion, next after intramuscular and
slowest after intraspinal injection.
The writer recommends the subcu-
taneous injection of 10 c.c. (2}^
drams) antito5fin on the first, fifth,
eighth, and twelfth days after an
injury. As soon as any signs of
tetanus develop a subcutaneous in-
jection of 25 per cent, magnesium
sulphate is given, the amount de-
pending on the weight of the patient.
This generally has to be repeated
four times the first twenty-four
hours'. Careful watch of the patient
must be kept so that thd additional
doses may be given at the proper
time. If the subcutaneous adminis-
tration is not effective, then it should
be given intramuscularly. Straub
gives it intravenously, but this in-
volves some danger to the heart.
T. Kocher (Correspondenzbl. f.
schweizer Aerzte, xlv, 1249, 1915).
As to general treatment, the case
should be placed in a darkened quiet
room. No one but the doctor and
nurse should have access, and every
possible source of irritation causing
spasm should l)e rigorously excluded.
The diet should be liquid, nourish-
ment by enema being employed if the
trismus is marked. Of remedies for
combating the spasm chloroform is
most quickly efficacious, but the re-
lief obtained is liable to be temporary
only, and secondarv hepatic lesions
may be caused. Nitrite of amy! will
occasionally abort a paroxysm. Other
antispasmodics are chloral hydrate,
chloretone. Calabar bean, the bro-
mides, and curare. Continuous warm
baths are helpful in most instances.
524
TETANUS (BONDURANT).
Ice to the spine is also recommended,
as is bleeding.
McClintock and Hutchings found
chloretone the best substance to re-
lax the muscles in tetanus. Subse-
quently Hutchings published 6 cases
treated with chloretone, with 4 re-
coveries. Chloretone has the ad-
vantage over the intraspinal injection
of magnesium sulphate in its greater
safety. Hobbs and Sheaf (Brit.
Med. Jour., Nov. 5, 1910).
Two cases of tetanus in which the
writer employed atropine. A colored
boy, 14 years old, who under, usual
measures was given by the mouth
% grain (0.008 Gm.) of atropine
every two hours for 3 doses and then
every four hours. From the first
dose the spasms markedly decreased
and the patient obtained good rest
at night. In about four weeks he was
up and about. Small doses of calo-
mel and sodium sulphate were given
to keep the bowels open, and the
wound was dressed with hot turpen-
tine. A second was treated similarly,
but with smaller doses, and by the
beginning of the fourth week all
symptoms had disappeared. The
writer has seen many cases of tet-
anus, and was surprised at the efifect
of the treatment. A Government vet-
erinary surgeon told him that he
employed large doses of belladonna
with small doses of morphine in tet-
anus in animals, and that a fatal re-
sult rarely occurred. R. F. SecorestO'
(Editorial, Lancet, May 21, 1910).
Special care as to cardiorenal
measures is necessary, drugs such as
digitalis, strophanthus, camphorated
oil, hexamethylenamine, squill, lac-
tose, diuretic infusions, and Vichy-
water being recommended. To make
up for respiratory inadequacy oxygen
inhalations were given every hour or
even every quarter-hour. Venesec-
tion, in 1 case, .leemed to diminish
convulsive attacks. Combined use
of morphine, camphorated oil, ether,
and oxygen, is recommended in
allaying the convulsions. Joly (Bull.
de I'Acad. de Med., Jan. 26, 1915).
Various combinations of the most
effective aj^ents liave been used, ap-
parently with benefit.
The writer uses a combination of
antitetanus serum, subcutaneous in-
jection of 5 c.c. (1>^ drams) of a 2
per cent, solution of phenol, plus
local cauterization of the wound with
concentrated phenol. This does not
produce an eschar at once; so it bur-
rows deep and efifectually sterilizes.
In 4 cases of tetanus after shrapnel
wounds this method was successful.
The writer administered the phenol
injections once or twice a day at
first, increasing to 5 or 6 a day.
Voelcker (Miinch. med. Woch., Oct.
27, 1914).
Six out of 8 cases of tetanus ended
favorably under intravenous use of
both antitetanic serum and chloral
hydrate. The serum injections were
given daily, beginning with a mas-
sive amount, 50 c.c. (12>4 drams),
and gradually diminished to 10 c.c.
(2>4 drams). Where the symptoms
returned after a period of quiet,
anaphylactic manifestations upon re-
sumption of the injections were
avoided by the previous administra-
tion (during the quiet? period) of 10
c.c. (2^ drams) of the serum by
rectum. The total amount of serum
used ranged between 100 and 350 c.c.
(3^ to 12 ounces). Chloral hydrate
was used in a 5 per cent, solution,
of which 60 c.c. (2 ounces) were
given at a dose; in some cases 3 such
doses were administered in a day.
The efifect of each dose was quiet
sleep lasting three hours, after which
a marked reduction in the convul-
sions persisted. Barnsby and R.
Mercier (Bull, de I'Acad. de Med.,
Mar.. 23, 1915).
Saline solution bids fair to occupy
an important position in the treat-
ment of tetanus. Not only does it
tend to counteract thirst while pro-
moting osmosis, but it may be given
with other useful agents — ether,
glucose, paraldehyde, etc.
TETANUS (BONDURANT).
525
Being unable to obtain antitetanus
serum in an extremelj^ serious case,
the writer treated the patient, a
mulatto of 25, by cauterizing the
wound, bleeding (500 c.c), infusing
a similar amount of saline solution,
and then allowing all the cerebro-
spinal fluid that dripped slowly from
a lumbar puncture to escape. He
then washed out the cerebrospinal
canal with saline solution containing
0.3 per cent, sugar, and left 2 syringe-
fuls in the canal. These procedures
were repeated the next day, giving
an hour each time to them, washing
out the canal with a liter (quart) of
the saline, a drop at a time. The
reaction, severe the first day, was
much milder the second, and the pa-
tient afterward dropped to sleep and
began to mend, and the procedures
were repeated during the first five
days, using smaller amounts, and the
man left the hospital cured, the
twelfth day. Kras (Wiener klin.
Woch., Jan. 11, 1912).
Case in which spasms were con-
trolled, sleep procured and feeding
with milk rendered possible by re-
peated intravenous infusion of 15 to
30 c.c. (yz to I ounce) each of ether
and paraldehyde in normal saUne
solution, producing prompt hypnosis,
followed by relative muscular relax-
ation for several hours. Atkey (Lan-
cet, Jan. 18, 1913).
Case in which the disease began
insidiously. Treatment was intensive
— serum, magnesium and morphine.
The patient, however, seemed doomed;
so that a new resource was sought.
Fifteen cm. (1/2 ounce) of ether were
given in 750 cm. (1^2 pints) of saline
infusion, and the case at once began
to improve, the treatment being con-
tinued until recovery. Hercher
(Miinch. med. Woch., Aug. 17, 1915).
Attempts to destroy the tetanus
germs with the ultraviolet rays have
been made with apparent success.
The radiation of jagged wounds
with ultraviolet rays will kill tetanus
bacilli and the bacilli of malignant
edema at the. site of infection. This
supplements surgical cleansing. Kro-
mayer's lamp and the artificial high
solar light may be used to generate
the rays. Jacobsthal and Tanim
(Miinch. med. Woch., Ixi, 2324, 1914).
Ultraviolet rays used in 4 cases
and the men recovered. The incu-
bation period had ranged from nine
to seventeen days. Jesionek (Miinch.
med. Woch., Mar. 2, 1915).
Bilateral phrenicotomy has been
resorted to to prevent death through
spasm of the diaphragm.
Animal experiments having shown
that phrenicotomy paralyzed the dia-
phragm without serious consequences
to the victim, the intervention was
tested on an 8-year-old boy with tet-
anus. The symptoms included a se-
vere spasm of the diaphragm. In
a general spasm the thorax was sud-
denly fixed in the maximal inspira-
tory position, while both the throat
and abdominal muscles were rigid.
The face cyanosed. Consciousness
was finally lost and three or four
minutes expired before the seizure
passed over. The writer now divided
both phrenics behind the sternomas-
toid muscles. The patient then had
numerous convulsions without dysp-
nea. Attacks of the latter returned,
however, and were met by artificial
respiration and inhalations of oxygen
under pressure. As the patient, on
account of esophageal spasms, was
no longer able to take nourishment
gastrostomy was performed. He
made a slow recover}'. His general
health did not suffer as a conse-
quence. The onl}' drug received dur-
ing the tetanus was chloral. Jehn
(Miinch. med. Woch., Oct. 6, 1914).
PROPHYLAXIS. — While the
remedial value of antitetanic serum,
except perhaps in very large doses
introduced by every avenue available,
spinal, cutaneous, etc., has not been
demonstrated during the European
war, its merits as a prophylactic
agent have clearly asserted them-
526
TETANUS (BONDURANT).
selves. From 500 to 1000 U. S. A.
units have been found to suffice in
most instances, while in severe
wounds the repetition of the dose
once or twice at intervals of a week
is indicated. As emphasized by Mac-
Conkey, the occasional cases in which
antitoxin appears to liave no preven-
tive action may often be traced to
reaction of a quiescent focus or to
too early or too energetic active or
passive movements. When operation
is proposed in wounded men who
may have been infected with tetanus
bacillus it is imperative to bear in
mind that there may be toxin circu-
lating in the body. A large prophy-
lactic injection is consequently nec-
essary, so given as to insure absence
of free toxin in the blood at the time
of the operation and for some time
after. Subcutaneous injections, ex-
cept as supplementary agents, are out
of the question here because of the
slow rate of absorption. If the in-
jection be given intramuscularly, then
the operation should not take place
for several hours. An intravenous
injection permits of the operation be-
ing performed at once.
The reliability of senim in prevent-
ing tetanus is not absolute. Early
tetanus after serum injection is
mainly due to imperfect sterilization
of recent wounds and should be
largel}^ preventable. Late postseric
tetanus may be prevented in over
one-half the cases by injecting serum
before all secondary operations.
Serum treatment exerts a notable
efifect on the course of postseric
tetanus. Lumiere (Ann. de I'lnst.
Pasteur. Jan.. 1917).
Highly concentrated serum in doses
sufficient to maintain protection, such
as 3 c.c, may be repeated weekly as
long as seems advisable without fear
of anaphylaxis. Editorial (Lancet,
Jan. 20, 1917).
Report of 3 cases of delayed onset
of tetanus following gunshot wounds
of bone. The periods of inculjation
were 86, 106 and 146 days, respec-
tively. M. Foster (P,rit. Med. Jour.,
Feb. 10, 1917).
Tetanus of the extremities results
from local toxic impregnation through
traumatism. It generally appears
late, being due usually to an attenu-
ated tetanic infection. While a few
cases had been recorded before the
advent of serum treatment, the num-
ber of instances has increased enor-
mously since then, so that localized
tetanus may be considered essentially
a result of preventive serum therapy.
E. Chauvin (Rev. de med.. Mar. -Apr.,
1918j.
A definite part seems to be played
by B. welchii in the causation of tetanus.
Its capacity for harm can be almost
eliminated by the use of B. ■welchii anti-
toxin. The Vibrion septique may also
play a part. W. J. Tulloch (Brit.
Med. Jour., June 1, 1918).
During the early part of the war
there were 24 cases of tetanus among
each 1000 of English wounded, and
still more among the French. Injec-
tion of antitoxin was first made com-
pulsory in all cases of infected
wounds, and later in all wounds.
Thereafter less than 1 in 1000 de-
veloped tetanus, and these rare cases
usually had received no antitoxin.
The serum, in the developed cases in
France, was generally given subcu-
taneously or intravenously. The
British advocated the intraspinal
method. W. H. Park (Med. Assoc, of
N. Y.; X. Y. Med. Jour., Xov. 2.
1918).
The writer recommends the inhala-
tion of ether, though not enough to
put the patient to sleep. The patient
holds the mask himself and the ether
is given, 60 c.c. (2 ounces) morning
and night, by the drop or teaspoon-
ful. Seven patients recovered, but
the eighth died the tenth day. Au-
drain (Prog, med., Sept. 20, 1919).
E. D. BONDUR.AXT,
Mobile.
in
socs
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THEOCINE.
THIOCOL.
527
lit*
li
\,n :
' :-i'
THEOBROMINE. See Diuretin.
THEOCINE.— Theocine is the trade
name for synthetically prepared theo-
phylline, the alkaloid of tea-leaves. It is
closely related to caffeine and to theo-
bromine, the double salt of which, theo-
bromine sodium salicylate, known as
diuretin, has been much employed as a
diuretic. While the average urinary in-
crease caused by the latter is three-eighths
more, theocine causes 6.3 as much. Theo-
cine occurs as a white, odorless, crystal-
line powder having a bitter taste, and
soluble in 180 parts of water at ordinary
temperature, and in 85 parts at 98.6° F.
(37° C), sparingly soluble in alcohol and
insoluble in ether. It forms easily soluble
compounds with ammonium and potas-
sium, a less soluble one with sodium,
but a freely soluble double salt with
sodium acetate (theocine, or theophylline,
sodio-acetate).
The usual dose of theocine or the sodio-
acetate is from 3 to 5 grains (0.2 to 0.35
Gm.), given three times daily, in warm
tea. It may also be given in suppository
or enema, to avoid direct irritation of the
stomach; its hypodermic administration
is not advised because so often ineffi-
cacious, and sloughing of the skin has
followed its use by hypodermoclysis. It
should never be given on an empty
stomach.
PHYSIOLOGICAL ACTION.— Theo-
cine has a diuretic action similar to that
of caffeine and theobromine, which is be-
Ueved to be due to a direct effect upon
the secreting cells of the kidney. Not only
is the water of the urine increased, but
also the salts (especially sodium chloride).
When theocine acts at all it acts promptly
(in two or three hours), and in small
doses, and its effects are not prolonged.
The first dose is generally the most effi-
cient in producing marked diuresis.
On the gastrointestinal mucous mem-
brane theocine acts as a local irritant, as
is shown by the frequency with which
nausea and vomiting may occur, by the
occasional diarrhea (sometimes mucous
in character), and by hemorrhagic ero-
sions found post mortem.
Effects on the nervous system are not
usually observed until the third or fourth
day, when irritation of the cortical motor
centers is apparent, and may be severe
enough to cause convulsions (Stross,
Schlesinger, Allard, and Hundt), or even
death (Hundt 2 cases, Alkan, and Arn-
heim). Like all caffeine-like drugs, it
may cause wakefulness and excitement
(Minkowski, Stross, Hundt) even in mod-
erately small doses, in which case the
evening dose should be combined with an
hypnotic or the last dose given not later
than noon (Stross). Belladonna will re-
lieve the disagreeable effects of theocine
without lessening its diuretic action.
Cardiac action and blood-pressure are
apparentlj^ uninfluenced by theocine.
THERAPEUTIC USES.— Theocine is
employed in the treatment of cardiac af-
fections, nephritis, dropsy, etc., where a
rapid diuretic effect is desired. On ac-
count of its toxic properties, theocine
should be administered only in cases
where life is in immediate danger or
when other diuretics have failed. The
drug acts best when there are large serous
accumulations, particularly in cardiac or
cardiorenal disease, in which there is still
left considerable renal secreting tissue. In
chronic nephritis diuresis may be expected
if a goodly portion of the renal epithelium
is still functionally active; in advanced
chronic interstitial nephritis little effect
should be looked for, but in acute
nephritis very p-rofuse diuresis may be
obtained and large dropsical accumula-
tions absorbed.
In ascites due to hepatic cirrhosis and
chonic peritonitis, the drug often fails; in
alcoholic cirrhosis calomel is the supreme
diuretic (Stross). W.
THERMIC FEVER. See Heat
Exhaustion and Thermic Fever.
THIOCOL.— Thiocol is potassium-
guaiacol sulphonate. It occurs as a white,
crystalline, odorless, permanent powder,
having a faintly bitter saline, but not un-
pleasant taste. It is neutral in reaction,
or slightly alkaline, readily soluble in
water, dissolves in alcoholic solutions, but
is insoluble in absolute alcohol, and in
ether or fats. It is incompatible with sil-
ver salts, ferric compounds, and perman-
526
TETANUS (BONDURANT).
selves. From 500 to 1000 U. S. A.
units have been found to suffice in
most instances, while in severe
wounds the repetition of the dose
once or twice at intervals of a week
is indicated. As emphasized by Mac-
Conkey, the occasional cases in which
antitoxin appears to have no preven-
tive action may often be traced to
reaction of a quiescent focus or to
too early or too energetic active or
passive movements. When operation
is proposed in wounded men who
may have been infected with tetanus
bacillus it is imperative to bear in
mind that there may be toxin circu-
lating in the body. A large prophy-
lactic injection is consequently nec-
essary, so given as to insure absence
of free toxin in the blood at the time .
of the operation and for some time
after. Subcutaneous injections, ex-
cept as supplementary agents, are out
of the question here because of the
slow rate of absorption. If the in-
jection be given intramuscularly, then
the operation should not take place
for several hours. An intravenous
injection permits of the operation be-
ing performed at once.
The reliability of serum in prevent-
ing tetanus is not absolute. Early
tetanus after serum injection is
mainly due to imperfect sterilization
of recent wounds and should be
largely preventable. Late postseric
tetanus may be prevented in over
one-half the cases by injecting serum
before all secondary operations.
Serum treatment exerts a notable
efifect on the course of postseric
tetanus. Lumiere (Ann. de I'lnst.
Pasteur, Jan., 1917).
Highly concentrated serum in doses
sufficient to maintain protection, such
as 3 c.c, may be repeated w^eekly as
long as seems advisable w^ithout fear
of anaphylaxis. Editorial (Lancet,
Jan. 20, 1917).
Report of 3 cases of delayed onset
of tetanus following gunshot wounds
of bone. The periods of incubation
were 86, 106 and 146 days, respec-
tively. M. Foster (Brit. Med. Jour.,
Feb. 10, 1917).
Tetanus of the extremities results
from local toxic impregnation through
traumatism. It generally appears
late, being due usually to an attenu-
ated tetanic infection. While a few
cases had been recorded before the
advent of serum treatment, the num-
ber of instances has increased enor-
mously since then, so that localized
tetanus may be considered essentially
a result of preventive serum therapy.
E. Chauvin (Rev. de med., Mar.-Apr.,
1918).
A definite part seems to be played
by B. welchii in the causation of tetanus.
Its capacity for harm can be almost
eliminated by the use of B. welchii anti-
toxin. The ribrion septique may also
play a part. W. J. Tulloch (Brit.
Med. Jour., June 1, 1918).
During the early part of the war
there were 24 cases of tetanus among
each 1000 of English wounded, and
still more among the French. Injec-
tion of antitoxin was first made com-
pulsory in all cases of infected
wounds, and later in all wounds.
Thereafter less than 1 in 1000 de-
veloped tetanus, and these rare cases
usually had received no antitoxin.
The serum, in the developed cases in
France, was generally given subcu-
taneously or intravenously. The
British advocated the intraspinal
method. W. H. Park (Med. Assoc, of
N. Y.; N. Y. Med. Jour., Nov. 2,
1918).
The writer recommends the inhala-
tion of ether, though not enough to
put the patient to sleep. The patient
holds the mask himself and the ether
is given, 60 c.c. (2 ounces) mornmg
and night, by the drop or teaspoon-
ful. Seven patients recovered, but
the eighth died the tenth day. Au-
drain (Prog, med., Sept. 20, 1919).
E. D. BONDURANT,
Mobile.
THEOCINE.
THIOCOL.
527
THEOBROMINE. See Diuretin.
THEOCINE.— Tlieocine is the trade
name for synthetically prepared theo-
phylline, the alkaloid of tea-leaves. It is
closely related to caffeine and to theo-
bromine, the double salt of which, theo-
bromine sodium salicylate, known as
diuretin, has been much employed as a
diuretic. While the average urinary in-
crease caused by the latter is three-eighths
more, theocine causes 6.3 as much. Theo-
cine occurs as a white, odorless, crystal-
line powder having a bitter taste, and
soluble in 180 parts of water at ordinary
temperature, and in 85 parts at 98.6° F.
(37° C), sparingly soluble in alcohol and
insoluble in ether. It forms easily soluble
compounds with ammonium and potas-
sium, a less soluble one with sodium,
but a freely soluble double salt with
sodium acetate (theocine, or theophylline,
sodio-acetate).
The usual dose of theocine or the sodio-
acetate is from 3 to 5 grains (0.2 to 0.35
Gm.), given three times daily, in warm
tea. It may also be given in suppository
or enema, to avoid direct irritation of the
stomach; its hypodermic administration
is not advised because so often ineffi-
cacious, and sloughing of the skin has
followed its use by hypodermoclysis. It
should never be given on an empty
stomach.
PHYSIOLOGICAL ACTION.— Theo-
cine has a diuretic action similar to that
of caffeine and theobromine, which is be-
lieved to be due to a direct effect upon
the secreting cells of the kidney. Not only
is the water of the urine increased, but
also the salts (especially sodium chloride).
When theocine acts at all it acts promptly
(in two or three hours), and in small
doses, and its effects are not prolonged.
The first dose is generally the most effi-
cient in producing marked diuresis.
On the gastrointestinal mucous mem-
brane theocine acts as a local irritant, as
is shown by the frequency with which
nausea and vomiting may occur, by the
occasional diarrhea (sometimes mucous
in character), and by hemorrhagic ero-
sions found post mortem.
Effects on the nervous system are not
usually observed until the third or fourth
day, when irritation of the cortical motor
centers is apparent, and may be severe
enough to cause convulsions (Stross,
Schlesinger, AUard, and Hundt), or even
death (Hundt 2 cases, Alkan, and Arn-
heim). Like all caffeine-like drugs, it
may cause wakefulness and excitement
(Minkowski, Stross, Hundt) even in mod-
erately small doses, in which case the
evening dose should be combined with an
hypnotic or the last dose given not later
than noon (Stross). Belladonna will re-
lieve the disagreeable effects of theocine
without lessening its diuretic action.
Cardiac action and blood-pressure are
apparently uninfluenced by theocine.
THERAPEUTIC USES.— Theocine is
employed in the treatment of cardiac af-
fections, nephritis, dropsy, etc., where a
rapid diuretic effect is desired. On ac-
count of its toxic properties, theocine
should be administered only in cases
where life is in immediate danger or
when other diuretics have failed. The
drug acts best when there are large serous
accumulations, particularly in cardiac or
cardiorenal disease, in which there is still
left considerable renal secreting tissue. In
chronic nephritis diuresis may be expected
if a goodly portion of the renal epithelium
is still functionally active; in advanced
chronic interstitial nephritis little effect
should be looked for, but in acute
nephritis very profuse diuresis may be
obtained and large dropsical accumula-
tions absorbed.
In ascites due to hepatic cirrhosis and
chonic peritonitis, the drug often fails; in
alcoholic cirrhosis calomel is the supreme
diuretic (Stross). W.
THERMIC FEVER. See He.at
Exhaustion and Thermic Fever.
THIOCOL.— Thiocol is potassium-
guaiacol sulphonate. It occurs as a white,
crystalline, odorless, permanent powder,
having a faintly bitter saline, but not un-
pleasant taste. It is neutral in reaction,
or slightly alkaline, readily soluble in
water, dissolves in alcoholic solutions, but
is insoluble in absolute alcohol, and in
ether or fats. It is incompatible with sil-
ver salts, ferric compounds, and perman-
530
THIOSINAMINE.
been reported from thiosinaniine, espe-
cially when combined with massage, pas-
sive movements, etc. In keloids the re-
sults have not been as good, only fresh
keloids developing on old scars being in-
fluenced (Marmoiton). Hebra and others
have reported good results in scleroderma
and in chronic acne, Juliusberg in scars
from lupus, Unna in smallpox scars, Glas
in rhinoscleroma, and Castellani in my-
cosis fungoides. Various authors have
lauded its effects upon local injection in
Dupuytren's contraction (retraction of the
palmar aponeurosis), though others no-
ticed no definite improvement. It has
also been used in chronic synovitis, Neis-
wanger, for the removal of unsightly op-
erative scars, has used a 10 per cent, oint-
ment of thiosinamine in hydrated wool-
fat, combined with ingestion of 1>2 grains
(0.1 Gm.) of the drug 3 times daily. Thio-
sinamine may also be used locally in 5 to
20 per cent, admixture with soap or
plaster (Mears).
Ustimovitch has reported disappearance
in five months of a sarcoma of the neck
in a man 26 years old under 30-minim (2
c.c.) injections of a mixture of thiosin-
amine, 1 part; glycerin, 4 parts, and
water, S parts, the dose being gradually
increased.
In esophageal stenosis, thiosinamine has
been reported of value when used in con-
junction with bougies. Results in urethral
strictures have not been as good as in
esophageal. Occasional good results in
indurated conditions of the stomach, py-
loric stenosis and perigastric adhesions,
have been recorded, and as regards the
intestinal tract the remedy has been used
with some success in chronic constipation
due to bands and adhesions following
laparotomy, as well as in cicatricial stric-
tures of the rectum.
Among respiratory affections the best
results have been obtained in chronic
pleurisies without exudation, and in thick-
ened pleurae. Renon states that in pul-
monary emphysema and chronic fibrous
conditions of the lungs and pleurae thio-
sinamine perceptibly diminishes dyspnea.
Marked improvement has been noted
from it in cicatricial stenosis of the
larynx.
In chronic aortitis with stenosis and in-
sufficiency, and in chronic adhesive peri-
carditis, dyspnea is often Ijcttered by
thiosinamine (Renon). In adherent peri-
cardium with mediastinitis very marked
improvement may be witnessed. In ar-
teriosclerosis partial relief from headache
and dyspnea is sometimes afforded; the
blood-pressure may be gradually reduced
by prolonged use of the drug. Lydston
has reported a case of chronic renal dis-
ease with "phenomenally" enlarged and
hardened arteries in a man of 70 years, in
which % grain (0.012 Gm.) of thiosinamine
in a capsule 3 times a day, gradually in-
creased to 1 grain (0.06 Gm.), apparently
caused, in about 4 months, a marked re-
duction in the size and hardness of the
vessels (without any change in the blood-
pressure).
In diseases of the nervous system the
best results from thiosinamine have been
seen in cases of neuritis from scar
pressure. In some tabetics it will relieve
pain, and in sclerosing cerebrospinal af-
fections and spastic paraplegia, it some-
times diminishes contractures (Renon).
In gynecology, thiosinamine may be
tried to promote absorption of adhesions
causing uterine retroflexion and retrover-
sion, as well as of chronic inflammatory
exudates in the parametrium.
In ophthalmology, good effects have
been reported in leucoma of the cornea
following keratitis, in other forms of
corneal opacity, and in postneuritic optic
atrophy. Synechiae are improved by the
use of mydriatics with thiosinamine, which
assists in the absorption of inflammatory
exudates of the iris and choroid (Mar-
moiton). Cicatricial ectropion, symble-
pharon, and cicatricial contractions of the
eyeHds due to trachoma were found favor-
ably affected by Suker. The drug may be
administered by the customary routes or
as an eye-wash of 8 to 15 parts of thio-
sinamine and 4 to 7^ parts of antipyrin
in 100 parts of water, used for 5 minutes
twice a day. It is contraindicated in de-
tachment of the retina, vitreous opacities,
and all acute inflammatory processes.
In otologic practice, thiosinamine treat-
ment has been applied by Tousey, Ler-
moyez, and many others, in particular in
deafness due to adhesions or sclerosis of
the middle ear (with the stapes still mov-
THYMOL.
531
able and in the absence of labyrinthine
involvement). Lermoyez, introducing hot
thiosinaniine-antipyrin solution through
the external meatus every evening, and
also applying systematic massage of the
tympanic membrane twice a week, fre-
quently noted an improvement in hearing
in 2 weeks, most marked in cicatricial ad-
hesions following cured otorrheas, or
where a large perforation permitted en-
trance of the solution into the tympanic
cavity. Hitschler, giving thiosinamine in-
ternally in similar cases, together with
injections into the middle ear through the
Eustachian tube, noted improvement in
some, but failure in a considerable pro-
portion of instances. The drug has also
been used, at times with success, in aural
vertigo and tinnitus aurium. S.
THOMSEN'S DISEASE. See
Muscles: Myotonia Congenita.
THORACENTESIS. See Chest,
Injuries and Surgical Disorders of.
THORACIC DUCT, INJURIES
OF. See Chest^ Injuries and Sur-
gical Disorders of.
THORACOPLASTY. See
Chest, Injuries and Surgical Dis-
orders of.
THORACOTOMY. See Chest,
Injuries and Surgical Disorders of,
THORAX, WOUNDS AND
INJURIES OF. See Chest, Injur-
ies AND Surgical Disorders of.
THORIUM. See X-RAYS and Ra-
dium,
THREAD-WORMS. See Para-
sites: OxYURis Vermicularis.
THROMBOSIS. See Vascular
System. Sx'rgtcal Diseases of.
THRUSH. See Mouth, Lips,
and Jaws : Parasitic Stomatitis.
TUYMOL.-Thymol, U. S. P. (thy-
mol; thyniccamphor ; thymic acid; meth-
ylisopropylphcnol ), is a phenol present in
the volatile oil of Thymus vulgaris, a gar-
den-herb of Europe. Its chemical formula
is C6H3(CH3)(OH)(C3H7). It is ob-
tained commercially from oil of ajowan.
Thymol occurs in large, colorless, trans-
lucent crystals, having a thyme-like odor,
and a pungent, aromatic, slightly caustic
taste. It is freely soluble in alcohol, ether,
chloroform, glacial acetic acid, and oils,
but requires 1100 to 1200 parts of water
for aqueous solution. Its dose ranges
from 1 to 2 grains (0.06 to 0.12 Gm.).
Oleutn thymi, U. S. P. (oil of thyme),
often misnamed oil of origanum, is a
volatile oil distilled from the leaves and
flowering tops of ThyDius vulgaris and
containing, when assayed by the official
process, not less than 20 per cent, by
volume of phenols. It occurs as a color-
less liquid with a strong odor of thyme
and an aromatic, afterward cooling, taste.
It is soluble in one-half its volume of
alcohol, in 1 to 2 volumes of 80 per cent,
alcohol, and in ether and chloroform.
Dose, 3 minims (0.2 c.c), chiefly used
externally.
Thymolis iodidum, U. S. P. (thymol
iodide; dithymol diiodide) is identical
with Aristol (q. v.). Thymol salicylate
(thymyl salicylate; thymosalol; salithy-
mol), unofficial, has been used as a sub-
stitute for phenyl salicylate (salol), but
presents no advantage over the latter,
being weaker in action, though less toxic,
PHYSIOLOGICAL ACTION. — Lo-
cally, thymol is irritating, but, like phenol,
also analgesic. It is less irritant to open
surfaces than phenol, though, according to
most observers, more strongly toxic to
the micro-organisms of putrefaction. It
is less soluble in the body fluids than
phenol, and is, therefore, less rapidly
absorbed.
Taken internally, thymol acts much like
phenol, though in toxic doses it causes
less central nervous stimulation (mani-
fested in convulsions) than the latter.
Used repeatedly in doses of 20 to 30
grains (1.3 to 2 Gm.) per diem it causes
epigastric heat, at times accompanied by
diaphoresis, tinnitus, deafness, frontal dis-
comfort, diarrhea, and occasionally nausea
and vomiting. The urine is discolored
greenish or brownish. Continued inges-
tion of thymol in small doses brings about
emaciation. Large amounts depress the
central nervous system and reduce reflex
h2>2
THYMOL.
action, lower the blood-pressure and tem-
perature, and may induce fatal coma.
Only an infinitesimal proportion of in-
gested thymol is excreted with the feces
(Schultz and Seidell). This would indi-
cate that thymol is almost completely ab-
sorbed from the alimentary tract. Ac-
cording to the experiments of Seidell .
(1915) in dogs and in human subjects be-
ing treated for hookworms, however, only
one-third to one-half the amount ingested
can be recovered (as thymol glycuronate)
from the urine. The remaining one-half
to two-thirds is apparently destroyed or
temporarily fixed in the body, or is, pos-
sibly in part, eliminated through the
lungs.
UNTOWARD EFFECTS AND POIS-
ONING.—Stiles and Boatwright (1913),
administering thymol 464 times to 243
hookworm patients in doses of 5 to 60
grains (0.3 to 4 Gm.) — usually 10 to 20
grains (0.65 to 1.3 Gm.) — noted ill effects
after 205, or 44.1 per cent., of the admin-
istrations; these ill effects comprising
nausea in 66 instances; weakness, 62;
burning in the stomach, 45; dizziness or
staggering. 44; headache, 14; vomiting, 13;
burning in the throat, 8; pain in the
"stomach," 7; drowsiness, 5; sickness after
discharge from treatment, 3; and dyspnea,
irregular heart, and syncope, 1 each. In
some instances these symptoms seemed
due, in part at least, to the magnesium
sulphate used in conjunction with the
thymol.
Thymol has in several cases produced
death. In a child death has followed 15
grains (1 Gm.); yet, according to Bozzolo,
in one adult 225 grains (IS Gm.) were ad-
ministered in 12 hours without any re-
sulting symptoms of poisoning. Violent
delirium has at times been noted in
thymol poisoning.
Treatment of Thymol Poisoning. — This
consists in evacuation of the stomach with
the stomach-tube or an emetic, the giving
of a saline purgative and demulcents and
the use of respiratory and circulatory
stimulants, together with external heat,
as required.
THERAPEUTICS.— Internal and Sys-
temic Uses. — Since Bozzolo, in 1881, dis-
covered that thymol was efficient in ex-
pelling the hookworm, the drug has been
a standard remedy in uncinariasis. The
most approved plan of treatment consists
in giving one or two preliminary doses
of magnesium sulphate in the evenings
preceding the day of thymol administra-
tion, then thymol the next morning di-
vided into 2 or 3 doses, given at 6 and 8,
or 6, 7, and 8 a.m., followed at 10 .'^.m. by
another dose of magnesium sulphate. The
doses advised are 45 to 60 grains (3 to 4
Gm.) in divided amounts for an adult,
given in 5-grain (0.3 Gm.) capsules, and
7^ grains for a child of 5 years. The
treatment is repeated once a week until
the feces show absence of the parasites.
In patients already greatly weakened by
hookworm infection Stiles omits the pre-
liminary dose of magnesium sulphate and
gives 10-grain (0.6 Gm.) or slightly larger
doses of thymol 1 to 3 times at intervals.
When the patient has regained sufficient
strength by reason of the partial hook-
worm elimination thus effected, the cus-
tomary treatment with larger doses is
carried out.
Thymol has been used with success in
tapeworm parasitism by Canipi, Artault,
and others. Artault (1913) gives 4 grains
(0.25 Gm.) of the drug every morning on
an empty stomach for some daj^s. The
tapeworm is, as a rule, expelled on the
third or fourth day, but the treatment is
continued for a week to insure complete
elimination, the scolex often being passed
unnoticed. Guillon (1913) holds thjmiol
the most reliable, as well as the least ex-
pensive, of all teniafuge remedies. After
limiting the last meal on the preceding
daj- to milk, he gives in the morning 3
cachets of thymol, each containing 15
grains (1 Gm.) for male adults, 12 grains
(0.75 Gm.) for women, and correspond-
ingly smaller doses for children, at hourl}'
intervals, followed, 45 minutes after the
last dose, by 1 to 1% ounces (30 to 50
Gm.) of sodium sulphate. The patient
should refrain from going to stool until
a distinct need is felt. The effects of the
treatment are usually complete 2 hours
after ingestion of the purgative. Alcohol
and oils, including castor-oil, are to be
avoided during the treatment.
Thymol may be given internally with
benefit as an intestinal antiseptic in acute
and chronic intestinal disorders, including
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS). 533
typhoid fever and infantile diarrhea, ac- of thymol has been of service in acne and
cording to F. P. Henry, Kiissner, Testi, alopecia circumscripta.
and others. Henry's method of adminis- Hofifmann (1912) found a 5 per cent,
tration is to give the drug, prepared with solution of thymol in 60 per cent, alcohol
Castile soap, in 2- to 3- grai 1 (0.12 to 0.2 efficient as a skin disinfectant, and espe-
Gm.) doses every 6 hours. Others have cially advises its use to disinfect the mu-
used somewhat larger amounts. The drug cous membranes in operative work, not-
may act to some extent as an antipyretic ably in gynecology. The application to a
and general sedative in these cases, but mucous membrane should never exceed 2
its use in large doses for these purposes minutes, and care must be taken to pre-
alone is not warranted, the salicylates be- vent contact of the solution with serous
ing much safer. surfaces. In preoperative skin disinfection
Geronne (1915), in order to ren- the solution should be applied 1 hour and
der typhoid bacillus carriers innocuous. again 5 minutes before the operation
gives 15 grains (1 Gm.) of charcoal half (Kuhn). Contact of the solution with the
an hour before and 2 7^-grain (0.5 Gm.) perineum or scrotum is to be avoided,
thymol capsules half an hour after meals. A 50 per cent, alcoholic solution of
The charcoal is intended to delay sys- thymol applied to the hands, neck, and
temic absorption of the drug and prolong face is effective in keeping off mosquitoes,
its local action. Oil of thyme may be employed internally
Local Uses.— In catarrhal affections of in bronchial affections and as a carmina-
the upper respiratory passages the follow- tive in colic. Externally it is useful in
ing inhalant has been recommended: — pruritus, weeping forms of eczema (to
B. ThvmoUs, lessen the discharge), and as a pleasant,
PhcnoUs, fragrant antiseptic for the bath. S.
Mentholis aa gr. v (0.3 Gm.).
Olei eucalypti 5ij (60 c.c). THYMUS, LYMPHATICS,
Oleipini 5iij (90 c.c). AND MEDIASTINUM, DIS-
^' EASES OF.— FUNCTIONS of the
A teaspoonful of the above is added to THYMUS. — Many different functions
boiling water and the steam inhaled, or have been attributed to this organ. An
20 to 30 drops placed on cotton or a analytical study of all the work done in
sponge and held up to the nose. this connection, however, and personal in-
As an antiseptic mouth-wash, a 1 per vestigations have shown that each repre-
cent. solution of thymol in dilute glycerin sents a part of its actual role and that
may be employed, or, as a milder prepara- they may all be grouped more or less
tion, the official liquor antisepticus, which within the scope of the function attrib-
contains, among other ingredients, minute uted to them in the section on Thymus
amounts of thymol. Toothache may be Organotherapy (volume i, p. 792) viz.,
relieved by cleansing carious cavities and that the thymus supplies, through the
inserting a bit of cotton dusted with thy- agency of its lymphocytes, an excess
mol; to dissolve the thymol and hasten of phosphorus in organic combination
its effect the mouth may be washed out (nucleins) which the body, particularly
with lukewarm water (Hartmann). In the osseous, nervous, and genital sys-
leucorrhea injections of 1:3000 to 1:1000 tems, requires during its development and
thymol solution have proven useful. growth, i.e., during infancy, childhood,
Thymol irrigations in amebic colitis and adolescence, or later if need be.
have been recommended by Musgrave. These nucleins play another important
In eczema, psoriasis, pityriasis, and role in the body at large, that of taking
ringworm, thymol used locally has been Part in the autoprotective functions of
found of value. Addition of a little al- the body— in conjunction with other lym-
cohol facilitates the preparation of a phatic structures.
1:1000 aqueous solution, which is usually FUNCTIONS OF THE LYMPHAT-
sufficiently strong. A 2 per cent, ointment ICS. — These vessels, as is well known,
534
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
occur in every tissue and organ of the
body supplied with blood-vessels. Their
currents flow in one direction only, from
the periphery to the center, and discharge
into the great veins near the heart the
fluids which have been taken up in the
solid tissues of the body. Besides absorb-
ing from the blood the vital pabula for
the tissue-cells and acting as drains for the
waste products of cellular metabolism and
detritus of various kinds, these vessels
functionate as absorbents from the cuta-
neous surface, and are the principal car-
riers of septic materials from the periphery
to the central circulation. The serous flow
from wounds, which necessitates the em-
ployment of drainage, comes from severed
lymphatic vessels. The lymphatics are,
therefore, involved in all wounds, and
form a filter for lymph, but also a protec-
tive barrier by opposing, mainly by means
of the white corpuscles elaborated by
their glands or nodes, the multiplication
of bacteria that may have penetrated the
skin or mucosa, and to stay as long as
possible their progress toward the blood-
stream. They become the seat of a vio-
lent local inflammatory process if need
be, to protect the body at large.
Besides these important functions of
defense, the lymphatics and all normal
lymphoid tissues supply (from my view-
point), through their lymphocytes, nu-
cleins required by all tissues, notably the
bones and nerves, in which phosphorus in
organic combination is utilized. They
carry on functions of the thymus in this
particular and without the aid of the lat-
ter organ after the involution of this or-
gan at puberty or later.
ANOMALIES OF THE THYMUS
AND LYMPHATICS.— Absence of the
thymus has been recorded. This anomaly
is usually observed, however, in acephal-
ous monsters. In the latter and also in
anencephaly and hemicephaly the gland
may be abnormally small. The lymphatic
system shows so many anomalies that it is
a question whether a distribution of its
channels and glands that may be regarded
as exactly typical exists. This applies
especially to the smaller vessels which are
here and there absent, to be replaced by a
network of small channels. The more
striking anomalies are those of the duct.
It may be double; it may form a fork, the
extra arm of which opens into the right
sul)clavian vein, while the left as usual
opens into the subclavian of the corre-
sponding side, or into the right subclavian
vein, the right internal jugular, etc. Again,
a large terminal plexus may send channels
to the nearest venous channel. The im-
portance of these anomalies lies in the
fact that a wound, say of the right side of
the neck, may involve a large lymphatic
channel where, under normal circum-
stances, such should not be the case. This
teaches that in surgical work we cannot
depend upon the classic distribution of
the lymphatic vessels and nodes.
DISEASES OF THE THYMUS.
Although considerable literature on dis-
eases of the thymus is available, it may be
said that apart from status thymolym-
phaticus, treated below, very little is
known concerning them. It maj^ how-
ever, become involved in general infectious
tuberculosis, for instance. So rarely does
this disease occur primarily in the thy-
mus, that Rolleston could find but one
case on record. Syphilis with the thymus
as primary seat is also rarely witnessed.
In both these morbid processes, the thy-
mus may become the seat lesions in com-
mon with other organs. Primary tumors
of the thymus are seldom met with, but
this is compensated for by the variety of
growths which may extend to it. These
include various forms of sarcoma, espe-
cially those peculiar to the lymph-nodes
at large, and lymphadenoma, carcinoma,
cysts, and teratoma.
Inflammation and abscess are not in-
frequentl}' met in the course of certain
infections, particularly pericarditis, pleu-
ritis, pyemia, and Ludwig's angina. Irre-
spective of a true inflammatory process,
are focal hemorrhages which may occur
in the course of typhoid fever, diphtheria,
and the exanthemata. These are impor-
tant in the sense that they may become
starting points for fibrous areas which
impair the functions of the organ suffi-
ciently in some cases to inhibit the
physical and mental development of the
child and to so reduce the nutrition of the
osseous system as favor the development
of rhachitis and other osseous disorders.
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS). 535
ENLARGEMENT OF THE THY- tioii and somewhat counteracted by
MUS AND LYMPHATICS. lying on the side or sitting up and
This condition is not uncommon, leaning forward. The stridor may
particularly in children. It is usually virtually cease after the crying or
termed status lymphaticus, but as coughing paroxysm is over, or it may
shown in the present article practic- persist in the form of an inspiratory
ally all the symptoms are due to the wheeze, which appears greater at
thymic enlargement in adults, as well times soon after nursing or feeding,
as in children. The term status thy- It may be stationary or progressive
micolymphaticus is, therefore, to be wntil a condition approaching asthma
preferred, and will be used in the is initiated. An acute infection, espe-
present to cover both supposedly cially diphtheria, pertussis, and bron-
different disorders. chopneumonia, is often the starting
point of thymic stridor.
STATUS THYMICOLYMPHATI- Thymic Asthma.— This condition,
CUS. also known as Kopp's asthma, may
SYMPTOMS. — The salient symp- occur as a progressive aggravation of
tom of thymic enlargement is diffi- the former, and may end in death,
cult respiration, both during inspira- Sometimes, however, it comes on
tion and expiration, but particularly without antecedent symptoms, and
marked during the former. The in- resembles closely violent attacks of
tensity of the symptom varies, and, asthma, with inspiratory stridor, at-
although they may merge into each tended with cyanosis pallor, inspira-
other, three phases have been recog- tory laryngeal stenosis, sometimes
nized: thymic stridor, thymic asthma, accompanied by spasm of the glottis,
and thymic death, each of which may retraction of the suprasternal space,
occur independently of the others. and of the scrobiculus and thorax.
Thymic Stridor, — This form, which The child throws its head backward
is often congenital, may become and shows all the signs of impending
manifest soon after birth, during cry- suffocation, with dilated pupils, weak
ing or screaming, and is aggravated and rapid pulse, etc. In some cases
when the infant throws its head there is also marked dysphagia. Such
backward in doing so. It tends to an attack may pass off completely,
suggest the presence of a foreign or considerable stridor may persist,
body, and may give rise to a percep- even though respiration appear nor-
tible wheeze, which may develop into mal. Again, repeated attacks may
a suction sound, until it suggests, occur in rapid succession, becoming
with the accompanying symptoms, gradually more intense until death
including retraction of the supraster- supervenes. Temporary, or even per-
nal notches, an attack of croup — for manent, recovery may occur, but, un-
which it was often taken formerly, fortunately, such cases are rare.
Rarely, however, the difficulty is Thymic Death. — Under this head
most marked during expiration, and are included cases in which death oc-
then the latter tends to be vibratory curs suddenly without previous his-
or saccadee in character. The stridor tory of thymic asthma, the thymus
is aggravated by the recumbent posi- being found sufficiently enlarged
536
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
post mortem to compress the trachea,
the recurrent laryngeal, the vaf^us,
the great vessels of the upper thorax
and lower cervical region, and the
right auricle. Thymic death occurs
not only in children, but also in
adults, especially in the latter during
coitus, dancing, swimming, etc., and
at all ages during or after intense
emotional excitement, anger, fright,
anesthesia, slight operations, the ex-
traction of teeth, etc. In most in-
stances of thymic death, however, the
victim is a child found dead in bed —
doubtless as a result of asphyxia, due
to tracheal stenosis, laryngeal spasm,
or cardiac paralysis — with an en-
larged thymus, found at autopsy, as
sole evidence. Such cases may be the
source of unwarranted accusations of
criminal suffocation, and an autopsy
should always be performed if pos-
sible.
[The mechanical factor cannot be de-
nied in the presence of the considerable
evidence accumulated in recent years.
Thus, the asphyxia of thymic asthma was
completely relieved by Chevalier Jackson
when he exposed the gland and lifted it
away from the trachea. Various sur-
geons have also noted that compression
and kinking, of the trachea could be pro-
duced by the thymus, immediate relief
following restoration of its normal shape.
In a case of Clessin's a pin could be in-
troduced with difficulty through a tracheal
constriction caused by thymic pressure.
Considerable additional evidence to this
efifect is available. S.]
An important feature of the disease
in point, in view of its fatality in a
large proportion of cases, is the
recognition of subjects who are liable
to it. While some show no symptom
capable of affording a suspicion of
such a proclivity, the majority do.
These have been grouped under the
general term of status lymphaticus:
status thymicolymphaticus. While
the former indicates that the lym-
phatic glands may be enlarged with-
out there being enlargement of the
thymus, it is likewise true that
thymic enlargement may be present
irrespective of any involvement of
the lymphatics. We have, therefore,
two groups of symptoms to iden-
tify :—
Thymic Symptoms. — An enlarged
thymus may usually be discerned by
determining the area of dullness gen-
tle percussion affords.
As shown in the annexed plate this
area may either be an irregular triangle
or heart-shaped, with its base covering
the sternoclavicular articulation and its
apex somewhere about the third rib over
the base of the heart. The boundaries of
the area of dullness extend beyond the
sternal lines on each side, but practically
always more to the left, where the dull-
ness is usually most marked than to the
right. If in this location the dullness ex-
tends Yi inch or more beyond the sternal
line, enlargement of the organ is prob-
able; if, besides this, the dullness can be
traced across the sternum, and also ob-
tained to the right of this bone, the pres-
ence of a greatly enlarged gland is prob-
able. Bulging of the upper part of the
sternum and enlarged veins over the
chest (see colored plate) are sometimes
witnessed. Laryngoscopy and tracheoscopy,
by enabling an expert to locate the site of
pressure, are very helpful.
The X-rays, skiagraphy, are useful to
establish the diagnosis beyond a doubt.
A distinct shadow (following out the line
of dullness, as a rule) on the left of the
sternum, sometimes as far down as the
ensiform cartilage and over the pericar-
dium, is obtained in positive cases.
Auscultation is sometimes of use
to detect pressure on the trachea, the
edge of the intratracheal projection
giving rise to a friction sound when
impinged upon by the circulating air
during both inspiration and expira-
Venous Engorgement Due to Enlargement of the Thymus. (Browning.)
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
537
tion. A distinct wheeze may some-
times be detected. Sometimes this
sound is reduced in intensity by caus-
ing the patient to lean forward dur-
ing auscultation.
As regards general symptoms
traceable to the thymus, their char-
acter depends upon the pathological
condition present. In some there is
hyperplasia of the organ.
[As I have urged elsewhere, a normal
gland may greatly enlarge after copious
feeding. Such a gland, when its involu-
tion has been delayed, or, when it is the
seat of hyperplasia, may, after such a meal,
become a source of danger if from any
cause, coitus, violent exertion, dancing,
etc., the resulting rise of blood-pres-
sure further increases the size of the or-
gan. S.]
In certain subjects, the enlarged
thymus is no longer composed of its
normal elements, but has degener-
ated into a mass of adipose tissue —
virtually a foreign body. Such a
gland, in infancy, childhood, and even
adolescence, often is inadequate func-
tionally, and gives rise to symptoms
of thymic insufficiency.
These in their mild degrees are: I.
Deficient development of the osseous sys-
tem, bad teeth, etc., sufficient in some in-
stances to suggest the presence of a mild
form of rhachitis, due to a deficient as-
similation of calcium, a function with
which the thymic nucleins are closely
connected. 2. Mental indolence and even
backwardness, due to the same deficiency
of nucleins, which during development
are supplied in excess to the nervous sys-
tem including, of course, the cerebral
cells. 3. A low relative lymphocyte
count, owing to the inadequate formation
of thymocytes — the thymic lymphocytes.
Closely allied with the functions of
the thymus are those of the thyroid
apparatus. If, as is the case in some
patients, there is insufficiency of the
former, more or less insufficiency of
the thyroid may also prevail. Hence,
the fact that in some cases of status
thymicolymphaticus various symp-
toms of hypothyroidism, sometimes
with goiter, appear. There is adipo-
sis, or, rather, thickening of the skin
with edema, suggesting the larval
type of myxedema ; even the brain
has been found edematous post mor-
tem in some cases. The complexion
is pale and pasty, and the patient
appears anemic.
Eczema is frequently observed and
other eruptions occasionally. An-
other frequent accompaniment of
persistent thymus is infantile devel-
opment of the genitalia and deficient
hair growth. This, likewise, is ob-
served in status thymolymphaticus.
Lymphatic Symptoms. — The super-
ficial lymph-glands, notably those of
the neck and axilla, are more or less
enlarged. In some cases but two or
three lymph-nodes may be hyper-
plasic ; in others, as shown post mor-
tem^ practically all are involved, the
bronchial, intestinal, mesenteric, and
retroperitoneal in particular.
[From my viewpoint the hyperplasia of
the lymph-glands indicates a compensa-
tive hyperactivity to supply the organism
at large the lymphocytes and nucleins
which the hypoactive or functionless thy-
mus fails to furnish in adequate quantity,
and simultaneously to break down as
much as possible whatever bacterial or
chemical poisons may be present. When
their protective role becomes inadequate
we may have the so-called attacks of
"lymphotoxemia," which sometimes occur
periodically, as do epileptic convul-
sions. S.]
The tonsils and lingual tonsil are
usually enlarged, and the postnasal
space is the seat of adenoids. The
spleen is sufficiently increased in size
in some cases to become palpable.
538
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
and show, under percussion, a con-
siderably increased outline.
On the whole, when the thymus and
thyroid are excluded from the pathology
of status thymolymphaticus, and the
symptoms of secondary or concomitant
deficient activity of other ductless glands
are taken into account, there is little
left, in so far as the lymphatic glands are
concerned, beyond their compensative en-
largement and any consequence this may
entail.
A child or adolescent showing any
of the above morbid phenomena and
who is subject to attacks of dyspnea
on exertion or of laryngismus stridu-
lus is in danger of thymic dyspnea,
which may unexpectedly assume pro-
portions leading to fatal asphyxia.
PATHOGENESIS.— That pres-
sure by the thymus causes the
stridor, and even fatal asphyxia, is
held by most authorities. Con-
versely, Paltauf, Friedleben and their
school have attributed all the morbid
phenomena to a toxemia, many clin-
icians and investigators, including
Hart, Rachford, and Pinde, having
identified the pathogenic poison as an
accumulation of toxic wastes due, in
turn, to excessive secretory activity
of the gland. It is to the action of
these poisonous wastes that they at-
tribute the swelling of the lymphatic
nodes and tissues. Klose and Vogt,
on the other hand, attribute the mor-
bid phenomena, even thymic death,
to an acid intoxication. The enlarge-
this is as follows in the majority of
cases: The presence of an overactive thy-
mus, whether enlarged or not, in a child,
or of persistent thymus after puberty
when its active participation in the de-
velopment of the body should virtually
have ceased, means a corresponding pro-
duction of thymic lymphocytes and nu-
cleins over and above the needs of the
body. Metabolism being unduly acti-
vated, toxic wastes accumulate in the
blood which provoke the toxic symptoms
observed in status thymicolymphaticus.
These toxic symptoms may also be
brought on by the toxins of certain
diseases.
The excessive production of nucleins
increases correspondingly the functional
activity of all tissues, including the thy-
roid and adrenals. The excess of adrenal .
secretion produced gives rise to the con-
tracted heart, aorta, and peripheral arteries
noted in all cases by Bar*-el and the dila-
tation of the superficial veins. The over-
production of the thyroid secretion is so
marked, owing to the hyperplasia wit-
nessed— sufficient in some cases to give
rise to goiter and exophthalmos — that
some clinicians have emphasized the re-
semblance of the syndrome in some
cases to that of Graves's disease.
Conversely, where, as is occasionally
observed, the glandular hyperplasia has
been followed by degenerative changes,
atrophy, fibrosis, etc., we may encounter
symptoms of larval myxedema and even
Addison's disease. A thymus which
though enlarged may have undergone adi-
pose transformation may also awaken
symptoms of status thymicolymphaticus,
including those due to thyroid and ad-
renal deficiency.
TREATMENT.— In view of the
foregoing data the treatment should
nient of the lymphatic glands, which be governed by the nature of the
occurs as a complication of various
diseases, is but a counterpart of the
foregoing, the only difference being
that a toxin of exogenous pathogenic
organisms fills the role of toxic.
All these views, apparently so contra-
dictory, are harmonized by my own inter-
pretation of this, morbid process. Briefly,
pathogenic process. The one effect-
ive agent is X-rays, but if its use
coincides with an enlarged thymus
rendered deficient through focal de-
generative changes, with secondary
cretinism, myxedema or Addison's
disease, it will do more harm than
good.
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
539
The untoward efifects attributed to this
method of treatment appear in some
cases at. least to have been due to lack of
discrimination on this score. Such cases
are apt to show a general leucopenia,
more or less marked rhachitic or cretinic
symptoms. Where, on the other hand,
such symptoms are absent and there is a
relative lymphocytosis or even leucocy-
tosis, the X-rays may prove effective and
even curative, as shown by numerous
recorded reports.
Complete thymectomy is inadvis-
able in young children, owing to
the danger of interfering with their
development, — skeletal, mental, and
sexual. After puberty, especially in
adults, the organ is virtually a mass
of adipose tissue acting as foreign
body ; the operation does not offer
the same dangers. Partial subcap-
sular thymectomy, ligation of some
of the thymic arteries, exothymo^
pexy, i.e., raising of the organ and
stitching it to the sternum, which
may readily be combined with partial
thymectomy, are available for chil-
dren, and are usually very effective.
The organ being located immediately
below the upper edge of the sternum,
bulging out even during dyspneic
paroxysms, it may easily be reached
for stitching. In some cases, how-
ever, resection of the manubrium
sterni is necessary for partial thy-
mectomy.
Thymectomy Technique. — As performed
by C. H. Mayo this procedure is as fol-
lows: A curved transverse incision, which
includes skin and platysma, is made low in
the neck. The inner borders of the at-
tachments of the sternomastoid muscles
are incised; the sternohyoids are cut
across. If the thymus be enlarged, it is
seen as a pinkish gland projecting into the
neck from behind the sternum, at least
during respiration. The gland may now
be caught gently with clamps and drawn
upon until the fingers can be used for
direct traction. The vessels are not large,
the fascia which incloses the gland is
loose, and there is but little difficulty in
clamping and ligating as one lobe is re-
moved. If it be deemed necessary, the
second lobe can be elevated and a portion
of it removed. In a case operated on in
the Mayo cliinc only one lobe was re-
moved. The relief was immediate and yet
there were occasional symptoms of pres-
sure for a number of days. The cure was
ccmplete. A drain should not be used
unless indications for drainage are urgent.
In case it be advisable, a folded strip of
rubber tissue should suffice for the few
hours during which the procedure may be
necessary.
Deep intubation is very effective
for the alleviation of asphyxic phe-
nomena if the end of the tube reach
below the seat of obstruction ; short
tubes are obviously useless. Tra-
cheotomy is effectual under similar
conditions, particularly if asphyxia is
impending, when oxygen inhalations
are also employed. Cold compresses
over the thymus and the upright
position tend to decongest the thy-
mus, and to relieve the dyspnea.
The general measures are ineffect-
ual unless a clear indication for them
prevails. Thus, in the presence of
myxedematous symptoms, thyroid
gland is helpful. In others the
iodides will prove beneficial if a his-
tory of syphilis, inherited or acquired,
be obtained, and where eczema oc-
curs. In the presence of rhachitic
symptoms, calcium lactate w^ith thy-
roid gland in small doses, often prove
beneficial. It is in these cases also
that thymus gland proves useful.
Any abnormal condition found
should be remedied, remembering,
however, that anesthesia and opera-
tions readily induce death in such
cases, and that deep intubation or
tracheotomy may become necessary
at any moment. The parents should
540
THYMUS, LYMPHATICS, AND MEDIASTINLM (SAJOUS).
also be apprised of the dangers of
operative procedures in such cases.
Prevention of Paroxysms. — As
stated elsewhere, copious feeding'
tends to cause enlargement of the
thymus.
In infantile marasmus, on the other
hand, the thymus is the seat of so-called
atrophy, but one which promptly disap-
pears under appropriate and sufficient food.
An enlarged thymus, moreover, may be
found completely collapsed post mortem.
This indicates that the organ structur-
ally resembles a sponge which readily en-
larges under suitable conditions, which in
the cases in point may menace the pa-
tient's life.
Under these conditions, cases in
which thymic stridor or asthma pre-
vail should be kept under low diet, in
so far as meats, eggs and other sub-
stances rich in nucleoproteins are
concerned. Anything capable of rais-
ing the blood-pressure, such as vio-
lent exercise, excitement, crying,
screaming, etc., should be avoided.
Cold or hot baths, sea-bathing, may
also cause sudden thymic death. A
suitable position, that in which the
little patient breathes with the great-
est freedom, whether this is sitting
up, lying on the side — the favored
positions — or on the back, shoiild be
sought, and the patient encouraged to
retain it. Throwing of the head
backward favors the production of
attacks. Unusual care should be
taken to assist children having an en-
larged thymus, in the avoidance of
acute infections, and thereby hyper-
emia of the gland. Another impor-
tant feature is to avoid constipation
by suitable' measures, and, if possible,
to insure for the patient an out-of-
door life in a mild climate, where
catarrhal disorders of the respiratory
tract may be prevented.
DISEASES OF THE LYMPHAT-
ICS.
The functions of the lymph-glands, to
act as filters for the lymph and protect
the blood against all harmful agents that
may come from the cellular spaces or
penetrate the lymphatic stream through
the cutaneous covering, bring them into
contact, as may be surmised, with a multi-
tude of pathogenic factors. Under normal
circumstances they protect the body with-
out showing, through an increase in size,
evidence of overactivity. When, however,
an unusual reaction becomes necessary, en-
largement occurs and persists as long as
needed to successfully oppose the patho-
genic agent. Exaggeration of this activity
is the underlying cause of most of these
diseases.
LYMPHADENITIS.
This is an inflammation of the
lymph-glands due to violent defen-
sive activity provoked by an accumu-
lation in them of pathogenic bacteria
or poisonous substances. It may re-
cede when the invasion of these mor-
bid agents ceases, or proceed to sup-
puration with necrosis of the lym-
phoid elements, when its phagocytic
cells are overcome by the pathogenic
agent.
Lymphadenitis may be acute or
chronic. It may occur as a result of
virtually any disease due to bac-
teria or parasites. Even vaccinia
may awaken a severe reaction of
the axillary glands, though suppura-
tion here is due to infection of
the vaccine lesion. Rubella is an-
other mild disorder in which lym-
phadenitis may occur. Among the
parasitic diseases in which lympha-
denitis is witnessed are malaria and
trypanosomiasis may be mentioned.
Buboes, whether gonorrheal or chan-
croidal, or as features of bubonic
plague, probably represent the most
aggravated forms of lymphadenitis.
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS). 54I
The various forms of this disease, edema of the limb is present, owing
including acute and chronic lym- to involvement of the deeper layers
PHADENiTis and TUBERCULOUS LYMPHA- of the vessels and their obstruction
DENiTis, have been reviewed in the by the inflammation. Erysipelatous
article on Adenitis in the first vol- patches not infrequently appear along
ume, page 374, to which the reader the course of the inflamed absorbents,
is referred. Tuberculosis of the and coalesce until they are of consid-
BRONCHiAL GLANDS is considered be- erable size. If the deeper-seated
low with the diseases of the medias- lymphatics are first implicated, the
tinum. glandular signs are first observed; if
the inflammation continues to be con-
LYMPHANGITIS. fined principally to the deep vessels,
Lymphangitis, also termed angio- it gives rise to a great and brawny
leucitis, is an inflammation of the swelling of the limb, with much, if
lymphatic vessels due to infection by any, superficial redness. The consti-
organisms and toxic materials of tutional symptoms, at first of an ac-
various kinds. It is usually divided tive form, may gradually subside into
into two forms, capillary or reticular the asthenic type.
lymphangitis, when the superficial The disease usually terminates in
lymphatic capillaries are alone af- resolution at the end of a week or ten
fected, as in erysipelas; and tubular days; exceptionally it may terminate
lymphangitis when the larger ducts in erysipelas. In some cases limited
and trunks are involved in the mor- suppuration may take place or a
bid process, as is the case after snake- chain of abscesses form along the
bites, septic wounds, etc. course of the lymphatic vessels and
SYMPTOMS. — What constitu- glands. In other cases, after the dis-
tional symptoms appear are depend- appearance of the inflammatory
ent upon the severity and extent of symptoms, a state of chronic and
the infection. The patient may be rather solid edema (lymphedema) is
seized with rigors, followed by fever, left, giving rise to a species of false
attended, not infrequently, by vomit- hypertrophy resembling elephantiasis
ing and diarrhea. These symptoms in some cases. Lymphadenitis may
may precede the local signs of the occur as a complication, owing to de-
disease by 12 or 14 hours, but fre- position in the glands of septic or in-
quently accompany them. Examina- fective materials, and give rise to pain
tion of the region, if superficial, will and swelling, sometimes suppurative,
reveal a number of fine, red streaks, accompanied in some cases by chills
at first scattered, but gradually ap- and even septic fever. More rarely
proaching one another so as to form death results from erysipelas, py-
a distinct band, about an inch in emia, or from secondaiy abscesses.
breadth, running from the affected especially in patients with impaired
part along the inside of the limb to constitution, in whom the disease has
the neighboring lymphatic glands, been extensive and has become asso-
which have become enlarged and ten- ciated with low cellulitis,
der. The band itself feels somewhat DIAGNOSIS.— The diagnosis of
doughy and thickened. More or less superficial lymphangitis is usually
542
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
easy. The tender red streaks indi-
cate the tubular variety. The diffuse
redness of the reticular form, with its
superficial edema, tenderness, and
constitutional symptoms, differentiate
it from erythema or dermatitis. From
phlebitis it is distinguished by its
superficial redness, the inflammation
of contiguous glands, and the absence
of the knotted corded state which be-
longs to an inflamed vein ; the pain
and fever are usually less in phlebitis.
Inflammation of the deep lymphatics
is not easily differentiated from cel-
lulitis; if glands are early involved,
if lymphatic edema is present, if
patches of reticular lymphangitis ap-
pear at points of anastomosis with
deeper trunks, inflammation of the
deep lymphatics may be assumed.
ETIOLOGY.— The etiology of the
reticular variety has already been re-
ferred to. Tubular lymphangitis is
always caused by the entrance into
the aft'ected duct of bacteria and bac-
terial products of more than usual
virulence. The absorption of septic
matter from infected wounds always
follows, but does not generally cause
an extensive inflammation of the
lymph-channels ; a lowered vitality,
asthenia, etc., which entail defective
defensive activity, predispose to it.
Frequent irritation of the infected
wound and retention of septic secre-
tions in it are frequently exciting
causes. Trivial wounds may be in-
fected with virulent septic material
(snake-bites, dissection wounds).
Bathing the hands in putrid fluid for
some time, without any discernible
breach of surface, has been followed
by lymphangitis.
TREATMENT. — Lymphangitis
being a septic disease, the treatment
should be conducted on antiseptic
lines. The original wound, through
which the septic virus has gained en-
trance into the lymphatic circulation,
should be thoroughly cleansed and
disinfected with iodine, ichthyol or
blue ointment. The affected limb
should be elevated and kept quiet
and warm. Free incision will relieve
any tension, and is advised even be-
fore the appearance of suppuration.
All foci of suppuration should be
evacuated by" incision, disinfected,
and drained. Extirpation of the
gland is sometimes necessary. Com-
presses wet with an aqueous solution
of bichloride of mercury (1:2000)
should be laid upon the affected
parts, the compresses being remoist-
ened as they begin to dry, and reap-
plied until the inflammation has en-
tirely disappeared.
The constitutional symptoms usu-
ally demand more or less attention,
especially in the direction of support.
Quinine and nux vomica are helpful
in this connection. Free elimination
should be insured by means of
aperients. Opiates may be needed to
relieve pain, but their use should be
avoided if possible, as they diminish
the secretions. The mineral acids
and bitters are useful, as digestion is
usually impaired. Nourishing food
should be freely administered, and
stimulants, such as milk-punch, given
in the more severe cases. Bandaging
and massage will best overcome any
edema which may be left after the
acute symptoms have subsided.
LYMPHANGIECTASIA; LYM-
PHANGIOMA.
While lymphangiectasia means dila-
tation of the lymphatic vessels due to
obstruction, lymphangioma means an
advanced stage of lymphangiectasia
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS). 543
in which the dilatations are large and a result of rupture or incision of the
tend to form a tumor. lymph-radicles or smaller trunks is
SYMPTOMS. — Lymphangiectasia known as lymphorrhea. An excessive
may occur in the superficial and deep discharge of lymph, in either manner,
lymphatic networks and in the lym- provokes symptoms of general debil-
phatic trunks. The inner side of the ity like those induced by hemorrhage,
thigh is the favorite location for this Rupture of a dilated lymphatic along
disorder, but it has also been seen in the urinary tract and the consequent
the anterior abdominal walls, about lymphorrhagia produce chyluria-. If
the ankle- and elbow- joints, and on the tunica vaginalis testis be the seat
the prepuce. In the superficial lym- of a lymphorrhagia, chylocele results,
phatics this condition appears first as Lymphangiomata, varicose lymph-
small elevations, giving the skin an vessels, may form lymphatic nevi,
appearance like the rind of an orange ; which are slightly raised from the
subsequently it appears as small vesi- skin, and are either colorless or pink-
cles covered with a thin layer of epi- ish, giving off lymph when punc-
dermis. The larger lymphatic trunks tured. These are due to blocking of
are, at the same time, frequently af- the lymph-channels of the afifected
fected similarly. The vessel may area. Varicose swelling of the lym-
either be dilated cylindrically into phatics in the inguinal regions may
round, beaded enlargements, often simulate hernia. In any region, how-
semitransparent, and but slightly ever, it may form a tumor, caz'ernous
compressible, or ampullae may be lymphangioma, the spaces of which
formed on them, giving rise to more are filled with lymph. Dilatations of
or less soft swellings, fluctuating un- the blood-vessels may coexist with
der the finger. There is usually those of the lymphatics, producing a
some edema either from obstruction mixed tumor. When such mixed
of the lymphatics or from the im- growths occur in the tongue they
peded flow of the lymph ; the afifected produce an enlargement of the organ
parts may become swollen by a hard, known as macroglossia; when occur-
compact, brawny edema which is not ring in the lips, this enlargement is
reducible by position or pressure, known as macrocheilia.
lymphedema. This condition may lead ETIOLOGY. — Both lymphangiec-
up to elephantiasis (q. z'.). Areas of tasia and lymphedema are often
lymphangiectasis are liable to attacks congenital owing to defective devel-
of erysipelas, doubtless owing to the opment or to obstructions to the
diminished resistance they offer to lymph-stream, of a mechanical or in-
pathogenic organisms. flammatory nature, during intra-uter-
In a majority o-f recorded cases a ine life. Inflammation and throm-
discharge of lymph, lymphorrhagia, bosis are the usual causes of the
has been observed, caused by a rup- acquired variety, resulting in a dila-
ture of the vesicles. It varies in tation of tlie radicle and primary
amount and duration, and is apt to channels, with lymph-stasis and ede-
be intennittent in character. An- ma of all the tissues supplying the
other form of lymph-discharge which narrowed or occluded vessels. Cica-
occurs normally from all wounds as tricial contraction, pressure by tumors,
544
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
or occlusion of the lympli-channels
by tuberculous or cancerous material
may also be etiological factors in this
condition. In a lar^^e class of cases
occurring' in tropical regions, the
presence of the Filaria sanguinis
hominis in certain lymphatic vessels
has been shown to be the cause of
lymph-thrombosis and inflan'tmation.
TREATMENT.— Circumscribed
dilatations and isolated cystic en-
largements may be removed by ex-
cision. Massage, the elastic bandage,
and support in an elevated position
will give relief in the diffused dilata-
tions and edema due to persistent ob-
structive causes, in cases in which
collateral lymphatic circulation may
become sufficiently developed to re-
lieve the stasis ; when such collateral
circulation is not developed and sta-
sis is not relieved, these means will
not suffice. If all other means fail,
ligation of the main artery of supply
to the limb would be justifiable. In a
few recorded cases rapid improve-
ment has followed ; in others none.
Amputation may be done, if the con-
dition is confined to an extremity and
causes serious annoyance. Similar
tumors involving the genitals should
be excised, care being taken to pre-
serve the penis and testes by dissect-
ing them out of the diseased mass.
The use of the elastic bandage about
the base of the growth will prevent
hemorrhage during the operation and
facilitate the dissection.
TUMORS OF THE LYMPHATIC
SYSTEM.
Tumors of the lymphatic system
include both benign and malignant
growths. Among the former may be
mentioned the lymphadenoma, which
is limited to the gland itself, and is
due to simple hyperplasia of the
glandular elements. The more com-
mon form, however, is the lymphan-
gioma, which comprises various nevi,
moles, etc., of the skin and tongue.
The cystic tumor occasionally ob-
served on the neck, hygroma, cys-
ticum, colli, and the lymphangioma-
tous cysts, which occur on the arms,
trunk, mesentery and thighs, are con-
genital, as a rule, and occasionally in-
terfere with delivery owing to the
large size.
The malignant growths include
Hodgkin's disease, or pseudoleukemia
(treated in full, page 346, in the sixth
volume). Another growth of this
class not infrequently met with is the
lymphangioma hypertrophicum, or
fleshy wart, which may arise from
the lymph-space of practically any
tissue. These growths may, and usu-
ally do, run a benign course ; but
they occasionally undergo malignant
change, particularly in serous mem-
branes. Lymphosarcoma or sarcoma
of the lymphatic glands is occasion-
ally observed. In its early stages it
differs little from other glandular hy-
pertrophies, but later it manifests its
malignant character by involving ad-
jacent tissues and by the appearance
of secondary deposits in the various
internal organs.
As is well known, the lymphatic
vessels spread carcinomatous and
other cells, thus causing secondarv
growths of the lymphatic glands.
These, however, are reviewed under
the headings of the causative dis-
eases.
TREATMENT.— In all these dis-
eases excision should be resorted to
where possible, especially where the
possibility of malignancv present or
remote exists. Electrolysis and X-rays
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
545
have proven to be the most active tonsils and the pharynx may be con-
measures for the removal of benign gested and the lymphatic tissues
growths when surgical intervention is swollen, but the throat symptoms are
refused or is impracticable. Various usually of short duration. The gland-
measures employed in the treatment ular enlargement appears on the sec-
of angiomata (g. v.) may also prove ond or third day, and while it lasts
efficient. In lymphosarcoma, Coley's the glands, especially those along the
fluid, }A minim (0.03 c.c), gradually border of the sternocleidomastoid
increased until 10 minims (0.6 c.c.) muscle, may vary in size from a pea
are injected into the growth, have to a goose-egg. The glands are pain-
given good results (Spencer). Ra- ful to the touch or pressure, but there
dium is recommended by Kelly and is rarely any redness or swelling of
Burnam, Turner, Abbe, and others, the skin covering them, though there
in this disease. Benzol was found ef- may be, occasionally, some puffiness
fective by Moorhead, 1 dram (4 c.c), of the subcutaneous tissues of the
rapidly increased to 5 drams (20 c.c.) neck and a slight difficulty in swal-
being given, with X-ray exposures lowing. The submaxillary, axillary,
inguinal, mesentery glands, the liver
and spleen may also be enlarged and
twice weekly.
GLANDULAR FEVER.
This is a contagious and sometimes
epidemic disease of children and de-
bilitated adults, characterized by a
marked febrile movement, and en-
tender.
The muscles of the neck may
be painful and stifif. When the tra-
cheal and bronchial glands are in-
, ^ 1^1 f , volved there may be a feehng of dis-
largement and tenderness of the , . , , . ,
comfort m the chest, with a spas-
miodic cough. There is usually
marked pallor, though the blood-
count may show no abnormality.
The glandular swelling usually con-
tinues two or three weeks. The com-
plications reported in this disease are
suppuration of the swollen glands,
hemorrhagic nephritis, acute otitis
media, and retropharyngeal abscess.
cervical Imphatic glands, and some-
times of the axillary, inguinal, me-
diastinal and mesenteric glands.
In an epidemic of glandular fever that
occurred among the inmates and employes
of the Northern Indiana Hospital for the
Insane, in the winter of 1904-5, the notable
features were, according to F. W. Ter-
flinger, Logansport, Ind. (Jour. A. M. A.,
March 7, 1908), the number of persons at-
tacked (150) and their ages, ranging from
18 to 80. This disease has been considered ^he convalescence, as a rule, is quite
a_ disorder of childhood. Sex, age, and slow, but on the whole the prognosis
occupation had no influence, but in adults is favorable,
complications and sequelre were rare. ETIOLOGY.— Although doubtless
SYMPTOMS. — The onset is sud- due to some pathogenic organism, it
den, pain on moving the head and is doubtful whether any specific germ
neck and sometimes chills being, as can be incriminated. The prevailing
a rule, the first noticeable symptoms, view is that pyemic infection with
There may be some abdominal pain, the streptococcus as main agent un-
accompanied by nausea and vomit- derlies the disease, and that the main
ing. The temperature ranges from source of infection is the upper
101° to 104° F. (38.2° to 40° C). The respiratory tract.
8-35
546
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
TREATMENT.— The treatment is
on the whole symptomatic, but from
my viewpoint small doses of calomel
at the onset tend to shorten the dura-
tion of the disease by enhancing the
bactericidal and antitoxic power of
-the blood and its phagocytic cells.
Locally, belladonna ointment, or guai-
acol, painted over the swollen glands
seem to give the best results. While
the bowels should be kept free, mild
aperients are alone necessary, as act-
ive catharsis tends to debilitate. Sa-
line solution enemas are alone neces-
sary in most instances. The strontium
salicylate has been recommended to
combat directly the pathogenic agent
or agents.
MEDIASTINUM, DISEASES OF
THE.
The diseases of the mediastinum, the
space formed by the sternum in front, the
vertebral column, from the fourth dorsal
down behind, the diaphragm below, and
the pleura on each side are considered in
the present connection because most of
the tumors which grow therein start from
remnants of the thymus, while its lym-
phatic glands are, of all its structures,
those most frequently diseased. These are
with relative frequency the seat of tuber-
culosis, of abscesses which may compro-
mise life.
ACUTE AND CHRONIC ME-
DIASTINITIS.
Inflammation of the connective,
adipose and glandular tissues ^vhich
surround the mediastinal organs may
be acute or chronic.
Acute mediastinitis may occur as a
result (1) of traumatisms, blows upon
or crushing of the chest or back,
penetrating wounds, etc. (see Chest,
Injuries of), which often lead to the
formation of abscesses that are dan-
g-erous to life, because the mediasti-
num is a closed space surrounded by
vital organs, and difficult of drainage ;
(2) of extension of neighboring in-
flammatory processes of the lungs
and pericardium, especially in acute
pericarditis (see Mediastinopericar-
ditis in the article on Heart and
PericardiUxM, Diseases of), lobar
pneumonia, acute pleurisy and peri-
tonitis— the diaphragin in the latter
disease being the pathogenic inter-
mediary— acute osteomyelitis of the
chest- walls ; tracheal, esophageal and
bronchial abscesses, ulcerations, etc.,
which open into either mediastinal
space; and (3) of metastasis, such as
may occur in pyemic and infectious
pyemia, septicemia, erysipelas, ty-
phoid fever, smallpox, etc. This pro-
cess represents, in some cases, but an
extension of a general lymphadenitis,
being restricted to the mediastinal
lymph-glands.
Chronic mediastinitis may occur as
a sequel of the acute form, but
the most frequent cause of chronic
mediastinitis is tuberculosis of the
mediastinal lymph-glands — the tuber-
culous lymphadenitis of this region
— occurring as a complication of pul-
monary or osseous tuberculosis (espe-
cially in Pott's disease). Cancer may
also lead, probably through metas-
tasis to chronic mediastinitis. Syph-
ilis is, next to tuberculosis, the most
frequent cause of this condition and
in adults probably the most usual
etiological factor, when aneurism,
which often involves the medias-
tinum, is taken into account.
These various morbid conditions
lead to the formation of granula-
tions, fibrous adhesions, etc., and the
resulting compression upon, con-
striction or distortion of, the vari-
ous structures the mediastinal spaces
contain, the thoracic duct and lym-
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS). 547
phatic glands, the mediastinal veins "burning-," — probably due to reflex
and rarely the esophagus and trachea, hyperchlorhydria, — and some dyspha-
SYMPTOMS. — Acute mediasti- gia, being about all the patients can
nitis, unless it be due to injuries, is recall. Or, distressing symptoms
difficult to recognize when mild, such as dyspnea, marked cyanosis,
When the inflammatory process is severe dysphagia, due to pressure of
severe or widespread in the areolar enlarged glands on the trachea or
tissue of the cavity, local symptoms upper bronchi, may occur; again,
may be identified. The most impor- laryngeal symptoms such as hoarse-
tant of these at first is oppression in ness, laryngeal paralysis, unequal
the chest, then throbbing, sometimes pupils suggesting pressure upon the
burning, substernal pain, aggravated recurrent laryngeal or sympathetic
by motion and breathing, which ex- nerves — probably of syphilitic origin
tends through to the back and in some — may vary the picture. But even
cases radiates along the intercostal the more common types of chronic
nerves, or, as does angina pectoris, inflammation of the mediastinal are-
toward the shoulders. The distant olar tissue and glands may mechan-
pains are doubtless due to pressure, ically awaken serious symptoms,
which plays an important part in the cough, periodical attacks of dyspnea,
symptomatology of some cases. Thus vertigo, substernal pain, engorgement
we may have dyspnea and cough, of the superficial veins and even
owing to pressure upon the trachea syncope. Non-tuberculous enlarged
and larger bronchi ; dysphagia owing glands, due to the many causes men-
to compression of the esophagus ; tioned may, moreover, give signs
rarely, enlargement of the superficial which, as emphasized by Honeij, of
veins and cyanosis of the lips, Cambridge, are often mistaken for
through pressure on the venous those of apical tuberculosis,
trunks. These symptoms are added Abscess of the mediastinum is a fre-
to those of the causative malady, the quent complication of both acute and
febrile process of which is aggravated, chronic mediastinitis. Irrespective of
Acute mediastinal inflammation, when that due to tuberculosis of the lymph-
not severe, usually declines after a nodes, it may appear in the course of
week or ten days. Severe cases may erysipelas, empyema, the eruptive
last as long as the causative disorder, fevers and other febrile disease — the
or lapse into the chronic form. whole series capable of provoking
In chronic mediastinitis, the forma- mediastinitis, particularly trauma-
tion of fibrous tissue, which not un- tisms. It may also occur as an exten-
commonly follows lobar pneumonia, sion of purulent processes in neigh-
syphilis, rheumatic fever, and other boring regions, the neck, vertebral
diseases, may give rise to symptoms column, sternum, ribs, lungs, pleura,
which vary with the parts constricted esophagus, pericardium, etc. Sub-
or compressed. Often, however, the sternal pain extending to the back,
subjective symptoms are rare and fever, sometimes preceded by chills,
vague, a sensation of pressure behind .sweating, rapid and sometimes ir-
the sternum with slight pain, which regular pulse, and. if the afi"ected mass
the patients sometimes describe as and its purulent accumulation be
548
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
large, more or less dyspnea. Bulging"
of the chest-wall and a pulsating
mass which sometimes affords fluc-
tuation at the edge of the sternum or
in the suprasternal notch on gentle
percussion, and is sensitive to pres-
sure, is occasionally observed. After
remaining localized for a time the
abscess may cause erosion of the ster-
num or break externally above it, or
again burrow along a rib and through
the skin, but it may also rupture into
one of the adjacent organs, — the
esophagus, when vomiting of pus will
occur; the trachea or bronchi, when
dyspnea, cyanosis and even fatal
asphyxia may occur, unless the pus
be voided by coughing. The pleura,
pericardium, abdomen, etc., and even
the large blood-vessels, may thus be-
come invaded. Where the opening
occurs externally and not too far from
the sternum a fistula may form, af-
fording drainage without, however,
procuring recovery.
Tuberculous Mediastinal Lympha-
denitis.— Of the chronic disorders of
the mediastinum, this is by far the
most common, particularly in chil-
dren. In these, irrespective of any
actual pulmonary disease, a persistent
cough, resembling that of pertussis
and apt to be most severe at night,
may be due to such glands in part
owing to the pressure exerted by
them, upon the adjoining bronchi, and
irritation of their sensory nerves.
These glands may or may not be
tuberculous, but it is always best to
base the treatment upon the theory that
they are tuberculous, so frequently
does such prove to be the case, even
where the common causes of medias-
tinal tuberculosis, pulmonary or os-
seous tuberculosis, cannot be dis-
cerned. This is important also be-
cause such glands act very frequently
as foci for general infection and tend
to form abscesses and rupture into
the adjoining respiratory passages,
the trachea and upper bronchi par-
ticularly ; also in blood-vessels, the
esophagus, pleura, pericardium, etc.,
and to cause sudden death by asphyxia,
cardiac arrest, etc. Or, a fistulous
opening into these various cavities
or through the skin may be formed,
as we have seen. Besides the spas-
modic cough we may then have a
variety of symptoms which may at
one time or another suggest prac-
tically all thoracic diseases, including
pulmonary tuberculosis, emphysema,
and cellulitis, chronic bronchitis, a
neoplasm and even aneurism in the
mediastinal area. Prominent among
these signs may be mentioned dysp-
nea, dysphagia, dilatation of the
superficial veins or at least of the
larger venous trunks, cyanosis, hoarse-
ness, and even aphonia ; sensation of
constriction of the chest; pain radiat-
ing to the back, somewhere between
the first and fourth dorsal vertebrae;
tenderness over the mediastinal, irreg-
ular heart action, remittent pyrexia,
and emaciation — all these supple-
menting whatever tuberculous proc-
ess (primary or secondary) may ex-
ist elsewhere.
Tuberculosis of the Bronchial
Glands. — This subject appears in this
location because of the proximity of
the bronchial glands to those of the
mediastinum, and owing to the fact
that the symptomatology, physical
diagnosis, and treatment of tuber-
culosis of these glands are practically
those of tuberculosis of the corre-
sponding structures.
As is the case with the mediastinal
glands, the bronchial glands are fre-
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
549
quently involved in infectious dis-
eases, pertussis, bronchopneumonia,
bronchitis, measles, influenza, and
other infectious diseases. In all of
these, however, resolution usually oc-
curs, and no untoward effect follows.
This does not apply to tuberculosis
of these glands, primary or second-
ary, which is of common occurrence in
children and always a menace, through
dissemination of the tuberculous
process, not only to the lungs, but
also to the meninges. Bronchial tu-
berculous glands are prone also to sup-
purate, and by breaking into neigh-
boring large vascular trunks, venous
and arterial, a bronchus, the pleura
or the pericardium promptly entail
death. It may extend also to all the
lymphatic nodes of the thorax, etc.,
giving rise to all the phenomena of
acute phthisis, and also to the mes-
enteric gland, thus causing abdominal
tuberculosis, etc. In all such cases
the outlook is serious, unless active
measures be taken to stay the mor-
bid process. Hence, the importance
of a correct diagnosis early in these
cases. The physical signs enumer-
ated under diagnosis are of great
aid in this connection, in addition to
the tuberculin and other tests.
DIAGNOSIS.— Apart from the
symptoms enumerated, but few physi-
cal signs are helpful when tuber-
culosis (see below) of the medias-
tinal lymph-glands is excluded. In
chronic mediastinitis, laryngeal tug-
ging attributed to traction by the
secondary fibrous bands has been ob-
served by some ; others refer to re-
traction of the chest-wall over the
area when fusion with the pleura
or pericardium has occurred. Con-
versely, bulging of the chest-wall is
not infrequent, thus introducing a pos-
sibility of confusion with abscess
and aneurism of the mediastinum.
The fact, however, that fibrous medi-
astinitis is, in the majority of cases,
due to tuberculosis of its lymphatic
nodes, suggests that the many physi-
cal signs available for the recognition
of the latter may prove of service in,
the present connection, particularly
where enlarged glands containing pu-
rulent masses are concerned. Radi-
ography and bronchoscopy are some-
times helpful.
Physical diagnosis as developed in
the study of tuberculous mediastinitis
may be said to be useful in all medi-
astinal disorders.
Percussion, using the distal joint of
the middle finger as pleximeter and
striking lightly, is especially helpful.
Anteriorly, however, the presence of
the thymus in children tends to intro-
duce confusion, while a substernal
goiter may also mislead, both by
eliciting dullness.
Dullness over the sternoclavicular
articulation ceasing beyond the ster-
nal margin is another sign elicited by
thymic and thyroid enlargement.
When, however, besides clearl}^ de-
fined dullness in these locations, we
also obtain it in the back, from the
first to the fifth or sixth vertebral
spine (as well emphasized by John
C. Da Costa, Jr.) and laterally to the
middle of the scapula, the area be-
low this level affording clear reso-
nance, the probability of the presence
of enlarged mediastinal glands is very
great. In the presence of the other
symptoms enumerated above the
diagnosis of enlarged mediastinal or
bronchial glands is virtually war-
ranted.
Strongly corroborative are certain
signs brought out by auscultation.
550
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS).
D'Espine's sign is one of these ; while
normally the whispered voice is con-
veyed tO' the ear down to and includ-
ing the seventh cervical vertebra,
then becomes weaker, the presence of
enlarged lymph-glands reduces the
limit ol sound transmission to the
fourth and even the third vertebra.
Again, both inspiration and expira-
tion may be found to cause rhon-
chus about the bifurcation of the
trachea (Rillict's sign) when the
glands are greatly enlarged. A ven-
ous hum when the head is thrown
back {Eustace Smith's sign) is some-
times obtained quite plainly when the
glands are large enough and so sit-
uated as to compress the vessels in
or adjacent to the area involved.
Perez's sign, a mediastinal friction
sound during each respiratory move-
ment, may also be obtained in some
instances. On inspection engorged
branching veins (see colored plate op-
posite page 536) are occasionally ob-
served ; the chest-wall may show
some lACalized bulging, while the
motions of the chest on the corre-
sponding side may appear restrained.
Radiography is sometimes elucidative
by furnishing unusual shadows.
The tuberculin test should always
be employed if there is any doubt con-
cerning the presence of tuberculosis.
If this proves negative, a Wasser-
mann should be resorted to, chronic
mediastinitis being in most instances
'due either to syphilis or to tuber-
culosis. Bronchoscopy is sometimes
of service to indicate distortion of or
pressure upon the trachea, but the
possibility that an abscess might be
present precludes measures that sub-
ject the patient to undue manipula-
tions or fear, especially as is often
the case if the sufferer is a child.
TREATMENT.— In acute medias-
tinitis the treatment is that of the
causative disorder with such local
applications — cold compresses, etc. —
as will tend to give the patient com-
fort. If saline solution is not used in
the causative acute disease and is not
contraindicated, hypodermoclysis or
at least enteroclysis should be tried.
By increasing the osmotic properties
of the blood and reducing its viscid-
ity, it facilitates its passage through
the lymph-glands and promotes there-
by resolution of those that are the
seat of an inflammatory process.
In the chronic form Sergent's dic-
tum that practically all non-traumatic
cases that are not clearly due to ex-
tension of neighboring and identifi-
able disorders are due to hereditary
syphilis or tuberculosis, should guide
at least the first efforts at treatment.
The iodides, biniodide of mercury,
and even mercurial inunctions should
be tried, even if the Wassermann
reaction is negative, where the pos-
sibility of inherited syphilis exists.
Thyroid gland is often useful in these
cases.
When abscess occurs incision and
drainage are indicated. It may be
reached anteriorly either by an in-
cision between the ribs or by trephin-
ing the sternum. Posteriorly, resec-
tion of the ribs close to their verte-
bral ends alone affords enough space
to permit complete elimination of the
pus, and if need be resection of the
glands and other diseased structures.
In tuberculous mediastinitis and tu-
berculosis of the bronchial glands the
measures indicated for general tuber-
culosis should invariably be employed,
since involvement of structures other
than these thoracic glands may ex-
ist, though unrecognized. Out-of-
THYMUS, LYMPHATICS, AND MEDIASTINUM (SAJOUS). 55I
door life and nutritious food are, The symptoms depend in great
therefore, important features of the measure upon which of these medias-
treatment. As to internal medica- tinal spaces is involved, the attach-
tion, the iodides and creosote carbo- ments of the tumor, the rapidity of
nate or guaiacol and arsenic, in doses its growth and its encroachment upon
adjusted to the age of the patient, are the adjacent organs. While at first
the most effective agents at our dis- it may awaken no symptoms, these
posal. Tuberculin is highly spoken become manifest as soon as any de-
of by some clinicians. In a child, gree of pressure is exerted upon
^0000 milligram or less, if the re- them. Thus as regards the anterior
action be too great, may be given mediastinal space, pressure upon ar-
once a week hypodermically, or tried teries may awaken inequality of the
first by the mouth, various authors radial pulses ; on the veins — the
having found it active when adminis- most frequent efifect — it may cause
tered in this manner. The bovine tu- cyanosis with varicosity of the veins
berculin is said to act similarly, of the chest (see colored plate) and
Koch's old tuberculin may be used, neck, and also edema of the face; if
and the dose gradually increased. both arteries and veins are com-
The X-rays, employing the Cool- pressed, coldness and lividity and
idge tube, may be used coincidently, swelling or edema of the hands and
with either of the above measures, fingers, and sometimes of the whole
with considerable advantage. Helio- arm, may be observed. Hoarseness
therapy has given good results. Sea- and aphonia, and inequality of the
air is of material help in all cases, and pupil due to pressure upon the in-
may even prove curative if the stay ferior laryngeal, vagus, or sympa-
at the seashore is sufficiently pro- thetic nerves. Pleurisy and pericar-
longed. When rupture of a node ditis, with effusion and even displace-
threatens, surgical measures (see ment of the heart, may be caused.
Chest, Surgery of) ar'e indicated. These signs point to a tumor of the
anterior mediastinum. Percussion
TUMORS OF THE MEDIAS- affords little more than unusual dull-
TINUM. ness, and auscultation nothing re-
The tumors which may develop liable. Eustace Smith's sign — a mur-
in this region are sarcoma, carci- mur over the manubrium when the
noma, cysts (both dermoid and hyda- head is thrown backward — is some-
tid), fibroma, lipoma, teratoma, chon- times elicited. A radiograph is often
droma and gumma. But of these by helpful.
far the most frequently observed are When the posterior and middle
sarcoma and carcinoma, the former mediastinal spaces are the seat of the
starting in most instances from a tumor, the symptoms differ consider-
remnant of the thymus gland. All ably from those described. If the
othe'- structures in and about the trachea and bronchi are compressed
mediastinum may, however, act as and also the vagus, there are inspira-
starting point of a growth or act as tory dyspnea, which may become
intermediaries for invasion of its distressing, and a paroxysmal cough
cavities from neighboring organs. resembling pertussis, sometimes with
DOZ
THYROID GLAND, DISEASES OF (SAJOUS).
blood-stained expectoration ; if the
esophagus, dysphag-ia and nausea,
and even vomiting" in some cases.
Pressure upon the ascending vena
cava is not infrequent ; edema of the
lower extremities of the abdomen ;
pressure upon the azygos veins may
produce ascites, and also pleural
effusion.
The physical signs may, in this
connection, afford considerable infor-
mation ; they are the same as those
produced by mediastinal tuberculous
glands (see Diagnosis under the pre-
ceding heading). Bronchial breath-
ing may be noted.
As to general symptoms, a slight
rise of temperature seldom exceeding
102° F. (39° C.) may occur, but it
tends to fluctuate and is sometimes
accompanied by sweats. In some
cases, on the other hand, hypother-
mia has been noted, due doubtless to
mechanical disturbance of the cir-
culation. At first there is no discom-
fort in the chest, but pain may ap-
pear and become very severe if the
neoplasm be of solid texture. In
cancerous cases the cervical and axil-
lary glands may be enlarged. The
destructive process usually entails
cachexia ending in death.
TREATMENT.— The frequency
with which growths in this location
prove to be gummata or tuberculous
lymph-nodes renders a trial of iodides
and even of the biniodide of mercury
or salvarsan, if a syphilitic history
can be obtained, advisable. Calcium
lactate may prove beneficial. Apart
from these varieties of growth, how-
ever, surgical removal or the use of
radium in massive doses (Burnam)
are the only procedures that afford hope.
C. E. DE M. Sajous,
Philadelphia.
THYROID GLAND, DIS-
EASES OF. — The most important
disorders of the thvroid : sroiter,
Graves's disease or exophthalmic
goiter, and cretinism or myxedema-
tous idiocy, hyperthyroidism, tumors,
etc., having already been reviewed,
this section will be devoted to the re-
maining diseases of this organ.
FUNCTIONS.— The functions of the
thj'roid gland, as I interpret them, having
already been described in this work with
a summary of the evidence, a brief outline
will alone be submitted here: Briefly the
thyroid gland carries on, with its gland-
ules, the parathyroids, two important cor-
related functions. 1. It enhances oxida-
tion by increasing the sensitiveness or in-
flammability of the phosphorus which all
tissue cells, particularly their nuclei, con-
tain, to the action of the oxygen in the
blood, its cellular elements and the tissue
cells at large. 2. It takes part in the auto-
defensive functions of the body in co-oper-
ation with its parathyroid glandules by in-
creasing the sensitiveness (as opsonin) of
what phosphorus bacteria, their toxins, en-
dotoxins, toxic wastes, etc., m.ay contain,
to oxidation by the oxygen present in the
blood, its cellular elements and tissue
cells.
HYPOTHYROIDIA.
This is a constitutional disease,
also known under the terms hypo-
thyroidism, larval myxedema, thyroid
insufficiency, due to deficient activity
of the thyroparathyroid apparatus
when the secretory activity of the
latter is not sufficiently impaired to
give rise to the most advanced and
progressive type of the disease:
myxedema.
SYMPTOMS.— Cases of hypothy-
roidia, though commonly met in prac-
tice, are seldom recognized. These
patients usually apply for relief of pain,
particularly in the back or in the
occipital region, and occasionally for
migraine or neuralgia. The "back-
THYROID GLAND, DISEASES OF (SAJOUS). 553
ache" may consist of sacrolumbar during- continued speaking. Palpita-
pains, of coccyg-odynia, or in most tions, sometimes of a distressing
instances of severe deep-seated dis- character and with severe pain, may
comfort between the shoulder-blades, also occur. The heart is often found
which rest in bed tends to aggravate dilated with weak systole and occa-
rather than to improve. They com- sional murmurs. The blood-pressure
plain of feeling fatigued, languid, som- is low, from 80 to 110 mm. Hg., and
nolent on rising-; while, as the day the pulse weak and rapid,
wears on, their condition improves. The blood-forming organs being
Their temperature is low, and they also inadequately nourished, anemia is
complain of always feeling cold, espe- the rule, the erythrocytes being usu-
cially at the extremities. Their hands ally reduced to about 3,000,000, with
are flabby, damp ; cold chills may more or less anisocytosis. The hemo-
even be complained of. globin percentage may be consider-
The patient appears older than her ably lowered,
age — women constituting a large pro- The teeth, especially the molars,
portion of these cases. The hair may tend to become loose and carious un-
be prematurely gray, showing a duly early, owing to the deficient cal-
marked tendency to fall in patches cium and phosphorus metabolism
from the forehead and median line, which deficient th3^roparathyroid se-
which tends to become wider, and cretion entails, and need the constant
from the occiput. This loss, which attention of the dentist. They are
is attributed by the patient to the also exceedingly prone to become tar-
headaches, may be such as eventually tarous and require frequent cleansing,
to cause complete alopecia. In Where the teeth are neglected, as in
marked cases the hair may be coarse, the poor, they are rapidly lost, fre-
dry, and brittle, as in the cretin. The quent toothache causing them to be
eyebrows also show a tendency to drawn. The gums tend to bleed
fall, but — a characteristic sign of hy- readily when brushed and to recede
pothyroidia — the loss is limited to from the teeth, and are red and swol-
the external or outer ends. This len unless the toilet of the mouth be
shortening of the eyebrows and the carefully attended to.
frontal loss of hair denote, jointly. The deficiency of germicidal activ-
rather marked cases, though the ity (phagocytic and humoral) mani-
shortened eyebrows are frequently festing itself where protection is usu-
met in the less severe. Pads of fat ally quite active, i.e., along mucous
especially prominent over the clavicles surfaces, the nasopharyngeal mucous
are characteristic of rather marked memlM-ane is also apt to be congested
cases. Such symptoms, which belong through the local accumulation of
to true myxedema, are rarely ob- germs, the tonsils showing, for the
served, however, though a waxy hue same reason, a predilection to acute
of the facial skin and puffy lids are inflammation. The nasal mucosa is
not uncommon. often found turgescent, owing to pas-
■ Dyspnea or oppression, due to dc- sivc congestidn of the underlying tis-
ficient oxygenation of the blood, is sues. This gives the voice a nasal
complained of on climbing stairs or "twang," but it may also be husky or
554
THYROID GLAND, DISEASES OF (SAJOUS).
otherwise modified or veiled, through
infiltration of the laryngeal mucosa.
Constipation due to deficient peris-
talsis is the rule, and it is often suffi-
ciently obstinate to necessitate con-
stant purgation — which tends to in-
crease the intestinal torpor. Fecal
impaction is not uncommon. The
liver is passively congested and en-
larged— a fact due to the low general
vascular tension, which explains also
the presence of varicose veins, vari-
cocele, and kindred vascular disorders
frequently observed in these cases.
Flat-foot is sometimes observed, a
condition due to relaxation of the in-
terosseous muscular and ligamentous
supports ; fetid hyperidrosis is also
marked in some cases. The osseous
framework is often defective, "pigeon-
breasts," narrow chests, and a predis-
position to caries being comimon.
The organs of generation are often
the seat of functional disorders. The
uterus is often found retroflexed.
Impotence or loss of sexual desire is
common. Amenorrhea is frequent,
but metrorrhagia may also occur,
owing to the low vascular tone, par-
ticularly of the arterioles. During
lactation the pallor tends to increase,
and edema, especially of the ankles,
anemia, lassitude, and intellectual
torpor may intervene and last until
the infant is weaned.
Hallucinations of sight — as of small
animals running across the room —
and hearing, rumbling noises or run-
ning water, and various forms of tin-
nitus may occur. Melancholia or, at
least, an uncontrollable sadness, due
to deficient nutrition of the cerebrum,
is often witnessed in severe cases,
especially during menopause. The
mind, even in the milder cases, is usu-
ally obtuse. In predisposed subjects,
hypothyroidia increases the chances
of insanity.
DIAGNOSIS.— The thyroid af-
fords very little information under
physical examination in these cases.
One lobe may feel smaller than the
other when, on the patient being
asked to swallow, the organ is raised
under the palpating fingers; it may
seem unusually small, and the neck
unusually flat ; but, again, it may ap-
pear enlarged.
The dififerential diagnosis of hypo-
thyroidia introduces various common-
place disorders in which drugs are some-
times found to fail. Any rebellious case
of rheumatism, neuralgia, coccygodynia,
anemia, a functional heart disorder,
constipation, hepatic congestion and
adynamic disorders, including the
mental torpor of many backzvard chil-
dren— may thus have, as an under-
lying cause, insufficient power to re-
act against their causative poisons
owing to insufficiency of the thyroid
apparatus.
ETIOLOGY.— Hypothyroidia may
be hereditary or acquired. The most
important hereditary causes which en-
tail defective development, morpho-
logical and secretory, are syphilis, al-
coholism, and the gouty diathesis.
Even far back in the parental lines
on either side, these, from my
viewpoint, transmit their influence
through the intermediary of the duct-
less glands, especially the thyroid,
adrenals, and pituitary body, which,
jointly carry on oxidation and metab-
olism and thus constitute, so to say,
the tripod of the vital process.
The acquired form is often due to
conditions which weaken organically
or functionally the secretory activity
of the thyroid apparatus. The repeti-
tion of pregnancy too many times
THYROID GLAND, DISEASES OF (SAJOUS).
555
may not only cause recurrence of hy-
pothyroidia by exhausting the thy-
roid apparatus, but it may likewise do
so in a woman previously free of any
disorder of the ductless glands. Pro-
longed lactation acts in a similar way,
the maternal milk serving to protect
the nursling against infection. In-
fectious diseases, especially those of
childhood, including the milder ones,
measles and mumps, and likewise
variola and typhoid, may also pro-
duce hypothyroidia by causing inter-
stitial and parenchymatous lesions,
which ultimately lead to sclerosis and
atrophy. The resulting phenomena
are proportionate, of course, with the
degree to which the functions of the
thyroid are inhibited. They may ap-
pear in the midst of the disease, the
child failing thereafter to grow phys-
ically and mentally and becoming
flabby and pale, while showing the
typical symptoms of functional hypo-
thyroidia— if not its more advanced
stage, cretinoid infantilism. Trau-
matism of the thyroid may also pro-
duce it.
PATHOGENESIS.— At the pres-
ent time little or no effort is made by
writers to explain the manner in
which thyroid insufficiency brings
about its characteristic symptoms.
The functions I have attributed to
the thyroid and to the adrenals enable
us to do otherwise. With these func-
tions in abeyance or depressed, we
have to deal with three essential mor-
bid factors: 1. Deficient tissue oxida-
tion, the rate of metabolism and
nutrition in all tissues, particularly
those rich in phosphorus, such as the
nervous sytem, cellular nuclei, etc.,
being retarded. 2. Deficient breaking
down of waste products, fats, etc.
(slowed metabolism entailing defi-
cient catabolism), with accumulation
of fat, detritus, wastes, etc., in the
blood and tissues as a result. 3.
Deficient resistance of the body to
infection and intoxication, owing to
insufficient production of opsonin
(the thyroparathyroid secretion) and
of the other antitoxic and germicidal
blood constituents and phagocytic
cells, as a result of the slowed metab-
olism in all organs producing them.
TREATMENT.— Small doses of
an American preparation of desic-
cated thyroid, which contains 5 grains
of sheep's gland, cause gradual dis-
appearance of the morbid phenomena,
while large doses may aggravate
them. One grain (0.066 Gm.) during
meals is sufficient to begin with in an
adult. This may be gradually in-
creased until 2-grain (0.132 Gm.)
doses are given if need be. Patients
seldom stand larger doses well, and
these are only warranted when the
prolonged use of the smaller dose
fails to improve the patient. Often
when improvement is not noticed the
fault lies with the preparation admin-
istered ; a change should then be
made. In mild cases one-half of the
above doses, or even less, often
suffice. One gram of English desic-
cated thyroid (B. W. & Co.) contains
but 1 grain (0.066 Gm.) of the gland
proper, and is admirably suited for
the use of small doses. Often, frac-
tional doses are more efifective than
the larger.
When the anemia is profound, the
efifects of treatment are enhanced by
giving desiccated adrenal gland, 2
grains (0.132 Gm.), and a small dose
of iron, 1 grain (0.066 Gm.) of Blaud's
pill, with each dose of thyroid. Such
a small dose of iron does not increase
constipation, and contributes to the
556
THYROID GLAND, DISEASES OF (SAJOUS).
rapid building up of the hemoglobin
molecule. The three agents can be
given in a capsule. The constipation
should receive careful attention. Sa-
line purgatives or high injections of
saline solution two or three times a
week are sometimes necessary in
severe cases to evacuate completely
the lower bowel. This measure may
be resorted to the first three or four
weeks if needed, and replaced by
glycerin suppositories until a free
motion occurs daily. Usually the
fourth week of thyroid treatment is
attended by considerable progress in
this and all other directions.
MYXEDEMA OR PROGRESSIVE
HYPOTHYROIDIA.
DEFINITION.— This disease is
the maximum expression of hypothy-
roidia, as it develops after the proc-
ess of body growth has been accom-
plished, i.e., in the adult. When it
occurs during childhood or adoles-
cence, it stunts growth of body and
mind and is then known as cretinism.
(See page 668 in the seventh volume.)
SYMPTOMS.— The symptoms of
myxedema are those of hypothyroidia,
but considerably intensified and end-
ing in death when left untreated.
The patients sufifer almost continu-
ously from cold; their temperature,
both oral and rectal, being always
subnormal — as low as 93° F. in some
instances — unless some fever be pres-
ent. The least exposure to cold
causes the lips, nose, ears, and finger-
tips to become cyanotic. The ex-
tremities are, as a rule, cold and often
purple or livid.
The pre-eminent symptom of the
disease, however, is a peculiar edema
of the skin and mucous membranes.
This phenomenon, which led Ord to
designate it "myxedema," is a "jelly-
like swelling," as he termed it, which
causes the body, particularly the
face and suprascapular regions —
commonly the seat of cushions or
pads — to become irregularly swollen.
The infiltrated tissues are elastic,
firm, and resistant, but do not pit on
pressure, as in true edema, though
they vibrate under lateral stroking.
The skin is yellowish or wax-like, a
circumscribed patch of redness being
present, as a rule, below each cheek-
bone. It is also dry, rough, and scaly,
though that of the face may be rela-
tively smooth, and may desquamate
in flakes or in the form of a fine
powder. Patches of pigmentation vary-
ing from yellowish brown to the actual
bronzing of Addison's disease may
occur. The hair also undergoes
changes ; it becomes coarse, luster-
less, and breaks easily. It is grad-
ually lost, falling out in patches, at
first where the traction attending the
use of the comb is greatest, i.e.,
where the hair is parted, the brovv^,
and the occiput. The lids droop over
the eyeballs — though exophthalmos
may occur, due to primary exophthal-
mic goiter — causing the patient to
appear sleepy, while an effort to
raise the upper lid is manifested by
elevation of the eyeballs. There is
usually considerable lachrymation,
due to glandular leakage.
The mucous membranes being in-
volved, as is the skin, those of the
mouth and nasopharyngeal cavities
appear pale and tumefied. The teeth
tend to decay, and may become black
within a comparatively short period,
owing mainly to deficient calcium
metabolism, or readily break off and
fall out. This is greatly aggravated
by the recession of the gums and the
THYROID GLAND, DISEASES OF (SAJOUS).
557
readiness with which these struc-
tures tend to ulcerate and bleed.
Stubborn stomatitis, with free saliva-
tion, dribbling from the corners of
the mouth, and erosions of the buc-
cal, pharyngeal, and laryngotracheal
memibrane, may appear.
The tumefaction of the oral mucous
membrane and of the palate, tongue,
and lips renders enunciation very im-
perfect and jerky ; this condition be-
ing aggravated by the narrowing of
the nasopharyngeal lumen, it gives
what voice there is a "nasal" char-
acter. It is also rendered coarse and
low, that of a woman being some-
times lowered sufficiently in pitch to
recall that of a man. Edema of the
larynx is not infrequently a cause of
death. In some cases, however, the
whole oral cavity is uncomfortably
dry. The entire alimentary canal,
down to the rectum, is also more or
less infiltrated, causing anorexia, gas-
trointestinal disorders, and constipa-
tion, which may alternate with at-
tacks of diarrhea. There is, as a rule,
a profound distaste for meat. The
patients experience trouble in under-
standing questions and in expressing
their wants and ideas, a fact which
often renders them extremely irri-
table. Mental disorders, are frequent
in these cases, melancholia and even
mania being observed. Total lack of
interest in their surroundings, som-
nolence, and amnesia are comfnon.
Great lassitude with exhaustion
upon the slightest exertion is the
rule. Some cases are unable to
raise the head at all or to stand.
Others lapse into paralysis. Fibril-
lary tremor and muscular quivering
are often noticed. Locomotion is
tentative, often waddling; missteps
are frequent, beiiig produced by a
slight obstacle. The ataxic gait may
prevail. Sensation being, as a rule,
markedly impaired, while the finger-
joints are stift'ened, the usefulness of
the hands is greatly compromised.
Small objects are held with consider-
able difficulty, and easily dropped,
while such diminutive articles as
pins, needles, and even small buttons
are not felt at all. Tingling, formica-
tion, and pruritus are often com-
plained of.
The senses of smell and taste are
commonly impaired or perverted, the
patient complaining of foul odors, a
bitter or acid taste, etc. Vertigo is a
relatively frequent symptom. The
vision is occasionally dimmed and
optic atrophy has been observed.
Tinnitus aurium is not uncommon,
and the hearing is often impaired.
Hemorrhages from one or more or-
gans are common. Epistaxis, hem-
optysis ; bleeding at the gums, which
may prove severe on- extracting a
tooth ; intestinal, uterine, and even
cerebral hemorrhages may occur.
Probably the most common symptom
of this class, however, is menorrhagia.
Post-partum hemorrhages are also
common in these cases. The men-
struation is irregular, as a rule, and
often ceases altogether until appro-
priate treatment procures recovery.
The urea excretion is diminished in
most cases, and markedly so when
the disease is advanced. In the lat-
ter case, both albuminuria and glyco-
suria (probably alimentary) may oc-
cur, but disappear when the thyroid
treatment is instituted. Casts are
also found in advanced cases.
Myxedema progresses slowlv, a
case lasting, as a rule, from six to
twenty years, unless the patient is
carried off through some intercurrent
558
THYROID GLAXD, DISEASES OF (SAJOUS).
trouble, which is often the case.
Tuberculosis and pneumonia are the
infections to which thev seem to be
especially vulnerable — owing- to the
enfeebled condition of their autode-
fensive resources. Nephritis, pericar-
ditis, and cerebral hemorrhage seem
to be next in the order of frequency.
Periods of amelioration sometimes
occur, Init sooner or later the patient
relapses into his previous state, and
gradually dies of exhaustion.
DIAGNOSIS.— The symptoms are
so characteristic that a mistake can
hardly be made. The thyroid gland
is distinctly reduced in size in about
75 per cent, of the cases of myxedema,
its outline being hardly discernible
by palpation in some of these. Con-
versely, some are abnormally large at
first, and may then gradually atrophy
irregularly, the portion which fails to
decrease being resistant to pressure.
ETIOLOGY. — Myxedema occurs
about six times in women to once in
men, and it may devlop at any time of
life, though the period between the
thirtieth and sixtieth years shows by
far the largest proportion of cases.
There is a marked familial influence,
some families showing several cases.
While hypothyroidia, alcoholism, and
syphilis are likely to be the predomi-
nant parental factors, in true myx-
edema tuberculosis and neuroses are
met with much more frequently in
the family antecedents of the patient.
The main causes appear to be rapid
child-bearing, the menopause, worry,
mental shocks, and injuries, especially
to the head. Neoplasms, fungi, and
entozoa capable of destroying or in-
hibiting a sufficient area of the gland
have also been known to cause it.
PATHOLOGY.— Atrophy, due to
the development of fibrous tissue, the
glandular elements of the organ be-
ing reduced in proportion, is the pre-
dominating lesion in the thyroid. It
may follow local inflammatory lesions
in connection with acute articular
rheumatism, erysipelas, syphilis, ac-
tinomycosis, cancer, an acute thy-
roiditis, local injuries, etc., which
serve to destroy a part of the gland-
ular parenchyma, and annul in pro-
portion its secretory functions. Ex-
cessive child-bearing, shock, and the
menopause can hardly be regarded
as causes of an inflammatory process,
however, and it is probable that we
are dealing, in this connection, rather
with functional exhaustion of the or-
gan, or with an endarteritis or peri-
arteritis of its vascular supply.
TREATMENT.— The curative ef-
fect of thyroid gland in myxedema
was discovered by Murray, but here,
as in the milder hypothyroidia, large
doses should not be used. One grain
(0.066 Gm.) of the desiccated thyroid
(American preparation), three times
daily, suffices to begin with ; this dose
may be gradually increased ^ grain
(0.033 Gm.) until 2 grains (0.132
Gm.) are given at each meal, and
initil the temperature is raised to
normal. If this is exceeded the dose
should be reduced to 1^ grains
(0.099 Gm.) or less. The pulse
should also be watched, an increase
of fifteen beats indicating the need of
reducing the dose. The tolerance of
each case should be carefully studied.
The patient should spend his time in
an arm-chair during the day, at first,
if possible, in the open air, and begin
to walk around only when his tem-
perature and pulse become normal.
Violent exercise may prove fatal. The
efifect of the remedy is to cause grad-
ual disappearance of all the morbid
THYROID GLAND, DISEASES OF (SAJOUS).
559
symptoms, but if its use is discon-
tinued they as surely return. Two
grains (0.132 Gm.) daily suffice, how-
ever, to perpetuate the recovery in
most instances.
When the asthenia is marked and
the heart, as is usually the case under
these conditions, is considerably di-
lated, a small dose of digitalin, ^o
grain (0.0033 Gm.), three times daily,
or the desiccated suprarenal gland of
the U. S. P., or, better, the pituitary
gland, 1 grain (0.066 Gm.) during-
meals, greatly hastens the curative
process.
Grafting of thyroid tissue is now
used successfully to prevent the need
of constantly taking thyroid gland.
The conditions for success according
to Christiani, of Geneva, are: that
only normal and living tissues be
used ; that the grafts be small (about
the size of a grain of wheat), but
very numerous ; that they be inserted
in very vascular subcutaneous cellu-
lar tissue, and that only human thy-
roid be employed. This makes it
possible to obtain small grafts from
a removed goiter containing areas of
normal tissue, and to transplant them
into the cretinous subject. The tis-
sue can be kept alive an hour in
physiological saline solution. A very
sharp instrument should be used to
cut the grafts to avoid crushing them.
They are then introduced in situ,
where they gain a perfect foot-
hold, becoming perfect thyroid paren-
chyma. Christiani obtained distinct
improvement in 60 per cent, of his
cases, which included myxedema,
cretinism, dwarfism, etc., remarkable
results in 34 per cent., and no result
in 6 per cent. The most striking re-
sults were in the various types of
cretinism, i.e., infantile myxedema.
SURGICAL DISORDERS OF THE
THYROID APPARATUS.
INJURIES.— When bacteria in-
vade the gland a true acute thyroi-
ditis (q. v., p. 46, fifth volume) occurs ;
complications of a serious nature may
follow, the gland having been in some
instances converted into an abscess
cavity or into a fibrous mass devoid
of functions. A destructive injury
may thus initiate cretinism in chil-
dren and myxedema in adults.
In wounds of the thyroid, inflam-
mation and pus formation occurs only
when the solution of continuity is
small and infection occurs. If the
wound is of medium size or large,
copious hemorrhage (sometimes very
difficult to arrest) follows, and the
exposed tissues are cleared of foreign
materials under strict asepsis, they
may heal by first intention.
A chronic thyroiditis may follow
the acute type, however, either
through perpetuation of the infec-
tion in some small portion of the
gland or the formation of a sinus
which fails to heal. In the majority
of instances, it occurs concomitantly
with chronic processes, such as syph-
ilis, tuberculosis (especially the mili-
ary form), echinococcus cysts, actino-
mycosis, etc. The prognosis in these
cases is less favorable than in the
acute form, since more or less im-
pairment of the functions of the organ
follows the destructive action of the
abscess upon the glandular tissues
and the resulting fibrous induration.
Both the acute and chronic types are
prominent causes of hypothyroidia
with its long train of morbid results.
The formation of a thyroid abscess
causes the course of tlie j)rocess to be
more protracted. As a rule, the
glandular mass is studded with nu-
560
THYROID GLAND, DISEASES OF (SAJOUS).
merous purulent foci, which, if close
one to the other, tend to run together.
Each ahscess tends to break through
the adjacent soft tissues, including-
the skin. The trachea and esophagus
may therefore be invaded by a puru-
lent stream when rupture occurs.
Metastatic abscesses may also appear
in the cervical cellular tissue. When
spontaneous rupture occurs through
the skin, or when the abscess is sur-
gically evacuated, the inflammatory
process recedes rapidly. When, how-
ever, it is left to itself, the purulent
infiltration of surrounding parts may
give rise to serious complications, by
involving, besides the trachea and
esophagus, referred to above, the
mediastinum, the pleura, and the
lungs proper, causing septic pneu-
monia, and also the large vessels of
the neck and chest and thus causing
pyemia. Thyroid abscesses bleed
readily and are sometimes the source
of severe capillary hemorrhages.
TREATMENT.— The treatment of
wounds of the thyroid is subject to
the rules that prevail elsewhere, but
conservation of normal tissues should
be the aim, even in arresting hemor-
rhage ; ligatures and forceps in fact
will tear through if attached to its
parenchyma; hence they should be
confined to vessels and the frame-
work and skin, using cautery, cold,
astringents or other familiar meas-
ures, if suture ligatures or purse-
string sutures fail to hold.
Where no solution of continuity
exists and an abscess forms, surgical
measures may become necessary. Ac-
cording to Kocher: "The presence of
pus is difficult to demonstrate and
premature incision must be avoided.
If necessary, the gland itself should
be exposed. If incision of the abscess
is not followed by rapid recovery, the
]iresence of multiple al)scesses should
be suspected. Fistula points to ex-
tensive necrosis. In such a case the
afifected half of the gland must be
excised. Partial thyroidectomy may
also be considered in cases of thy-
roiditis that have become chronic
and in chemicotoxic thyroiditis." In
the chronic thyroiditis attended by hy-
pothyroidia, thyroid gland should be
given, and the actuality diseased part
removed surgically, especially if dysp-
nea is present. The chronic proc-
esses due to syphilis, tuberculosis,
ecliinococcus cysts, and actinomycosis
should be treated by the measures
indicated in those conditions.
SURGERY OF THE THYROID.
Of the operations on the thyroid
and parathyroids those performed for
goiter are the most important.
INDICATIONS.— In simple goiter sur-
gical treatment is occasionally demanded:
(1) owing to the disfigurement, where the
swelling is large; (2) because of symptoms
due to pressure on the trachea, esophagus,
larynx, or other structures in the neck or
upper part of the thorax; (3) when en-
largement of the goiter is rapid and a
malignant nature is suspected; (4) when
symptoms of hyperthyroidism appear; (5)
when infection of the goiter occurs. Many
patients come to the surgeon for cosmetic
reasons alone. The risk attending opera-
tion in simple goiter being slight under
proper precautions, radical treatment, pro-
vided medical measures have proven in-
effectual, may be looked upon with favor
in cases requesting it, — especially since a
considerable proportion of simple goiters
may subsequently undergo changes result-
ing in injury to the heart, kidneys, and
liver, and possibly become cancerous in
later life.
Goiters should be operated on when they
are nodular, cystic, or beginning to ad-
here to neighboring structures, especially
in adults. Removal of both lobes of the
thyroid i§, however, to be avoided in non-
THYROID GLAND, DISEASES OF (SAJOUS).
561
malignant goiters. If both are enlarged,
unilateral removal is indicated, the lobe
which is the larger and extends lower and
more deeply into the neck being the one
to be removed. At times this deeper lobe
is the larger of the two; it should, never-
theless, be the one to be selected for re-
moval. Where the trachea is displaced,
that lobe which causes the distortion
should be removed. In adenoma or cystic
goiters, Socin's operation, intraglandular
enucleation, may be resorted to.
In diffuse colloid and general adeno-
matous goiter, the removal of one lobe and
of the isthmus is generally the procedure
of choice, though in some instances re-
moval of a portion of each lobe, as advised
and practised by Mikulicz, is required.
After the unilateral operation the remain-
ing lobe generally undergoes later a re-
duction in size. Since, moreover, the
extirpated lobe is that which is the
most diseased, or exclusively diseased, the
greater part of the enlargement can gen-
erally be removed without serious reduc-
tion of the properly functionating paren-
chyma.
In rapidly growing parenchymatous
goiter in young individuals arterial ligation
has been advised for the purpose of caus-
ing atrophy of the goiter tissue.
Encapsulated thyroid tumors may be
removed by perforation of the gland sub-
stance and enucleation with the finger or
a blunt instrument. This is generally the
case in the largest substernal goiters.
Encapsulated thyroid adenomata are apt
to become cystic. Enucleation is, here
again, the procedure of choice, tapping or
injection, which might suggest themselves
as simpler expedients, being inadvisable.
Tapping may, however, be resorted to in
the course of removal of a cystic sub-
sternal goiter to facilitate its extraction
from beneath the sternum. Even in freely
movable goiters, provided they can be
pushed down behind the sternum or
clavicle, removal is considered advisable,
as a prophylactic measure.
In large adenomata in which there is
only a thin layer of thyroid tissue over an
extensive area of the tumor resection-
enucleation may be carried out, the por-
tion of thyroid tissue over the tumor be-
ing left attached to and removed with it.
and the cut edges of the gland then united
with sutures.
OPERATIVE PRECAUTIONS.— In
operating for goiter or any other tumor of
the thyroid, it should be- borne in mind
that the internal jugular vein may be
found lying on the goiter, and that the
recurrent laryngeal nerve is very close to
the thyroid artery on the right, passing
either under or over it, being deeper and
against the esophagus on the left side.
The proximity of this nerve to the goiter
on both sides exposes it greatly not only
to operative injury but also to pressure by
the growth, with paresis of one or both
vocal cords as result. To avoid, therefore,
having the operative procedure incrimi-
nated for any laryngeal motor disorder sub-
sequently discovered, the operator should
always have a competent laryngologist
examine the larynx. This will aid also in
deciding whether a general anesthetic can
be used; for if there is paresis of the ab-
ductors, a tracheal distortion or contrac-
tion of the tracheal lumen from any cause
capable of causing dyspnea, general anes-
thesia is contraindicated. Local anesthe-
sia plus scopolamine-morphine anesthesia
(q. V.) should be employed. As shown by
several instances, sudden death may occur
during the operation: from general anes-
thesia, closure of the glottis, pressure upon
the trachea, or bending or collapse of the
latter when the goiter is raised, irritation
of the laryngeal nerves, reflex cardiac ar-
rest, air-embolism, and hemorrhage.
Another cause of death should be
guarded against, viz., acute thyroidism, a
term given to a condition which may ap-
pear at any time within two days after
the operation and sometimes almost im-
mediately after it, and consists of intense
dyspnea, a very rapid pulse, high periph-
eral temperature, which then falls rapidly
to subnormal with death in a few hours.
This condition has been attributed, as its
name indicates, to the colloid freed by thy-
roid as it is being enucleated, which is
thought to be absorbed by the exposed
tissues, and to a toxic action of this
colloid — the so-called thyrotoxis.
[This explanation, based on a pure
assumption, diverts the operator's attention
from the true condition present, profound
shock. It has been my good fortune to
-36
562
THYROID GLAND, DISEASES OF (SAJOUS).
save life when called in after the surgeon
with the means generally recommended:
avoiding colloid leakage; adrenalin solu-
tion applications, cauterizing the stiunp or
suturing the capsule over it, drainage, etc.,
had failed to arrest the lethal trend. Al-
most immediate recovery was obtained,
when deep shock (due from my viewpoint
to a temporary arrest of adrenal functions
owing to loss of the stimulus the adrenals
receive from the thyroid hormone) was
accepted as cause, and adrenalin in saline
solution injected intravenously. S.]
The parathyroids are important organs
in this connection. Gley showed removal
of these small organs causes tetany.
Hence the fact that the parathyroids should
ahvays be respected in all operations on the
thyroid. They are usually avoided, by
leaving in situ the posterior portion of its
capsule, behind which they lie. They are
quite small, only about the size of small
flattened peas or beans (almost 7 mm. in
length by 4 in breadth and 2 mm. in thick-
ness). In the thyroid proper they will be
found to be as it were independent, being
separated from the thyroid parenchyma by
a capsule. If one is accidentally re-
moved it should at once be returned to
the capsule of the thyroid lobe left in situ,
but tetany fails to develop as a rule, if
two uninjured parathyroids remain, unless
the patient eats much meat.
Should parathyroid tetany develop, para-
thyroid grafts (see vol. i, p. 737) should
be implanted as soon as possible, but in
the mean time, as advised by C. H. Mayo,
the parathyroid serum of Beebe and
Berkeley, should be injected and a 5 per
cent, solution of calcium lactate given
orally, to prevent the attacks of tetany,
which, untreated, may cause death. (See
also Tetany, p. 628, vol. iii.)
Operative Technique. — According to C.
H. Mayo, experience in 50(X) operations
has shown that the best exposure to be
obtained is through a transverse incision
low in the neck, the skin and platysma
being turned together each way from the
incision. Should further exposure be
necessary, the sternohyoid may be sec-
tioned high in the exposed area to prevent
movement of the cutaneous scar and pre-
serve a working muscle. In simple goiters
it is best to extirpate a greatly enlarged
lobe. If both lobes are symmetrically en-
larged, division of the isthmus with
double resection of the gland is indicated
for the best cosmetic results. Midline en-
capsulated adenomas should be enucleated
with division of the isthmus. Lateral en-
capsulated adenomas may be enucleated
or the whole lobe extirpated.
Recent experience has increased the
frequency with which a portion of each
lateral lobe, rather than the whole of one
lobe, is removed. In 45 per cent, of non-
toxic goiters dealt with at the Mayo
Clinic the enlargement proved to be due
to multiple adenomata of various types,
seldom confined to a single lobe of the
thyroid. Thus in many instances, "double
resection" is the procedure actually car-
ried out, the posterior portion of each lobe
being, however, left in situ. In toxic
goiter patients Willard Bartlett (1917) re-
sorts to a bilateral operation removing
most of the gland tissue on both sides —
subtotal thyroidectomy. To enable lady
patients to conceal the scar with a chain,
string of beads, or ribbon, this surgeon
passes a chain about the neck with the
patient in the usual erect posture and
marks out the incision along it in advance.
In Balfour's technique, the isthmus is
first divided, and a series of artery clamps
placed on the larger vessels in the capsule.
The lobe to be operated on is then en-
circled with an incision through the cap-
sule just anterior to the clamps, and the
gland resection made by wedging out the
anterior part of the lobe. A continuous
mattress suture of catgut is then intro-
duced behind the line of forceps, con-
trolling bleeding and obliterating the cav-
ity in the center of the lobe. Returning
in the opposite direction, the same suture
catches the edges of the capsule and rolls
them together into the semblance of a
normal thyroid lobe. The opposite lobe is
then similarly dealt with. Pool (1917) in
many cases uses a clamp with long deli-
cate blades instead of the series of artery
forceps; the clamp not only controls
hemorrhage but also facilitates the resec-
tion by lifting up and steadying the thy-
roid lobe. Bartlett closes the skin in-
cision with No. (KKX) Chinese silk on a No.
12 non-cutting cambric needle. Accord-
ing to Miles F. Porter (1919) the best re-
TOBACCO.
563
suits are secured by closure with subcu-
ticular sutures, supplemented by adhesive
plaster, if necessary, to perfect the coap-
tation.
C. E. DE M. Sajous
Philadelphia.
THYROID THERAPY. See
Animal Extracts: Thyroid Gland.
THYROIDISM. See Animal
Extracts: Thyroid Gland.
THYROIDITIS. See Goiter.
THYROTOMY. See Larynx,
Diseases and Surgery of.
TIC DOULOUREUX. See
Nerves, Peripheral, Diseases of,
TINEA. See Parasites, Diseases
Due to.
TINEA FAVOSA, TONSU-
RANS, TRICHOPHYTINA. See
Hair, Diseases of.
TINEA NODOSA. See Piedra.
TINNITUS AURIUM. See In-
ternal Ear, Disorders of.
TOBACCO.— T abac urn (tobacco,
leaf tobacco) is the commercial dried
leaves of Nicotiana tabacum (fam., Sola-
nacese). Tobacco has been official in most
pharmacopoeias, but the leading ones have
discarded it. For commercial purposes
the petiole and midrib are removed, and
are known as tobacco-stems, which are
largely employed as an insecticide, espe-
cially by florists. The plant is a tall,
stout, glandular, hairy herb, with large,
long leaves, annual or perennial, accord-
ing to the region in which it grows. The
leaves are gathered and hung up, for sev-
eral weeks, to dry or "cure," with the tops
downward. After curing, the leaves are
removed from the stems, assorted as to
size and quality, gathered into small
bundles (hands), and packed for market-
ing. Tobacco contains, in addition to a
number of salts, resin, gum, sugar, etc.,
1 to 8 per cent, of the poison, nicotine, the
amount of which determines the strength
of tobacco, and nicotianin, or tobacco-
camphor, which is the source of the aroma
or flavor. While the toxic action of to-
bacco-smoke was thought to be due chiefly
to nicotine, certain oxidation products, as
collidine, pyridine, picoline, and other
bases of the same series, besides ammonia
and traces of ethylamine, must be con-
sidered in that connection. When sub-
jected to dry distillation, tobacco yields a
brown-black, tar-like liquid of a strong
and very characteristic empyreumatic
odor, called oil of tobacco. The principal
interest of tobacco to the physician cen-
ters in its poisonous effects.
PHYSIOLOGICAL ACTION. — To-
bacco is a local irritant to mucous mem-
branes, a stimulant to the secretions, and
when swallowed is a laxative or purge,
depending on the amount ingested. Ex-
periments with nicotine have shown that it
causes a brief primary stimulation of the
spinal cord, medullary centers, and, in par-
ticular, the ganglia of the sympathetic
and vagosacral autonomic systems, fol-
lowed by marked depression of the same
nerve-cells. These actions account for the
rise in blood-pressure through vasocon-
striction, the glandular stimulation, and
the excitation of involuntary muscle tis-
sues, including those of the alimentary
tract and bladder, which small amounts of
the drug customarily produce. After
larger amounts, the opposite effects pre-
vail. Gannon, Aub, and Dinger have
shown nicotine capable of exciting in-
creased activity of the adrenals.
ACUTE POISONING.— In overdose,
or in those unaccustomed to its use, it
produces nausea and vomiting, quick,
deep, and then labored respiration, great
muscular relaxation, giddiness, mental
confusion, restlessness, feeble circulation,
general depression, and, occasionally,
clonic convulsions (apparently of spinal
origin), followed by complete loss of
reflexes, and death from respiratory
paralysis. Many of the fatal cases have
followed the use of tobacco as an external
antiseptic application, or as a parasiticidal
enema, rapid absorption of the nicotine
following.
CHRONIC POISONING. — A long-
continued heavy use of tobacco produces
chronic inflammation of the upper air-
passages (nasopharyngitis), indigestion,
anorexia, cardiac irregularity and palpita-
564
TONGUE, DISEASES OF.
tion (tobacco-heart), deafness, headache,
giddiness, tremors, and other nervous
symptoms due to congestion of the. brain,
spinal cord, and peripheral nerves. The
eye loses its vision for colors, and com-
plete blindness may result from degen-
eration of the optic nerve. The testicles
atrophy and become discolored, and the
ovary of the female habitue shrivels into
a small kernel, hard and yellow (fibrous
degeneration). Libido and virility are
markedly diminished. It is believed that,
owing to the frequent increase of blood-
pressure, it causes arteriosclerosis, a com-
mon result of long-continued abuse of
tobacco.
Most of the evil effects from tobacco
abuse, unless very pronounced, disappear
upon removal of the drug, fresh air and
exercise, baths, bromides and digitalis to
slow and strengthen the irritable heart,
and similar hygienic and symptomatic
measures. It is claimed that the blood-
pressure is increased, and that arterio-
sclerosis is a common result of long-con-
tinued abuse of tobacco.
TREATMENT OF ACUTE POISON-
ING.— When poisoning has occurred from
the ingestion of a poisonous dose, and
there is not free emesis, wash out the
stomach repeatedly, using an abundance
of warm water, or give an emetic of
mustard (4 drams in 1 to 4 ounces — 15
Gm. in 30 to 120 c.c. — of water), zinc sul-
phate (20 grains in 1 ounce — 1.3 Gm. in
30 c.c.^of water), or apomorphine hydro-
chloride hypodermically (2 to 4 minims
— 0.12 to 0.25 c.c. — of a 2 per cent, solu-
tion); repeating every fifteen minutes till
effective. To antidote the residual poison
give tannic acid (30 grains in 1 ounce — 2
Gm. in 30 c.c. — of water) before vomiting
has ceased, or before last siphoning of
stomach. If tannic acid is not at hand,
give iodine (1 to 2 grains — 0.06 to 0.12
Gm.) — with potassium iodide (5 to 10
grains — 0.3 to 0.6 Gm.) in water (1 to 4
ounces — 30 to 120 c.c); strong tea or
decoction of oak-bark (4 drams in 4
ounces — 15 Gm. in 120 c.c. — of water) may
be used. To eliminate the absorbed
poison give water freely and spirit of
nitrous ether (1 dram — 4 c.c). To coun-
teract the dangerous symptoms, give
strychnine nitrate hypodermically (%5
grain— 0.0024 Gm.), or administer tincture
of nux vomica (30 minims — 2 c.c) by
mouth to stimulate respiration and sup-
port the heart. Stimulate with brandy or
whisky (2 to 4 drams — 4 to 8 c.c.) per
dose, or spirit of chloroform (20 to 40
minims — 1.3 to 2.6 c.c). The patient
should be kept in the recumbent position
with warm applications to the chest and
extremities, and cold applications to the
head. W.
TOE, HAMMER-. See Ortho-
pedic Surgery.
TOE-NAIL, INGROWING.
See Nails, Diseases and Injury of.
TONGUE, DISEASES OF.—
TONGUE-TIE, OR ANKYLOGLOSSIA.
— This condition is due to an abnormally
short frsenum linguae, to which were for-
merly attributed many of the disorders of
infancy. It is only when it is sufficiently
short to cause the tongue to be held be-
hind the incisors that a frenum can pre-
vent suckling or interfere with articula-
tion. In most cases, the trouble disap-
pears as the child grows, persistent
tongue-tie being extremely rare.
Undue elongation of the frenum may
produce similar symptoms, especially when
its upper insertion is unusually near the
tip.
Treatment. — Although division of the
frenum presents no difficulty, it is prac-
tically never indicated. Again, it may be-
come dangerous if the presence of the
ranine arteries is not borne in mind, fatal
hemorrhage having occurred. The tissues
should therefore be carefully examined
and the portion cut be isolated from any
A-essel encountered. Blunt-pointed scis-
sors are used, after anesthetizing the parts
with a 10 per cent, solution of cocaine,
applied with a camel's-hair pencil. The
mouth should be kept scrupulously clean.
When the frenum is excessively long,
reaching sometimes to the point of the
tongue and impeding its movements, sim-
ple section is not sufficient; excision must
be resorted to.
LINGUAL PAPILLITIS.— This is an
inflammation of the papillae of the tip of the
tongue, sometimes ulcerative, often met
with in gastric disorders. Its only symp-
TONGUE, DISEASES OF.
565
torn is a burning or lancinating pain on
the anterior two-thirds of the organ, with
greater intensity on its tip and borders.
The pain, often recurring at intervals in
the form of neuralgic attacks, is aggravated
by the ingestion of food — solid or liquid,
excepting of milk. No other trouble,
either of general and special sensibility or
of the salivary secretion, is observable.
Examination with the naked eye does not
reveal any noticeable alteration, but
examination with the magnifying-glass
shows, in several places, and chiefly on
the borders and tip of the tongue, little
red points, ulcerated and very tender, the
number of which is greater in proportion
as the pain is more violent. The lesions
are evidently in the sensory terminals of
the lingual mucosa.
Treatment, — Touching (with the aid of
the magnifying-glass) each ulcerated tip
with pure silver nitrate fused on the end
of a probe or galvanocautery, a few points
being cauterized at each sitting, is the
only efficient local measure, besides treat-
ment of the causal gastric disorder.
PARENCHYMATOUS GLOSSITIS.—
Inflammation of the tongue is usually due
to traumatism. It may be caused by slight
injuries inflicted during mastication, or to
carious teeth, scalds, bites, incised or
punctured wounds, laceration, etc. In-
flammation of the tongue probably never
occurs without the introduction in its
parenchyma of some pyogenic organism.
Symptoms. — Swelling of the organ,
sometimes causing it to protrude from the
mouth, is usually the first symptom.
Severe pain follows and deglutition is im-
peded. When the swelling involves the
lymphatic elements in the posterior por-
tion of the tongue, dyspnea may appear,
owing to pressure on the epiglottis.
Stomatitis and ptyalism are more or less
marked. The breath is usually fetid,
owing to a thick, yellowish coating on the
lingual surface, which may also present
striae of ulceration. There may be con-
siderable fever. The symtoms become
aggravated up to the third or fourth day,
when there is a lull, followed by gradual
improvement. Occasionally an abscess
forms deep in the organ, as a rule, close
to the periphery. Gangrene sometimes
occurs; rarely, but one side is affected.
Treatment. — The tongue should be kept
moist and clean, by means of a mucilag-
inous solution containing 10 grains (0.65
Gm.) of boric acid to the ounce (30 Gm.)..
This can best be done by the patient him-
self with a cotton swab. A 25 per cent,
solution of argyrol is effective for super-
ficial ulcerations. Continuous cold com-
presses or, if the mouth can be closed,
small pieces of cracked ice are grateful.
When there is great infiltration, scarifica-
tions with a thin knife (under antiseptic
precautions) afford marked relief if a cou-
ple of ounces at least of blood are drawn.
Severe pain fnay be counteracted by paint-
ing the organ occasionally with a 4 per
cent, solution of cocaine. When an ab-
scess forms, evacuation of the pus by in-
cision soon reduces the glossitis.
When feeding becomes difficult a cath-
eter introduced on the side of the tongue
into the pyriform sinus — i.e., alongside the
larynx— adequately serves for the giving
of liquid food. Rectal alimentation is
sometimes necessary, and occasionally
tracheotomy to avoid asphyxia. Saline
purges early in the case tend to shorten
the duration of the glossitis.
CHRONIC GLOSSITIS.— This condi-
tion, also known as glossitis desiccans, is,
in many cases, attributed to syphilis, when
in truth it is but the result of tobacco
irritation, or, as shown by Brocq, due to
gastric affections in rheumatic subjects.
Strong alcoholic drinks are occasionally
the cause.
Symptoms. — The tongue is red and sen-
sitive, especially near the edges, and oval
grayish patches resembling those of syph-
ilis replace papillae or epithelial cells which
have yielded to the superficial ulcerative
process. The resemblance to syphilis is
accentuated by deep furrows, which tend
to separate the tongue into island-like,
lobulated surfaces. A foul breath is
often present, especially in drunkards.
The history and the results of treatment
alone facilitate diagnosis.
Treatment. — Correction of dietetic
errors is of prime importance. If syi>Iiilis
is suspected, a course of potassium iodide,
freely diluted with water, will do no harm
if no luetic troulilc is present. Applica-
tions to the furrows of silver nitrate solu-
tion, 20 grains (1.3 Gm.) to the ounce (30
566
TONGUE, DISEASES OF.
c.c), with a camel's-hair pencil (never the
solid stick), or if the tongue is sensitive a
25 per cent, solution of argyrol, soon im-
proves them. The oral cavity should be
kept scrupulously clean, and washed out
three times daily with a saturated solution
(1 dram — 4 Gm. — to the pint — 500 Gm.) of
potassium chlorate. If pain exists, espe-
cially after meals, the tongue should be
cleansed and a 4 per cent, solution of
cocaine applied with a cotton pledget to
the painful areas.
LEUKOPLAKIA.— This disorder is as-
similated by various authors to psoriasis,
herpes zoster, etc. While it may affect
the entire mouth, it is usually most marked
on the tongue, and consists of whitish,
opaline patches of cicatricial aspect, which
tend to disappear spontaneously and to
reappear. It awakens no symptoms other
than slight pain at the seat of the lesions,
which are, in reality, narrow, minute
ulcers. The pain is increased by contact
with irritants.
Leukoplakia occupies an important posi-
tion in diseases of the tongue, since it is
thought bj'^ many authorities to be a fre-
quent— in at least one-third of the cases —
precursor of epitheliomatous cancer of
that organ. The lesions usually consist of
epithelial thickenings which many assimi-
late to, or trace to, syphilitic mucous
patches (79.85 per cent., Erb; 65 per cent.,
Neisser). Hence the need, in every in-
stance, of a Wassermann to establish the
diagnosis. It has been observed in child-
hood as a result of hereditary syphilis.
Smoking — including the pressure of the
pipe-stem — angular tooth-fragments or de-
fective plates have also been incriminated.
Treatment. — A 20 per cent, solution of
potassium iodide frequently painted on the
affected points, according to Rosenberg,
has cured stubborn leukoplakia in a few
days. Other efficient agents are X-rays,
and an ointment of salicylic acid 5 grains
(0.3 Gm.) to the ounce applied several
times daily according to Hartzell. A cop-
per sulphate, 20 per cent, solution, applied
daily over the cleansed tongue, is pre-
ferred by some.
The first sign of cancerous change as
observed by Parker is cracking in the
white covering or its ragged border which
exudes blood or serum, a feeling of stiff-
ness in the affected area being also ex-
perienced. When such an area becomes
indurated to any degree local excision
should not be delayed. It is the only way
to avoid the final evolution of this disease
into true epithelioma. Solid silver nitrate
should never be used.
ECZEMA OF THE TONGUE.— This
condition is characterized by the presence
of patches on the tongue, also sometimes
on the cheeks and lips, which tend to heal
in the center while the border spreads to
unite with that of other patches. It is due
to desquamation of the epithelium. The
peculiar appearance of the organ has
caused the disease to be termed also geo-
graphical tongue, owing to the sinuous
outlines of the patches. Some itching and
burning are about all the symptoms com-
plained of during the many years the dis-
order may last. It is often mistaken for
syphilitic ulceration, and is due, in most
instances, to a gouty diathesis.
Treatment. — The itching and burning is
relieved by a 4 per cent, solution of
cocaine applied with a cotton pledget.
The iodides or thyroid gland and a meat-
free diet should then be employed for a
time to counteract the formation of toxic
waste. Locally either a 25 per cent, solu-
tion of argyrol, a weak solution of silver
nitrate, or a saturated solution of potas-
sium chlorate are efficient measures if used
frequently.
ULCERATION OF THE TONGUE.—
The tongue frequently becomes the seat of
ulcers, benign and malignant, and the
recognition of their true identity is fre-
quently of importance. They may be
divided into four classes: —
Simple Ulcer. — This usually occurs
around the edge of the tongue, and its
border may be tumefied and raised, as in
epithelioma. In the neighborhood, how-
ever, may often be found a carious tooth,
or the lesion may be traced to some other
form of traumatism. While there is
swelling around the base, it is limited in
extent and there is no induration such as
characterizes cancer.
Upon removal of the cause, and the
remedial measures described under Glos-
sitis, it soon disappears.
Syphilitic Ulcer. — These are usually pre-
ceded by induration; in cancer this indu-
TON-GUE, DISEASES OF.
567
ration almost always appears after the
ulcerative process has begun. The ulcer
in syphilis is usually located near the tip;
a cancerous ulcer is on the side. There
are usually two or more gummata; can-
cerous ulceration is always single. The
tongue is often furrowed and fissured in
syphilis; never in cancer. There is often
a history of syphilis, and test treatment
soon establishes the diagnosis.
Tuberculous Ulcer. — This ulcer is single,
as in cancer, but there is no induration;
though it may, by its color, resemble a
gumma, it is often yellow. The base may
present minute, yellowish dots, even if the
ulcer is grayish white; this is the main
habitat of tubercle bacilli, which can often
be detected in scrapings. Tuberculous
ulcers sometimes heal, leaving a scar; a
cancerous ulcer spreads steadily. A tuber-
culous ulcer usually coexists with tuber-
culosis in another region, especially the
larynx. Lupus rarely, if ever, attacks the
tongue primarily.
Cancerous Ulcer. — The ulcer attending
cancer, besides the features already noted,
is ragged and everted, progresses irregu-
larly in various directions, and is angry-
looking. It soon becomes fungous and
granular, is covered with an ichorous,
fetid liquid, and bleeds upon the least con-
tact: a condition witnessed in no other
variety. The neighboring glands soon be-
come enlarged: the only condition in
which this also occurs is lupus, but this
seldom if ever attacks the tongue pri-
marily. The age of the patient, beyond
forty years, at which cancer occurs, is
seldom, if ever, that at which lupus is
observed.
Treatment. — The treatment is, of course,
that of the causative condition, but the
local measures are those described under
Chronic Glossitis.
TUMORS OF THE TONGUE.— Statis-
tics based upon 13,824 recorded cases of
tumor by Roger Williams showed that out
of this number 880, or 6.3 per cent., origi-
nated in the tongue. Of these, 804 were
epithelioma (91.3 per cent.), while the re-
maining forms consisted of sarcoma (of
which but 33 cases had been reported up
to 1910 according to Serafini), papilloma,
cystoma, fibroma, adenoma, myxoma, and
angioma.
Ranula is a relatively common retention
cyst of the sublingual or submaxillary
glands; mucous cysts originating from the
mucous glands of the floor of the mouth
on each side of the tongue and also im-
mediately behind the incisors under the
frenum, which it raises, are not intre-
quently taken for more serious growths.
This applies also to thyroglossal or thyro-
lingual cysts, formed by remnants of the
mucous glands of the thyroglossal sinus
which, in the embryo, passes from the
foramen cecum of the tongue to the thy-
roid isthmus, and also to sublingual der-
moids formed from remnants of the duct
between the foramen cecum and the hyoid
bone. All these benign growths rarely
attain large size, but at times this is suffi-
cient to interfere with speech and degluti-
tion. Parasitic cysts, including echino-
cocci, cysticerci, etc., have also been
found, though rarely, in the lingual tissues.
Treatment. — In ranula or any of the
mucous cysts, excision of the cyst is the
most satisfactory procedure. Or an incis-
ion may be made and the interior is cau-
terized with phenic acid. All other benign
growths should be extirpated if they cause
any discomfort. For the removal of thy-
roglossal cysts, general anesthesia and
preliminary tracheotomy may be required.
G. B. New reports 2 cases of lingual
lymphangioma cured by radium.
CANCER OF THE TONGUE.— As
shown above, the variety of cancer most
frequently met with here is epithelioma.
Symptoms. — These depend upon the lo-
cation of the lesion. When it begins far
back in the mouth, the submaxillary or
posterior sublingual regions become sen-
sitive, and darting pains reaching the ear
are complained of. Lobular, movable,
hard swellings may perhaps be felt: infil-
trated glands. Deglutition soon becomes
somewhat impaired, and the tongue is
moved with difficulty during articulation.
The submaxillary glands have, by this
time, probably become fixed and enlarged,
and the disease progresses rapidly. Pro-
fuse ptyalism is soon followed by the
expectoration of foul pus, often tinged
with blood — all evidences that ulceration
has begun. This exposes the patient to
death from hemorrhage, owing to the
proximity of the growth to large vessels.
568
TONGUE, DISEASES -OF.
When the growth starts anteriorly, the
process may be followed with more pre-
cision. A small slit or crease, a minute
hypertrophied papilla, or a small warty
projection may prove to be the primary
focus. The crown of this soon becomes
ulcerated and covered with thin scabs,
which the patient removes as fast as
formed, leaving a bleeding surface. Then
gradually develops the typical epithelio-
matous ulcer with ragged edges, and a
hard, broad, infiltrated base and fungous
outgrowths filled with fetid pus, which
gives the breath a repulsive odor. As the
neoplasm spreads, the suffering of the pa-
tient becomes gradually more acute, the
tongue is immovable, the submaxillary
glands markedly enlarged, and he grad-
ually sinks as a result of starvation and
exhaustion, if hemorrhage does not bring
on sudden death. When the growth be-
gins anteriorly, the lymphatics are not in-
volved as early, and the chances for a suc-
cessful operation are consequently greater.
Etiology. — Cancer of the tongue is
comparatively rare among women — about
16 per cent, of reported cases. This is,
to a certain degree, accounted for by the
causative factors, the principal ones being:
smoking, jagged teeth, the scars of syph-
ilis, alcoholic drinks, the pressure of a
pipe-stem on one spot, traumatism; vari-
ous disorders of the tongue, especially
leucoplakia, etc.; briefly, any condition
which tends to cause irritation of circum-
scribed area of the organ. The promis-
cuous application of solid nitrate of silver
or any kind of caustic is also thought to
be a prolific source.
The age of incidence corresponds to
that of cancer in other parts of the organ-
ism, namely, after 45 years. Occasionally,
however, it occurs earlier, but a large pro-
portion of such cases are observed in
women. Hereditary predisposition may be
traced in many cases.
Prognosis. — Left to itself, lingual epi-
thelioma steadily progresses, and death
occurs in from eighteen months to two
years after the character of the neoplasm
has been recognized. In a series of 69
cases treated by Sachs the average time
between the onset and the time the cases
presented themselves for treatment was
five months. It is probable, therefore.
that two years represent the average dura-
tion of life. The prognosis is also greatly
influenced by the operation; the more
radical this is, the better are the chances,
especially if glands are involved. Early
involvement of the glands is an unfavor-
able sign, particularly when the cervical
glands behind the angle of the jaw are
affected. An operation, if performed when
the case is not too far advanced, invariably
prolongs life even in cases of recurrence.
This is especially evident in private cases.
Butlin's percentage of cures in 102 opera-
tions was 16 in the hospital group and 26
in private cases. This is due, in his opin-
ion, to the fact that private patients, being
better educated, apply for operation much
earlier than do the others. In the majority
of cured cases the disease was situated in
the anterior two-thirds of the tongue.
But even some of the worst cases may be
cured if the disease has not invaded the
tonsillar and neighboring regions.
Treatment. — Many methods of removal
such as the elastic ligature, the chain or
wire ecraseur, and the actual cautery, have
been tried and ultimately abandoned. X-
rays may be tried, but the results have
been dubious. Early excision of the neo-
plasm with the knife or scissors is the
only procedure which has given good re-
sults.
Butlin's Technique. — According to But-
lin, whose results have been, when com-
pared with those of many other operators,
most satisfactory, removal of the entire
tongue is not essential to a successful op-
eration. With the cancer, he reinoves
three-fourths of an inch of apparently
healthy tissue around it in every direction.
When the disease is on the border of the
tongue, half the tongue to an inch behind
the inargin of the disease is exsected.
Where the disease is near the tip or fore-
part of the dorsum, the forepart of the
tongue is removed. Butlin removes the
entire contents of anterior triangle of the
neck. He makes a careful dissection of
the triangle, to insure that all the con-
nective tissue and glands be taken out in
one mass. Search is made between the
muscles in front for one or two deeper-
seated lymphatic glands, and those in
front of the parotid gland and about the
angle of the jaw are taken out with the
TONGUE, DISEASES OF.
569
contents of the triangle. The submental
and parotid glands are not so easily and
certainly removed eii masse in this opera-
tion as the submaxillary and carotid
groups. This is done at a second opera-
tion, and not at the time of the excision
of the tongue.
If the growth is removed in the
superficial stage, with a margin of one-
half to three-fourths of an inch of
healthy tissue, recurrence is practic-
ally certain not to take place. In the
diffuse stage the most important sign
is a loss of definite outline of the
growth, the margins no longer being
hard and well defined. This condi-
tion is associated with submucous in-
volvement and bears no relation to
size of the growth. Regardless of the
extent of the operation — which should
be radical and include all muscles —
that may be done in this stage, it is
impossible safely to give a favorable
prognosis. W. Trotter (Lancet, Oct.
24, 1914).
Whitehead's Technique. — Walter White-
head, after extensive experience, advised
the following procedure, which many sur-
geons now recommend: The patient is
placed completely under anesthesia during
the first stage of the operation, but after-
ward only partial insensibility is main-
tained; the mouth is securely gagged and
kept fully open throughout; the head is
supported in such a position that, while
the best light is secured, the blood tends
■to gravitate out of the mouth rather than
backward into the pharynx. A firm liga-
ture is passed through the tip of the
tongue for traction. The first step con-
sists in dividing the reflection of mucous
membrane between the tongue and the
jaw and the anterior pillars of the fauces.
Rapid separation of the anterior portion
of the tongue from the floor of the mouth
is then made. If possible, the lingual ar-
teries should be secured with Spencer
Wells's forceps prior to division. A liga-
ture is passed through the glosso-epiglot-
tidean fold before finally separating the
tongue. A mercurial solution should be
applied to the floor of the mouth, and the
surface painted with an iodoform styptic
varnish.
Hemorrhage is one of the most im-
portant dangers encountered in amputa-
tion of the tongue and subsequently.
Whitehead's operation is done with scis-
sors after the lingual artery has been
ligated. But if this should give way, the
following procedure recommended by
Heath arrests the bleeding: The fore-
finger passed well down beyond the epi-
glottis is made to hook forward the hyoid
bone and drag it up as far as practicable
toward the sjanphysis menti. The effect
of this is to stretch the lingual arteries so
as to completely control for a time the
flow of blood through them.
Kocher's Technique. — Another danger
connected with excision of the tongue is
septic pneumonia or bronchopneumonia,
brought on through infection from the
wound. This is prevented to a great
degree by Kocher's method of plugging
the pharynx with carbolized sponges and
iodoform gauze, after tracheotomy had
been performed. The trachea is thus
totally disconnected from the wound and
no pus can enter it. But the Trendelen-
burg position obviates the necessity of
this preliminary step, which further weak-
ened the patient.
Kocher's operation is performed as fol-
lows: "An incision is made commencing
a little below the tip of the ear and ex-
tending down the anterior border of the
sternomastoid muscle to about its middle,
then forward to the body of the hyoid
bone and along the anterior belly of the
digastric muscle to the jaw. The result-
ing flap is turned up on the cheek and the
lingual artery is ligated as it passes under
the hypoglossus muscle. Commencing
from behind, all the structures in the sub-
maxillary fossa are removed, viz.: the lym-
phatic glands, the maxillary and, if neces-
sary, the sublingual glands. The opposite
artery is now tied by a separate incision
if the whole tongue is to be removed.
The mucous meml)ranc along the jaw and
the mylohyoid muscle are then divided and
the tongue drawn out through the incision
and removed with scissors or galvanocau-
tery."
After-treatment. — More than ordinary
attention must be given to this. Before,
during, and after the operation the mouth
should be kept as aseptic as possible by
570
TOXIC FOODS, OR PTOMAINE POISONING.
means of borax or potassium permanga-
nate solution, 20 grains (1.3 Gm.) to the
ounce (30 Gm.) of the former, and 1
grain (0.065 Gm.) to the ounce (30 Gm.) of
the latter. After the operation White-
head washes the parts with a solution of
bichloride of mercury, dries it thoroughly,
then applies an antiseptic varnish com-
posed of the ingredients of Friar's balsam,
but substituting a saturated solution of
iodoform in ether. This he found to be
more comfortable to the patient than
gauze or lint. Some surgeons prefer to
pack the cavity with moist iodoform
gauze — mad -. with glycerin and rosin dis-
solved in alcohol. Treves, when the ooz-
ing has ceased, dusts the mouth with
iodoform, then every three hours renews
this, after carefully spraying the mouth
with a solution of hydrogen peroxide and
another of phenol, and mopping the tis-
sues dry.
At first rectal feeding is obligatory.
After a day or two the patient can
usually take liquid food from a feeding
cup. As soon as he is able to sit up, the
second or third day, he should, as much
as possible, hold his head forward and
downward so as to prevent gravitation of
the discharges into the pharynx and esoph-
agus. But rectal feeding should be con-
tinued to sustain the patient's strength.
INJURIES OF THE TONGUE.— In-
juries of the tongue are seldom danger-
ous, though profuse bleeding sometimes
ensues. The organ is frequently bitten
during falls, trismus, an epileptic attack,
etc., and occasionally completely severed.
Injuries of external source are infrequent,
owing to the protected position of the
organ. Foreign bodies are occasionally
introduced, and remain in the lingual
tissues, giving rise subsequently to an
enlargement suggesting a growth.
Treatment. — In slight or moderate trau-
matisms the use of ice, compression, etc.,
soon arrests the flow. If this does not
succeed, solution of ferric chloride or the
cautery may be tried. Profuse hemor-
rhage requires ligation of the cut artery —
probably the ranine, easily found usually
by raising the tongue. Approximation
with sutures sometimes sufifices even when
the hemorrhage is quite severe, but it is
usually easier to find and tie the main
bleeding vessel. Sutures should be tied
with unusual care, to avoid loosening of
the knots by movements of the tongue.
Loose pieces heal quickly when carefully
adjusted. While the wound is healing, the
mouth should be kept as nearly aseptic as
possible by means of a saturated solution
of sodium borate, frequently employed. S.
TONGUE-TIE. See Tongue,
Diseases of.
TONSILS. See Pharynx and
Tonsils, Diseases of.
TORTICOLLIS. See Muscles,
Diseases of.
TOXEMIA. See Wounds, Septic.
TOXIC FOODS, or PTO-
MAINE POISONING.-Poisoning
by foods was formerly attributed to pto-
inaines, which are alkaline products of
cadaveric decomposition, and to letico-
maines, also alkaline, but products of
metabolism, some of which are toxic.
Modern investigations have tended to
show, however, that bacterial toxins were
the main factors in the morbid process.
To these factors must be added infections
conveyed to the consumer by foods de-
rived from diseased or contaminated ani-
mals, and also certain foods containing al-
kaloids, metallic poisons, adulterants, etc.
The element of sensitization or anaphy-
laxis has recently been suggested as a
possible factor of the morbid process.
MEAT POISONING. — Besides pto-
maines, i.e., cadaverin, putrescin, sepsin,
etc., which may be, when in sufficient
quantity, detected by smell and taste, the
toxins of various bacteria may render
meat toxic irrespective of any change
sufficient to ofifend these senses. The
most active of these are the following: —
Bacillus enieritidis. This bacillus, iso-
lated by Gartner, belongs to the colon
group. It is a short, flagellate, and mod-
erately motile rod, the toxin of which is
very active, and resistant to heat. In
keeping with infections by the typhoid
colon group that due to the B. enteritidis
causes the appearance, in infected individ-
uals, of specific agglutinins in the serum,
thus affording an important diagnostic
TOXIC FOODS, OR PTOMAINE POISONING.
571
sign, Widal's reaction is often positive.
This form of poisoning is usually due to
the ingestion of meat derived from animals
slaughtered while ill. Even cooking does
not prevent the toxic effects — another dis-
tinguishing sign. The meat is usually nor-
mal as to color, odor, and flavor. Any
meat kept several days or made into
some form of sausage is most apt to
cause trouble. The introduction of cold
storage has greatly increased the number
of cases of this form of poisoning; canned
meat occasionally gives rise to poisoning
from the same cause.
The presence of B. enterifidis in vomited
matter or stools may be ascertained by
planting some of either on malachite-
green agar, and by injecting some in mice.
The agglutination test referred to above
should also be employed.
Bacillus bottdinns. This organism, first
isolated by Van Ermengen, has been
found mainly in hog flesh, particularly in
sausages and hams, but also in canned
vegetables and fruit. It differs totally
from the organisms of the colon group in
its mode of action, in that it resembles the
tetanus bacillus, being found in the soil
and in the feces of animals and growing
anaerobically.
Its presence in suspected food may be
ascertained by injecting some of the lat-
ter into rabbits and guinea-pigs or feed-
ing it to mice. Cultures grown anaero-
bically, as stated, when one week old and
filtered, should prove highly toxic to test
animals in which they are injected. Like
that of tetanus the toxin of B. bottd'uius is
soluble and the effects produced are those
of an intoxication and not of infection, the
organism being a pure saprophyte which
does not multiply to any harmful extent
in the body.
Bacillus protcus. This organism isolated
by Levy is apt to be found in meats, in-
cluding that of fish, which have undergone
putrefaction. It is to its toxin that the
morbid symptoms provoked are credited,
since uninfected putrid meat and fish,
"ripe" or "high" game, are used as steady
diet in some countries without harmful
effects. It is often present in meat, how-
ever, the consumption of which proves
harmless. Its pathological effects are not
as severe as those of the preceding types
reviewed, and are of shorter duration.
Its bacilli are as toxic when dead as when
alive, but a moderate heat (60° C. =
140° F.) suffices to annul the activity of
their toxin.
The presence of B. proteus may be de-
termined by culture and by feeding the
suspected food to mice, in which it will
cause death within 24 hours from gastro-
enteritis. The B. protcus may be sup-
planted, however, after a given time by
the Bacillus paratyphostis referred to below.
Bacteria of Diseased Meat. — The con-
sumption of meat from an animal suffer-
ing from specific disease is the cause of
the vast majority of cases of poisoning.
Not infrequently the flesh from animals
which had died of such a disease, even
though boiled, in some instances, had been
consumed. The multiplication of the
specific germ then continued in the meat
or in the persons by whom it was eaten.
Puerperal or traumatic septicemia and
pyemia, peritonitis, enteritis — usually with
the B. enterifidis, paratyphostis, suipestifer
(hog cholera) as leading pathogenic agents
in the latter disease — and anthrax, are the
main disorders of animals to which this
form of poisoning has been traced. Beef,
veal, pork, horse flesh, and fowl, espe-
cially when minced or prepared in the
form of sausages, owing to thorough dis-
semination of the germ during the process
of chopping, have afforded the largest
number of cases. An epidemic of pneu-
monia which cost 490 deaths in Middles-
borough, England, was traced to an im-
ported stock of bacon. A mild form of
typhoid fever has also been traced to the
B. paratyphostis, which differs but slightly
in cultural peculiarities from the colon
bacillus.
Symptoms. — These vary according to
the nature of the pathogenic organism the
poisonous meat contains.
If the B. cnteritidis be the source of the
toxin, the symptoms a'^pear rapidly, i.e.,
within a few hours, and consist of nausea,
vomiting, diarrhea, and severe colic, soon
followed by marked weakness, sweating,
and collapse. Herpetic or urticarial erup-
tions have been observed. Catarrhal
pneumonia and nephritis may occur as
sequelae, but as a rule no complications
follow, though convalescence may be
572
TOXIC I'OODS, OR PTOMAINE POISONING.
greatly protracted. The mortality does
not exceed 5 per cent. The B. sniscpticus
(of swine plague) gives rise to very simi-
lar symptoms.
When the B. botiilinus is the offender
the symptoms point to involvement of
the nervous system. While gastroab-
dominal phenomena — nausea, vomiting, and
gastric pain — occur, these are followed
by disturbances of vision, diplopia, amau-
rosis, dilatation of the pupil, with loss of
reaction to light, ptosis, dysphagia, in-
tense thirst, suffocative coughing, constric-
tion at the throat, aphonia, cardiac dis-
turbances, hypothermia, cold extremities,
soon followed in lethal cases by delirium
and coma. In favorable cases the latter
fail to appcr and recovery occurs, though
very slowly, extreme prostration some-
times persisting several weeks. The mor-
tality is greater than in the B. enteritidis
cases.
The B. proteiis provokes a gastroenteritis,
with nausea, vomiting, severe colic, and
very fetid diarrhea; also headache, vertigo,
and marked weakness, — all of which occur
soon after its ingestion with food. These
symptoms usually last but a short time,
ending, as a rule, in recovery. Cooking
tends to destroy the toxin of this germ.
Hence the occurrence of toxic phenomena
in cases in which raw meat had been
consumed.
FISH POISONING.— Some fishes are
inherently toxic, either through the pres-
ence of a poisonous body in the liver,
ovaries, etc., or through their roe or
spawn. The liver of the swordfish illus-
trates the former and the roe of the
barbed sturgeon and pike the latter. In
Japan and China fngu-po'soning is due to
a substance in the ovaries and testicles
of Tetrodon and Diodon. The symptoms
produced by the latter resemble greatly
those of curare poisoning.
Bacteria, as in meat intoxication, account
for the majority of cases of fish poisoning,
with B. proteus, B. paratyphosus, and B.
enteritidis as prominent factors, and
B. botulinus as an occasional one. The
fish may show nothing abnormal when
eaten and yet, even though salted, be per-
meated with bacteria the toxins of which
are active, as we have seen after boiling,
excepting in the case of B. proteus. Pto-
maines, which may be very poisonous, are
also found in fish that have undergone
decomposition; but these ptomaine-like
bodies are more active in the earlier
stages of decay than later. Any softness
of the flesh or any degree of unpleasant
odor should cause any kind of fish to be
rejected.
As in meat poisoning the use of dis-
eased fish, especiall}^ if eaten raw, transfer
to the consumer the pathogenic organisms
of that disease. If it is a disorder, septi-
cemia, for example, which is communi-
cable, toxic phenomena will appear.
Canned fish, salmon in particular, has
caused poisoning, owing, according to
Vaughan, to a micrococcus developed
therein. The tin of the can and metallic
poisons derived from it have been incrimi-
nated, but on weak grounds. Finally,
various parasites may be transmitted
through their larvae, by infested fish eaten
raw or but slightly cooked.
Symptoms. — The symptoms of fish poi-
soning are at first, as in the case of meat,
gastrointestinal: nausea, vomiting, diar-
rhea, and more or less severe colic. In
some cases, this is only accompanied by
intense prostration, cold extremities, and
a weak and rapid pulse, with more or less
dryness of the throat and mouth. In the
severer type, however, the gastrointestinal
reaction is accompanied by vertigo, dysp-
nea, aphonia, and cyanosis, all with numb-
ness and intense prostration. Relaxation
of the sphincters, collapse and death may
follow within a few hours.
SHELLFISH POISONING.— Mussels
are said to owe their violently toxic prop-
erties to the presence of a ptomaine, myti-
lotoxin, but this accounts for but one of
three syndromes, the two others being
clearly those of B. enteritidis and B. botu-
linus. Oysters also have produced two
forms of poisoning due to these patho-
genic organisms, but these mollusks are
principally harmful through the criminal
cupidity of some dealers who place them
in waters contaminated with sewage in
order to fatten them, or owing to the care-
lessness of others who allow the waters
of storage pits to remain unchanged sev-
eral days or even weeks. It is in sewage-
contaminated waters that oysters acquire
the typhoid bacillus which they transmit
TOXIC FOODS, OR PTOMAINE POISONING.
573
to their consumers. Numerous epidemics
have been traced to them. Lobsters and
crabs occasionally give rise to toxic phe-
nomena, but only when eaten after their
decomposition — which occurs early in
these animals because of their identity as
scavengers — has begun, and in canned
lobster after the can has remained open.
It must not be forgotten that the most
active ptomaines are produced at the very
start of this process. Clams, sliriiiips, and
cockles occasionally prove harmful under
the same conditions and in the same
manner.
Symptoms. — The symptoms due to the
violent ptomaine mytilotoxin of mussels are
distinctive in the sense that they provoke
marked peripheral heat and pruritus, and
also a series of papular and vesicular erup-
tions which follow one another in rapid
succession. The two other forms of poi-
soning this shellfish may awaken are
those described under Meat Poisoning,
due to B. enteritidis, viz., gastrointestinal
symptoms, nausea, vomiting, diarrhea,
etc., and B. botulinus, vertigo, headache,
numbness, marked prostration, coma, etc.
As to oysters, the symptoms may also be
those caused by the enteritidis and botu-
linus toxins, but in most instances they
are those of transmitted typhoid. Lobsters,
crabs, clams, shrimps, etc., may cause nau-
sea, vomiting, colic, headache, diarrhea,
etc., and in others urticaria or paralytic
phenomena.
MILK, CREAM AND CHEESE POIS-
ONING.— The toxic effects of milk have
already been considered in full in the
articles on Nursing and Artificial Feed-
ing, in the seventh volume, and Typhoid
Fever in the present volume, to which the
reader is referred. Besides the toxic ef-
fects described under those heads, acute
intoxication from milk may occur, owing
to the presence in it of essentially the
same organisms that render meat toxic:
B. enteritidis, and another bacillus of the
colon group, B. enteritidis sporo(je)ics, for
which, particularly in warm weather, milk
afifords an excellent culture medium. It is
always owing to the same bacteria that
most cases of poisoning due to cream-
puffs, ice-cream, custards and other foods
of this class, occur. Cheese owes its oc-
casional toxic effects partly to the same
group of bacteria of the colon group,
which multiply during the storage and
ripening process, and partly to a toxin
termed by Vaughan tyrotoxicon, the source
of which has not as yet been determined.
Symptoms. — The gastrointestinal symp-
toms of the enteritidis toxin and the vari-
ous types of infantile diarrhea have been
reviewed in the article on this subject.
Often the symptorns are clearly those of
dysentery {q. v.). Tyrotoxicon poisoning
due to cheese also causes gastrointestinal
symptoms, but often with violent chills,
coldness of the surface, severe colic,
marked prostration, weak and irregular
heart action, and in severe cases delirium
and coma. Egg-containing custards, puffs,
etc., cause much the same phenomena.
MUSHROOM POISONING.— The
toxic effects of mushrooms are mainly
due to two alkaloids: muscarine — formed
by the oxidation of choline in the Agaricus
viuscarius — and phalline, contained espe-
cially in the Ama)iita phalloides. Phalline
is a toxalbumin of extreme violence, which
is alro found in some venomous animals,
such as the rattlesnake. Both species of
mushrooms, however, contain other chem-
ical substances the nature of which has
not been determined. Edible mushrooms
may become toxic through putrefactive
changes in them, in keeping with other
foods reviewed.
Both the species of poisonous mush-
rooms referred to above have zvhite gills
and zvhite spores, while all the edible gill-
bearing species, except Coprinus comatus,
have gills of some other color. In Cop-
rinus comatus the spores at maturity are
black. Several species of mushrooms hav-
ing both white gills and white spores be-
ing edible, however, a beginner should not
pick them, as he might easily mistake an
amanita for them.
A high color, a scaly or spotted surface,
and tough or watery flesh are usually asso-
ciated with poisonous properties. Toxic
mushrooms, moreover, grow clustered on
wet or shady ground, the edible, singly, in
dry pastures. Those which have a bitter
or styptic taste, or which burn the fauces,
or that yield a pungent milk, those of
livid color, and which, on being bruised,
assume various hues, ought to be avoided.
It should be remembered, also, that . all
574
TOXIC FOODS, OR PTOMAINE POISONING.
plants of this class readily undergo de-
composition, and should therefore be eaten
as fresh as possible.
The prevailing belief that a silver piece
will indicate poisonous mushrooms by be-
coming black when cooked with them is
erroneous. If there is any suspicion that
the mushrooms on hand are toxic, the fol-
lowing process, used by market-women in
Washington, according to Mr. Coville, of
the United States Department of Agricul-
ture, can be employed before they are pre-
pared for food: The stem is scraped, the
gills are removed, and the upper part of
the cap is peeled. The mushrooms are
then boiled in salt and water, which re-
moves any toxalbuiiiin that Diay be present;
then steeped in vinegar, which removes the
alkaloid. >
Symptoms. — The symptoms of mush-
room poisoning dififer according' to which
of the two alkaloids is present. Those of
muscarine poisoning indicate a vasomotor
paresis of cerebrospinal origin, following
a gastrointestinal eflfort at elimination.
After a period varying from half an hour
to fifteen hours, giddiness is experienced,
and nausea, with salivation, vomiting,
cramps, diarrhea, dimness of vision, and
dyspnea follow in quick succession. The
stools sometimes contain fragments of the
fungus. The patient appears drunk and
excited, *:hen drowsy. These symptoms
are usually the precursors of convulsions,
and are preceded by anuria. Cardiac ac-
tion is weakened, and th" pulse is slow
and thread-like. The pupils, at first con-
tracted, become dilated as death ap-
proaches. The reflexes are, in part or
quite, abolished, and cold sweats appear.
Respiration gradually becomes more dififi-
cult and stertorous, the pulse becomes im-
perceptible, and death occurs either in
coma or in the midst of a convulsion.
The symptoms may progress rapidly or
slowly, some cases dying a few hours after
the first manifestation, others lasting two
or three days.
In favorable cases the stupor is not of
long duration, the respiration and pulse
are more active, and all the symptoms
mentioned gradually disappear. But great
care is required in this connection. The
patient may appear perfectly well a few
hours, and even days, and suddenly re-
lapse and die. Three days, at least, must
elapse before the patient can be deemed
out of danger.
In phalliue poisoning the toxic agent
tends to dissolve the blood-corpuscles,
thus bringing about a condition simulating
cholera. Severe cramps in the abdomen
and lower limbs, particularly, come on a
few hours after ingestion of the fungus.
Violent diarrhea, the stools becoming
choleraic (rice-water stools), vomiting, al-
gidit}% collapse, cyanosis, muscular con-
traction, and convulsions sometimes follow
one another in more or less rapid succes-
sion: a series of symptoms differing en-
tirely from muscarine poisoning. The
symptoms increase in intensity without
the mental hebetude and torpor witnessed
in the latter, though, when death is ap-
proached in from two to four days, in-
creasing somnolence, due to carbonic acid
poisoning, may be witnessed.
The prognosis is far less favorable than
in muscarine poisoning, 75 per cent, of the
cases having proven fatal.
Treatment of Food Poisoning. — In all
the foregoing forms of poisoning it is im-
portant that the patient be kept quiet and
in the recumbent position to prevent heart-
failure. Lavage of the stomach or emesis
as early as possible is indicated; but,
also to protect the heart, a depressant
emetic such as tartar emetic should be
avoided. Apomorphine, K2 grain (0.005
Gm.) for an adult, or a tablespoonful of
mustard in lukewarm water, are effective.
A saline solution enema is helpful to evac-
uate the intestine, unless the stools be
frequent and contain fecal matter, which
indicates that physiological elimination is
taking place. If the latter fails to occur,
as is sometimes observed in severe cases,
croton oil, 1 drop on the tongue, and
glycerin and water, 1 ounce (31 Gm.) of
each, injected into the rectum should be
resorted to; saline cathartics should be
avoided.
Once the gastrointestinal canal is relieved
of its toxic contents, or before this is
completed, if the prostration is severe and
the cardiac action very rapid or irregular,
morphine should be administered hypo-
dermically, or, better, if the patient's
stomach will not rebel, the camphorated
tincture of opium (paregoric). Either of
TOXIC FOODS, OR PTOMAINE POISONING.
575
these opiates will very soon restore the
circulatory equilibrium, the surface becom-
ing- warm, the heart stronger.
In mushroom poisoning, atropine, the
physiological antidote of muscarine, should
be given at once hypodermically, the dose
ranging from Yi^o grain to Moo grain
(0.0005 to 0.00065 Gm.), according- to age.
If the case is not seen too late it causes
dilatation of the pinhead pupil as soon as
its physiological effects are produced. It
is also useful in phallin poisoning.
To further sustain cardiac action, digi-
talin should be given at fixed intervals.
Strychnine is also useful. Pituitrin sug-
gests itself as a valuable agent in this
connection, 15 minims (1 Gm.) being in-
jected intramuscularly. The poisonous ac-
tion reaches its crisis, then gradually re-
cedes. The aim, therefore, should be to
maintain life by sustaining the action of
the heart throughout the dangerous
period. Hot coffee, chloroform liniment
rubbed in with flannel over the abdomen,
and sinapisms to the calves, are effective
adjuvants.
All cases of food-poisoning are followed
by considerable depression; strychnine,
digitalis, and iron are efficient agents in
this connection,
GRAIN AND VEGETABLE POISON-
ING.— Ergot. — Rye often becomes the
host of a fungous parasite, Claviceps pur-
pura, when grown on virgin soil or when
the soil is carelessly cultivated. Con-
sumers of rye-bread, especially numerous
in some parts of Europe, are therefore ex-
posed to its effects, and epidemics of
ergotism have thus been caused, and are
apt to occur immediatelj^ after harvest.
These are attributed to twO' active prin-
ciples: cornutin and sphacelinic acid. This
subject has already been reviewed under
Ergot. (See' page 568 in the fourth
volume.)
Chicken-pea. — This seed is often mixed
with others used as food, and may cause,
after prolonged use, nervous disorders of
spinal origin, transverse myelitis espe-
cially. This is termed lathyrisni, and is
met in India and y\frica.
Sprouting Potatoes. — These may at
times contain a poison, solanine, an al-
kaloid of its botanical group, resembling
in effects those of belladonna, stramonium.
hyoscyamus, and tobacco. In most in-
stances reported, gastroenteritis came on
after partaking of some cooked sprouting
potatoes. The symptoms were collapse,
prostration, with more or less jaundice.
During sprouting much more solanine is
developed. In using such potatoes care
should be taken to thoroughly peel the
vegetable and take out the "eyes" deeply,
thus minimizing the danger. It is doubt-
ful whether potatoes in themselves are
ever toxic.
Treatment. — The treatment of ergot
poisoning is reviewed in the fourth vol-
ume, referred to above. As regards lath-
yrism and solanine poisoning the general
lines indicated are purgatives to insure
elimination of the toxic, and stimulation
with strychnine or adrenaline in saline
solution by hypodermoclysis, to facilitate
renal elimination and restore the vascular
tone. Morphine tends also to counteract
the effects of the poisons, and is indicated
to relieve pain.
PELLAGRA, OR MAIDISM.— Corn is
by far the most important malefactor in
the series of food poisons, if it can finally
be shown to be the actual cause of pella-
gra. The whole question, however, must
still be considered sub judice.
The prevailing view at the present time
is that this disease, also termed maidism,
the victims of which have been estimated
at 30,000 in the United States alone, is a
nutritional disturbance due to the use, as
food, of corn in which some bacillus has
caused putrefactive changes that render it
toxic. But the nature of this organism
has never been determined. Many germs
of the colon tj^pe, streptococci, etc., the
smut of corn, molds, etc., have been in-
criminated by as many investigators. The
antizeists or opponents of the corn theory,
however, have attributed the disease to
products of defective digestion, to infec-
tive agents, to water-bred insects, to the
stable fly, to certain parasites, to unsani-
tary living conditions, to avitaminosis, etc.
The disease seems, in America at least,
to show a predilection for females, the
ratio being about 4 to 6. Children are
rarely affected; it begins to appear about
the fifteenth year, then becomes gradually
more frequent until the beginning of the
sixth decade, when it is most fatal, par-
576
TOXIC FOODS, OR PTOMAINE POISONING.
ticularly among males. Negroes, espe-
cially girls, are more susceptible to it than
whites. While the course of the disease is
chronic, its most active period is during
the summer months, considerable im-
provement coinciding with the onset of
cool weather. It is especially common in
Italy, Spain, France, Roumania and in the
southern and western parts of the United
States.
Pathology. — The morbid changes are
clearly those of a degenerative trophoneu-
rosis with the spinal cord as focus of inor-
bid activity. The lateral tracts bear the
brunt of the process, but the posterior
tracts may also be involved, particularly
in the upper dorsal and cervical regions,
the changes resembling those of tabes.
The muscular elements — skeletal, intes-
tinal, and vascular — are the seat of fatty
degeneration; the bones are ill-nourished
and brittle. Among the more prominent
changes also are those of the brain-cells,
with infiltration of the meninges. Even
the mucous membranes and skin are the
seat of trophoneurotic changes, some-
times sufficiently marked as to cause gan-
grene.
Symptoms. — The earlier symptoms tend
to appear during the spring with lassitude,
debility, vertigo, insomnia, headache, and
slight indigestion. There usually is, at this
time or later, a sensation of superficial heat
throughout the body, including the oral
mucosa, which appears red and swollen.
Gradually as the morbid process advances
the orogastric symptoms become more
marked. The salivary gland becoming in-
volved, there is copious salivation; the
tongue and oral mucosa become intensely
congested, the former being often de-
nuded, ulcerated or "stippled"; often a
fibrinous exudate is formed resembling
diphtheritic false membrane. All mucous
membranes, faucial, rectal, vaginal, etc.,
are all intensely red. Nausea, vomit-
ing, violent and persistent diarrhea with
watery stools (occasionally hemorrhagic)
are prominent symptoms, though occa-
sionally constipation is present. Neural-
gia, neuritis, muscular cramps, irritability,
mental torpor, or aberration which event-
ually may lead to melancholia, with de-
lusions of persecution and suicidal tend-
encies, or to maniacal outbursts. There
is anemia, but a blood-count and hemo-
globin percentage seldom show it to be
severe.
Cutaneous symptoms are prominent fea-
tures of the disease. They consist of
erythema, usually on exposed parts of the
body, face, hands, etc., which is sym-
metrical. The skin is rough, and pain and
exfoliation reveal an underlying suppura-
tion, followed by dark pigmentation. Re-
curring attacks of the trouble lead to
thickening of the pigmented areas and
eventually to atrophy. Bullae and vesicles
are sometimes observed. The latter is
termed the "wet" form with crevices,
ulceration. Occasionally, however, the
cutaneous symptoms fail to appear, caus-
ing the condition known as pellagra sine
pellagra. Conversely, all the symptoms
may appear in very rapid sequence, con-
stituting the fulminating type.
As the disease progresses, all the symp-
toms increase in gravity, the muscular
weakness becoming excessive, the diarrhea
an uncontrollable, though painless, flux;
the mental disorder a delirious dementia,
the heart's action extremely weak and
irregular. The patient dies in marasmus,
when an intercurrent disease does not end
his sufTerings earlier. Many cases recover,
however, especially during the earlier
stages of the disease. The mortality
averages about 25 per cent.. In children
in whoni the disease is occasionally wit-
nessed, recovery readily follows under
appropriate measures.
Treatment. — Of the many remedies tried
arsenic, in the form of Fowler's solution
in 5-minim (0.33 Gm.) doses, gradually in-
creased, has alone given good results, but
its action should be closely watched and
its use suspended a few daj's at intervals.
Atoxyl is another excellent agent of this
class. Babes and others have reported
rapid cures by giving it hypodermically
while arsenic was being given orally and
by injections. The dose of atoxyl is 5
grains (0.33 Gm.); this may be increased
slowly and injected intramuscularly, dis-
solved in cold sterile water, twice a week.
Soamin, the arsenilate of atoxyl, has been
given orallj' in smaller doses with suc-
cess. One important feature of the use
of arsenic and its congeners in pellagra, is
that the treatment should be started six
TREMORS (TAYLOR).
577
weeks before the expected recrudescnce
of the disease during early spring, thus
anticipating it. Sodium cacodylate has
also been highly recommended. Salvar-
san has not so far met expectations.
The diet is an important feature of the
treatment. In this country, where all
kinds of food are available, the elimination
of com from the diet is possible. In
Italy, where the only food within reach
of the very poor is polenta, made of corn-
meal, laws have been provided for their
protection, wholesome and dry meal being
alone available. Owing- to the condition
of the mouth, which should be treated ac-
cording to the form of stomatitis (q. v.,
vol. vi, p. 717) present, soft foods, pep-
tonized milk, meat broths, well-boiled
cereals, soft-boiled eggs, mashed potatoes,
etc., should be employed until the oral
cavity is sufficiently restored. According
to Goldberger, of the U. S. Public Health
Service, a liberal amount of fresh animal
and leguminous protein foods will nearly
always prevent the annual recurrences.
Another important feature is rest; hence
the importance of hospital treatment of
those cases. Hydrotherapy has been ex-
tolled by man}'. As previously stated,
change of climate is of great value — pos-
sWAy owing in part to the radical change
S.
See CoNjuNc-
See Venesec-
of diet it entails.
TRACHOMA.
TIVA, Dl.SEASES OF.
TRANSFUSION.
TTON AND Transfusion.
TRAUMATIC NEUROSES.
.See Vasculak System, Disorders of.
TREMATODES. See Parasites,
Diseases Due to.
TREMORS.— In this section will
l>c placed those disorders in which
tremor is the predominant symptom :
viz., TREMOR as an independent symp-
tom; PARALYSIS AGITANS and MULTI-
PLE SCLEROSIS.
TREMOR.— Thongh but a symp-
tom, tremor, or rhythmical involtm-
tary oscillations of one or more parts
of the body, often leads the patient
to seek advice from the general prac-
titioner.
While no form of tremor is abso-
lutely distinctive of any one disease
or group of them, some aid is ob-
tained as to the nature of the morbid
process by noting the relative speed
of the oscillations. As was strongly
urged by Crenshaw {New York Med-
ical Jonnial, February 12, 1916j their
diagnostic signihcance is about as
follows: (1) ^^^ith the exception of
the tremor of Parkinson's disease,
coarse tremors indicate organic dis-
ease. (2) Fine tremors indicate toxic
or finictional conditions. (3) Effort
tremors suggest central organic le-
sion. All tremors are of central
origin, and practically all disappear
during sleep. The disease which
gives us the most typical effort
tremor is multiple sclerosis. This
tremor is perhaps next most constant
in brain tumors. Tremors aft'ecting
the face or tongue are most charac-
teristic of alcohol and general paresis.
Tremors of the head are oftenest
found in senility, while trembling of
the legs generally results from fear
or fatigue.
To distinguish clearly the relative
speed of tremors, the patient should
stretch out his arms, extend his
fingers, and separate them as far as
possible. A fine tremor may also be
detected by touching the patient's
finger-tips when the hand is disposed
as stated. Tremors of the tongue and
face are best detected by having the
patient close his eyes and protrude
his tongue as far as he can. Trunk
tremors are readily felt by standing
behind the patient's back and placing
the hands on his shoulders. Tremors
may be divided into the following
types : —
8—37
578 TREMORS (TAYLOR).
Senile Tremor. — This type is sal- poisoning affects chiefly the arms
dom observed l^efore the seventh de- and legs, and is increased by mus-
cade. It affects mainly the hands, cular effort. Mercurial tremor is
arms, and head, and is increased by often confmed to the face, tongue
motion. It is doubtful whether a and extremities ; fine at first, it may
true senile tremor exists. It is usu- become choreiform. Ptyalism and
ally traceal:»le to arteriosclerosis, the stomatitis often appear simultane-
excessive use of tobacco, heredity or ously with the tremor. Alcohol, ar-
hysteria. senic, copper, chloral hydrate, co-
Hysterical Tremor. — Tremor is caine, morphine, ergot, and other
commonly observed in hysteria, and drugs may also cause it. It may
may be its only objective symptom, occur in miners after choke-damj)
Such a case is often traceable to poisoning, and as a manifestation of
heredity. Thus in a case reported by intestinal autointoxication. Prostatic
Regnault, hysterical tremor had ex- hypertrophy may cause it by produc-
isted in the patient's great-grand- ing retention of stagnating urine,
father, grandfather, uncle, two aunts. Malaria, syphilis, neurasthenia ty-
mother, and sister. Often it follows phus and other adynamic diseases
a shock, physical or emotional, or may also engender tremor; it is ob-
both. It is increased by motion, also served frequently during convales-
when the patient is watched or when cence from severe illness under the
the tremulous extremity is held, and stress of exertion.
often ceases when the patient's at- Infantile Tremor. — Tremor is not
tention is diverted, or by an effort infrequently observed during infancy
of his will. Internal vibrations may or early childhood as a result of le-
be complained of, which may persist sions, temporary or permanent, of
during repose. The so-called trail- the meninges and cortex in the
matic tremors belong to this category, course of infectious processes. As a
Hereditary or Family Tremor. — rule it subsides without treatment ;
This form differs from others, in that occasionally, however, imbecility fol-
it affects the muscles only. All the lows. This unfavorable result may
members of a family may suffer from also occur in the unilateral tremor of
it, beginning during childhood in children, but, as a rule, recovery may
some, though later in the majority, be expected, if the feeding and hy-
and increasing with age. The oscil- gienic surroundings of the child be
lations are very rapid and occur only attended to.
during voluntary motion, any mus- Intention or Volitional Tremor. —
cular strain increasing its intensity. In this form, the tremor appears only
A peculiarity of this form, which when a motion is carried out through
greatly resembles the tremor of pa- volitional effort. Thus, as in a case
ralysis agitans and often is limited to of Moyer's, there would be no tremor
the hands, is that alcoholism tends to while the hands lay in the pa-
arrest it, at least temporarily. tient's lap, but with voluntary effort
Toxic Tremor. — This form is often they were immediately thrown into
traceable to intoxication by occupa- tremor. When asked to convey a
tional agents. That due to lead glass of water to her mouth the
TREMORS (TAYLOR).
579
tremor was much more marked.
This is sufficient, in some patients,
to cause the water to be spilled in
all directions. Writing is difficult.
This is the kind of tremor observed
in multiple disseminated sclerosis,
treated below.
ETIOLOGY AND PATHO-
GENESIS.— The manner in which
tremors are produced is still sub
judicc. Preston has explained it by
the general fact that the normal num-
ber of contractions occurring when
the muscles contract, which is 32 per
second, has been found by Brouar-
del, Marey, Gowers, and others to be
reduced to 6 or 7 per second in pa-
ralysis agitans, multiple sclerosis,
mercurial tremor, etc. That they
may not be due to pathological le-
sions is shown by the fact that they
may be caused by cold, fright, anger,
or great emotion. This should be
borne in mind in making a diagnosis.
Nervous females, especially when be-
ing examined by a physician, show
often in a marked degree this acute
tremor. The pathological forms may
also include besides those referred to
above (a) cerebral or spinal lesions,
such as primary lateral sclerosis, dis-
seminated sclerosis, ataxic lateral
sclerosis, posthemiplegic affections,
bulbar paralysis, general paralysis,
myelitis, by compression especially,
and certain forms of chronic men-
ingitis; (b) lesions of nerves and
muscles, as neuritis and muscular
atrophies ; (c) exophthalmic goiter,
athetosis and chorea.
Adamkiewicz has urged that tremor
arose from disturbances in the ccjui-
librium of the two spinal innervating
stimuli. Two currents pass along the
spinal cord to the ganglion-cells of
the anterior horns from which the
nerves for the muscles arise. One of
these currents passes along the pos-
terior columns, the other along the
pyramidal tracts. The former arises
in the cerebellum and keeps the mus-
cles in a state of tension ; the other
originates in the cerebral cortex and
conveys voluntary impulses to the
muscles. When both currents are
properly balanced, they act upon the
muscles as a stimulus and as a check
like whip and rein. If the excitation
along the posterior columns is in-
sufficient the muscles deprived of
their check become unruly and pro-
duce ataxia. When, on the other
hand, the muscles are controlled by
the current along the posterior col-
umns and the regulating action of the
pyramidal tracts is absent, as, for ex-
ample, in lateral sclerosis, the mus-
cles of the lower extremities are in a
state of excessive tension ; so that the
joints become immovable and the
gait stiff, labored, and dragging. If
the patient attempts to move, the
hypertensioned muscles develop a
state of tremor. In the beginning
this tremor is slight, but in propor-
tion as the tension of the muscles in-
creases it becomes augmented, until
finally a tremor paroxysm develops.
TREATMENT.— The multiplicity
of causes of tremor render it neces-
sary to refer the reader to the sec-
tions on the underlying diseases or
poisons for curative measures. Senile
tremors are now attributed to some
pathological condition which must
be carefully sought and appropriately
treated. Depressants, such as the
bromides, hyoscyaminc hydrol)romate,
etc., should be avoided in the aged.
Formic acid has been found effective.
In liysf erica! tremor, besides the
measures addressed to the causative
580
TREMORS (lAYLOR).
disease itself (q. t'.) gelsemium, the
bromides, and the faradic current arc
helpful. Toxic tremors, due to alco-
hol, mercury, copper, lead, cocaine,
etc., yield to the treatment of chronic
poisoning by these agents given in
full in their respective section. In
the alcoholic form, Liegeois found
that the addition of picrotoxin or
veratrine to strychnine, and the use
of galvanic baths gave excellent
results.
Among the remedies which have
afforded aid in the various forms,
when these occurred in individuals
capable of standing depresgants with-
out harm, may be mentioned veronal
(Combemale) and acetanilide. Atro-
pine in ^oo-gi'^iii (0.0003 Gm.) doses,
or arsenic, cold douches, and galvanic
ibaths have been recommended for
sthenic subjects.
PARALYSIS AGITANS (Parkin-
son's Disease; Shaking Palsy). — A
chronic nervous disorder character-
ized by tremor, muscular weakness
and rigidity.
SYMPTOMS.— The tremor of pa-
ralysis agitans possesses characteris-
tics that are not ol)served in other
forms. As a rule, it appears insid-
iously after perhaps neuralgic pains,
paresthesias and vertigo, though it
may appear suddenly after a fright,
a violent emotion, or a traumatism.
It affects first the hand, beginning
with a finger and extending upward,
until the forearm is affected, thence
to the foot, but it is so slight that
the patient hardly perceives it. It
may cross the body, as it were, pass-
ing from right arm to left leg, thence
to the right leg, or may affect one
limb only. It may disappear for
days, or even weeks, then reappear
with more or less increase in the
area involved. Moyer noted, in the
early period of rigidity, when diag-
nosis was difficult, a "cog-wheel," in-
termittent resistance felt when ex-
aminer grasps the wrist with one
hand, steadies the arm above the
elbow with the other, and makes
rapid flexion and extension of arm.
The peculiarity of the tremor is
mainly due to the position assumed
l)y the extremity affected. The
iingers, for instance, assume the posi-
tion required to hold a pen, the four
straiglitened fingers, united at their
tip, tremble simultaneousl}^ while the
thumb oscillates rapidly and syn-
chronously in their direction. Or, as
is frequently the case, the movement
of the index finger and thumb is that
of rolling pills. The wrist motion is
one of supination and pronation.
This, combined with the motions of
the fingers, renders writing difficult,
then impossible. The head and face
may take part in the tremor, although
the motion of the latter is mainly
communicated to it by that of the
extremities and occurs late. These
movements occur while the muscles
are at rest, but cease when the pa-
tient is asleep. Under the influence
of the will their intensity may be re-
duced to a certain extent. Ulti-
mately, however, the tremor occurs
during sleep, and may interfere with
the patient's rest.
The muscular rigidity is a special
feature of paralysis agitans. It af-
fects the flexor muscles, the extensors
being strikinglv weak, and begins by
painful cramps which, though tem-
porary at first, finally become perma-
nent. Under the influence of this
rigidity, the head, trunk, and the
limbs assume special positions char-
acterized by stiffness. The fingers
TREMORS (TAYLOR).
581
may then assume the position ob-
served in arthritis deformans, the
first phalanx bent, the second ex-
tended, and the third bent. The head
may remain fixed in position, the eyes
become fixed, and the features ex-
pressionless and mask-like, the so-
called "Parkinson mask." There may
be dribbling of the saliva, which the
patient fails to swallow, or which ac-
cumulates in the mouth owing to in-
creased activity of the salivary gland.
As shown by Frankel, there is a well-
marked irregular thickening of the
skin, and a peculiar adherence to the
subcutaneous tissues. This is espe-
cially marked over the forehead.
When the muscles of the tongue
and lips participiate in the morbid
process, the speech becomes difficult,
slow, hesitating, monotonous, and
high-pitched. Or there may be stut-
tering, the patient attempting to
speak rapidly.
Later on the muscular rigidity
causes the thighs to become rapidly
raised toward the abdomen, but there
is no true contracture nor the epi-
leptoid tremor of lateral sclerosis, the
rigidity being due to the fact that ex-
tension becomes impossible, though
the opposite condition, fixed exten-
sion, is at times observed.
Tremor was noted in 203 of 219
cases studied in Dr. M. Allen Starr's
clinic. In rare instances this symp-
tom may be absent.
In cases of paralysis agitans which
do not exhibit the usual tremor, the
diag"nosis can readily be made on ac-
count of the characteristic attitude
and gait of the patient. The earliest
signs of the disease are stated to be
stiffness and clumsy movements in
the upper limbs on one side. The
fingers are usually specially involved,
so that the movements of flexion and
extension are generally early af-
fected, as may be also those of
abduction and adduction. Pains in
the joints, dyspeptic symptoms, and
salivation are sometimes met with
earlj^ in the disease. Oppenheim
(Deut. med. Woch., Dec. 16, 1905).
Besides the cramps already alluded
to, the patient complains of a sensa-
tion of excessive heat, showing ther-
mometrically an excess of 6° F. in
some cases (Gowers). Localized
sweating is sometimes observed.
The attitude and gait of the patient
are characteristic. While the back is
bowed and the head bent forward, the
arms, flexed at the elbows, are held .
away from the trunk. Conversely,
the knees are held so closely that
they often rub in walking. This pe-
culiar position, with the center of
gravity carried forward, causes the
patient to act, when he attempts to
walk, as if he were falling forward ;
he, therefore, trots forward as if try-
ing to save himself and cannot stop
until he meets an object capable of
holding him. The same disturbance
of gravity causes him to fall if pushed
backward.
Apart from slight paresthesia early
in the history of the disease, there is
as a result no disturbance of sensa-
tion ; the bowels and Ijladder also
continue to act normally in the aver-
age case.
The advanced stage of the disease
is characterized by a peculiar pare-
sis, and has been termed the "para-
lytic period." The tremor diminishes
greatly in intensity, and tlie patient
enters a cachectic condition, during
which disorders of nutrition occur.
He gradually sinks into a marasmus,
with diarrhea, anasarca, incontinence
of urine, and gradual reduction of
mental powers. An intercurrent af-
582 TREMORS (TAYLOR).
fection, especially i)neum(iiiia, usually disease has been found to exist in
closes the scene. relatives in 16 per cent, of the cases.
Hypertonicity of the muscles, In Hart's study of M. Allen Starr's
rather than the tremor, is the main 219 cases, 31 were directly traceable
feature of shaking palsy. Case in . ,,.^ ,• , • , ^ •
, . , , r , r to traumatism, which comes next in
which, after a few months of un- j • r
usual business worry, a man of 48 order in frequency, as a cause, to emo-
was assaulted by bandits and the tion. Ruhemann traced 7 cases out
syndrome gradually developed of of 35 clearly to an injury, the typical
Parkinson's disease, progressing till phenomena appearing shortly after
his death at 85. The nature and seat +1-,^ i„+4.„r „„j • -ji
, , -, , r , , t"^ latter and sfrowms;- rapidly worse,
of the process responsible for shak- . , • , .
ing palsy is still a mystery, and that ^^ previously emphasized by Charcot.
no authentic case of recovery is l^alz, out of 55 cases, found that in
known. Rizzuto (Policlinico, Nov. 8 the tremor developed immediately
21' 1915). after the accident. Krafft-Ebing, in
DIAGNOSIS. — It is only in its a study of 110 cases, found that in
early stages that paralysis agitans cases of traumatic origin the disease
can be mistaken for another disease, always begins at the location of the
Multiple sclerosis differs from it, in trauma, while after other causes it
that it has increased reflexes and in- starts at the upper extremity, the
tention tremor, while the tremor is hand, wrist, etc. Charcot believed,
increased by muscular movement, therefore, that the disease was due^
such as bringing a glass of water when it followed injury, to an as-
to the lips. Posthemiplegic trembling cending neuritis, a view favored by
also resembles paralysis agitans, but Krafft-Ebing, though he was unable
the history of a paralytic stroke soon to find the typical lesions of neuritis.
points to the nature of the disease. Savary Pearce attributed paralysis
Hysteria may simulate perfectly pa- agitans to commotion of the brain
ralysis agitans mainly, however, when it occurs as a consequence of
through autosuggestiveness. By con- traumatism.
suiting the review of tremors sub- A disorder of the ductless glands
mitted at the beginning of this has been suggested by various writ-
section, each form can readil)^ be ers. The presence of several symp-
identified. toms of myxedema was observed
ETIOLOGY, PATHOGENESIS, by Lundborg, Moebius, and others.
AND PATHOLOGY. — Paralysis Again, while thyroid extract has been
agitans usually occurs in subjects found of value in cases, Horsley long
above the age of 40 years, and most ago, and also Dercum, noted that
frequently between 50 and 60. It is thyroidectomy caused symptoms sim-
oftener observed in men than in ilar to those of paralysis agitans.
women. Emotional factors, grief, Castelvi found the thyroid sclerotic
worry, shock, appear as the main ex- and atropied in two cases of this dis-
citing cause, after which come trau- ease. That it "might be the result
matism, infectious diseases, alcohol- of some glandular secretion" was
ism, exposure, overwork and sexual suggested by Dana in 1899. Lund-
excesses. Direct hereditary transmis- borg (1903), Berkley (1905), and
sion can rarely be traced, though the others iscribed it to insufBciency of
TREMORS (TAYLOR).
583
the parathyroids, and Castelvi, to
hypothyroidism.
The disease has been attributed by
Moebius, Frankel, Burzio, and others
to intoxication. That toxic sub-
stances accumulated in the blood can
cause tremor is suggested by Hock's
case, in which an enlarged prostate
was also present. During the peri-
ods of urine retention the tremor
became intense, though, when the
elimination of urine was not pre-
vented, not very marked. Dana, in
1893, ascribed the tremor to "micro-
bic toxins," and Gauthier to toxics of
muscular origin. In 5 out of 7 cases,
the urine was found to contain a
large excess of phosphoric acid.
While these pathogenic factors,
taken individually, do not account for
the disease, a possible clue to its
cause is suggested when all of them,
collectively, are taken into account.
Thus, emotion, grief, shock, trauma-
tism, and other causes enumerated
are all conditions which tend, either
by commotio cerebri or otherwise, to
debilitate the organism. That the
ductless glands are themselves de-
bilitated functionally along with all
other organs is self-eyident. If, with
Sajous, we grant the ductless glands
a leading role in tissue metabolism,
and in the defensive functions of the
body, their debilitated state renders
them inadequate to carry on these
functions, and the toxic wastes they
should destroy accumulate in the
blood, initiating and perpetuating a
condition of the arteries akin to
senile degeneration, but presenting
elements of arteriosclerosis, as
Sajous holds, sufficient to initiate
and sustain the process of denutri-
tion. Modern methods of staining
sustain this view. Thus Gordinier, in
a study of 24 cases, found uniformly,
thickening of the vascular walls with
perivascular increase of neuroglia
and sclerosis with degeneration, and
atrophy of the nerve-cells and fibers.
From Sajous's viewpoint, then, the
cause of paralysis agitans should not,
as has been done, be attributed to a
single factor. We should rather look
upon the disease as the result (1) of
any morbid influence capable of dis-
turbing, through shock, emotional,
traumatic, or chemical, the physical
integrity of nerve-centers, cerebral
and spinal, including those govern-
ing the functions of the ductless
glands ; (2) of a diminution of the
antitoxic efficiency of the latter or-
gans, thus permitting an accumula-
tion of toxic wastes in the blood ; (3)
of degenerative changes in the walls
of the cerebrospinal and muscular
blood-vessels and in the nerve-cells.
All these factors acting in patholog-
ical sequency, and finally conjointly,
in an individual predisposed to tro-
phic degeneration, through age or
other contributory condition, best ex-
plain the development of the disease
and its lethal trend.
TREATMENT.— The foregoing
pathogenesis accounts for some of
the beneficial results obtained, and
suggests measures through which
the disease may be met with some
degree of success.
Organotherapy has been tried ex-
tensively in this disease, but although
benefit has been claimed for various
preparations, it does not appear to
have efl"ected more than improve-
ment. Thus parathyroid gland was
tried by Berkley, Dana, A. A. Smith,
F. L. Taylor, Grinnan, Petersen, FI.
II. Jane way, and R. Kingman, with
results varying from "improved" to
584
TREMORS (TAYLOR).
"really extraordinary improvement,"
a negative result being- obtained in
only one child. "All the ])atients re-
marked upon a curious increase in
courage, comfort and mental energy
while taking the remedy." Berkley
states that the extract degenerates
rapidly, and that it should be tested
physiologically beforehand ; this may
account for the negative and even
harmful results noted by others.
Thyroid failed also to produce last-
ing results. It is probable, however,
that parathyroid extract (gr. y^^) —
0.0013 Gm.) given early in the case
and gradually increased would give
better results. As Sajous pointed out,
and as confirmed by others since, the
parathyroid is the main antitoxic fac-
tor of the thyroid mechanism. This
action accounts, in the light of the
pathogenesis submitted, for the bene-
ficial effects obtained.
Encouraging results have also been
obtained by treating the case as if it
were one of arteriosclerosis. This
subject has been considered in full
in the article on that disease.
Antispasmodics merely depress the
sensitiveness of the centers. They do
not promote a curative process,
therefore, and merely control the out-
ward manifestations of the disease.
Hyoscine hydrobromate, duboisine,
the bromides, including camphor bro-
mide and belladonna, are the agents
most used.
Hyoscine hydrobromate, suggested
by Erl), has given the best results
that can be expected from these
agents, i.e., temporary relief of the
trembling, pain, restlessness, insom-
nia, and some relaxation of the rigid-
ity. Administered hypodermically, it
causes pain and dryness of the mouth,
while the risk of intoxication is in-
creased. It is preferably given in
small doses, beginning with ^/4oo-
grain (0.0003 Gm.) doses, twice a
day. This may be cautiously in-
creased up to ^-,0 grain (0.0004
Gm.). All the nervous symptoms,
trembling, restlessness, and flushing
particularly, have been known to
cease under the influence of %o grain
(0.001 Gm.), but such doses cause a
distressing dryness of the throat,
rapidity of the pulse, and dilatation
of the pupil. Only freshly prepared
solutions can be depended upon.
Rest aids the remedy in promoting
the desired effects. The addition of
chloroform-water, 2 drams to each
dose, was recommended by William-
son, who obtained better results from
this sedative than frorn any other.
Duboisine sulphate, introduced by
Mendel, is preferred by some neurol-
ogists. It also mitigates the tremor
and relaxes the rigidity. It has been
employed in doses of Yioo grain
(0.0006 Gm.) to Yqq grain (0.001
Gm.), but these larg-e doses may
also induce dryness of the mouth,
nausea, vertigo, and visual disturb-
ances. These signs of intolerance in-
dicate that the use of the remedy
should be discontinued.
Morphine is recommended by no
less an authority than Krafft-Ebing,
l)Ut its tendency to constipate and the
danger of morphinism must not Ije
overlooked. Buia recommends intra-
venous injections of a 5 per cent,
solution of sodium nucleinate in nor-
mal saline solution, beginning with
% grain (0.01 Gm.), then giving %
and y^ grain (0.02 and 0.05 Gm.) up
to 1^ grains (0.1 Gm.) every three
da3^s. Five injections should thus be
given in series, to be followed by an
interval of five to ten days, after
TREMORS (TAYLOR).
585
which the initial smallest dose should
again be started with. When such
doses no longer produce the desired
febrile reaction, the amount may be
increased up to 5^4 to 6 grains (0.35
to 0.4 Gm.). The solution used must
always be freshly prepared.
Passive exercises have been recom-
mended by a number of writers. My
own method consists in the execution
of a series of carefully arranged
movements, both passive and active,
by which the contractions are over-
come, the joints loosened, and flexi-
bility therefore induced. Further,
education of the voluntary move-
ments is important, especially of the
extensors of the arm and flexors in
the legs. Massage to the back is
also employed. The entire surface of
the body should be rubbed twice a
da}^ for from five to ten minutes.
MULTIPLE SCLEROSIS. — SY-
NONYMS. — Disseminated multiple
sclerosis; Disseminated nodular scle-
rosis ; Insular sclerosis ; Sclerose en
plaques.
DEFINITION.— A chronic disease
of the brain and spinal cord, charac-
terized by the presence of fibrous or
sclerotic patches disseminated in
these structures, the most prominent
symptoms of which are intention
tremor, scanning speech and nystag-
mus.
SYMPTOMS.— The variability of
the onset, which may be sudden or
gradual, and the frequent presence of
lesions other than those to which
multiple sclerosis is due, besides the
irregular distribution of the subjec-
tive symptoms render its earlier
diagnosis difficult until the charac-
teristic symptoms enumerated in the
definition appear. As we have seen,
intention tremor occurs when a vol-
untary eftort is made, such as raising
a glass of water to the lips, picking
up objects, bringing the fingers of
one hand against those of the other,
etc., the trembling ceasing at once
with the efifort. It affects also the
head when it is raised from the pil-
low. In the second important symp-
tom, scanning speech, the envmcia-
tion, though slow and measured, is
indistinct, owing to defective co-or-
dination of the larynx, tongue, and
lips, both the latter organs being the
seat of tremor. Nystagmus, rapid
oscillations of the eyeballs from side
to side, is another striking phenom-
enon. Optic atrophy, sometimes pre-
ceded by optic neuritis, is present in
40 per cent, of the cases.
Eye symptoms may develop early
and for a long time may be the
only manifestations of the disease.
Uhthoff estimated that multiple scle-
rosis is responsible for 45 per cent,
of all the cases of rctrobull:)ar neu-
ritis; Oppenheim, 50 per cent, and
Fleischer 65 per cent. It occurs
acute and fleeting, with recurrence
in the same or the other eye, with
intervals of months or years, in one
case six j^ears. The ephemeral re-
trobulbar neuritis with multiple scle-
rosis develops with the ordinary
syndrome; headache, pains in and
back of the eyeball, increased by
movements of or by pressure on it;
there may also be dizziness and
flashes before the ej^es, and central
scotoma develops. The impairment
of vision brings the patient to the
physician. H. Gjessing (Norsk Mag.
f. Lacgevid., Feb., 1915).
Increased tendon reflexes and other
spastic phenomena are commonly ob-
served, leading ultimately to spastic
rigidity. Paresis, leading up to pa-
ralysis, may occur with spastic phe-
nomena as early signs, but the
spiiincters remain quite normal until
586
TREMORS (TAYLOR).
toward the close. The paretic phe-
nomena may be ephemeral — the so-
called hysterical or intermittent type
— and be preceded or accompanied by
disturbances of sensibility.
While these phenomena may be said
to represent the salientcs of a classical
case, it must be borne in mind that
the location of the lesions in the
brain or various parts of the cord
may alter the picture materially.
Thus in the most common of these
aberrant forms, the spinal, progres-
sive paraplegia unaccompanied by
sensory disturbances, may predomi-
nate. The lesions may even be lo-
calized in the sacrum, and cause
disturbances of the sphincters and
sexual functions, and also pains in
the lower extremities. The compara-
tively rare cerebral type may, con-
versely, be initiated with vertigo,
headache, vomiting, and eventually
lead to melancholia, or the opposite,
exaltation, imbecility, etc., though in
rare instances. Apoplexy with cere-
bral hemiplegia has also been ob-
served.
DIAGNOSIS.— When the Charcot
triad : the intention tremor, scanning
speech and nystagmus are present,
the diagnosis is readily made. Multi-
ple sclerosis differs from paralysis
agitans, in that in the latter the
tremor is not of the intentional type.
B'rom Friedreich's disease, which also
affects several members of a family,
there is flaccidity of the muscles and
no spasm, nor eye symptoms. In
hysteria the symptoms of multiple
sclerosis may be faithfully repro-
duced, but they are ephemeral; yet
post-mortem findings indicate that
true multiple sclerosis may, in turn,
simulate hysteria. The various forms
of tremor should be differentiated
from the toxic forms through their
history and symptoms, etc. None
really present the characteristics of
multiple sclerosis.
ETIOLOGY. — Multiple sclerosis
is rarely met, even in European
clinics where uncommon diseases are
carefully sought out for purposes of
study. The majority of cases occur
in subjects between 20 and 40 years
of asfe ; it is sometimes witnessed in
children, and occasionally in several
children of the same family. But in-
fectious diseases, syphilis, scarlet
fever, smallpox, typhoid fever, and
many others are its principal cause ;
in fact, it may follow either one of
these diseases after very few weeks
or months. The toxics which, we
have seen, may cause tremor — lead,
mercury, arsenic, copper, zinc, etc. —
may also cause multiple sclerosis.
Overwork, cold, traumatisms, and ex-
cesses have also been incriminated,
but not on very substantial grounds.
Syphilis, in rare instances, may
cause a symptomatology indistin-
guishable from that of typical multi-
ple sclerosis, and this without the
formation of sclerotic plaques, but
by the ordinary lesions of syphilis,
viz., arteritis and meningitis. Syph-
ilis may also produce in the spinal
cord sclerotic plaques resembling
those of multiple sclerosis, without
producing the typical symptoms of
this disease. Spiller and Woods (Univ.
of Pa. Med. Bull., Mar., 1909).
In a case of multiple sclerosis in
a man of 18 years, whose father was
syphilitic and tabetic, the most
prominent symptoms were ataxia,
Romberg's, symptom, Argyll-Robert-
son pupil, transient palsies of left
leg and right arm, transient oculo-
motor palsies, unequal pupils, trem-
ors, and speech disturbances. Mental
symptoms were those of progressive
dementia and euphoria. The clinical
TREMORS (TAYLOR).
587
diagnosis was paresis, but necropsy
proved it to be a case of multiple
sclerosis with widely disseminated
lesions. F. X. Dercum (N. Y. Med.
Jour., June 8, 1912).
PATHOLOGY. — Multiple sclero-
sis affects both the white and gray
substance, mainly the white sub-
stance, of the brain and the myelin
of nerves. The patches may form
anywhere, and may differ in size
from that of millet seed to that of a
walnut. They may occur on the sur-
face or in the depths of the cerebro-
spinal system from the brain to the
filum terminale of the cord, and may
number several hundreds. In the
nerves, the axis-cylinders are usually
respected, but their myelin may be
destroyed; gliosis is marked in prac-
tically every instance. The vessels
in the patches show marked altera-
tions, their coats, the external partic-
ularly, being considerably thickened.
PROGNOSIS.— The only hopeful
cases are those which show a ten-
dency to remissions. Occasionally
such ultimately recover. The possi-
bility of apoplectiform seizures should
be borne in mind when dealing with
cerebral cases, and reserve be the
rule as to prognosis. In steadily pro-
gressive cases showing no remissions,
the outlook is always very grave. If
the patient is optimistic as to his
ultimate recovery, this should, how-
ever, be left undisturbed, encourage-
ment being, in fact, decidedly helpful.
TREATMENT.— The cause of the
disease should be sought, and, if pos-
sible, removed. This applies as well
to the cases of toxic origin — lead,
mercury, alcohol, malaria, etc. Thus,
in a case of plumbic and mercurial
origin the iodides and electricity will
prove useful ; in the malarial cases.
quinine; in the syphilitic, salvarsan
or biniodide of mercury. The cases
due to acute infectious diseases are
sometimes benefited by the early use
of the specific antitoxin. The salicy-
lates may prove helpful where rheu-
matism— itself perhaps due to strep-
tococcic infection — may be traced.
While the patient's strength should
be conserved, confinement to bed is
harmful. So are warm baths, mar-
riage, and pregnancy. Light massage
or effleurage, regulated gentle exer-
cises in the open air, in a warm cli-
mate are helpful. Of the remedies
which have shown some value in
practically all cases of undetermined
orioin have been arsenic in small
doses, and potassium iodide also in
small doses. Scopolamine hydrobro-
mide is useful to check the tremor.
The writer gives every second or
third day a hypodermic injection of
15 minims (0.9 c.c.) of the following
solution: —
IJ Scopolaviiiie Ity-
drobromide .. gr. y-, (0.013 Gm.).
Distilled water.. 3v (20 c.c).
Cherry laurel
water 3v (20 c.c).
M.
The treatment should be sus-
pended if symptoms of intolerance
are shown, such as mydriasis, dry-
ness of the throat, sleeplessness, etc.
Boteano (Jour, de med. de Paris,
Apr. 4, 1908).
Thiosinamine has been recom-
mended by Frankel, but the numer-
ous cases of this rare disease to which
he refers suggest the possibility of
erroneous diagnosis in a large num-
ber of instances, the drug having
proven inefficient in other hands.
Thiosinamine often dues a great
deal of good. During the last four
years 75 cases of multiple sclerosis
were treated with this drug by the
588
TRICHOPHYTOSIS.
author, and of these 33 showed no
imprt)vemcnt and 15 a decided im-
provement. One course of treat-
ment usually consisted of one injec-
tion of 2.3 c.c. (37 minims) every
third to fourth day into the nates
for six weeks. Baths, massage, gym-
nastics and electricity assist the
action of the drug. M. Frankel
(Neurol. Centralbl., nu. 1, 1913).
J. Madison Taylor,
Philadelphia.
TRICHOCEPHALUS DISPAR.
See P.\K.\siTES, DisEA.sE.s Due to.
TRICHOPHYTOSIS. - T r i c h o -
phytosis, or ringworm, is a fungous dis-
ease attacking the general surface of the
body, the scalp, the beard, and the nails.
It may be caused Ijy either of two para-
sitic fungi — the Microsporon audoxiini, or
small-spored fungus, and the trichophyton,
or large-spored fungus, of which there are
several varieties.
The varieties of ringworm are: (1) Tinea
circinata (ringworm of the body, herpes
circinatus, tinea trichophytina corporis);
(2) Tinea tonsurans (ringworm of the scalp,
herpes tonsurans, tinea trichophytina cap-
itis); (3) Tinea sycosis (barber's itch,
parasitic sycosis, ringworm of the beard,
tinea trichophytina barbse) ; (4) Tinea cruris
(ringworm of the genitocrural region,
tinea trichophytina cruris, eczema mar-
ginatum); (5) Tinea tinguium {onychomy-
cosis, ringworm of the nails). Varieties 2,
3, and 5 have already been considered.
(See Tinea in the fifth volume, page 159.)
SYMPTOMS.— Tinea circinata is char-
acterized by vesiculosquamous patches, in
the shape of rings, upon the cutaneous
surface. Beginning as irregular, pea-
sized, hyperemic, scaly patches, they as-
sume, in a few days, a circular shape with
very fine papules or vesicles around the
border. As the patches spread, the cen-
ters heal and the patches become ring-
shaped, dull pink or red in color, with
borders slightly elevated and the seat of
a brawny desquamation. Gyrate lesions
are formed by the confluence of adjacent
patches. Exceptionally patches are ob-
served with several concentric rings, or
the centers may not become cleared, in
which case the lesions are circular, but
not annular. More rarely, the lesion is
an elevated plaque with deep involvement
of the skin, small pustules occupying the
sites of the hair-follicles. The lesion of
ringworm is often a solitary one, usually
few in number, more rarely in large num-
bers on the face, neck, arms, l)acks of
the hands, and body. Itching is usually
slight.
In tinea cruris, the lesion very closely
resembles tliat of eczema intertrigo, the
patches being dull brownish-red in color,
the border often with well-defined mar-
gins, at times slightly elevated. The erup-
tion may spread very rapidly, involving
the thighs, groins, genitals, mons veneris,
and nates. Eczema is a frequent compli-
cation, with severe itching, especially at
night.
In tinea imbricata, a form of tropical
body ringworm, large areas of the body
become the seat of brownish, concentric
rings, and large-sized scales, giving the
body the appearance of being clay-cov-
ered. The face and scalp are usually
unaffected.
ETIOLOGY.- — Tinea circinata is more
common in children. It is transmitted b^-
contact and through toilet articles (towels,
etc.). Cats and dogs are a common source
of the disease.
PATHOLOGY.— The fungus is found
in the epidermis, especially in the corne-
ous layer. The mycelium, consisting of
long, slender, sharply contoured, bifur-
cated, joined threads, is abundant. The
spores, rounded, highly refractile bodies,
varying from Mooo to %on inch in diam-
eter, are scanty. For examination, the
scales are scraped off with a knife, placed
on a microscopic slide, a drop of caustic
potash (10 to 40 per cent.) added, and the
cover-glass applied with sutTicient pres-
sure to flatten out the scales. The fungus
can be seen with a %-inch objective, but
more in detail by using a M2 immersion
lens.
PROGNOSIS.— Although this disease
usually yields promptly to treatment, tinea
cruris is more rebellious.
TREATMENT.— Parasiticide ointments ■
and lotions, of mercury, sulphur, beta-
naphthol, resorcin, tar, picric acid, sodium
carbonate, iodine, and chrysarobin are all
TRIONAL.
589
efficient. Sodium thiosulphate solution
(1 to 8 of water) and mercury bichloride
(H grain — 0.03 Gm. — to the ounce — 30 c.c.
— water) are effectual applications.
Care must be taken in tinea cruris to
prevent an acute dermatitis; soothing
parasiticides are best here; the stronger
remedies should be avoided.
Cutaneous epidermic ringworm is cured
by tincture of iodine diluted with five
times its volume of alcohol. When ring-
worm is unaccompanied by inflammation,
as in the common ringworm of children,
the X-ray well managed is the method of
election (Sabouraud). W.
TRIGGER FINGER. See Ten-
dons, BURS.^ AND FaSCI.E, DISEASES OF.
TRIONAL.— Trional, or diethylsul-
phonemethylethylmethane (C.sHisS204),
is the trade name of SHlflionethylmethan-
ttJii, U. S. P., an oxidation product of
mercaptol. It occurs as colorless, lus-
trous, odorless, crystalline scales, having
a bitter, camphoraceous taste in watery
solution. It is soluble in 195 parts of
water at 77° F. (25° C), more readily in
boiling water, and readily soluble in al-
cohol and ether. It is given in doses of
from 15 to 30 grains (1 to 2 Gm.), in
powder, capsule, or cachet, in seltzer
water, or with large quantities of hot
liquids, milk, soup, or beer, because of
its sparing solubility; it should not be
massed except on addition of other agents
to aid in its disintegration.
PHYSIOLOGICAL A C T I O N.— H.
Koppers found that trional acts upon the
cortex of the brain, that it does not affect
the respiration rate, that blood-pressure
is slightly reduced, and that a certain
amount of caution should be used in
cardiac cases. Later experiments by
Shick, and confirmed by Ott, show that
trional does not affect the irritability of
motor nerves, leaves the sensory nerves
intact; but depresses the reflex excitability
and acts as a narcotic. Trional at first
hastens the pulse rate, but afterward de-
presses it, the arterial tension being at
first raised and then afterward lowered.
The respiration rate is slightly increased.
Kornfield claims that trional acts by de-
pressing the central nervous centers and
along with others the vasomotor center,
and hence the fall in blood-pressure. The
action of trional is more marked if the
patient is quiet and not disturbed by pain
or excitement. Action normally takes
place in 20 to 30 minutes after the drug
is ingested.
POISONING BY TRIONAL.— There
appears to be a strong resemblance be-
tween the symptoms due to the cumulative
effect of trional taken for a considerable
length of time and those due to acute
poisoning.
The symptoms of acute poisoning are
those of acute gastrointestinal poisoning
with marked loss of equilibrium, vertigo,
ataxia, vomiting, and watery diarrhea,
which may change abruptly into consti-
pation. The bodily temperature becomes
subnormal, the pulse becomes small and
rapid. The urine becomes strongly acid
and there may be hematuria with hyaline
and granular casts and albumin. Somno-
lence, hallucinations, marked cutaneous
hyperesthesia, stertorous breathing and
cyanosis have followed in some cases; in
others dizziness, headache, and tinnitus
auriuni.
Chronic trional poisoning is character-
ized by anorexia, vomiting, constipation,
and epigastric pain. Collapse and death
may supervene. Hematoporphyrin is usu-
ally found in the urine and casts are not
infrequent. Cardiac weakness appears and
dilatation murmurs may develop at the
aortic and mitral valves. Multiple neu-
ritis is not uncommon.
Treatment of Poisoning by Trional, — If
seen promptly, siphon out the stomach
with plenty of warm water by means of
a stomach-tube. In absence of tube give
emetic of mustard (4 drams in 1 to 4 fluid-
ounces — 15 Gm. in 30 to 120 c.c. — water),
zinc sulphate (20 grains in 1 fluidounce —
1.3 Gm. in 30 c.c. water), or 2 to 4 minims
(0.12-0.25 c.c.) of a 2 per cent, solution of
apomorphine hydrochloride hypodcrmat-
ically. To eliminate the drug from the
system give spirit nitrous ether, 1 to 2
fiuidrams (4 to 8 c.c.) and magnesium sul-
phate, 1 ounce (30 Gm.) in a tumblerful
of water. Give freely of water made al-
kaline with sodium bicarbonate. To coun
teract the depressing symptoms, give
abundance of strong coffee or titrated
590
TROPACOCAINE.
caffeine, 2 to 3 grains (0.12 to 0.2 Gm);
for cardiac weakness give camphor, and
for colic administer morphine.
THERAPEUTIC USES.— Trional is
chicn}- used as an hypnotic. Sleep is
usually induced promptly, within 10 or 15
minutes, the sleep being calm and natural
and the awakening normal and free from
after-effects, except that there is a ten-
dency to sleep during the next day.
If the drug has no efifect after 2 or 3
successive nights, it should be replaced
by some other hypnotic. Interruption in
its use from time to time is advised ta
avoid cumulative effects. The constipation
caused by its use should be relieved by
appropriate remedies, and the hyperacidity
of the urine diminished by the use of al-
kaline drinks.
In epilepsy, S. Weir Mitchell found that
trional was benelicial; either the number
of attacks was diminished, their severity
lessened, or the general physical condi-
tion of the patient improved. In simple
agrypnia, melanchoHc depression, condi-
tions of moderate oppression, as well as
in mania not attended by violent halluci-
nations, a refreshing sleep of from 6 to 8
hours was often obtained from the use
of trional. In the more active conditions
of excitement of chronic mania, and in
paralysis accompanied by moderate motor
restlessness, larger doses (30 grains — 2
Gm.) gave reliable results, the efifect being
absent or very slight on the first, but satis-
factory during the following days. In
paralytics suffering from extreme motor
and psychical maniacal excitement satis-
factory effects were seldom obtained from
similar doses, while in many cases 45
grains (3 Gm.) proved inactive. W.
TROPACOCAINE. -This alka
loid [CsH^NOcCtIIsCO)], called also
benzoylpseudotropeine, is obtained from
the leaves of a Java coca plant. It differs
markedly from cocaine in its constitution
and also in its therapeutic effects in hav-
ing slight mydriatic properties, besides
being about one-third as toxic as cocaine,
but in no wise inferior in local anesthetic
power. The hydrochloride is usually em-
ployed in solutions varying from 3 to 5
per cent, and in amount not exceeding
1 grain (0.06 Gm.).
PHYSIOLOGICAL ACTION.— T h e
action of troiiacocaine hydrochloride as a
local anesthetic in ophthalmcjlogy has
been studied by Annin. The tests were
made with 3 and 5 per cent, solutions in
boiled water or normal physiological salt
solution. The dropping of the solution
into the eye causes some burning and
lachrymation. Anesthesia of the cornea
and conjunctiva is complete in one minute,
but does not last very long; 3 drops of
a 3 per cent, solution causes complete
anesthesia lasting from 2 to 4 minutes,
and is followed by an incomplete anes-
thesia for 2 to 3 minutes; from 3 drops
of the 5 per cent, solution complete anes-
thesia lasts 3 or 4 minutes, followed by
an incomplete anesthesia for 2 to. 5
minutes. Tropacocaine has a slight myd-
riatic effect, but practically no effect upon
accommodation or intraocular pressure.
The diffusion into the anterior chamber is
considerably increased, especially when
the solution is made with plain water.
The corneal epithelia are softened, but
the deeper layers of the cornea are un-
affected. Tropacocaine does not become
changed on boiling; its solution can there-
fore be easily sterilized. Solutions in dis-
tilled water may be kept for months
without losing their anesthetic power or
developing fungous formation.
When full doses are administered by
lumbar injection, a feeling of oppression,
occasional pallor, cyanosis of the lips, and
a tendency to syncope are noticed. The
blood-pressure is lowered and respiratory
depression occurs. After the anesthetic
effects have passed off there are some-
times headache and backache; in a few
instances a trace of albumin appears in
the urine, due apparently to some toxic
action of the drug on protoplasm, but no
permanent ill effects on the kidneys have
been reported.
UNTOWARD SYMPTOMS are met
with diffusible stimulants, pituitrin, saHne
infusion and artificial respiration,
THERAPEUTIC USES.— Tropacocaine
is used as a local anesthetic for short
operations on the eye and skin, and ex-
tracting teeth and roots. It may be used
for applying painless cauterization, in the
treatment of peripheral neuralgias, con-
tusions, distortions, sprains, painful
TRYPANOSOMIASIS, OR SLEEPING SICKNESS.
591
bruises, etc., in arthritic pain, and as a
means of diagnosis in differentiating be-
tween peripheral, central, or reflex neural-
gic processes, and between simulated and
actual pain.
It is used by lumbar puncture, for
operations on the legs and perineum,
}i grain (0.05 Gni.) being sufficient, but
for abdominal operations 1 grain (0.06
Gm.) is required; it should not be used
on children less than 14 years old, but old
age is not a contraindication. W.
TRYPANOSOMIASIS, or
SLEEPING SICKNESS. -This dis-
ease is rarely observed outside of Africa,
where it is due to the presence, mainly in
the blood and cerebrospinal fluid and swol-
len lymph-nodes, of a parasite, the try-
panosoma, a flagellated hematozoon com-
monly found in animals. The parasite is
about three times the diameter of a red
corpuscle, fusiform and prolonged into a
single flagellum at one end. It is trans-
mitted to man through the bite of the
tsetse fly (Glossina palpalis), which is not
known to exist on the American continent.
SYMPTOMS.— The period of incuba-
tion, though not clearly established, is
very long. While the onset is gradual in
negroes, in the white race it may be sud-
den and manifest itself by fever, but with-
out chills or marked sweating, which lasts
from two to four days; it is followed by
a remission during which hypothermia
may occur, and is uninfluenced by quinine.
Enlargement of the posterior cervical
lymph-nodes, often followed by polyade-
nitis, is usually discernible soon. At first
the nodes are no larger than a small pea
and soft, but on puncture are found to
contain trypanosomes. They afford, there-
fore, opportunity for early diagnosis.
Deep-seated pains and marked sensitive-
ness of the tissues on pressure also ap-
pear early.
Cutaneous lesions are more apt to occur
in the white than in the black race. They
usually consist of papulovesicular patches
of erythema, especially numerous on the
thorax; areas of edema beginning, as a
rule, in the eyelids, may extend to the
face, then appear at the ankles and some-
times involve the whole body.
The foregoing symptoms may constitute
the whole syndrome for a long time in a
given case. Then appear the nervous phe-
nomena which coincide with the appear-
ance of trypanosomes in the subarachnoid
space and other areas of the cerebro-
spinal system. While the patient becomes
listless and dull and readily lapses into
periods of drowsiness, vagaries of disposi-
tion, emotional outbursts, weeping, anger,
etc., intersperse at first the growing men-
tal torpor. Tremors and even epileptic
seizures and also symptoms of insanity
with homicidal tendencies and one of
various spinal disorders may appear, espe-
cially in the white race.
The mental torpor during the intervals
between these acute manifestations is now
accompanied by the symptom which dis-
tinguishes the disease. As the hebe-
tude increases, drowsiness becomes more
marked, until it lapses into a practically
continuous sleep. At first the patient may
be roused, especially at mealtime, but this
becomes increasingly difficult. A stupor-
ous state then leads to coma and the pa-
tient dies unless, as is often the case, an
intercurrent disease carries him off before
this stage is reached.
DIAGNOSIS.— During the long period
of incubation and before the fever stage
begins, the only signs are the enlargement
of the cervical glands and the presence of
trypanosomata in fluid drawn from these
nodes. After the fever stage has begun
the afternoon febrile process and also the
change of disposition, excitability, etc.,
will afiford additional evidence. The in-
efficiency of quinine in the treatment is
also suggestive. For the detection of the
parasite the Romanowski technique (see
vol. V, p. 379) should be employed. It is
not always readily found and a daily ex-
amination for a considerable period is
sometimes necessary early in the history
of the case.
PROPHYLAXIS.— Wherever it has
been possible to rid the land of bush,
grass, etc., on the shores of rivers, lakes,
etc., where the blood-sucking Glossiua pal-
palis thrives, great good was done. Re-
moval of an infected tribe to an unin-
fected region also proved preventive; but
on return to the infected region, the in-
sects were not found to have lost their
power to convey the trypanosome owing
592
TUBERCULOSIS, ACUTE (SAJOUS).
to the presence in the region of infected
animals, game, etc. The partially clad
natives being more frequently attacked
than the Europeans, covering of the ex-
posed tissues with mosquito netting and
screening of dwellings are also indicated.
TREATMENT. — Arsenical preparations
have on the whole given the best results.
Atoxyl, which is more toxic when given
by the mouth than when administered in-
tramuscularly, TYi grains (0.5 Gm.), may
be given twice weekly in 10 per cent, solu-
tion. Mercier and Gamble have cured
thus 66 per cent, of their cases. Atoxyl
acts directly upon the trypanosomes and
■ they gradually decrease in nundier. It is
most efficient before the nervous phe-
nomena appear, and should be persisted
in, but discontinued for a time if toxic
symptoms — headache, faintness, dryness
of the throat, strangury and disturbances
of vision — appear. Arsenophenylglycin, a
yellow light powder introduced by Ehr-
lich, is also very efticient, but more poi-
sonous than atoxyl. Among alternates or
substitutes which have been used with
more or less satisfactory results where
atoxyl could nnt be obtained have been
sodium cacodylate, quinine cacodylate.
Fowler's or Donovan's solutions, arsenous
acid, and iron arsenate. The young were
found by Laveran to yield more readily
to treatment than adults. In some cases
a combination of two preparations suc-
ceeds where a single one fails. The addi-
tion of strychnine to the arsenical used is
also helpful. A change of the kind of
preparation is sometimes necessary, Ehr-
lich having shown that trypanosomes
gradually acquire an artificial immunity to
certain drugs. Salvarsan and neosalvar-
san have not met expectations.
Report based on 370 cases. In the
first or fever stage best results are
obtained by a comljined oral, intra-
muscular, and intravenous treatment.
Orally the following is used: Tartar
emetic, % grain (0.03 Gm.); caffeine,
2 grains (0.12 Gm.); tartaric acid, 5
grains (0.3 Gm.); tinctures of opium
and of nux vomica, of each 5 minims
(0.3 c.c); chloroform wrater, enough
to make 1 ounce (30 c.c). One
ounce /. I. d., in water. Intramuscu-
larly, soamin, 0.25 to 0.77 Gm. (4 to 12
grains), is given every five days. In-
travenously, a 2 per cent, solution of
tartar emetic is used on alternate
days in doses of 4 to 12 c.c. (1 to 3
drams), increased by 1 c.c. (16 min-
ims) at each injection until toxic
symptoms arise. The dose is then
reduced by 1 c.c. and maintained. A
week's rest is given after five weeks'
treatment. Recovery followed in 3.9
per cent, of cases and improvement
in 27.9 per cent. Masters (Jour, of
Trop. Med. and liyg., Feb. 1, 1918).
Various antimonial compounds have
been used with some success. Rankm
(1913) found precipitated metallic anti-
mony the most effective agent, beginning
with a 1-grain (0.065 Gm.) dose, watching
closely its effects, and if no untoward re-
sult occurs, ly. grains (0.1 Gm.) repeated
at intervals of four days. Each dose is
.stirred in a glass mortar with Yz ounce
(15 Gm.) of saline solution, a funnel and
tube, with a large needle, being used.
Saline solution is run in before and after
the antinidny suspension. The sodiotar-
trate of antimony may be given in from 1
to 2 grains (0.06 to 0.13 Gm.) with a glass-
ful of water, but orally only. Various
other salts are being tried, including the
supposedly non-toxic trioxide of antimony,
in a 30 per cent, oil emulsion given intra-
muscularly. Antimonial preparations have
been found to act harmoniously with ar-
senical preparations, and as temporary
substitutes. Among other agents tried
may be mentioned trypan-red parafuchsin
and other dyes; mercuric bichloride,
methylene blue, thyroid gland, etc., but
none, so far, have approached in value
either the arsenical or the antimonial
preparations. £.
TUBERCULOSIS, ACUTE -
Acute tuberculo-sis is the result of a
more or less sudden development of a
tubercular process either in the body
at laro-e or in one or more org-ans. It
may be primary or secondary, and
usually follows a rapid and fatal
course. It is mainly observed clinic-
ally in the form of acute miliary tuber-
culosis and acute pneumonic phthisis.
TUBERCULOSIS, ACUTE (SAJOUS). 593
ACUTE MILIARY TUBERCU- more or less fever, which tends to in-
LOSIS. crease rapidly, the temperature reach-
Acute miliary tuberculosis is the ing 104° F. (40° C.) or more. Occa-
result of a sudden formation of sionally, however, afebrile cases are
miliary tubercles in one or more met. With the high fever there ap-
organs. In the vast majority of in- pear mental torpor, hebetude, soon
stances the primary focus of infection followed by low delirium, with the
is either a pulmonary tuberculous typical dry and brownish tongue of
nodule or a group of tuberculous the typhoid state, the face being either
lymphatic glands, the tracheobron- pale or dusky, the cheeks showing a
chial nodes in particular. Any tuber- circumscribed bluish or reddish area,
culous structure may, however, act as The evening rise of temperature may
focus of infection and thus initiate also occur, but not regularly, the
a fulminating type of tuberculosis diurnal rise sometimes appearing in
which may prove fatal within a few the morning. The pulse is extremely
weeks. The pre-eminent role of rapid, and out of proportion with the
tuberculous bronchial glands in the fever.
process, and the various signs through The respirations are hurried, and
which their presence may be recog- more or less cyanosis is usually ob-
nized, have been reviewed in the served. There is some cough, but the
article on the Thymus and Lym- expectoration is slight and mucoid
PHATic Glands, on page 538. The unless a tuberculous focus be present
lymphatic vessels and veins, into in the lungs. Profuse sweating and
which a tuberculous abscess may rup- sudamina are common and herpes
ture, represent the most usual inter- likewise, but rose-colored si)ots are
mediaries for the dissemination of the rarely, if ever, witnessed. The spleen
infection. Acute tuberculosis occurs is usually enlarged ; there is no diar-
in most instances in adolescents and rhea, but intestinal hemorrhage may
children. occur. The clioroid is often the seat
Three forms or clinical varieties of of tubercles. Some degree of peri-
miliary tuberculosis are recognized : carditis, pleurisy, peritonitis, or men-
the general or typhoid form, in which ingitis may complicate the case. The
the morbid process is widespread ; the prostration, stupor, and emaciation
pulmonary form, in which the lungs increase rapidly and the patient soon
are invaded, and the meningeal form, succumbs. Often this occurs as a re-
in which the pia mater and often its suit of one of the complications just
corresponding membrane in the spinal mentioned.
cord are invaded by miliary tubercles. The diagnosis is at first difficult, the
SYMPTOMS AND DIAGNOSIS, disseminated form being often mis-
— General or Typhoid Form. — The taken for typhoid fever. Rut there
symptoms resemble closely those of are many distinguishing points. The
typhoid fever. The incubation period, presence of a tuberculous focus has
which may last a few' days or weeks, already given rise, as a rule, to sug-
is attended bv prostration, general gestive symptoms which the history
malaise, headache, and sometimes of the case will reveal. 'I'he irregu-
chills. Then follows, in most cases, larity of the fever curve, the occa-
8—38
594
TUBERCULOSIS, ACUTE (SAJOUS).
sional morning- rise and the unduly
rapid pulse considered together are
also suggestive. While epistaxis is
rarely observed, petechiae are prac-
tically never seen. The respirations
are labored and rapid, while cyanosis
is usual. Finally, while the Widal
reaction is negative, the von Pirquct
reaction for tuberculosis is positive.
Pulmonary Form. — This type dif-
fers from the former in that the
brunt of the acute process manifests
itself in the lungs. Any structure in
these organs or all its component tis-
sues may suddenly become invaded :
the alveolar walls, the peribronchial
and perivascular tissues, the paren-
chyma, etc. Hence the resemblance
of the disease to bronchopneumonia.
Its starting point may either be, as in
the typhoid type, a nidus of tubercles
anywhere in the body, especially in the
bronchial glands, but often it occurs
as a sudden complication of chronic
pulmonary tuberculosis. Again, it
may follow an acute infectious dis-
ease, pertussis, measles, typhoid fever,
etc., or any other disorder capable of
severely debilitating the body and its
defensive efficiencv, thus rendering: it
readily vulnerable to infection. In
the latter case, there is a general fail-
ure of what health may have been
recovered after the acute disease.
A\'hen a tuberculous focus is the
source of infection, no period of in-
cubation is apparent, a sudden rise of
temperature, running more or less
continuously for some time and reach-
ing often to 105° F. (41.8° C), inaug-
urating the acute process. Here
again we meet, now and then, the
exacerbation of temperature in the
morning, which distinguishes the
disease from typhoid fever. Rarely
no febrile phenomena appear.
Respiratory phenomena occur early.
Dyspnea soon becomes intense, espe-
cially in children in whom a respira-
tory rate of 80 and over per minute
is not infrequent, with more or less
dyspnea and cyanosis. These phe-
nomena may be preceded by cough
which persists and is sometimes
severe. Cheyne-Stokes breathing is
sometimes observed. The expectora-
tion presents no special characteris-
tic, although it may contain tubercle
bacilli, and occasionally resemble the
rusty sputum of pneumonia. Late in
tlie history of the case, however,
it is mucopurulent. Bronchovesicu-
lar breathing and subcrepitant rales
and dullness over areas of consolida-
tion are the main physical signs
elicited.
In children the pulmonary form of
miliary tuberculosis may run a very
rapid course, but in adults its prog-
ress is less rapid, as a rule, than the
generalized or disseminated form.
Meningeal Form. — In this variety
the onset of miliary tubercles occurs
in the basal pia mater, the morbid
process extending in some instances
to the corresponding spinal mem-
brane. As shown by Holt, 70 per
cent, of cases of acute meningitis in
young children are due to tuber-
culosis, while in these and in infants
it is usuallv a manifestation of a ofen-
eral infection. This form is usually
divided into three stages : 1. Stage of
cerebral excitement, which comes on
more or less suddenly with nausea
and vomiting, severe headache, great
irritability, or convulsions, soon lead-
ing at times to coma. The hydro-
cephalic cry, which consists of screams,
short or prolonged, due to intense
pain; alternating pallor and flushing;
the tache cerebrate of Trousseau, a
TUBERCULOSIS, ACUTE (SAJOUS).
595
red streak formed by passing- the nail
lightly over the surface ; exaltation of
the senses causing photophobia, tin-
nitus, hypersensitiveness to sound,
muscular spasms with rigidity, opis-
thotonus, and moderate fever are
prominent signs of this stage. 2.
Transitional stage, in which the acute
symptoms subside ; mental torpor,
delirium, strabismus, retraction of the
head, obstinate constipation, tremors,
twitchings, convulsions, followed by
paralysis of various muscles of the
iris and lids, face and limbs, areas of
flushing; the abdomen being often re-
tracted or scaphoid. 3. Stage of paral-
ysis, with stupor interspersed with
convulsions. This includes spreading
of the paralytic areas, hemiplegia,
aphasia, amaurosis, anesthesia, etc.,
indicating the gradual failure of all
motor centers. A typhoid state of
short duration may then supervene,
followed by collapse, Cheyne-Stokes
breathing, hypothermia and death
with or without convulsions.
The disease lasts three or four
weeks, as a rule, sometimes longer.
Recovery is occasionally observed,
however. A malignant form inaug-
urated by violent convulsions has
been known to cause death in a few
days, while, conversely, some cases
have dragged on sufficiently long to
be regarded as chronic.
DIAGNOSIS.— Although acute
miliary tuberculosis may be con-
founded at first with many disorders,
owing to the several forms in which
it may occur, the presence of an an-
tecedent tuberculous disease, its usual
prevalence in, children and adoles-
cents, the presence of tubercles in the
choroid, and finally the von Pirquet
test soon indicate the true character
of the disease.
PATHOLOGY.— The pathology of
tuberculosis in its various forms being
reviewed at length in the succeeding
general article, the reader is referred
thereto for this division of the subject.
TREATMENT.— The statement
that the treatment of miliary tuber-
culosis is futile or purely palliative,
often met in textbooks, is unfortunate.
The occurrence once in a while of a
recovery indicates that the defensive
resources of the body can occasionally
oppose the morbid process success-
fully. Our efi^orts should aim, there-
fore, to enhance the efficiency of those
resources. This may be done by ad-
ministering small doses of mercury as
early as possible, preferably the bin-
iodide of mercury, ^/^o grain (0.002
Gm.) every three hours. Wright rec-
ommends the succinimide of mercury ;
he injects intramuscularly from 5 to
13 drops of an aqueous solution, 10
minims (0.65 c.c.) of which contains
gr. y^ (0.013 Gm.) of the succinimide.
Six injections in the course of ten
days suffice. Guaiacol or creosote
carbonate, 10 grains (0.65 Gm.),
every three hours is also useful. Tu-
berculin in small doses by the mouth
or by injection may provoke a salu-
tary reaction if used early. Europhen
inunctions, using an ointment 15
grains (1 Gm.) of europhen to the
ounce (31 Gm.) of petrolatum rubbed
thoroughly into the back and pos-
terior part of the scalp niglit and
morning, have also proved curative,
according to Mowat, when given witli
small doses of potassium iodide and
the bromides to control tlic convul-
sions. Thyroid gland in 1 -grain
(0.065 Gm.) doses, every three hours,
with digitalin, i/,, grain (0.006 Gm.)
f(ir an adult or correspondingly less
for a child, is also useful to enhance
596
TUBERCULOSIS, ACUTE (SAJOUS).
tlie defensive efficiency of the blood
and phagocytes.
Tn the mening-eal form spinal punc-
ture every second or third day re-
lieves sufferingf and reduces the ex-
cessive respiratory rate. Morphine
hypodermically is also indicated to
relieve the severe suffering-. Hexa-
methylenamine has been used as a
bactericidal agent, owing to its pene-
tration into the central nervous sys-
tem.
ACUTE PNEUMONIC PHTHISIS.
This disease, also known as acute
phthisis, florid phthisis, and popularly
as galloping consumption, is charac-
terized by a rapid invasion of the
lungs bv tubercle bacilli derived
either from a tuberculous area in the
lung itself or in some other organ, or
from the exterior through infection,
and tending to progress rapidly to-
ward a fatal issue.
SYMPTOMS.— In the adult, acute
pneumonic phthisis is initiated by
symptoms resembling so closely those
of acute lobar pneumonia, that the pos-
sibility of the actual condition present
only suggests itself when the ex-
pected crisis is missed. Following a
cold, a period of lassitude or slight
malaise there occurs a chill with fever
and cough. While at first the sputa
are mucoid, they soon become rusty
and a bronchial hemorrhage may fol-
low. More or less pain on the af-
fected lung, sometimes on both sides,
and dyspnea are complained of. All
these symptoms steadily grow worse ;
the fever reaching often 105° F. (41.8°
C), and being accompanied by severe
night-sweats, rapid emaciation and
extreme prostration. The sputa are
now purulent, and may be found to
contain tubercle bacilli and elastic
tissue. Consolidation of one or more
lobes and areas of softening may now
be discerned by the physical signs,
submucous and subcrepitant rales.
The downward course proceeds rap-
idly and leads to death in from three
to six weeks, though in some cases
the progress of the disease is slower.
This occurs particularly when periods
of remission are noted.
A milder or subacute type is also
witnessed in which, though the symp-
toms are virtually similar to the fore-
going, the ])runt of the infection oc-
curs in the bronchi and pleura, and
leads to a typhoid state which may
end in death. The course of this dis-
order is slower and attended with re-
mission. Such a case may prove fatal
in from two weeks to two months, or,
as is occasionally the case, pass into
chronic pulmonary tuberculosis.
In children the disease occurs in
the form of an acute bronchopneu-
monia, usually as a sequel to measles,
pertussis, scarlet fever, teething, or
any disease of childhood which has
greatly exhausted the auto-protec-
tive resources of the little patient.
Marked fever, stubborn cough and
distressing dyspnea and other symp-
toms of bronchopneumonia (see sec-
ond volume, page 675) appear, but
intensified and tending toward a rapid
exhaustion of the sufferer. It differs
also from ordinary bronchopneu-
monia, in that tubercle bacilli and
elastic tissue are found in the sputum.
Death occurs, as in the preceding
form, in from two weeks to two
months.
TREATMENT.— The treatment is
the same as that for acute miliary
tuberculosis, described above, in addi-
tion to the measures indicated in the
various diseases : lobar pneumonia,
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
597
bronchitis, pleurisy or bronchopneu-
monia simulated, but with the tuber-
cle bacillus as pathogenic factor.
C E. DE M. Sajous,
Philadelphia.
TUBERCULOSIS, CHRONIC
PULMONARY.— Tuberculosis is
due to the presence in the body of
the tubercle bacillus and of the toxins
the latter elaborates, and also to the
reactions provoked by these irritants.
Chronic pulmonaiy tuberculosis oc-
curs when the brunt of the tuber-
culous process manifests itself in one
or both lungs, and develops more or
less slowly therein.
SYMPTOMATOLOGY. — Al-
though tuberculous infection occurs
in from 50 to 70 per cent, of all per-
sons, it does not develop in all, a large
proportion never having symptoms
or disability due to the infection.
Among those in whom it produces
recognizable symptoms the type of
the disease developed varies greatly
owing to the variability of the de-
fensive reactions, which may be
either delayed, deficient, aberrant, or
excessive in different individuals— or,
indeed, in the same individual at dif-
ferent times. Thus it is that, in the
latent types, pulmonary tuberculosis
may heal without ever being recog-
nized, or that the symptoms produced
may be due to an excessive raction of
one of the protective mechanisms and
not be referable to the lung at all, and
that periods of progression may alter-
nate with periods of apparent arrest.
The clinical varieties of this disease
are therefore more numerous than is
generally believed and the symptoma-
tology more multiform.
It is customary to incUulc in these clini-
cal groups, acute pneumonic phthisis.
reviewed under the foregoing heading,
chronic ulcerative phthisis and fibroid
phthisis considered in the present article.
In its course, however, tuberculosis may
pass from one form to the other, exacer-
bations and quiescence following each
other and acute processes breaking out in
those with latent tuberculosis. The fre-
quency with which tuberculosis is unrecog-
nized or even unsuspected, at least for
long periods, by even competent physi-
cians is probably due to the textbook
practice of giving a picture of the dis-
ease or describing its clinical course, when
such picture or description applies only
to a small proportion of cases which are
frank and open. Consequently, in this
article, the different symptoms will be
described separately.
Loss of Strength. — A tendency to
tire easily both mentally and physic-
ally is the most constant and prob-
ably the earliest symptom of tuber-
culosis, being a prominent manifesta-
tion of the latent form.
So-called neurasthenia or chronic
fatigue is extremely common, fre-
quently so predominating in latent
and healed tuberculosis that the
tuberculous nature of the trouble is
missed. It is seen especially in the
resisting members of tuberculous
families.
Marked weakness occurs in the
more advanced and in the toxic cases.
Indigestion. — Irritability of the stom-
ach with eructations, occasional py-
rosis, sour taste, often nausea, vomit-
ing, heartburn, and epigastric heavi-
ness, fullness and distress — usually
occurring an hour or two after a meal
and relieved by eating, is a common
symptom, frequently being the pre-
dominant one in latent tuberculosis.
In more advanced cases the stomach
often undergoes dilatation and even
anatomical changes, such as chronic
atrophic gastritis, with hypnchlorhy-
dria now predominating. \"omiting
598
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
occurs as a troublesome symptom,
coming on after or during- a severe
coughing spell.
Anorexia. — Loss of appetite is an
early and common symptom.
Anemia. — Early and latent cases
often present a picture of anemia or
chloro-anemia with its customary
symptoms.
A ntonomic Disturbances. — Vasomotor
changes and the phenomena of auto-
nomic ataxia occur in the majority
of all types of tuberculosis, including
the latent and healed forms. In the
order of their frequency these are
sweatings, exclusive of night-sweats,
migraine, flushings, urticaria, sub-
jective sensations of cold — such as
chilliness, asthma, burning, especially
of one side of the face or one portion
of the body, angioneurotic edema, a
tendency to excessive bleeding, ex-
clusive of hemoptysis, subjective sen-
sations of heat.
Lowered Blood-pressure. — Hypoten-
sion is an almost constant symptom,
becoming more marked as the disease
advances. The blood-pressure taken
in the reclining position varies much
more than in health from that taken
in an upright position.
Increased Pulse Frequency. — Accel-
eration of the pulse rate is an early
and most suggestive symptom, noted
also in latent cases.
Fever. — Elevation of temperature
usually occurs at some time in all
tuberculous patients and is frequently
produced by exercise, emotion, and
oncoming menstruation, and some-
times by digestion. It is chronic as a
rule and occurs in the afternoon.
Cough. — While not among the earliest
symptoms, nor yet among the most
constant, except in the active cases
which progress to a frank form, cough
is usually the first symptom that is
noted or that draws attention to the
lungs ; but on the other hand it may
excite no suspicion or even attract
little notice. The character varies
from a dry, hacking cough, or it may
])e a clearing of the throat, to a loose,
productive cough which may even
become paroxysmal and cause vomit-
mg.
Expectoration. — Expectoration, al-
though a common is not an early
symptom, as a rule regularly appear-
ing later than the cough. It may be
unnoticed because the patient swal-
lows it, this being particularly true of
children and women. Expectoration
is most common in the morning on
rising, and next after eating, while in
many old cases most of the sputum is
raised during the night.
Hemoptysis. — Hemorrhage from the
lung occurs in over half the known
cases of tuberculosis. It frequently
discloses a previously unrecognized
tuberculosis by being the first symp-
tom of a hitherto latent form. It may
appear in any stage of the disease.
The amount of blood lost in twenty-
four hours also varies. In half the
cases of hemoptysis the sputum is
merely streaked with blood. Blood-
streaked sputum, however, may lie the
forerunner of a larger hemorrhage
and usually is seen for several days
after such larger hemoptysis. In
some instances hemoptysis is brought
about by overexertion, traumatism,
coughing, sneezing, emotion and fa-
tigue, but in most cases it occurs
without any apparent exciting cause.
The menstrual period and the pre-
menstrual period are the times when
women are most liable to hemop-
tysis. Sometimes in sanatoria epi-
demics of this symptom occur, as if
TUBERCULOSIS, CHROXIC PITLMONARY (MYER SOLIS-COHEN). 599
the hemorrhages were caused by some causes such as certain articles of food,
germ or intercurrent infection. slight indiscretion in diet, overfeed-
Hoarseness. — An alteration of the ing, chilling of the abdomen, etc., is
voice occurs at some time during the frequently met with early in the his-
oourse of the disease, although in tory of the case.
many cases the voice remains normal. Neuritis. — Pain, paresthesia, anesthe-
The voice may become weaker, less sia, and analgesia may be the result
clear, lower, thicker, hoarse and tone- of a neuritis induced by toxic ab-
less. A tendency to huskiness, or sorption.
hoarseness may occur early and be Psychical Clmngcs. — The mental
present even in latent cases. conditions most frequently met with
Pain. — Pain occurs at some time in in tuberculosis, according to Mc-
't>
almost, although not in every case of Carthy, are neurasthenia, a tend-
pulmonary tuberculosis, and may be ency to introspection, together with
one of the earliest symptoms. marked nervous irritability, which
Night-siucats. — Perspiration during leads to a change in the patient's dis-
the night is a common symptom of position, so that he becomes irritable,
pulmonary tuberculosis, and when "cranky" and often unhappy, mental
present always suggests this disease, depression, and impairment of mem-
It does not occur often in the early ory. A suspicious mental attitude,
stages, however, but occasionally may mental confusion, and a tendency to
be the earliest symptom. It may delusions also occur in advanced pul-
occur not only at night but whenever monary tuberculosis,
the patient falls asleep, though it The spes phthisica, the consumptive's
should be distinguished from the hopefulness, so commonly met with,
vasomotor sweating mentioned under has little or no relation to the real
(I
Automatic Disturbance." prognosis.
Emaciation.— \N2iSimg is the charac- PHYSIC AL EXAMINATION.—
teristic symptom from which tuber- Inspection. — The skin is often clear
culosis derives its popular names of and of good color, usually pale, some-
"consumption" and "phthisis" (the times dull and opaque, giving a
Greek for wasting). Loss of weight muddy complexion, but occasionally
may be considered a common symp- there is a general bronzing or patches
tom and a fairly early one, being pres- of light-yellow to pale-brown pig-
ent in most latent cases. Occasion- mentation. Flushing is commonly
ally it may be the first and most seen and may be unilateral. In many
prominent or even the only symptom, a black line is left when silver is
Dyspnea. — Shortness of breath on ex- drawn across the face (of course, in
ertion is common in tuberculosis, the absence of powder). In some
especially in nervous individuals, cases the blood-vessels show well
Except on exertion, however, dyspnea through the skin. Nearly all show
is not a marked symptom in early or dermographia.
chronic or uncomplicated cases. £3'^. — The conjunctiva are often
Diarrhea. — As a symptom diarrhea is pale. In about half the patients a rim
common only in advanced cases, but of sclera shows above or below the
a tendency to diarrhea from slight cornea. In a smaller number the rim
600
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
of the sclera is visible when the pa-
tient fixes his eyes on a near object.
The eyebrows are unconsciously
raised when he opens his eyes widely.
In some the pali)ebral fissure is
widened on fixing- the gaze and rais-
ing the eyebrows. Actual exophthal-
mos is not infrequent.
The pupils are said to be frequently
unequal, that on the affected side be-
ing more dilated than the other and
more sluggish in its reaction to light.
Occasionally they are widely dilated.
The gums are often pale. Sometimes
a bluish-red line is found along the
margin of the gums. A high, angular
palate is of common occurrence. The
soft palate is often of a pearly, bluish-
white tint, and covered with a mucoid
moisture.
The fingers often have bulbous en-
largement at their ends — the so-called
clubbed fingers.
Hyperextension of the fingers on
the metacarpals or of the terminal on
the penultimate phalanges has been
found in advanced or rapidly advanc-
ing cases.
The finger-nails frequently are curved
over the ends of the fingers. In a
large majority the nails are tricolored,
a band of red being at the tip, the
lower end, just above the half-moon,
being bluish, and the space between
being white. This is usually most
marked in the thumb-nails.
The thyroid gland is frequently en-
larged, one of the earliest symptoms
of tuberculosis being slight swelling
of this gland.
The shape of the chest may be nor-
mal or it may present the various
gradations to the so-called paralytic
thorax, which type may exist, how-
ever, in the absence of tuberculosis.
Ankylosis of the union of the first
ril) with the sternum has been noted
in a large j)ercentage of cases.
Enlarged venules or capillaries are
often present over the anterior walls
of the chest, especially along the
lower margin of the ribs and to a less
extent on the upper portion of the
chest, front and back.
Asymmetrical and local alterations
of the chest are common, especially
in advanced cases. The thorax often
becomes flatter on the afifected side.
Local flattenings and depressions may
also occur. A frequent phenomenon
is dropping of the acromial end of
the clavicle, which normally is higher
than the sternal end. The clavicle is
usually slightly more prominent on
the affected side and the supraclavic-
ular fossa is flattened or even hol-
lowed, marked depressions above and
below the clavicle occurring in ad-
vanced cases.
Expansion of the chest may be good
in early cases, but as a rule retardation
and limitation of motion occur very
early, frequently confined to the af-
fected side. One of the first physical
signs is usually a unilateral limita-
tion or lagging or both. In some pa-
tients, according to Brown, a compen-
satory increase of movement of the
lower chest on the afifected side seems
to occur, and in doubtful cases may
aid in localizing the diseased focus.
The limitation of motion becomes
more marked as the disease advances.
Limited expansion is associated by
Bandeliar and Raepke with an old
lesion, while delayed respiratory
movement is regarded as an early
symptom and evidence of new in-
volvement. A unilateral drawing in
of the apex of the lung may occur.
Drawing in of the intercostal spaces,
especially of the lower portions of the
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
601
chest, often shows the presence of
pleural adhesions, while bulging of
the intercostal spaces usually indi-
cates an efifusion.
Valuable aid may be given in suit-
able cases by Litteris diaphragmatic
sign, which consists of a visible wave
two inches and a half to two inches
and three-quarters in amplitude due
to the respiratory movement of the
diaphragm. Unilateral diminution of
diaphragmatic movement is due to
disease of the lung or the pleura and
is an early symptom of slight, initial
apical disease.
Palpation. — Delay of respiratory
movement and deficiency in expansion
can best be estimated by palpation
combined with inspection.
Vocal fremitus is little if at all
changed in many early cases. Nor-
mally greater on the right, if it is
equal on both sides it is either in-
creased on the left or decreased on the
right. When markedly increased it
usually indicates consolidation, but in
advanced cases it is too variable to be
of much diagnostic value.
By palpation we may detect a
greater resistance of the chest-wall
over the infected area, especially when
the finger is used as a pleximeter.
Percussion. — Properly performed,
percussion gives valuable informa-
tion ; improperly performed it is of
doubtful value for exact work if it
does not lead one into serious error.
It should be light, especially if the
lesions be superficial.
An extremely light and gentle per-
cussion known as threshold percus-
sion is also employed, — one so light
that a scarcely perceptible sound is
produced. Auscultatory percussion is
used in tuberculosis chiefly in out-
lining the lungs.
The percussion note in a normal
chest may be modified by a number
of normal conditions, such as posture,
atelectasis, or lung-collapse, respira-
tory movement, the slight decrease of
resonance normally present at the
right apex, heavy muscles, a thick
layer of fat, and local prominence of
individual ribs, or of many ribs as in
scoliosis.
The first step in percussion, accord-
ing to many, is the outlining of the
lungs and the marking out of the
resonant areas above the shoulder-
girdle, where the lateral borders of the
apical resonance are projected as a
broad vertical band extending from
the clavicle across the shoulder to the
scapula, known as Kronig's "band oi
resonance."
The condition of the underlying
lung is best determined by comparing
the percussion notes made with simi-
lar technique over the two lungs in
corresponding places. Each lung
should then be examined separately,
beginning below where the normal
resonance for that lung exists and
percussing upward toward the apex.
Slight apical dullness can usually be
better detected in this way, especially
if both apices be involved.
Where the lesion is very slight the
note may be resonant, as the lesion
must reach a certain size before it
produces any change in the percus-
sion note. Even when consolidation
exists, the note may be hyperresonant
or tympanitic from lowering of the
tension, from compression of the in-
tervening tissue by small foci, and
from emphysematous changes — all of
which may mask the dullness. The
first change indicating tuberculous in-
filtration is usually, however, a short-
ening of the duration of the percus-
602
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
sion note, accompanied in many cases
l)y a rise in pitch and a diminution of
the loudness. Impaired resonance or
very slight dullness is also a common
early sign. In doubtful cases it is
well to percuss the same spot during
both inspiration and expiration. Ac-
cording to Aufrecht, in the very early
lesions in the apex the note is clearer
on inspiration and duller on expira-
tion. As the consolidation increases
the percussion note as a rule becomes
distinctly dull and may even pass into
flatness, although it sometimes may
be little changed, even in advanced
cases. Even when present, dullness
is not necessarily a sign of consolida-
tion, but may be caused by a thick-
ened pleura, pleural efifusion, com-
pression of the lung, atelectasis, gan-
grene, large-sized pulmonary infarc-
tion and tumor of the lung.
Hyperresonance or slight tympany
may be due to increase of function in
the well lung when the other is ex-
tensively involved and in the healthy
area of the afifected lung below the
consolidation, to relaxation of the
lung-tissue surrounding a tuberculous
lesion, and to transmission from un-
derlying bronchi. A tympanitic over-
note, on the other hand, may be pro-
duced by the presence of a cavity
with thick walls or overlaid with con-
densed lung or much thickened pleura,
although such a condition may only
give more or less dullness or, if the
cavity is deep enough, normal reso-
nance. Small cavities may give no
change of note. A clear amphoric
note may be heard over a pneumo-
thorax and also over a cavity, usually
one that is large, superficial, with
smooth walls and having open con-
nection with a bronchus. Over a
cavity it is best elicited with the pa-
tient's mouth open. The cracked-pot
sound, especially if in the apex, is also
produced over a cavity that communi-
cates by a narrow opening with an
open bronchus, especially if the chest-
wall is thin and yields to the percus-
sion stroke. The sound is elicited by
firm percussion during expiration, the
patient's mouth being open and the
plexor finger remaining in contact
with the pleximeter finger instead of
rebounding. A cracked-pot sound oc-
casionally can be elicited in health
over the chest of a screaming baby
and over very thin elastic chests, par-
ticularly in children, above a pleural
efTusion, above a consolidation, in
pneumonia before consolidation has
taken place, and over a pneumothorax
freely communicating with a bron-
chus. It is oftener absent over cavi-
ties than present, according to Landis.
Different kinds of changes in the
tympanic note occur in cavities. The
sound elicited by percussion over a
cavity communicating with a large
bronchus is louder, more distinctly
tympanitic, and higher in pitch when
the mouth is open than when it is
closed (IVintich's sign.) This change
may be distinct in some positions of
the body and indistinct or absent in
others, when the cavitv contains fluid
which occludes the communicating
bronchus in one position but leaves it
open in the other {interrupted Win-
tick's sign.) The note over a cavity
is higher in pitch at the end of a deep
inspiration than after expiration and
may even disappear {Friedreich's
sign). A cavity containing fluid in-
termittently will give alternately dull-
ness and tympany when full and
empty, respectively. The tympanitic
sound elicited over a cavity contain-
ing fluid may change its pitch with
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 603
change of position in the patient, and "one, one, one," are the words
especially if the cavity be larger in usually spoken by the patient. Aus-
one diameter than in the other (Gcr- cultation of the spoken voice is prob-
hardt's sign). The outlining of the ably the least valuable physical sign
heart is an important use of percus- in pulmonary tuberculosis, as it does
sion. Tuberculous changes in the not always give accurate informa-
lung frequently alter the outline of tion. It should nevertheless be prac-
the heart, superficial or absolute car- tised carefully over the entire chest,
diac dullness becoming displaced as small or deep-seated lesions are
toward the affected side, due to often first detected by this means,
shrinking of the lung, and correspond- The whispered voice, however, is
ingly diminished on the sound side more reliable and should also be very
from compensatory emphysematous carefully ausculted. The words "one,
changes in the unaffected lung. In two, three" are commonly used for
muscles that are wasted direct per- whispering. While whispering pec-
cussion often causes local contraction toriloquy is commonly heard over a
of the part struck, which rises in little cavity, it is not pathognomonic and
humps, known as myoidena. may even be absent over a cavity. It
Auscultation, — Vocal resonance in is usually soft, low and blowing when
health is heard more pronouncedly heard over a cavity and harsh, higli-
on the right, in persons with thin pitched and tubular when heard over
chest-walls and in persons with a consolidation.
strong and low-pitched voice. The Vocal resonance is diminished in
sounds produced by the spoken voice atelectasis, pleural effusion and thick-
are heard more distinctly and louder ened pleura. Most patients produce
over an area of infiltration and con- some sounds in their noses which are
solidation, vocal resonance being then transmitted to the chest, thus modify-
increased. As the consolidation be- ing the breath sounds. Others on
comes more marked the sound is breathing through the nose may pro-
transmitted comparatively distinctly duce a sound in the throat or against
to the ear, being known then as bron- the teeth. Hence they should be
chophony. When the words are shown to breathe quietly and deeply,
transmitted so distinctly that they The whole chest should be gone
seem to come from the chest-wall, we over carefully first on quiet — then on
speak of pectoriloquy. This occurs forced — breathing, no portion of the
over a cavity communicating with a lung being omitted. As in percus-
large bronchus and sometimes over sion, symmetrical spots on both sides
marked consolidation. Amphoric are compared, after which different
voice is a cavernous voice with metal- portions of the same lung may be
lie echo, heard over a large cavity compared with one another,
with thin, smooth walls and over a Certain extraneous sounds may
pneumothorax. Egophony is a trem- prove confusing, such as the hum-
ulous and bleating vocal resonance ming muscle sound due to contrac-
heard as a rule at the uppermost limit tion of the inspiratory muscles and to
of a pleural effusion and sometimes shivering, and a venous sound above
over an infiltration. "Ninety-nine" the clavicle.
604 TUBERCULOSIS, CHRONIC PULMONARY (MVER SOLIS-COHEN).
The inspiratory murmur is often
very faint in the i)rcsence of thick
chest-walls and on (|uict respiration
in i)ersons accustomed to a seden-
tary life, who have never breathed
properly.
Normally the breath sounds may
be somewhat exaggerated with the
-expiratory murmur louder, and more
prolonged on the right side above the
second rib anteriorly and the second
vertebral spine posteriorly.
In ausculting the breath sounds we
observe the quality and strength of
the inspiratory and expiratory mur-
murs and their relative duration and
character. One of the first changes
in early pulmonary tuberculosis may
be an impure, harsh, hoarse, vesicular
sound, often having an uneven or
vibratory character. Sometimes, usu-
ally in connection with exaggerated
vesicular breathing, the inspiratory
murmur and occasionally the expira-
tory murmur, instead of being contin-
uous, is jerky, or wavy, or cog-wheel.
When synchronous with cardiac sys-
tole, however, and when heard on both
sides, it is not an indication of infiltra-
tion. Weakened or distant breath
sounds, especially when confined to
one apex, is very suggestive of tuber-
culous infiltration. It may, however,
be due to limited motion caused by
pain, adhesions, feeble musculature or
to a thickened pleura or chest-wall, to
a constriction of a bronchus by a pres-
sure of large bronchial glands, to eflfu-
sion, or pneumothorax. Another
early sign of infiltration is a prolonga-
tion of the expiratory sound with a
constant increase in loudness, some
harshness, and a slight rise in pitch.
Prolongation of expiration with less
or no harshness may, however, be
heard over healthy lung-tissue, when
it indicates the presence of emphy-
sema. Harsh or puerile breathing is a
somewhat later sign and is often
heard in the area around a diseased
focus. When heard on the unaffected
side in advanced cases it often indi-
cates compensatory action of the
healthy lung. With increase in con-
solidation the breath sounds become
vesicular, bronchial, and broncho-
vesicular in character, the type de-
pending upon which element pre-
dominates. The expiratory murmur
becomes more and more prolonged
and harsh while the inspiratory mur-
mur becomes higher in pitch and
shorter in duration.
When all vesicular quality is lost
and both sounds become harsh and
loud we have bronchial breathing, the
extent, pitch, and intensity of which
varies in accordance with the nature
and extent of the lesion. It indicates
the presence of consolidation, fibroid
tissue, a dilated bronchus, or a cavity
communicating with a bronchus, and
may also be heard above a pleural
efifusion. Over a cavity bronchial
breathing often becomes lower in
pitch and has a more hollow quality,
l^eing then known as cavernous
breathing. When the latter has a
metallic quality it is called amphoric
breathing and usually indicates a
comparatively large, smooth-walled
cavity of regular shape and com-
municating with a. bronchus through
a small opening. It is also heard
over a pneumothorax communicating
with a bronchus. Another sign indi-
cating the presence of a cavity, ac-
cording to many observers, is meta-
morphosing breathing in which the
breath sounds suddenly change dur-
ing inspiration from vesicular to bron-
chial or vice versa.
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 605
In addition to changes in the breath deep breath, in some instances rales
sounds one hears on ausculting the are said to be heard only when the
chest certain adventitious signs. As patient is in a reclining position. Pot-
a rule they are due to disease of the tenger has been able to elicit rales
lung or pleura, but a few may occur which were not present in ordinary
accidentally or independent of disease respiration by having the patient lie
and thus cause confusion. The latter on the well side, thus forcing the dis-
are caused by hair on the chest, a eased lung to greater activity. It is
very dry skin, a stethoscope not said that rales are more apt to be
evenly or firmly applied, firm pressure heard early in the morning,
of the stethoscope against the chest In examining for rales the patient
in very stout or very muscular in- should be ausculted first on quiet
dividuals, contraction of the muscle breathing, then on forced breathing,
fibers of the muscles and tendons of and finally after coughing,
the head and shoulder-girdle, friction In early cases of pulmonary tuber-
between the shoulder-blade and tho- culosis rales often occur only during
rax, crackles produced in the shoulder- inspiration following- a cough, as pre-
joint, sounds produced by the act of viously stated, at times only at the
swallowing, and to a less extent by end of inspiration, and occasionally
ascending sounds from the esophagus only during expiration after a cough,
and by similar noises caused by move- The earliest rales heard are usually a
ments of the stomach and intestines, few fine crackles limited to one spot,
Rales are usually heard in acute most frequently in the apex, persist-
and in active tuberculosis of the lungs ent after cough, and not transitory,
and in the more advanced cases. In In some cases a wheeze or whine is
incipient cases they are rarely heard heard. A few fine persistent rales
on quiet breathing and as a rule only may be present.
during forced inspiration following As the disease progresses rales are
cough, properly performed. It is usual ofien heard even on quiet breathing,
to have the patient cough with some A few fine moist rales are heard both
force but as noiselessly as possible during inspiration and expiration
before taking a full, fairly rapid in- over a limited area, most commonly
spiration. Babcock has the patient above or below the clavicle, slightly
cough at the end of inspiration. Ac- more often on the right side, and fre-
cording to Brown, the absence of quently in the supraspinous area,
rales cannot be confirmed unless the Later the rales become more difi'used
patient gives two slight coughs at the and more numerous and then mediiun
end of and as part of the expiration sized and moderately coarse. \\ ith
and then takes a full inspiration, rapidly advancing softening and with
Similarly, Bandelier and Roepke meet cavity formation the rales become
many cases in which even numerous large and moist. Over a small cav-
rales can only be detected after the ity the rales most frequentlv have
patient has coughed some five or six a sharjj-ringing, metallic character,
times, one after another, without in- while over large cavities they arc usu-
spiration between, like the cough of ally coarse and bubbling. In old
whooping-cough, and then takes a cavities they mav appear as hisses,
606
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
creaks, and sonorous and sibilant
rhonchi. A localized click, squeak,
or croak is regarded by Pottenger as
suspicious of cavity formation. Reso-
nant rales occur both over cavities
and where none exist.
Gurgling- rales may indicate either
cavity formation or bronchial dilata-
tion. Post-tussive suction, a peculiar
high-pitched, sucking sound occur-
ring during the first part of inspira-
tion following cough, is heard not
uncommonly over cavities, according
to Brown, but also does occur where
no other sign of cavity exists. Metal-
lic tinkling is of rare occurrence and
is found only in large cavities and
pneumothorax. Persistence and con-
stancy as to character and location
^are characteristic of rales in pulmo-
nary tuberculosis, their position and
type changing only as the disease
progresses or retrogrades.
One must be careful to distinguish
true rales from the innumerable sibi-
lant and sonorous rales of asthma,
and pleuritic friction sounds.
With the exception of these crepi-
tations, pleuritic friction is rare in
early stages. While not common,
isolated pleuritic friction sounds over
an apex are suggestive of tuberculous
apical pleurisy. Thin or medium-
sized frictions are frequently found at
the bases posteriorly and point to an
old pleurisy. This is not at all un-
common when tuberculosis is present
at the corresponding apex.
Undue transmission of heart sounds
to the right apex so that they are
distinctly audible there, is a valuable
sign of infiltration of the underlying
lung, if increased cardiac action
through nervousness or through car-
diac disease can be excluded. It is of
no less value when heard at the left
apex and at times may occur over the
small areas of the lung, especially in
the base behind.
Some accentuation of the second
pulmonic sound is frequent in ad-
vanced but uncommon in early stages.
At times what is known as the sub-
clavian murmur is heard over the
subclavian artery more often above
the clavicle than below it and either
during both inspiration and expira-
tion or partly in each. Forcible in-
spiration increases it when just
audible. It denotes an inflammatory
pleuritic process resulting in adhesion
including the subclavian artery. It
is most frequently found with apical
tuberculosis and, owing to the prob-
ability of chronic pleurisy being
tuberculosis, this sign has a sugges-
tive significance.
X-ray Examination. — An X-ray pic-
ture, taken and interpreted by an
expert rontgenologist, is often of con-
firmatory value. It seldom shows
early changes, gives no informationi
as to the specific nature and activity
of the disease, and is subject to errors
of interpretation. It frequently aids
in doubtful though not early cases,
however, and in differential diagnosis,
and gives valuable information in re-
gard to the position and condition of
the neighboring organs.
The Blood. — The blood-picture in'
pulmonary tuberculosis is not con-
stant but varies with the stage, the
acuteness, the progress, the complica-
tions, the climate and the treatment.
The earliest and most constant
change is a reduction of the color-
index — a condition of chlorosis. This
is common in latent cases. The
hemoglobin is usually more or less re-
duced ])Ut may show a percentage
above normal.
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 607
The red blood-cells are usually di- The clotting-time of the blood was
minished but seldom in proportion to shortened in the one hundred cases
the hemoglobin, rarely falling under examined by the writer and in Vie-
3,000,000 in uncomplicated cases, rondt's cases, but was normal in
They not uncommonly are increased twelve cases tested by Addis,
above normal, especially in patients Sputum; Microscopical Examina-
undergoing treatment. tion of. — In every case suspected to
The leucocytes in incipient and mod- be one of pulmonary tuberculosis the
erately advanced cases are at times morning sputum coughed up from the
somewhat reduced in number, but as lung should be examined microscopic-
a rule are fairly normal. In the far- ally, repeatedly if with negative re-
advanced stage they are usually in- suits. Even if the patient states he
creased in number, especially during does not expectorate, one should ex-
softening or cavity formation. The amine a sputum obtained by clearing
differential count bears a relation to his throat in the morning, or after
the stage and progress of the disease meals, or a swab of the throat, or a
and the amount of lung involvement, slide on which the patient has coughed
The polymorphonuclear ncutrophiles for eight or ten mornings. Little
are increased as the disease advances flecks of pus or cheesy particles from
and the involvement extends as the five or six different parts of the speci-
patient grows worse, and are de- men, where present, or, if absent
creased as the patient improves. Ac- from the thickest and most purulent
cording to most observers, in favor- part of the specimen, are smeared on
able and improving cases there is a a glass slide and, after fixing by being
decrease, and in unfavorable cases an passed through a flame, stained for
increase, in the number of these neu- one to five minutes with carbol-
trophilic cells with one and two fuchsin which is brought just to a
nuclei at the expense of those with boil. The specimen is then decolo""-
three, four, and five nuclei, the in- ized by immersion for five minutes in
crease being greater the more severe a 20 per cent, solution of sulphuric
the case, although the writer's figures acid or for half a minute in spirit of
showed the reverse. The lymphocytes nitrous ether, washed in water (if not
are reduced in number the more sufficiently decolorized again sub-
advanced the disease and the greater jected to this treatment), and coun-
the amount of lung-tissue involved terstained with concentrated aqueous
and are increased as the patient methylene-blue solution or Loffier's
improves and diminish as he gets alkaline methylene-blue. When tu-
worse. The mononuclear and transi- bercle bacilli are few, the sputum may
tional cells are unaffected by the 1)e treated with antiformin and the
stage, extent or progress of the dis- centrifugated sediment examined,
ease. The proportion of cosinophiles, While the presence of tubercle
according to a number of observers, bacilli in tlic sputum is diagnostic of
diminishes as the patients grow tuberculosis, their absence even on
worse and increases as they improve, repeated examination docs not ex-
but was not aflFected in the writer's elude it. especially in early cases, as
cases. they are found only in a small pro-
608
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEK).
portion of incipient cases. Elastic
libers are suggestive of tuberculosis
and usually indicate extensive de-
struction of pulmonary, bronchial, or
tracheal tissue. Secondary organ-
isms from the middle of washed
sputum examined within fifteen min-
utes of its expectoration may indicate
secondary infection if present after
repeated examinations.
DIAGNOSIS.— In making a diag-
nosis of tuberculosis, especially in
difficult cases, one must give proper
weight to many points in the history
and physical examination, as well as
call to aid X-ray examination and
various laboratory and other tests. A
possible source of infection, predis-
posing factors, suspicious symptoms
as given above, especially hemopty-
sis, cough, and pleurisy, must all be
taken into consideration. A positive
diagnosis cannot properly be made
from symptoms alone, but even the
absence of demonstrable physical
signs will not be sufficient to abso-
lutely eliminate pulmonary tuber-
culosis when the symptoms are very
suggestive. Nor is the presence of
slight or indefinite physical signs
sufficient to establish a diagnosis in
the absence of symptoms. Definite
physical signs are usually diagnostic.
The combination, however, of both
signs and symptoms, even though one
or both may be slight, is the surest
guide. The presence of tubercle
bacilli in the sputum decides the diag-
nosis, but their absence is of no sig-
nificance. As already stated. X-ray
examination may be helpful.
The complement-fixation test as now
perfected is of distinct value.
Tuberculin, usually in the form of
old tuberculin, is used for diagnosis,
administered beneath the skin, on the
aljraded skin, on the unbroken skin,
and in the eye. The oplitlialmo-
tiibercnliji test consists of introduc-
ing a drop of a 1 per cent, solution
into the conjunctival sac of one eye,
being followed by a conjunctivitis
when positive. It is generally re-
garded as too dangerous. The siib-
cutaneous test is considered the most
reliable, but the writer regards it also
as too dangerous.
The other three methods of testing
with tuberculin, however, are safe,
although less reliable than the sub-
cutaneous test.
In the cutaneous or von Pirqnct
test the skin of the forearm is scari-
fied through a drop of old tuberculin,
while in the more accurate intracuta-
neous test the tuberculin is injected
into the skin itself just below the epi-
dermis. A positive reaction is shown
by the formation of an areola, indura-
tion or papule at the site of inocula-
tion in from twenty-four to forty-
eight hours. A negative result usually
indicates absence of tuberculosis. A
positive reaction shows that the body
has at some time and in some way
been infected with tubercle bacilli ; it
indicates tuberculous infection but
not necessarily tuberculous disease.
Its disadvantage is that it may be
present in apparently health}^ per-
sons, but this may prove in some
ways an advantage in revealing latent
tuberculosis. The percutaneous or
Aloro test, which is of least value,
consists of rubbing into an area of
the skin about 10 square inches with
moderate pressure for one minute a
piece of 50 per cent, tuberculin oint-
ment the size of a pea. When posi-
tive, red points or confluent red spots
or even small papules appear in
twent\-four to forty-eight hours.
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 609
DIFFERENTIAL DIAGNOSIS, animals, etc., or enter the air-passages
— In every doubtful case of illness with contaminated dust, air, or spray,
tuberculosis must be borne in mind Infection through the skin is rare,
as a possibility. Of the many dis- A frequent method of entrance, espe-
eases and conditions that may be cially in children, is by way of the
mistaken for or be simulated by intestinal tract, either in infected milk
tuberculosis, lack of space prevents or other food, or in swallowing with
more than their mere mention, the saliva or food bacilli which have
Among the latter are chlorosis, de- entered the mouth from other objects,
bility, nervous dyspepsia, Graves's the bacilli passing through the intes-
disease, autonomic ataxia, malaria, tinal wall by way of the lacteals and
typhoid fever, bronchitis, influenza, thoracic duct into the blood, being
pleurisy, asthma and pneumonia, both sometimes arrested in the mesenteric
acute and chronic. Among the for- nodes. On their way down, the
mer may be mentioned general dis- organisms may enter the tonsil and
eases such as concealed sepsis, includ- thence find lodgement in the lym-
ing a perinephritic or prostative phatic glands draining it. In the
abscess, a suppurating tonsil, pyelitis, majority of cases the respiratory tract
a mild chronic appendicitis or sal- is probably the route of infection,
pingitis, endocarditis, pyorrhea al- The bacilli entering the air-passages
veolaris, pernicious anemia, Graves's may reach the lung directly or by
disease, myocarditis, and cardiac de- way of the lymphatics or blood-stream
compensation. Chest conditions sim- after passing through the mucous
ulating pulmonary phthisis are : in- membrane of the nose, mouth, or
fluenza, bronchiectasis, pleurisy with throat. The predisposition of the
effusion, and abscess, gajigrene, syph- lungs is in many cases due in part to
ilis, tumor, parasitic and fungous their peculiar arrangement. Not only
disease, actinomycosis, hydatid dis- do the inspiratory air-currents bring
ease, and infarct of the lung, pneumo- the bacilli to the smallest bronchioles,
noconiosis, collapse and induration of but the whole volume of venous
the lung, and pneumothorax. blood with the lymph from all
ETIOLOGY AND PATHOGEN- the lymphatic channels is brought to
ESIS. — 'i\iberculosis is the most the lungs, where the slowing of the
widespread of all diseases, from one- blood-stream in the pulmonary capil-
seventh to one-tenth of all deaths and laries favors the deposition there of
an enormous proportion of invalidism any bacilli in the circulation,
being due to it; from 50 to 70 per The presence in the body of the
cent, for all ages representing the tubercle bacillus, with its foreign
api)r()ximate frequency of tuberculous toxic nucleoproteids, fats, and phos-
infection. This infection probably phorus, stimulates automatically the
occurs usually during infancy and protective and health-preserving and
childhood. The tubercle bacillus may health-restoring mechanism of the
enter the mouth from contaminated body, with which all animals are
fingers, lips, toys, eating utensils, endowed.
floor, furniture, clotin'ng, handker- The conflict between the body and
chiefs, bed-clothing, towels, food, the bacillus is probably influenced by
8-39
610
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
the numl)er and virulence of the lat-
ter and by the power of resistance
possessed by the former. Inasmuch
as only a portion of those in whom
tuberculous infection occurs develop
tuberculous disease, it is customary
to assume that a predisposition exists
in those who succumb.
The causes of a subnormal resist-
ance to tuberculosis are either nat-
ural or acquired. Among the natural
causes are race, a defect in vital
energy, a deficient functional activity
of the adrenal system, a deficiency
in the tissues of mineral salts,
constitutional weakness or mal-de-
velopment — the habitus phtliisiciis—
puberty, menopause, menstruation,
pregnancy, and lactation are other
natural causes of subnormal resist-
ance.
Acquired predisposition results from
local or general influences which
lower the powers of resistance of the
whole organism or of individual
organs and increase the probability of
infection on exposure by diminishing
the natural resistance of the normal
cell. Among the general diseases
thus acting are diabetes, syphilis, and
the general debility following severe
infections, such as typhoid fever,
rheumatic fever and malaria, chronic
gastrointestinal disease, especially
chronic gonorrhea, nephritis, car-
cinoma, chronic heart disease with
cardiac or pulmonary stenosis. Other
depressive influences that either pre-
dispose to tuberculous infection or
else so low^er the resistive power that
a latent lesion previously held in
check becomes active are certain
traumata accompanied by surgical
shock, such as are produced l)y falls,
railway accidents, severe labor, and
operations, and various psychic fac-
tors, such as grief, disappointment,
fear, shame, anxiety, shock, religious
gloom and terror, and psychical de-
pression, and other conditions, such
as unfavorable climate and climatic
changes, puerperal complications.
Another group of causes which
may be included under the head of
privation are : want of proper blood,
of air, want of light, want of cleanli-
ness, want of clothing, want of shel-
ter, want of enjoyment.
Under the head of excesses are in-
cluded dissipation, particularly sexual
excesses, overeating and overdrink-
ing, overexercise, exhausting or un-
resting labor, physical or mental,
leading to bodily and mental over-
strain and overfatigue, prolonged
lactation, lactation continued during
pregnancy, too frequent and rapidly
succeeding pregnancies, and violent
and consuming emotions, rage, jeal-
ousy, greed, inordinate ambition, and
the like. In addition to the conditions
producing predisposition to tuber-
culosis, there are many conditions
that act locally in w^eakening the re-
sistance of the lungs. Among them
are slight mechanical injuries to the
smallest bronchial tubes from inhala-
tion of particles of mineral, metallic,
vegetable or animal dust ; chemical
injuries from substances such as cor-
rosive vapors and gases ; and gross
traumatic injuries from direct or in-
direct violence, such as punctures,
shots, blows, falls, crushing, all of
w^hich injuries may also bring into
activity a latent focus; and various
catarrhal and inflammatory diseases
afifecting the smaller respiratory pas-
sages and the lungs, such as lobar
pneumonia and bronchopneumonia,
influenza, measles, scarlet fever,
whooping-cough, variola, diphtheria,
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 611
tonsillitis, and bronchitis. These dis- the blood-vessels, which in turn may
eases also frequently develop a latent be determined by the number, rela-
tuberculosis or favor a new infection, tion, virulence and location of the
While primary pleurisy is so fre- invading bacilli. It is believed that
quently a symptom of tuberculosis, the slower the development of the
being often the first symptom of an changes, due to a fewer number or
hitherto quiescent tuberculosis, sec- relatively low virulence of the bacilli
ondary pleurisies due to trauma, or to a relatively greater resistance
pneumonia, and other respiratory of the tissues, the more marked will
diseases may have a predisposing be the proliferative over the infiam-
influence, especially when pleural matory and exudative processes, and
adhesions hamper respiratory move- vice versa. The proliferating cells
ment and thus render the expulsion of force apart and open up the fibers of
intruding bacilli more difficult and the original connective tissue, which
precipitate their development. together with long interlacing proc-
PATHOLOGY. — The living tu- esses sent out by the epithelioid cells,
bercle bacilli, on entering the body, especially the giant cells, become the
multiply and as a result of their me- reticulum of the tubercle, being as a
chanical irritation as foreign bodies rule most apparent at the margins,
stimulate the tissues surrounding The pressure on the peripheral layers
them to an exuberant growth having exercised by the cell proliferation
a reparative character. This consists causes them to be densely heaped up
in a new formation of epithelioid cells, and flattened, thus tending to encap-
produced chiefly from connective-tis- sulate the tubercle. The included
sue cells, but also from the epithelial vessels are destroyed by coagulation
and endothelial cells of the capillaries, and no new vessels are formed in the
At the same time the endotoxins of tubercle.
the tubercle bacilli and the products As seen by the naked eye the
of their disintegration evoke an in- tubercle forms a little, gray, trans-
flammatory reaction, characterized by parent granule somewhat smaller
the migration in numbers of leuco- than a millet-seed,
cytes, mostly lymphocytes, from the In the center of the tubercle there
capillaries of the infected focus to the begins a process of coagulation ne-
periphery of the newly formed nodule crosis in the cells, affecting first the
and in many cases between the epi- leucocytic elements and then the
thelioid cells. A new cell is also epithelioid cells. This proceeds out-
formed from the great enlarge- ward, until the tubercle is a uniform
ment of an epithelioid cell and the mass of debris inclosing fat globules
multiplication of its nucleus, known in which tubercle bacilli are still
as a giant cell. With the migration abundant, ])resenting microscopically
of the leucocytes occurs a more or a yellow color.
less serous exudation into the newly Several small tubercles at the same
formed nodule, the amount of coag- point may caseate in their center,
ulable inflammatory exudate — fibrin — join together and f(irm a caseous
being subject to a great variation and nodule (A wirying size, and cheesy
dependent on the degree of injury to masses may be formed by an aggre-
612
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
gation of such nodules, usually in
small groups of lobules, occasionally
in an entire lobe, or even the greater
part of a lung.
These cheesy masses may undergo
softening, fibroid limitation (encap-
sulation), or calcification, their fur-
ther and ultimate fate depending
upon the resistive power of the
patient.
Suppuration or softening is largely
the result of an infection with pus
organisms, but may occur without
their co-operation. When the case-
ous contents of a tubercle or a caseous
nodule softens and breaks through
into a bronchus, a small cavity is
formed and the previously closed
tuberculosis has become open, per-
mitting the escape of secretion con-
taining bacilli into the bronchial
tubes, and so externally. This is
usually the first step in the wider in-
volvement of the lung, violent respira-
tory movements and cough aided by
gravity tending to distribute the
bacilli back into the previously un-
infected bronchi and thence into the
finest bronchioles and the associated
air-vesicles, where new tuberculous
lesions result. The disease may also
spread by continuity, or through the
lymphatics or blood-vessels.
A tubercle heals in several ways.
The epithelioid cells may exhibit pro-
longation into spindle-shaped fibro-
blasts which proceed to form con-
nective tissue that gradually pene-
trates the whole tubercle, converting
it into fibrous tissue. Diffuse con-
nective-tissue overgrowth may render
large parts of the lung, especially
at the apices, airless and quite
indurated with fibrous infiltration.
This is known as fibroid phthisis and
has a very chronic course and a rela-
tively favorable termination. In-
stead of the replacing connective tis-
sue being formed by the tuberculous
cells themselves, it is more com-
monly derived from fibrous tissue
which is always formed around a
tuberculous process, and restrains and
limits thiC spread of the disease. The
caseous contents of a tubercle may
remain encapsulated in the connective
tissue and be absorbed or wholly or
partly calcified. By the formation of
granulation tissue an empty cavity
may become gradually smaller and by
cicatricial contraction may entirely
heal. If the cavity is too large, or the
contraction prevented by adhesions,
it may be healed by the formation of
a firm, smooth, pyogenic membrane.
PROGNOSIS.— Prognosis in tuber-
culosis depends upon a correct esti-
mate of the character of the tissue-
soil, and the virulence of the infection,
the nature and extent of the disease,
and upon the proper management of
the patient. In acute miliary tuber-
culosis and in florid phthisis it is
invariably bad, as both go on to a
fatal termination. Prognosis even in
chronic cases had best be guarded and
indicate merely the probabilities.
Favorable circumstances are a well-
built thorax, a good constitution, good
general health, good digestion and
appetite, infrequent pulse, normal or
high blood-pressure, absence of fever,
bad previous and good present and
future environment, methodical hab-
its, tractability, self-control, resolu-
tion, perseverance, an early diagnosis,
gain of weight on ordinary diet, grad-
ual and continuous improvement of
cough, progressive diminution of the
sputum, increase in hemoglobin, red
blood-cells, and in the percentage of
lymphocytes, and possibly of poly-
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 613
morplionuclear neutrophiles contain- short duration, severe symptoms oc-
ing three or more nuclei, incipiency, curring with sHght physical signs, a
limited lesion with disease of some lesion of wide extent, large cavities,
duration, a complete and constant excessive fibrosis in both lungs, a
absence of all rales after coughing, a sudden change from a purulent to a
gradual change from purulent to a frothy, watery sputum, the occur-
mucoid sputum, absence of tubercle rence of lung stones, good previous
bacilli in the sputum, arthritis, rheu- environment, bad present and future
matism, gout, mitral stenosis, slight environment, poor financial condition,
emphysema, favorable financial con- unskilled management, and the oc-
dition, and skilled management of the currence of any complication, espe-
treatment. cially tuberculous laryngitis, hemor-
Unfavorable circumstances are: rhagic pleural effusion, empyema,
phthisical build, undermining of pneumothorax, diabetes mellitus, pul-
strength by disease, excesses, alco- monary stenosis, pulmonary gan-
holism, bodily and mental over- grene, lardaceous disease, tuberculous
strain, frequent pregnancies, difficult stomatitis or pharyngitis, edema,
labors, grief, privation, and other melancholia, insanity, syphilis, bron-
factors lowering the resistance and chiectasis, persistent anemia, chronic
nutrition, chronic affections of the peritonitis and weak heart — all in-
digestive and assimilative organs, fluence more or less effectively the
failing appetite, progressive loss of issue.
weight, easily accelerated pulse, con- TREATMENT. — The chief aim in
stantly frequent pulse, fever unaf- treating a patient with tuberculosis
fected by absolute rest, high fever, is to aid and increase the natural de-
copious and frequent hemoptysis, the fensive powers of the individual, rein-
presence in the sputum of numerous forcing his vital energy and rendering
short tubercle bacilli, especially when his tissue-soil as unfavorable as pos-
in clumps, and of elastic fibers, in- sible for the growth and spread of the
creasing years after the age of twenty, tubercle bacillus. There are many
A tardy diagnosis, an acute on- ways in which we can render assist-
set with extensive or marked physical ''^nce, the most essential and most im-
signs, loss of weight approximating portant being to bring the patient's
one-quarter of the body weight and general health to the highest possible
especially one-third, a steady loss of standard by attention to general hy-
weight, strong ant-ipathies to the giene and nutrition. This is the sine
proper food, marked cachexia, cya- <7"^ "on of tuberculosis therapy, and
nosis of the lips, face, and extremities is considered by many, erroneously in
and following hemoptysis, long-con- the writer's opinion, to be the whole
tinned amenorrhea, albuminuria if treatment. That it must be the
more than transient, an increase in foundation of eveiy method cm-
the proportion of polymorphonuclear ployed, no one can dispute,
leucocytes and possibly in those with Fresh Air. — Fresh air by day and
one and two nuclei, primary infec- by night is the most important factor
tions at the base, advanced disease, in recovery. At home the patient
scattered foci, an extensive lesion of can get fresh air ov a porch or ver-
614
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
anda, in a wall-tent or a specially
constructed, well-ventilated tent, each
having- a wooden floor, in a yard, on a
balcony, on a roof, or in a room with
thorough ventilation. In the last,
bed-patients can utilize window tents
or have a bed whose end projects
out the window.
In sanatoria, patients also use
rooms with thorough ventilation,
open halls, piazzas, porches, verandas,
bungaloes, lean-tos, huts, cabins,
kiosks, shacks, sun-traps, properly
ventilated tentsy chalets, and shelters.
Change of climate and environment,
irrespective of their character, often
proves beneficial. In general that
climate is suitable for the individual
patient that increases the activity of
his digestive functions and thus stim-
ulates nutrition, improves the tone
of his nervous and circulatory sys-
tems, either by invigoration or pro-
tection, raises his vital energy or
resistive power, lessens his exposure
to secondary infections, and in cer-
tain cases has a palliative influence on
distressing symptoms. As a rule the
young, the robust or fairly robust, the
patients with early and active lesions,
large eaters, do best in a cold, dry,
variable and hence invigorating cli-
mate. Older, weakened, more or less
delicate persons need most frequently
a climate of protection, which is
warm, moderately dry, equable, shel-
tered, and of lower altitude.
Rest. — In all acute and subacute
cases this is important. Acute and
toxic cases require absolute rest in
bed. Absolute rest is also best at the
beginning of treatment in every case
and is desirable for an hour or two
after the mid-day meal in the major-
ity of patients taking the chair cure.
In the rest cure or chair cure, famil-
iarly spoken of as "the cure," the pa-
tient reclines in a comfortable reclin-
ing or steamer chair, preferably not
of canvas, and not in a hammock, as
the last two tend to compress the
thorax. The chair cure is usually
kept up strictly for at least two
months in most cases and thereafter
when the patient is not exercising or
resting in bed. Slightly febrile or
anemic patients, those much reduced
in weight, with cardiac decompensa-
tion, with blood-streaked sputum,
should rest the whole day. Febrile
patients in the earlier stages of the
disease, should spend 6 to 8 hours in
their chairs at first, the time grad-
ually being reduced as their condition
improves.
Exercise. — Febrile and toxic pa-
tients in bed at absolute rest should
be spared every unnecessary move-
ment. After the temperature has
remained normal for a week and the
disease is quiescent, the patient may
begin active exercise in the form of
a short walk on the level in the open
air in the morning at a slow rate,
about two miles an hour, with fre-
quent pauses for rest.
The physician must carefully super-
vise the exercise and see that it does
not produce fatigue, fever, rapid pulse
or signs of reaction, intoxication, or
inactivity. After a patient has walked
one-quarter to one-half hour on the
level, he may attempt an incline,
taking the ascent at the beginning of
his walk while fresh. He should
always walk with an upright car-
riage and breathe through his nose.
It is important always to finish the
walk in time to rest for a quarter to
half an hour before meals. A patient
who bears well long walks, especially
up hill, can be put on light work.
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
615
which under favorable conditions can
be gradually increased, until he is ac-
complishing' the amount of work he
was accustomed to doing- in health.
Carriage and automobile riding, and
boating are permitted for definitely
regulated periods when the patient is
able to walk but a few minutes. As
the power for work returns, mild
sports, such as croquet, fishing and
hunting, when not entailing too much
exercise, skating by those proficient,
gentle or light calisthenics, may be
permitted. When the disease has
been arrested for some months, golf
(without the full swing), gentle
bicycle riding on the level, row-
ing, paddling, skeeing, snow-shoeing,
swimming in great moderation, sled-
ding, tobogganning, and horseback rid-
ing may be indulged in, all in moder-
ation. Violent sports, such as tennis,
racquets, foot-ball, base-ball, hand-
ball, hockey, lacrosse, polo, fox-hunt-
ing, wrestling, boxing, gymnastics,
bowling, and the like, should be
avoided, owing to the danger of over-
exertion with its tendency to causing
a relapse. The contraindications to
active exercise are fewer, rapid pulse
not due to lack of exercise or a recent
acute attack, blood in the sputum, and
loss of weight.
Respiratory Exercises. — The sim-
plest forms of respiratory exercise
are simple deep breathing and sigh-
ing; or, a slow and steady inspiration
through the nose, without overdisten-
tion of the lungs, may be followed by
a rapid, jerky expiration. In addition
the arms may be raised during in-
spiration and lowered during expira-
tion, toward the end of which they
may press upon the chest. The ob-
ject is to increase respiratory capac-
ity. Another method of breathing
with an entirely different object is the
impeding of inspiration by means of
Kuhn's lung suction mark, or by hav-
ing the patient inhale through a quill
toothpick held between the lips or
through a small aperture made by the
lips or through compressed nostrils,
or through a partially closed glottis.
This produces negative pressure in
the thorax, causing marked aspiration
of blood from the right side of the
heart into the lungs, producing a
passive (Bier's) hyperemia, and at
the same time promoting the circula-
tion of lymph. The lower oxygen
tension affects the blood-producing
apparatus, causing an increase in
hemoglobin and in the number of red
and white blood-corpuscles.
Diet. — Suitable nourishment is es-
sential to recovery, being equally as
important as, if not of greater impor-
tance than, fresh air.
The most approved diet consists of
three regular meals of ordinary good,
plain, wholesome, varied mixed food
with lunches between consisting of
eggs, milk, beef-juice, koumyss, kefir,
broth or some prepared food. The
lunches may be dispensed with when
a patient has attained the normal
weight for his height and age, unless
he feels the need of them. Meat,
preferably beef and mutton, espe-
cially the former, and best rare, is
probably the most important food,
and at first should be eaten three
times a day. Fresh eggs are also im-
portant and can be taken raw or
cooked, up to six a day. Pure milk
is also valuable, in daily quantities of
three or fnur pints, but drunk slowly.
Butter, bread, cheese, vegetables of
all sorts, salads, and fresh and cooked
fruits complete the dietary. The
meals should be chosen with care as
616 TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
to variety, tastefully and appetizini[^ly bonated water, a little tea, coffee or
prepared, and served attractively, brandy, peptonizing or pancreatizing
punctually, and quickly. powders, or lactic acid bacilli, or in
The patient should eat slowly and the form of buttermilk or koumyss,
masticate well, for which his teeth kefir, curds, or whey ; and various pre-
must be put and kept in good condi- pared proprietary foods. One must
tion. In a general way he should eat 'je careful to avoid disturbing the
just enough food to enable him to digestion or injuring the kidneys,
gain on an average one to two pounds Clothing. — The clothing should be
per week until the normal weight for of open texture, light, loose, not op-
his age and height are reached and pressive, and suited to the climate
then just sufficient to maintain this, and season. Underwear and socks or
Many patients, however, do not gain stockings of finely combed wool or
on this ordinary diet or cannot eat of silk or of a mixture of wool and
or digest it, and require special diets cotton should be worn winter and
or extra food. The best diet in the summer, as wool and silk are non-
writer's experience is two to two and a conductors of heat, keeping in the
half or three pounds of beef a day body heat in winter and keeping out
eaten in the form of rare beefsteak, the overheated air in summer ; at the
rare roast beef, rare hamburger steak same time by absorbing moisture in
or meat balls, rare-meat loaf, raw meat the fibers as well as between them
chopped up with onions, celery, green they can absorb ordinary perspiration
peppers, etc., and raw scraped beef without becoming damp and also al-
sandwiches. Half an hour before each low it to evaporate slowly without
meal the patient should drink one chilling the skin. Corsets may fit
cup of hot water for each half-pound tightly around the hips but should be
oi meat to be taken. Carbohydrates loose about the chest. The day
must usually be excluded from this clothing should be removed and aired
diet, as they usually interfere with at night and as little clothing as pos-
the ability to ingest such large quan- sible worn in bed.
tities of meat, but green vegetables Bathing. — For the purpose of re-
and salads may be allowed. In sur- moving the perspiration, grease, scurf
alimentation we may employ zomo- and epidermic scales, and thus pro-
therapy in the form of meat-juice; moting physiological breathing, ex-
also cream, butter, cod-liver oil and cretion and relieving the lungs of part
olive oil ; eggs — cooked or raw, plain of their work, the patient should take
or in milk or as egg-nog, or as an egg- a cleansing bath with soap and hot
lemonade, or taken as a raw oyster water of a temperature of 90° to 95°
with lemon-juice or catsup, whole, or F. once or twice a week, for 5 to 15
just the yolk or the white ; milk — raw minutes, followed by a brief cool
or boiled, hot or cold, in large or douche, sponge or ablution of 68° to
small quantities, plain or with the 80° F. The stimulating or hardening
addition of table salt, sodium citrate, both consists in the application of
lime-water, bicarbonate of soda, mal- cold water followed by dry friction
ted milk, barley-water, or oatmeal- and can be taken in a number of
water ; one of the prepared foods, car- forms, the type, temperature and
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 617
duration being- suited to the individ- than fifteen pounds to the square
ual patient. Every tuberculous pa- inch, which is not often obtained in
tient can take some form of this cold a private house.
stimulating bath, w^hich is best taken Chest Compress. — Hydrotherapy is
immediately upon rising in the morn- applied directly to the chest in the
ing. Its benefit comes from the re- form of the stimulating chest com-
action following- it, which is pro- press to increase the circulation in the
moted by a brisk rubbing with a dry lungs, including active hyperemia, to
towel after the bath until the skin be- quiet the movements of the ches,t and
comes pink and warm and also, in therefore of the diseased lungs, to
those weak or unaccustomed to cold tranquilize the whole organism, and
bathing, by supplying heat to the produce sleep, lessen cough and irri-
body before the application of cold by tation, and alleviate pains in the chest
means of a hot tub-bath or hot and side. The Winternitz cross-
sponge-bath of 100° F. for 3 to binder consists of an 8-inch linen or
5 minutes or of a brisk dry rub or muslin bandage about 7 or 8 yards
exercise. A cloth wrung out of cold long, well wrung out of cold water
or iced water and frequently changed and, beginning at the right axilla,
should be applied to the head, or the carried over the left shoulder across
head should be frequently bathed in the back to the point of origin, then
cold water, during the cold procedure, brought forward across the front of
The mildest form and that most easily the chest to the left axilla and finally
borne is the cold ablution, in which transversely across the back and over
water of a constant temperature from the right shoulder, terminating on the
85° to 65° F. or less, not lowered dur- front of the chest. A dry flannel
ing the bath, is rubbed with friction bandage is applied similarly accu-
on the skin with the hand or with a rately covering the first at every
rough wash-cloth or bath-glove — not point. This is left on all night but
with a soft sponge. The duration may also be used during the day, be-
may vary from a couple of seconds toi ing then reapplied after drying and
a minute or two. The patient may rubbing the skin into a glow every
stand in a dry tub or in 12 inches of 3 or 4 hours for bed patients and
water at 100° F. Another form of every 5 or 6 hours in febrile cases,
the stimulating bath is the cold full Instead, napkins or towels or a jac-
bath in which the patient jumps into ket made of three or four thicknesses
a tub of water at a temperature of of old linen, made to fit close up about
from 85° to 65° F. or colder, and re- the neck and to come down to the
mains in for several seconds, exercis- lower edge of the ribs, wrung out of
ing, all the while, and then jumps out. cold water, may be ap])lied to the
In the cold shower, which may be of chest and covered by flannel,
the same temperature and df live, ten Tuberculins and Sera. — The object
or fifteen seconds' duration, the me- of specific treatment is to produce
chanical stimulation to the skin active or passive immunity. r>v the
caused by the force of the water pro- administration of dead tubercle l)acilli
motes the reaction. I'^or this the or their products, known as tuber-
pressure of the water must be not less culin, the affected organism is stimu-
618 TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
lated to prepare actively the specific out this i^iiide there is no way of de-
protective bodies, wiiich it has not termining- with any degree of accuracy
been able of itself to form in sufficient the proper dose for the person that
quantities. The administration of has never taken tuberculin, the initial
sera, instead of imitating the natural dose being always fixed arbitrarily or
process of self-healing, supplies to guessed at. Most every one is in
the affected organism ready-made favor of beginning with a minute
protective materials that have been dose, but there is a great difference
formed in other organisms. Among of opinion as to what constitutes a
the sera used for the production of minute dose, some giving a tenth and
passive immunity are Maragliano's others a hundred-thousandth of a
serum, Marmorek's antitubercular milligram. In order to give an
serum, and Bruchetinni's serum-vac- amount that will probably do no
cine and curative serum. Their value harm, the writer usually begins with
is regarded as doubtful and certainly one millionth of a milligram, when no
far below that of the active immuniz- test is made for hypersensitiveness.
ing tuberculins. The tuberculins Every dose after the first is deter-
most commonly used are Koch's old mined by the effect produced by the
tuberculin (O. T.\ tuberculin Ruck- preceding dose, which may be seen
stand (T. R.), bacilli emulsion (B. in the opsonic curve, leucocytic count,
E.), bouillon filtrate (B. F.). Many leucocytic differential picture, Arneth
other forms of tuberculin have been count, temperature curve, subjective
and are used and may possibly be of and objective symptoms and physical
equal, greater or less value than those signs.
mentioned, but their use is more re- For practical purposes sufficient in-
strictive. Each form has its advo- formation can be gained by a careful
cates, but many observers believe study of the clinical symptoms and
that the majority of tuberculins used physical signs. A dose that is fol-
clinically are of equal value. The lowed the same day or the next day
writer prefers tuberculin Ruckstand. by a favorable reaction, such as a
Tuberculin may be administered feeling of well-being, rise of spirits,
either hypodermically or by mouth on increase of appetite, fall of an cle-
an empty stomach at least half an vated temperature to normal, or re-
hour before a meal. Patients differ duction of the extent of the daily
so in their sensitiveness to tuberculin fluctuation of the temperature, is the
that one may require a dose one appropriate dose for that patient and
thousand or one million times that should be maintained so long as it
required by another patient who may provokes such favorable phenomena.
be aparently of the same type. White Nor should any change be made in
and Williams and the writer endeavor the dose when it is followed by a very
to determine the exact dose for the slight unfavorable reaction that lasts
individual patient by testing for his but a few hours, or at most a day,
hypersensitiveness to definite amounts and is then followed by an improve-
of tuberculin, the former using the ment in the symptoms or general con-
vo)i Pirquct cutaneous test and the dition. The dose should always be
writer the mtracntancous test. With- reduced if it causes symptoms of an
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 619
unfavorable reaction, such as rise of
temperature, increase of symptoms,
malaise, anorexia, pains, loss of
weight, etc. (with the exception just
mentioned), or if definite and pro-
longed painfulness and inflammation
occur at the site of injection — the
skin reaction. If the rise of tempera-
ture and the other symptoms last but
a few hours, the dose may be reduced
a half; if they last all day the next
dose should be one-tenth, or less, of
the preceding dose. When the re-
action has been marked or has lasted
several days in spite of rest, the next
dose should be one hundredth to one
thousandth of the last dose. A dose
that produces no efifect of any kind
should be increased, even in febrile
cases, until signs of a favorable or
unfavorable reaction appear. The
dose should also be increased when
the hitherto appropriate dose is losing
its efifect, as shown by a rise to a
higher level of a temperature that has
been kept down, or the reappearance
of more marked daily fluctuations,
and an increase of symptoms which
had previously been ameliorated. A
safe rate of increase in ordinary cases
is about 50 per cent, of the preceding
dose, or, according to the following
scheme: 1, 1,5, 2, 3, 5, 7, 10, 15, 20,
30, etc. The intervals betv/een doses
may be three to seven days in patients
who have shown no effect of any
kind from tuberculin and in those who
are doing well on it. In advanced
cases and in nervous and susceptible
individuals, and with the larger doses,
ten days would often be better. After
an unfavorable reaction one must
wait until all the reactive symptoms
have disappeared, a week or more
after, if the reaction has been severe.
Every uncomplicated case of pul-
monary tuberculosis of the first and
second stages with no or slight ele-
vation of temperature is usually
suitable for tuberculin treatment. In
the writer's experience latent cases as
a rule were not benefited by tuber-
culin.
Iodine. — Despite the skepticism of
many authorities iodine has stood the
test of time in the treatment of tuber-
culosis and has plenty of testimony
of experienced and trustworthy clin-
icians and some laboratory evidence as
to its eflicacy in this disease, espe-
cially in the early stages. In fact, it
is regarded by many as a specific,
producing a vital reaction and im-
munization.
Iodine may be given by mouth or
by inunction or intravenously. The
best preparation by mouth is iodo-
form free from biproducts or impuri-
ties, such as the eka-iodoform of
Schering. It may be given in doses
of 5^ grain (0.008 Gm.) three times
daily, increased gradually to the
point of tolerance. Tincture of
iodine, compound tincture of iodine
and Lugol's solution, given in drop
doses in a glass of water before meals,
increased gradually to the point of
tolerance, has a local action in quiet-
ing vomiting and increasing the ap-
petite in addition to its general efifect.
A host of proprietary preparations of
iodine may possess more or less or
equal value.
By inunction iodine is given in the
form of europhen or iodoform in oil
or iodized oil. An excellent formula
of Flick's is europhen, .lij ((S Gm.) ;
Ol, gaultheria, f.lij (8 c.c.) ; Ol. olivae,
q. s. ad f.^j (30 c.c).
Intravenously 10 minims (0.6 c.c.)
of a 40 per cent, ethereal solution of
li(|uid paraffin which contains Yi grain
620 TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
(0.03 Gm.) of iodoform may be in- chemical used by her in combating
jected every second or third day. tul)erculous infection and healing
Creosote and its Derivatives. — An- tul)erculous disease,
other agent that has stood the test of The ])rc])arations most used are
time, despite the skc]>ticism expended calcium chloride, calcium lactate, cal-
by many authorities, is the creosote cium lactophosphate, and the average
group. They are especially applic- dose is 5 to 15 grains (03 to 1 Gm.)
able when destructive changes have three times daily to every three hours,
begun and also when the toxemia and It is essential to give calcium
increased destruction of the third throughout the whole of pregnancy
stage are manifest. and lactation when there is an extra
In this group are creoisote, guaiacol, strain on the body's supply. Given
and their carbonates. The prepara- during the menstrual period, when
tion of preference is creosote car- calcium is excreted in large quanti-
bonate, which may be given in doses ties in the lochia, it may avert the
of 5 drops gradually increased to the hemoptysis which is so common at
point of tolerance and is best admin- this period. In hemorrhage its em-
istered well beaten or shaken up in ployment is general, on account of
hot milk. In giving creosote the pure its action in increasing the coagula-
beechwood creosote is used, beginning bility of the blood ; but for this it
with 3^ or 1 minim (0.03 or 0.06 c.c.) must be given in large doses, 15 to 20
and increasing to the point of toler- grains (1 to 1.3 Gm.) every three
ance. It may be given in large hours.
draughts of hot water or in milk, wine Thyroid gland in doses of 1 to 3
or one of the malt preparations, al- grains (0.065 to 0.2 Gm.), increased
ways after meals. It may also be gradually, if desired, to tolerance or
given in capsules with an oily vehicle, to 5 grains (0.3 Gm.) three times
Guaiacol carbonate can be given in daily, is given to increase the general
capsules in. doses of 3 to 7^ grains nutrition and activate the defensive
(0.2 to 0.45 Gm.) three times a da}^ process more vigorously. It should
increased slowly to 15 or 20 grains be borne in mind, however, that
(1 to 1.3 Gm.). Ten to 25 minims American preparations contain 5
(0.6 to 1.5 c.c.) of guaiacol have been grains of the gland to 1 grain of the
painted on the skin .to reduce tem- desiccated gland on the market.
perature. Sajous, who introduced its use, warns
Arsenic and its Compounds. — Ar- against its employment in the ad-
senic may be given by mouth in the vanced stages of the disease,
form of arsenious trioxide, arsenious Nuclein is given to produce leuco-
iodide and Fowler's solution, or h}- cytosis and increase the opsonic
podermically in the form of sodium index. It may be given by mouth in
cacodylate, ^ to 1 c.c. (8 to 16 min- the form of 1 dram (4 Gm.) of a 5 per
ims) of a 10 per cent, aqueous solu- cent, solution of nucleinic acid three
tion being injected two or three times times daily, or of 50 to 150 grains
a week. (3.2 to 10 Gm.) of dried yeast in milk
Calcium. — In giving calcium we aid twice a day, or of an ounce (30 c.c.)
nature by increasing her supply of a of brewers' yeast twice or three times
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 621
a day. Nucleinic acid may also be Ichthyol has been extensively em-
given subcutaneously and intraven- ployed in tuberculosis. It may be
ously. given in capsule or in a liberal quan-
Cinnamic acid and its sodium salt tity of water followed by lime-juice,
hetal are also given to produce leuco- lemonade or coffee. The dose is 2
cytosis, and the latter also for its drops, gradually increased,
action in increasing connective tissue Camphor is given subcutaneously
about the tuberculous focus. They in daily doses of ^^ to 1>^ grains (0.03
are given by mouth, inhalation, sub- to 0.1 Gm.) in a 10 per cent, solution
cutaneous injection, but preferably by of olive oil. It is usually given as a
intravenous or intramuscular injec- heart stimulant, having a favorable,
tion. but not constant, eft'ect on the heart.
Mercury. — B. L. Wright employs pulse and respiration, but is also said
daily deep muscular injections of to have a favorable influence upon
mercuric succinimide, beginning with fever, sweating, expectoration and
Yiij grain (0.004 Gm.), slowly in- sleep.
creasing the dose to the point of toler- Digitalis in small doses is given by
ance. He gives a course of 30 injec- Jacobi to prevent the cardiac en-
tions, followed by two weeks' interval feeblement, circulatory weakness, and
of rest, and then by another course of general debility, due to a chronic ail-
30 injections, and so on, for a year; ment with the addition of obstruc-
after which a rest of from 2 to 3 tion in the lungs. Beddoes gave digi-
months is given, whereupon, if the talis in large doses as a result of his
patient is not cured, treatment is empiric observation in cases of gal-
resumed. Stuart, Shattuck, Bow- loping consumption, with high fever
ditch, Edelheit, and Giampetro had and rapid pulse, and reports striking
previously given mercury in tuber- instances of the benefit following its
culosis. use, his observation having been em-
Strychnine. — According to Pepper pirically confirmed by S. Solis-Cohen,
and others, the dose of strychnine, who says it must l)e given contin-
which is at first a small one, is con- uously and fearlessly, up to the point
sequently gradually increased until of tolerance, the only contraindication
the .physiological effects of the drug being evidences of untoward effect on
are noted. S. Solis-Cohen says that the stomach.
the large doses should be given only Nitroglycerin is considered useful
for limited periods and that the use in the early stages by S. Solis-Cohen,
of strychnine should not be continued and is used in hemorrhage bv many,
indefinitely, as this tends to exhaust Quinine in large doses was admin-
nervous structure and nervous energy, istered by Jaccoud in the fever of dif-
Most physicians, at the present day, ferent stages of phthisis, not less than
merely employ strychnine in ordinary 16 grains (1.04 Gm.) of quinine sul-
dosage as a tonic or general stimu- phate or 22 grains (1.4 CjUI.) of qui-
lant, for its favorable action upon nine hydrobromate being given in
lowered blood tension, weakened twenty-four hours. The writer has
heart, jaded appetite, and neuras- obtained excellent results in many
thenia. cases of tul)crculous toxemia, with
622 TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN).
reduction of the high septic fever and amount of secretion and its aspiration
amelioration of the other toxic symp- into other healthy parts,
toms, by the exhibition by mouth of The simpler method of procedure
the quinine bichloride and urea, given and the one usually employed is to
in doses of 5 to 10 grains (0.3 to 0.6 introduce without anesthesia, under
Gm.) every three hours to once a day, aseptic conditions, through an inter-
administered in capsules. While the costal space, a small aspirating needle
results may be due to the quinine connected with a suitable apparatus,
alone, there is a possibility that some entrance into the pleural cavity being
of the good effects may be due to the ascertained by the reading of an at-
urea. tached monometer. When free pleu-
Urea in doses of 10 to 15 grains ral space is encountered, from 500 to
(0.6 to 1 Gm.) three times daily in- 1000 c.c. of nitrogen gas, or atmos-
creased to 50 grains (3.2 Gm.) three pheric air passed through sterile cot-
times daily, has been used by Dixon, ton filters is introduced. The infla-
Harper, Buch and others with good tion is repeated every two or three
results, which still others have failed days until the lung is completely
to obtain. collapsed, as indicated by Rontgen
Iron is indicated in the secondary examination : then once a week, and
anemia of tuberculosis. The best re- later, when the pleura loses its capac-
sults seem to follow the daily hypo- ity for absorption, at intervals of from
dermic use of 0.05 Gm. (•% grain) of two to three weeks,
the citrate of iron obtained from Benefit, apparently lasting, and
Italian pharmaceutical houses or 0.03 palliation occur in many cases, but on
Gm. ilA grain) of the cacodylate of the other hand in a number of cases
iron. Blaud's pills, syrup of the difficulties, accidents, and distinct
iodide of iron, and tincture of the harm have resulted. In the presence
chloride of iron are also useful prep- of extensive adhesions it may be im-
arations. possible to find the pleural space.
Other drugs which are regarded of Pleural effusion is a common occur-
value in the treatment of pulmonary rence, frequently being met with in
tuberculosis include sodium salicylate, Z?) to 100 per cent, of an operator's
salicylic acid, sodium benzoate, ben- cases. Other complications are pyo-
zoic acid, hypophosphites, glycero- pneumothorax, air-embolism, pleural
phosphites, palladium chloride, allyl reflex causing death, inability of the
sulphide, codliver oil, balsam of Peru, lung to re-expand, with permanent
silver, and lecithin. loss of the functional capacity of the
SURGICAL TREATMENT.— Ar- lung, and the formation of adhesions
tificial Pneumothorax. — Air is intro- preventing subsequent inflation. Con-
duced into the pleural cavity to sequently, conservatism is desirable
produce collapse of the lung, the in the selection of cases. A conserva-
compression and immobilization tend- tive attitude is that in early or even
ing to stop the growth of tuberculous moderately advanced cases the pa-
foci, to cause healing by cicatricial tients should be given the benefit of a
contraction, to diminish the amount try at the ordinary hygienic-dietetic
of toxic absorption, and to lessen the treatment. If they do not improve,
TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLIS-COHEN). 623
then one should, not delay too long in moderate, and by treating any causal
inducing pneumothorax. Extensive intercurrent affection,
adhesions on the side in question, con- Night-siucats are usually relieved by
siderable destructive disease on the ordinary hygienic measures, but may
other side, severe cardiac disease, and require in addition frequent nourish-
severe complications in other organs, ment at night when awake, sponging
which do not include laryngeal dis- at bed-time with vinegar and water,
ease, or non-tubercular diarrhea, are pure vinegar, cool water, nv formalin
strict contraindications. in alcohol, the application of the cold
Chondrotomy of the first rib car- stimulating chest compress all night,
tilage is designed to bring about a or of an ice-bag to the abdomen for
widening and mobilization of the up- several hours in the evening, and
per thoracic aperture, but has not atropine, picrotoxin, agaricin, arc-
met with general approval. matic sulphuric acid, or camphoric
Extra-pleural thoracoplasty aims to acid l)v mouth.
I)ut the chest-wall into such a condi- Cough, when in excess of psycho-
tion that the diseased lung becomes logical needs, can often be controlled
collapsed and motionless, for which by mental discipline, sips of cold
rib resection, with more or less re- water, or alkaline water, bits of ice,
moval of bone, is necessary. It also orange-juice, lozenges, candy drops,
lacks favor. the stimulating chest binder, inhala-
Inhalations. — Continuous or inter- tions. Sometimes sedatives may be
mittent antiseptic or medicinal inhala- required, such as cherry-laurel water,
tions have been advocated, the patient syrup of wild cherry, hydrocyanic
wearing a zinc inhaler carrying a acid, chloroform, chloral and bro-
sponge and fitting like a cage over the mides and even opiates such as co-
mouth and nose and being kept in deine, heroine and dionin.
place by elastic bands around the Hemoptysis demands calming, rest
ears. Various medicaments have been in a semi-recumbent position, with-
used, the most valuable being equal drawal of food and fluids and substi-
parts of creosote, alcohol, and spirits tuting meat-juice with ice, pieces of
of chloroform ; one-fourth each of car- ice in mouth occasionally, an ice-bag
bolic acid, creosote and spirits of over the heart, forbidding of moving
chloroform and one-eighth each of or talking, nitroglycerin, morphine,
tincture of iodine and spirits of ether; calcium in large doses, thyroid gland,
and ethyl iodide. Other substances the injection of horse serum or of
used singly or variously combined citrated human blood, emi)tying the
are myrtle, eucalyptol, thymol, men- bowels, and in severe cases bandaging
thol, oil of peppermint, camphor, the limbs and, where the site of the
bromoform, and formaldehyde. hemorrhage is known willi certainty,
TREATMENT OF SYMPTOMS, the induction of artificial pneumo-
— Fe%>cr is combated by absolute rest thorax.
in bed, out of doors if possible, tepid PROPHYLAXIS. — Prophylaxis is
sponging, ice-cap if grateful, creosote general and individual. huli\idiial
carbonate, the bichloride of quinine prophylaxis consists in precautions
and urea, tuberculin when the fever is taken by the patient to avoid infect-
624 TUBERCULOSIS, CHRONIC PULMONARY (MYER SOLJS-COHEN).
ing-. Inasmuoh as the spray from a and of maxims printed on the backs
cough may contain the bacilli, when a of street-car transfers; the distribu-
patient coughs he should hold in tion in tenements and homes of art
front of his mouth a Japanese napkin posters with advice on them, the use
or a cloth which is then put in a of the columns of the newspapers and
paper bag to be subsequently burned, the i)ulpit, the holding of exhibits,
He should expectorate into such a the giving in various languages of
paper napkin' or cloth or into a paper popular lectures, and of special talks
sputum cup which is burned or into to special groups, the employment of
an indestructible sputum cup, pocket the phonograph and moving picture
flask or spittoon containing a disin- and use of seals and stamps,
fectant. The patient should have his The administrative control of tu-
own eating utensils, which are kept berculosis with compulsory notifica-
and washed separately. He should tion enables the health authorities to
avoid hand-shaking aad kissing. protect the public from tuberculosis
Well persons, especially those sus- as they do from other communicable
ceptible or of tuberculous families, disease through the exercise of a sufifi-
should pay strict attention to per- ciently strict surveillance over tuber-
sonal hygiene — by which is meant culous individuals so as to make them
proper air, proper food, proper bath- take adequate precautions to render
ing, proper exercise and rest, and themselves free of danger to other
avoidance of excesses of all kinds, persons, and through the fumigation
By building up one's resistive power of rooms that have been occupied by
and increasing the protective sub- consumptives. Of equal importance
stances of the body, one renders less is the increasing of resistance to
likely the occurrence of tuberculous tuberculosis by demanding hygienic
diseases following a chance tuber- conditions in house, tenement, fac-
culous infection. tory, store, and workshop, with refer-
Probably the most important gen- ence to lighting, heating, ventilation,
eral prophylactic measure is the edu- plumbing, cleanliness, overcrowding
cation of the public; one of the great and air space; the proper arrange-
causes of consumption being the ment of a city with regard to the
ignorance of the general public as to relative width of the streets and the
the nature and extent of the disease, height of the buildings, the laying out
and as to its prevention and treat- of small parks, open spaces, and chil-
ment. Campaigns of education should dren's playgrounds ; attention to the
consequently be carried on by public purity and character of the food sup-
health officials and anti-tuberculosis plies, especially the milk supply, the
societies and insurance companies, in- supervision of slaughter houses, the
eluding the preparation and distribu- regulation of the hours and condi-
tion of suitable literature in the form tions of labor; attention to school
of leaflets, pamphlets, and books hygiene and the establishment of
adapted for the public as a w^hole and open-air schools and classes ; the
for special classes or groups, and pub- proper sweeping of streets and dis-
lished in different languages; the posal of refuse, destruction of the fly,
utilization of posters or bill-boards suppression of indiscriminate expec-
TUBERCULOSIS OF SEROUS MEMBRANES AND SKIN.
625
toration and provision for the dis-
posal of sputum, and the maintenance
of sanitary precautions in railroad
and railway cars, especially sleeping-
cars. For the proper care of tuber-
culous patients it is incumbent on the
health or other authorities to provide
dispensaries, sanatoria, day camps,
night camps, classes, home hospitals,
preventoria, farm colonies, nurses and
proper accommodation in insane asy-
lums, prisons, reformatories, alms-
houses and boarding schools.
Myer Solis-Cohen. M.D.,
Philadelphia.
TUBERCULOSIS OF THE
SEROUS MEMBRANES AND
SKIN.— Several disorders of the serous
membrane, i.e., tuberculosis of. the pleura,
pericardium, peritoneum, etc., have al-
ready been reviewed in the articles on
the diseases of these various organs.
There remain for consideration tubercu-
losis of mesentery and endocardium, the
latter of which is encountered with com-
parative rarity.
Mesenteric Tuberculosis or Tabes Mes-
enterica. — This disease is characterized
by a tuberculous infection of the lym-
phatic nodes of the mesentery, and is ob-
served mainly in young children who
have been fed on milk derived from tuber-
culous cows; or it may be secondary to a
tuberculosis elsewhere in the body. In
older children and adults it may be due
to the inhalation and swallowing of
bacilli-laden dust or foods. Both bovine
and human tubercle bacilli may cause the
disease, the bovine type being causative
in 60 per cent, of all cases.
Tuberculosis of the mesenteric
glands in children is a very common
condition, being found in practically
every child submitted to an abdom-
inal operation. This is due to the
fact that the food stagnates in the
ileocecal region while it undergoes
absorption of a large part of its
water. This pause is made in a
warm, slightly alkaline medium and
the contained micro-organisms mul-
tiply very rapidly. This is shown
by cultures from here and from
other portions of the intestinal tract.
Corner (Lancet, Feb. 17, 1912).
SYMPTOMS. — There are two distinct
clinical types of the disease. The first or
acute type may begin suddenly with more
or less sharp, colicky pain, nausea, vomit-
ing, and marked tenderness on the right
side somewhere between the umbilicus
and the cecum with more or less fever.
The attack is usually taken for one of
acute appendicitis. On opening the ab-
domen the appendix is found normal, but
one or more caseating enlarged glands
are found on the mesentery, often to the
right and opposite the second or third
lumbar vertebra. If removed, even
though the glands be found laden with
tubercle bacilli, recovery usually results.
In the second or chronic type, with grad-
ual development, the mesenteric glands
are more or less destroyed functionally;
there is gradual emaciation, therefore,
even though an effort at compensation be
made by the patient through excessive
appetite. The unassimilated food putrefy-
ing in the intestinal canal causes diar-
rhea with excessively fetid stools. Pallor
of the skin and mucous membranes, slight
fever of an intermittent type, and weak-
ness become increasingly pronounced.
There is more or less severe colic, the ab-
domen being also painful when com-
pressed and sometimes swollen. This,
however, is often due to a peritoneal
effusion. A moderately hard fluctuating
or doughy mass may usually be felt in
the abdomen, particularly in children.
The von Pirquet reaction is useful to es-
tablish the diagnosis on a solid footing.
Many young subjects harbor tuber-
culous glands that do not give rise to
appreciable symptoms, but they may be-
come the starting point of a general in-
fection. On the other hand if recovery
occurs the possibility that the inflamma-
tory adhesions formed may compromise
the functional integrity of the intestine is
to be borne in mind. The chronic form
progresses steadily toward a fatal issue
if left untreated.
DIAGNOSIS.— Primary tabes mesen-
terica affords a sufficiently clear history
and syndrome to warrant its recognition
8—40
626
TUBERCULOSIS OF SEROUS MEMBRANES AND SKIN.
if the cnlarg-ed glands are palpable.
Obscure abdominal pain with persistent
digestive disturbances and steadily pro-
gressive emaciation suggest its presence.
In children and adolescents a pain in the
right alidominal area between the um-
bilicus' and the cecum or below the um-
bilicus, especially when there are palpable
masses, is suggestive of tabes mesen-
terica. There may be pain on both sides,
and the feces may contain mucus, blood-
streaks and tubercle bacilli even where
there is no diarrhea. A skiagraph is help-
ful in locating the enlarged glands.
PROGNOSIS.— As compared with the
prognoses of other tuberculous diseases
tabes mesenterica is probably that which
ofifcrs the best chances of recovery. If
discovered early much may be done by
medical measures. The prognosis is also
good under operation provided it is per-
formed when the glands form a palpable
mass. In the acute form an exploratory
incision, even without removing the tuber-
culous gland, may prove curative. Under
all conditions, however, the prognosis
should be guarded, owing to the fre-
quency of unexpected complications.
TREATMENT.— The medical treat-
ment is the same as that recommended
for tuberculosis of the peritoneum (see
seventh volume, page 391). Of special
value, however, is creosote carbonate 5 to
10 drops three times a day. Warm com-
presses and mercurial ointment inunc-
tions over the abdomen are also recom-
mended.
As to surgical procedures they are indi-
cated when the medical measures fail to
cause improvement. Laparotomy is bene-
ficial even without removing the diseased
glands, and, as stated by Corner some
years ago, experience has shown that
resection of the glands should be done
only when they form a palpable mass,
care being taken to distinguish them from
tumors due to tuberculous peritonitis.
A child with movable tumor of the ab-
domen, not fecal, who is losing flesh and
wasting, should undergo operation.
TUBERCULOSIS OF THE MYOCAR-
DIUM.
This condition usually occurs as a com-
plication of miliary tuberculosis and
tuberculous pericarditis. The tubercles
or miliary nodules tend to follow the
course of the vessels. The only signs by
which its presence may be surmised is a
more or less sudden weakness of the car-
diac contractions, a true cardiac mya-
thenia.
TREATMENT.— Besides the measures
addressed to the general causative dis-
order, digitalis is indicated' to sustain the
cardiac action, and promote nutrition of
the musculature. Besides, rest, though in
the open air, becomes imperatively neces-
sary to decrease the danger of cardiac
arrest.
TUBERCULOSIS OF THE SKIN.
Tuberculosis of the skin maj' be divided
into seven main forms: scrofuloderma,
true tuberculosis, miliary tuberculosis (or
Milium, previously considered in the
sixth volume), tuberculosis verruca cutis,
lupus vulgaris, and lupus erythematosus.
SCROFULODERMA.— The term
"scrofula" being equivalent, in the light
of modern teachings, to tuberculosis, this
disorder is now regarded as a tuber-
culous disorder of the skin due to infec-
tion and ulceration of the underlying
lymphatic glands.
Symptoms. — Scrofuloderma begins in
one or more lymph-nodes, in most in-
stances in those of the neck, but also
those of the face, lids, bones, and other
regions. The infected glands swell, in-
volve the overlying skin, the latter grad-
ually becoming violaceous or livid owing
to the pressure upon its vessels and de-
fective nutrition. The gland then breaks
down, the skin likewise, and a sanious
pus is discharged. The ulcers formed
have ragged edges and multiply along
the chain of lymph-nodes, forming linear
ulcerations while fistulas undermine the
cutaneous tissues. The ulcers are prac-
tically painless and if cicatrization occurs
the scars are irregular, knotty, and de-
pressed, having an ugly, permanent re-
minder, especially where the neck is af-
fected, of the so-called "scrofulous" taint.
Etiology and Pathogenesis. — The pa-
tients are practically always young, have
unusually transparent though doughy and
anemic skins, thick lips, especially the
upper, and are flabby, dull, prone to
TUBERCULOSIS OF SEROUS MEMBRANES AND SKIN.
627
lymphatic enlargements, adenoids, ton-
sillitis, catarrhal disorders of various
kinds, and are a ready prey for infectious
diseases, particularly those due to the
tubercle bacillus. Although the tubercle
bacillus cannot always be found in the
swollen glands, inoculation of the pus in
guinea-pigs usually give rise to typical
tuberculous swellings.
Treatment. — This should include meas-
ures addressed to the body at large, since
the actual extent of the infection in a
given case is never known. Nutritious
food, especially milk and eggs, pure air,
sunlight, sea-air, the iodides and hypo-
phosphites, guaiacol, and creosote car-
bonate are the standard measures indi-
cated. Mercury succinimide, V- grain (0.013
Gm.) subcutaneously, has also been used.
A striking effect on cutaneous
tuberculids is produced by arsphen-
amine. Fifty-three per cent, of 17
cases were completely cleared of
lesions, and only 12 per cent, failed
to show betterment. Outdoor life,
forced diet, correction of vascular ab-
normalities and stasis by elastic sup-
port, and removal of secondary pyo-
genic foci in tonsils, teeth, etc., are
important adjuvants. Stokes (Amer.
Jour. Med. Sci., Apr., 1919).
Radium used in the various forms
of skin tuberculosis, including lupus
vulgaris, with good results. Aikins
(Urologic and Cutaneous Review,
Jan., 1918).
Tuberculin does not seem to prove
effective in the average case, but in very
small doses it sometimes acts beneficially
in children in the presence of a positive
von Pirquet reaction. X-rays and helio-
therapy have also gi^'en good results in
some cases. The local and surgical meas-
ures have already been treated in full in
the article on Tuberculous Adenitis, in
the first volume, page 356, to which the
reader is referred.
TRUE TUBERCULOSIS OR TUBER-
CULOSIS CUTIS.— This rare disease is
due to contact with tuberculous ulcera-
tion. It is characterized by small tuber-
cular growths usually found on the lips,
the vulva, or anus, which gradually soften
and become the foci of ulcerations.
These are usually covered with sanious
purulent discharge, retained in situ by
the clear-cut edges of the ulcers. When
this discharge is removed, the bottom of
the ulcer is found to be red; if left in
place it becomes transformed into a gray-
ish crust.
Treatment. — The treatment is the same
as that for scrofuloderma. But reinfec-
tion constantly recurring, cure is depend-
ent upon that, of the general infection.
TUBERCULOSIS VERRUCA CUTIS,
also known as verruca necrogenica, post-
mortem warts, etc., is the result of a tu-
berculous infection of the skin in the
course of autopsies, or any other form of
contact with infected tissues.
Symptoms. — This rare disease starts as
a nodule, which eventually resolves itself
into a patch ranging in size from that of
a millet-seed to that of a half-dollar.
Each patch is surrounded by two zones,
one red or violaceous, the other brown-
ish red. The outer zone contains a row
of small pustules, but the inner is the seat
of wart-like growths. These are more or
less scaly and produce pus when squeezed
from side to side. The patch ultimately
flattens and becomes converted into a
smooth and thin, scarified patches are
added to the original ones by confli'ence
and thus spread, though very slowly, the
disease being essentially chronic. The
spreading patches cause no pain unless
pressed upon. The lesions are in most
instances on the hands, the knuckles in
particular, the region most exposed to
infection in the occupations which expose
to contact with infected animals and their
carcasses, the disease being mainly ob-
served in veterinary surgeons, butchers,
dead-house attendants, hostlers, drovers,
etc. Unlike lupus it tends to heal in the
center by scar formation, while new
ulcers are being formed.
Treatment. — The treatment of this con-
dition is similar to that for lupus vulgaris,
i.e., thorough destruction of the ulcers by
one of the various forms of cauterization
or, in the milder cases, by the use of
pyrogallol. All these measures are given
in treatment under the next heading.
LUPUS VULGARIS.— This is a tuber-
culous lesion of the skin or mucous mem-
brane, characterized by brownish-red
628
TUBERCULOSIS OF SEROUS MEMBRANES AND SKIN.
patches, which may proceed to ulceration
and invade adjoininjj tissues.
Symptoms, — Lupus begins in the form
of yellowish-red or copper-colored pro-
jections or nodules varying in size, from
that of a millet-seed to that of a split
pea. They may become aggregated into
patches which, by coalescing, in turn
cover extensive surfaces; but, as a rule,
they do not; they are indolent, soft, and
elastic, and sometimes slightly sensitive
to pressure. When the seat of several
blood-vessels, they assume the form
known as the myxomatous lupus, and,
when exceedingly vascular, the angioma-
tous lupus. Their progress is exceedingly
slow.
In lupus cxccdciis the cutaneous tubercles
break down and ulcerate, and become
covered with scabs, overlying a bed of
sanious pus; under this the ulceration
gradually extends, eating its way in all
directions. The neighboring tissues are
slightly tumefied, and a narrow, reddish
areola is usually present. After a certain
time, the ulceration involves the deeper
structures, and all tissues — muscular, car-
tilaginous, tendinous, etc. — are gradually
invaded. The mucous membrane of the
nose, mouth, pharynx, larynx, and the
conjunctiva are often gradually included
in the destructive process, and deformities
of the nose, mouth, lids, etc., result. Un-
fortunately, this terrible disease shows a
distinct predilection for the face, though
it may also develop in the skin of the
limbs, buttocks, and trunk. Again, the
ulcerative form almost invariably attacks
the nostrils, internally or externally,
destruction of this organ being but a
matter of time unless the disease is
mastered.
In the lupus exfoliativus the tubercles
remain practically stationary, then flatten
out, and leave in their stead a wrinkled
surface, which becomes exfoliated, and
ultimately disappears, leaving in its stead
a small scar.
When the destructive process advances
with great rapidity, destroying every-
thing in its wake, it is termed lupus vorax;
when the suppuration is slight and the
lesion is hard, verrucose, or papilloma-
tous, it is termed lupus verrucosus or
papillomatosus; when the affected tissues
are greatly thickened and deformed, it is
termed lupus hypcrtrophicus, etc.
All the forms of lupus, with the ex-
ception of lupus vorax, progress slowly.
It may, after a period of slow develop-
ment, become stationary and even recede
until complete recovery is attained. This
is rarely observed, however. A peculiar-
ity of the disease is its tendency to be-
come complicated with other cutaneous
disorders: erysipelas, adenitis, epithe-
liomatous cancer, etc.
Diagnosis. — Lupus vulgaris may be con-
founded with tertiary syphilis, epithelioma,
rodent cancer, and scrofuloderma. The
syphilitic eruption most likely to be mis-
taken for lupus is j^ subcutaneous gumma,
which after a time ulcerates and becomes
covered with a scab; this heals and
others form just beyond, advancing in a
serpiginous manner. A scar is formed
vi'hich resembles lupus, except that there
is pigmentation around the patch, and
the cicatrix is thinner, softer, and less
fixed than lupus.
Epithelioma is more painful, progresses
more rapidly, and is liable to hemor-
rhages; lymphatic glands in the neighbor-
hood and the deeper structures are in-
vaded. The edges of the ulcer, too, are
raised and hard. Rodent cancer arises
late in life, the edges of the ulcer contain
no nodules, and there are no granula-
tions on the ulcer. It is always single,
and does not cicatrize spontaneouely.
Etiology and Pathology. — The majority
of patients show a decided tendency to
tuberculosis in their family history, or
are tuberculous themselves. Hence the
predilection of some families to lupus.
This includes the cases in which contami-
nation of the skin occurs through the
lymphatics from tuberculous foci else-
where in the body. It is essentially a dis-
ease of the young. It may begin as early
as the second year and is more fre-
quent in males than females.
The lesion consists of a small cell-in-
filtration deep in the corium at first and
which thence penetrates all cutaneous
structures. The tubercle bacillus is found
therein, but not in large numbers.
Prognosis. — Although recent labors
have improved the chances of recovery,
the disease remains a difficult one to over-
TUBERCULOSIS OF SEROUS MEMBRANES AND SKIN.
629
come, and sometimes seems to baffle all
efforts. Again, it may apparent!}- yield
to appropriate' treatment and suddenly
reappear — all features which should sug-
gest reserve.
Treatment. — An important feature of
the treatment of lupus vulgaris is atten-
tion to the general health. It is a tuber-
culous affection and, therefore, due to
inadequate defensive efficiency. Out-of-
door exercise, wholesome food, tonics,
etc., tend greatly to assist the local meas-
ures by increasing the powers of resist-
ance of the tissues to bacillary invasion.
Radical measures are necessary to
eliminate every cell of the diseased area.
This may be done in various ways:
curetting with dermal curette, cauteriza-
tion with g-ilvanocautery, at cherry heat,
or the Paquelin cautery, multiple scari-
fications with the scarifying knife, or
destruction of the individual tubercles by
boring followed by phenic acid applica-
tions. Electrolysis, the needles being
passed through the patch, has also been
advised.
Excision is the most radical of meas-
ures, but the cosmetic results are often
such as to require considerable plastic
work, unless the lesion be relatively
small. A graft must then be inserted
fitting exactly the area excised. Thiersch
grafts sometimes give good results. Sub-
dermal separation of the diseased area
may also be resorted to. It is done by
inclosing the area between two parallel
incisions down to the muscle and detach-
ing the skin from the latter so as to form
a bridge flap; underneath the latter is
then drawn iodoform gauze dipped in
Peruvian balsam to prevent union of the
separated surfaces. This "undermining"
treatment (Payr) causes the skin to re-
cover its normal condition, leaving no
defect. Local anesthesia suffices for all
these procedures unless the lesion be ex-
tensive. It should be remembered, how-
ever, that all cutting operations involve
the danger of causing general infection
when the cutaneous lesion is a primary
one, and that the operative asepsis should
be rigid.
Among the milder though none the less
effective agents used arc pyrogallic acid,
a 10 per cent, petrolatum salve being
kept in situ several days, then replaced by
a weaker salve as ♦^he ulceration heals.
Strong salves of pyrogallol are painful.
Lactic acid is an efficient and compara-
tively painless caustic. The crust having
been, if possible, removed, the parts are
spraj-ed with a 4 per cent, solution of co-
caine, and the edges, after three or four
minutes, are carefully moistened with the
acid, using a small cotton pledget or a
wooden tooth-pick for the purpose.
A saturated solution of trichloracetic
acid, prepared by adding 10 drops of dis-
tilled water to 1 ounce (31 Gm.) of pure
crystals, is also active, used in the same
way. The two last-named acids exert a
selective action on the tuberculous nod-
ules. The applications are followed by
the formation of crusts which exfoliate in
from five to ten days. The areas touched
every two weeks should not be larger
than one inch in diameter. Phenic acid
may be painted on the diseased area
from two to four days in succession. Or
Unna's salve muslin composed of phenic
acid 20 parts, mercuric bichloride 1 part,
and oxide of zinc 36 parts may be used.
Solid carbon dioxide whittled to a tip,
a disk, etc., can be used to destroy the
lesions by keeping it in contact with them
about one minute. It is practically
painless owing to the intense cold de-
veloped which acts as anesthetic. The
slight subsequent burning may be con-
trolled by cold compresses or a weak
solution of cocaine.
White recommends Boeck's paste com-
posed of pyrogallic acid, resorcin, and
salicylic acid, of each 7 parts; gelatin and
talc, of each 5 parts. This is applied to
the diseased tissue with a wooden spat-
ula and covered with a thi-' layer of ab-
sorbent cotton. Within 24 to 48 hours,
chocolate-colored pus begins to run from
the lower level of the dressing and con-
tinues to do so, but in dinn'nishing amounts.
At the end of a week the application is
removed by the aid of diachylon oint-
ment, and a clean, granulating surface is
disclosed, dotted with numerous islands
of healthy, active epithelium. Dewar ob-
tained recovery with the following: After
washing off the scabs with hot water, the
lesions are dried, and thin pieces of cot-
ton-wool, soaked in a 5 per cent. st)lution
630
TUBERCULOSIS OF SEROUS MEMBRANES AND SKIN.
of cocaine, arc applied to the ulcers for a
few minutes. On removing tliesc, thin
films of cotton-wool, soaked in a 10-
volume solution of peroxide of hydrogen,
are left on and kept in position hy touch-
ing the edges with collodion. Every
second day the patient is given an intra-
venous injection of 15 ininims (0.9 c.c.)
of an ethereal solution of iodoform plus
li(|iii(l parafiin.
Tuberculin has not on the whole proven
satisfactory, though a few instances of
recovery have been reported. Yet the
presence of foci elsewhere warrant its
use along with measures addressed to
general tuberculosis. Valuable in this
connection is I'fannenstiel's method — 30
grains (2 Gm.) of sodium iodide per day
in divided doses, while the lesion is kept
constantly moist with a 10-volume solu-
tion of hydrogen peroxide. Free iodine
is liberated in the lesions.
The Finsen light treatment or photo-
therapy is very efficient, though slow. Of
1200 cases treated at the Finsen Institute,
Copenhagen, 60 per cent, were cured.
Artificial heliotherapy with the
carbon arc light found valuable in
lupus. The entire body was exposed
to the rays for one-quarter to two
and a half hours, every second day.
The course lasted from four to eight
months. Reyn and Ernst (Hospital-
stid., May 16, 1917).
' Lupus near facial orifices requires
crossed linear scarifications. The
nasal fossae must be carefully treated
by scarifications or scraping, followed
by cauterization. After scarifica-
tion, potassium permanganate or
zinc chloride should be applied, and
finally mercurial plaster. Lupus of
very small extent on the face, limits,
or trunk should be excised. Moder-
erate-sized lupus is susceptible to
heliotherapy or repeated scraping,
followed by cauterization and iodo-
form dressings. In ulcerated lupus,
mercurial plasters or potassium per-
manganate should first he tried. Rap-
idly spreading forms demand scarifi-
cation at once; turgid forms, calomel
injections or some form of radiother-
apy. Brocq (Jour, de med. et de
chir. prat., Feb. 25, 1919).
Exposure to direct sun rays five hours
daily, where, as in Egypt, the sunshine is
unclduded, has also given good results.
The rest of the face is protected and the
eyes shaded with a dark bandage. Ra-
dium, in heavy doses, acts more rapidly
than the Finsen light, and may con-
veniently be used in cavities, the nose,
mouth, etc. X-rays give the best results
when the lesion is ulcerated and hyper-
trophic; this breaks down rapidly, but the
smooth, dry lupus does better under the
Finsen light and other measures. Where
this is possible, however, the simultane-
ous use of Finsen light and X-rays gives
far better results than either employed
singly. Some hold that Bier's hyperemia,
using suction cups, is more effective, and
acts more rapidly than X-rays.
LUPUS ERYTHEMATOSUS. — This
disease, also known as lupus superficialis,
seborrhoea congestiva, lupus sebaceus,
etc., is not believed to be tuberculous, as
a rule, but the tubercle bacillus has been
found in some cases with other indica-
tions of tuberculosis.
Symptoms. — The earliest appearance of
lupus erythematosus is a patch of redness
around the opening of a sebaceous gland.
This gradually spreads, and the surface
becomes scaly, the margin being defined,
and slightly raised; the spots coalesce,
and new ones form which, in their turn,
join the older ones. The center of each
patch may become covered by thick,
shagreen-like scabs, which, when forcibly
detached, bear on their imder surface
dried columns of epidermic cells which
have been pulled out of the dilated open-
ings of the sebaceous glands. The disease
often becomes stationary after spreading
to a considerable extent; the margins then
lose their bright hue, and a depressed,
punctate scar remains. When hairy parts
have been affected, permanent baldness
results from destruction of the hair-folli-
cles. It occurs on the face oftener than
elsewhere, and tends to be symmetrical.
Starting on the nose or one cheek, it
spreads in both directions, and in severe
cases resembles a butterfly, the wings on
the cheeks and the body on the nose.
Other patches appear on the lobules of
the ears, and occasionally on the fore-
head, the backs of the hands, and the feet.
TUBERCULOSIS OF SEROUS MEMBRANES AND SKIN.
631
Several forms have been identified: (1)
the diffuse or disseminated, which, though
following the ordinary forms, progresses
more or less rapidly, and resembles the
papular stage of eczema or urticaria, and
is rather rare; (2) the tclangiectasic, char-
acterized by thickening and redness of the
skin due to dilatation of its vessels; (3)
the nodular, in which raised, reddish
nodules about the size of a lentil or small
bean occur, usually about the face.
Etiology. — Lupus erythematosus seldom
occurs after the thirtieth year or before
puberty, about two-thirds of the cases be-
ing in females. It attacks people with
feeble circulation such as are liable to
chilblains, etc., and it chooses for its
starting point a part where the blood-
supply is poor and where there is little
subcutaneous fat: e.g., the nose, or ear.
The eruption can sometimes be traced to
exposure, to great heat, or to cold.
Many guesses are available concerning
its actual pathogenesis, but none meets
the various phases of the syndrome.
Treatment. — Many cases of lupus ery-
thematosus can be cured, according to
Unna, by the use of external applications.
Among the external remedies which he
has seen to do most good is the following
prescription: —
R Zinci oxidi,
Boli ruhrce aa 30 grs. (2 Gm.).
Boli albce,
Magu. carbon, .aa 45 grs. (3 Gm.).
AmyVi 2Y2 drms. (10 Gm.).
M.
Another formula which, long continued,
was found to be followed by a cure in a
number of cases, without the help of any
other remedy, is a combination of soap
collodion, as in the following formula: —
B Collodion 5 drms. (20 Gm.).
Sal>. virid Y^ to 1 dram (2
to 4 Gm.).
M.
The same clinician frequently employs
medicated collodion painted over the af-
fected area from 2 to 4 times a day. The
collodion used for the preparation r.iust
have a neutral, not an acid, reaction: —
B Saponis viridis 2 to 4 i)arts.
Collodii flex 20 parts.
M.
B Safonis viridis,
Ac. salicylici aa 2 parts.
Collodii flex 20 parts.
M.
To be used if the skin shows much
irritation: —
R Ichthyolis 5 parts.
Collodii flex 20 parts.
M.
If the lesions are non-inflammatory,
pale, and anemic, Kanoky paints them
with a strong iodine preparation, repeated
three times a week, and administering
salicin internally. The latter may be al-
ternated with quinine, or the latter sub-
stituted altogether. Where the induration
is marked and the condition notably slug-
gish, agents possessing marked stimulat-
ing power are indicated. Salicylic acid,
40 parts, or pyrogallic acid, 10 parts, sus-
pended in collodion, 1(X) parts, are applied
at night with a camel's-hair pencil. If
this causes too much irritation it should
be temporarily discontinued and a sooth-
ing application substituted, such as: —
B Zinci oxidi Hij (^O Gm.) .
Old oliz'cc iSx (40 Gm.).
M.
If the lesions are in the non-inflamma-
tory, pale, and anemic state he advises
painting them with a strong iodine i^rep-
aration, repeating it three times each
week. Ilartigan, in cases with circum-
scribed lesions of the sebaceous and
telangiectatic type, obtained the best re-
sults with a 2 per cent, solution of zinc
sulphate or copper sulphate. MacLeod
and others recommended zinc ionization.
A 2 per cent, zinc sulphate solution is
used, with a current of about 5 milliam-
peres, ten minutes at a time, to each
patch. Nine sittings in all are given.
Under this treatment the scaliness and
redness disappear, leaving a pale, supple,
slightly depressed scar.
Tuberculin often fails to benefit, and
may prove dangerous and even fatal as
in Ravogli's case. Nor are the X-raj-s
nearly as effective as in true lupus, and
may even prove Iiarmful. The Finsen
liglit has not given encouraging results.
The liquid air treatment, however, is effi-
cient, as shown by Fox, Dade, and others,
632
TURPENTINE (TEREBENE; TERPIN HYDRATE).
but the most satisfactory agent is the
solid carbon dioxide. Gottheil states that
while the intense cold prevents severe
pain, light pressure for, say, 20 seconds,
will give a moderate reaction without the
ultimate formation of scar tissue, or with
an amount of it so superficial as to be
practically negligible. Harder pressure for
60 seconds or so will occasion marked
reaction and destruction of the skin. And
between these two extremes any desired
amount of tissue destruction and scar for-
mation can be gotten. C. E. de M. S.
TURPENTINE (TEREBENE;
TERPIN HYDRATE). -Turpentine
(crude, or white, turpentine; common
frankincense; tcrebinthina, N. F.) is a con-
crete oleoresin obtained from Pinus paliistris
and other specimens of Pinus (nat. ord.,
Coniferoc). From this crude turpentine a
volatile oil is distilled which is officially
known as oleuiit tcrebinthina; (U. S. P.),
from which are prepared the official tur-
pentine liniment and rectified oil of tur-
pentine. Turpentine oil is a solvent for
wax, iodine, sulphur, phosphorus, and the
fixed oils.
When the oil of turpentine is distilled
ofif from turpentine a resin (rosin) is left
which is official {resina, U. S. P.) and from,
which are prepared the official resin cerate
and plaster.
Canada balsam {tcrebinthina canadensis)
is obtained from the balm-of-Gilead fir
{Abies balsamea).
Other substances related to turpentine
are terebene and terpin hydrate, also to be
considered in this article.
PREPARATIONS AND DOSES.—
Tcrebinthina, N. F. (turpentine), occur-
ring in yellowish, opaque, brittle, glossy
masses, sticky internally and with a char-
acteristic odor and taste. It is soluble in
alcohol.
Tcrebinthina canadensis, U. S. P. VIII
(Canada turpentine; Canada balsam; bal-
sam of fir), the natural oleoresin of Abies
balsamea, occurring as a viscid, pale-yel-
low, transparent liquid with an agreeable
pine-like odor and a terebinthinate,
slightly bitter taste. On exposure to the
air it gradually dries to form a transpar-
ent varnish. It is soluble in ether, chlo-
roform, benzol, xylol, turpentine, and oils.
Oleum tcrebinthina:, U. S. P. (oil of tur-
pentine), a volatile oil recently distilled
from turpentine, occurring as a thin, color-
less liquid with a characteristic odor and
taste which become stronger with age
and air exposure. It is soluljle in 3 times
its volume of alcohol.
Oleum terebinthina: rectificatum, U. S. P.
(rectified oil of turpentine), made by shak-
ing oil of turpentine with an equal volume
of the official solution of sodium hy-
droxide, recovering about three-fourths of
the oil by distillation, and filtering. Its
physical properties are the same as with
the preceding, over which it is preferred
for internal use. Dose, 5 to 30 minims
(0.3 to 2 c.c); average, 15 minims (1 c.c).
Emulsum old terebinthina, U. S. P. (emul-
sion of oil of turpentine), containing 15
per cent, by volume of rectified oil of
turpentine, together with expressed oil of
almond, acacia, and syrup. Dose, 1 flui-
dram (4 c.c).
Resina, U. S. P. (rosin)j occurring usu-
ally in angular, translucent, amber-colored,
brittle fragments, with a faint odor and
taste of turpentine, inflammable, easily
fusible, and soluble in alcohol, ether, ben-
zol, acetic acid, oils, and caustic alkalies.
Dose 4 grains (0.25 Gm.).
Ceratum resina, U. S. P. (rosin cerate;
basilicon ointment), made by melting to-
gether 7 parts of rosin, 3 parts of yellow
wax, and 10 parts of lard.
Ceratum resin<e compositum, N. F. (com-
pound rosin cerate; Deshler's salve),
made by melting together 45 parts each of
rosin and yellow wax, 60 parts of pre-
pared suet, 23 parts of turpentine, and 27
parts of linseed oil.
Linimcntiun tcrebinthina, U. S. P. (turpen-
tine liniment), made by dissolving 13
parts of melted resin cerate in 7 parts of
oil of turpentine and mixing thoroughly.
Tcrcbenum, U. S. P. (terebene), a liquid
consisting of dipentene and other hydro-
carbons, obtained by the action of concen-
trated sulphuric acid on oil of turpentine
and subsequent rectification with steam.
It occurs as a colorless, thin liquid with a
thyme-like odor and an aromatic, tere-
binthinate taste, only slightly soluble in
water, but soluble in 3 times its volume of
alcohol. It gradually becomes resinified
on exposure to light and air, and acquires
TURPENTINE (TEREBENE; TERPIN HYDRATE)
633
an acid reaction. Dose, 3 to IS minims
(0.2 to 1 c.c); average, 8 minims (0.5 c.c).
Tcrpiiii hydras, U. S. P. (terpin hydrate;
dipentene glycol) [CioHis(OH)2 + H2O],
the hydrate of the diatomic alcohol terpin,
occurring in colorless, rhombic crystals,
nearly odorless and having a slightly aro-
matic and bitter taste, permanent in the
air, soluble in about 200 parts of cold and
32 parts of boiling water, in 10 parts of
alcohol, in 100 parts of ether, and in 200
parts of chloroform. It melts and loses
water when heated to 116° C. Dose, 2 to
10 grains (0.125 to 0.6 Gm.); official dose,
4 grains (0.25 Gm.).
PHYSIOLOGICAL ACTION.— Oil of
turpentine, taken internally in moderate
doses, gives rise to a sensation of warmth
in the stomach. By ."reflex" excitation the
circulation may be quickened and the
warmth of the skin increased.
According to Eustace Smith small doses,
such as 5 or 10 minims (0.3 to 0.6 c.c.)
have but little tendency to irritate the
kidneys, while in doses of 2 to 4 drams
(8 to 16 c.c.) or more the aperient action
of the drug prevents its absorption in ap-
preciable amount. Doses such as J/a to 1
dram (2 to 4 c.c), however, must be given
with caution, tending to cause irritation
of the genitourinary tract, with strangury
and hematuria. The urine in which tur-
pentine is being excreted acquires an odor
of violets. Binet found that traces of tur-
pentine appear in the expired air in a few
hours after its ingestion.
The coagulability of the blood is appar-
ently increased by turpentine. According
to some researches conducted many years
ago (1889) by Bremond and Henocque it
tends to increase bodily oxidation and
improve nutrition.
Externally, turpentine causes reddening
of the surface and sometimes vesication.
It possesses marked antiseptic powers.
Terebene and terpin hj'drate produce, so
far as is known, general effects similar to
those of turpentine. They are both
credited with activity as stimulating ex-
pectorants, acting by local excitation of
the bronchial mucosa as they are being in
part eliminated through it. Terebene has
a more pleasant odor than turpentine.
Terpin hydrate has been held to be better
borne by the stomach than terebene,
though perhaps slightly less active as
expectorant.
UNTOWARD EFFECTS AND POX-
SONING. — A scarlatinoid rash may follow
ingestion of relatively large doses of oil of
turpentine. In Blackwood's case such a
rash followed the taking of 55 minims (3.5
c.c.) in twenty-four hours. Redness and
mottling of the fauces may coexist
(Angus). Ingestion of an ounce (30 c.c.)
of oil of turpentine in Grupel's case
caused marked chilliness, giddiness, and
staggering gait, followed by painful urina-
tion, hematuria, thirst, anorexia, and head-
ache, with recovery extending through
three weeks. In some of the severe cases
vomiting and purging, bloody stools, ab-
dominal pain, suprapubic tenderness, and
suppression of urine are noted. In the
fatal cases, which are rare, marked cir-
culatory weakness, coma, and respiratory
failure follow. Joachim has reported such
a case in a child of 3 years who drank a
quantity of turpentine, death following in
less than two hours. Poisoning can take
place from inhalation. In Newman's case,
that of a varnisher, the symptoms were
persistent nausea, disturbance of speech,
mental exhilaration, frontal headache, irri-
tation about the gums, bladder irritability,
constipation, dyspnea, and the usual odor
of violets of the urine.
Treatment of Poisoning. — This consists
in thorough evacuation of the stomach
with emetics, if the case is seen early;
purging with liberal doses of magnesium
sulphate; giving milk, barley-water, or
other demulcents; morphine hypodfermic-
ally to relieve pain and severe cramps;
hot flannels to the abdomen; a mixture of
potassium citrate with belladonna or hyo-
scyamus to promote renal action and allay
bladder spasm, and saline hypodermo-
clysis or infusion for elimiiiatory purposes
and the relief of impaired circulation.
THERAPEUTICS.— Externally, turpen-
tine is of value as a rubefacient, to induce
counterirritation over deep-seated foci of
intlammation. For this purpose a liniment
of turpentine may be used or, to secure a
more pronounced action, the "turpentine
stupe" may be availed of by dipping
pieces of flannel or of an old blanket in
hot water, wringing them out, then drop-
ping warmed oil of turpentine over them.
634
TURPENTINE (TEREBENE; TERPIN HYDRATE).
Or, 1 dram to 1 ounce (4 to 30 c.c.) of
turpentine may be stirred in a quart of
boiling water until emulsified, and the
stupes wrung out of the resulting fluid.
Again, 1 part of turpentine may be mixed
with 7 parts of olive or cottonseed oil, ap-
plied to the part, and the area covered
with a hot fomentation. Stupes are ad-
vantageously covered, in turn, with cotton
or gauze followed by oiled paper or silk.
When used to relieve intra-abdominal dis-
turbances, as in tympanites and pain of
moderate degree in typhoid fever, the
stupes should not be allowed to grow cold
on the skin, but changed every 10 or 15
minutes until the surface has been well
reddened.
In rheumatic joint or muscular affec-
tions, including lumbago, an ointment or
plaster containing turpentine may be
used.
Turpentine acts rather powerfully as an
antiseptic, and is recommended by Leven
for rubbing into the skin once daily in
tinea versicolor and for use in compresses,
applied morning and evening, in tinea
tonsurans. In sloughing ulcers and gan-
grenous processes, oil of turpentine, freely
applied, is of great value as a non-corro-
sive disinfectant (G. Ross). Bonnaire and
Charrier use it to disinfect the uterine
cavity where iodine has failed, and Cramer
lauds its local effects in infected abortion
cases. As a hemostatic turpentine is
highly recommended by G. G. Turner,
especially in alarming secondary hemor-
rhage in which no bleeding point can be
caught, and in bleeding tooth-sockets,
after vaginal hysterectomy, etc. All
blood-clots should be removed and the
wound then packed with gauze that has
been soaked in oil of turpentine and
squeezed nearly dry.
In tympanites the oil may be used by
rectum in amounts of ^ to 1 fluidram
(2 to 4 c.c.) in copious enemas of warm
water.
Injections of turpentine are recom-
mended in myiasis or infestation of the
orifices of the body wounds with fly-
maggots.
Hypodermic injection of 16 minims
(1 c.c.) of oil of turpentine — 8 minims
(0.5 c.c.) in young children — usually into
the cellular tissue of the abdominal wall
or thigh, has been employed, in inducing
the so-called "aseptic fixation abscess,"
with asserted marked benefit on the gen-
eral condition in a certain proportion of
cases of septicemia and of primary bron-
chopneumonia following various infec-
tions.
Internally, turpentine is used especially
in disorders of the alimentary tract and
respiratory sj^stem. In the tympanites of
typhoid fever its ingestion in 5- or 10-
minim (0.3 to 0.6 c.c.) doses in an emul-
sion 3 times a day is advised, in conjunc-
tion with external and rectal use. The
condition of the mouth is also held to be
improved bj' it in this disease. To expell
hookworms and tapeworms a 5^-ounce (15
c.c.) dose of turpentine, combined with
castor oil, is effective, though not entirely
free of the possibility of untoward side-
effects. Frequent small doses are often
successful where a single large dose fails
to destroy a tapeworm (J. D. Palmer). In
infantile digestive disorders with flatulence
and colic, Eustace Smith orders, e.g., for
an eight months' child, 1 minim (0.06 c.c.)
of the rectified oil, rubbed up with 3
minims (0.2 c.c.) of castor oil and 2 grains
(0.12 Gm.) of gum tragacanth, made up to
a teaspoonful with water, and disguised
with small amounts of fluidextract of
licorice, oil of cloves, and chloroform. In
the abdominal cramps of older children,
the same author recommends 3 or 4
minims (0.2 to 0.25 c.c.) of the rectified
oil, with or without double the quantity of
castor oil, rubbed up with a spoonful of
the mistura amygdalae (B. P.), to be given
3 times a day. J. H. Williams finds its
stimulating effect on the mucous mem-
branes useful in chronic catarrhal gastro-
intestinal affections in general, and also
employs it in colliquative diarrheas in
combination with bismuth salts.
In respiratory affections turpentine and
its derivatives are used as antiseptics and
to arrest excessive bronchial secretion,
e.g., in bronchorrhea and fetid bronchitis,
as well as in the bronchial catarrh of pul-
monary tuberculosis. In the latter condi-
tion, terpin hydrate in 2- or 3- grain (0.12
to 0.2 Gm.) doses is useful. In pulmonary
abscess and gangrene of the lung, 5-minim
(0.3 c.c.) doses of turpentine oil or of tere-
bene may be given 3 or 4 times daily,
TYPHOID FEVER (ROBIN).
635
gradually increased to 10 minims (0.6 c.c).
For the bronchitis associated with bron-
chopneumonia, Jackson recommends ter-
pin hydrate, with or without small doses
of codeine. The irritating cough and
bronchorrhea sometimes following lobar
pneumonia are often allayed by 10-minim
(0.6 c.c.) doses of terebene in capsules 3
times a day. In each of these conditions
the. drugs are frequently employed by in-
h .lation, sometimes combined with euca-
lyptol and creosote, with good results. A
tin or zinc respirator, containing a sponge
upon which the drugs are dropped, may
be used, or a teaspoonful of turpentine or
terebene may be poured upon boiling
water and the patient directed to inhale
the vapor for IS minutes every two hours.
In acute follicular tonsillitis oil of tur-
pentine constitutes a beneficial, though
homely and somewhat severe, local appli-
cation. In hiccough 10 drops of turpen-
tine, with 30 drops of spirit of nitrous
ether in an aromatic water, exerts a stril'-
ing effect (Smith). In laryngitis sicca,
terpin hydrate in 3- to 5- grain (0.2 to 0.3
Gm.) doses 3 or 4 times a day has been
advised.
In hemorrhagic conditions turpentine
has also been credited with therapeutic
power. In purpura hemorrhagica occur-
ring in well-nourished, full-blooded chil-
dren, Eustace Smith strongly recommends
2- to 4- dram (8 to 16 c.c.) doses of oil
of turpentine, with an equal amount of
castor oil, once daily. Slightly smaller
doses are inefficient and even dangerous,
as they may fail to produce a cathartic
effect. In hemophilia, he states, catharsis
with turpentine will sometimes arrest the
bleeding where local styptics have failed.
In the melena of typhoid fever and in
hemoptysis, 10 or 15 minims (0.6 to 1 c.c.)
may be given on sugar 3 times a day, but
the effect is less certain than from the
larger amounts in purpura. The drug has
also been claimed of value in hematemesis,
hematuria, and metrorrhagia. In hemor-
rhagic measles turpentine may possibly
be of value.
Turpentine oil in doses of S minims
(0.3 c.c.) 2 or 3 times a day frequently
acts as a diuretic and, according to J. A.
Munk, will often establish a normal flow
where other diuretics have failed. As it
may irritate the kidneys in larger doses,
such doses are not warranted except as an
emergency measure in advanced nephritis.
The drug seems useful in atonic condi-
tions of the bladder, including the incon-
tinence of bladder atony, and especially
where long-standing, low-grade, infective
inflammation exists. In pyelitis due to
gravel, 10- or 15- drop doses 2 or 3 times
daily after meals tend to allay the inflam-
matory process (Smith). In markedly
chronic, painless cystitis, turpentine has
been used to activate local circulation,
the drug being persistently given up to
slight tenesmus and augmented urination.
In infectious fevers of adynamic type,
including yellow fever, turpentine has by
some been considered of value as a gen-
eral stimulant. L. T. de M. S.
TWILIGHT SLEEP. See Scopo-
lamine.
TYPHLITIS. See Appendicitis.
TYPHOID FEVER.— DEFINI-
TION.— An acute infectious endemic
and epidemic disease caused by a spe-
cific micro-organism — the bacillus of
Eberth and Gaffky — and character-
ized by a more or less typical tem-
perature curve, enlargement of the
spleen, epistaxis, roseola, iliac tender-
ness, diarrhea, and, pathologically,
by enlargement and ulceration of the
agminated and solitary glands of the
ileum.
SYMPTOMS.— A typical case of
typhoid fever presents a course which
is quite characteristic. For several
days there is a vague feeling of dis-
comfort, slight headache, chilliness,
dryness of the skin, aching, digestive
disturbances, such as navisea, vomit-
ing or diarrhea, particularly if a purg-
ative is taken. The symptoms are
generally worse in the afternoon, yet
are not severe enough to entirely in-
capacitate tlie jiatient. The condition
is often attributed to a cold or a "run
down condition." As a rule, a phy-
636 TYPHOID Ji-EVER (ROBIN).
sician is consulted on the third or fected. The ataxia is manifested at
fourth day of the disease. By this first by a mental dullness and apathy.
time the patient complains of rather The tons^ue, when protruded on re-
severe headache, giddiness, pain in quest, is not readily withdrawn ; it is
the limbs and back, chilliness, thirst tremulous, as are tlie extremities. In
and anorexia. The fever is found to severe cases, a low muttering de-
be higher in the evening by a degree lirium, a wakeful sleep, so-called
to a degree and a half, and higher on coma vigil, subsultus tendinum and
succeeding days. The pulse is rapid, carphologia, or picking at the bed-
ranging from 90 to 100 ; respirations clothes, occur. In the beginning of
accelerated, tongue furred, the skin the third week the symptoms are ag-
hot and dry, and the abdomen dis- gravated, reaching the acme from the
tended, with, generally, tenderness fourteenth to the twenty-first day,
and gurgling in the right iliac fossa, when a gradual improvement sets in.
In a number of cases epistaxis is The morning remissions become more
present. During the second week decided and the evening temperature
the symptoms become more pro- lower than that of the preceding day ;
nounced and definite. From the sev- the stools are less in number and
enth to twelfth day rose-colored spots more normal in character; the pulse
appear on the abdomen and some- is slower and stronger ; the tongue
times upon other parts of the body, becomes moist ; the patient looks
These papules are round, slightly ele- brighter from day to day, sleeps bet-
vated and disappear on pressure, ter and evinces a greater desire for
The tongue, which has been whitish food. During the fourth week the
yellow with red edges and tip, be- temperature becomes normal and
comes dry and brown ; the teeth and convalescence is established, lasting
lips are covered with sordes; the one or two weeks, or even longer, de-
gums often bleed on slight pressure ; pending on the degree of exhaustion
the bowels are distended with gas, sufifered. Even if favorable, convales-
and the diarrhea, if present, is more cence may be interrupted by a re-
frequent, the stools being of an ochre crudescence of the fever due to undue
color. The temperature gradually excitement, fatigue, or immoderate
rises, preserving the same step-like eating. These attacks generally sub-
course, reaching the acme toward side under proper treatment. When
the end of the second week. The the case tends to an unfavorable issue,
usual range is 101° to 102° F. (38.3° the diarrhea continues unchecked ; the
to 38.9° C.) in the morning and 103° abdominal pain and tympanites in-
to 104° F. (39.4° to 40° C.) in the crease; the patient becomes more
evening. The respirations are corre- exhausted and lies motionless upon
spondingly quickened. The urine is his side or back, drowsy and apathe-
scanty and red, owing to excess of tic, uttering feeble moans ; the face
urates. is flushed, the features pinched ; the
The skin is dry, but at times skin hot, the pulse fast and feeble;
bathed in perspiration, particularly the teeth and tongue blackened with
toward morning. The nervous sys- sordes ; the special senses obtunded ;
tem is more or less profoundly af- the low muttering delirium gradually
TYPHOID FEVER (ROBIN).
637
lapses into coma, which terminates
in death in a few hours.
Varieties of Typhoid Fever. — The
disease may be so moderate that
it presents few symptoms of any sig-
nificance, or so severe that some
grave malady other than typhoid may
be suspected. In some cases even the
fever may be absent, the disease
manifesting itself by a general ma-
laise with persistent intestinal irrita-
tion. In such cases a laboratory diag-
nosis is made. Or, the disease may
manifest itself by a slight indisposi-
tion and a mild fever, the patient
usually attending to his business till
hemorrhage or even perforation dis-
closes the nature of the afifection.
These so-called "walking typhoids"
are by no means rare and present
grave danger, not only because of the
liability to complications, but because
they are unrecognized typhoid car-
riers. Then there is the abortive
type, ending in a week or ten days in
convalescence. This type is probably
caused either by an organism of low
virulence or some other bacillus of the
typhoid group. Of severe types the
most frequent is the kind ushered in
by high temperature and rapidly fatal,
or that suggestive of acute menin-
gitis.
The Temperature. — Variations in
the temperature curve are frequent,
especially: (1) Low irregular tem-
perature without any tendency to
progressive elevation. (2) Initial hy-
perpyrexia accompanied by a chill
and rigor. (3) Remittent or even
intermittent fever of the malarial
type. (4) Initial hyperpyrexia with
chills, headache and sweating closely
resembling an attack of malaria,
the "sudoral typhoid" of Jaccoud.
Another variation described by
Hare and Beardsley is the "pneumo-
typhoid" in which "the bacillus of
Eberth exercises its primary influ-
ence upon the pulmonary paren-
chyma, producing signs and symp-
toms which are practically identical
with those of ordinary pneumonia,
even to the rusty sputum, although
the usual vigor of onset, as seen in
croupous pneumonia, may be absent
or modified, and the onset in general
more insidious. In these cases to-
ward the ninth or tenth day the high
fever falls but slightly in place of the
characteristic crisis, and when diar-
rhea and rose spots appear the pos-
sibility of the entire illness being due
to a typhoid infection comes upon the
mind of even the careful physician
for the first time." Hyperpyrexia
may be marked, reaching 105° F.
(40.5° C), and at timos 110° F.
(43.3° C), often subsiding in a
few days. If the hyperpyrexia per-
sists toward the end of the second
or third week, a fatal issue may be
looked for. A low range of fever
generally points to a mild infection,
although fatal cases have been re-
corded of this type. Liebermeister re-
corded 250 cases of what he called
"afebrile abdominal catarrh," which
he regarded as typhoid on accovmt of
the presence of other symptoms, such
as enlargement of the spleen, roseola,
etc. Similar cases have been ob-
served by others. In the same group
may be included the Tyf^hus Ici'issimiis
(Griesinger), very mild and terminat-
ing in eight to fourteen days. In
these, correct diagnosis depends on
the Widal test. This form is impor-
tant, since many cases of mild fever,
occurring particularly in the country,
are diagnosed as "bilious fever" or
"malaria," and considerable damage
638 TYPHOID FEVER (ROBIN).
may accrue to the community from a feature ; it may be quite profuse,
neglected water pollution. The occurrence of fever, chills and
Again, high fever may persist to the sweats, mimics a fairly complete
fourth, fifth and even sixth week. In picture of malaria. Some authors
such cases the infection is very se- mention a peculiar odor of the skin of
vere and intestinal ulceration exten- a musty, semicadaverous character,
sive. These are to be distinguished Edema of the skin may occur as a
from cases in which continuous hy- result of venous stasis, nephritis or
perpyrexia is due to complicating anemia. Due to poor nutrition, the
cholecystitis, pneumonia, tuberculosis nails and hair often sufifer, especially
or other disease. In the latter event the latter, and Osier mentions lines
the curve shows a sudden rise at some of atrophy of the skin on the abdomen
period in the course of the fever. and lateral aspects of the thighs sim-
As a rule, the fever subsides grad- ilar to linca atrophica of pregnancy,
ually, by lysis. Rarely, termina- They are possibly due to neuritis,
tion is by crisis, convalescence being The rash, a diagnostic sign, de-
established at once. This possibility velops about the seventh or the ninth
should be borne in mind when inter- day. In rare instances it occurs on
preting a sudden drop of tempera- the third day, and may be scarlatini-
ture. as indicative of hemorrhage or form in character. It consists of rose-
perforation, colored spots, or flattened slightly
The fever bears a fairly constant re- raised papules, from 2 to 4 milli-
lation to the severity of the disease, meters in diameter, which disappear
excepting cases in which a low fever on pressure. The spots may be few
is the result of marked depression of or many, and may come out in suc-
the organism. The height and per- cessive crops. They are usually
sistence of the fever present con- found on the abdomen, chest, back,
siderable prognostic value. Assum- and sometimes the extremities and
ing an average temperature of 102° to the face. In rare cases the eruption
104° F. (38.9° to 40° C.) and an aver- coalesces, producing the appearance
age mortality of 10 per cent., the lat- of measles; in others, there is a
ter rises with the former, reaching generalized erythema, suggestive of
100 per cent, in cases in which the scarlet fever. Other dermatoses are
temperature reaches 107° F. (41.6° petechia; the taches bleuatrcs, which
C.) and over, or the morning tem- are steel-gray spots scattered on the
perature is over 106° F. (41.1° C). abdomen and supposed by some
Chills. — Usually the onset of ty- authors to be caused by pediculi ;
phoid is merely marked by chilly sen- sudamina ; urticaria; tarhe cerebrate,
sations. In some cases, however, a red line produced by drawing the
chills occur, and may recur through- finger-nail over the skin, supposed to
out the course, and even during defer- occur in meningitis, but also found in
vescence. They may, however, denote typhoid and other fevers ; herpes
some complication, and may lead to labialis; dermatitis exfoliativa; ery-
confusion with malaria. thema nodosum ; hemorrhagic erup-
The Skin. — As a rule the skin is tions in the neighborhood of the
dry. In some instances sweating is joints; gangrene of the skin.
TYPHOID FEVER (ROBIN),
639
Bed-sores. — These are areas of su-
perficial necrosis caused by pressure
and irritating discharg-es. They are
observed in patients who are very ill
and emaciated, and who lie mostly on
the back. Bed-sores are rare in pa-
tients who are properly nursed, as
they can be avoided by changing the
position of the patient, frequent
changes of soiled linen and free use
of soap and water after defecation.
The Digestive System. — At the on-
set the mouth is dry, the tongue
swollen and furred. Later the coat-
ing is thick and brown, the tongue
becoming ulcerated if the case is
severe and hygiene of the mouth
neglected. Such patients may suffer
from stomatitis, or .acute parotitis.
Infection of the submaxillary glands
may also occur.
A mild pharyngitis occurs at the
onset of most cases. In some it be-
comes severe, and the palate and ton-
sils may become affected.
The esophagus may show inflam-
mation of the mucous membrane, and
sometimes ulceration. In a few of
the recorded cases of ulceration ty-
phoid bacilli were found in the
lesions.
The Stomach. — As a rule the mild
gastric disturbances depend on fever
and general toxemia. In some cases,
however, gastric irritation is so
severe as to interfere seriously witli
nutrition. Typical typhoid gastric
ulcers have been recorded.
The Intestines. — In the average
typical case the intestinal changes
follow a regular course: (1) hyper-
emia; (2) ulceration; (3) sloughing;
and (4) cicatrization, the symptoms
being pain and tenderness in the
ileum, gurgling in the right iliac
fossa, tympanites due to increased
bacterial action, and diarrhea. In
some cases, however, there may be
little or no ulceration in the intes-
tines, and constipation may either
supplant the early diarrhea or occur
throughout. Often diarrhea is due
chiefly to purgatives, or to improper
feeding, particularly the use of broths.
Diarrhea aggravates the patient's con-
dition : (1) The withdrawal of con-
siderable amounts of fluid causes
disturbance in the circulation. (2)
The contents of the colon being in a
fluid state, bacterial activity is much
greater, with consequent toxic ab-
sorption. (3) Secondary intoxication
exerts a profound influence on the
nervous system and metabolism,
greatly interfering with the patient's
nutrition. Very probably the vitality
and resistance of the cells are lowered,
ulceration is deeper and more exten-
sive, and owing to the distention,
hemorrhages and perforation are more
apt to occur. With so much bacterial
activity there is always a possibility
of some symbiosis, which augments
the virulence of the typhoid bacilli.
Meteorism is frequent, especially
in cases accompanied by diarrhea. It
usually occurs during the height of
the disease, and indicates marked
toxemia. The distention causes in-
terference with respiration and the
heart's action. In some cases it may
produce intestinal paresis, estal)lish-
ing a vicious circle by the diminished
peristalsis increasing the tympanites.
Pain. — Abdominal pain is frequent.
It varies from tenderness in the right
iliac fossa to generalized pain, par-
ticularly on pressure. In some cases
the pain is caused by increased peris-
talsis, distention with gas or indiges-
tion ; in others, an enlarged spleen,
or, by lesions in the gall-bladder,
640
TYPHOID I'EVER (ROBIN).
lunges, pleura or abdominal viscera.
The lymplioid tissue of the appendix
is often involved and tenderness in
this reg-ion may mislead into a diag-
nosis of acute appendicitis. Many un-
necessary appendectomies have thus
been performed. On the other hand,
coincidence of typhoid fever and ap-
pendicitis is by no means impossible,
and, indeed, probably occurs in num-
erous instances, but is overlooked.
The Rectum. — In a number of
cases rectal ulceration occurs, caus-
ing slight bleeding. Perforation of a
rectal ulcer has been recorded.
The Abdominal Organs. — The liver
is sometimes invaded by the typhoid
bacilli. It is enlarged, tender and
may show focal necrosis, abscess and
pylephlebitis. In milder grades jaun-
dice may occur — the "bilious re-
mittent" of the older writers, a con-
ception of the disease which still
clings to some physicians.
The gall-bladder is often infected,
the bacilli gaining access through the
circulation. As a rule, there are
no severe disturbances. In some
cases, however, severe cholecystitis is
ushered in, with severe pain, chills,
vomiting, and sudden rise of tempera-
ture. This may subside in a few days,
or perforation of the gall-bladder and
peritonitis take place.
The Spleen. — Splenic enlargement
is constant. It is the organ in which
typhoid bacilli are invariably present,
causing hyperemia and swelling of
the lymphoid tissue. The enlarged
organ is often tender.
The Respiratory System. — Various
grades of inflammation of the upper
respiratory tract are common. Hy-
peremia of the nasal mucosa occurs
early. It may be slight, causing dis-
charge of bloody mucus, or intense,
resulting in profuse bleeding. The
phaiynx and larynx may show slight
catarrhal inflammation of a severe
grade, causing ulceration, with its at-
tendant symptoms. A mild bronchitis
occurs almost invariably in the be-
ginning. It may be so intense as to
cause numerous rales and bloody ex-
pectoration, thus suggesting pneu-
monia.
Typhoid infection of the pleura has
been reported. The attack differs
from acute pleurisy, in that the gen-
eral symptoms are out of all propor-
tion to the local signs. In cases of
effusion, the typhoid bacillus has
been found in the fluid (Westcott).
The Circulatory System. — The
heart shows changes peculiar to tox-
emia. Evidences of myocardial de-
generation miay occur as the dis-
ease progresses and exhaustion takes
place. Endocarditis caused by the
typhoid bacillus has been noted, pre-
senting no peculiar clinical features.
Thrombosis of the arteries and, more
frequently, the veins occurs as a
complication, usually caused by a
local phlebitis.
Blood-pressure. — This is usually
low, varying from 115 to 125 early
in the disease and 100 to 110 later.
Taken repeatedly, a systolic pressure
lower than the pulse rate is an indi-
cation of cardiac weakness. A sud-
den drop in pressure points to hem-
orrhage, while a gradual rise shows
improvement.
The Nervous System. — Nervous
manifestations are common. Early,
the pains in the back, vertigo, severe
headache, insomnia and difficulty in
ideation point to peripheral nervous
irritation. Later, the low muttering
delirium, the coma vigil, amnesia, and,
at times, evidences of marked menin-
TYPHOID FEVER (ROBIN).
641
geal irritation show how profoundly
the cerebrospinal centers are affected.
In some cases the mental state may
assume the aspect of a psychosis ;
many such patients have been sent
to institutions for the insane. Mania,
delirium accompanied by definite de-
lusions, paranoia and melancholia
have all been noted. This fact should
put the physician on his guard in
every case of acute insanity.
Actual meningitis in typhoid is
rare, and the diagnosis of "typhoid
meningitis," frequently made, is gen-
erally erroneous. Symptoms of men-
ingeal irritation are common, and at
times may be indistinguishable from
those of true meningitis. The lum-
bar puncture clears up the diagnosis.
Also met with are cerebral throm-
bosis and embolism, poliomyelitis,
convulsions, bulbar paralysis, epi-
lepsy, neuritis, and various neural-
gias.
The Genitourinary System. — The
urine resembles that of other feb-
rile conditions. It is usually lessened
in amount, with excess of urates and
pigments and high specific gravity,
due to increase of urea and uric
acids. Often there is a marked in-
crease in urea nitrogen, and also in
the ammonia and amido-acids, sug-
gestive of a toxemia from cellular
disintegration. In most cases, if at
all severe, albumin is present. It is
evanescent, and but rarely perma-
nent. Indican is increased. In about
30 per cent, of the cases typhoid bacilli
appear in the urine during the third
week. Other micro-organisms may
also be present, particularly the colon
bacillus. These bacteria may give
rise to cystitis and pyelitis.
Retention of urine is c|uite common
at the onset. When late, it is due to
stupor ; the bladder may become dis-
tended enormously without the pa-
tient complaining about it. The
physician should inquire about the
bladder function and ascertain if the
organ is distended. In view of the
usual low resistance, catheterization
should be avoided as far as possible.
Incontinence of urine is most fre-
quent in patients who are in a stupor,
and may be associated with disten-
tion. Great care should be exercised
in mantaining absolute cleanliness.
The reproductive organs are some-
times aft'ected. Cases of orchitis,
mastitis and ovarian abscess, caused
by the typhoid bacillus, have been re-
ported. Menstruation usually ceases ;
pregnancy, if present, is interrupted,
if the attack is severe. "The typhoid
bacillus may pass from the mother
to the child in utcro, usually in cases
with hemorrhagic lesions in the pla-
centa. The child apparently always
dies of the typhoid septicemia, but
does not necessarily show intestinal
lesions. The agglutination reaction
is not always given by the fetal blood,
and if present it may have been due
to changes arising in the blood of
the fetus" (McCrae).
Cases of puerperal typhoid infec-
tion have been reported.
COMPLICATIONS. — The most
serious are hemorrhage and perfora-
tion. Hemorrhage may occur early,
due to oozing from the hyperemic
areas. This form is not, as a rule,
serious. The more severe hcuK^r-
rhages occur at the end of the second
and through the third week. The
patient is suddcnlv restless and anx-
ious, and the pulse more fre(|uent
and l)Ounding. A hemorrhage has
occurred. This ma\' be slight, a few
<lrams soon appearing in the stools,
8—41
642
TYPHOID FEVER (ROBIN).
or profuse, a pint or more. In the
latter case the pulse becomes rapid
and feeble, and a decided drop in
temperature takes place. There may
be only a sing-le hemorrha.i^e or a
number of them, or the bleeding is
more or less continuous. In severe
bleeding- the pulse becomes rapid and
feeble. The blood-pressure falls to
80 or 90 mm. Ilg., the hemoglobin is
reduced, and the red cells may be re-
duced to 2,000.000 per cm. The
coagulation time is increased. If
toxemia is not severe, the hemor-
rhage alone is not fraught with great
danger. But if the patient is pro-
foundly toxic and exhausted, a pro-
fuse hemorrhage may so affect the
circulation as to prove fatal.
Perforation. — This occurs in about
2 to 3 per cent, of the cases. It re-
sults from the extension of necrosis
of a typhoid ulcer; its usual site is
the ileum. One should be on the
lookout for it where abdominal dis-
tention, diarrhea and pain are promi-
nent symptoms. In view of the
favorable surgical results, the recog-
nition of perforation at its earliest
possible moment is of great impor-
tance. The earliest symptom is acute
abdominal pain. In some cases,
paroxysmal pain and tenderness may
be present for several days before
perforation occurs. Broadly speak-
ing, any decided change in the condi-
tion of the patient's abdomen during
the third or fourth week of the dis-
ease should be carefully scrutinized,
particularly in the right lower quad-
rant. The principal features of per-
foration are thus summarized by
McCrae : —
"1. General Appearance. — This may
be suggestive at the onset, the fea-
tures having a more or less pinched
expression, especially if there be
sweating. As a rule this does not
persist, and in a few hours later there
may be nothing marked. If general
peritonitis develops we have the
characteristic facies of that condition.
"2. Temperature. — The course of
this is variable. In many patients im-
mediately following perforation there
is a slight elevation, followed later by
a drop. ... A sudden fall or sud-
den elevation may occur with the
perforation. Later on the tempera-
ture may rise with the peritonitis,
but, as a rule, changes in the tem-
perature are too uncertain to be of
much value.
"3. Pulse and Respiration. — Usually
these both show increase, but there
is no certainty in this, for patients
have been operated on in whom
neither the pulse nor the respiration
rates had especially altered. Gener-
ally the respiration rate increases at
the time of perforation, and this may
be a valuable sign. Later on both
the pulse and respiration rate almost
invariably increase.
"4. Gastric Symptoms. — Hiccough,
nausea or vomiting may occur at time
of perforation. ... In several pa-
tients the sudden occurrence of one
of these has first aroused suspicions
of perforation.
"5. Abdominal Conditions. — These
are by far the most important. . . .
Abdominal pain may be fairly con-
stant, but is usually paroxysmal.
The local abdominal features are (a)
increase in distention, which is often
not present until some hours after
perforation. It should always be
carefully looked for, ... (b)
Changes in the respiratory move-
ment : these, if present early, are
very valuable. The decrease in the
TYPHOID FEVER (ROBIN). 643
extent of movement may be seen the process be low in the abdomen
only below the navel or may be more there may be marked tenderness on
on one side than the other. But gen- pressure high up in the rectum, some-
eral peritonitis may be present with times more on one side,
well-marked retention of the respira- "7. Boiucls. — As a rule they do not
tory movement, (r) Rigidity : this move after perforation, but this is not
. . . should always be most carefully invariable.
noted. Light palpation should be "8. Leucocytes. — Perforation is usu-
employed, and it is especially im- ally followed by an increase in their
portant to compare the two sides of number. There are three fairly well-
the abdomen. With perforation it marked groups of cases : the first, in
may be some hours before rigidity is which there is a steady increase in
marked, and too much importance the number from hour to hour ; the
should not be attached to its ab- second, in which there is a slight in-
sence. Persistent rigidity of one rec- crease in the first two or three hours
tus muscle is an important sign, (rf) and then a rapid fall, and the third,
Muscle spasm : this is, as a rule, the in which there is practically no
mxost important local sign. It may change or even a fall. The initial
be quite local and found in part of rise may be very temporary. . . .
one rectus only, {e) Movable dull- Counts can be of service only if
ness : this may suggest the presence there are previous ones available for
of free fluid in the peritoneal cavity, comparison. Many of the conditions
but great caution should be observed which cause abdominal pain may also
in drawing such a conclusion, as it produce leucocytosis. It is in the
may be given by fluid in the bowel, group in which the leucocytes in-
This is especially likely to occur if crease steadily that the blood-counts
there has been diarrhea, which is give the most assistance. The pres-
often the case in the patients with ence of leucocytosis is most impor-
perforation. (/) Obliteration of liver tant, l)Ut from its absence no conclu-
dullness : this is of value in two con- sion should be drawn. A steadily
ditions ; first, if it occur in an abdomen dropping count may suggest a severe
which is flat or scaphoid, and second, general peritonitis.
if it has appeared suddenly in a non- "9. Blood-pressure. — In many pa-
distended abdomen. ... {g) Signs tients there is a sharp rise with the
on auscultation : these are of very perforation. This is not invariable,
doubtful help. Some writers, espe- ... It should be of aid in the diag-
cially the French, have laid stress on nosis of hemorrhage from perfora-
the fact that gas could be heard es- tion. In one patient the rise in
caping from the bowel through the blood-pressure occurred aliout three
perforation. The writer heard it in hours before the first sign of perfo-
one patient with perforation in whom ration.
there was also a curious sound on "Advance in the signs is an im-
auscultatory percussion comparable portant aid, and the patient sliould hQ
to the coin sound in pneumothorax. carefully watclied for tliis. The dis-
"6. Rectal Examination. — This tention may gradually increase, the
should always be made. ... If respiratory movements decrease, and
644
TYPHOID FEVER (ROBIN).
the tenderness with rigidity and mus-
cle-spasm become more marked. But
one should not wait for too much ad-
vance before deciding on exploration.
"Lastly, as an aid in the diagnosis
of perforation we must include an
exploratory incision, for it is well to
recognize that it ma}- be impossible
to make a positive diagnosis without
this. ... In some patients, espe-
cially those who are toxic or de-
lirious, it may be quite impossible to
make an early positive diagnosis. No
one can lay down rules which will
always apply — every patient is a new
problem. The conditions which are
most likely to be mistaken for per-
foration are as follows : —
"(1) Peritonitis from other causes:
This is not common and its definite
recognition is difficult. ... In these
cases an exact diagnosis is not an
important matter, because the treat-
ment is the same as for perforation.
(2) Appendicitis : This may be due
to a typhoid process or may be dis-
tinct, and either acute or acute ex-
acerbation of a chronic condition.
The condition can hardly be posi-
tively recognized and the same re-
marks apply as to the preceding
group. (3) Hemorrhage : This may
give a picture much like perforation,
but the fall in blood-pressure and in
the percentage of hemoglobin is an
aid in diagnosis. The association of
the conditions has to be kept in mind
and every patient with hemorrhage
should be carefully examined with
the possibility of perforation in view.
Rigidity and muscle-spasm are not
as common in hemorrhage as in
perforation. In one patient of this
series with both, in whom the symp-
toms were very severe, the fall in
hemoglobin did not seem enough to
correspond to a hemorrhage sufficient
to give all the symptoms. . . . (4)
Phlebitis : This, in the iliac veins,
may give very suspicious symptoms,
and in one such case of this series
exploration was done. The careful
examination of the leg for swelling
and the femoral region for tenderness
may give the correct diagnosis. (5)
Intestinal conditions, such as ob-
struction, strangulation, intussuscep-
tion, may cause difficulty. (6) At-
tacks of abdominal pain without evi-
dent cause : In these patients careful
continued examination should ex-
clude them beyond doubt. Perfora-
tion of an ulcer in the stomach does
not require an}- special discussion."
Other complications more or less
serious are : Peritonitis from causes
other than perforation, hemorrhagic
pancreatitis, diphtheritic laryngitis,
pneumonia, both lobar and lobular,
hypostatic congestion of the lungs,
pleuritis, endocarditis and embolism,
otitis media, acute nephritis, thyroidi-
tis, periostitis and other bone lesions,
arthritis, suppuration and gangrene.
Typhoid fever may also be associated
with other diseases, presenting a
somewhat distorted clinical picture,
as malaria (rare), tuberculosis, erup-
tive fevers, gastrointestinal disorders,
trichinosis, syphilis, gonorrhea and
appendicitis.
DIAGNOSIS.— Diagnosis based on
clinical symptoms presents difficul-
ties which are at times insurmount-
able. A snapshot diagnosis of ty-
phoid fever is frequently made by
the thoughtless physician only to be
forced to acknowledge his mistake
or else compelled to fall back on the
lime-honored, but dishonest misrep-
resentation of his ability to "abort"
the disease. Again, a case of typhoid
TYPHOiD FEVER (ROBIN).
6+5
overlooked may mean an intestinal
hemorrhage or perforation when
neither patient nor physician is pre-
pared for it. As there is not a single
pathognomonic symptom of typhoid
fever, the attending physician should
refuse to make a positive diagnosis
on the first or second visit. This de-
lay should not occasion any anxiety,
since the general treatment of the pa-
tient would not materially change
were the case one of typhoid. In 4
or 5 days, careful observation will
generally permit of a satisfactory
diagnosis, particularly in localities
where typhoid is practically the only
continued fever.
The signs and symptoms which are
suggestive of typhoid fever are: (1)
gradual onset ; (2) headache and
mental dullness; (3) irregular tem-
perature wnth a distinct rise in the
evening; (4) bronchitis, with slight
expectoration; (5) epistaxis; (6) rela-
tively slow dicrotic pulse ; (7) furred,
tremulous tongue ; (8) diarrhea ; (9)
enlargement of the spleen; (10) rose
spots; (11) iliac tenderness; (12) hy-
poleucocytosis, with an increase of
the mononuclears.
There are certain symptoms which
are against a diagnosis of typhoid, as
herpes, coryza and conjunctivitis.
The diseases with which typhoid
fever is often confounded are tuber-
culosis, malaria, typhus fe\er, sep-
tic conditions, endocarditis, influenza,
ptomaine poisoning, acute exanthe-
mata, trichinosis, secondary syphilis,
cerebrospinal meningitis, pneumonia,
pleurisy, appendicitis, acute nepliritis.
and other conditions accom])anied b\'
a continued fever.
It is in the obscure cases tliat the
laboratory methods of diagnosis are
of greatest value.
The Widal test was described in
volume i, page 458, and volume v,
page 384, and Ehrlich's diazo-reaction,
now rather discredited, in volume iv,
page 109.
Propliylactic inoculation with triple
vaccine (T. A. B. — typhoid and para-
typlioids A and B) has wrought ma-
terial changes in the 3 diseases. The
symptoms liave become so modified,
or so many are absent which were
diagnostic, that the clinical diagnosis
of enteric infection has become very
ditficuh. The agglutinin test has also
been modified, but it still remains the
one method of making a reasonably
certain diagnosis. The techniciue of
Dreyer and Walker, of quantitative
determination of the agglutinins for
each of the 3 organisms against
standard agglutinable cultures, is the
method to be used, but it must be
carried out by an experienced worker.
The test must be repeated at regular
intervals to obtain the curve of each
of the 3 agglutinins. A positive re-
sult is shown by a rise in the agglu-
tinin curve for 1, or at times 2, of
the organisms amounting to 100 to
200 per cent. This rise reaches its
maximum between the sixteenth and
twenty-fourth days of the disease.
H. M. Perry (Lancet, Apr. 27, 1918).
The Bordet-Gengou Reaction. —
This is a biochemical reaction.
Five substances are required to perform
the test, (a) Typhoid antigen. This is
an emulsion of killed typhoid organisms.
(b) The serum from a typhoid fever pa-
tient, which is heated to a temperature
of 55-60° C. for half an hour. Tliis con-
tains the typhoid amboceptor, (r) The
l)Iood-serum from a guinea-pig. This
provision is known as the complement.
id) The hemolytic serum, which is ob-
tained Iiy immunizing a rabbit with the
red corpuscles of another animal, e.g., the
sheep. This ra1)bit's serum will then
cause hemolysis of sheep's corpuscles /;/
vitro. The serum is heated to destroy the
complement. (c) The suspension of
sheep's corpuscles in normal saline.
The lirst 3 substances are placed in a
640
TYPHOID FEVER (ROBIN).
sterile test-tu1)c, wliicli is well shaken and
then placed in an incubator at 57° C. for
1 hour. The complement will he found to
have united firmly to the typhoid am-
boceptor and typhoid antijj^en, which are
now represented as the emulsion of ty-
phoid organism.
The hemolytic scrum, suitably diluted,
and the sheep's corpuscles are then added,
and the whole, thoroughly shaken. An
opaque red fluid results. The tul)e is then
placed for about 2 hours in an incubator
at 57° C. ; the red corpuscles will have
sunk to the bottom of the tube, having
undergone no hemolysis, and the fluid in
the tube remains colorless.
A control is made by preparing another
tube, in which the serum of the typhoid
patient is replaced by that of a normal
individual. Here the red blood-corpuscles
are destroyed, and the solution in the
tube is of a transparent red color. He-
molysis is complete because the comple-
ment, not being anchored to the typhoid
amboceptor and typhoid antigen, is free
to fix itself to the hemolytic amboceptor
and red corpuscles.
The Ophthalmic Reaction in Ty-
phoid.— This test was developed in
1907 by Chantemesse who claimed
that it gave a very early indication of
typhoid fever.
The method was subsequently modified
by P'loud and Barker, and by Austrian,
who prepares his antigen from a mixed
culture of 80 different strains. These are
grown in plain bouillon for 24 hours and
are then scdimented, washed and killed
by heating for 2 hours at 60° C. The mass
of bacilli is then thoroughly dried and
ground with sodium chloride crystals in
an agate mortar, after which it is ma-
cerated with water for 3 days and the
watery extract precipitated by pouring
into absolute alcohol. The residue is then
collected, dried, pulverized, and a solution
made in the proportion of 10 mg. to 1 c.c.
of water. One drop of this solution drop-
ped into the lower conjunctival sac of the
typhoid patient produces reddening of the
conjunctiva and sometimes slight edema
of one or both eyelids. The reaction
reaches its height in from 6 to 10 hours.
Isolation of Typhoid Bacilli from
Body Fluids. — It has l)cc()me pos-
sil>le to isolate typhoid bacilli from
the blood, feces, urine, rose spots,
and spinal lluids. In some cases
a blood-culture may prove of great
diagnostic value, jiarticularly in dif-
ferentiating typhoid fever frotn other
bacteremias. In such cases the cHn-
ician may make the initial culture and
turn it over to the bacteriologist for
further study. The technique is thus
described by Hektoen : —
"The best method to secure blood for
bacteriological study is venous punctures
under the most scrupulous asepsis. Nat-
urally, glass syringes are preferable to
metallic because more easily sterilized
and because transparent. . . . By
some it is regarded as sufficiently cleans-
ing to wash the area about the puncture
with alcohol or ether. In practically all
cases one of the veins at the elbow, usu-
ally the median, is selected for the punc-
ture, and a moderate constriction of the
arm will distend them. ... In fleshy
persons ... it may be necessary to
make the puncture more or less blindly.
"Immediately on withdrawal of the
needle, after filling the syringe, suitable
media should be inoculated with the blood
before clotting takes place. In most cases
it will probably be deemed most advan-
tageous to inoculate small quantities of
the blood, e.g., 1 c.c, into large quantities
of some liquid medium like bouillon, e.g.,
100 c.c. The main reason for this dilution
is the necessity to overcome, as far as pos-
sible, the natural bactericidal properties
of blood, at least for some bacteria.
"During the process of inoculating
flasks . . . the mouth of the un-
corked flask should be held in such a way
that bacteria cannot fall in . . .
Undoubtedly organisms sometimes are
picked up from the deeper layers of the
skin as the needle passes through. In
most instancs the contaminating organ-
isms will be found to be vulgar staphy-
lococci, and it will be a safe rule to
place no significance on the development
of growths of staphylococci, especially
TYPHOID FEVER (ROBIN).
647
other than Staphylococcus pyogenes aureus,
in cultures from, the blood.
"The inoculated flasks are then placed
in the incubator for 24 to 48 hours, when
they are examined for turbidity and other
evidences of bacterial growth. When the
bouillon remains sterile the blood-cor-
puscles fall to the bottom intact, the
supernatant fluid becoming clear, or nearly
so. In the case of streptococci a frequent
early evidence of growth is diffusion of
hemoglobin, i.e., laking of the blood owing
to the development of a special hemolytic
substance . . . Typhoid bacilli usu-
ally cause a diffuse turbidity of bouillon
in 24 to 48 hours. In order to secure
easily sufficient material for microscopic
examination and for subcultures froin
flasks of blood-cultures the use of long
sterile pipettes is very convenient."
A new method for the isolation of ty-
phoid bacilli from the blood has been
devised by Cole, Davison, and Cronk.
In it the disturbing bactericidal power of
the blood is eliminated by the employ-
ment of typhoid bacilli killed by heating,
or the filtrate from typhoid cultures after
autolysis. Wright and others have shown
that the specific amboceptors are ab-
sorbed by such dead bacilli or their re-
ceptors. This practical application of
this principle permits of isolation of
typhoid bacilli from the blood in about
70 per cent, of the cases. Only 1 c.c. of
blood is required, easily obtained in
a syringe and added to 10 c.c. of the
media. This greatly simplifies the use of
blood-cultures.
The isolation of typhoid bacilli from the
feces, urine and other fluids requires
special media. The Hiss plating medium
consists of 10 Gm. of agar, 25 Gm. of
gelatin, 5 Gm. of sodium chloride, 5 Gm.
of Liebig's beef-extract, 10 Gm. of glu-
cose, and 10(X) c.c. of water. The reaction
is 2 per cent, of normal acid. The typhoid
bacillus is distinguished by the appearance
of the colonies and the non-formation of
gas. In a tube medium of similar com-
position, but with less agar and more
gelatin, the typhoid bacillus produces a
uniform cloudiness in 18 hours, without
gas formation. Drigalski and Ctmradi
introduced a differentiating medium by
modifying the ordinary lactose litmus
agar by the addition of nutrose and
crystal violet. The latter inhibits the
growth of many other bacteria. On this
medium, typhoid colonies are blue. The
"endomedium" appears to be gaining
favor among bacteriologists. This me-
dium is made up of 10 Gm. of extract of
meat, 10 Gm. of peptone, 5 Gm. of sodium
chloride, 40 Gm. of agar, 5 Gm. of lac-
tose, 5 c.c. of a 10 per cent, alcoholic
solution of fuchsin, and 25 c.c. of a 10 per
cent, solution of sodium sulphite. The
colonies of typhoid bacilli on this medium
are colorless, while those of the colon
bacilli are red.
ETIOLOGY.— The typhoid bacil-
lus was discovered by Eberth in the
spleen and mesenteric glands of ty-
phoid fever patients in 1880. In 1884
Gaffky established definitely its etio-
logical responsibility and obtained
pure cultures of it.
The bacillus is a short, somewhat
slender rod, with rounded ends, ac-
tively motile and possesses a number
of peripheral flag-ella. It stains read-
ily with the usual aniline dyes, and is
decolorized by Gram's method. It is
facultative aerobic and grows well in
ordinary culture media.
Bouillon. — Uniform cloudiness
without the fonnation of a pellicle.
Gelatin. — Characteristic leaf-shaped
colonies. No liquefaction. In stabs,
growth along entire extent of stab
with thin surface growth.
Potato. — Barely visible, moist, glis-
tening growth.
Milk. — No coagulation. Litmus
milk turned red.
Dunham's Peptone Solution. — No in-
dol produced.
Sugar Broths. — No gas. Formation
of acid in all sugars, except lactose
and saccharose.
The typhoid ])acillus grows well at
room temperature, but most luxuri-
antly at 37.5° C. Its thermal death
648
TYPHOID ]"EVER (ROBIN).
point is 56-60° C. for 10 minutes. It
remains alive on culture media iuv
years, in natural waters for about a
month, and in ice for 3 months.
When injected into the lower ani-
mals a fatal septicemia may be pro-
duced, but no typical pathological
changes. In man definite lesions are
produced, and the bacilli pass into
the blood-stream and thence to other
tissues. They are eliminated with
the various secretions and disappear
from "the bodv in 4 or 5 weeks. Oc-
casionally they remain in the body
for months, and even years, the
resulting- "typhoid carriers" being of
great epidemiological importance.
The efifect of the germ is due to
endotoxins set free by its destruction.
Robust subjects often suffer from
greater toxemia than weak, because
of the more rapid destruction of ba-
cilli and vigorous liberation of endo-
toxins taking place. These stimu-
late the production of immune sub-
stances in the blood-serum, bacteri-
cidal and bacteriolytic, agglutinating
and precipitating, i.e., killing, dis-
solving, agglutinating or precipitat-
ing typhoid bacilli in contact with
them. Their exact nature and origin
remain unknown. They are certainly
different from the antitoxic principles
produced in response to the irritation
of soluble toxins, as in diphtheria and
tetanus. And it is for this reason
that an antityphoid antitoxic serum,
like the serum against diphtheria or
tetanus, is not a rational agent.
There are various other bacteria
which commonly invade the intes-
tinal tract, and are so closely related
as to suggest some common progeni-
tor, if not a possible mutation. Thus,
the colon bacillus has been shown
closer to the typhoid bacillus than
su()p(jsed. It was demonstrated by
Sallus that the colon bacillus forms
the same aggressins as the tyj^hoid.
The group includes the colon bacillus,
the typhoid, paratyphoid, the dysen-
tery bacillus, and Bacillus fccalis al-
kaligciics. Closely related to this
group is the Bacillus lactis a'crogcnes,
an ordinary saprophytic organism.
A number of these organisms may
produce a disease w4iich, but for the
absence of the specific agglutina-
tion reaction against typhoid bacilli,
might be mistaken for typhoid. The
organisms of the enteritidis group
cause severe gastrointestinal symp-
toms, characterized by profound
toxemia. Bacillus coll communis (colon
bacillus) is a normal resident of the
intestinal tract of man and animals,
but under certain conditions of
virulence and susceptibility is capa-
ble of producing severe pathological
changes. Bacillus fccalis alkaligciics
resembles the typhoid bacillus very
closely, but is only slightly patho-
genic. Bacillus enteritidis, or the
meat-poison bacillus discovered l)y
Gartner, is also closely related.
The following grouping based on
cultural characteristics is given by
Dunham : —
Division I. — Typhoid-like morphology
(motile).
A. No sugars fermented. Tj'pe B. fccalis
alkaligcnes.
B. y\cid in dextrose, but no gas. Type
B. typhosus. Agglutination in typhoid
serum.
C. Acid in dextrose, but gas only when
other constituents are favorable. No acid
or gas from lactose or saccharose. No
agglutination in typhoid serum. Includes
Bacillus "Cwyn" and Bacillus "O" of
Gushing.
D. Acid and gas from dextrose. No acio
or gas from lactose or saccharose. Grows
more rapidly than typhoid. No agglutina-
TYPHOID FEVER (ROBIN).
649
tion in colon-immune serum. Slight re-
action with some typhoid sera. Includes
Gartner's B. eiiteritidis, B. Morscelc, Gun-
ther's meat-poisoning bacillus, hog-cholera
bacillus, B. psittacosis, B. morbificans bov'is,
Durham's Bacillus "A," B. typhi murium.
Division II. — Colon-like morphology
(motile).
E. Acid and gas from dextrose; none
from lactose or saccharose. Rate of
growth and colony appearance inore like
colon than typhoid.
F. Acid and gas from dextrose, and no
gas from lactose. Types isolated by
Durham.
G. Acid and gas from dextrose; acid,
no gas, from lactose. Dififer from F in
serum reactions.
H. B. coli communis. Acid and gas from
dextrose and lactose; none from saccha-
rose.
I. B. coli commiinior. Acid and gas from
dextrose, lactose, and saccharose.
Division III. — Non-motile. Polysac-
charide splitters (starch). Type B. lactis
iicrogc^ncs. Includes bacilli of iiiurosus
capsulatus group and Friedliinder's bacillus.
The Bacillus dysentcricr differs from
the typhoid bacillus in being very
slig-htly motile, slightly in cultural
behavior, and in the absence of the
specific agglutination reaction. Sev-
eral varieties of it ha\'c been de-
scribed which ferment certain sugars.
The paratyphoid bacilli are or-
ganisms l)elonging either to the en-
teritidis groups or the psittacosis
group, which produce a disease re-
sembling typhoid. The serum reac-
tion is frequently the only means of
differentiation from true typhoid.
The other factors which enter into
the etiology of typhoid fever are : —
1. Sex. — The disease is more prev-
alent in males.
2. Age. — Typhoid is rare under 2
years, and most common between 20
and 30. It may occur at any age.
3. Predisposition. — 1 > o d i 1 y vigor
does not confer immunity against ty-
phoid. On the contrary, the robust
frequently succumb to it. The possi-
bility of infection is greater among
those in contact with the patients, as
physicians and nurses, and among the
poor when proper isolation is not
possible.
4. Season. — Typhoid is most prev-
alent in early autumn, possibly be-
cause this is usually the vacation sea-
son when many persons go to the
country.
5. Distribution. — Typhoid fever is
not bound by any geographical limits.
It occurs in the tropics and far into
the North. However, in cities in
which the water-supply is pure and
the sewage properly disposed of, its
incidence is reduced to a minimum,
or what is known as "residual
typhoid."
PATHOLOGY.— Typhoid fever
may be said to be a constitutional
disease with local manifestations,
very much like diphtheria, except
that the former is a bacteremia. The
intestinal changes are general and
specific, the former comprising a ca-
tarrh of the small and large intestines
associated with epithelial desquama-
tion. The specific changes affect the
intestinal lymphoid elements and are
best described in stages : First iveck
— (a) Hyperemia and swelling of the
ileum, (b) Marked enlargement of
Peyer's patches and solitary follicles
which steadily increase, forming,
finally, large smooth elevations ; the
original hyperemia disappears from
the patches and they become whitish
in color. Second zveek — (a) Anemic
necrosis of the lymphoid tissue, due
to circulatory obstruction. (b) Ex-
foliation of the mucosa, (c) Forma-
tion of sloughs and ulcers. Third
week — (a) Development of granula-
650 TYPHOID FEVER' (ROBIN).
tion tissue, (b) Growth of epitlielium kidneys may undergo albuminoid de-
over the areas of necrosis, (c) New generation, due to the typhoid bac-
formation of glandular elements, (d) teria or their toxins. The abdominal
Complete healing of the ulcers. muscles and the adductors of the
The typhoid ulcer is situated on thighs are commonly the seat of
the surface of the intestine opposite hyaline degeneration, the heart-mus-
to the mesenteric attachment. Its cle of cloudy swelling. Degeneration
long axis lies in the long axis of the also occurs in the bone-marrow,
intestine. This location is important The Blood in Typhoid Fever. — The
because contraction of the cicatrix alkalinity of the blood is diminished,
does not, therefore, cause stricture of The coagulation time is diminished
the intestine. The edges of the ul- in the early stages and increased dur-
cer are sharply cut and the floor is ing convalescence. This increase,
formed by the mesenteric mucosa, which may depend on the increase of
Ulcers of the solitary follicles are not calcium salts in the blood of patients
confined to the surface opposite the who subsisted chiefly on a milk diet,
attachment of the mesentery. Ex- is frequently the cause of thrombosis,
tending through the muscular wall. To prevent this, Wright and Knapp
an ulcer may invade one of the ar- advise addition of sodium citrate to
teries and lead to a severe hemor- the milk (20 to 40 grains — 1.3 to 2.6
rhage. Further extension may per- Gm. — to the pint — 500 c.c.) as soon
forate the intestinal wall. Resulting as the danger from intestinal hemor-
escape of intestinal contents is in- rhages is over. During the first week
variably followed by fatal peritonitis, there is a diminution in the hemoglo-
HISTOLOGY. — The cellular in- bin, but the red cells remain normal,
crease in the Peyer patches and In the second week the cells grad-
solitary glands is due to endothelial ually diminish, the anemia corre-
proliferation in the lymph-spaces, sponding to the severity of the dis-
capillaries and lymphoid tissue caused ease. The leucocytes are decreased
by the irritation of the typhoid after the first week, the lowest level
toxins. The cells are large, with being reached during the fifth or
pale-staining nuclei, abundance of sixth week, after which they increase,
acidophilic protoplasm, and are pha- In some cases, however, a leucocyte
gocytic. By blocking up the tymph- count of 10,000 per cm. may occur,
channels, they produce thrombosis of due to concentration of the blood
the capillaries and local necrosis. The through diarrhea, sweating, vomiting
typhoid ulcer is thus a coagulation or cold baths. Of course, if a com-
necrosis caused by thrombotic ische- plication occurs, hyperleucocytosis
mia. takes place, if the patient's vital
The mesenteric lymphatics, spleen, powers are sufficiently strong to re-
liver, larynx and other organs may be act. Where hemorrhage or perfora-
the seat of typhoid ulcers. The tion fails to cause a hyperleucocyto-
spleen may show infarction, may be-, sis, the prognosis is extremely grave,
come ruptured or gangrenous. The and, in perforation, the probability of
liver shows cloudy swelling, with relief from surgical intervention very
areas of coagulation necrosis. The doubtful.
TYPHOID FEVER (ROBIN).
651
Qualitative leucocytic changes are
noted during the third week, pro-
gressive decrease of the polymor-
phonuclear neutrophiles and conse-
quent increase in the mononuclear
forms taking place. The eosinophiles
are almost invariably decreased ; also
the blood-plaques. Myelocytes are
found in severe post-typhoid anemia.
Typhoid bacilli are found in the
blood in practically all cases. Their
appearance there coincides with the
onset, and they may be frequently
demonstrated before the serum reac-
tion develops. With defervescence
the bacilli disappear, but reappear
with a relapse.
PROGNOSIS. — There is no pa-
tient so well but may die as a result
of some complication ; there is none
so ill but may recover. From 5 to 10
per cent, of the cases will succumb,
no matter what the treatment. Never-
theless, the outlook in a case does
depend on the care in treatment. A
patient whose case is diagnosed late,
who receives an abundance of drugs
which either depress the heart or
disturb digestion, and who is care-
lessly nursed, does not have good
chances of recovery. Vital resistance
also plays an important role. Unfor-
tunately, we have no means of accu-
rately gauging this resistance to bac-
terial toxins. The factors which
influence the prognosis unfavorably
may be summed up as follows : —
Age. — From 25 to 40 and above.
Habits. — Alcoholism, dissipation.
Severity of the Infection. — Hyper-
pyrexia, delirium, coma, and tremor
appearing early ; scanty urine ; mete-
orism ; exhaustion ; a rapid pulse
(above 120) ; feeble first heart sound;
persistent diarrhea; stupor, or nerv-
ous disturbances; gastric irritation.
Complications. — Hemorrhage, per-
foration, pneumonia, nephritis, throm-
bosis, etc.
Sudden death may occur as a re-
sult of acute dilatation of the heart,
delirium cordis and embolism.
Perforation. — Recovery without op-
eration is extremely rare. When op-
eration is resorted to before general
peritonitis sets in, the result depends
on the condition of the patient at the
time, the toxemia, the intestinal le-
sions and the kind of micro-organism
which escapes into the peritoneal
cavity. If toxemia is marked, the
bowels extensively necrosed, or the
escaping contents contain strepto-
cocci, the prognosis is grave, not-
withstanding early operation.
Relapse. — Defervescence is some-
times suddenly interrupted by a rise
of temperature and recurrence of ty-
phoid symptoms ; or the temperature
may remain normal for a week, and
even longer, when the relapse occurs.
Relapse is difficult to explain on any
accepted theory of immunity. If re-
covery depends on the development
of immunity, the latter should pro-
tect the individual against reinfec-
tion. It is probable, as suggested by
Durham, that a relapse is due to in-
fection with another variety of a
typhoid organism against which the
typhoid patient has not become im-
munized.
As a rule, if the primary attack of
typhoid fever is mild, the relapse is
severe, and 7'ice versa. The mor-
tality in relapse is never as high as
in the primary attack, hemorrhage
and perforation being less common.
TREATMENT.— Tlic main factors
in the treatment arc careful nursing
and well-regulated diet. Treatment
may be divided into Wvq heads: —
652
TVrTTOID FEVER (RORTN).
1. Diet and g^encral management.
2. Hydrotherapy.
3. Medicinal.
4. Vaccine and serum treatment.
5. Treatment of complications.
1. Diet and General Management,
— The patient should be put to bed
in a warm, well-ventilated room. He
may, in summer, be kept out-of-
doors. Ornaments, flowers, bric-a-
brac, etc., should be banished, espe-
cially if the patient be delirious.
Careful nursing is absolutely essen-
tial. The nurse should record (1)
the daily quantity of urine ; (2)
the temperature, pulse, and respira-
tions ; (3) the number and character
of bowel movements ; (4) the quan-
tity of fluid intake; (5) anything of
special interest.
A purge may be given at the onset
of the disease ; thereafter the bowels
should be kept open — moving at least
every second day — with enemata.
Later, if they become sluggish, cot-
tonseed oil, 4 or 6 drams (16 or 24
c.c), may be given, and as con-
valescence proceeds, a gentle laxa-
tive.
The patient should be kept as \vell
nourished as possible during the
course of the disease. Carbohydrates
should be freely given, to save the
proteids. The patient should imme-
diately be put upon a liquid diet, of
which milk forms the main, though
not necessarily the only, component.
The criterion is the state of the di-
gestion. In recent years greater lib-
erality has been practised." Cream,
ice-cream, calf's foot jelly, broth, al-
bumin-water, raw or soft-boiled eggs,
strained soups, junket, etc., are per-
missible. Alcohol, as a rule, is an
unnecessary adjunct to the diet.
With the first signs of distention or
of curds in the stool the milk should
be stopped iov from 24 to 36 hours.
In convalescence the diet is slowly
increased.
The following lists are offered
as sample diets given to patients
throughout the course of illness : —
Outline of Average Typhoid Diet.
Breakfast, 6 a.m.: Farina 1 portion,
with lactose 1 oz. and cream 1 oz. Coffee
6 oz., with cream 1 oz. and lactose ]/> oz.
8 A.M.: Hot milk 6 oz., with cream 1
oz. and lactose J/2 oz.
10 A.M.: Cocoa 1 cup (8 oz.), with
cream 1 oz. and lactose J/^ oz. Bread and
butter 1 slice.
Dinner, 12 m.: Broth 8 oz.; bread and
butter (in form of milk toast), 1 slice of
bread with milk 4 oz. and cream 1 oz. and
lactose yi oz.; egg (poached) 1; rice
1 portion, lactose 1 oz. and cream 1 oz.
2 P.M.: Ice-cream 1 portion; bread and
butter 1; milk 6 oz., with cream 1 oz.
and lactose 3^ oz.
4 P.M.: Orangeade 8 oz., with egg 1, and
lactose J/2 oz.
Supper, 6 p.m.: One of the wheat break-
fast foods 1 portion, with cream 1 oz.
and lactose 1 oz; bread and buter 1; egg
1; malted milk 2 oz., with milk 6 oz.,
cream 1 oz. and lactose 3^ oz.
8 P.M.: Orangeade 6 oz., with egg-albu-
min 1 oz. and lactose 3^ oz.
12 P.M.: Hot milk 6 oz., with cream 1
oz. and lactose yi oz.
4 A.M.: Lemonade 6 oz., with egg-albu-
min 1 oz. and lactose yi oz.
Outline of a Moke Liberal Typhoid Diet.
Breakfast, 6 a.m.: Farina 1 portion with
lactose \y2 oz. and cream Ij/^ oz.; bread
and butter 2 (without crust); egg 1; coffee
5 oz., with cream lYi oz. and lactose 1 oz.
8 A.M.: Hot milk 6 oz., with cream V^
oz. and lactose K> oz.
10 A.M.: Malted milk 2 oz., with milk 6
oz., cream 1^4 oz. and lactose 1 oz.; bread
and butter 2.
Dinner, 12 m.: Broth 8 oz.; bread and
l)Utter (in form of milk toast) 2, with milk
6 oz., cream IJ/j oz. and lactose 1 oz.;
eggs (poached) 2; rice 1 portion, with
cream \]/2 oz. and lactose 1^/2 oz.
TYPHOID FEVER (ROBIN).
653
Table 1. — Total Calokies Per Day on Average Typhoid Diet.
Food Substance. Ainoiint. Calories.
Cereal 3 portions at 160 480
Lactose 8 oz. at 125 1,000
Cream 10 oz. at 70 700
Bread and butter (without crusts) ... 4 slices at 87 348
Eggs 3 at 60 180
Egg-albumin 2 at 40 80
Cocoa 1 cup (8 oz.) at 180 180
Milk 28 oz. at 20 560
Ice-cream 1 portion at 90 90
Broth 8 oz. at 7 56
Malted milk 2 drams at 120 (per oz.) 30
Total calorics 3,704
Table 2. — Total Calories Per Day on Liberal Typhoid Diet.
Food Substance. Amount. Calories.
Cereal 3 portions at 160 480
Lactose 10 oz. at 125 1,250
Cream 16 oz. at 70 1,120
Bread and butter 12 slices at 87 1.044
Eggs 5 at 60 300
Egg-albumin 2 at 40 80
Cocoa 2 cups (16 oz.) at 180 360
Ice-cream 1 portion at 90 90
Milk 36 oz. (6 cups) at 120 ( per cup) 720
Broth ■. 8 oz. at 7 56
Malted milk 2 drams at 120 (per oz.) 30
Total calorics 5,530
2 P.M.: Ice-cream 1 portion; Itread and
butter 2; milk 6 oz., with cream 1^ oz.
4 P.M.: Orangeade 6 oz., with egg 1 and
lactose Y2 oz.
Supper, 6 p.m.: Wheat breakfast-food 1
portion, with cream IJ/2 oz. and lactose IJ/2
oz.; bread and butter 2, egg (scrambled) 1,
cocoa (2 cups) with cream 2 oz. and lac-
tose 1 oz.
8 P.M.: Orange-albumin (white 1 egg),
with lactose J^ oz.
12 P.M.: Hot milk 6 oz., with cream 2 oz.
4 A.M.: Orange- or lemon- albumin
(white 1 egg), with lactose >2 oz.
The followins^ foods are recom-
mended for appropriate cases: —
For practical purposes, the milk-sugar
may be measured in a medicine glass.
Each measured ounce weighs 18 Gm.. If
milk-sugar is added to water in tlic pro-
portion of 24 Gm. to 30 c.c. and the water
brought to the l)oiling point, the milk-
sugar is completely dissolved.
According to the lists the patient is fed
once in 2 hours, from 6 a.m.. to 8 p.m. and
during the niglit at 12 p.m. and 4 a.m.; 3
times a day, the feeding is amplified so
as to resemble a meal. In their applica-
tion the cereal was varied, the newer
partially prepared and more palatable
cereals being introduced, to the great rel-
ish of the patient. In the interval feedings
highlj' nutritious articles were chosen, and
particularly tli()-.c with high carbohydrate
value. Thus, milk, cocoa, cofifee, to each
of which was invariably added 3^ ounce of
cream and 1/2 ounce of lactose, were given.
Also orangeade or lemonade with egg-
albumin could be made into drinks carry-
ing considerable caloric value by the ad-
dition of lactose and cane-sugar. Burrill
B. Crohn (Jour. Amer. Med. Assoc, Jan.
27, 1912).
654
T^■^"ll()ll) i-EVEk (Koi'.iN).
Foods anu Their Calory Value.
Name. Amount. Calories.
Apple sauce 1 ounce 30
BreaG Average slice (33 grams)
Butter 1 pat Cf^ ounce)
Cereal (cooked) 1 heaping taljlespoonful (IJ^ ounces)
Crackers 1 ounce
Cream (20 per cent.) 1 ounce
Egg 1 (2 ounces)
Egg, white i •
Egg, yolk 1
Lactose 1 tablespoonful (9 grams)
Milk (whole) 1 pint (350) 1 ounce
Potato (whole) 1 medium
Potato (mashed) 1 tablespoonful
Rice (boiled) 1 tablespoonful
Sugar, cane • 1 lump
Sugar, milk 1 tablespoonful
Toast Average slice
80
80
50
114
60
80
30
50
36
20
90
70
60
16
36
80
The following diet is given by Grandy:
1. Fluid. 2. Milk, buttermilk, malted milk,
whey, junket, plain ice-cream, blanc-
mange, milk-toast (without crust), soft
crackers, cocoa, broths, rice, lactose, eggs
(soft boiled or raw), finely minced chicken.
3. Steak, chop, white meat or chicken (in
small quantities), toast, bread, cereals,
crackers, eggs in any form, mashed pota-
toes, tomatoes (strained), stewed fruits,
oysters. Patients must be told to chew all
food well. He generally starts the pa-
tient on milk for a day or two and then
adds one extra article to the diet daily,
watching the symptoms. Thus he first
adds a heaping teaspoonful of milk-sugar
to each glass of milk; next day, an ounce
of cream, bringing up calories to 2000 a
daj% or if he adds two tablespoonfuls of
milk-sugar to each glass, which is seldom
objectionable, he gets 2400 calories a day.
Next he adds milk-toast or crackers, using
the same preparation of milk, milk-sugar
and cream to moisten, though Grandy
never objects to the patient eating these
articles dry if the crust is cut from the
bread. Then bread and butter are added;
then eggs either raw, soft-boiled or in a
custard made with milk-sugar, such a cus-
tard made after Coleman's recipe amount-
ing to 360 calories, or a raw egg can be
stirred in a cup of cocoa. Sweeten every-
thing with milk-sugar, thus giving much
nourishment without making it nauseat-
ingly sweet. Thus, a saucer of ice-cream
can be made to give 500 calories and an
orange-albumin raised from 50 to 100
calories or more. Sandwiches of scraped
beef or finely cut chicken can often be
advantageously given. With the above
diet Grandy has had little emaciation, no
hunger, shorter convalescence, and an ap-
parent avoidance of relapses.
2. Hydrotherapy. — Internal hydro-
therapy is effectively used in almost
any fever. External hydrotherapy,
however, finds a field peculiarly its
own in typhoid: (1) cold sponge; (2)
cold packs; (3) cold baths.
Cold Sponge. — The water may be
tepid, cold, or ice cold, according to
the patient's temperature. In some
cases of high fever the desired reac-
tion may be obtained with tepid
sponges when the iced sponge fails.
The sponging should be continued
for 15 to 20 minutes, accompanied by
active friction. The iced sponge is
the most generally used form.
Cold Pack. — This is rarely used ex-
cept where there are pronounced
nervous symptoms and a tub is iiot
available. The patient is wrapped in
a sheet wrung out in water at 60° to
TYPHOID FEVER (ROBIN).
655
65° F., then water from a watering
pot is sprinkled over him.
Cold Bath. — The patient is com-
pletely immersed, except for his head,
in water of a temperature between
70° and 85° F. He remains in the
tub for 15 to 20 minutes, and then is
taken out, placed on a dry sheet, and
covered with a blanket. A stimulant
is often administered after the bath.
In the Murphy treatment, the Fow-
ler position is not used, the patient
being kept flat. The fluid used is
sodium chloride, 1 dram (4 Gm.) to
the pint (500 c.c). An ordinary rec-
tal nozzle is inserted into the rectum,
and the fluid allowed to flow steadily
through the day and intermittently
through the night. About 2 quarts in
12 hours are used. The advocates of
this treatment claim that, while it
does not shorten the disease, it pro-
motes diuresis, lessens toxemia, and
renders delirium rare.
Cold colon flushings for the reduc-
tion of temperature are recommended
by Penoyer. A small rectal tube is
inserted and from 1 to 3 pints of
water at 40° to 50° F. passed in
small quantities and allowed to re-
turn through the tube. This may be
repeated every 4 to 6 hours.
External hydrotherapy is usually
applied when the patient's tempera-
ture is 102.5° F. (39.2° C.) or over.
The rectal temperature is taken im-
mediately after the application, and
again ^ hour later. The contra-
indications are peritonitis, hemor-
rhage, phlebitis, severe abdominal
pain, and great prostration.
3. Medicinal Treatment. — Year by
year this is less important. There is
no specific drug treatment, l)ut it is
usually advisable to give urotropin
after the second week. During the
first 2 weeks a diuretic mixture is
often used, chiefly for the psycholog-
ical effect. Antipyretics are, as a
rule, to be avoided. Occasionally 1
or 2 doses may be of some value.
Quinine, while it is of doubtful value,
is widely used. The writer is not in
accord with the usual attitude toward
intestinal antisepsis. The cases with
constipation, generally mild, require
no special treatment except "bread
pills" or their equivalent. With the
patients with diarrhea, the proposi-
tion is altogether different. Here we
have a colon full of liquid contents,
and with many organisms causing
active putrefactive changes in the
favorable medium. To the typhoid
toxemia there is added a bacterial in-
toxication due to the associated mi-
cro-organisms. While it is freely
admitted that it is impossible to
sterilize the intestine, mesenteric
glands, spleen or blood-stream, it
■does appear rational to minimize the
intestinal putrefaction and fermenta-
tion. Clinical observations estab-
lishing the validity of certain drugs
in the reduction of intestinal putre-
faction have been questioned by in-
vestigators and laboratory workers,
on the ground that, to produce intes-
tinal antisepsis a drug must be given
in doses that are poisonous. Actual
clinical results, however, show that,
for some unaccountable reason, cer-
tain drugs act in the body as power-
ful germicides, even in small doses.
Quinine destroys Plasmodium ma-
laria, yet is at best feebly antiseptic.
Ipecac in tropical dysentery and thy-
mol in hookworm disease certainly
prove the efficacy of intestinal anti-
septics when applied to parasites.
Observing how bacteria are affected
l)y even slight changes in the reaction
656 TYPHOID FEVER (ROBIN).
of the medium, we can readily admit • lart^e bowel, a rectal tube may be
the possibility of a certain dci^^ree of passed. If a severe diarrhea occurs,
intestinal antisepsis. Guaiacol carbo- a starch and opium enema may be
nate, probably the most satisfactory given. Or, instead, a combination of
drug, may be employed in large bismuth, opium, and acetate of lead
doses, 2 to 5 grains (0.13 to 0.3 Gm.) may be given by mouth. An ice-bag
every 3 hours. In combination with or cold compress to tlic abdomen re-
powdered charcoal, in konseals, it not lieves pain accompanying diarrhea,
only allays putrefaction, but helps For constipation, enemata are the
to reduce meteorism : — best treatment. Unless contraindi-
B Sodii citratis, cated, the bowels should be moved at
Gnaiaculis carbonatis, least every other day. Addition of Yi
Pulveris carbonis animalis, ^^ ^ ounce (15 c.c.) of turpentine to an
enema often relieves meteorism.
aa gr. iij (0.2 Gm.).
M. et ft. konscal nu. j. j^^ hemorrhage absolute rest in bed
Sig.: One in water or grape-juice . , ^, , ,
-, , must ht nni)osed. 1 he greatest care
every 6 hours. ^ » _
should be exercised, even in the use
Lactic acid bacilli, either in fer- ^,f ^ bed-pan. Ice mav be given by
mented milk or in liquid culture, of- mouth. A light cold compress should
fer another very excellent method ,^g placed on the abdomen. Stimulate
of inhibiting putrefactive bacteria. jf necessary. Hypodermoclysis and
4. Vaccine and Serum Treatment, transfusion of blood may be tried if
—Vaccine and serum therapy have tiie hemorrhage be large. Some au-
yet to prove their value. They offer thorities warmly recommend turpen-
no advantage over the ordinary treat- tine. A high rectal injection of nor-
ment. mal saline solution may be employed.
5. Treatment of Complications. — Gelatin may be given by mouth or
In toxemia, water should be given sterile tetanus-free gelatin hypoder-
freely by the mouth, if possible ; if not, mically. Calcium lactate in doses of
by the bowel. External hydrotherapy 15 grains (1 Cim.) every 4 hours is
should be instituted immediately, valuable. Opiates should not be
Alcohol may be used advantageously, given, as they would obscure the
Headache and delirium may be re- symptoms of perforation, and also
lieved or prevented by an ice-bag or favor tympanites.
cold compresses to the head. Mor- In perforation and peritonitis the
phine is sometimes necessary to quiet only hope is early diagnosis and op-
delirium. Lumbar puncture is also eration. Operate without waiting for
useful. The greatest aid in the treat- peritonitis to make the diagnosis
ment of nervous complications is hy- certain. Peritonitis diminishes the
drotherapy, both external and in- chances of recovery by one-half,
ternal. For pain and tympanites. Patients stand laparotomy well ; so in
fomentations and turpentine stupes doubtful cases it is best to operate,
are indicated. Turpentine may be A majority of the cases of chole-
given by mouth, in doses of 15 cystitis recover. Urotropin and vac-
minims (0.8 c.c), and also by ene- cines are indicated in chronic cases,
mata. For the relief of gas in the These failing, operation is advisable.
TYPHOID FEVER (ROBIN).
657
For phlebitis, set the limb at rest
and wrap in raw cotton. Ichthyol is
often of service. A sedative lotion
will relieve pain.
Urotropin in lO-grain (0.6 Gm.)
doses usually clears up cases of bacil-
luria. If orchitis, mastitis, parotitis,
etc., occur, an ice-bag should be ap-
plied. At the first signs of suppura-
tion, incise and drain.
If boiic-lcsioiis complicate the dis-
ease, the vaccines are w^orthy of a
trial, and if they fail, operation is the
only hope. Typhoid periostitis does
not always result in suppuration,
but, as a rule, requires operation. In
typhoid spine fixation is indicated.
Bcd-sorcs can be avoided by care-
ful nursing. All the parts should be
absolutely clean and dry. The sheets
should be unwrinkled. The back
should be sponged with alcohol.
Pressure should be avoided by the
use of rubber rings.
Treatment of Convalescence. — The
convalescent acquires a ravenous ap-
petite. As a rule, no solid food
should be allowed for at least ten
days after the temperature has re-
turned to normal. If given too soon,
it may give rise to a slight fever,
called the "febris carnis." The pa-
tient may sit up at the end of the
first week of convalescence. Emo-
tional disturbances should be avoided,
as they may cause recrudescence. Pro-
tracted diarrhea may retard recovery.
In these cases, restrict the diet and
give large doses oi bismuth. .An as-
tringent injection may be employed.
The treatment of a relapse is that of
the exciting cause.
Cases of post-typhoidal insanity in
the hands of an expert usually re-
cover. If phlebitis has occurred, an
elastic stocking should be worn dur-
ing the day. If the collateral circula-
tion is good, the swelling will disap-
pear, but in most cases there is a
permanent disability. Cases of post-
typhoid neuritis usually recover, at
times, only after months or years.
Massage of the paralyzed and atro-
phied muscles is certainly the best
treatment.
The treatment of typhoid carriers is
difficult. Urotropin should be given
persistently, and in large doses.
Drainage of the gall-bladder will cure
some cases. The vaccines, however,
ofifer the best chances. Increasing
doses are given at intervals of 10
days, starting at 25 to 1500 million.
THE PUBLIC HEALTH AS-
PECT OF TYPHOID FEVER.—
Typhoid presents one of the most
serious problems before a commun-
ity. It is the disease most often
caused by sewage-polluted water, and
next to tuberculosis and pneumonia
is the principal cause of sickness and
death. There occur annually in the
United States about 50,000 deaths
from typhoid fever, the estimated
number of cases being at least
500,000.
The bacillus of typhoid is taken in
with food and drink which contain it,
and is excreted from the body of the
typhoid-fever patient with the feces.
The latter gains access to the nearest
water-supply and the typhoid bacilli
infect the water. Precisely in this
way epidemics originate in towns
and cities whicii are obliged to drink
the sewage of other municipalities
located on their watershed. Of
course, there is always a possibility
of direct infection by coming in con-
tact with the patient's feces or urine,
but epidemics cannot thus arise.
The problem is simply one of keep-
H~\2 ,
658
'IN ri loll) ii':vi':i>; (Uomx).
insj^ the hricilli out of the water-sup-
ply, and this can be accomplished
only by proper sanitation. In this
country the location of towns along-
watersheds is such that the sewage
of one community is nonchalantly dis-
charged into the water-supply of the
other. Proper disinfection of the
water is, therefore, the only means of
guarding against typhoid epidemics.
Purification of Water. — A number of
methods, all more or less efficient, have
been introduced to purify water, either
by or without filtration. One of the
methods of purification without filtration
consists in exposing: the water to the air
in small streams. This was proposed by
Lind, more than a century ago. The
water is passed through a sieve, or a per-
forated tin or wooden plate, then falling
through the air in finely divided currents.
Sulphuretted hydrogen, offensive organic
vapors, and possibly dissolved organic
matters are thus removed. This process
has been used in Russia on a large scale.
Again, typhoid bacilli are all destroyed
by boiling water acting on them for 10
minutes.
Permanganate of potassium is some-
times used to purify water containing con-
siderable organic matter. The perman-
ganate rapidly oxidizes this matter.
There is no certaintj', however, that the
germs of specific diseases are destroyed
by this salt, in the proportion in which it
could be used for water purification. A
yellow tint is given to the water by
the permanganate which is due to finely
divided peroxide of manganese. This does
no harm, but is unpleasant. Bromine has
been used for a similar purpose, and is
claimed to give good results. It may be
neutralized by ammonium or other alkali.
In 1904, Moore and Kellerman, of the
U. S. Bureau of Plant Industry, advised
the use of copper sulphate, finding that in
a ratio of 1:100.000 copper sulphate is
an efficient germicide, destroying the colon
and typhoid bacilli. It was also discov-
ered that copper vessels are capable of
purifying water through the colloidal
copper. Later reports, however, showed
that the claims of Kellerman and his fol-
lowers are greatly overdrawn. Aside from
the fact that it would not be safe to intro-
duce copper sulphate into the system
for a long time, the germicidal action of
copper has been found to be very un-
certain.
Regarding the effect of copper and
other metals on B. coli, it has been found
that the organism disappears in the fol-
lowing number of days: Zinc, 10 days;
iron, 15 days; tin, 41 days; aluminum, 41
days; copper, 43 days; lead, 97 days; and
in another experiment: Zinc, 10 days;
copper, 10 days; tin, 23 days; iron, 23
days; lead, 23 days; aluminum, 31 days.
Filtration. — Filtration has proven the
most reliable means of removing both
suspended matter and bacteria from pol-
luted water. Filtration is practised on a
small scale — domestic filters — and on a
large scale. Of the domestic filters only
those made of unglazed porcelain (the
Pasteur filters) or infusorial earth (the
Berkefeld filter) are to be relied upon.
Their pores form tortuous channels in
which the bacteria are retained. At
length the filter is permeated with bac-
teria, which are pushed through, as it
were, bj^ the incoming armies. The filter-
ing unit should, therefore, be frequently
scrubbed and sterilized in the oven or by
boiling at least once a month. All other
domestic filters on the market are prac-
ticallj' worthless, if not harmful because
of the false security they give.
On a large scale, water may be purified
by sedimentation, slow sand filtration, or
the English method, and rapid sand fil-
tration, or the American method, also
known as mechanical filtration.
In sedimentation water is confined in
reservoirs holding 30,000,000 to 50,000,000
gallons and allowed to become clarified
by the particles of mud falling to the bot-
tom. Incidentally, the bacteria are car-
ried down and some oxidation of the or-
ganic matter takes place. Usually about
75 per cent, of purification takes place by
this method. In St. Louis the water is
treated with iron sulphate and lime before
final sedimentation. The purification of
the water is thus greatly enhanced.
Slozv Sand Filtration. — This method was
originally employed in London to re-
move from water the matter in suspen-
TYPHOID FEVER (ROBIN).
659
sion. Later, however, Frankland showed
that the filters also remove most of the
bacteria. Since 1890 the Massachusetts
State Board of Health has been conduct-
ing extensive experiments on slow sand
filtration, and placed it on a solid scientific
basis. The principle underlying it is a
biological one.
The forces are the same as operate nat-
urally when a foul surface pool per-
colates slowly through the ground and
crops out in the form of a pure, sparkling
spring. The upper layers of the ground
swarm with various bacteria which live on
dead organic matter. In a word, the or-
ganic substances of the water are at-
tacked from all sides and converted into
harmless mineral substances, the latter to
be taken up by the plants as food. If
any pathogenic bacteria happen to be
present they find a strange, uncongenial
environment. The relatively low tem-
perature chills them; then, being parasitic
in nature, they cannot prepare food for
themselves, while the food that they find
is rapidly consumed by their competitors,
which are in greatly predominating num-
bers. Thus, the pathogenic organisms
soon perish.
Similar conditions prevail in the slow
sand filter. Here we have a bed of fine
sand about three feet thick, through which
the water percolates at a rate of 3,000,000
to 4,000,000 gallons per acre per day.
Suspended matter in the water passing
through is deposited between the sand
grains, in the upper inch or two. The
infusoria, algae, and bacteria in the water
are now entangled and form a slimy film
about the sand grains, on the surface of
the bed. The various bacteria at once
commence to work, each species per-
forming its particular function and mak-
ing a struggle for existence. The result
of this is the transformation of the com-
plex organic molecules into simple in-
organic compounds. Pathogenic bacteria
are enmeshed in this iilm and soon perish
in the unfavorable cnvironnunt. In time
the upper mud-film becomes more com-
pact, until but little water passes through,
viz., about once in three weeks. When
this occurs, the filter is drained, the
upper layer of the beds removed, and fil-
tration resumed.
Sand filters have been installed in al-
most all the large cities of Europe, and
wherever installed have reduced typhoid
mortality to a very small percentage.
In this country the first slow sand filter
was built by Kirkwood, in Poughkeepsie,
N. Y., in 1877. The first filter, however,
contributing to our knowledge of the sub-
ject, and which has served as a model for
other plants, is the slow sand filter con-
structed in Lawrence, Mass., in 1893. This
filter has been in operation ever since,
giving excellent results, both as to im-
provement of the polluted Merrimac
water and reduction of typhoid mortality.
Slow sand filters exist in a number of
American cities, the most notable of which
is Albany, where a covered slow sand
filter was constructed by Mr. Hazen in
1899. The improvement in the mortality
from typhoid fever and diarrheal diseases
has been very marked.
Slow sand filters have also been con-
structed in Providence, R. I.; Washing-
ton, D. C; Hudson, N. Y.; Mount Ver-
non, N. Y. ; Far Rockaway, L. I.; Ilion,
N. Y. ; Yonkers, N. Y. ; Somersworth,
N. H.; Ashland, Wis.; Superior, Wis.; St.
Johnsbury, Vt.; Milford, Mass.; Nan-
tucket, Mass.; Nyack, N. Y.; Lambertville,
N. J.; Salem, N. J.; Rock Island, 111.;
Grand Forks, N. D. ; and are in the course
of construction in Philadelphia, Pa.; Pitts-
burgh, Pa.; Wilmington, Del., and other
cities. Experience thus far gained war-
rants the general proposition that prop-
erly filtered water is fully equal in its
hygienic purity to a pure natural supply.
Mechanical Filters. — In the mechanical,
rapid or American system of filtration, the
water is conducted through sand as in
slow sand filters. Foreign substances
are retained mechanically, but this reten-
tion is aided by the application of chem-
icals. Through these, and due to the ab-
sence of biological action, the filters can
be operated at much higher rates than
slow sand filters. Their usual rate is
125,000,000 gallons per acre per day,
while slow sand filters are operated at
about 3,000,000 gallons. A more rapid
passage through a slow sand filter would
I)e liable to wasli the bacteria from the
sand grains about which they live, and
so interfere with success.
660
TYPHOID FEVER (ROBIN).
The chemicals usually used in "mechan-
ical filters are sulphate of aluminum or
sulphate of iron and lime. The former,
when used, is led into the water before it
enters the filters and there combines with
the lime naturally present in nearly all
waters to form hydrate of aluminum and
sulphate of calcium. The former, in-
soluble, agglomerates, by means of its
stickiness, the bacteria and other par-
ticles into masses such as cannot pass
between the sand grains. When sulphate
of iron and lime are used, the action is
exactly similar, but hydrate of iron is
formed instead. Owing to the more
rapid operation, the dirt accumulates on
the surface faster than it does in a slow
sand plant, necessitating more frequent
cleansing.
In mechanical plants the cleansing of
the sand is accomplished by turning a
current of filtered water upward through
the sand, and at the same time agitating
the whole bed of sand by means of rakes
driven mechanically or by compressed air
forced through the sand from below. All
foreign matter is thus carried to the top
of the filter, whence it is conducted to
the sewer by pipes. The cleansing op-
eration usually takes about ten minutes,
and its frequency depends entirely upon
the chajacter of the water treated, —
ordinarily about every twenty-four hours,
2 to 5 per cent, of the filtered water being
required for cleaning purposes.
Skillfully constructed and operated,
these filters are equal in efficiency to a
slow sand filter; but, on the other hand,
the mechanism of operation is much more
complex, the possibility of some unlooked-
for derangement greater, with consequent
imperfect purification of the water.
Chlorine Gas. — Compressed chlorine has
been largely employed in purifying water,
either alone or in combination with fil-
tration. The method is remarkably effi-
cient, and when carefully used is in no
way objectionable.
Flies in Typhoid. — The role of the
domestic fly as a carrier of typhoid
bacilli was definitely established dur-
ing the Spanish-American and Boer
Wars. A special commission found
that flics were responsible for a se-
vere epidemic among soldiers in the
Southern camps in Florida. Plies
were observed to swarm over in-
fected fecal matter in the pits, and
then visit and feed on the food pre-
pared for the soldiers in the mess-
tents. When lime had been recently
sprinkled over the contents of the
pits, flies with their feet whitened
with the lime Avere seen walking over
food. Typhoid gradually disappeared
in the fall of 1898 with the approach
of cold weather and the consequent
disabling of the fly.
This circumstantial evidence was
substantiated by Firth and Ilorrocks
in England ; Hamilton, of Chicago,
and Ficker, of Leipzig. The latter
caught flies in a house at Leipzig,
where 8 cases of typhoid had oc-
curred. The flies were kept in 10-
liter flasks, into which sugar, strips
of blotting-paper .and typhoid bacilH
were introduced. The typhoid cul-
ture was spread on the inside of the
blotting-paper. After 18 to 24 hours
the flies were transferred to clean
flasks, and this was repeated every 2
or 3 days for over 4 weeks. They
were at last killed with ether and
crushed, and the remains transferred
on gelatin. A growth of typhoid ba-
cilli was o4)tained from flies crushed
23 days after exposure to infection.
"From their disease-carrying potentials
the mouth and legs and intestines of flies
are important parts. The six legs are
bristly and strong, each leg has two claws,
and between the claws there are soft,
sticky pads called pulviUi, with which tlie
fly clings to seemingly impossible slippery
surfaces: for there are hairs around the
pad which secrete a sticky fluid. The
mouth consists of a proboscis which ends
in two flabby pads, which can be pro-
truded and applied to the food. There are
no teeth, but each mouth-pad has some
TYPHOID FEVER (ROBIN).
661
hard ridge which can be used as rasps or
saws for breaking up small hard objects
in the food; the flies' saliva does the rest
of the mastication. The saliva is poured
out on to the sugar and a thick paste is
made. The mouth-pads are there applied,
and the paste is sucked up and swallowed.
Then the ^y moves on and repeats the
process. Some of the paste adheres to the
pads and the proboscis, and the fly then
uses her front legs to clean her face. In
consequence her legs become covered with
food too and with any germs it may con-
tain, and she uses the hind legs to clean
the front ones, and then they are all cov-
ered with food and its germs. But the
fly likes to live in the midst of plenty,
and the more filthy the food she has stick-
ing to her mouth and legs, the better she
enjoys it. The germs like it too, for the
fly never has a bath. It is a grand dirty
life for all concerned.
"It can be readily understood how dis-
ease germs live and multiply on these
sticky surfaces. . . . There is no doubt
that germs are swallowed by flies, and can
and do multiply within the bowels of the
insects. The fly's internal digestive appa-
ratus is very simple. There is a throat
winding up the proboscis, a long gullet
leading to the stomach and intestines.
There is also a crop connected with the
gullet by a long tube: this crop is a large
distensible bag where food is stored until
hunger requires its digestion. According
to Dr. Graham Smith, house-flies, after
a meal, frequently regurgitate drops of
fluid from their mouth, and these drops
are responsible for the larger marks on
the lump-sugar or on the window-pane.
The smaller marks are those of excretion,
fully digested by the fly and passed from
the intestine, which contains an almost
pure nidus for bacteria. Thus are fly-
specks made. Everything seems to have
been disposed by a provident nature for
the germination of germs on and in
house-flies. These insects can harbor and
foster typhoid and cholera bacilli on their
feet, on their mouths and proboscides." —
E. H. Ross ("The Reduction of the Do-
mestic Flies").
PROPHYLAXIS.— "The primary
responsibility for the spread <>f the
disease rests, in great measure, with
the physician in charge of the case.
It is incumbent on him to see that
no avenue by which the bacilli can
escape into the external world is left
unguarded. All germs excreted by
the patient should be at once thor-
oughly destroyed. For this purpose
no half measures should be tolerated.
Disinfectants (true germicides, not
antiseptics) should be employed, and
in strength sufficient to destroy with
certainty the germs in the material
on which they act. . . . The disin-
fection should be carried on day by
day throughout the course of the dis-
ease. Disinfection after the termina-
tion of the disease is of minor im-
portance. Disinfection of the air is
also relatively unimportant. The
germs are borne by the solid and
liquid excretions, and the hands,
clothing and food soiled with them.
Direct contagion, although possible,
is rare.
"To disinfect the urine the best
solutions are : phenol (carbolic acid)
1 : 20, in an amount equal to that of
the urine, and bichloride of mercmy
1 : 1000 in an amount Y^r, that of fluid
to be sterilized. These mixtures with
the urine should stand at least 2
hours.
"In case there is demonstrable ba-
ciUnria, hexamethylenamine may be
given to cause disappearance of the
bacilli from the lU'ine, but under no
circumstances should its administra-
tion permit the disinfection of the
urine to be neglected.
"To disinfect stools, phenol is most
useful. It is cheap and efficient, if
used in strong solutions. The stool
should be mixed with about twice its
volume of 1:20 phenol solutimi and
allowed to stand for several hours.
662
TVrilOTn I'EVER (ROBIN).
"Disinfection of the bath-water
after use is best accomplished, ac-
cording to E. Babncke (Centrall)l. f.
Bakteriol., xxvii, 800, 1900), by the
use of chloride of lime; 250 Gm. (^
pound) of chloride of lime will ren-
der the ordinary bath of 200 liters
(quarts) sterile in Yi hour.
"In cases in which sponging is
practised, the amount of water used
would be small, and would require
correspondingly a small amount of
the disinfectant.
"If there be any expectoration, the
sputum should receive the same care
as in tuberculosis. It is best to col-
lect it in small cloths, which may be
burned.
"All the linen leaving the patient's
bed or person should be soaked for 2
hours in 1 : 20 phenol solution, and
then sent to the laundry, where it
should be boiled. It is recommended
to boil the dishes from which the pa-
tient has eaten before they are taken
from the room. If this precaution is
impracticable, they should at least be
treated in some other way, as by
wrapping in paper so that they can-
not convey infection. They should
afterward be boiled or washed sep-
arately from the other dishes.
"It is also recommended that the
nurse should wear a rubber apron
when bathing or handling otherwise
a typhoid patient, and should also
wear rubber gloves or else wash the
hands thoroughly in a 1 : 1000 bichlo-
ride solution after she has finished,
or she should wash thoroughly in
soap and water, followed by 70 per
cent, alcohol.
"Great care should be taken to pre-
vent access of flies to typhoid excreta
and to food supplies. The room of
the typhoid patient should be kept
thoroughly screened in fly season.
The nurse or other attendants should
be taught to regard every specimen
of urine as a pure culture of typhoid
bacilli, and should carefully avoid
the spilling or scattering of drops of
urine.
"The danger from contamination
with the urine should be impressed
on the convalescent patient, who
should be encouraged to continue the
use of hexamethylenamine and to re-
port to the physician for examination
of the excreta until it is satisfactorily
shown that no more typhoid bacilli
are being passed by the patient,
either in the urine or feces." {Jour.
Amer. Med. Assoc.)
Typhoid fever may also be com-
municated by drinking contaminated
milk, bacilli gaining access to the
water used in washing the cans or in
adulterating the milk. Direct con-
tamination from the hands of a "ty-
phoid carrier" is also possible. Once
in the milk, the typhoid bacilli find a
most favorable medium for rapid de-
velopment. A milk epidemic can
usually be traced by following out
the cases on a suspected milk route.
Other foods which may carry the
typhoid bacilli are oysters and
green vegetables. Repeated epidem-
ics have been caused by oysters kept
in sewage-polluted beds. The cus-
tom of fattening oysters in fresh
water, often polluted, is pernicious.
Lettuce, celery, radishes, and other
truck-farm products may carry ty-
phoid bacilli as a result of the ferti-
lization of small truck patches by
human excreta. These vegetables,
consumed raw, often after a perfunc-
tory washing, constitute a serious
menace.
Ice may be the source of infection
TYPHOID FEVER (ROBIN).
663
if manufactured from polluted water,
or obtained from a polluted stream.
Use of ice from an unknown source
in drinking-water is inadvisable.
Direct infection from sick to well
is not uncommon when the attend-
ant is careless in handling- the patient
or the soiled linen. This mode of
transmission, however, is not a usual
source of epidemics.
Typhoid Vaccination. — This is the
most important form of prophylaxis.
The vaccine ("typhoid prophy-
lactic") is a suspension of dead ba-
cilli in salt solution, with 0.25 per
cent, of tricresol added as a measure
of safety. The vaccine is accurately
standardized by counting the bacilli ;
5CX) millions are given as the first
dose and 1000 millions each for the
second and third, 10 to 20 days later.
The skin of the upper arm is sterilized
with iodine and the vaccine is injected
subcutaneously. There is a local re-
action consisting of a small red and
tender area lasting about 48 hours.
The general reaction, when present,
gives rise to a headache and malaise,
and sometimes to fever, chills, and
occasionally nausea, vomiting or di-
arrhea. Severe reactions do not oc-
cur in more than 1 to 3 persons per
1000. They all pass off quickly and
leave no trace. Only the healthy
should be vaccinated.
In 1911 the use of antityphoid vac-
cine was made compulsory for all
men in the army under 45 years of
age. As a result, both the morbidity
and mortality from typhoid fever
were practically eliminated. During
the European war, vaccination
against typhoid having been rigidly
enforced in the main contending
armies, the incidence of the diseases
was very slight. More trouble was
experienced from paratyphoid infec-
tions, until systematic vaccination
against these was likewise enforced.
As a rule, a vaccine protecting against
both the typhoid and the A and B
paratyphoid organisms is now gen-
erally employed. The initial dose of
0.5 c.c. contains, in addition to 500
million B. typhosus, half that number
of each of the paratyphoid germs.
Doul)le this dose is, as a rule, subse-
quently injected twice at eight to six-
teen day intervals.
PARATYPHOID FEVER.— This is
produced hy 1 of 2 organisms, viz., either
the paratyphoid bacillus "A" or "B."
Symptoms and Diagnosis. — Willcox
divided the cases into 3 groups: Those
with sudden onset and characteristic symp-
toms; mild cases, often classed as pyrexia
of unknown origin; and severe toxic cases
closely resembling true typhoid.
As described by Torrens and Whitting-
ton, there are 2 distinct types of onset:
60 per cent, of the patients feel increas-
ingly ill for a variable number of days
(the average being 4) before they seek
medical advice. The other 40 per cent,
are overcome in a few hours or collapse
while at their duties. The symptoms
noted, in the order of freciuency, are:
headache, diarrhea, abdominal pain, ach-
ing pains in the limbs, shivering, extreme
general weakness, backache, and epistaxis.
Other less common Init not rare symp-
toms are cough, nausea, and vomiting, loss
of appetite, dizziness, deafness and con-
stipation.
Usually a condition described as "leth-
argic," "heavy," "drowsy," "inert," etc., is
found, except in tiie mild cases; the tem-
perature in the second week varies from
99.2° to 102.4° F. (37..3° to 39.0° C.) and
produces the "spiky" temperature chart
which is characteristic, a steady tempera-
ture being observed in only 5 per cent, of
cases; the pulse is low in proportion to
the temperature, even more so tlian in
true typhoid, e.g., a jjulse of 70 when the
temperature is 102..S° F. (39.1° C); the
blood-pressure is usually from 80 to 1(X)
mm. llg., systolic. Spots, which occur in
664
TYPHOID FEVER (ROBIN).
75 per cent, of all cases, appear in crops
which last for 3 or 4 days, are first seen
about the 7th to the 10th day, hut in some
instances as late as the 35tli day. The
tongue is practically as in typhoid, and
the alxlomen offers no changes except in
al)Out 30 per cent, in which there is some
distention. The spleen is enlarged to pal-
pation or percussion in 60 per cent. The
only cliange in the chest is an occasional
bronchitis.
Complications. — The important compli-
cations are bronchitis in about 4 per cent.,
meteorism rarely, hemorrhage (more com-
mon in paratyphoid B) in about 5 per
cent., perforation in 3 per cent., and
thrombosis of the femoral vein in 3 per
cent. Other complications and sequelae
are: relapse, recrudescences of fever,
pleurisy, empyema, abscess of lung, peri-
carditis with effusion, tachycardia, laryn-
gitis, tonsillitis, otitis media, parotitis,
suppurative orchitis, neuritis, meningis-
mus, mental weakness in convalescence,
periostitis, pyelitis, cholecystitis, abscess
of spleen, and peritonitis without perfora-
tion. The mortalit}- in paratyphoid B was
found by Torrens and Whittington to be
a little over 4 per cent.; of paratyphoid
A, less than 1 per cent.
Diagnosis. — A positive diagnosis can be
made only by recovering the specific
bacillus from the blood, feces, or urine,
or, by discovering evidence in the 1)lood
that the patient has acquired, or is acquir-
ing, an immunity to a specilic infection
(agglutination reaction). According to
Carles and Marcland, a slow pulse, not
above 80, is of some significance in the
distinction of paratyphoid from typhoid.
Treatment. — This is similar to that of
typhoid fever. Editors.
TYPHOID FEVER IN IN-
FANCY.—According- to Dr. Griffith
the onset in infants is, as a rule, de-
cidedly shorter than later — roughly, 3
to 4 days before the fully developed
attack is reached, this being marked
by the appearance of roseola or by
the fever reaching its height. In
about one-third of the cases the onset
may be called sudden, the tempera-
ture being often at its height when
medical aid is first invoked. The
step-like rise of the adult type is rare.
Vomiting is a frequent early symp-
tom, at times very troublesome; di-
arrhea is oftener observed than later
in life, and is probably more frequent
than constipation. Cough is not a
very common early symptom, nor is
abdominal distention. Loss of ap-
petite is frequent ; nose-bleed is un-
common; there is not much prostra-
tion. Convulsions are rare, and an
onset simulating meningitis is very
unusual.
In the developed attack vomiting is
comparatively frequent ; diarrhea con-
tinues to be oftener seen than con-
stipation ; coating of the tongue is
common, but dryness and Assuring
are very exceptional; there is not
much anorexia; distention is fre-
quent, but not troublesome. Of re-
spiratory symptoms, cough is perhaps
oftenest seen, but less common than
in adults. Epistaxis does not often
occur. The pulse maintains its
strength except in the severer cases.
Nervous symptoms of the nature of
depression are not at all a prominent
feature in infancy; and it is only in
the severe cases that there is marked
jn-ostration. On the other hand, the
manifestations of nervous excitation
are oftener seen than later, viz., irri-
tability, fretfulness, and crying.
Roseola is perhaps as frequently
seen in infancy as later, and seem-
ingly tends to appear earlier in the
attack, oftenest somewthere from the
fourth to the sixth day ; and the same
is true of splenic enlargement. Ab-
sence of a leucocytosis is as charac-
teristic as in adults; also the Widal
reaction.
The temperature is not character-
TYPHUS FEVER.
665
istic, and many variations are wit-
nessed. It may continue elevated
from 103° to 105° F. (39.4° to 40.5°
C), little influenced by bathing, for
a week or more ; then becoming- more
irregular. In many other cases it is
very irregular throughout. The final
fall is often rapid, almost by crisis.
It is always more rapid than in
adults, lasting only three to four
days, and being without the evening
rise and morning fall. The total
course is three weeks or less ; in
many, not over two weeks.
TYPHOID FEVER IN EARLY
CHILDHOOD.— The onset is not
so sudden as in very many cases in
infancy, yet often abrupt. The at-
tack may be ushered in by convul-
sions, or may exhibit for a few days
confusing meningitic symptoms. Of-
tener, however, the onset is remark-
ably insidious, nothing of importance
being suspected until, perhaps, the
roseola and enlarged spleen are found.
It is thus frequently difficult to de-
termine when the attack commenced.
In the eruptive stage there is gen-
erally an absence of the evidences
of the typhoid state so common in
adults. Nervous symptoms are little
marked ; at most, as a rule, some ap-
athy, with, perhaps, slight nocturnal
delirium. Diarrhea is less frequent
than in either infancy or later child-
hood. Dryness of the tongue is rare.
Vomiting is more common than in
adults. Abdominal distention is sel-
dom troublesome. The temperature
is more suggestive of typhoid fever
than in infancy, but tlie third stage is
always short and without any remit-
tent character. The total duration is
two to three weeks. Complications
are infrequent. To all this there are,
of course, numerous exceptions.
TYPHOID FEVER IN LATER
CHILDHOOD.— After the age of 6
years, the disease gradually ap-
proaches the adult type, especially
after the age of 10 years. Diarrhea
is now often troublesome, due to
greater intestinal ulceration. Hem-
orrhag'e and perforation are more
liable to occur. The typhoid state is
more likely, yet not to the extent
seen in adult life, and only in severe
cases. The course is longer than be-
fore, frequently ecjualling the ordi-
nary 4 weeks of the adult, and the
temperature of the third stage is
often more remittent.
The pathology is the same as in
adults, except that ulceration of the
ileum is less common. Splenic en-
largement is prominent, and should
be sought where the diagnosis is
doubtful.
The treatment, as in adults, is
symptomatic, and depends largely on
the condition of the patient. Careful
nursing and attention to diet are of
far greater importance than drugs.
A. Robin,
Wihnington, Del.
TYPHUS FEVER (Typhus Grav-
ior; Typhus Exanthematicus; Camp
Fever; Ship Fever; Jail Fever; Spotted
Fever; Putrid Fever.)— DEFINITION.—
An acute infectious febrile disease, com-
mencing abruptly, continuous in type,
reaching its crisis in about two weeks,
accompanied by maculated or petechial
spots on the surface and prominent
nervous symptoms.
SYMPTOMS.— The period of incuba-
tion lasts between seven and fourteen
days. The patient then abruptly develops
pains in the head, back, and limbs, with
a chill or alternations of heat and cold,
soon followed by decided fever and
marked prostration. Epistaxis has been
noted. The face becomes markedly
flushed, the skin dry and red, and the
666
TYPHUS FEVER.
vessels of the conjunctiva injected. The
tongue usually shows a white coat, the
mouth is dry, the pulse frequent and
moderately full, the bowels inactive, and
the urine dark and scanty. There is
much restlessness, or mental dullness,
with indications of delirium. The spleen
is usually early enlarged.
The symptoms reach their climax in
five to seven days. The temperature ad-
vances with but little or no morning re-
missions from 103° F. on the first day to
104° or 106° F. on the fifth or sixth day,
after which it recedes one or two degrees
each morning, rising again in the after-
noon and evening. During the same
period the tongue becomes more thickly
covered with a dry, brown coat; sordes
appears; the pulse often reaches 120 to
130 per minute, and is less full. The
breathing is accelerated and shallow; a
dry, congested condition of the respira-
tory membranes is generally present, and
later more or less hypostatic lung en-
gorgement.
In most cases a rash appears between
the third and fifth days, first over the
abdomen and upper chest, then, in two or
three days, over the back and extremities.
The face, though red and swollen, seldom
exhibits the eruption. Many of the spots
are dull-red and appear as though be-
neath the cuticle. Others are more pap-
ular, and in severe cases they undergo
hemorrhagic transformation or begin as
petechia, presenting later a dirty, bluish
color, and only partially disappearing on
pressure. In mild cases the eruption is
generally slight, or even absent. A dis-
tinct leucocytosis generally exists.
In a few severe cases vomiting and di-
arrhea occur early in the disease, but, as a
rule, the stomach and bowels are inactive
and the abdomen free from gurgling and
tympanites. The delirium is frequently
of the alert, violent type, but may pass
into coma vigil. In the most severe cases
the patient becomes early and persistently
delirious, the conjunctival vessels injected,
and the pupils small. A copious petechial
or hemorrhagic eruption appears, the
temperature rises to 105-8° or 107.6° F.
(41° to 41.9° C), and the pulse to 140 per
minute and weak. The urine is scanty
and albuminous. Tremor and subsultus
tcndinum arc marked. Such cases gener-
ally end fatally in the first week. In a
larger number of fatal cases these symp-
toms develop more slowly and do not end
in death until the end of the second week
or the first half of the third. When the
patient is progressing toward recovery
there is dullness and light delirium, from
which the patient can be more readily
roused during the morning hours. Such
cases may reach a crisis about the end of
the second week, when the patient falls
into a more natural sleep, awakening later
with his mind clear, skin moist, and urine
free. After one or two bowel evacua-
tions, rapid defervescence follows, and in
two o-r three days convalescence is fully
established, though accompanied by great
prostration. The skin lesions, except the
petechise-, pass off before the deferves-
cence. Exceptional cases occur during
almost every epidemic, featured by active
diarrhea and vomiting. Again, cases are
occasionally met with in which laxatives
are required throughout the course of the
disease. Such cases generally exhibit
much delirium o.r stupor and subsultus.
Brill's Disease. — A mild form of typhus
fever has been shown by Brill and others
to be rather common in the eastern United
States, having probably been mistaken
previously for typhoid fever, which, in
some ways, it resembles. Anderson and
Goldberger showed, in 1912, that this mild
typhus was identical with the typhus
("tamarillo") frequently met with in
Mexico. The condition should manifestly
be constantly borne in mind by the phy-
sician in the presence of doubtful typhoid.
DIAGNOSIS.— The diseases with which
typhus has been oftenest confounded are
tj'phoid, cerebrospinal meningitis, malig-
nant measles, septicemia, and some cases
of acute miliary tuberculosis. The chief
diagnostic features in the differentiation
from typhoid fever are the short pro-
dromic stage in typhus; the more marked
chill; the more prompt fever, without
morning remissions during the first week;
the more severe pains in the first stage;
the greater delirium, stupor, and sub-
sultus, with little or no diarrhea or tym-
panites; and especially the papular or
petechial eruption, which appears earlier
in a single crop, does not fade completely
TYPHUS FEVER.
667
on pressure, and is common on the ex-
tremities. An eruption of dark-red or
purplish macules may, however, appear in
advance of, or be interspersed vi^ith, the
more papular clusters. The Widal reac-
tion and blood-cultures are important as
differential laboratory tests. From meas-
les typhus is distinguished by the appear-
ance of the eruption on the abdomen and
chest first instead of the face and neck;
the less prominent coryza and oough; the
absence of Koplik's spots, and the less
severe course (except in malignant meas-
les). The usual drop in temperature
coincident with the measles eruption does
not occur in typhus. Cerebrospinal fever
is distinguished by the more intense nerv-
ous phenomena, with somewhat less pros-
tration; the more- common vomiting; the
usually lower fever; Kernig's sign; the
positive lumbar puncture, and, perchance,
the existence of an epidemic of this dis-
ease at the time. The eruption in cere-
brospinal meningitis is macular and less
constant than in typhus. Differentiation
of typhus from septicemia may be impos-
sible until after a few days' observation.
Brill's disease is to be differentiated
from typhoid by the short incubation (4
or 5 days); the chill; the reaching of the
fastigium in three days.; the relatively
slight temperature remissions; the defer-
vescence not exceeding 60 hours in dura-
tion; the maculopapular eruption, with
periphery indistinct and irregular; its not
infrequent appearance on the limbs, and
occasionally on the palms and soles, as a
single crop, with petechise occasionally,
and sometimes confluence; the early ap-
athy and prostration; labial herpes in 6
per cent, of cases; constipation almost in-
variable; no bowel hemorrhage; headache
intense and persistent; Widal and blood-
cultures always negative; absence of re-
lapse, and convalescence speedy.
ETIOLOGY AND PATHOLOGY.—
Typhus fever prevails chiefly among those
living in overcrowded, uncleanly, and ill-
ventilated houses, camps, prisons, and
almshouses, and with insufficient food.
The formerly prevalent "ship typhus" of
sailing vessels is now practically un-
known, owing to the more rapid and
sanitary emigrant passenger traffic in late
decades established. The disease in its
severe, typical form is> rare in the United
States, occurring chiefly in certain dis-
tricts bordering on the Baltic Sea, in
Hungary and Turkey, in southern Italy,
in northern Africa, and to some extent
in the British Isles. It is largely a cold-
weather disease. No age is exempt,
though children under 6 years seem rela-
tively insusceptible, and about two-thirds
of the cases occur between the ages of
15 and 40- Numerous physicians and
nurses have been victims.
That the virus of typhus is transmitted
by the body louse has been abundantly
proved by Nicolle, Ricketts, and others.
The head louse is probably also a carrier
(Anderson and Goldberger), but not the
crab louse. The disease is apparently not
transmitted by fomites, nor by direct con-
tact unless such contact permits of ex-
change of body lice. Various organisms
have been described as the cause of the
disease. Evidence has been presented that
the Bacillus typhi c.raiitlicniatici described
by Plotz, of New York, in 1914, and
studied also by Baehr, Olitsky, Denzer,
and Husk, is the actual etiological factor.
It is a gram-positive, anaerobic bacillus,
was obtained from the blood of typhus
patients, recovered from animals, and
yielded agglutination and complement-
fixation reactions with blood taken after
the crisis. According to Friedberger, the
Bacillus proteus X 19 of Weil-Felix is the
pathogenic agent. Craig and Fairley
(1918) deemed the agglutination test with
this organism (Weil-Felix reaction) an
invaluable diagnostic aid.
The intestinal follicles in typhus may
be swollen, but Peyer's patches and the
mesenteric glands show no change. The
early splenic enlargement is likely to have
subsided after the middle of the second
week.
PROGNOSIS. — Murchison, in 18,592
cases of typhus, collected from the lead-
ing hospitals of London, Edinburgh, Glas-
gow, and Paris, found an average mor-
tality of 18.78 per cent. During severe
epidemics the mortality in European hos-
pitals has been from 20 to 25 per cent.,
and in unsanitary surroundings it may
rise to 50 per cent. In mild epidemics it
may not exceed 10 per cent. In the mild
American cases described I)y Brill it is
668
UREMIA (SAJOUS).
less than 1 per cent, (one death among
Brill's 255 cases). Crowding, cverexer-
tion, alcoholism, a petechial eruption, hy-
perpyrexia, a soft or irregular pulse, and
pulmonarj' or renal complications are un-
favorable prognostic features. In the
aged and in small children the mortality
is high; in older children, low.
PROPHYLAXIS.— This consists essen-
tially in the destruction of lice that may
have become infected with the virus, and
in avoidance of all contact with the pa-
tient or his effects until this has been ac-
complished. The patient's clothing should
be sterilized or burned up, his hair
clipped, and the head washed with 4 per
cent, phenol solution. Those living with
him should be similarly dealt with, and
the premises thoroughly cleaned — prefer-
ably fumigated with sulphur (not formal-
dehj'de), using 2 pounds of sulphur for
every 1000 cubic feet of space, properly
sealing the room, and not opening it for
at least two hours. General prophylaxis
during an epidemic consists in isolation
of the patients in tents or temporary bar-
racks, periodic inspection of crowded, un-
sanitary premises, and a general campaign
against lice. Prophylactic vaccination has
seemed effectual in tests made in Serbia,
Russia, and Mexico (Plotz).
TREATMENT.— Absolute rest in bed
and pure, fresh air are essential. A liquid
diet should be given, comprising milk and
its modifications, albumin-water, broths,
and even eggs. Milk containing 1 ounce
(30 c.c.) of fresh lime-water in every 6
ounces (180 c.c.) may be alternated at
two-hour intervals wnth a broth. An at-
tempt should be made by giving water
freely at regular intervals, to augment the
output of urine to several liters (quarts)
a day. A mixture of equal parts of liquor
ammonii acetatis and spirit of nitrous
ether may be given to promote diaphore-
sis as well as diuresis, and calomel ad-
ministered to evacuate the bowel, to be
followed by saline purgatives in the sub-
sequent course of the disease. Warm
enemas, containing 2 drams (8 Gm.) of
sodium chloride, are useful. Irrigations
of the nose and mouth with some mild,
alkaline, antiseptic solution are indicated,
as in typhoid fever.
For the fever, hydrotherapy, preferably
in the form of the cold tub-bath, as in
typhoid fever, should be instituted; in the
mild cases, cool sponging or packs may
suffice. For the nervous symptoms, an
ice-bag or cold cloth should be kept in
contact with the head, and where there is
pronounced delirium or headach'e, or
sleeplessness, Dover's powder, 10 grains
(0.6 Gm.), with bromides, 20 grains (1.2
Gm.), may be given, or, better, in severe
cases, morphine subcutaneousl}^
When evidences of circulatory weaken-
ing appear, not uncommonly accompanied
by shallow respiration, impaired resonance
over the lung bases, and increasing
stupor and muttering delirium, stimulants
such as strychnine, gr. %o to %) (0.0015
to 0.003 Gm.) hypodermically, caffeine
sodiobenzoate, 7jj grains (0.5 Gm.) hy-
podermically, camphor oil injections, and
digitalin, gr. Yrj (0.012 Gm.) hypodermic-
ally, are indicated. To reduce the chances
of serious hypostatic congestion the pa-
tient should be frequently rolled from
one side to the other. Laryngeal edema
may require tracheotomy. Saline infusion
should be available for immediate execu-
tion at any time after the eruptive stage.
During convalescence, which is usually
rapid, nutritious but easily digested food
should be supplied. The patient should
be kept very quiet for some days after
defervescence, a depressive circulatory
reaction, as a rule, following the cessation
of fever. S.
u
ULCERS AND VARICOSE
ULCERS. See Vascular System,
Surgical Diseases of.
UREMIA. — Uremia is a term ap-
plied to a group of symptoms at- disease of the kidneys (gouty kidney.
tributed to the retention in the blood
of substances which should normally
have been excreted in the urine. It
is met with
m
Bright's and other
UREMIA (SAJOUS). 569
scarlatinal nephritis, cancer, tubercle, in a few hours from a rapid deepen-
suppuration, etc.), in diseases such as ing of the coma; or the patient may
cholera, typhus, and yellow fever; recover and continue permanently
and also in cases of anuria, obstruc- free from the symptoms. Again,
tive or non-obstructive, pregnancy, uremia may recur, sooner or later,
and parturition. and death follow.
SYMPTOMS. — Two clinical types The acute convulsive form may be
of uremia may be distinguished, the marked by symptoms almost exactly
acute and chronic : — simulating those of epilepsy ; there
Acute uremia includes all the cases may be no loss of consciousness; or
in which the symptoms develop sud- the spasms may be confined to cer-
denly. It occurs not only in the dif- tain groups of muscles, and thus sim-
ferent forms of nephritis, but also in ulate tetanus. The attack is sudden,
angina pectoris, pulmonary emphy- with or without warning. It may be
serrra, chronic endarteritis, and other a single attack, or a. rapid succession
■disorders, and seldom lasts more of them may occur: 5 or 6, or even
than a few days. Two main forms more, in the course of twelve hours,
are commonly recognized : the coma- These attacks may prove i:apidly
tose and the convulsive. fatal, either during the paroxysm or
In the ac]ite comatose form, coma in the coma which succeeds it ; or
develops rapidly after the appearance they may be recovered from. Con-
of headache, vertigo, more or less vulsions may occur in any of the
disturbance of vision, vomiting, somr various forms of Bright's disease, but
nolence, general malaise-, often with most frequently in the cirrhotic and
a positive Babinski reflex preceded inflammatory varieties ; they may, in-
by a preliminary depression of all deed, be the first warning of the ex-
reflexes ; or it may be unattended by istence of cirrhosis of the kidney,
premonitory symptoms. In some Both these acute types may be so
cases, epileptoid convulsions alter- merged as to render the identification
nate with coma. The face is usually of either impossible. Hence, the so-
pale ; the pupils react slowly to light called "mixed form" of some authors,
and are dilated or unaltered ; in other Chronic uremia develops gradually,
cases we may observe a red spot on as a rule, and may not be recognized
the cheek, injected conjunctivae, and at once, although the pathognomomic
contracted pupils. There is a pe- listlessness -and indifi^erence of man-
culiar, stertorous breathing — not the n\sr in cases of Bright's disease be-
deep snoring observed in hemor- comes somewhat more marked. The
rhagic ajioplexy, but a sharper, more movements become slower, and
hissing sound, jiroduced by the rush sjreech is somewhat indistinct. Dim-
of expired air on the hard palate or ness of vision, tinnitus aurium, an
teeth. Anuria is frequent and may uneasy feeling in the head, or. ]-)er-
occur as initial symptom. Amaurosis, haps, violent and persistent hcad-
which disappears as suddenly as it ache may be present. Asthmatic at-
scts in, may also occur; deafness tocks — uremic asthma — most frequent
likewise, though rarely. Indicanuria at night may occui". There is. as a
is usually present. Death may occur rule, marked pallor. The blood-pres-
670
UREMIA (SAJOUS).
sure is g-enerally hi.c^h, 200 mm. or
more, and the heart is often hyper-
trophied. The symptoms occasionally
improve or disappear. Init they uni-
formly recur, and gradually become
more intense.
The drowsiness may pass into
stupor. When the patient is roused
to speak, articulation is at first thick
and indistinct, but, later, he cannot
be made to respond ; stupor deepens
into coma ; the breathing assumes
the characteristic stertor before men-
tioned ; Cheyne-Stokes breathing may
occur independently of the comatose
state. Stomatitis, with fetor of the
l^reath, redness, swelling and tender-
ness of the oral mucosa, hiccough,
vomiting, and diarrhea are common.
Exceptionally, the patients may
^sufifer from a noisy delirium, in
which prolonged howling alternates
with muttering or with paroxysms of
excitement, or delusional insanity
(folic Brightique). There may be
low prolonged muttering, with a
repetition of the same word or
phrase. Subsultus tendinum and
twitching of the facial muscles are
commonly seen throughout. Cramps
in the muscles, especially in those of
the calves, are common. Convul-
sions, diarrhea, and vomiting are fre-
quently present. Epistaxis may oc-
cur, but is rare. Pruritus is usually
complained of, and is thought to be
due to irritation of the cutaneous
nerves by the urea excreted adven-
titiously by the sweat-glands. In-
deed, crystals of pure urea may cover
the body with a frost-like but odor-
less coating. The action of the heart
and pulse is strong at first, then
feeble. The temperature tends to be
subnormal excepting during convul-
sions, but may become considerably
elevated when death is approaching.
The patients pass into a condition of
great prostration, with alternating
delirium and stupor ending in fatal
coma. Death may occur, as an ex-
ception, in the early stage of the
inflammatory form. Chronic uremia
may continue many weeks.
DIAGNOSIS. — Acute comatose
uremia may closely resemble cerebral
apoplexy with loss of consciousness,
but may be distinguished from it by
the absence of unilateral paralysis,
the character of the breathing, pulse,
and heart-action, and the urine.
Acute convulsive uremia may re-
semble epilepsy, but it usually lacks
the initial cry, the death-like pallor,
the predominance of unilateral con-
vulsions, the inturning of the thumbs
upon the palms, and the loss of reflex
irritability. The urine, after an epi-
leptic seizure, may reveal the pres-
ence of albumin and a diminution of
urea, but it soon returns to a normal
condition ; in uremia it is always dis-
tinctly albuminous. The condition
of the pupils and the examination of
the urine will distinguish this condi-
tion from poisoning by opium or
belladonna.
Chronic uremia, w^hen fairly estab-
lished, is usually recognized without
difficulty. An examination of the
urine furnishes the most valuable
evidence. Chronic uremia may some-
times resemble meningitis, from which
it may be differentiated by the his-
tory of the illness, the condition of
the urine, the temperature, breath-
ing, and weak pulse and heart action.
Certain cases develop gradually and
pass into a typical typhoid stated-
such are met most frequently at or
after middle life and in connection
with chronic interstitial nephritis.
UREMIA (SAJOUS).
671
Renal insufficiency should be de-
termined by the phtJialein test and
others given in vol. VI, p. 203.
The writers recognize 3 types of
so-called "uremia." The first, fea-
tured by convulsions, is merely a
chloridemia, and occurs mostly in the
young; the second, true uremia
(azotemia), occurs at all ages, and the
third, pseudouremia, after 40. Re-
covery is the rule in the first type;
death is inevitable in true uremia,
while pseudouremia permits of pro-
tracted survival. Treatment of the
first type requires restriction of salt
and water; of the second, restriction
of protein food and salt, with plenty
of water; of the third, some restric-
tion of fluids, with rest and event-
ually tonics and heart stimulants.
The first type is essentially mechan-
ical, from retention of salt and v/ater;
in the second, toxic, urea and indican
being the main toxic substances. In
the third, or arteriosclerotic type,
the symptoms resemble true uremia,
but are due merely to deranged cir-
culation. Blood indican reveals true
uremia, lleini and Tchertkoff (Rev.
med. de la Suisse rom., Jan., 1918).
ETIOLOGY.— That uremia is due
to the retention of excrementitious
products is imdoubted, but the na-
ture of these products is unknown.
Herter has shown that it could not
be urea, though it is in marked ex-
cess in the l)lood. Strauss found the
ammonia and nitrogen content of the
blood greatly increased, notwith-
standing the marked hydremia, the
brain and kidneys being also edema-
tous— a fact believed by some to ac-
count for the symptoms. A fall of
the CO2 tension below normal causes
acidosis, according to Straub and
Schlayer. Croftan had previously
urged acidosis of metabolic origin as
the most probable pathogenic agent.
Cerel)ral anemia is thought by some
to explain the symptoms.
PROGNOSIS.— The occurrence of
uremia is always grave. When, how-
ever, uremic convulsions are due to
acute disease, the prognosis is more
hopeful, as the conditions leading up
to them are often amenable to treat-
ment. Puerperal cases are very fre-
quently recovered from, as the com-
bination of circumstances to which
they owe their origin is of short
duration. The chronic form of ure-
mia is hopeless, though life may, by
judicious care, be prolonged.
Experiments showed that the thy-
roid has unquestional)ly some influ-
ence on the clinical picture of uremia,
either by neutralization of toxins or
by stimulating the adrenals. It has a
toxin-destroying function. Remond
and Minvielle (Bull, de I'Acad. de
med., Mar. 6, 1917).
TREATMENT.— The first indica-
tion is to restore the secretory func-
tions of the kidneys. To this end we
may apply dry cups, leeches, hot poul-
tices over the loins and administer
bland diuretics. It is often foimd that
the action of diuretics is delayed until
the bowels have been well emptied by
means of salines or elaterium. Cal-
omel, sometimes recommended, tends
to irritate the kidney, and should not
be used. The use of the hot pack or
of diaphoretics will hasten and assist
the action of a diuretic. Venesection
is a valuable measure, especially in
puerperal and acute inflammatory
cases. Lumbar puncture is in inany
instances helpful. Gastric lavage
has also been used for the latter
purpose. Saline solution should be
avoided, owing to retention of the
cliloridcs and the likelihood of in-
creasing the hydremia, besides dis-
turbing the osmotic balance.
If the blood-pressure is high and
the pulse tense, nitroglycerin is indi-
672
UREA, DETERMINATION OF.
cated. Anders recommends its free
use, and combines it with aconite, 2
minims (0.12 Gm.), the dosage being
adjusted to the intensity of the vas-
cular tension. Amyl nitrite, iiflialing
10 drops, is very efficient, with spirit
of nitrous ether, to sustain the effect.
If the heart's action becomes feeble,
digitalin, cafTeine, or strophanthus
may be used, but not if the blood-
pressure is still high.
An essential feature is the with-
holding of all foods during an attack
of uremia. Frequent irrigation of
warm water will, besides keeping the
bowels free, enable the body to ab-
sorb water, if it needs it.
C. E. DE M. Sajous,
Philadelphia.
UREA, DETERMINATION
OF. — Normal human urine contains from
1 to 3 per cent, of urea. If much less
than 1 per cent, the patient is retaining
poisonous products that should be elimi-
nated; if more than 3 per cent, his loss is
greater than his gain and his metabolism
is on the down grade. For a man on a
mixed diet the daily average excretion of
urea varies from 24 to 40 grams, average
33 grams; on a non-nitrogenous diet or
while fasting the excretion will vary from
15 to 20 grams. Women excrete rather
less, from 20 to 32 grams. As much as
100 grams have been excreted when a
very rich protein diet was used.
SPECIFIC GRAVITY METHOD.—
As urea is the main factor in the specific
gravity of urine, the latter is an approxi-
mate measure of the amount of urea, if
the urine contains no sugar. From long
observations it has been found that a
specific gravity of 1014 corresponds to
about 1 per cent, of urea, of from 1014
to 1020 to about 1.5 per cent., of from
1020 to 1024 to about 2 or 2.25 per cent.,
and of 1028 to about 3 per cent. This will
not hold good in fever and cachexia,
where diminished chloride excretion is
the rule. Sugar, if present, must first be
removed by fermentation in applying this
method.
SODIUM HYPOBROMITE
METHOD.— The estimation by this
method may be quickly made by use of
the Dorcmus ureometer. This consists of
a specially constructed tube with grad-
uations and a pipette capable of measur-
ing one cubic centimeter. The reagent
used is the hypobromite of soda. This
solution is, however, unstable and is
commonly made for each test; but the
formula devised by the late Dr. Charles
Rice of Bellevue Hospital enables the
physicians to keep on hand two stable
solutions ready for use and obviates the
necessity of opening a bottle of bromine
every time a test is made. They are easily
prepared, but pure chemicals should be
uesd.
This method, though easy of applica-
tion, is not entirely reliable, as urea is
not completely decomposed by sodium
hypobromite in the concentrations occur-
ring in the urine, and a number of other
nitrogenous compounds, as ammonia, cre-
atinin, etc., suffer partial decomposition
and vitiate the result. Occasionally one
of the two errors mentioned neutralizes
the other (C. G. L. Wolf).
Solution A.
Sodium hydroxide 40 Gm.
Distilled water 100 c.c.
Solution B.
Bromine 12.5 Gm.
Sodium bromide 12.5 Gm.
Distilled water 100 c.c.
For use, take 1 part of each solution
and 3 parts of water.
In making the determination fill the
tube with the sodium hypobromite so that
no air remains in the blind end. Then
with the pipette measure 1 c.c. of the
urine and carefully and quickly pass its
curved beak back into the bottom of the
filled tube as it is tilted forward, to pre-
vent escape of gas. Then gently pass the
urine out of the pipette by means of the
nipple attached, until it is entirely emp-
tied. The lighter urine rises to the top
through the hypobromite solution and its
urea is decomposed, giving off two gases,
one of which is reabsorbed; the other, the
nitrogen, is collected at the top, and as
soon as the frothing ceases the quantity
of urea may be read off directly by means
UREA, DETERMINATION OF.
673
of the metric graduations on the tube giv-
ing the percentage.
If, as is rare, the urine contains more
than 3 per cent, of urea it will be neces-
sary to do the test again, using urine
diluted half with water and of course
multiplying the percentage thus obtained
l)y two.
DAVY'S METHOD.— Pour a measured
quantity of urine into a graduated (metric)
tube partly filled with mercury, add an
excess of the hypochlorite of soda and
invert the tube. In a few seconds de-
composition of the urea commences, the
carbonic acid is absorbed by the hypo-
chlorite and the nitrogen collects in the
upper part of the tube, from which the
urea content may be easily calculated.
BENEDICT'S METHOD.— In this
method a sulphuric acid bath is required
which must be kept at a temperature of
from 162° to 165° F. The technique rec-
ommended for the estimation of urea in
urine is as follows: 5 c.c. of urine are
introduced into a rather wide test-tube,
and about 3 grams of potassium bisul-
phate and from 1 to 2 grams of zinc sul-
phate are added. (The quantities of these
salts may be measured roughly. An excess
of the zinc salt is to be avoided, as too
large a quantity tends to cause slight
frothing during the final distillation.) A
liit of paraffin and a little powdered
pumice or talc are then introduced into
the tube (to prevent frothing and spat-
tering) and the mixture l^oiled practically
to dryness, either over a free flame or,
more conveniently, by floating the tube in
a jiath of sulphuric acid kept at about
130° F. The tube is then placed in a
sulphuric acid bath which is maintained
at from 162° to 165° F. (not lower), and
left there for one hour. During this heat-
ing the tube must be weighted (a large-
sized screw-clamp is convenient), so that
it will be immersed in the acid for at
least throe-fourths of its length. At the
end of the hour the tube is removed from
the bath, the acid washed off under the
tap, a little distilled water poured into the
tube, and the contents washed (with the
aid of heat) quantitatively into an 800 c.c.
distillation flask. (A small amount of
black pigment finally adhering to the sides
of the tube may be disregarded, as the
ammonium compounds are readily soluble.)
The fluid in the distillation flask is diluted
to about 400 c.c, rendered alkaline through
the addition of 15 to 20 c.c. of 10 per
cent, sodium hydroxide (or 25 c.c. of 15
per cent, sodium carbonate), and distilled
for forty minutes into an excess of stand-
ard acid. The residual acid is then ti-
trated, and the urea nitrogen calculated
(after subtraction of the previously deter-
mined ammonia nitrogen). In dextrose-
containing urines this method may be
employed in combination with the Morner-
Sjoqvfst method.
Doremus's ureometer.
FOLIN'S METHOD.— This method is
based on the fact that urea, when boiled
with saturated solutions of magnesium
chloride, is converted into ammonia. Five
c.c. of urine, 20 Gm. of crystalline mag-
nesium chloride, and 2 c.c. of hydrochloric
acid are placed in a flask, closed with n
reflux condenser of the shape given in cut.
The mixture is heated on an electric stove
for 90 minutes, the heat being greatest in
the beginning and reduced toward the end
of the reaction. The heat is so regiilated
that drops of liquid falling from the con-
denser emit a marked hiss when they fall
upon the contents of the flask. The flask
is now cooled and to its contents are
added 500 c.c. of distilled water. The di-
luted contents are transferred ([uantita-
tively to a distilling flask. Ten c.c. of
43
674
UREA, DETERMINATION OF.
sodium hydroxide, a little talc and a small
piece of paraffin are added to prevent
frothing. The distillate is received in a
definite volume of standard sulphuric
acid and finally titrated with alkali. A
control estimation must be made to ascer-
tain the ammonia contained in the 20
grams of the magnesium chloride, as it is
seldom ammonia-free. The preformed
ammonia must also be estimated, and sub-
tracted from that of the total ammonia
found by this method.
The foregoing method is conceded to be
one by which we may accuratelj- estimate
the urea nitrogen, and is growing in favor
with the great majority of laboratory
workers.
MARSHALL'S METHOD.— This
method is said to be peculiarl}^ useful in
its application to pathological urines since
the presence of glucose and protein, usu-
ally so annoying in the estimation of
urea, are without influence here. In the
preparation of the enzyme solution, soy
beans are ground to a fine powder which
can be preserved in well-stoppered dry
bottles for months without appreciable
loss of activit)'; 25 grams of this powder
are mixed with 250 c.c. of distilled water,
and allowed to stand with occasional agi-
tation for about an hour; 25 c.c. of N/10
hydrochloric acid are now added and the
mixture allowed to remain a few minutes
longer (best in a water bath at about 35°
C. — 95° F.), when a large proportion of
the protein of the bean extract is precipi-
tated. The mixture is filtered; the filtrate
treated with a few drops of toluene and
preserved for use in a stoppered vessel.
On standing the originally clear fluid be-
comes opalescent, and finally a precipitate
is formed, but the solution remains suf-
ficiently active for use in the method at
least five days after its preparation when
kept at the room temperature. This solu-
tion is alkaline to methyl orange, and 2
c.c. generally require from 0.28 to 0.34 c.c.
N/10 hj'drochloric acid for neutralization.
This factor should be determined once for
2 c.c. of each preparation and can then be
employed as a correction as long as the
solution is used. The alkalinity is ap-
parently constant from day to day. If
for any reason the extract should not be
distinctly alkaline to methyl orange, less
acid should be used in its preparation, as
an extract which reacts acid to methyl
orange is scarcely active.
In the execution of the method 2 5-c.c.
portions of the urine are measured into
flasks of 200-300 c.c. capacity and diluted
with distilled water to about 100-125 c.c;
2 c.c. of enzyme solution are added to
one flask, a few drops of toluene to each
and the solution allowed to remain, well
stoppered, at room temperature over
night. The fluid in each flask is titrated
to a distinct pink color with N/10 hydro-
chloric acid, using methyl orange as an in-
dicator. The amount of hydrochloric
acid required for the contents of the flask
containing the urine and enzyme solution
less the amount used for 5 c.c. of urine
alone and that previously determined for
2 c.c. of enzyme solution, corresponds to
the urea originally present in the sample
of urine.
Since 1 c.c. of N/10 hydrochloric acid
is equivalent to 3 mg. of urea, the number
of cubic centimeters required multiplied
by 0.6 gives the value of urea expressed
in grams per liter of urine. The time re-
quired for complete hydrolysis of the
urea depends on the quantity of urine
used, the concentration of the urea, the
amount of enz3'me pres.ent and the tem-
perature of action. The velocity of the
reaction is approximately twice as rapid
at 35° C. as at 25° C, and directly pro-
portional to the enzyme concentration
within certain limits. The conversion is
complete in less than one hour at 35° C,
when 10 c.c. of the enzyme solution are
employed instead of 2 c.c. A cloudiness,
however, is produced on titrating a solu-
tion containing 10 c.c. of the enzyme mix-
ture, which renders the end point uncer-
tain and the procedure less accurate. With
the use of only 2 c.c. of enzyme solution
this cloudiness is scarcely noticeable.
If more rapidity is required than is at-
tained by the method as outlined, diges-
tion for three hours at a temperature of
35-28° C. will suffice, or, if accuracy is
to be sacrificed to rapidity, less urine and
more enzyme solution can be used. A
rough estimate may thus be obtained. W.
URETERS. See Kidneys and
Ureters, Dise.vses of.
URETERS AND BLADDER, EXAMINATION OF.
675
URETERS AND BLADDER,
EXAMINATION OF.-cystos-
COPY. — Cystoscopy consists in inspec-
tion of the interior of the bladder after
insertion of an instrument which illumi-
nates the organ and also magnifies the
image from its internal surfaces — the
cystoscope.
Varieties of Cystoscope. — Cystoscopes
are classified as direct or indirect, accord-
ing as the line of vision from the point
inspected is straight or is deflected by a
prism. In the indirect cystoscopes a
rectangular prism near the distal extrem-
ity of the instrument refracts the incom-
ing light rays at an angle of 90° and
also inverts the image. The indirect
variety of cystoscope is in more general
use than the direct. It permits of back-
ward inspection in the direction of the
prostate.
Cystoscopes are also classified as non-
irrigating, irrigating, catheterizing, and o/'-
crating cystoscopes. In the irrigating in-
strument provision is made for changing
the fluid in the bladder, where vision be-
comes dim because of turbidity due to
blood or pus, without removal of the
instrument. In many instruments, con-
tinuous irrigation — often a necessary pro-
cedure— is provided for. With the Nitze
instrument, however, the irrigation is dis-
continuous, an inward flow of fluid, fol-
lowed by an outward flow, being pro-
duced.
Catheterizing cystoscopes may be of
either the direct or the indirect type. In
the former the catheterizing tubes are
propelled directly from the shaft of the
cystoscope into the ureters; in the latter,
they are curved or displaced toward the
ureters by levers operated with thumb-
screws from the external portion of the
instrument. The Brown-Ruerger pris-
matic (indirect) and the Tilden Brown
direct catheterizing cystoscopes are in
common use; irrigation is provided for in
both of these instruments. The ureteral
openings are more readily located with
the indirect instrument than the direct,
but the process of catheterization itself is
easier with the latter.
Operating cystoscopes comprise instru-
ments such as those of Nitze and P.rans-
ford Lewis, and the Caspar modification
of the Nitze. These cystoscopes are of
value in removing bits of calculi or other
foreign bodies from the bladder or ure-
teral openings, in breaking up small cal-
culi, in dilating ureters contracted at their
lower terminations, and in applying rem-
edies to vesical ulcers. Their use to re-
move papillomas is, however, inadvisable,
the base of such growths remaining and
later tending to become malignant.
#
Nitze's double cathcterizingr cystoseoiie with attach-
ment for irrigation of the bladder. {Morton . )
In women the Kell}- cystoscope, con-
sisting essentially of a tul)e through which
light is directed with a mirror, is widely
used.
Preparation of the Cystoscope for Use.
— Careful sterilization of the instrument
before use is required, cystoscopy necessi-
tating a perfect aseptic technique. The
instrument should, if ])ossil)le, be first
taken apart and thoroughly cleansed with
green soap in water. It should then be
l^laccd in a 1 to 500 formaldehyde solu-
tion for fi\e niinutt^s, or exposed to for-
maldehyde gas for an hour or more, to be
followed bv washing with sahne solution.
676
URETERS AND BLADDER, EXAMINATION OF.
A 5 per cent, solution of phenol may be
used instead, but exposure to it fur twen-
ty-four hours is desirable; before use the
phenol is washed ofif with glycerin. Al-
cohol may likewise be employed, but im-
mersion of the eye-piece in it must be
avoided.
Before introduction of the instrument it
should also be connected with the rheo-
stat and proper lighting of the small elec-
tric bulb at its tip made sure of. It
should likewise be known that the bulb
used is actually a "cold" lamp, burns of
the bladder mucosa sometimes occurring
where a hot bulb is left in contact.
Lubrication of the cystoscope is efifected
with sterile glycerin.
Preparation of the Patient. — The pas-
sage of steel sounds for a few days be-
fore cystoscopy is of advantage in creat-
ing a tolerance of the urethra which
facilitates the introduction of the instru-
ment. In certain cases a preliminary
meatotomy or urethrotomy is required.
Where the patient's general condition is
poor, or retention of urine exists, prophy-
lactic administration of IS grains (1 Gm.)
or more of hexamethylenamine, in divided
doses on each of the two preceding days,
is advisable.
Special cystoscopic tables upon which
the subject is maintained in a semireclin-
ing posture with the knees apart and
raised soinewhat above the level of the
pelvis are on the market. The procedure
can, however, be carried out almost as
conveniently on any other form of table,
including those available in the ordinary
household. A sterile covering should be
placed over the subject's legs, as little as
possible being left exposed other than the
penis, which should l)e carefully cleansed
with tincture of green soap and water,
followed by mercury bichloride solution,
then surrounded with a sterile wet dress-
ing.
General anesthesia is required only in
the case of greatly hypersensitive ure-
thras, and in children. To nervous adult
subjects '4 grain (0.015 Gm.) of morphine
sulphate may be given. In the average
case, local anesthesia with 2 per cent, co-
caine, or, preferably, one of the newer,
less toxic drugs, such as alypin or novo-
caine, is sufficient. The anesthesia is best
secured by the use of an instillator, such
as the Keyes-Ultzmann instrument, 1
fluidram (4 c.c.) of the cocaine solution,
or slightly more of a 5 per cent, alypin
solution being introduced. A large por-
tion of the anesthetic solution should be
instilled in the posterior urethra, the
remainder being used for the anterior.
Ten minutes should be permitted to
elapse for the anesthetic to act.
Technique of Cystoscopy. — When cer-
tain of the older forms of cystoscope are
used, the bladder must be irrigated and
filled through a rubber or silk catheter
before the introduction of the instrument.
Usually, however, these procedures are
carried out through the sheath of the
cystoscope itself or its irrigating attach-
ment. Before the instrument is intro-
duced it should be well lubricated and the
light turned on. The introduction itself
is performed as with the ordinary metallic
sound, the shaft being first held close to
the abdomen as the penis is worked up
along it, the instrument next allowed to
settle into the curved portion of the ure-
thra below the pubis, and the shaft then
carried gently down between the thighs
until its beak slips through the neck of
the bladder. In difficult cases the intro-
duction may be facilitated by deep pres-
sure above the pubis or by inserting a
fingei" in the rectum as a guide to the tip
of the instrument.
The cystoscope having entered, the
bladder is repeatedly in part filled with
sterile warm water, normal saline solu-
tion, or 2 per cent, boric acid solution,
and allowed to re-empty itself. When
the outflow is found to be absolutely
clear, the l)laddcr is redistended with the
fluid until the patient experiences a slight
desire to pass water. The investigation
of the bladder may then be proceeded
with. Throughout, such lifting of the in-
strument from the exterior as will raise
its tip from the trigone of the bladder —
compression or injury of which is chiefly
responsible for pain and bleeding induced
in cystoscopy — should be, as much as pos-
sible, carried out.
Removal of the cystoscope is per-
formed merely by reversal of the steps
gone through in its introduction. It
should preferably be preceded by evacu-
URETERS AND BLADDER, EXAMINATION OF.
677
ation of the fluid in the bladder and in-
troduction of some dihite antiseptic solu-
tion, e.g., 1:10,000 silver nitrate, to be
again passed after the cystoscope has
been withdrawn.
Uses of Cystoscopy. — Cystoscopy has
come to occupy a most important place
in urinary surgery, not only permitting of
precise diagnosis in conditions formerly
guessed at, but greatly improving the
chances of complete operative relief in
afifections, especially renal, in which in-
tervention was formerly so postponed as
frequently to lose its curative value.
Thus by cystoscopy we gain definite in-
formation not only as to the presence
of foreign bodies in the bladder, tumors,
stones, cystitis, malformations, etc., but
also as to the condition of the kidneys
themselves. The procedure is indicated
in all puzzling conditions of the bladder,
kidneys, and ureters, except in the pres-
ence of acute inflammation anywhere in
the lower urinary or genital tract. It is
invaluable in the determination of the
origin of hematuria and pyuria not due to
disease of the urethra, and in affections
of structures adjacent to the bladder may
be employed to ascertain whether this
organ is likewise being attacked. In cases
of pronounced prostatic enlargement it is,
however, at times unsatisfactory or im-
possible, and is contraindicated — unless
preceded by drainage of the bladder —
where there is pronounced sepsis from
retention of urine in these cases.
In using the indirect cystoscope the
vault of the bladder is usually inspected
immediately after the introduction of the
instrument. Next, upon drawing the lat-
ter out to the sphincter, the internal
(ipening of the urethra is' examined. Fin-
ally, the condition of the side walls, the
base, and the openings of the ureters is
inquired into.
In cystitis the mucous membrane will
be found reddened, and the vessels nor-
mally forming a red network on the yel-
lowish-pink membrane itself will have
disappeared, being obscured by the sur-
rounding diffuse red coloration. In addi-
tion, erosion, hemorrhage, ulceration, tra-
bcculation, or sacculation may be noticed.
In tuberculosis of the bladder tubercles
and ulcerations will be found extending
from the neck of the bladder or the
orifices of one or both ureters as centers
to any of the remaining surfaces of the
organ.
Tumors of the bladder are detected
through the cystoscope even better, espe-
cially when small, than by inspection of
the incised organ. As in tuberculosis,
the disease is most likely to be found
near the ureteral and urethral openings.
The entire organ should, however, be
carefully examined, using the direct
cystoscope to inspect areas not illumi-
nated by the indirect, in order that no
focus for subsequent recurrence be left
when operative removal is undertaken.
Hemorrhage due to bladder tumors will
readily be differentiated by cystoscopy
from renal hematuria.
Prostatic enlargement encroaching on
the bladder lumen is revealed by cys-
toscopy even where, as is sometimes the
case, rectal palpation is negative. Pro-
nounced lowering of the outer end of the
instrument between the thighs may be
necessary in these cases to permit the in-
strument to ride over the prostatic ob-
stacle during its passage into the bladder.
An indirect cystoscope must be used.
The instrument having been introduced
deeply, it is slowly drawn out until the
prostate appears as a rounded, reddish
organ, the exact intravesical conforma-
tion of which is then appreciated by
gradually turning the cystoscope and by
noting the extent to which the instru-
ment has, at different points, to be
pushed in or withdrawn to keep the mar-
gin of the prostate in view. A hyper-
trophied median prostatic lobe may,
owing to its elevation, eclipse the "bar"
normally visible between the ureters, and
may alter the shape of the trigone and
disturb the normal relationship of the
ureteral openings or even hide them.
Where there is retention of urine cys-
toscopy should be availed of, according to
Keyes, only for the diagnosis of stone
or as a preliminary to operation.
Among other conditions in which cys-
toscopy is of diagnostic value are car-
cinoma of the prostate, varicose veins of
the bladder, and ureteral cysts so situated
as to be \isil)le in the bladder cavit\'.
In renal affections, unless incipient,
678
URETERS AND IVLADDI
M\,
EXAMINATION OF.
consideraldc information may he gained
by inspection of the ureteral orilices. An
appearance of cystitis rduiid one of these
openings is, to some extent, indicative of
renal trouble abf)ve. Frc(juently in kid-
ney infection tiie ureteral opening is
eitluT (lilatrd or cintractetl. Ulceration
may likewise be noted, and if the normal
jets of urine from the ureters are lacking,
extensive disease of the ureters and pre-
suuKibly of the kidneys is shown. Where
there is marked renal suppuration the
purulent character of the urine excreted
by it may be manifest as the fluid appears
at the ureteral (outlet.
Tuberculosis of the kidney is especially
suggested (1) by shallow, crateriform
ulcers with clearly defined congested mar-
gins and necrotic bases, situated at or
near the ureteral opening, and (2) by
displacement of the vesical trigone to the
affected side, with funnel-shaped depres-
sion of the ureter mouth on that side, due
to shortening of the diseased and thick-
ened ureter. Sometimes there is no ap-
parent ureteral change in spite of pro-
nounced tuberculous involvement of the
kidney.
In nephrolithiasis a calculus may occa-
sionally be noted projecting from the
ureteral opening. Stones in the bladder
inaccessible to the searcher are also re-
vealed by cystoscopy. In using the oper-
ating cystoscope f(jr removing foreign
bodies from the bladder or breaking up
small stones in it, air instead of fluid is
generally used to distend the organ, the
manipulations usually causing so much
bleeding as to obscure vision in the blad-
der, in spite of continuous irrigation.
Extravcvsical conditions altering the in-
ternal appearance of the bladder are
especially common in the female sex,
owing to the proximity of the reproduc-
tive organs, with their varied pathology.
Cystocele causes distortion of the vesical
trigone and may obscure the ureteral
openings; cystoscopy may give a better
idea of the exact size of the cystocele
than mere vaginal inspection. Acute
uterine anteflexion or enlargement of the
uterus from pregnancy or other causes
are reflected in pronounced depression of
the posterior vesical wall or vault and
sometimes in vascular stasis in a part of
the bladder. Cystoscopy is of special
service in such cases in ascertaining
whether the extravesical process has
caused adhesion to the bladder, such ad-
hesion causing, e.g., edema and folds of
the mucosa, varicosities, areas of sub-
mucous hemorrhage and, in the case of
tumors or serious inflammatory processes,
actual invasion of the bladder-wall by the
disease, possibly followed by perforation
and fistula formation. Thusy in cancer of
the cervix venous congestion in the lower
portions of the bladder suggests involve-
ment of the vesicovaginal septum, and
thq degree of operability of the condition
is shown by observation of the, extent of
retraction of the bladder and of elevation
of the vesical trigone. In men, extra-
vesical conditions that may influence the
cystoscopic appearance of the bladder in-
clude, in particular, affections of the pros-
tate, rectum, and sigmoid.
Ureteral catheterization is indicated for
purposes of accurate diagnosis in all in-
stances of suspected sui'gical disease of
the kidneys; in obstinate bladder inflam-
mation, to find out if the kidneys are in-
volved, and in cases of suspected calculus
in the ureter, the catheter being used to
find out the exact situation of the stone
or facilitate its discharge, or in radiog-
raphy, to bring out the situation of the
ureters on the plates. In renal tuber-
culosis ureteral catheterization is almost
indispensable, affording certain knowl-
edge as to which kidney is chiefly or ex-
clusively diseased and giving definite
operative indications. In hydronephrosis
the procedure may be used to estimate
the capacity of the renal pelvis — colored
fluid being injected into the pelvis, then
allowed to run out — and to fill the pelvis
and ureter with some opaque silver prep-
aration (coUargol or argyrol) preliminary
to X-ray examination. Both in hydro-
nephrosis and in nephrolithiasis and
ureteral stone, ureter catheterization is of
great importance in ascertaining the
functional value of the kidney before
operation is undertaken. The technique
of ureteral catheterization is described in
volume vi, pages 226 and 227.
Urinary segregation consists in obtain-
ing the urines of the two kidneys sep-
arately by the insertion of an instrument
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 6/9
which partitions off the two sides of the
bladder. The Luys separator, consisting
essentially of a metal sound in the curve
of which a rubber diaphragm is stretched
up with a small chain after the instru-
ment has been introduced, is generally
employed.
The method is, in fact, merely an in-
ferior substitute for ureteral catheteriza-
tion, and its indications are practically
limited to cases in which, for some
reason, the ureteral orifices cannot be
located while no distortion of the blad-
der sufficient to prevent the use of the
separator exists. T. and S.
URETHANE. — Urethane (^thylis
carbamas, U. S. P.), C:iHoCH2N02, is an
.ester of carbamic acid and obtained by the
reaction of alcohol upon urea or one of
its salts. It occurs in columnar colorless
crystals or scales, having a faint, peculiar
odor, and a cooling saline taste like salt-
peter. It is soluble in less than its own
weight of water, 0.6 part of alcohol, 1
part of ether, L3 parts of chloroform,
and 3 parts of glycern. It is incompatible
with alkalies, acids, antipyrin, butyl-
chloral hydrate, camphor, carbolic acid,
euphorin, menthol, betanaphthol, resor-
cinol, salol, or thymol, in trituration.
■ As a sedative it is given in doses of
from 10 to 20 grains (0.6 to 1.3 Gm), in
powder, capsule, or solution, one to four
times daily, as a hypnotic, 30 to 45 grains
(2 to 3 Gm), in 3 portions at one-half to
one hour intervals, in 10 per cent, solu-
tion. The maximum single dose is 75
grains (5 Gm); the maximum daily dose
is 150 grains (10 Gm).
PHYSIOLOGICAL EFFECTS.— Ethyl
carljamate is a hypnotic resembling paral-
dehyde in its physiological action, but
lacks its unpleasant taste and odor. When
effective the sleep produced is quiet and
tranquil, and generally without depression
or other unpleasant after-effects.
POISONING BY URETHANE.—
When given in overdose urethane causes
distinct depression of the respiratory cen-
ters, the heart, and the spinal cord. Death
from a fatal dose is due to asphyxia.
Treatment of Poisoning. — The treatment
for poisoning by this drug is the same as
that recommended for paraldehyde poison-
ing (vii, 301): atropine, strong coffee,
electricity and respiratory stimulants.
THERAPEUTIC USES.— Urethane is
employed for its hypnotic, antispasmodic,
or sedative effects in nervous or functional
insomnia, eclampsia, nervous excitement,
tetanus, and as antidote in poisoning by
strychnine, resorcinol, or picrotoxin. W.
URETHRA. See Urinary and
Genital Systems, Surgical Diseases
OF.
URINALYSIS. See Index under
titles of various abnormal conditions
of urine : Albuminuria, Lactosuria,
Tyrosinuria, etc.
URINARY AND GENITAL
SYSTEMS, SURGICAL DIS-
EASES OF.— DISEASES OF THE
URETHRA.
ANOMALIES OF THE URETHRA.
— Congenital occlusion and entire absence
of the urethra are very rare. Occlusion is
usually due to a thin membrane, which
may be broken through with a bougie or
trocar and cannula. If firmer, it may be
divided with an appropriate knife (teno-
tome), or by external incision, either with
or without suprapubic cystotomy and re-
trograde catheterism, according to its
situation and extent.
Transplantation of mucous membrane
from the cheek may be tried to make
good the defect in the urethral lining.
Congenital stricture of the urethra is
relatively common, occurring chiefly at
the meatus, rarely in the membranous
urethra. The latter type is treated in the
same manner as acquired stricture. Stric-
ture at the meatus in exceptional cases
induces reflex symptoins of irritation or
the manifestations of urinary retention,
and is treated by meatotomy. After suit-
able cleansing of the parts, a Mo-grain
(0.006 Gm.) tablet of cocaine is placed in
the recess behind the strictured meatus
and dissolved with a drop or two of adre-
nalin solution. When blanching follows,
the membrane is cut with a blunt-pointed
bistoury and a packing of cotton dusted
with glutol inserted.
Urethral pouches, usually just behind
680
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
the glans, distending during micturition
and causing subsequent dribbling, are oc-
casionall}- noted, and may be remedied by-
removal of the redundant tissues and su-
ture ol the mucous membrane and skin.
EPISPADIAS.— Epispadias, or absence
of the roof of the uretlira, is occasionally
met with. It may be either complete or
partial. In the former variety the entire
roof is absent and there is also exstrophy
or absence of the anterior wall of the
bladder and the overlying portions of ab-
dominal wall, resulting in complete incon-
tinence of urine.
Treatment. — In partial epispadias of
suhicient extent to demand relief closure
of the defect by operation is indicated. If
there is plenty of material the edges may
be freshened and brought together over
a catheter by means of sutures. If not, a
flap may be taken from the anterior ab-
dominal wall and turned downward to
form the new roof of the urethra. If
necessary, the penis may be first straight-
ened by making one or more' deep trans-
verse incisions across its dorsum, each of
which is then sutured so that its ends are
approximated.
Thiersch's operation is performed in
four stages. The first is the formation of
that portion of the canal which normally
is situated in the glans. The second stage
is the formation of the remainder of the
roof of the urethra, two flaps of suitable
length being made from the integument
on the dorsum of the penis. The third
step is intended to* close the small space
between the two previous operations.
The fourth step consists in closing the
space between the posterior portion of
the new urethra and the orifice leading to
the bladder.
Enough time should be allowed between
each of these steps for perfect healing.
The operation is generally not immedi-
ately successful throughout, fistulse often
forming and portions of the flaps failing
to unite, so that the total period of treat-
ment is frequently prolonged.
The method of operating for exstrophy
of the bladder is described under that
heading.
HYPOSPADIAS.— This is a congenital
defect in which the floor of the urethra
is absent. According to Bouisson it oc-
curs in 1 out of every 300 males. It is
usually associated with downward curva-
ture of the penis. The deficiency may be
small or large, the cases being grouped,
according to the position of the urethral
orilice, into (1) balanic, with the meatus
at the base of the glans; (2) penile, with
the meatus at any point along the pen-
dulous urethra; (3) perineal, with the
meatus in the perineum.
The cause of hypospadias is arrest of
development. The diagnosis is readily
made upon inspection.
Treatment. — It is usually unnecessary
to interfere in cases of the balanic variety.
In the other cases the treatment con-
sists in straightening the organ and form-
ing a proper canal. The former is accom-
plished b}' making one or more trans-
verse incisions through the skin and any
bands of tissue which tend to hold the
organ in the abnormal position. It is oc-
casionally necessary to carry the incision
into the corpora cavernosa. The in-
cisions should be united by sutures in
a longitudinal direction, the long axis
of the wound being thus at right angles
to the line of the original incision. The
penis is to be held by dressings upward
against the body until the next step in the
operation is to be carried out.
According to the method of Nove-
Josserand, a stout probe, then a catheter,
are passed beneath the skin from the
hypospadic meatus to the glans and
through the latter. The new urethral
canal is formed by wrapping an Oilier
skin-graft, 4 cm. wide, from the inner
side of the thigh, outside in around the
catheter, passing it under the skin already
raised, and holding it in place with
sutures of 00 catgut. In the Rochet
modification of this operation an elon-
gated flap from the scrotum, with its nar-
row base at the hypospadic opening is
wrapped outside in round the catheter in-
stead of the Oilier graft.
In some cases where the defect is in
the anterior half of the urethra, it will
be found advisable to make use of the
redundant prepuce. An incision is made
through both layers of the prepuce on
the dorsum close to the corona. The
glans is slipped through this incision, the
2 layers of the transposed hood of dorsal
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
681
prepuce separated, beginning- at its cut
edge, and the raw surface thus formed
made to cover over that which resulted
from turning flaps over a catheter to form
a new urethra (Wood's operation).
Beck's operation, at times em-
ployed where correction of a balanic
hypospadias is insisted upon by the
patient, consists in liberating the
urethra for some distance behind the
orifice, pulling it forward through a
channel punched in the glans, and
sewing it to the apex of the latter.
INJURIES OF THE URETHRA.—
Wounds of the urethra may be produced
from without or within. Incised wounds
from without, if longitudinal, heal read-
ily. If transverse, there is much bleeding
and the proximal end, in case of complete
section, retracts. The divided ends should
be secured and apposed with interrupted
catgut sutures % inch apart and not pass-
ing through the urethral epithelium. Sub-
sequent continuous catheterization for
several days is indicated, with frequent
antiseptic irrigations of the urethra and
bladder.
Punctured wounds from without will
probalily require a permanent rubber
catheter for some days and a lead-water
and alcohol dressing over the external
wound. Full-sized urethral bougies should
later be passed at intervals to prevent
undue scar contraction.
Lacerated wounds from without, involv-
ing the urethra, require a permanent cath-
eter. The urethra should 1)e united over
this with fine catgut sutures if possible.
The external wound should be allowed to
heal by granulation usually. Exception-
ally, clean wounds in favorable condition
may be closed by primary suture. Careful
suturing of the urethra will do much to
prevent stricture formation. At the end
of a week or ten days the catheter may
be removed, after which a 'steel bougie
should be introduced at regular intervals.
Injuries of the urethra produced from
vi^ithin — usually false passages caused by
attempts at passing metal instruments in
cases of stricture — rccjuire mild antiseptic
irrigations of the urethra (1 to 200(1 pro-
targol or 1 to 6000 potassium perman-
ganate solution) and the internal use of
urinary antiseptics.
RUPTURE OF THE URETHRA.
— This occurs chiefly either behind
an old tight stricture or from a fall in
which the patient alights astride
some sharp object, -such as the edge
of a board or a rail. Occasionally it
results from fracture or disjunction
of the pubic bones, "breaking" chor-
dee, or some other form of trauma-
tism.
Symptoms. — In cases due to stric-
ture a small, painful swelling will
usually appear at some point along
the urethra. This may form an ab-
scess, or may give rise to a rapidly
spreading cellulitis, with the usual
signs of inflammation. Upon inquiry
it will be found that the stream of
urine has been gradually diminishing
in size, and that it has been passed
with increasing difficulty. There may
be complete retention.
Rupture of the urethra from alight-
ing astride, a sharp object or from in-
jury of the pubes occurs in the mem-
branous portion ; from "breaking"
chordee or other rare forms of
trauma, in the pendulous portion.
Pain, hemorrhage, and retention of
urine are the common symptoms in
these cases. Swelling and ecchy-
mosis may or may not exist, depend-
ing at first upon the nature of the
accident and later upon whether
there is extravasation of urine or not.
There may be immediate perineal
swelling due to extravasated blood.
The pain is usually not severe. Bleed-
ing from rupture in the pendulous
urethra always appears at the meatus.
That from the nicmbrancms urethra
may also appear at the meatus or flow
1)ack into the bladder and lead to
hematuria. In rupture of the pos-
682 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
terior urethra both bleeding- from the small or medium size, after thorough
meatus and perineal swelling- may be cleansing f)f the glans and prepuce,
absent. Complete retention of urine The catheter, previously boiled,
may immediately follow the accident, should be connected with a fountain-
due ta extensive laceration, or occur syringe containing an antiseptic solu-
after some hours, as a result of tion, then oiled in carbolized vaselin
swelling and blood-clot. If the case or other suitable lubricant, the solu-
is not seen early, and a permanent tion permitted to pass for a moment,
catheter introduced, extravasation of and finally, the catheter slowly and
urine will probaly occur at the point very gently introduced, the fluid
of rupture, with rapidly spreading flowing meanwhile. The urethra is
cellulitis. thus thoroughly irrigated, the fluid
In all forms of urethral rupture, a escaping around the catheter. Among
subsequent traumatic stricture is al- appropriate antiseptic fluids are:
most inevitable. The mortality from potassium permanganate, 1 : 5000 ; bi-
the condition is, however, relatively chloride of mercury, 1 : 10.000 ; phenol
low, Terrillon reporting 12 deaths 1 : 500, and boric acid, 10 or 15 grains
among 170 cases. to the ounce of sterile water. If the
Treatment. — In suspected rupture catheter passes into the bladder
of the urethra, the parts should be easily, the urine should be witiidrawn
inspected for any external evidences with it every six or eight hours. If
of injury. Inquiry should be made the catheter passes only with diffi-
as to the appearance of blood at culty and after repeated efiforts, it
the meatus and as to whether urine should be allowed to remain, securely
has been voided. In the milder held by any appropriate means. If it
form of rupture of the pendulous fails to pass the point of rupture,
urethra, giving rise to merely a other sizes or forms may be tried,
sharp pain, slight bleeding, and a few The Nelaton catheter is very useful,
painful micturitions, expectant treat- the point being kept on the roof of
ment is indicated. The patient should the urethra, which in partial tears is
be put to bed, purgation instituted, less apt to be involved than is the
hexamethylenamine given internally, floor. If a catheter enters the bladder
and 3 to 5 c.c. (48 to 80 minims) of it should be allowed to remain,
1 : 2000 silver nitrate or 1 : 1000 pro- If no catheter whatever will pass
targol solution injected into the an- into the bladder, a metal bougie or
terior urethra twice a day, catheter- other firm instrument should be in-
ization being avoided unless dysuria troduced until it is arrested. Its
or retention of urine demand it. The point should then be exposed (this
subsequent scar contraction, gen- may be done under local anesthesia)
erally starting six weeks after the in- by a median incision, thus guiding
jury, will later require treatment. the operator to' the distal end of the
In more severe cases, with consid- torn canal. The proximal end should
erable bleeding, interference with then be sought. When found, a soft-
urination, and a decided hematoma, rubber catheter should be passed
an attempt should be made to pass an into the bladder from the meatus, and
elbowed or soft-rubber catheter of the divided urethra sutured with fine,
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
683
chromicized catgut, if at all possible.
In seeking the proximal end of the
urethra, very careful search should
be made in the wound before doing
much dissecting, as this would add toi
the difficulty of locating it. When
the usual means fail, suprapubic pres-
sure wnll frequently cause urine to
exude and thus indicate the urethra.
The external wound should be united
by sutures if conditions permit, drain-
age being introduced if necessary.
A catheter retained in the bladder
should be kept clean by irrigation
through and around it with boric acid
or other mild antiseptic solution. It
may be remolded in from five to ten
days, depending upon the extent of
the injury. Subsequently steel
sounds should be very gently passe-d
every second day, gradually using
larger sizes until the full caliber for
the particular patient has been
reached. After the wound has healed
firmly the bougies must be continued,
at first once a week ; later, once a
month, then with diminishinug fre-
quency for one or two years. In all
cases a tendency to stricture forma-
tion persists throughout life, neces-
sitating occasional use of the bougie
indefinitely.
During the early treatment, with
or without operation, the wound
should be frequently examined to
detect the earliest evidences of infil-
tration of urine if this should occur.
This would indicate that the catheter
was not efficiently draining the blad-
der. Extravasation, with swelling,
pain, and heat, requires early and free
incisions and frequent antiseptic irri-
gations and dressings.
According to Guyon and others.
immediate external urethrotomy and
suture are indicated in all cases of
perineal rupture as well as in severe
injuries of the -pendulous urethra, the
ultimate results of suture being- much
superior to those -of continuous cathe-
terization. Where the loss of tissue
has been too great to permit of
suture, a perineal tube may be used
for a few days, followed by perma-
nent catheterization from meatus to
l)ladder and later, if necessary, by a
secondary operation for fistula closure.
Report of 3 cases in which a per-
meable channel was constructed after
severe war wound of the urethra. A
strip of vaginal mucosa from a pa-
tient subjected to colpoperineor-
rliaphy was wound around a bougie,
raw surface out, fixed in place with
fine silk, and introduced into a tun-
nel made for it in the subcutaneous
tissues. Dilatation was 1)egun on the
seventh or eighth day. Success com-
plete in 2 cases and fair in the third.
Legueu (Paris med.. June 1, 1918).
FOREIGN BODIES AND CALCULI
IN THE URETHRA.— Symptoms.— May
be absent, or be manifest as severe pain,
hemorrhage, and retention of urine. Un-
removed foreign bodies may form nuclei
for stones in the urethra or bladder, or
may excite urethritis and become encysted
or ulcerate through, fistula and later stric-
ture resulting. Urethral calculi may ex-
cite symptoms gradually — slight gleet, dy-
suria, and finally i)criurcthritis and fistula
formation.
Diagnosis. — External palpation may be
supplemented by gentle searching with
a sound, with pressure on the outside to
keep the body from entering deeper, and
by examination with a finger in the
rectum.
Treatment. — Foreign bodies can some-
times be removed by injecting oil into
the meatus, s(|ueezing the latter shut,
having the patient attempt micturition,
and letting the meatus open when the
urethra has become distended. A soft,
long body may be extracted by repeatedly
pushing the urethra back over it like a
glove finger, thus gradually working it
out; repeated transfixion of the body
684
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
through the urethra with a needle may be
necessary to afford the required purchase
on it. This method failing, a wire loop or
long urethral forceps may be tried. IMns
situated with their points outward can be
removed by pushing their shaft through
the urethra until the position of the head
can l)e reversed, when the pin is pushed
out of the meatus head foremost. In
cases of stricture meatotomy, urethrotomy
or continuous dilatation of the urethra
may have to be performed before extrac-
tion with forceps becomes possible. If all
these maneuvers p.rove unsuccessful, peri-
neal section will be- required. In cases of
acute trouble from a calculus lodged in
the posterior urethra, the stone can some-
times be pushed back into the bladder.
GONORRHEA..— DEFINITION.
— A contagious, specific inflammation,
of the mucous membrane of the
urethra or vagina, accompanied by a
mucopurulent discharge, and due to
infection with the gonococcus, first
described by Neisser.
In involvement .of the urethral
canal the condition is termed gono-
coccal urethritis. The disease may
also be communicated to other, mu-
cous surfaces, most frequently the
conjunctiva (see Conjunctiva, Dis-
eases of), and occasionally the rec-
tum.
Inflammation of the urethra may
result from causes other than the
gonococcus, as described under the
succeeding heading.
Gonorrhea usually results from
sexual intercourse v^ith a person suf-
fering from the disease. It may be
transmitted in. occasional instances
by means of contaminated towels or
clothing, etc.
SYMPTOMS.— Acute Gonococcal
Urethritis. — The commonest example
of gonorrhea is that of the urethra in
the male. The disease usually mani-
fesf? '>'-(-! f ^^■ithin three to five days
after the intercourse. The first symp-
tom is an irritation of the meatus,
which becomes swollen and of a
deeper' red color than normal, and
shows a slight, thin, whitish dis-
charge. Urination usually causes
considerable local' .smarting. The in-
flammation then extends backward
and rapidly becomes more intense" so
that in twenty-four to forty-eight
hours the discharge has become pro-
fuse, thick, yellowish, and, in the
se^verer cases, tinged with blood.
Pain in urinating is very intense
(ardor nrincc). The patient has ob-
stinate erections, especially at night,
accompanied by severe pain. The
characteristic phenomena know^n as
chordec consists in a downward bend-
ing of the organ during erection due
to loss of elasticity of the inflamed
urethra, the corpora cavernosa mean-
while distending and elongating as
usual ; when this occurs the pain is
especially severe.
Symptoms of acute posterior ure-
thritis develop in a large percentage
of initial gonorrheal infections, and
appear usually between the fifth an'd
the fifteenth days. The patient is
obliged to urinate at very short in-
tervals, and pain is experienced espe-
cially at the close of micturition.
Swelling of the mucous membrane
and periurethral tissues may be so
marked as to greatly reduce the
stream of urine. Blood may run
from the urethra at the end of urina-
tion, and intense perineal pain may
result from the pronounced tenesmus.
Subsidence of the urethritis starts,
in the second or third week, at the
meatus. Decline in the remainder of
the anterior urethra begins about a
week later, and in the posterior ure-
thra very soon after. Gonococci and
URINARY AND. GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
685
a slight purulent discharge often per-
sists eight to. twelve weeks, though
they may disappear in six.
The severity of each symptom
varies widely in different cases. The
first attack of gonorrhea nearly al-
ways causes more severe symptoms
than subsequent attacks. A person
who has once had gonorrhea, how-
ever, seems predisposed to urethral
irritation or inflammation, doubtless
induced by infectious or other causes
so mild that a healthy urethra" would
remain unaffected. In this so-called
subacute or catarrhal type of gonor-
rhea the chief symptom is the dis-
charge, which is more watery than in
the acute severe form. Gonococci and
pus cells, often with a mixed infec-
tion, are to be found in relatively
small numbers. Slight irritation on
passing urine may coexist. Under
treatment the discharge is soon re-
duced to the "morning drop."
Chronic Gonococcal Urethritis. —
Gonorrhea persisting longer than
three months is arbitrarily considered
as chronic, even though, it be inter-
rupted by .acute exacerbations. It
usually results from persistence of
gonococci in the urethral lesions, yet
other bacteria may alone be pres-
ent {postgonococcic chronic urethritis).
Chronic anterior urethritis is mani-
fested merely in a. purulent, semi-
purulent, or mucoid discharge (gleet)
which may be intermittent. A sense
of moisture about the metaus, or a
gluing together of its lips in the
morning, may alone be noticed. The
so-called "clap shreds," however, are
likely to occur in the urine. Chronic
posterior urethritis, according to
many, is practically synonymous with
chronic prostatitis, the two condi-
tions being clinically rarely distin-
guishable, and the latter almost al-
ways complicating the former. The
symptoms include urethral discharge ;
disturbances of urinia.tion, e.g., abnor-
mal frequency or urgency, pain, slow-
ness in starting or finishing, obstruc-
tion) ; the presence of clap-shreds in
the second glass in the 2-glass test ;
reflex discomfort or pain along the
penile urethra or in the perineum or
back, and occasionally disturbances
of the sexual function.
DIAGNOSIS.— A red and swollen
meatus, with a whitish discharge,
affords very suggestive — and pro-
nounced swelling, with ardor urince
and chordee, almost conclusive — evi-
dence of acute gonococcal urethritis.
A positive diagnosis is made, how-
ever, only by finding gonococci in the
discharge. This is effected as fol-
lows : A thin film of pus in a clean
slide or cover-glass is dried at a
gentle heat and fixed by passing
quickly 3 times' through an alcohol or
gas flame. Paltauf's solution [aniline
oil, 3 parts; absolute alcohol, 7 parts;
•distilled water, 90 parts ; shake to-
gether for two minutes, filter till
clear, and add 2 parts of Griibler's
powdered gentian violet] is now ap-
plied for three minutes, the excess
shaken off and the slide blotted, and
Lugol's solution [iodine, 1 ; potassium
iodide, 2; distilled water, 300] ap-
plied for exactly two minutes. The
preparation is then washed with ab-
solute alcohol for exactly ^^ minute,
and counterstained with Bismarck
brown [phenol, 2; saturated watery
solution of Bismarck brown, 98] for
three to five minutes. Examined
microscopically under a "J/io oil im-
mersion objective, the gonococci —
coffee-bean shaped and occurring
both intra- and extra- cellularlv in
(386 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
pairs, fours, or other multiples of 2— COMPLICATIONS.— Acute an-
will exliil)it a lig-ht-brown tint (bein^ terior g-onococcal urethritis may be
negative to Gram's test, i.e., decolor- complicated by periurethral abscess,
ized by the Lugol solution), while due to the bursting outward of an
the pseudogqnococci (positive to abscessed urethral gland. The fistula
Gram's) will show- a deep-purple, al- resulting from its rupture at the sur-
most black color. face usually heals spontaneously.
Culture of the gonococcus, carried IJalanoposthitis, apparently due to
out on a slightly alkaline medium mixed infection, may develop in per-
containing human blood-serum, is sons with a long or tight prepuce, but
rarely necessary in the diagnosis of yields easily to the customary meas-
urethritis. ures (see Penis, Diseases of).
In addition to the examination for Acute posterior urethritis may be
gonococci, the diagnostic study in complicated by acute prostatitis
acute urethritis may appropriately in- Avhich, however, hardly excites any
elude the 2-glass test, cloudy urine symptoms, unless suppuration is al-
in both glasses signifying posterior ready beginning^ (see Abscess of the
urethritis, while if only the first is Prostate). A mild trigonitis, as a
cloudy, posterior involvement may be rule, coexists. Seminal vesiculitis
absent. In chronic urethritis, the and epididymitis may also develop
urethra may in addition be examined (see Diseases of the Seminal Vesi-
for periurethral nodules or stricture, cles and Diseases of the Penis and
the testicles for epididymitis, and any Te.sticles). Pyelonephritis and peri-
secretion expressed l)y massage from tonitis are very rare complications of
the prostate and seminal vesicles, for gonorrhea in the male,
gonococci. Infiltrations of the an- The chief complication of chronic
terior urethra may be detected with a anterior urethritis is stricture, herein-
well-lubricated No. 24 or 26 F. bul- after to be discussed. Follicular ab-
bous bougie. Accurate diagnoses of scesses or abscesses of Cowper's
the conditions existing in special por- glands may also be noted as shot-like
tions of the urethra may be made nodules along the urethra, suppurat-
with one of the various forms of ing and keeping up a slight discharge
urethroscope adapted for examination for prolonged periods,
of the anterior urethra or the S\vin- Chronic gonococcal urethritis is in
burne instrument, which illuminates the majority of cases complicated by
the floor of the posterior urethra. chronic prostatitis; chronic seminal
The gonococcus complement-fixation vesiculitis is frequently added to the
test, while conclusive when positive, latter disorder.
is often negative in acute and sub- PROPHYLAXIS. — Relative safety
acute urethritis. It is chiefly of value after infective intercourse may be se-
in gonococcal arthritis, in pelvic in- cured by immediate urination and
volvements in women, in the vagini- washing with soap and water, fol-
tis of female children, and in deter- lowed by injection of a 20 per cent.
mining whether gonococcal infection argyrol or 1 per cent, protargol solu-
has been eradicated in chronic ure- tion, to be retained five minutes,
thritis. Such an injection must be made
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
68;
within twelve hours if good chances
of success are desired.
ABORTIVE TREATMENT.— Ill
theory the abortive treatment of
gonorrhea is ideal. It is successful,
ho.wever, only in the very earliest
manifestations of the disease, and in
^-practice patients are rarely seen at
this stage. After the gonococci have
penetrated beneath the superficial lay-
ers of the epithelium, and the symp-
toms are well marked, this method
should not be used. In adopting it,
the surgeon should be guided to some
extent b}^ the patient's wishes. There
are cases in which it is imperative to
cut the' disease short. It should be
explained that the abortive treatment
will be followed by considerable in-
flammatory reaction, and that it may
fail to arrest the disease.
Given, therefore, a patient present-
ing himself within one toi three days
after exposure, with sligiit irritation
at the meatus and a scant, watery
discharge, the advantages and disad-
vantages 'of the abortive treatment
should be fairly presented, and, if he
so elects, the surgeon is justified in
carrying out this method. The
technique is as follows : The patient
urinates,, the anterior urethra is
washed out with sterile water or
boric acid solution, 10 drops of a 4
per cent, solution of beta-eucaine are
injected, and a solution of silver
nitrate, 20 grains (1.3 Gm.) to the
ounce of distilled water, is applied to
the first inch and a half or so of the
urethra, either with a French pointed
urethral syringe or a cotton swab in-
troduced through an endoscope. The
patient is then treated as for the early
stages of acute gonorrhea. All the
symptoms of acute anterior urethritis
develop rapidly, and in successful
cases they gradually subside and dis-
appear in a few days. In unsuccess-
ful cases the disease runs the usual
course.
Instead of this single, powerful ap-
plication, frequent, copious irriga-
tions of the anterior urethra with
potassium permanganate, 1 : 2000 ;
mercury bichloride, 1 : 5000 ; or silver
nitrate, 1 : 1000 may be employed.
By this method the patient is spared
the discomforts of the more active
treatment, but success is less likely.
Intermediate between the 2 meth-
ods is the injection, after local anes-
thetization of 1 dram (4 c.c.) of a 5-
grain (0.3 Gm.) to the ounce (30 c.c.)
solution of protargol, to be retained
three minutes. The injection is re-
peated regularly every two hours, the
1-ounce bottle being filled to the top
with distilled water every time it be-
comes half empty, thus gradually re-
ducing the strength of solution in-
jected.
If any of these methods has been
tried and has failed, the following
routine treatment should be carried
out : —
REPRESSIVE TREATMENT.—
In the most severe cases, with
high-grade inflammation, profuse dis-
charge, ardor iirincc, and chordee, it is
very desirable to have the patient go
to bed, or at least to be as quiet as
possible. A light diet should be
ordered, consisting largely of milk,
with l:)read, potatoes, well-boiled rice,
and similar plain farinaceous foods.
Greasy and highly seasoned articles,
cofiFee and tea, asparagus, tomatoes,
salad dressings, acid fruits, and pas-
trv must especially be shunned.
Water should be taken freely. The
bowels should be kept rather freely
open with small doses of some saline
688 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
laxative, repeated as often as neces- the "compound salol capsule" of J.
sary. The use of alcohol should be W. White, containing- phenyl salicy-
forbidden. Sexual excitement is late and oleoresin of cubebs, of each,
harmful, and coitus must be posi- 5 strains (0.3 Gm.) ; Para balsam of
tively interdicted. The urethral dis- copaiba, 10 grains (0.6 Gm.) ; and pep-
charge should be received on a small sin, 1 grain (0.06 Gm.). Four to 6 of
piece of absorbent cotton held in these capsules are given daily after
])lace by a gonorrhea apron, or simi- meals. Capsules of either cubebs or
lar device, and the glans and prepuce copaiba, or of the two in combina-
bathed frequently with soap and tion, may be given, and in the more
warm water, both for cleanliness and chronic stages the oil of sandalwood,
to avoid balanoposthitis. Great care 10 to 20 minims (0.6 to 1.2 c.c.) after
must be observed in disposing of the each meal, is efificient.
soiled cotton, totvcls, and all other Locally, cleanliness secured by fre-
articles contaminated zvith the dis- quent bathing and suitable means to
charge, and the hands should be most receive the discharge is very desir-
carcfnlly ivashed after each dressing, able. Rubber covers and bulky dress-
as gonorrheal pus, if transferred to ings that macerate the parts are ob-
the eye in any manner, excites violent jectionable. A small pledget of anti-
inflammation, septic absorbent cotton, held in place
Gonorrhea is a local disease, and by the prepuce, forms a good dress-
must be treated largely locally. In- ing. A bag of some thin material,
ternal remedies are of use, however: fastened round the loins, is of assist-
(1) to render the urine: neutral or ance for additional support. If urina-
faintly alkaline, and hence less irri- tion is accompanied by severe pain,
tating; (2) to increase the flow of great relief will be secured by im-
urine ; and (3) to allay irritation of mersing the penis in a vessel of water
the urinary tract by sedative drugs, as hot as can be borne comfortably
Liquor potassae meets the first indica- during the act -of passing wate'r.
tion, given in doses of 10 minims Urethral injections or irrigations
(0.6 c.c), fireely diluted, 4 to 6 times may be employed from the beginning
a day. Potassium citrate fills both of the disease. Certain points must
the first and second indications. The be kept in mind in this connection :
dose is 20 grains (1.3' Gm.) in half a 1. Nothing is to be introduced into
glass of water every two to four the urethra until it has been cleansed
hours. With either of these may be by passing urine. 2. The solutions
combined sweet spirit of nitre if there used in the early stages must be ex-
is fever, and potassium bromide to ceedingly mild unless abortive treat-
lessen nervous excitability. The ment is attempted. 3. In the begin-
tiiird indication cannot well be met ning the injection is confined to the
when the urethritis is very acute, first inch or two of the urethra. In
When the severity of the inflamma- high grades of inflammation the solu-
tory symptoms has passed ofi^, how- tions should be slightly alkaline, and
ever, cubebs, copaiba, or sandalwood used as warm as can be borne. Any
oil may be administered with advan- application that causes severe or pro-
tage. A satisfactory combination is longed pain or smarting is harmful.
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
689
In an acute case the injection may be
of potassium permanganate, 1 : 10,000
to 1 : 5000 in normal salt solution, as
in the following formula : —
B Potassii permangana-
tis gr. ss-j (0.03-0.06 Gm.).
Sodii chloridi 3ss (2 Gm.).
Aqua destillatce f^xj (330 c.c.) .
M. Sig. : Use four to six times daily, as
directed.
increased, according- to tolerance,
from 1 : 6000 to 1 : 2000. No solution
stronger than the latter should be al-
lowed to* enter the bladder.
When the posterior urethra be-
comes acutely involved (in about 90
per cent, of cases — Keyes) hand injec-
tions 4-estricted to the anterior urethra
should be stopped, the treatment be-
ing confined to copious irrigations
Such injections may be carried out with relatively weak solutions, e.g.,
by the patient himself, previously in- 1 : 10,000 permanganate to begin with,
structed in their technique by the sur- According to some the organic
geon, by means of a blunt-pointed silver salts are preferable to potas-
hard-rubber urethral syringe, holding sium permanganate, causing a greater
at least ^ fluidounce (15 c.c.) or a reduction in the proportion of subse-
soft rubber bulb with conical point. quent chronic gonorrheas. Keyes,
A similar solution may be employed ("■(/■, generally uses 10 per cent,
to "irrigate" the urethra. To a pint argyrol, of which the patient injected
(500 c.c.) of distilled water may be 2 drams (8 c.c.) 3 or 4 times daily to
added from ^ to 1^ grains (0.05 to be retained ten minutes. After the
0.1 Gm.) of potassium permanganate first few days the treatment is con-
and 45 grains (3 Gm.) of sodium trolled by daily examinations of the
chloride, the solution warmed, and discharge for gonococci, the injec-
placed in a fountain-syringe to which
a urethral nozzle is attached by rub-
ber tubing. The reservoir should be
2 feet above the pubes. Urine having
first been passed, the solution is al-
tions being temporarily stopped if
evidences of undue irritation appear.
If pus shows in the second urine, the
anterior urethritis having already
been well controlled, posterior instil-
lowed to run, and the conical nozzle lations once or twice a day 1 c.c. (16
fixed firmly in the meatus. As soon minims) of 20 per cent, argyrol or
as the anterior urethra is distended 0.5 c.c. (8 minims) of 0.5 per cent,
the nozzle is removed and the urethra protargol, or gentle posterior irriga-
allowed to empty itself. This is re- tions once a day with 1 : 2000 protar-
peated until the pint of solution is all gol or 1 per cent, argyrol are carried
used. The solution should be used as out.
warm as can be comfortably borne,
and the reservoir elevated 2 or 3 feet
if only the anterior urethra is to be
irrigated ; 4 or 5 feet if also the pos-
terior (the resistance of the com-
pressor urethrse having to be over-
Pain in micturition is best treated
by rendering the urine slightly alka-
line and by drinking water very
freely.
For the relief of painful erections
or chordee, the patient should be in-
come, that the solution may enter and structed to empty the bladder just
fill the bladder). The irrigations may before retiring for the night, and to
be given twice, later once, a day, the 1)c awakened by an alarm clock at the
strength of solution being gradually end of three or four hours for the
8—44
690 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
same purpose. He should sleep upon pain. Durint^ this period one of the
a hard mattress, with but lii^ht cover- capsules already alluded to should be
ing-, and should avoid lying- upon the given.
back. A hot bath before retiring As the discharge diminishes, the in-
will tend markedly to reduce the local jections may be made stronger and
congestion. In the daytime hot 5- more astringent. Any of the follow-
minute sitz baths or a hot-water bag ing may be employed : Zinc sulphate,
to the perineum may be ordered, lead acetate, or alum, 1 to 5 grains
Bromides may be given in full doses. (0.06 to 0.3 Gm.) to the ounce (30
and in the more severe cases chloral c.c.) of water; glycerite of tannic
hydrate or opium. A suppository of acid, 10 to 30 minims (0.6 to 2 c.c.) to
opium, belladonna, and monobro- the ounce ; and fluidextract of hy-
mated camphor may be administered drastis, 5 to 10 minims (0.3 to 0.6 c.c.)
at bedtime, for severe pain only. If to the ounce, using the milder
a painful erection occurs, the patient strength first, and gradually increas-
should arise and apply cold locally, ing the proportion. Various com-
Rarely heat gives greater relief. Cold binations of these drug's may often be
applications to the spine are also made with advantage. The Brou as-
sometimes efficient. tringent injection is an efficacious
Such is the routine treatment dur- combination: —
ing the first few days in the cases ij Ziiici siilphatis gr. xv (1 Gm.).
with very acute symptoms, ^^'hen Plumbi acetatis gr. xx (1.3 Gm.).
these subside, or when from the be- Tinctnra- oM',
ginning the symptoms are subacute ^'"^'"'-^^ ,a,nhir..^^ fjij (8 ex.).
^^ . /^ , , , V ^ Aqiice q. s. ad fSvj (180 c.c).
the mjections may be made somewhat ^
stron*^er ^ c/..' —
'^ ' .. When the discharge becomes very
U Potassn permanga- ^ . . . .
natis gr. ss-j (0.03-0.06 Gm.). scant and watery, the mjections be-
Acidi borici 3j-iss (4-6 Gm.). ing made less often, although the
Aqiice destillata f5vj (180 c.c). strength may be cautiously increased.
M. Sig.: Use as an injection four times j,^^^^ occurring during gonorrhea
a day after urination. ^^^^^^^^ J^^ ^^^^^^^ ^^^ applications of
An injection such as the followmg tincture of iodine or ichthyol, a spica
is useful in a large proportion of cases bandage, and rest. If suppuration
at this stage : follows, aspiration or incision is in-
I^ Hydrargyri chloridi dicated
rorromw .gr-i/ia-Ve (0.005-0.01 Gm.). . " , , , , r i
^. . ,, 7 ,^, Among the last traces of gonorrhea
Zmci plioiolsnlpho- ^ ^
natis gr. xxiv-xxx (1.5-2 Gm.). to disappear is a drop of discharge or
Phenolis gr. x-xij (0.6-0.8 Gm.). an undue moisture, observed at the
Glyceriti boroglyc- meatus on rising in the morning.
eriiii (25 per ct.) . fSii (60 c.c). c-i j r -i.! i- i
,^ .,, ^ Shreds of epithelium may, however,
Aquce destillatcc, q. s. . ' . -^
3^ fjyj (180 c.c). continue m the urine for some time
(White.) After the patient appears to be
This is to be used in the same man- well, his habits should be guarded for
ner as the previous prescription. It a few weeks, as the discharge may
may be diluted at first if it causes recur from sexual excess, overindul-
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
691
gence in alcohol, etc. In some in-
stances in the subsiding- stage the dis-
charge seems kept up by excessive
treatment. This should be guarded
against.
Presumptive evidence of complete
cure of gonococcal urethritis is ob-
tainable clinically and positive evi-
dence bacteriologically. Gonococci
have probably disappeared when mas-
sage of the prostate and vesicles, 3
glasses of beer, and dilatation with a
Kollmann dilator or full-size sound
at 2-day intervals fail to cause a
discharge ; when no* reinfection has
occurred in three years, or where epi-
thelial cells predominate over pus-
cells in the discharge and centrifu-
gated urinary sediment. Shreds in
the urine do not necessarily imply
gonococci. A sparkling urine and
absence of discharge and all symp-
toms for a month indicate a cure.
Positive bacteriological evidence in-
volves testing by stain and culture
(by a competent bacteriologist) the
discharge (if present), the centrifu-
gated urinary sediment, and the
urine passed after prostatic and
vesicular massage or the secretion
obtained from these glands. Cases
persisting for two or three months
usually have localized areas of infec-
tion in some of the urethral follicles
or pouches,, superficial ulcerations, or
even beginning stricture formations,
and call for a careful uretliral ex-
ploration.
Treatment of Chronic Gonorrhea.
— Mild cases of chronic gonorrhea are
often favorably influenced by hy-
gienic measures, general and local. A
generous, stimulating diet should be
allowed and outdoor exercise, grad-
ually increased in amount and sever-
ity as tolerance increases, encouraged.
Sexual intercourse should be inter-
dicted as long as gonococci persist in
the discharge, but after that may be
sparingly indulged in to obviate the
local congestion arising from un-
gratified sexual desire. From the
standpoint of internal treatment, free
use of alkaline mineral waters is gen-
erally alone indicated. Inquiry for
such predisposing factors as consti-
tutional disorders, marital reinfection,
congenital or acquired deformities,
and oxaluria or phosphaturia should
be made, and their correction, if pres-
ent, undertaken.
Local treatment may advantage-
ously be begun by daily injections of
astringents, such as zinc acetate. A
preparation recommended by Keyes,
consisting of zinc sulphate, 3 grains
(0.2 Gm.) and dilute lead subacetate
solution (U. S. P.), 3 fluidounces
(100 c.c.) — to be shaken up — is of
value. Intermissions should be made
every few weeks. Where gonococci
are still found in the discharge, in-
jections of protafgol may give better
results than thei astringent injec-
tions. In cases with only a slight
discharge, irrigations with 1 : 4000
(later strengthened) potassium per-
manganate solution may be substi-
tuted for the injections.
Where results from these pro-
cedures are insufficient, the urethra
should be examined with a bulbous
bougie (bougie a boule) or electric
urethroscope. The former suffices to
detect all parietal thickenings, con-
strictions, granular areas, and papil-
lomas of the anterior urethra, and
where such are found establishes the
advisabilitv of treatment l)y gradual
urethral dilatation. The latter has for
its object to encourage reabsorption
of inflammatory exudates and to
692 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
empty distended urethral inlands, and
is performed at tirst with conical
steel sounds (unless the urethral
caliber is already about 21 F.), later
with the Kollmann or Oberlander
urethral dilators. The use of the
sounds, to be passed twice weekly, is
described under Stricture of the
Urethra, in this article. Their pass-
age should be preceded by ingestion
of hexamethylenamine and followed
by intravesical irrigation with 1 : 4000
potassium permanganate. When the
largest size sound that will enter the
meatus is reached the Kollmann dila-
tor— well lubricated and sterile —
should be substituted. By its use
rapid progress can frequently be
made, without causing marked bleed-
ing or pain. Dilatation of the pos-
terior urethra is only in a certain pro-
portion of cases required ; for its prac-
tice a curved anteroposterior Koll-
mann or other dilator is necessary.
Dilatation is of -chief value when the
urine is already nearly free of pus,
and is contraindicated where the pus
still shows gonococci.
With dilatation may be combined
with advantage massage of the pros-
tate and seminal vesicles (see Dis-
orders of the Prostate and Disorders
of the Seminal Vesicles, in this
article). Where these organs are
considerably involved, indeed, mas-
sage should be started practically
from the beginning of treatment.
When massage is impracticable or
proves deleterious, daily rectal douch-
ing with hot normal saline solution
(120° F.) from a 3^-gallon receptacle
hung at an altitude of two feet,
through a double-current rectal tube
or psychrophore, may be sul)stituted.
An intermission of a few days should
be allowed from time to time, the ob-
ject being to apply heat to the pros-
tate while avoiding irritation of the
rectum.
Inhltrations of the urethral glands
and follicles, though generally cured
by the dilatation treatment, are some-
times refractory. They are best
treated through the urthroscope, elec-
trically illuminated, a 5 or 10 per cent,
solution of silver nitrate being ap-
plied directly to the affected areas,
once or twice weekly, after these have
been wiped dry of secretions. Sup-
purating follicles may be destroyed
with the electrocautery; thickened
glands, slit (i[jen with a fine bistoury,
and anv ])(>lyps found, removed with
forceps, cautery, or snare. Granular
or eroded areas should be treated
with 1 or 2 per cent, silver nitrate.
Good results in acute and chronic
gonorrheal urethritis reported from a
polyvalent vacc'ne made from a large
number of samples of the gonococ-
cus, together with other aerobic and
anaerobic germs.- The vaccine is in-
jected in the buttocks every other
day, beginning with 100 and increas-
ing to 400 millions. Urethral irriga-
tions with mercury oxycyanide are
begun after the fourth or fifth vac-
cine injection. By this method a cure
was effected in fifteen to twenty-five
days in 95 per cent, of about 300
cases. G. Baril (Bull, de I'Acad. de
med., Aug. 13, 1918).
Acriflavine found valuable in gon-
orrhea. In anterior cases, 3 c.c. (48
minims) of a 1:1000 solution were
injected, to be retained five minutes.
In posterior cases, 15 to 30 c.c. (J/j
to 1 ounce) were injected through
into the bladder, retained in the ure-
thra for five minutes and in the blad-
der till the next voiding. Injections
were given twice a day. Davis and
Harrel (Jour, of Urol., Aug., 1918).
GONORRHEA IN WOMEN.—
This affects, in the order of frequency,
the urethra, cervix, vulva, and vagina.
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 593
Urethra. — In the incubation period,
changes in the external meatus, and
appearance of the discharge, gonor-
rhea of the urethra in women is iden-
tical with that of men. There is fre-
quent urination, attended with a
scalding sensation, and the discharge
may irritate the parts contiguous to
the meatus. The bladder is apt to
become affected, owing to the very
short urethra, in which event the fre-
quency of urination and tenesmus
may be extreme.
TREATMENT.— In severe cases
much benefit will be obtained by put-
ting the patient at absolute rest. Fre-
quent bathing of the parts with water
as hot as can be borne, to which a
little sodium bicarbonate or borax
has been added, is; of assistance. In-
ternally, potassiurri citrate or bicar-
bonate, or even liquor potassae, is in-
dicated to give a faint alkaline re-
action to the urine, which should be
tested frequently and the dose of the
drug regulated according to the
effect. Water should be taken freely.
The urethra should be irrigated with
some form of reflux catheter, or with
a Nelaton catheter of small size per-
mitting- return flow round the instru-
ment. The formulae given under the
treatment of gonorrhea in the male
should be employed, and the. patient
should invariably urinate before the
irrigation. The solution should be
very weak at first, then made stronger
as the acutcness of the symptoms
subsides.
Vagina and Vulva. — Gonococcal
infection of the vagina and vulva, in-
cluding Bartholin's glands, are con-
sidered in tlic article on Vagina and
Vulva, Diseases oi\ in this volume.
Cervix. — Gonorrhea of the cervix-
is the most serious form of the dis-
ease, inasmuch as it may extend up-
ward, involving the uterus, tubes,
ovaries, and peritoneum. Nor is the
danger over when the acute symp-
toms have subsided. The disease
may remain latent in the cervix for a
long time, ready to assume fresh
virulence and spread to other struc-
tures under favorable conditions.
• SYMPTOMS.— These are variable
and by no means characteristic.
There is but a moderate amount of
discharge, which might easily escape
notice, especially in those with a pre-
vious leucorrhea. In the more severe
cases there may be a feeling of full-
ness or weight in the pelvis, increased
by exercise. Menstruation is apt to
be more frequent and profuse than
normal, and may be unusually pain-
ful. If the cervix be examined, it will
be found swollen and of a deeper red
than normal, with the os somewhat
everted, or pouting. A tenacious
secretion of mucopus will be seen
issuing from the os and bathing the
adjacent parts. The mucous mem-
brane around the os may have ex-
foliated, leaving an eroded or ulcer-
ated surface. Such conditions may
persist indefinitely.
TREATMENT.— In acute cervical
involvement, hot vaginal irrigations
with 2 per cent, boric acid solution,
Yz to 1 per cent, lysol, or 1 : 5000 or
1 : 10.000 mercury bichloride are of
value, though some object to them on
the ground that the protective acid
vaginal secretion is thus washed
away. When the acuteness of the
process is subsiding an attempt may
be made to prevent its further ascen-
sion by cleansing the cervix and os
carefully with the aid of a bivalve
specuhnn, swabbing with 1 : 2000 mer-
cury bichloride, dilating the cervix.
694 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
and destroying the mucous membrane
by curetment or pure phenol or silver
nitrate. Such active measures should,
however, l)e undertaken only by those
specially experienced, as there is dan-
ger of infectinc: the endometrium. A
milder procedure likewise of value
consists in applying- daily and later,
on alternate days, the vaginal cervix
and cervical canal — especially to any
erosions noted — tincture of iodine,
Lugol's solution, a 10 per cent, or
stronger solution of argyrol, a 2 to 10
per cent, protargol solution, or a 3 to
5 per cent, solution of silver nitrate.
Where the tissues are boggy and
chronically hyperemic a 10 per cent,
zinc sulphate solution may be in-
stilled. The applications may well
he followed by the insertion of a dry
tampon dusted with aristol or iodo-
form or of ai 10 per cent, boroglycerin
or ichthyol and glycerin tampon. Be-
tween office treatments, home douch-
ing with the mild antiseptic solutions
(boric acid, etc.) above mentioned
may be prescribed, with or without
ichthyol suppositories.
In gonorrhea of the uterine cavity,
similar procedures may be employed,
the uterus being swabbed out with
silver nitrate solution or tincture of
iodine, followed by the insertion of
iodoform gauze tampons. The treat-
ment of gonococcal endometritis, sal-
pingitis, and ovaritis appertains to
the field of the gynecologist rather
than that of the genitourinary special-
ist, and for information on these sub-
jects the reader is referred to the
articles on Endometritis, volume iv,
and Ovaries and Fallopian Tubes,
Diseases of, A^olume vii.
PERIURETHRITIS AND URE-
THRAL FISTULA.— Periurethritis is
usually a complication of gonorrhea or
stricture, hut may also follow trauma of
the urethra, affects the anterior urethra,
is often due to outward rupture of an
ahscessed urethral gland, and begins as a
hard, somewhat sensitive nodule from
which, especially in periurethritis compli-
cating stricture or trauma, invasion of ad-
joining tissues takes place, with ultimate
discharge through the skin. In stricture
cases it arises from masses of cicatricial
tissue, generally behind the stricture, a
febrile reaction taking place when sup-
puration begins, may so press on the ure-
thra as to cause retention of urine, and
may discharge into the urethra or invade
the subcutaneous tissues of the perineum
and even of the lower limbs and inguinal
regions, causing one or more fistula.
Urinary infiltration and gangrene are pos-
sible, and often fatal, complications.
Urethrorectal fistula is an uncommon
condition, usually involving the prostatic
urethra, and due to trauma — sometimes
operative — prostatic abscess, malignant
disease, or tuberculosis.
Treatment. — Acute periurethritis should
be treated by rest of the part and wet or
ichthyol dressings. When free suppura-
tion develops, the abscess should be in-
cised, either from within through a ure-
throscope or externally, according to
indications. In stricture cases the use of
steel sounds benefits simple periurethritis,
but where abscess formation occurs drain-
age through a median incision in the
perineum is indicated, together with in-
cision of the stricture itself. Whenever
urinary fistute are formed, their healing
is distinctly favored by injections into
their urethral end, made with a fine
pipette, through a wire urethral speculum,
of a strong (5 to 25 per cent.) solution of
hydrogen dioxide in ether; such dilatation
of the stricture as will render easy the
flow of urine through the normal channel
is, furthermore, essential. Where infil-
tration of urine takes place through the
subcutaneous tissues, free incisions must
at once be made and all dead tissue
removed.
Urethrorectal fistulas of inflammatory or
traumatic origin often close spontane-
ously. Where this does not occur, closure
can often be effected by simple suturing
or more complex surgical procedures. In
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
691
fistulas due to cancer or tuberculosis, how-
ever, success is not to be expected.
COWPERITIS.— Inflammation of Cow-
per's glands, two small structures of
cherry-stone size situated in the muscular
tissue between the layers of the triangular
ligament in the male, immediately l)ehind
the bulb of the urethra, occurs as a com-
plication of gonorrhea, and is manifested
as a small tender mass just to one side of
the median line in the perineum. The
condition is analogous to periurethritis,
and is unavoidably liable to confusion
with inflammation of other smaller glands
surrounding the perineal urethra. The
resulting abscess may extend some dis-
tance under the deep fascia before ruptur-
ing the latter and discharging through the
skin.
Treatment. — The treatment is similar to
that of periurethritis. (See above.)
NON-GONORRHEAL URETHRITIS.
— This may be due to one of a large variety
of causes, such as traumatism, overstrong
injections, permanent catheterization, for-
eign bodies, internal use of irritant diure-
tics, marked acidity of the urine or oxa-
luria, and, in women, the contact of
irritating uterine or vaginal discharges. It
may also accompany gout or syphilis, or
be of herpetic, eczematous, tuberculous,
or papillomatous nature. Previous gon-
orrhea or sexual excesses predispose to
simple urethritis.
Symptoms. — Traumatic urethritis is of
varying severity, according to the degree
of irritation produced. Pain often appears
immediately, and a mucous or purulent
discharge, with or without blood, appears
in twenty-four hours. Urethritis ab in-
gcsfis is usually mild, and may be excited
by alcohol, cantharides, arsenic, turpen-
tine, etc. Gouty urethritis begins in the
posterior urethra, causing frequent pain-
ful urination and a scanty discharge.
Syphilitic urethritis may be manifest as a
chancre of the urethra, as a mild urethral
inflammation accompanying the secondary
eruptions, or as a gummatous ulceration.
Herpetic urethritis represents an exten-
sion of external herpes of the genitals,
and may cause a mild dysuria and dis-
charge. In tuberculous urethritis ulcera-
tion usually develops near the neck of the
bladder, causing marked irrital)ility of the
latter, and later persistent cystitis, with
great pain at one point when a bougie is
passed and a bloody, though slight, dis-
charge. Papillomatous urethritis is de-
scribed under Tumors of the Urethra, q. v.
Diagnosis. — 'This is made by inquiry
and examination for one of the above-
mentioned factors, as well as by study of
the discharge. Simple urethritis is differ-
entiated from gonococcal urethritis by the
absence of gonococci and by the usually
mild symptoms, swelling of the meatus
being slight or absent, micturition and
erection painless, and the discharge often
only mucopurulent. Bacteria isolated from
the discharge in simple urethritis are gen-
erally those found at times in the normal
urethra. Gouty and syphilitic urethritides
are recognized from coexisting phenomena
of these diseases; chancre in the urethra
is usually palpable from the exterior as a
hard lump. Herpetic and eczematous ure-
thritides are, in many instances, diagnosed
by the presence of similar extraurethral
lesions. In tuberculous urethritis evi-
dence of the specific process responsible
may at times be found in the discharge.
Treatment. — The cause of the affection
should, if possible, be removed. In sim-
ple urethritis the local treatment is that
of a declining or chronic gonococcal ure-
thritis (q. v.); the organic silver-salts are,
however, without value in this form
(Keyes). Mild astringent injections are
of use. Internally, such drugs as sodium
bromide, opium and belladonna may be
prescribed if indicated; likewise diluent
drinks and a saline purgative. Heat ap-
plied to the perineum is likely to bring
some relief. In gouty and syphilitic ure-
thritis, the customary constitutional treat-
ment should be instiuted; daily flushing of
the urethra with 1 to 8000 silver-nitrate
solution is sometimes indicated and bene-
ficial. Eczematous urethritis is treated
with arsenic and alkalies internally and
cold or iced water irrigations locally.
Herpetic urethritis requires astringent in-
jections and tuberculous disease is treated
much as vesical tuberculosis. (See Tuber-
culosis of the Bladder, in this article.)
STRICTURE OF THE URE-
THRA.— The normal urethra is dila-
table to a certain caliber, depending
696
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
upon the circumstances of tlie flaccid
penis. Any condition interfering"
with this normal dilatability is called
a stricture.
VARIETIES. — Stricture may re-
sult from inflammatory changes such
as accompany acute urethritis. This
condition is temporary and subsides
under appropriate treatment. On
the other hand it may be due to mus-
cular spasm, usually of the compres-
sor urethrse. itself the result of the
irritation caused by an acute ure-
thritis or a urethral erosion, either
alone or existing- behind a stricture,
or, more rarely, of reflex irritation
from hemorrhoids, anal fissure, etc.
Finally, stricture may result from
the organization and contraction of
lymph following gonorrhea or other
urethral injury. The latter type is
called an organic or true stricture..
Congenital stricture of the urethra is
rarely observed. The diagnosis and
treatment are similar to those of or-
ganic stricture.
SYMPTOMS.— These commonly
include a gleety discharge ; some in-
crease in the frequency of urination,
and dri])bling at the conclusion of the
act, which is apt to require a long^er
time than normal and may require
some voluntary effort. The stream
may be much smaller than normal,
and may be forked, twisted, or other-
wise altered. If one or more of these
signs be present in a man who has
had gonorrhea or other serious ure-
thral lesion, stricture may reasonably
be looked for. Temporary or persist-
ent complete retention of urine may
result from the cong-estion of the
urethra behind a stricture attendant
upon an alcoholic excess, a heavy
meal, or a chilling of the lower ex-
tremities. Other manifestations of
stricture include hematuria, abnor-
malities of the sexual function, and
pains due to accompanying prosta-
titis or cystitis.
DIAGNOSIS.— For exploration of
the urethra, the acorn-headed bougie
{bougie a boule) should be employed.
The following approximate rela-
tionship has been shown to exist be-
tween the circumference of the flac-
cid penis at the middle of the pendu-
lous portion and the caliber of the
urethra : —
Circumference of Caliber of Urethra.
Penis.
3 inches. 26-28 millimeters.
3% inches. 28-30 millimeters.
3^4 inches. 30-32 millimeters.
3-)4 inches. 32-34 millimeters.
4 inches. 34-36 millimeters.
A suitable lubricant for urethral in-
struments is liquid vaselin or liquid
albolene containing 2 per cent, of
phenol, or a 25 per cent, solution of
boroglyceride containing the same
amount of phenol. Lubricants solu-
ble in water, such as boroglyceride
and glycerin, are preferable in that
the sterilization of instruments cov-
ered with them requires only ten
minutes' boiling, as against one-half
hour in the case of instruments cov-
ered with oily lubricants (Albarran).
If a bougie a boule of appropriate
size can be passed into the bladder
and withdrawn without being ar-
rested at any point, the caliber of the
urethra must be considered normal.
If a stricture is present the instru-
ment will be arrested at the con-
tracted area if it is. distinctly smaller
than the bulb of the bougie, or, if the
caliber very nearly corresponds, the
stricture may not be detected imtil
the instrument is withdrawn, the
abrupt shoulder being especially de-
signed to detect contractions when
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
697
passing in this direction. The ex-
amination should be begun with an
instrument nearly equal to the nor-
mal caliber of the urethra as indi-
cated in the above table, and if it
meets an obstruction, smaller and
smaller sizes tried until one is found
that will enter the bladder. Stric-
tures may be met with so small that
nothing larger than a filiform bougie
will pass, and occasionally even this
cannot be introduced (impassable
stricture).
A perceptible grasping of the sound
by the resilient tissues of the stric-
ture as it is withdrawn indicates an
organic stricture rather than urethral
spasm or chronic inflammation.
In all urethral instrumentation, the
greatest gentleness should be used.
ETIOLOGY.— Nothing need here
be added to what has already been
said of the first two varieties of stric-
ture. Organic stricture is usually the
sequel of gonorrhea. The gonococci
tend to penetrate the mucous mem-
brane and to develop in its deeper
layers, thus establishing also a peri-
urethritis. The severity of the in-
flammation at one or more points
causes exfoliation of the ei)ithelium,
the urine therefore tending to infil-
trate the tissues. To prevent this
nature surrounds the vulnerable point
with lymph and later scar-tissue,
which gradually contracts, interfer-
ing with the dilatability of the ure-
thra. The contraction is very slow ;
months and perhaps years may pass
before the patient is aware of any dis-
tinct trouble in urination. In most
cases (67 per cent. — Thompson) gon-
orrheal stricture occurs in llie bulbo-
membranous part of the urethra, an-
other common site being the first 2)<^
inches from the meatus.
The next most frequent cause of
stricture is rupture of the urethra.
The resulting changes are very simi-
lar to those in inflammatory stric-
tures.
TREATMENT.— Strictures are
treated by (1) dilatation or (2) cut-
ting [(fl) internal urethrotomy; (b)
external urethrotomy]. The various
other methods sometimes described
are applicable to but very few cases
or are to be entirely condemned. All
of the following procedures must be
carried out with the most rigid at-
tention to antisepsis : —
Dilatation. — This method is to be
chosen in every case in which it is ap-
plicable. It is unsuitable in: 1. Im-
passable strictures. 2. Those below
No. 10 or 12 of the French scale, as
it is unsafe to pass bougies below
this size. 3. Strictures of the meatus
and first 1^ inches of the urethra, as
experience has demonstrated that
these will not yield to dilatation. 4.
Strictures of the pendulous urethra,
usually (if recent and of large caliber,
gradual dilatation should be tried).
5. Traumatic strictures, as a rule, are
not dilatable and require division.
Preparation for urethral dilatation
should preferably include the giving
of hexamethylenamine in 15-grain
(1 Gm.) daily dosage for one or two
days before the procedure, as well as
by washing the end of fhe penis with
soap and water and irrigation of the
meatus with 1 : 1000 silver nitrate
solution.
To prepare for gradual dilatation in
cases of stricture below 10 or 12
French, a whalebone filiform should
be introduced, or, if possible, two or
more, and retained from twenty-four
to forty-eight hours. This will soften
and enlarge the caliber of the stric-
698
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
turc. Or, having- passed a filiform
into the bladder, a Gouley tunneled
catheter may be introduced over this
as a o^uide and retained. The passage
of a filiform in difficult cases is facili-
tated by rotation after slight with-
drawal when the instrument catches,
by the use of a bent or twisted fili-
form, and by fillings the urethra with
riliforms, one of which will finally
engage after all lacunae and false pass-
ages have been occupied by others.
As soon as either of these methods
has secured sufificient enlargement,
gradual dilatation should be begun.
This treatment will usually be ap-
plied to strictures situated in the bul-
bous or membranous urethra, except-
ing those of traumatic origin.
In cases of sudden retention of
urine following exposure or table ex-
cesses, refractory to instrumentation,
relaxation may often l^e obtained
with repeated hot sitz baths or a pro-
longed hot full bath. If this fails,
aspiration of the bladder (see Reten-
tion of Urine, in this article) or ex-
ternal urethrotomy will be required.
Gradual dilatation is advised in all
strictures of the deep urethra if a
No. 12 French or larger instrument
can be passed. It should also be tried
in recent soft, large strictures of the
pendulous urethra, excepting those
of the first inch and a half of the
urethra. It is carried out as follows:
Suppose a No. 16 French bougie a
houle has demonstrated a stricture.
A- No. 17 or 18 metal urethral conical
sound should be passed and allowed
to remain a few moments, after which
a 19 or 20 may be introduced. The
next treatment should be three to
five days later, depending upon the
case, at which time probably an 18,
20, and 22 bougie may be passed, and
so on, mcreasmg one or two sizes at
each visit, until the normal caliber
has been reached. Occasionally a
stricture is so dense and inelastic that
the same sizes must be used at 2 or
more successive sittings before a
larger size will pass. In strictures
smaller than 15 F. but not requiring
the use of a filiform, the substitution
of woven conical bougies for m.etallic
instruments is advised owing to
greater danger of making a false
passage with the latter. The Koll-
mann dilator may be used where the
patient objects to having a congeni-
tallv narrow meatus cut or where the
stricture, already dilated to corre-
spond with the meatus, undergoes
rapid recontraction. The general
rule should be to "coax" the stricture
rather than to employ force. After
the full caliber has been obtained a
bougie of the proper size should be
passed at gradually increasing inter-
vals for two to three years, and, if any
tendency to recontract is observed,
throughout the patient's life.
Urethrotomy. — Gradual dilatation
having failed, or being impossible,
some form of cutting operation will
be necessary.
Internal Urethrotomy. — Strictures of
the meatus and first 1^^ inches of the
urethra maj^ be divided either with a con-
vex, blunt-pointed tenotome or with one
of the various forms of urethrotomes.
Strictures situated lJ/2. to AYz inches from
the meatus may be divided with a ure-
throtome, the dilating instrument being
best for this purpose. If the caliber is
below 15 French, it may be necessary to
use a urethrotome of the Maisonneuve
variety to prepare for the dilating ure-
throtome.
The division should be made in the roof
of the urethra. After the stricture has
been cut a bougie a boiile of appropriate
size should be passed to be sure that the
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
699
proper caliber has been obtained, and, if
not, a second division made.
A full-sized, freshly boiled, soft-rubber
catheter should be passed and retained
for seventy-two hours, a 1 : 2000 solution
of protargol being passed through as it is
withdrawn. Later full-sized metal bougies
should be passed as directed under grad-
ual dilatation, and again at longer inter-
vals for some years.
External Urethrotomy: A. With a
Guide — Syme's Operation. — This is usu-
ally required at the deep urethra, in
which situation it is called external
perineal urethrotomy. It is required in
strictures of the bulbomembranous and
membranous urethra that cannot be cured
by gradual dilatation.
A grooved staff is passed into the blad-
der, the urethra exposed by an incision
in the middle line of the perineum and
the stricture divided upon the staff. If
the staff will not pass the obstruction the
urethra is opened on the tip of the in-
strument just anterior to the stricture.
By carefully holding the divided edges of
the urethra apart a filiform may be
passed which will act as a guide in
dividing the contracted portion. Or, a
filiform may be introduced and over it a
tunnelled catheter staff.
B. Without a Guide — Perineal Sec-
tion.— Cases of impassable stricture of
the deep urethra require this procedure.
An instrument is passed as far as pos-
sible, and the urethra opened upon its tip
through a median perineal incision. The
strictured portion is then probed and
divided, carefully keeping in the line of
the urethra. A good light is essential.
Occasionally the strictured canal cannot
be located, when cither suprapubic cys-
totomy and retrograde catheterization or
extension of the operation so as to open
the urethra at the apex of the prostate
will become necessary. The operation
should be undertaken only by those who
have had considerable experience in this
line of work.
After each of these operations a rubber
catheter may be passed tbrdugh the
urethra into the bladder and retained for
several days. The perineal wound is
packed gently with gauze. After the
catheter is removed urethral bougies
should be passed, as directed after In-
ternal Urethrotomy.
URETHRAL, URINARY, OR CATH-
ETER FEVER.— Symptoms and Etiol-
ogy.— Not infrequently a patient will have
a chilly sensation or a slight chill after an
instrument has been passed into the blad-
der, especially for the first time (urethral
shock). This may be accompanied by
faintness, nausea, and weak pulse, but is
not followed by a hot stage or sweat, and
there is no elevation of temperature. The
phenomenon is supposed to be of reflex
origin, and does not constitute urethral
fever. It is of no significance and re-
quires no treatment.
In rare instances after instrumentation
of or operation on the urethra the patient
is seized with a severe chill, especially at
the time of the next urination, followed
by fever and sweat. There may be but a
single paroxysm, in which case the pa-
tient's condition returns to normal in
from a few to twenty-four hours. In other
cases the chill, fever, and sweat recur at
irregular intervals. The former is prob-
ably due to the absorption of a minute
dose of toxic material through a fresh
wound of the urethra caused by the in-
strumentation. The latter is undoubtedly
a genuine septic infection, the micro-or-
ganisms or their toxins being absorbed
through the urethral lesion and producing
a septicemia or pyemia of the gravest
type.
Patients who have suffered long with
stricture of the urethra and whose kidneys
have become infected secondarily seem
especially predisposed to this accident.
According to some, the occurrence of the
urinary chill is entirely limited to cases
with pre-existing disease of the kidneys,
generally a pyelonephritis, and the chill is
due to acute renal congestion, itself caused
by absorption of bacteria from the injured
urethra. Peculiarities of the condition are
that its incidence often has no relation to
the severity of the instrumentation carried
out, though manifestly increasing with its
depth, i.e., distance from the meatus.
The extreme gravity of the severer forms
of urethral fever should constantly be
borne in mind, and every effort made to
prevent its occurrence.
Acute urinary septicemia may follow
700
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
urctliral fever, and is clue to absorption
through the kidneys of toxic products
from retained, infected urine. A focal
suppurative nephritis is the patliohigical
process induced, and the syniptnins con-
sist of irregular, high fever, with or with-
out recurrent chills, and renal tenderness
and pain.
Chronic urinary septicemia results from
prolonged toxic urinary absorption, and is
characterized by low, irregular fever, an-
orexia, constipation, a tongue bright red
laterally, but often coated; dryness of the
mouth; a drawn, sallow or pasty face;
some polyuria, loss of weight, and drowsi-
ness, merging into a uremic state. Renal
suppuration is always, in some degree
associated.
Treatment. — The treatment of urethral
fever should be prophylactic. The most
rigid antisepsis and gentleness in urethral
instrumentation and the internal use of
one of the urinary antiseptics will usually
prevent it. The meatus, glans, and pre-
puce should be cleansed with soap and
water, followed by potassium perman-
ganate or boric acid solution, before cath-
eterization or other urethral instrumenta-
tion. Operations should be preceded by
the use of hexamethylenamine, TYz grains
(0.5 Gm.) 3 times a day for two days, and
by copious drinking of diuretic mineral
waters, and should be followed by irriga-
tion of the urethra and bladder, proper
provision being made for drainage.
If the disease has already become estab-
lished, boric acid and phenyl salicylate
(salol), 7K' to 10 grains of either, may be
administered 4 times a day, or, better,
hexamethylenamine employed in the dose
already mentioned. The urethra and blad-
der should be thoroughly irrigated at fre-
quent intervals with potassium perman-
ganate, 1 in 5000 to 1 in 2000; silver
nitrate, 1 in 8000, or boric acid or normal
saline solution.
Constitutional treatment is also impor-
tant. Quiet rest in bed should be imposed.
The patient will require a nourishing
diet. Three pints (1500 c.c.) of milk per
day will not be too much, and 3 to 6 eggs
should be given, either with the milk or
separately. Stimulants must be adminis-
tered freely. Whisky or brandy may be
given, the amount being determined by
the clYcct. I'ull (loses of strychnine
should be given, and digitalis may be
added if there is evidence of enfeebled
circulation. Diuresis, saline catharsis, and
hot foot-baths are indicated. In severe
cases, hot-air baths or the hot pack, and
cupping in the lumbar regions, may be
appropriate and beneficial.
Where toxic absorption seems progres-
sive in spite of the above measures, a
perineal urethrotomy or suprapubic cys-
totomy may become necessary to improve
drainage.
In acute or chronic urinary septicemia
similar measures are indicated, efforts be-
ing likewise made to relieve retention of
purulent urine, as by catheterization, ure-
throtomy, or cystotomy, and to over-
come renal suppuration, if necessary, by
nephrotomy.
CHANCROID.— Definition.—
Chancroid, or soft chancre, is a spe-.
cific, local venereal lesion due to the
streptobacilltis of Ducrey.
Symptoms. — After an incubation
period of from, one tO' five days — usu-
ally three to five — a pustule develops
which rapidly enlarges and in a few
days ruptures, forming an ulcer. The
latter is generally round and presents
sharply defined, perpendicular mar-
gins, with a deeply set, grayish yel-
low, soft, and irregular base. An
abundant, purulent, foul discharge is
liberated, which is autoinoculable, in-
ducing additional lesions as it passes
over adjacent tissues. The lesions
are surrounded by inflammatory are-
olae, are painful when rapidly enlarg-
ing, and bleed easily. A chancroid is
seldom indurated unless already
cauterized, associated with the hard
chancre of syphilis, situated at the
meatus or in the post-coronal sulcus,
or complicating phimosis. In the
male the commonest site of chancroid
is the coronary sulcus; in women, the
introitus. The lesions are usually
multiple, and may extend not only
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 701
over the external genitals, but also croid is, on the other hand, best defi-
over the perineum and onto the legs nitely ascertained — examination for
and abdomen. Untreated chancroid the bacillus of Ducrey being uncer-
lesions free of complications begin tain owing to the paucity of these
to heal in three or four weeks. No organisms and the many pyogenic
constitutional symptoms accompany and other bacteria present — by auto-
chancroids when uncomplicated. inoculation. This is carried out by
Etiology. — Chancroid is almost al- placing under the skin on the outer
ways transmitted by sexual contact, aspect of the thigh, by means of a pin
although instances of infection from or bistoury, a little pus from the sus-
the soiled hand are on record. An pected ulcer, the point being inserted
abrasion, albeit slight, is necessary deeply enough to draw the least pos-
for infection with it, unless contact sible amount of blood. If a typical
be very prolonged. Uncleanly habits chancroidal lesion appears on the
are an important predisposing factor, third day at this point, the test is
the use of soap and water upon ex- positive ; in case of doubt, the secre-
posure being almost certainly pro- tions of the new lesion may with ad-
phylactic. vantage be examined for the bacillus
The causative organism, discovered of Ducrey.
by Ducrey in 1889, is a dumb-bell Complications. — The commonest
shaped bacillus occurring both extra- complication of chancroid is inguinal
and intra- cellularly, and arranged adenitis (bubo), which is met with
typically in parallel chains. It is in about one-third of all cases. It
negative to Gram's test-stain, but may be uni- or bi- lateral, and, when
stains easily with methylene blue, the latter, is generally more marked
fuchsin, etc. As it excites no sys- on the side of the primary ulcer. The
temic reaction or immunity it can be involvement may be a simple inflam-
repeatedly inoculated in the skin sur- mation without suppuration, soon
face. It loses its virulence when terminating in resolution, or may ex-
heated to 105° F. tend to a periadenitis, with massive
Diagnosis. — This is ordinarily made adhesions of glands and surrounding
clinically, the history of recent ex- tissues, usually followed by suppura-
posure, and the multiple, discharging tion. The abscess, after rupturing,
ulcers, with or without bubo, being may heal like other abscesses or may
sufficient. Differentiation from syph- form a chancroid ulcer, from which
ilitic chancre is especially important, autoinoculation may take place (viru-
and is complicated by the fact that a lent bubo).
positive diagnosis of chancroid does Other possible complications in-
not exclude tlic ])ossibility of co- elude the "mixed sore" already re-
existing syphilitic infection in the ferred to, inflammatory phimosis due
chancroidal lesion itself. Such coex- t© chancroidal disease beneath a long
isting infection may often be detected prepuce, paraphimosis, balanopos-
tlinaigli examination of the discharge thitis, l)uttonlvoHng and destruction
for tlie spirocheta. (For further dis- of the preputial frenum. lymphan-
cussion see article on S^■l'll ii.is, in gitis, rapidly progressive and destruc-
this viilumcT- The presence of chan- tive ulceration (phagedena), and gan-
702 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
grcne. Phagedena from chancroidal
infection is less frequent than from
syphilitic lesions.
Treatment. — All chancroidal lesions
not more than a week old, whether
minute or larg-e, should be cauterized
with pure nitric acid. Each lesion,
with the surroundinq- skin, is first
waslicd with hydrogen dioxide. Pe-
trolatum is then applied round the
lesions, which are next carefully dried
with strips of blotting-paper, anes-
thetized with pure phenol or 10 per
cent, cocaine solution, and cauterized,
after the whitened surface has been
again dried, with nitric acid on a
glass rod until the open areas are
wholly stained brown or yellow. The
lesions are then again washed with
hydrogen dioxide and dressed with
calomel, or, even better, iodoform.
Where cauterization is refused by the
patient or fails, or the lesions are
over a week old, the treatment is
limited to washing ver}^ frequently
with hydrogen dioxide solution di-
luted one-half (this may be preceded
by soaking the penis in hot saline
solution), drying with cotton, and
dusting with iodoform, nosophen, or
calomel. When granulation begins
the lesions may be dressed with 1
part of ointment of mercury nitrate
to 7 of petrolatum ; cauterization with
the silver-nitrate stick or pure phenol
may be practised every few days, or
red or black wash may be continu-
ously applied.
In the prevention of complications,
protection of external lesions from
friction by means of a large cottort
dressing is of importance. To reduce
the chances of bubo, the patient
should stay as quiet as possible. As
soon as bubo appears, he should be
put to bed and a hot-water bag or
ichthyol dressing applied. Pressure
through a spica bandage of the groin
may be of value. If suppuration oc-
curs, evacuation should be effected
through one or more stab incisions,
the cavity washed out with hydrogen
dioxide followed by mercury bichlo-
ride solution, a warm 10 per cent,
iodoform ointment injected, and iodo-
form or a wet dressing applied exter-
nally. Injections of iodoform oint-
ment should be made every three
days until pus formation has been ar-
rested. Where chancroidal ulcera-
tion takes place in spite of treatment
the lesions should be cauterized and
dealt with like the primary sores, any
badly diseased tissues being, more-
over, cut away. Persisting hard
masses of inguinal glands should after
a time be excised, even if suppuration
has not occurred.
Where phimosis gives trouble, the
prepuce should be slit up (circumcis-
ion being often a failure at the time),
the cut margins touched with pure
phenol, and the ulcers thus exposed
cauterized.
Phagedena is met by the internal
administration of quinine, iron, and
milk punch, and by thorough local
use of the actual cautery, nitric acid,
or bromine — under general anesthe-
sia if necessary — followed by iodo-
form and wet dressings, or, better,
continuous antiseptic irrigation.
TUMORS OF THE URETHRA.— The
benign tumors of the urethra include
papilloma, fibroma, cysts, and angioma;
the malignant, carcinoma, and sarcoma.
In the male, tumors seldom occur unless
gonorrhea has preceded.
Papilloma is usually a multiple tumor,
occurs nearly always on the floor of the
urethra close to the meatus, and is ana-
logous to the papilloma (venereal wart)
often met with on the external genital or-
gans. The diagnosis of the deeper lesions
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 703
is made with the urethroscope or by-
means of an acorn-headed bougie, the
small warty outgrowths being felt with
the fingers from outside the penis as the
head of the bougie is being withdrawn.
The papillomata occurring, as is nearly
always the case, in chronic gonorrhea may
be associated with a persistent urethral
discharge (papillomatous urethritis). Ure-
thral papillomata readily bleed.
Treatment, — Destruction of the growths
through the urethroscope may be ef-
fected by vigorous scraping with cotton
on a probe, and with the urethral curette,
hemorrhage being arrested by pressure.
To prevent recurrence Keyes recommends
the application of a saturated alcoholic
solution of salicylic acid to the bases of
the growths twice weekly until their ten-
dency to return is checked.
Fibroma is met with singly, generally
in the bulbous urethra, usually associated
with a myomatous or myxomatous com--
ponent, and is very rare. Polyps of the
prostatic urethra are apt to cause hemor-
rhage from the urethra, with or without
difficulty in urination or catheterization.
The treatment is operative, the growth
being removed through a median perineal
incision.
Cysts of the urethral glands occur in
chronic gonorrhea.
Angioma is met with chiefly in women
in the form of the so-called urethral car-
uncle, near the external meatus. Frequent
painful urination and marked local sensi-
tiveness are characteristic of this lesion,
which may l)e excised or destroyed with
the actual cautery.
Carcinoma of the urethra is uncommon
and is almost invariably secondary to can-
cer of the prostate or penis. The lesion
is typically hard and wart-like, sometimes
resembling leucoplakia, and is treated by
excision or exposure to radium. Recur-
rence usually follows.
Sarcoma of the urethra is generally met
with in the female sex. The treatment is
excision.
DISEASES OF THE PROSTATE,
ANOMALIES,— These are rare ex-
amples of defective development and
occur only in conjunction with extensive
malformations of the adjacent urinary
and genital organs.
INJURIES OF THE PROSTATE.
Wounds of the prostate complicating
injuries to the perineum or rectum are
accompanied by the symptoms attending
lacerated wounds in general. If the
urethra is lacerated also, there will prob-
ably be retention of urine or extra-
vasation at the point of injury; or, reten-
tion may result from swelling of the
gland, simply, without injury of the ure-
thra. Infection of the wound will give
rise to a diffuse inflammation, or, what is
more serious, to phlebitis of the prostatic
plexus, which is prone to cause septicemia
or pyemia. The extravasation of urine is
apt to involve either the perineum or the
prevesical space; in the latter case, if not
checked by prompt incision and drainage,
it will involve the areolar, tissue of the ab-
domen, thighs, penis, and scrotum.
Wounds of the prostate caused by the
unskillful use of catheters will be followed
by hemorrhage, probably by retention,
and in some instances by inflammation of
the gland.
The constitutional symptoms depend
upon whether profuse hemorrhage has oc-
curred, or local inflammation or serious
infection of the wound taken place. Infec-
tious phlebitis is very apt to cause chills
and pronounced constitutional symptoms.
Etiology. — Wounds of the prostate are
rare, owing to the protected situation
of the gland. Lacerated wounds of the
perineum or rectum by a pointed object
may involve the prostate. It may rarely
be injured in extensive fracture of the
pelvic bones. It is wounded in punctur-
ing the bladder with a trocar from the
perineum, or even from the rectum. When
enlarged, it has been wounded by injudi-
cious attempts to pass a metal instrument
through the urethra into the bladder. It
is always cut in performing perineal
cystotomy.
Treatment. — The patient should be
confined to bed. Perineal wounds in-
volving the prostate require the same
treatment as do lacerated wounds else-
where. Foreign bodies should be re-
moved, l)lecding well controlled, the sur-
faces cleansed, and drainage provided for.
i'rcqucntly a tampon of iodoform gauze
will serve both to arrest the bleeding and
afford drainage. If the prostatic wound
704 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
he extensive, it is advisable to introduce
a catheter into the bladder through the
urethra and leave it in. If the urethra or
neck of the bladder has been opened by
the accident, the retained catheter is par-
ticularly important. If one cannot intro-
duce the catheter on account of urethral
laceration, perineal section should be
done. The catheter may then be placed
through the perineal wound, or, preferably,
through the entire urethra. If bleeding
has occurred backward into the bladder,
copious irrigations of warm, boric acid
solution through the bladder should be
employed. If the catheter becomes oc-
cluded by clots, they may be dislodged by
making suction with the syringe or by in-
jecting a little boric acid solution.
Wounds of the prostate caused by frac-
ture of the pelvis are treated upon gen-
eral principles. If the urethra be lacerated
a permanent catheter must be introduced,
cutting down, if necessary, upon the point
of laceration in order to pass the catheter.
(The treatment of rupture of the bladder
will be described under diseases of this
viscus.)
Injuries of the prostate resulting from
forced catheterization, if slight, recover
spontaneously; if more severe, they re-
quire the permanent catheter to provide
against retention from swelling,' the use! of
urinary antiseptics and copious draughts
of water and, perhaps also, mild sedatives.
Wounds caused in performing perineal
cystotomy do not require any special
attention.
In wounds from external causes fre-
quent irrigations with antiseptic solutions
and particular attention to antiseptic de-
tails are desirable, to limit the inflamma-
tory reaction and help avoid septic inflam-
mation of the prostatic plexus of veins.
All injuries of the urethra or bladder indi-
cate the internal use of urinary antiseptics.
FOREIGN BODIES AND CALCULI
IN THE PROSTATE. — Symptoms.—
Pain and tenderness in the perineum and
a frequent or almost constant desire to
urinate, the act being accompanied by se-
vere pain, are the prominent symptoms.
Upon rectal examination the gland will be
found somewhat swollen, unduly tense,
and tender. Occasionally the passage of
urine is interfered with. Softening or
lluctuation would indicate an abscess.
Etiology. — Small vesical calculi may
lodge in the prostatic urethra, or the
prostate itself. Occasionally during the
introduction of an old catheter a portion
will break off at the point and remain be-
hind. At times foreign bodies have been
introduced into the urethra, and, passing
beyond reach, lodged in the prostate.
Prostatic concretions, due to concentra-
tion and hardening of the prostatic secre-
tion, are common in middle-aged men, but
seldom attain a size causing symptoms
{e.g., larger than a pea); rarely, multiple
prostatic calculi coalesce to form a
branching mass extending forward and
backward in the urethra.
Diagnosis. — This is usually made by in-
troducing a metallic instrument, which
will impart a grating sensation to the hand
as it passes over the calculus or foreign
body.
Treatment. — In some instances, espe-
cially in the case of impacted, small cal-
culi, these bodies may be removed through
the urethra with the urethral forceps.
Bodies that cannot be thus removed
should be taken out by median perineal
urethrotomy. If suppuration should su-
pervene, the abscess should be treated ac-
cording to the principles applicable to
abscesses elsewhere.
ACUTE PROSTATITIS. — This
occurs in two forms : the follicular
and the parenchymatous. The former
is much more frequent than the latter.
Symptoms. — These vary greatly in
degree, probably according- to the
nature and virulence of the infecti'on.
A mild prostatitis may produce no
symptoms. In the mildest symptom-
prod'ucing form of the follicular vari-
ety there is a sense of heat and full-
ness in the perineum, with some in-
creased fi-'e'qnency of urination, which
is attended with more or less pain,
especially at the close of the act. In
the more marked cases the fullness is
replaced by severe pain, urination
may be frequent and painful and ac-
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 705
companied with tenesmus, or there other possible factors, traumatism is
may be complete retention. Sitting probably one of the rarest. Exposure
and defecation may cause considerable to conditions causing internal conges-
pain, and examination of the prostate tions (a "cold") is a more common
through the rectum will show the cause. Occasionally a passing or im-
organ probably enlarged and dis- pacted calculus in the prostatic ure-
tinctly tender. thra or some other foreign body will
In parenchymatous prostatitis, in excite inflammation. Excessive use
which all of the structures of the of cantharides will in some instances
prostate are involved, pain is more have the same effect,* as may also
marked than in the follicular variety, irritating injections- or strong chem-
and is frequently of a throbbing char- icals in the deep urethra. All these
acter. Frequent urination and tenes- factors very probably act by estab-
mus are greater, or more propably lishing a favorable soil for the de-
there will be retention from the ex- velopment of micro-organisms. Evi-
tent of the swelling. In the follicular dence is lacking to show that horse-
variety there is usually moderate back-riding and bicycle-riding are
fever. The parenchymatous form is productive of prostatitis if proper
apt to cause a higher temperature, saddles be selected. Acute prosta-
with marked constitutional symp- titis occasionally develops in the
toms, and not infrequently chills. course of the infectious fevers, and it
The usual history is that, following has been noted in a number of in-
a urethritis, the train of symptoms stances of pyemia,
above mentioned has developed more Treatment. — The patient should be
or less suddenly. This should always confined to bed. The diet should be
excite suspicion of a prostatic compli- liquid — chiefly milk. Water may be
cation. The condition is to be dis- given freely. A hot-water bag may
tinguished from acute cystitis, in, be applied to the perineum and rectal
which frequent and painful urination injections of hot water administered
is more pronounced, while the com- 3 or 4 times a day. In the more
plaints connected with the perineum severe cases the bed should be so
and rectum are proportionately less, arranged that the patient's hips are
In inflammation of Cowper's glands on a higher level than the shoulders,
the symptoms are confined to the If the inflammation is of a high
perineum. In all cases digital exami- grade, considerable relief is afiforded
nation of the prostate is the final by the application of a number of
test. leeches to the perineum and around
Abscess formation either in the the anus. Sitz baths at 100° to
pjastate itself or in the cellular tis- 105° F., frequently rejieated, give re-
sumes outside the gla-nd (peripVosta- lief by drawing the blood to the sur-
titis) frequently follows, the latter face. If there is marked vesical irri-
coTidition ■prodU'cing a large, boggy, tation great relief will be afforded by
te-nder, prostatic mass. a mixture of boric acid, sodium bro-
Eti'oiogy. — In the vast majority of mide, and tincture of belladonna.
cases prostatitis is due to infection Suppositories of ichthyol may with
from a posterior urethritis. Among advantage l)c used, and hexamethyl-
' S-45
706 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
enamine given by . the mouth. If
there is much fever, a diaphoretic
mixture containing- potassium citrate,
sweet spirit of nitre, and aconite will
be useful. If i)ain is excessive, a
little morphine may be added. If this
fails, suppositories of morphine or
opium may be given in addition. If
there is retention, the urine should be
drawn at regular intervals with a
soft-rubber catheter. If the inflam-
mation goes on to suppuration, it is
well to evacuate the abscess as soon
as softening or fluctuation is detected
by rectal ex:amination. This should
be done in the midline of the per-
ineum, carefully avoiding the urethra
and rectum. Small, circumscribed ab-
scesses which will probably not be
detected, usually rupture spontane-
ously into the urethra.
CHRONIC PROSTATITIS.—
Symptoms. — One of the most promi-
nent symptoms is a persistent ure-
thral discharge, often mucopurulent
in character. Sometimes this fluid is
obtainable only by massage of the
prostate. Discharge may occur at in-
tervals throughout the day, but is
especially noted during or after an
action of the bowels. In addition, the
patient will have at least some of the
following symptoms : Frequency of
urination, weight and dull pains in
perineum and loins, a tickling sensa-
tion or pain in the urethra, pain at
the end of urination, some perineal
tenderness which may make sitting
uncomfortable, and a moderately in-
creased sensitiveness of the prostate
on rectal examination. The lumbar
pains are typically constant in char-
acter and uninfluenced by micturi-
tion. Referred abnormal sensations
may be felt anywhere below the um-
bilicus, even at a point as distant as
the foot. Obstruction to urination,
due either to bar formation at the
median isthmus or to stricture of the
neck of the bladder, occasionally be-
comes a salient feature. There is
often some enlargement of the pros-
tate gland. Introduction of a cathe-
ter is likely to reveal marked hyper-
sensitiveness of the prostatic urethra.
The urine usually shows some cloudi-
ness, especially the first portion,
owing to shreds of mucopurulent
matter and masses of epithelium from
the prostatic urethra. Often, in fact,
chronic posterior urethritis coexists,
and sometimes also chronic anterior
urethritis. An extreme degree of
anxiety and mental depression is very
constantly observed, the seriousness
of the various symptoms being mag-
nified by the patient, particularly the
discharge, often erroneously supposed
by the laity to be semen.
D i a g n o sis . — Chronic prostatitis
must be dififerentiated from chronic
cystitis, vesical calculus, prostatic hy-
pertrophy, and seminal vesiculitis.
In the first of these the mental de-
pression and the prostatic tender-
ness are absent. If the urine be
passed in two portions, in prostatitis,
the second portion will be clear, while
in cystitis both portions are cloudy.
Vesical calculus is excluded if the
characteristic symptoms are not pres-
ent and by the careful use of the
sound.
Hypertrophy of the prostate usu-
ally begins after the fiftieth year of
life, and is much more common after
the sixtieth year. The distinction is
sometimes difiicult, the hypertrophy
not infrequently showing some de-
gree of associated chronic inflamma-
tion. The cloudy condition of the
first portion of urine in the two-glass
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
707
test, together with the mental condi-
tion and purulency of the expressed
secretion, point to inflammation of
the prostate, and their absence argues
against it.
Seminal vesiculitis, when chronic,
closely simulates chronic prostatitis.
Digital examination through the rec-
Jum will, however, show an absence of
fihanges in the prostate and probably
reveal a distended seminal vesicle.
■^ For doubtful cases Posner has pro-
posed the following test : An ounce
or two of urine is passed in one glass
and a like portion in a second glass, a
quantity still being retained in the
bladder. The prostate is then thor-
oughly expressed by massage either
with the finger in the rectum or an
instrument devised for the purpose.
The patient then passes the last por-
tion of urine. If chronic prostatitis
be present this portion will be cloudy
and the microscope show pus-corpus-
cles, shreds, epithelium, probably
micro-organisms, and possibly blood.
Care must be taken in this test not to
confound the fluid from a distended
vesicle, if such exists.
Etiology. — Chronic prostatitis de-
velops insidiously as such, or re-
mains as a sequel of an acute inflam-
mation. By far the commonest cause
of the condition is gonococcic pos-
terior urethritis, Keyes, e.g., having
noted a history of gonorrhea in 73.2
per cent, of a series of cases studied.
Among other causes of it are irri-
tating injections; improper use of
urethral instruments ; infection from
the blood-stream ; foreign bodies,
such as prostatic calculi, and condi-
tions causing a chronic congestion,
such as abnormal sexual practices,
constipation, hemorrhoids, etc. There
occurs also probably a chronic pyo-
genic infection in which either the
dose of the germs is so small or the
virulence so mild that only a mild re-
actionary inflammation results. Such
cases may complicate chronic gonor-
rhea and urethral strictures. Nott-
haft, examining 120 cases of chronic
prostatitis bacteriologically, found the
gonococcus in 47; other micrococci,
in 119; bacilli, in 15, and other bac-
teria, in 14. Young and his asso-
ciates, however, more recently ob-
tained a bacterial growth on agar in
only 8 out of 19 cases.
Treatment. — Every factor of pros-
tatic congestion should be removed
as far as possible, e.g., a contracted
meatus, urethral stricture, constipa-
tion, etc. Sexual excitement should
be avoided. Tonics are frequently
indicated. The diet and digestion
should receive attention as well as
such matters as exercise, bathing, etc.
Irritating articles such as Cayenne
pepper, mustard, sauces, vinegar,
pickles, tomatoes, and other acid vege-
tables and fruits, must be avoided.
Counterirritation to the perineum
by the daily application of equal jiarts
of tincture of belladonna and tincture
of iodine, or by the occasional appli-
cation of blistering collodion, will be
beneficial. The daily use of a jet of
cold water on the perineum from a
bidet is of value in most cases, the
cold and the force of the stream both
causing reflex contraction of the con-
gested blood-vessels. In some cases
hot hip-baths for a few moments each
day are of service. Ichthyol supposi-
tories may be prescribed.
In rebellious cases silver nitrate
may with advantage be introduced
into the prostatic urethra through a
special (Ultzmann or Keyes) syringe
with long, hard-rul)ber nozzle. At
708
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
first only 3 to 5 drops of a 1 per cent,
solution should be introduced, This
may be repeated after three to five
days. The strenj^th of the solution
may then be very gradually increased.
If this be done too rapidly or the
first application be unduly strong-,
considerable reaction and distress
will result. Some advise the gentle
introduction of a full-sized cold-steel
sound every three or four days.
Many believe massage to be the
ideal and rational therapy for chronic
prostatitis. It empties the ducts, im-
proves the circulation, and tends to
cause absorption of inflammatory
products. For this procedure the pa-
tient may lie on the back with the
thighs flexed and separated. The
massage may best be performed with
a finger in the rectum, protected with
a rubber finger cot, previously lubri-
cated. Moderate distention of the
bladder, if necessary with boric acid
solution, is of advantage. The gland
should be rubbed from the periphery
toward the urethra, pressure being
made first on oiie lobe, with a circular
motion or a lateral sweep of the
fing"er, then on the other lobe, and
finally on the prostatic sinus, to'
evacute the ducts into the urethra. If
strong pressure is being made, a few
strokes for each lobe are sufficient ;
if but gentle force is used, each lobe
may be stroked for a minute. The
force used is often graduall}^ in-
creased, but should be gauged accord-
ing to the patient's tolerance and the
efifects noted. Brief massage of the
seminal vesicles may with advantage
precede the prostatic manipulations.
The procedure should seldom be car-
ried out oftener than 2 or 3 times a
week. It may be continued until the
symptoms have abated and the puru-
lency of the expressed fluid largely or
entirely lost. Prostatic massage is
contraindicated in acute inflamma-
tions of the prostate, vesicles, or
urctlira.
ABSCESS OF THE PROSTATE.—
Symptoms. — These cases present the
symptoms of acute prostatitis in a marked
degree. There is generally fever, often
high, the pain is severe and often throb-
bing, and chills are apt to occur. Urina-
tion is extremely painful. The swollen
perineuin may acquire a dusky red color.
Retention of urine is very often a feature;
may even be the only symptom, unaccom-
panied by d3'suria or fever. The diagnosis
is confirmed if an area of softening or
fluctuation can be detected by digital ex-
amination.
Etiology. — Abscess after acute inflam-
mation of the prostate is most apt to
occur w^here treatment has been neglected
or the health of the patient is particularly
depressed. The suppuration may occur
early or late in the course of the disease.
There may be a single abscess or a
number.
Treatment. — As a rule, the abscesses
undergo resolution or open spontaneously
into the urethra, and complete recovery
occurs. As soon as distinct fluctuation
is detected, how^ever, it is desirable not
to wait, but to evacuate the abscess by
an incision in the perineum, avoiding
the urethra and rectum. The cases in
which this will be necessary are, how-
ever, comparatively few. The wound
should be packed with gauze and re-
dressed daily. Occasionally the abscess
bursts into the perineum, ischiorectal
fossa, or rectum, or burrows into neigh-
boring tissues, even as far as the umbili-
cus; hence the desirability of early evac-
uation.
PRO STAT ORRHE A. — Symp-
toms. — Prostatorrhea refers to the
periodical discharge from the ure-
thra of a colorless or slightly turbid,
whitish, viscid fluid, most frequently
observed after the passage of a hard
stool, but, in pronounced cases, also
at other times, e.g., after violent exer-
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (IVOOD).
709
cise, bicycle-riding', or sexual excite-
ment. The discharge is found on ex-
amination to be prostatic fluid. Irri-
tability of the bladder, with frequent
micturition, often coexists, as do also
neurasthenic symptoms. At times
spermatorrhea and impotence are
associated.
Etiology. — The condition occurs
almost always in young adults, and
seems often to be due to a relaxa-
tion of the prostatic ducts, not neces-
sarily accompanied by local inflam-
mation, but often the result, in turn,
of sexual excess, ungratified sexual
desire, or some other factor causing
local congestion or weakness (pro-
longed fever). With this may be
coupled overactivity of the prostatic
glands.
Treatment. — This consists in the
correction of bad habits or other
ascertainable causes, removal of the
hyperesthesia or prostatic congestion
by daily irrigations with 1 : 4000 sil-
ver nitrate solution with introduction
of the cold sound every 4 or 5 days,
and sedation of the irritable bladder
with hot hip-baths at night and bro-
mides and hyoscyamus.
ATROPHY OF THE PROSTATE.—
The prostate undergoes atrophy in a small
proportion of old subjects, and may also
atrophy after severe trauma, suppurative
involvement, or calculous formation. Con-
genital atrophy is likewise a possibility.
In eunuchs the growth of the organ is
arrested, and in cases of destruction or
removal of the testicles, or ligation of the
vasa, after puberty it tends to retrogress.
No symptoms result from the condition,
and treatment is unnecessary.
HYPERTROPHY OF THE
PROSTATE.— SYMPTOMS.— Con-
siderable enlargement of the prostate
may occur without any subjective
symptoms whatever. On the other
hand, a very moderate or slight en-
largement in other cases may give
rise to considerable annoyance. The
first symptom to attract the patient's
attention is, almost without excep-
tion, increased frequency of urination
(pollakiuria) , especially at night (and
particularly toward morning). The
patients -are obliged to rise once or
twice during the night to pass water..
No change is usually noticed at this
stage during the day. The nocturnal
frequency gradually increases and
finally the diurnal frequency is also
augmented. An observing patient
may note that the natural force of the
stream is lacking, that it is thin and
tends to fall vertically downward.
There is also apt to be some hesita-
tion in starting the stream, and stop-
page is frequently incomplete. Chill-
ing, worry, and alcoholic overindul-
gence augment the frequency of noc-
turnal micturition.
The subsequent course of the case
depends, to" some extent, upon
whether the urine remains sterile or
becomes infected. In the former case,
as the prostatic overgrowth pro-
gresses, there is corresponding ob-
struction to emptying the bladder.
At the conclusion of each act of urina-
tion a portion of the urine remains.
The bladder therefore becomes dis-
tended much earlier than if it had
been completely emptied. This, in
conjunction with the increased local
irritability due to congestion of the
bladder and prostate, is the cause of
the more frequent passage of urine.
When tlie amount of residual urine
reaches several ounces to a pint or
more, it naturally requires but a short
time for the bladder to become fully
distended and call for relief. The
organ at no time feels empty. In
710
URIXAin AXI) (;i':XITAL SYSTEMS, SURGICAL DISEASES (WOOD).
some Cases the obstruction is so j^reat
that normal urination is impossible ;
the bladder becomes distended to its
utmost limit, and tlic urine escapes
involuntarily from the urethra as fast
as it enters the bladder from the kid-
neys. This dribbling is a si^^nificant
symptom, and constantly deceives the
patient and not infrequently the
physician, the arg-ument being- that,
owing to the frequent or almost con-
stant passage of urine, the bladder
must be empty. Though generally
due to overflow in a filled bladder,
dribbling may occur, with but little
residual urine, owing to abnormal
irritabilitv of the bladder. Not in-
frequently dribbling is the original
symptom leading the patient to con-
sult a surgeon.
If the urine, becomes infected, as is
sooner or later always the case, often
as a result of catheterization, the
symptoms become very marked.
Urination may occur every two hours,
every hour, or even 3 or 4 times in an
hour. There may or may not be hy-
pogastric pain, depending upon the
degree of cystitis present, and the act
of urination is apt to be attended with
vesical tenesmus. In rare cases in
which there is moderate enlargement
of the prostate, but in which the
symptoms have been so mild as to
escape observation, after the patient
has been chilled or indulged in alco-
hol, or has gone an unusually long
time without passing water, he may
find himself unable to do so, and re-
sort to the catheter wnll be necessary.
This retention may be the first evi-
dence which the patient has had that
the prostate is afifected.
The amount of pain varies in dif-
ferent cases. In the milder forms it
is usuallv entirelv absent. In more
])ronounced types the patient will
complain of indefinite pains in the
hypogastrium, the groins, or the
small of the back, and a sense of full-
ness in the perineum or rectum. In
the later stages more or less severe
pain will be present either because of
a distended bladder or of cystitis.
There may be a soreness or smarting
of the urethra and shooting pains in
the glans, similar to those felt in
cases of vesical stone. In cases with
severe cystitis in which frequent and
violent efforts are made to pass water,
the tenesmus may result in hemor-
rhoids or prolapsus ani.
In the later stages, the urine is very
apt to contain blood, sometimes in
microscopic quantity only, in other
cases in large amount. As long as
the bladder remains uninfected there
are no characteristic changes in the
urine. In the presence of infection
the usual evidences of cystitis will be
observed.
The enlarged prostate sometimes
causes a marked erethism or even
priapism. The residual urine and the
resulting ammoniacal decomposition
predispose to the formation of phos-
phatic calculi. Patients with pros-
tatic enlargement frequently have a
stone in the bladder. Seminal vesicu-
litis is also a common, and epididy-
liiitis (often suppurative) an occa-
sional, complication of prostatic hy-
pertrophy.
DIAGNOSIS.— The diagnosis of
enlargement of the prostate is, as a
rule, attended with little or no
difficulty.
Among the conditions which may
cause more or less similar symptoms
are stricture of the urethra, stricture
at the neck of the bladder, prostatitis,
cystitis, vesical calculus, and tumor
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
711
of the bladder or the prostate itself.
Stricture of the urethra will be elimi-
nated if a full-sized urethral instru-
ment can be passed without obstruc-
tion. Stricture at the neck of the
bladder is differentiated with the
cystoscope, which will reveal a local-
ized prostatic thickening (prostatice
bar) even in the absence of enlarge-
ment of the prostate to the rectal
touch. Prostatitis, if acute, would
be most apt to follow urethritis, and
would be accompanied by fever and
much more marked local tenderness
than exists in the senile prostatic hy-
pertrophy. The chronic form usually
occurs in earlier life, and leads to the
characteristic symptoms already re-
ferred to. Vesical calculi, if present,
may be detected by the use of a vesi-
cal sound. Vesical tumors may be
suspected after excluding stone and
enlarged prostate (by rectal palpa-
tion) and diagnosed dc visu by cys-
toscopy. (For the differentiation of
prostatic neoplasm, see section on
Tumors of the Prostate.)
The final test for enlargement of
the prostate is digital examination
through the rectum, the finger en-
countering, instead of the normal soft
organ, a dense, rounded, smooth, and
generally symmetrical mass. Simul-
taneousFy the bladder may with ad-
vantage be palpated and the condi-
tion of the urinary stream and the
urine itself noted. The patient should
invariably be examined for residual
urine by gently passing a catheter
immediately after he has emptied his
bladder as completely as possible, an
elbowed or double-elbowed woven
catheter being used if the ordinary
soft-rubber catheter fails to pass.
Atony of the bladder is shown by a
feeble jet of urine or inability to start
the flow while recumbent. A signifi-
cant increase in the urethral length
is shown if urine fails to flow when
the catheter has been passed in 2 to
2y^ inches beyond the point where
the resistance of the cutoff muscle is
first felt. The length of the urethra
is increased in some cases to the ex-
tent of 1^ to 2 inches. The cysto-
scope may be of material assistance
in reaching a diagniosis.
ETIOLOGY AND PATHOLOGY.
— After a large number of post-mor-
tem dissections Sir Henry Thompson
claimed that 1 man in every 3 over
54 years of age showed some en-
largement of the prostate. In about
1 case in 7 the enlargement was suffi-
cient to cause some degree of obstruc-
tion, and in 1 case in 15 it was suffi-
cient to demand treatment. The con-
dition is so common at and after the
sixtieth year that some writers have
described it as physiological. This
view does not seem justified, since
according to most observers, in per-
haps two-thirds of the population,
there is no increase in size whatever.
Johnson, however, among 360 men
asserts he found prostatic hyper-
trophy in 79 per cent.
Prostatic hypertrophy seems to oc-
cur with about equal frequency in the
various classes of society; nor do the
habits of the individual, so far as can
be learned by inquiry, seem to bear
any relation to it. The efficiency of
such factors as senile involution,
sedentary life, gonorrhea, and sexual
excess in predisposing to the condi-
tion is as yet undetermined.
The normal prostate consists chiefly
of 2 lateral lobes, with a small inter-
mediate portion sometimes called the
middle or third lobe. In some cases
tlie increase in size appears to include
712
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
all parts of the i^dand alxmt equally —
a true hypertrophy. In others, it in-
volves only one portion or one lobe,
— strictly speaking- a hyperplasia.
Minutely, the hypertrophy may occur
in 3 types: (1) the soft, "adeno-
matous" type, with obstruction of the
ducts of the prostatic acini and cystic
dilatation of the latter; (2) the hard,
fibrous type, and (3) the pseudoade-
iiomatous type, characterized by the
growth of encapsulated, enucleable
nodules, small or large, in various
parts of the gland. As a rule, all 3
of these types are to be, found in a
single prostatic specimen. According
to the widely recognized theory of
Ciechanowski, the condition is origi-
nally due to a chronic inflammation of
the stroma of the. prostate, causing
duct obstruction, later scar formation
(the fibrous type), and encircling of
portions of gland-tissue by dilating
■ducts to form the characteristic
pseudoadenomata.
Non-symmetrical enlargements of
the -prostate mpre easily produce
symptoms than symmetrical. Urin-
ary obstruction may result from even
a slight hypertrophy of the middle
lobe. Either general or middle-lobe
hypertrophy causes elevation of the
posterior margin of the urethral inlet
— the so-called "prostatic bar" — form-
ing* behind it a .pouch in which the
"residual" urine collects.
PROGNOSIS.— The prognosis in
early cases is good if treatment
be forthwith instituted. Even after
acute retention, five or six years g^en-
erally elapse before chronic complete
retention is reached. Where partial
or complete chronic retention is al-
ready established the tendency, un-
less radical treatment is submitted to,
is, infection of the bladder having oc-
curred, toward extension of the re-
sulting inflammation up the ureters to
the kidneys, causing chronic pyelo-
nephritis and a urinary septicemia
wliicli leads eventually to death. Yet
by good management of the retention
even in these cases, to minimize
the back pressure on the kidneys,
progress of the renal infection
and functional deterioration may be
greatlv slowed.
TREATMENT.— In the earlier
stages, with slightly increased fre-
quency of urination -only, comfort
may be much increased by careful
hygiene. Tlic hypertrophic prostate
being chronically congested, every-
thing tending to increase this should
be avoided. The body should be
properly protected, to avoid catching
cold. The food should be plain,
easily digested, and non-stimulating;
meats should be sparingly taken, and
a diet largely of milk may be recom-
mended. The bowel function should
also be attended to. Regular, mod-
erate exercise is desirable.
Irritability of the bladder, as yet
unaccompanied by residual urine, may
also be treated by silver nitrate in-
stillations or by massage of the pros-
tate and the rectal douche. Acute
retention of urine mav require cathe-
terization, to be done with strict
cleanliness and coupled with internal
administration of hexamethylena-
mine'. Great caution should be exer-
cised when the bladder contains more
than 1 liter of urine. It is usually
best to withdraw part at a time, so as
to relieve the overdistention grad-
ually. ,
If the residual urine be 3 or 4
ounces (90 to 120 cc), a soft cathe-
ter should be passed once daily, pref-
erably at bedtime, to give a longer
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
713
period of rest at night. If it be 5 or
6 'Ounces (150 to 180 c.c), the urine
should be withdrawn morning and
evening, and, if half a pint or more,
it is desirable to pass the catheter
every eight hours. After withdraw-
ing the urine it is desirable to irri-
gate the bladder with warm boric-
acid solution, 10 or 15 grains (0.6 or
1 Gm.) to the ounce (30 c.c). If
there be pronounced cystitis, it may
be necessary to pass a catheter
oftener, and the bladder irrigations
then become especially important.
No drugs have any direct influence
upon the prostatic overgrowth, un-
less it be ergot, and opinion as to the
latter is divided. Half a teaspoonful
of the fliuidextract may be given 3
times a day for a considerable period.
Strychnine and other tonics are often
indicated for the general condition.
In catheterizing these patients,
difficulty is often experienced as the
instrument reaches the prostatic ure-
thra. For this reason it is necessary
in some instances to tiy^ different
forms of catheters. The elbowed
catheter is useful in difficult cases,
and the metal prostatic catheter, with
longer shaft and larger curve, will
sometimes pass easily when all other
forms are arrestd. In troublesome
cases the gentle passage of sounds or
the retention of a rubber or woven
catheter for a few days will often
greatly facilitate subsequent cathe-
terization. It should l)e an invari-
able rule to use thorough asei)sis in
all of the urethral instrumentation, to'
avoid cystitis. The ])aticnt practis-
ing autocatheterization must be thor-
oughly instructed by the surgeon in
this connection. Some advise that
yVi to 15 grains (0.5 to 1 Gm.)
of hexamethylenamine be ordered
taken daily throughout catheter life.
By gentle, cleanly, and infrequent
(though regular) use of the catheter,
a reduction in the amount of residual
urine can often be procured.
Operative Treatment. — The pallia-
tive treatment hereinbefore described
is disadvantageous in not being cura-
tive, in the possibility that it may at
any time fail to relieve, and in the fact
that the patient is not removed from
the danger of complications such as
prostatic abscess, epididymitis, or-
chitis, and especially ascending infec-
tion of the urinary tract. Radical
treatment, on the other hand, always
entails a certain chance of immediate
operative death. It is indicated,
therefore, only when palliative treat-
ment proves insufficient and the pa-
tient is seen to be gradually failing in
spite of careful management of the
case. Under these circumstances to
delay operation only serves to lessen
the chances of operative recovery.
Of the operative procedures recom-
mended for enlarged prostate, the
following deserve mention: (1) va-
sectomy ; (2) galvanocauterization ;
(3) cystotomy, for drainage, either
perineal or suprapubic ; (4) prosta-
tectomy.
Vasectomy, which grew out of the op-
eration of castration, recommended by
White in 1893, is the mildest of the pro-
cedures. Yet it has been followed by a
small mortality (3 to 5 per cent, in early
cases; 10 per cent, or more later) due to
the fact that the patients are all persons
in advanced years who have suffered from
chronic obstruction for some time, and
who, in consequence, are apt to have cys-
titis, dilated ureters, and surj^^ical kidneys.
Relief, more or less pronounced, follows
vasectomy in about 60 per cent, of the
cases. In some, conditions seem to return
approximately to normal. The operation
may be tried in patients with moderate
714 URINARY AXD GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
enlargement and several ounces of resid-
ual urine, in whom the difficulty or pain
in passing a catheter demand other treat-
ment, and who are old and feeble.
Substitution of a tunneling opera-
tion for prostatectomy in many cases
recommended. Destruction of the ob-
stacles to urination is effected with
the writer's direct vision air cysto-
scope and the galvanocautery. The
prostatic bar is cut vertically by the
cauterj' and the cut then opened out
laterally like a broad V. The second
step consists in destroying the lateral
lobes with the cautery as one would
dig a hole in a potato, the cystoscope
being gradually drawn forward. The
operation is best done in 3 to 6
weekly sittings. It is safe and does
not need general anesthesia. Luj-s
(Bull, de I'Acad. de med.. Feb. 12, 1918).
Galvanocauterization. — A. Bottini's Op-
LKATioN. — This method, originated by Bot-
tini, of Padua, in 1874, meets the require-
ments better than any other in cases in
which there is a distinct bar at the neck
of the bladder. The operation is carried
out by means of a prostatotome, con-
structed somewhat on the principle of a
lithotrite. What would correspond to the
male blade, however, has at the extremity
a platinum-wire loop which is heated by
an electric current. After the introduc-
tion the blades are turned in the direction
in which it is desired to make the section
of the prostate — generally posteriorly, to-
ward the rectum, — the current gently
turned on for a period previously found
by trial to be required for bringing the
blade to a red heat, and the wire loop
made to cut through the obstructing mass
by means of a screw attached to the han-
dle. A second and a third section (usu-
ally lateral) may be made if it is thought
necessary, the blade returned to its sheath,
and the instrument removed. Before be-
ginning the operation the bladder should
be partially filled with boric acid solution
and the posterior urethra anesthetized.
During use of the instrument a current
of cold water is kept constantly passing
through it, to prevent overheating. The
patient need remain in bed only twenty-
four hours. A steel sound may, with ad-
vantage, be occasionally passed during the
period of healing.
The mortality of Bottini's operation
ranges from 2 to 6 per cent., the deaths
being due chiefly to infection of the in-
cised prostate or to infiltration of urine
due to penetration of the instrument be-
3ond the prostatic structures. In some
instances no benefit follows the operation.
B. Chetwood's Operation. — The necessity
of conducting Bottini's operation entirely
in the dark, without a guide, is a manifest
objection to the procedure. This has led
some to substitute for it the Chetwood
technique, which consists in exposure and
incision of the membranous urethra as in
median perineal prostatectomy (see be-
low), examination of the prostatic urethra
and bladder outlet with the finger and, a
bar, stricture, or enlarged median lobe
having been found, the Chetwood prostatic
incisor, introduced through the perineal
wound and hooked over the prostate, the
index finger of the left hand passed into
the rectum and brought in apposition
with the point of the instrument, the cur-
rent turned on, and the hypertrophied tis-
sues divided by slow withdrawal of the
knife, the surrounding tissues being mean-
while kept cool by a small stream of water
passing in through the urethra and out
through the perineal wound. The effect
produced is controlled by subsequent in-
troduction of a finger in the urethra.
Where a median lobe requires broad ex-
cision two cauterizations in a V-shape
with the knife may be made.
Cystostomy, perineal or suprapubic,
may be carried out either for temporary
drainage or to establish a permanent new
urinary channel. In the former case, the
resulting physiological rest, in a few cases,
affords sufficient relief of prostatic con-
gestion to permit the urine to flow
through the normal channel. If this flow
cannot be re-established, a tube may be
inserted into the bladder for permanent
drainage. Several forms of these tubes
have been devised. The annoyance of
wearing the permanent tube, however, the
irritation of the surrounding skin, and the
continual soiling of the clothing render
the patient's life anything but happy.
Hence the late tendency to restrict the
field of cystostomy to serious cases in
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
715
which temporary bladder drainage is of
value as a preliminary to prostatectomy,
relieving renal retention and sepsis, and
enabling the patient better to bear the
shock of the subsequent remedial opera-
tion.
Prostatectomy must always be regarded
as a severe operation. Occasionally a
circumscribed enlargement of one portion
of the prostate may be easily and safely
removed through a suprapubic opening;
but the removal of the entire gland is
often a tedious procedure, usually at-
tended with severe hemorrhage. The
average mortality of prostatectomy by
the perineal route is about 6 per cent.;
that of suprapubic prostatectomy some-
what higher — 8 per cent, or more. With
the latter the chances of a complete cure
are, on the whole, greater than with the
former, which is more difficult of perform-
ance, and is occasionally followed, even in
the hands of the best operators, by incon-
tinence of urine or a urethrorectal fistula.
Convalescence from the suprapublic op-
eration, on the other hand, is far slower
than from the perineal. Where prelimi-
nary cystoscopy is impracticable, the
suprapubic procedure is that of choice, al-
lowing of a careful investigation of the
condition of the bladder-neck which the
perineal method does not afford. Which-
ever procedure be employed, prostatec-
tomy yields a cure in the great majority
of cases.
Suprapubic Prostatectomy. — This pro-
cedure is generally carried out by the
method of Freyer, a modification of the
earlier McGill and Fuller operations. The
bladder having been washed out and filled
with boric acid solution, a vertical open-
ing is made into it through a» suprapubic
incision, any calculi found in it removed,
and the prostate palpated, one or two
fingers of the left hand making counter-
pressure on the gland from the rectum.
The mucous membrane overlying any
prominent enlargement of the prostate
may be divided by the finger-nail or the
points of scissors. The index finger is
then passed through this cut, l)ctween the
gland and its capsule, and carried around,
in this line of cleavage, the whole of the
enlarged portions of the gland, which are
then torn or cut away, including the pros-
tatic urethra. An attempt may be made to
work between the lateral lobes and the
prostatic urethra and save the latter; this
maneuver is, however, rarely completely
successful, and experience has shown that
the prostatic urethra may be removed or
torn without harmful results. Finally, the
prostate is removed from the bladder with
forceps, and a large (Freyer) drainage-
tube, with small catheter attached, passed
in to the neck of the bladder for con-
tinuous irrigation. The enucleation should
be done with care and gentleness, keep-
ing close to the capsule of the gland.
Where the prostate is found so fibrous
and adherent as to render its enucleation
without undue tearing of the capsule im-
practicable, sufficient functional benefit
may be obtained by merely using the
actual cautery on the prostatic bar or
excising a V-shaped piece therefrom.
Perineal Prostatectomy: A. Median. —
The bladder having been irrigated and
filled, a grooved staff is introduced
through the urethra, a median incision
made in the perineum, and the urethra
opened into just anterior to the prostate.
A finger is introduced to explore the pros-
tate and bladder-neck through the urethra,
and the lobes, in turn, freed from the cap-
sule with the finger through a deep in-
cision made in each of them through the
lateral aspect of the urethra. The lobes
are loosened as much as possible from the
prostatic urethra, pieces of which, how-
ever, are usually torn off as the lobe is
being drawn out with volsellum forceps.
The middle lo!)e is, if necessary, similarly
dealt with. The pediculated median lobes
sometimes met with may be removed with
a tonsil snare. A douI)le irrigating tube is
finally introduced and irrigation at once
begun, to be continued several hours.
Hemorrhage from a tear of the prostatic
capsule is controlled witli gauze packing.
The perineal tube is usually to be removed
in two days, and the patient should prefer-
ably be got out of bed soon after.
B. Extraurethral. — Extraurethral per-
ineal prostatectomy, though used to a
large extent I)y Young and Albarran, is
more difficult than the median operation,
and is useful chiefly where the obstruction
is due to hypertrophy of the lateral lobes
or a short hypertrophy of the median tis-
716 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
sue. Lateral converging incisions, with
the apex of the V anterior, are made, the
rectourethralis muscle severed, the pos-
terior surface of the prostate exposed by
blunt dissection, the membranous urethra
incised, the prostatic urethra and bladder-
neck palpated vi^ith a finger in the urethra,
the lateral lobes removed through incis-
ions made into them from the outside, 1
centimeter from the midline, any further
masses felt by the finger within similarly
taken out, the prostatic incisions packed,
irrigation of the membranous urethra pro-
vided for, the edges of the lavator ani
muscle sutured, and the lateral parts of
the skin incision closed.
Impotence follows any form of prosta-
tectomy in a considerable proportion of
cases — seemingly somewhat oftener after
the perineal than after the suprapubic
method. It is attributed to destruction of
the prostatic urethra as well as to opera-
tive shock. Other possible complications
— of perineal prostatectomy in particular —
are epididymitis, urinary incontinence, and
retention of urine, the latter due to in-
complete operation, the obstruction to
urination remaining unrelieved.
TUBERCULOSIS OF THE PROS-
TATE. — Symptoms. — Perhaps one-third
of these cases are entirely free of symp-
toms or have so little inconvenience that
the disease is unsuspected. In the milder
forms there is slight irritation of the
bladder, with some frequency of urination,
which may be attended with burning pain.
There is a feeling of fullness or weight
in the perineum; there may be a muco-
purulent discharge from the urethra, and
a similar sediment in the urine. Hema-
turia is also often observed, and is occa-
sionally the first sign of the disease.
Diagnosis. — A consideration of the
symptoms and careful exploration by the
sound will serve to make the distinction
between prostatic tuberculosis and vesical
calculi. The presence of tuberculous de-
posits elsewhere should excite suspicion.
Finding tubercle bacilli in the urine would
be conclusive, but Guyon states that the
most careful examination fails to detect
them in SO per cent, of the cases. Digital
examination per rectum may show some
local enlargement and tenderness, and
prostatic massage is likely to yield muco-
purulent matter, in which tubercle bacilli
may be found.
Etiology. — The disease is generally be-
lieved to be invariably secondary to de-
posits elsewhere in the genitourinary
tract, though some consider it primary.
A chronic posterior urethritis sometimes
precedes it. Usually it occurs in anemic
persons with tuberculous foci elsewhere,
chiefly between the twentieth and forty-
fifth years. It is usually manifest in cir-
cumscribed collections of cheesy material
or abscesses. The latter tend to rupture
into the urethra, initiating a tuberculous
cystitis. Until such rupture occurs there
is often no symptom.
Treatment. — Prostatic tuberculosis can
be, to some extent, guarded against if
those with tuberculous tendencies avoid
all influences tending to cause congestion
or inflammation of the prostate. The
treatment is chiefly constitutional, unless
the local trouble demands operative inter-
ference. It is proper to delay the latter
as long as possible, both because the part
is not very accessible and because it is
apt to be a part of a general proces. Hill
and others have injected iodoform and
other substances into the bladder fre-
quently with benefit. Hill's formula is as
follows: —
R Iodoform 2 parts.
Mucilage of gum arahic. 4 parts.
Glycerin 2 parts.
Water 20 parts.
After washing out the bladder 1 dram
of this mixture is introduced. This inay
be repeated every second or third day, de-
pending upon how well it is borne. Par-
enchymatous injections of iodoform emul-
sion were recommended by Senn.
The question of operation will fre-
quently come up. In general, if the health
of the individual is good, and if the tuber-
culous process does not yield to palliative
treatment, an operation is indicated. The
gland may be approached from the peri-
neum and any diseased area evacuated and
thoroughly curetted. Prostatectomy is
indicated only if all evidence of involve-
ment of neighboring structures is absent.
If the patient has deposits elsewhere suffi-
cient to yield physical signs, and if the
general health is poor, no operative treat-
ment is to be recommended.
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 717
TUMORS OF THE PROSTATE. Bilateral sciatica is considered sug-
— Cysts of the prostate, including der- gestive of prostatic cancer. Hema-
moids and echinococcic cysts, have turia becomes marked when the dis-
been rarely recorded. These almost ease bursts' through t=he capsule of the
invariably cause retention of urine prostate. The bladder, seminal vesi-
after reaching a sufficient size to oc- cles, urethra, and remainder of the
elude the urethra by pressure. Upon pelvis are then rapidly invaded, and
examination by rectum a fluctuating metastases may take place in the in-
swelling may be detected. They are guinal, femoral, mesenteric, and retro-
treated either by aspiration or by in- peritoneal glands as well as in the
cision and drainage. spinal column and kidneys. Death
Carcinorna. — Carcinoma of the pros- usually follows within a year of the
tate is relatively common. Greene initial symptoms, though in some in-
and Brooks claim to have found a stances it is delayed for a long period,
histological structure suggestive of DIAGNOSIS. — Distinction be-
malignancy in 5 per cent, of all hy- tween prostatic carcinoma and hyper-
pertrophied prostates. More recent trophy is at first difficult and may be
obsei-vations have led some writers impossible. Unilateral enlargement,
to conclude that the actual incidence one or more nodules in the gland
is from 10 to 15 per cent. It occurs (prostatic calculi being excluded by
in two forms: as a slowly growing, the X-ray), .a stony hardness of the
circumscribed tumor, limited to the growth, unusual pain, and spontane-
gland itself, and as a diffuse infiltra- ous hemorrhage are all somewhat
tion of the prostate and base of the suggestive, but not plainly indicative,
bladder which develops rather rap- of cancer. Later, the wide distribu-
idly. The growth may be of a stony tion of the pain, rapid course, foul,
hardness, and is often characteristic- bloody urine, cachexia, extensive pros-
ally nodular. It is usually of the tatic enlargement, and palpable sec-
medullary type, and is generally ondary involvements remove all doubt
primary. It nearly always occurs in the diagnosis. Cystoscopy may be
after the age of fifty. of assistance.
SYMPTOMS.— The symptoms of TREATMENT.— This is chiefly
carcinoma of the prostate are those of palliative. At first, systematic cau-
obstruction from hypertrophy, except terization, tonics, a-nd sedatives may
that, when once estal)lished, they run prove of service. Later, excessive
a more rapid course. Carcinoma pain must be met by morphine inter-
gives rise' to more pain, however, than nally or by suppository. Permanent
does senile enlargement, and as soon drainage l)y suprapubic cystotomy, to-
as ulceration occurs there is hema- gether with colostomy when .rectal
turia. The pain is at first neuralgic in ulceration or oljstruction develops,
type. It may occur, only when ob- are appropriate palliative procedures,
struction to urination develops. It Operations for radical removal of a
is felt chiefly in the perineum or rec- cancerous prostate have not proved
tum, whence, however, it later radi- generally satisfactory. Young and a
ates to the genitals, lumbar regions, few other operators have reported a
sciatic nerves, and hypogastrium. few successful cases. The diagnosis
718 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
usually being- made relatively late, re-
moval of the entire prostatic capsule
and the neck of the bladder is, at the
least, required to eliminate the dis-
ease focus /;/ toto.
Sarcoma. — Sarcoma of the prostate
usually occurs in early life. The com-
mon symptoms are dysuria, retention,
hypogfastric and perineal pain, and
the presence of a tumor. Hematuria
usually occurs. The disease runs a
more rapid course than any other
prostatic affection.
Treatment. — The treatment is
symptomatic and palliative. An op-
eration would be proper only in the
most exceptional case.
DISEASES OF THE BLADDER.—
The subjects of Acute and Chkonic
Cystitis have been reviewed in the third
volume, page 712.
ANOMALIES.— Absence of the bladder
and double bladder are extremely rare
congenital deformities.
Urachus cyst or fistula is a rare condi-
tion arising through failure of the canal
connecting the bladder with the umbilicus
to close during fetal life. Where the canal
remains open throughout, a fistula results;
if only in part, a cyst, which may attain
a large size. Urachus fistula is generally
associated with obstruction in the urethra,
and may even become manifest only in
adult life after some affection causing such
obstruction has been contracted.
Treatment. — The first care should be to
overcome any existing urethral obstacle.
Injections of irritants, such as alcohol,
into the canal may then induce its closure.
If not, it should be excised.
EXSTROPHY OF THE BLAD-
DER.— Exstrophy, or absence of the
anterior wall of the bladder {ectopia
vesiccc), is by far the commonest con-
genital defect of this organ. It re-
sults from the failure of the lateral
portions of the urogenital cleft to
unite. It is most frequently observed
in male children {37 to 12 — Pousson),
and is accompanied by absence of the
roof of the urethra (epispadias) and
by a defect in the anterior abdominal
wall in front of the bladder, the pubic
bones being separated by a more or
less wide interval, so that the mucous
surface of the posterior wall of the
bladder protrudes in the hypogastric
and pubic regions. The ureteral ori-
fices can usually be found upon care-
ful inspection. Subjects of this de-
formity are usually poorly developed
and are apt to have other defects also.
In some cases the scrotum is cleft,
so that the external genitals of a male
child may somewhat resemble those
of a female. The testes are occasion-
ally undeveloped, and may or may
not occupy their proper position in
the scrotum. Inguinal hernias are
common. The protruding vesical
mucous membrane is thickened, ulcer-
ated, and bathed in mucus, and the
constant contact of the ammoniacal
urine with the surrounding skin gives
rise to a troublesome eczematous
condition. Eventually the bladder
niflammation travels up the ure-
ters, causing pyelonephritis, and the
twenty-first year of life is reached
only in 30 per cent, of instances.
Treatment. — The palliative treat-
ment consists in the use of some form
of urinal to collect the urine or of
other means to keep the patient as
dry as possible. The urinals custo-
marily used (Earle's, for example)
consist of a round, bulging, metallic
shield, the rounded margin of which
forms a groove around the bladder
defect. This is supported by a truss
and is connected below by a tube with
a rubber bag fastened to the thigh.
The surrounding skin should be fre-
quently bathed, and, if irritated, zinc
ointment applied. In very young
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 719
children the use of a urinal is imprac-
ticable ; cleanliness is to be main-
tained with hot water and irritation
minimized with ointments or dusting
powders.
The radical treatment consists in
some form of plastic operation, usu-
ally intended to close in the bladder
sufficiently to enable the urine to be
caught in a urinal.
In suitable cases it is advisable to
free the edges of the bladder and
unite them by sutures, leaving- an
opening below for the escape of urine.
Wood's operation is the autoplastic pro-
cedure usually recommended, and is per-
formed by taking a flap, of sufficient
length and width, from the anterior wall
of the abdomen, to cover in the extro-
verted border of the bladder, and so
folded over the protrusion that the skin
is next to the mucous membrane and the
raw surface external. Two rounded lat-
eral flaps with the attached portions cor-
responding to the base of the scrotum
and inguinal region on either side are
next made. The inner end of each in-
cision is continued along the correspond-
ing side of the urethral groove for one-
half its length. These flaps should be
large enough and so fashioned as to meet
in the midline. The middle flap is turned
downward so that the skin covers in the
bladder, and the free margin sutured to
the incisions on either side of the roof
of the penis. The lateral flaps are then
brought together in the midline over-
lying the first flap and sutured. The raw
surfaces from which the flaps were taken
are then drawn together as far as pos-
sible, using either sutures or harelip-pins.
The epispadic condition remains to be
remedied by operation at a later period.
The autoplastic operations enable the
patient to retain his urine for from
twenty minutes to as long as two hours.
No satisfactory bladder-sphincter is sup-
plied.
Maydl's operation, when successful,
permits of retention for four to six
hours, but is attended with a higher
operative mortality (14 per cent. — Peter-
son). It consists in cutting apart an
elliptical piece of bladder-wall, including
the mouths of both ureters, bringing up
a loop of sigmoid or rectum from the
peritoneal cavity, implanting the piece of
bladder into this loop, stripping the
mucous membrane from the rest of the
bladder, and closing the abdominal wound
as firmly as available tissues permit. In
a series of 36 cases collected by Peter-
son, this operation afforded good control
of the urine in 27 instances.
RETENTION OF URINE. — Defini-
tion.— Retention of urine refers to a par-
tial or complete inability to urinate volun-
tarily. The condition is a symptom, not
a definite disease.
Symptoms, — In acute retention the pa-
tient has an intense desire to urinate and
strains violently. Pain in the perineum,
penis, abdomen, and thighs may be experi-
enced. The enlarging bladder rises above
the symphysis, forming a dull, elastic,
fluctuating mass, less prominent in re-
cumbency than in the upright position,
and flanked by areas of tympany. When
the distention reaches its limit, the urethra
may be mechanically pulled slightly open,
an overflow of the excess of urine taking
place, without to any marked extent re-
lieving the distention. If no such over-
flow is possible, a typhoid condition event-
ually supervenes, which will prove fatal if
surgical relief is not given.
Chronic retention may follow partially
relieved acute retention, and is character-
ized by permanent inability to empty the
bladder completely. It is often very grad-
ual and insidious in onset, causes frequent
urination, and, when sufficiently marked,
leads to a periodic or almost constant
dribbling of urine, which represents an
overflow whenever the bladder reaches a
sufficient degree of distention. In such in-
stances no especial pain may be experi-
enced. An atonic condition of the bladder-
muscle is sooner or later superimposed.
Etiology, — Retention of urine in most
instances occurs as a complication of
either organic urethral stricture or pros-
tatic hypertrophy {q. v.). Less frequently
it is due to such obstructive causes as
congenital phimosis, imperforate prepuce,
or occluded meatus; tumor or abscess of
the penis; rough catheterization; tumor,
720 URINARY AND GENITAL S\STEMS, SURGICAL DISEASES (WOOD).
rupture, or impacted calculus or foreign
body of the urethra; prostatitis or pros-
tatic abscess or tumor; spasm of the mem-
branous urethra in acute or chronic gon-
orrhea; perineal or ischiorectal abscess;
projection of a submucous blood-clot into
the urethral lumen after contusion of the
perineum (Da Costa); pressure by a large
pelvic mass; fecal impaction, and stone in
the bladder. Occasionally it is due to dis-
turbance of the nervous or muscular ap-
paratus governing bladder evacuation, as
in shock or peritonitis, spinal concussion,
fracture of the vertebra?, diseases of the
spinal cord, operations on the rectum, pro-
tracted fevers, diseases causing muscular
wasting, use of belladonna, opium, or
cantharides, and hysteria. Reflex reten-
tion of urine may occur either through
excitation and spasm of the bladder
sphincter or through inhibition of the de-
trusor muscle tissue itself.
Complications and Sequelae. — Acute re-
tention may be complicated by suppres-
sion of urine or rupture of the urethra.
Chronic retention due to obstruction in
the urinary flow results in undue strain
and congestion of the bladder. The latter
hyl>ertro[>hies to make up for the obstruc-
tion, but finally becomes mechanically in-
sufficient and, as a result, permanently
infected owing to the formation of a pool
of residual urine in which bacteria find a
nidus and multiply. The cystitis may lead
to apparent further hypertrophy, which
represents merely an inflammatory infiltra-
tion and sclerosis of the bladder-wall.
Where the cystitis is less severe, the di-
lating bladder soon comes to present the
appearance of atrophy, its wall not only
being thin, but giving way in places, with
formation of trabecule or diverticulae.
The latter constitute the essential feature
of the so-called sacculated bladder, and
may come to be larger than the organ it-
self. Whatever the severity of the cystitis,
the atrophied condition of the bladder is
eventually reached. The bladder contain-
ing resjdual urine is not infrequently com-
plicated upon exposure of the lower limbs
or dietetic or alcoholic excess, by an at-
tack of acute congestion of the prostate,
which may temporarily transform the par-
tial into a complete retention of urine.
The kidneys in chronic urinary reten-
tion, sooner or later, feel the effects of
the mechanical and other disturbances ex-
isting in the bladder. The congestion and
increased pressure in the bladder, as well
as the resulting hypertrophic changes and
infection, are gradually transmitted along
the ureters to the renal pelves, especially
from the time when the retention of urine
in the bladder has become complete. The
sclerosis attending long-continued ureteral
and renal congestion renders these struc-
tures susceptible to infection, which, how-
ever, is likely to remain mild until the
back pressure has actually pouched them
out. Infection with ammonia-producing
bacteria is then likely to occur, and as a
result gradual, progressive atrophy of the
renal parenchyma takes place.
Treatment. — In acute retention arising
in cases of stricture or prostatic hyper-
trophy an attempt should gently be made
to introduce a small-sized rubber or
woven silk catheter, always with careful
aseptic precautions and lul)rication. But
little force should be used at any time.
If the ordinary type of catheter fails to
enter, one with a narrow olivary tip, or,
in prostatic cases, an elbowed or double-
elbowed catheter may be tried. Relaxa-
tion at the point of obstruction is favored
by keeping the patient warm in the recum-
bent position, or, still better, by placing
him in a hot bath, the temperature of
which is gradually increased to a point as
high as he can stand, even to the point
of nausea and faintness. Remaining in
such a bath for fifteen or twenty minutes
he will often be enabled to urinate while
in the water. Instead, a hot sitz bath at
104° F. (40° C.) may be given for a three-
minute period, to be repeated a quarter of
an hour later, if necessary. If these meas-
ures do not directly provoke urination,
another attempt to introduce a catheter
may be made.
When entrance into the bladder has
been efifected, only about one-half its con-
tents should be drawn ofif the first time —
about 500 to 1000 c.c. (1 or 2 pints)— rapid
complete evacuation of the distended or-
gan having occasionally caused hemor-
rhage, and even collapse and death. Some
time later the catheter may be reinserted
and the remainder withdrawn. If desired,
the organ may then be washed out with
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
721
warm boric acid solution. The patient
should then be kept at rest in bed, prefer-
ably for two days. Hexamethylenamine
should be given by mouth in 7^-^-grain
(0.5 Gm.) doses 3 times on the first day,
then in 5-grain (0.3 Gm.) 2 or 3 times a
day.
Where a rubber or woven instrument
cannot be made to enter the bladder, a
filiform bougie should be tried (see sec-
tion on Stricture of the Urethra). The
patient may, if desired, be placed under
anesthesia, or an injection of morphine
may be given. In prostatic cases a rubber
catheter, stiffened by the insertion in it of
a filiform bougie nearly to its tip, will
sometimes enter where the catheter alone
has failed. A metallic prostatic catheter
may also be tried, but is dangerous, easily
creating a false passage. When a filiform
bougie has been successfully employed a
Gouley tunnelled catheter may be threaded
on it and passed into the bladder; or, the
filiform may be simply fastened in place,
acting as a capillary drain which will
evacuate the bladder in the course of a
few hours. If a general anesthetic has
been given, the patient should then be well
covered, heat applied to the hypogastrium
and perineum, and suppositories of opium
and belladonna employed. Later insertion
of one or more additional filiform bougies
is sometimes advisable in the stricture
cases. Rest in bed should be ordered un-
til the local congestive process has abated,
when dilatation of the stricture or any
other curative measures indicated may be
undertaken.
In occasional cases all attempts to pass
a catheter or filiform into the bladder will
prove fruitless. In such instances tem-
porizing by aspiration of the bladder
every eight hours for one day, or even
longer, will sometimes result in such
abatement of the obsructive congestion
that a filiform or catheter can finally be
passed, especially if preceded by a hot
bath. Aspiration should be preceded by
percussion of the hypogastrium, to make
sure that the Ijladdcr is directly under the
abdominal parietes, and by local shaving
and antiseptic cleansing, e.g., with tincture
of iodine. A sterile aspirating needle 1%
inches (4 cm.) long is then pushed back-
ward and downward into the bladder from
a point about % inch (1 cm.) above the
symphysis pubis. Negative pressure is
then applied and about one-half the urine
in the bladder withdrawn. Suction is kept
up as the needle is being pulled out. The
puncture may be covered with iodoform
and collodion. Infection of the needle
track is uncommon, and is treated by in-
cision and drainage.
Where the insertion of a bougie or cath-
eter is impossible, even after aspiration for
twenty-four hours or longer, some more
radical operative procedure is imperatively
indicated (see Stricture of the Urethra
and Hypertrophy of the Prostate, in this
article). Where circumstances permit,
such a procedure is often promptly under-
taken without resorting to aspiration.
Acute retention of urine due to causes
other than stricture or hypertrophied
prostate may require different measures.
In simple inflammatory obstruction hot
sitz baths, hot-water or sand bags to the
hypogastrium and perineum, and supposi-
tories of opium, together with rest in bed,
will often suffice; if not, a soft catheter
may be used. In phimosis the prepuce
should be longitudinally split and circum-
cision later practised. In occluded meatus
the obstruction should be cut. In reten-
tion after catheterization the patient
should be put to bed and hexamethylena-
mine, laxatives, and diaphoretics given.
In obstruction due to spasm a metal cath-
eter should be pressed gently against the
contracted point until it passes. In fecal
impaction the rectum should be emptied
with a spoon. In retention due to bladder
paresis or nervous disturbance a rubber
catheter should be employed.
In chronic retention the treatment like-
wise differs according to the structures in-
volved (see sections on Hypertrophy of
the Prostate, Chronic Gonorrhea, Chronic
Prostatitis, and Stricture of the Urethra,
in this article; also Cystitis, vol. iii. Kid-
neys, DiSE.xsES OF, and Kidneys and Ure-
ters, Surgical Diseases of, vol. vi, etc.).
In the atony of the bladder resulting
from acute or chronic overdistention (or
from senility), the treatment should con-
sist of systematic catheterization accord-
ing to the amount of residual urine, as in
hypertrophy of the prostate {q. v.^, to-
gether with occasional bladder washings.
8-46
722 URINARY y\ND GENITAT. S^^STI':MS, SURC.ICAL DISEASES (WOOD).
with warm boric acid solution, faradic
electricity, and the internal administration
of strychnine and ergot.
RUPTURE OF THE BLADDER.
— This is usually the result of trau-
matism. The common causes are a
forcible blow in the hypogastrium
and fracture of the pelvis when the
bladder is full. Falls upon the but-
tocks or feet, heavy lifting, and strain-
ing at stool are also possible exciting
causes. Rupture from overdistention
is very rare, and usually occurs in
cases of obstruction due to prostatic
enlargement. Drunkenness, ulcera-
tion, or degeneration of the bladder,
and cystitis are also predisposing
causes. The accident is rare in chil-
dren. The tear may involve that por-
tion of the bladder-wall covered by
peritoneum, in which case the lesion
is said to be intraperitoneal ; if not, it
is described as extraperitoneal. Intra-
peritoneal ruptures result from the
different forms of traumatism, except-
ing fractures of the pelvis, and con-
stitute about four-fifths of the whole
number. The extraperitoneal cases
comprise chiefly fractures of the pel-
vis and rupture from overdistention.
Many of the ruptures take place on
the anterior aspect of the organ, and
many others in the vicinity of the
bladder-neck. Ruptures at the lateral
aspects or base are usually intra-
peritoneal.
Symptoms and Diagnosis. — The
symptoms vary according to the
nature of the accident, and may be in-
definite or absent for a time. Severe
pain and a tearing sensation are often
experienced, however, at the time of
injury. In intraperitoneal rupture the
patient displays more or less pro-
found shock, persistent severe hypo-
gastric pain, a desire to urinate — usu-
ally with inability to do so — and
great difficulty in walking. If a
catheter be carefully introduced, a
little blood or blood-stained urine
may escape, or nothing at all. If now
a measured amount (a few ounces) of
boric acid sf)lution be slowly intro-
duced, there will be no or only a par-
tial return flow. This test, if positive,
is diagnostic of rupture of the blad-
der, but a copious return does not ex-
clude rupture, as if the latter is of
limited extent or valvular all the fluid
may be recovered. Symptoms of
peritonitis may develop speedily or be
delayed several days, depending on
the condition of the urine.
Extraperitoneal ruptures — those in-
volving the base — are accompanied by
less shock, unless there be other in-
juries. Rigidity and tenderness of
the hypogastrium are noted, and
later a doughy infiltration of the
space of Retzius may be palpable.
Tenderness and infiltration may, in
some cases, be noticeable on rectal
palpation. The rent in the bladder
in extraperitoneal cases communi-
cates with cellular tissue, but not with
any cavity ; so that the bladder does
not empty itself as completely as in
intraperitoneal rupture. The urine,
however, and any boric acid solution
used, will return through the catheter
more or less blood-tinged. The es-
cape of urine in the tissues gives rise
to a cellulitis, manifested by pain and
fullness locally, and by fever and the
usual constitutional symptoms of a
severe local inflammation. Extensive
infiltration of the scrotum, perineum,
thighs, abdomen, and even the back
may occur.
The injection test, whether of boric
acid solution or air, is condemned by
some in acute cases on the ground
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
723
that it tends to spread infection and
increase shock.
Where the diagnosis remains in
doubt, the prevesical space should be
examined for extraperitoneal rupture
through a suprapubic incision, before
the peritoneum is opened for deeper
exploration.
Rupture of the bladder is always a
very serious accident. While the in-
traperitoneal variety in untreated
cases shows a somewhat higher mor-
tality than the extraperitoneal, nearly
all cases die. Of 'hi operated extra-
peritoneal cases, 35.1 per cent, recov-
ered (Mitchell) ; of 34 intraperitoneal
cases, 41.5 per cent. (Sieur).
Treatment. — Intraperitoneal rup-
ture indicates immediate laparotomy,
as the condition is otherwise certainly
fatal either from peritonitis or from
absorption of the urine, even if sterile.
The rent in the bladder should be
sewn up after the Czerny-Lembert
method of intestinal suture, the peri-
toneum also sutured, and the efficacy
of the suture line against leakage
tested by running in salt solution
until the bladder is filled. The wound
should then be closed, a gauze wick
being inserted, however, for drain-
age from the site of rupture. A cath-
eter should be retained for a week or
ten days while the wound is healing.
Extraperitoneal ruptures, if inac-
cessible, may be treated by the per-
manent catheter. In sucli cases irri-
gations of the bladder and careful ex-
amination should be made from day
to day for appearances of extravasa-
tion and inflammation either in the
space of Retzius or in the perineum.
Digital exploration of the rectum will
reveal any collection in the pelvis.
Such evidence calls fen- immediate,
free incision. In the cases in which
the ruptured point is exposed in ex-
ploration, the opening should be
sutured and tested, and drainage
through the external wound provided
for.
Wounds and contusions of the blad-
der not involving rupture are dis-
cussed in the article on Abdominal
Injuries, volume i.
CYSTOCELE.— Partial hernia of the
bladder in the male occurs in from 1 to 3
per cent, of all inguinal hernias. The or-
gan may also be involved in a femoral,
abdominal, perineal, or ischiatic hernia.
In inguinal hernia the bladder is extra-
peritoneal in the great majority of in-
stances, and the hernia is usually of the
direct variety in these cases. The diag-
nosis of cystocele, which may be reached
with the sound, is seldom made before the
radical hernia operation. If the organ be
cut into, it should be closed with Lembert
sutures, and permanent catheterization
instituted at the close of the operation.
Cystocele in women is a common
sequel of extensive perineal laceration
during parturition and is usually accom-
panied by prolapse of the uterus. Fre-
quency of urination and dysuria are the
chief symptoms, and cystitis and tra-
beculated bladder are possible sequelae.
These patients sometimes find it neces-
sary to push the prolapsed bladder for-
ward and upward in urinating.
Treatment. — Some relief may be af-
forded by the introduction of a suitable
pessary. Surgical correction of the dis-
placement, in common with that of the
uterus, is, however, to be preferred. (See
Pregnancy and Parturition, Disorders of,
vol. vii, and Uterus, Diseases of, in this
volume.)
FOREIGN BODIES IN THE BLAD-
DER.— Foreign bodies other than vesical
or renal calculi include a large varietj' of
articles introduced in the urethra from
morbid sexual motives and accidentally
slipping out of reach, e.g., pencils, glass
tubes, twigs, pipestems, stones, etc. Por-
tions of catheters or bougies, missiles,
teetli and Iiair from a ruptured dermoid
cyst, and seeds or bone entering through
a fistula may also reach the bladder.
724 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
Symptoms. — Foreign bodies may occa-
sion no symptoms for a prolonged period,
or pain and signs of cystitis may soon de-
velop. There is a tendency to stone for-
mation around any vesical foreign body,
and the symptoms of stone are sometimes
those which lead the subject to the
surjjeon.
Diagnosis. — This is made from the his-
tory or by cystoscopy. In cases of unac-
countable cystitis the possibility of a
known foreign body concealed from the
surgeon because of shame should come to
mind.
Treatment. — The probability of subse-
quent stone formation renders removal of
foreign bodies, even if causing no disturb-
ance at the time, advisable. Cystitis, if
present, having been reduced by rest in
bed and other measures for a few daj's, an
attempt should be made to extract the
foreign bodies with special forceps or a
small lithotrite. If persistent efforts of
this type prove fruitless, and in particular
if the foreign body is of glass, removal
through a suprapubic cystotomy opening
should be effected.
VESICAL CALCULUS.— When
certain of the soHd constituents of
urine are present in excess, a portion
is thrown out of solution in the form
of crystals. When a number of these
become adherent, a small calculus is
formed around which, as a nucleus, a
stone of some size is gradually
formed. A stone may form in the
bladder primarily or may develop
around a nucleus originating- in the
renal pelvis and passing into the
bladder.
Vesical calculi are composed, in the
order of frequency, of uric acid, the
earthy phosphates, and calcium oxa-
late. Stones composed of carbonates,
cystin, xanthin, and indigo are occa-
sionally met with.
The great majority of calculi con-
sist of uric acid. This form is usu-
ally oval, smooth, of moderate size,
and brownish in color, and is soluble
in dilute potassium hydroxide solu-
tion and with eflfervescence in nitric
acid. Uric acid calculi are met with
largely among children of the poorer
families, and in adult life chiefly,
among "free livers." The probable
cause in the former is food unsuited
to the time of life. The use of milk
is discontinued as soon as the child is
able to take solid food. The nitrogen-
ous elements, thus taken in beyond
requirements, are excreted as uric
acid and, being in excess, tend to form
calculi. In the latter class, liberal in-
dulgence in rich foods similarly fur-
nishes an amount of nitrogen far in
excess of needs.
Phosphatic (fusible) calculi occur
in alkaline urine, and there'tore espe-
cially after middle life. They are apt
to be associated with hypertrophied
prostate, the residual urine and
ammoniacal decomposition furnish-
ingf all the conditions necessarv for
the formation of a phosphatic stone.
They consist of magnesium-ammoni-
um phosphate together with calcium
phosphate. They may be of any size,
sometimes weighing several ounces
and less frequently a pound or two.
Calcium oxalate calculi, like the
uric acid stones, originate, as a rule,
in the renal pelvis. They do not at-
tain a large size, and are commonly
more or less round in outline and
dark brown in color. They dissolve
in hydrochloric acid. Their surface is
often mammillated, — a "mulberry"
calculus. These stones form in urine
containing a free deposit of calcium
oxalate crystals, — a condition termed
oxaluria, which appears to be asso-
ciated with disorders of digestion
and assimilation, and also with cer-
tain forms of neurasthenia.
These different constituents are not
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 725
infrequently found in association, in children. Prolapse of the rectum
Calculi composed of alternate layers or involuntary defecation from strain-
of uric acid and calcium oxalate are ing may result. Occasionally the
not unconmion, and either of these stream of urine will be suddenly ar-
compounds, or even a mixed calculus, rested by the stone rolling into the
is 'very apt to form a nucleus for a vesical neck ; this symptom is rare
phosphatic stone. in the old, the urethral orifice being
The causes of stone in the Ijladder often relatively high. The pain may
have already been hinted at, inappro- be constant or paroxysmal, or both,
priate food and an excess of articles As a rule, there is sharp, burning pain
leading to elimination of uric acid or toward the end of micturition, either
calcium oxalate being the potent fac- hypogastric or just behind the glans ;
tors. In the formation of phosphatic the pain then tends to disappear grad-
stones any obstruction to emptying of ually as the bladder fills with urine,
the bladder, chronic cystitis, and (In prostatic hypertrophy pain pre-
other causes of alkaline urine play an cedes, and stricture of the urethra ac-
active role. According to Rainey and companies, urination). Sometimes
Ord, increased density of the urine there is a constant dull ache in the
and the presence of colloids in solu- hypogastric region, especially in pa-
tion are essential factors, in addition tients subjected to constant jarring,
to the excess of urinary salts, in e.g., trainmen and those who drive
stone formations. Considerably more over rough roads. The pain, like the
than half of the vesical calculi are met frequency of urination, is increased
with in patients under twenty years, by activity and lessened by rest. Its
uric acid stones being especially fre- severity depends in a considerable de-
quent at this period of life, and most gree on the roughness of the stone
cases are in males. This is probably surface. Marked prostatic hyper-
accounted for by the much greater trophy and encystment of the stone
facility with which a minute calculus reduce the pain. Acute paroxysms
can escape through the much shorter ("attacks" or "fits of stone"), during
and more dilatable female urethra, which the symptoms are much worse,
Stone in the bladder is more com- occur at intervals as a result of an
mon in certain sections of the world acute infection or some unusual exer-
than in others. In the negTo race tion.
vesical calculus is rare. The urine is apt to contain traces
SYMPTOMS. — Symptoms of stone of the material of the stone, the mi-
are frequent urination, pain, and croscope showing either uric acid,
changes in the character of the urine, calcium oxalate, or pliosphates.
The frequency of micturition varies The presence of a stone usually
greatly in dififerent cases. It is usu- leads to hematuria, generally very
ally greater during the day, when the slight and not apparent to the naked
individual is active, than at night, eye. After exercise, the last part of
The desire for micturition often ap- tlic urine passed at micturition may
pears suddenly and irresistibly. In be tinted witli 1»1(><>(1. In cases of long
some instances urination is attended standing or with cystitis, more or less
by considerable tenesmus, especially pus will be present. Bleeding from
y26 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
the urethra between acts of urination the first instance) cystoscopy may
is evidence against vesical calculus. be availed -of. The X-rays may be of
Priapism and a tendency to exert use in the diagnosis of vesical cal-
traction on the prepuce have occa- 'culus.
sionally been observed in children, TRE ATMENT.— AVhile a stone
and in many cases various reflex pains may exist in the bladder for a long
are present. period without causing much irrita-
A history of renal colic, chronic tion, sooner or later there will be
cystitis, or the introduction of foreign cystitis, and probably infection -of the
material into the bladder may be kidneys. Therefore, if the patient's
obtained. health will at all permit, a vesical cal-
DIAGNOSIS. — The actual pres- cuius should be removed as soon as
ence of a stone in the bladder is de- possible after its detection. Efforts
termined by a vesical sound or stone- to dissolve the stone eitlter by inter-
searcher. This instrument has a shaft nal medication or by irrigation are
rather longer than the urethral bougie not to be recommended. Two meth-
and a shorter curve. It should not be ods are available for its removal, viz.,
larger than about No. 13 French. The litholapaxy and lithotomy,
patient should be recumbent, prefer- Litholapaxy is to be recommended
ably with the pelvis raised. It is in the vast majority of cases. In chil-
desirable to have some urine in the dren below four years of age, how-
bladder or, in the absence of this, to ever, it is often iuTpossible to intro-
inject about 100 c.c. (3|^ ounces) duce an evacuating catheter of suffi-
warm sterile boric acid solution, atten- cient size to carry out the fragments,
tion being paid to every detail of Above this age, with proper instru-
antisepsis. When the instrument, ments, litholapaxy is just as safe and
previously lubricated, has been intro- satisfactory as in th'e adult. Keegan
duced, its toe is turned downward and has performed litholapaxy with suc-
each portion of the bladder system- cess in' numerous small children, some
atically examined. The presence of a below two years of age ; his mortality,
stone is indicated by the sensation im- however, has been 4.3 per cent, in
parted through the instrument to the these cases. If there is a stricture, it
hands of the surgeon, but especially will usually be possible to" treat it
by an audible "click" produced by preparatory to-operating for the stone,
gently striking the stone with the end Occasionally prostatic hypertrophy
of the instrument. The diagnosis interferes with the introduction of the
should be made solely upon the latter lithotrite or the evacuating tubes, and
sign, as a ribbed bladder, especially thus prohibits this operation. In suit-
with phosphatic crusting, may give able cas'es White recommended vasec-
to the sense of touch the evidence of tomy and, after the prostate had un-
the presence of this stone. dergone sufificient atrophy, to proceed
Failure of the searcher to detect a with the litholapaxy. Or, suprapubic
stone does not absolutely prove its lithotomy and prostatectomy in 1 or
absence, as it may be fixed in a diver- 2 stages may be practised,
ticulum or ureter, or in a sac back of Cystitis is not usually a contraindi-
the prostate. In case of doubt (or in cation, as it can be treated beforehand
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 727
by urinary antiseptics internally and
bladder irrigations. In cases with -an
obstinate ammoniacal cystitis, how-
ever, or with a severe pyelonephritis
or prostatic abscess, requiring- good
drainage, perineal or suprapubic
lithotomy may be preferable.
The advantag-es of litholapaxy are
its safety (in experienced hands), the
avoidance of a wound, and the short
convalescence, uncomplicated cases
leaving- the house in from two to five
days" after the operation. A cutting
operation confines the patient to bed
for some weeks, and there is always
some danger of a urinary fistula re-
maining.
Lithotomy. — Cases occur in which the
crushing operation is inappropriate. In
addition to the contraindications already
mentioned, if it is suspected that the
nucleus of the stone is a foreign body of
any kind, introduced into the bladder by
accident or otherwise, 'it will be necessary
to perform lithotomy. In rare instances
also it is impossible to crush the stone
because of its hardness or its large size.
In cutting for stone the bladder may
be approached either suprapubically or
through the perineum. For removing
stones more than lYz inches in diameter
and for inspecting the bladder if any such
indication exists, the suprapubic method
should be selected. For smaller calculi
many prefer the perineal incision. Others,
however, open the bladder above the
pubes in every case. If the bladder-walls
are healthy, it is often possible satisfac-
torily to unite the bladder incisions by
sutures in the suprapubic operation, thus
overcoming one of the serious objections
to perineal lithotomy.
Before subjecting a patient to any
operation for stone in the bladder phenyl
salicylate or boric acid in doses of 10
grains (0.6 Gm.) 3 or 4 times a day
should be given for a few days; or, hexa-
methylenamine or urotropin in a dosage
of from 20 to 30 grains (1.3 to 2 Gm.) in
twenty-four hours, may be used. In
cases complicated by marked cystitis,
especially before litholapaxy, it is also ad-
visable to practise irrigation of the blad-
der 2 or 3 times daily for a few days be-
fore operation. A diet chiefly of milk and
more or less absolute rest for a few days
also add to the success of the operation.
A purgative should be given on the day
preceding the operation. If a cutting
operation is proposed, the parts should be
cleanly shaved and prepared as for other
operations. All of the instruments and
other articles to be used should be as
carefully sterilized as for any other
operation.
Technique of Litholapaxy. — The instru-
ments required for this operation are a
lithotrite, evacuator, evacuating catheters,
ordinary catheters of dififerent kinds, a
vesical sound, warm boric acid solution, a
syringe for irrigating the bladder, and
suitable receptacles. A basin or jar with
three or four thicknesses of gauze secured
over the top should be prepared to receive
the stone. One should have at hand in-
struments for lithotomy in the event that
litholapaxy should fail for any reason.
Of the lithotrites upon the market the
two chief forms are those of Bigelow and
of Weiss. Either will be found entirely
satisfactory. For children a special in-
strument has been designed by Weiss. Of
the various forms of evacuators, that de-
signed by Bigelow is perhaps the most
satisfactory. It should be fitted with sev-
eral evacuating catheters of dififerent sizes.
Before the operation the penis and pre-
puce should be well disinfected with green
soap and mercury bichloride solution, and
thorough irrigation of the anterior ure-
thra practised.
Ether having been administered, the first
step should always be the introduction of
the stone-searcher, to be certain that the
stone is still in the bladder. Unless the
surgeon can demonstrate its presence by
sound to at least one person besides him-
.self, it should be the rule to abandon the
operation. In such an event, subsequent
examinations may be. made and the subse-
quent course decided accordingly. If the
stone is detected, the next step should be
to introduce a suitable lubricated catheter
and withdraw the urine. The Ijladdor
should then be irrigated with warm boric
acid solution — 10 to 15 grains (0.6 to I
728 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
Gm.) to the ounce (30 c.c.) of sterile
water — until the fluid returns clear. A
quantity of the solution should now be
introduced and allowed to remain, the
catheter being withdrawn. In the adult
this quantity may be about 6 fluidounces
(180 c.c); for a child, 2 or 3 ounces (60
to 90 c.c). The patient should be in the
supine position, with the legs extended
but slightly separated.
The lithotrite is next lubricated and
carefully introduced into the bladder. A
right-handed surgeon may introduce it
while standing to the patient's left, but
should then pass to the right side of the
patient for the subsequent manipulations.
The instrument, having been introduced,
should be moved back and forth slightly
to see that it is free, and the beak then
turned toward the base of the bladder.
The ratchet which binds the two blades
should be released and the jaws separated
1 or 2 inches and again brought together.
If the stone is not caught the manipula-
tion is repeated, shifting the points in or-
der to sweep the different portions of the
base of the bladder. When the stone is
caught, the blades are held firmly together
and locked, after which the instrument is
revolved until the beak points anteriorly,
when the stone is crushed by screwing
down the handle. The blades are then re-
leased, turned again tow^'d the base of
the bladder, another fragment picked up,
turned forward, and crushed as before.
This procedure is continued until the in-
strument fails to seize any fragments too
large to be withdrawn through the evac-
uating tube. The blades of the instrument
are then tightly closed and locked, after
which it is withdrawn.
The largest evacuating catheter that will
pass easily should now be introduced, care
being taken to prevent any of the fluid
from escaping from the bladder, and the
evacuator — previously filled with warm
boric acid solution — attached. By alter-
nately compressing and relaxing the bulb
the fragments will be drawn into the lat-
ter and fall into the glass receptacle be-
low. This should be continued until no
more fragments are brought out. If bleed-
ing from the bladder colors the boric solu-
tion deeply, the bulb may be emptied and
refilled, the stop-cock on the outer end of
the catheter being closed meantime to
prevent escape of fluid. If during evacua-
tion of the fragments a click is repeatedly
heard as the bulb is relaxed, a fragment
remains which is too large to pass through
the eye of the catheter, and the lithotrite
will have to be reintroduced to reduce it.
When the bladder appears empty of frag-
ments the stone-searcher should be again
introduced, and if any portion of the stone
remains it should be crushed and removed.
It is undesirable, however, to reintroduce
the lithotrite oftener than absolutely nec-
. essary; the crushing process should be
carefully carried out, and as far as can
be determined, fully accomplished before
withdrawing the instrument. Finally, the
bladder should again be irrigated with
warm boric acid solution until the fluid
returns clear, when 2 or 3 ounces (60 to
90 c.c.) maj' be introduced and allowed to
remain. The patient is then returned to
his bed, and, if the operation has been a
long one, external heat applied and hot
compresses placed over the hypogastrium.
The urinary antiseptic should he continued
and the diet restricted to milk for two or
three days, until it is evident that con-
valescence is assured. Patients otherwise
healthy and who do well may be allowed
out of bed on the second or third day.
Clogging of the lithotrite during op-
eration is impossible with the modern
fenestrated instruments. Unusually hard
stones can generally be dealt with by
means of the Chismore lithotrite, which is
provided with an automatic hammer.
Unduly rough litholapaxy maj- be fol-
lowed by retention of urine, excessive
hemorrhage, cj'stitis, urethral fever, pros-
tatic abscess, epidiymitis, and even pj^e-
lonephritis. Prostatic catarrh may follow
even expert litholapaxy.
Cystoscopy should, if possible, be prac-
tised one month after litholapaxy to make
sure that no fragment of stone has been
left behind.
Technique of Lithotomy. — In general, in
adults the perineal route should be selected
under the following circumstances: (1) In
cases- of deep urethral stricture rebellious
to dilatation, in which, using the median
method, the stricture may be divided at
the same time. (2) In cases of stone of
moderate size and of such hardness and
tr
^-^:-VP.
I
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
729
.
nil
•^•^<!Te
density as to make too great demands on
the strength of the lithotrite or of the op-
erator. This condition occurs very rarely.
(3) In cases of atony of the bladder, with
little or no expulsive power, where there
is already a chronic cystitis, and where the
stone is of medium size.
Suprapubic lithotomy should be selected:
(I) when the stone is unusually large, and
also believed to be of exceptional hard-
ness; (2) in cases of marked prostatic
hypertrophy with pouched bladder, chronic
cystitis, and large stone; and (3) some-
times when the kidneys are diseased. In
children too young to permit of introduc-
tion of the litholapaxy instruments, the
lateral perineal operation is the method of
choice.
Pekineal Lithotomy. — Lateral.- — The in-
struments required are a grooved staff,
lithotomy knife, probe-pointed bistoury,
lithotomy forceps, lithotomy scoop, a
large-sized pure-rubber catheter, a cath-
eter en chemise, heinostatic forceps, scis-
sors, ligatures, and sutures.
The patient having been etherized, the
vesical sound is introduced and, if the
stone is detected, the operation proceeded
with. The urine is withdrawn, the blad-
der irrigated with warm boric acid solu-
tion, 6 or 8 fluidounces being allowed to
remain. The patient is then so arranged
that the buttocks project slightly from the
end of the table; the thighs are flexed
upon the abdomen and the legs upon the
thighs and retained in this position by as-
sistants or a Clover crutch. The grooved
staff is then introduced and placed in
proper position by the surgeon, after
which it is hebl accurately in this position
by an assistant. The handle should be
held either perpendicularly or inclined
slightly toward the patient's right groin,
and should be drawn well upward so that
the curve rests against the under surface
of the symphysis pubis The surgeon
should then fix in his mind the central
point of the perineum, which is midway
between the anus and the perineoscrotal
junction, and in the adult is about 1>^
inches in front of the former. Finally ob-
serving that the staff remains in proper
position, a lithotomy knife is introduced
vertically in the direction of the staff at
the central point of the perineum, just to
the left of the raphe, and carried down-
ward and outward a-cross the left ischio-
rectal space, terminating on a line between
the anus and the left ischial tuberosity,
rather nearer to the latter than the former.
This incision is deepest at the beginning
and becomes shallower at the posterior
extremity. It passes through the skin,
superficial fascia, transverse perineal mus-
cle, nerve, and vessels, the lower edge of
the anterior layer of the triangular liga-
ment, and the inferior hemorrhoidal ves-
sels and nerves.
The surgeon then introduces the left
index finger into the wound, and locates
the groove of the staff. The knife is now
passed along the finger and made to en-
gage in the groove, after which it is
pushed along toward the bladder, being
careful not to allow it to escape from the
guide until the gush of fluid indicates that
the bladder has been reached, when it is
made to cut downward and outward in the
line of the first incision. This divides the
membranous and prostatic portions of the
urethra, the compressor-urethr?e muscle,
the posterior layer of the triangular liga-
ment, a few fibers of the levator-ani mus-
cle, and the left lobe of the prostate. The
left forefinger should then be introduced
into the bladder, using the staff as a guide,
and when the stone is felt the staff with-
drawn, the lithotomy forceps introduced
along the finger and made to seize the
calculus, which is then extracted.
In children, in whom it is desirable to
operate through as small an incision as
possible, the lithotomy forceps may be in-
troduced along the groove of the staff and
the stone extracted without introducing
the finger at all. Little difficuly is experi-
enced in finding the stone in children, as
there is no pouching of the bladder. Oc-
casionally the stone is found too large to
be extracted through the incision; it may
then be broken into 2 or more fragments
with a lithotrite introduced through the
wound. It is desirable* to extract a stone
without fragmentation when possible, but
this should not be done at the risk of in-
juring important neighboring structures.
Finally, the bladder is explored to make
sure that other calculi do not exist, the
wound inspected for any bleeding vessels
to be tied, a large rubber catheter intro-
730
l-RIXARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
duced, the bladder irrigated, and a little
iodoform gauze laid in the superficial por-
tion of the wound around the catheter, —
which should be held in place by sewing
to the edge of the incision, — and a dress-
ing and T-bandage applied.
Usually the hemorrhage following the
incision subsides after the patient's legs
are brought together. If pronounced
bleeding continues from the deep portion
of the wound, it is best controlled by in-
troducing a catheter en chemise, made by
passing the end of a large rubber catheter
for about 2 inches through the center of
4 layers of sterile gauze about 8 inches
square and fixing the gauze in this posi-
tion by tying firmly with silk thread. This
is then introduced into the wound arrd
gauze packing placed firmly and evenly
around the catheter and inside the gauze.
The patient's knees should be bent over
pillows, the scrotum elevated, and the
linen under the patient changed when it
becomes wet. The catheter tube may be
taken out in forty-eight hours. By the
eighth to the twelfth day urinary flow
through the urethra will return. In chil-
dren no catheter tube is required.
Occasionally when the artery of the
bulb has been divided, hemorrhage is so
free as to demand a ligature or the appli-
cation of pressure forceps, which may be
allowed to remain one or two days. The
internal pudic artery has been wounded
by carrying the incision too far outward
toward the tuberosity of the ischium;
bleeding from this source may be similarly
arrested. The rectum has also been
wounded by carrjnng the incision too far
inward and failing to keep the blade of
the knife sufficiently lateralized; usually
the rectal wound heals spontaneously.
Median perineal lithotomy is performed
through an incision directly in the mid-
line of the perineum. The patient is
placed in the same position as for lateral
lithotomy, and the staff introduced, held
vertically, and drawn well up under the
pubes. The left index finger is introduced
into the rectum and the groove of the
staff located at the apex of the prostate.
A knife with a double cutting edge at the
point and a cutting edge of about 3 inches
on one side is introduced with the long
cutting surface upward 1 inch in front of
the anus and directed to the groove in the
staff at the point located by the finger.
When the point of the knife has reached
the groove of the staff, it is pushed on-
ward toAvard the bladder, so as to in'cise
the apex of the prostate and then with-
drawn, cutting upward for Y^ to» 1 inch. A
probe-pointed grooved director may then
be passed into the bladder on the groove
of the staff, to be used as -a guide for in-
troduction of the finger or lithotomy for-
ceps. There is comparatively little hemor-
rhage, but the operation provides only a
A-ery limited space in which, to work, and
is therefore suitable for calculi of the
smallest size only. The incision also ap-
proaches closely to the bulb anteriorly and
the rectum posteriorly, either of which
may be injured if the knife is carried
slightly beyond the limits mentioned.
Perineal lithotomy has gradually been
losing in popularity in fa.vor of -suprapubic
lithotomy, which, in adults at least, yields
a distinctly smaller mortality.
Suprapubic Lithotomy. — The instruments
required include scalpels, dissecting for-
ceps, hemostats, retractors, rectal bag,
lithotomy forceps, lithotomy scoop, cath-
eters, syringe, stone-searcher, scissors,
needles, and sutures.
The preparation of the patient has al-
ready been described. A-fter anesthesia
the presence of the stone should be de-
termined before proceeding. The next step
is th'e introduction of the rectal bag, pre-
viously oiled, well aj^ove the internal
sphincter. A catheter is then introduced,
the urine withdrawn, and the bladder
irrigated with warm boric acid solu-
tion, from 6 to 10 ounces (180 to
300 c.c.) being allowed to remain. A
catheter or rubber tube should be tied
round the penis to prevent expulsion of
the solution. From 8 to 10 ounces (240 to
300 c.c.) of boric solution should then be
injected into the rectal bag and retained.
In children the quantities of fluid in the
bladder and rectal bag should be much
smaller; or, owing to the higher position
of the bladder, the rectal bag may be dis-
pensed with altogether.
The incision should begin in the mid-
line about J/2 inch below the symphysis
pubis, and in the adult may be carried up-
ward about 3 inches. The incision is care-
L,,..-^ -,.
"J
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
731
'^i A
SilJiOtS,
N
,r-f;r
fully deepened, either between the muscles
or through them, until the transversalis
fascia is reached. This being divided, the
prevesical fat and connective tissue are ex-
posed. It is desirable to reach the bladder
by blunt dissection from this point, push-
ing upward the fat and connective tissue,
which often contain a number of large
veins, with the finger and scalpel handle;
this also raises the peritoneum out of dan-
ger. The peritoneal reflexion may be ab-
normally low in any case, and may be
opened if due caution is not observed.
The bladder having been exposed, all
bleeding should be controlled by pressure-
forceps, the bladder-wall transfixed with a
sharp" hook, and a scalpel thrust vertically
into the bladder, cutting downward toward
the symphysis. The edges of the bladder-
opening may then be caught with tenacula
or transfixed with needles carrying strong
silk threads. The forefinger may now be
introduced, and the stone located and re-
moved with forceps. Making certain that
the bladder is empty, if the walls are in a
healthy condition, one may close the in-
cision with chromicized catgut sutures.
These should be passed close together and
include all the coats except the mucous
membrane. The abdominal wound is
closed by suturing, a small drainage-tube
being introduced through the external
wound and retained until it is certain that
the bladder incision is going to heal
kindly. A catheter should be introduced
through the urethra and retained for a
week or ten days.
If the bladder-walls are unhealthy or
there is pronounced cystitis, so that im-
mediate suture is unsafe, the margins of
the bl dder-wound may be united by a few
stitches to the deeper portion of the ab-
dominal incision and a large drainage-tube
introduced. Siphon drainage by means of
a long tube reaching to a bucket on the
floor, with or without an attached recep-
tacle above containing fluid, is here very
useful in preventing the urine from satu-
rating the dressings and excoriating the
skin. The bladder should be frequently
irrigated and the skin around the wound
cleansed and protected with an antiseptic
ointment. As soon as the condition per-
mits, the external drainage should be re-
moved and the wound allowed to close.
TUBERCULOSIS OF THE
BLADDER. — The majority of cases
of tiiJDerculosis of the bladder occur
before the fortieth year. It is nearly
always secondary to- deposits else-
where, but 'Occasionally seems to be
primary. Many of the secondary
cases follow tuberculosis of th'e kid-
ney or an ascending- infection from
the epididymis. More rarely there
is direct extension from the prostate
or seminal vesicles.
Symptoms. — These develop insid-
iously. Advice is rarely sought until
the disease has lasted for some time.
The onset of symptoms may be in-
duced by urethral instrumentation.
The earliest manifestation is either
increased frequency of urination or
hematuria. The latter is characteris-
tically a terminal hematuria, i.e., is
most marked at the end of urination,
*and. is never very profuse, but when
once established tends to persist for
some time, the urine showing- at least
a light, microscopic sediment of red
cells. The bleeding occurs both day
and night, and different from that of
stone, is unaffected by exercise or
jolting. Pain generally follows sooner
or later. It is mild in some cases and
severe in others ; deposits at the neck
of the bladder always cause consider-
able pain. At first the pain, felt in
the penis -and perineum, occurs only
at the close of urination ; later, when
mixed infection has supervened or
ulcers developed, it is also experienced
l^efore urin"ation. Pus and blood iix
the urine are merely the result of the
ulcerating process, and not of the
tuberculosis per se. Cystitis develops
sooner or later, the pain, frequency of
urination, and tenesmus being then
much increased.
A characteristic feature is that the
^2,2 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
urine remains persistently acid, even
after mixed infection has been estab-
lished. The finding- of casts in the
urine suggests renal involvement.
Diagnosis. — There is nothing pecul-
iar about the symptomatology. The
diagnosis must rest upon the detec-
tion of tubercle bacilli in the urine of
a person who has the symptoms of
chronic cystitis, and upon cystoscopy.
Even if bacilli are found, one is often
unable to determine whether they
emanate from the kidney or the blad-
der, except by urethral catheteriza-
tion. Again, bacilli are not detected
in some cases of genuine vesical
tuberculosis. It is possible to have
renal tuberculosis in conjunction with
a non-tuberculous cystitis. The diag-
nosis will usually be made (1) by ex-
cluding the common causes of cystitis
— gonorrhea, vesical calculus, urethral
stricture, and hypertrophied prostate
— by the usual methods of detecting
these conditions, and (2) by noting
the evidences of marked cystitis with
tubercle bacilli in the urine and with-
out symptoms referable to the kid-
ney. A tuberculous family history or
the presence of a tuberculous lesion
elsewhere, e.g., in the testicles, pros-
tate, or lungs, would point to a simi-
lar condition in the bladder. Re-
peated examinations should be made
before deciding that tubercle bacilli
are absent.
Cystoscopy is likely to yield valu-
able evidence, either by showing the
presence of a tuberculous process or
by establishing its absence. If the
disease is present, groups of minute
whitish tubercles with surrounding
zones of congestion, or tuberculous
ulcers, round, relatively small, with
an uneven, yellowish floor and ele-
vated, slightly undermined edges
(Coplin), may 1)e discovered. Con-
centration of the lesions about tiic
ureters if the disease has been pri-
mary in the kidneys, or about the tri-
gone, if i)riniary in the prostate, may
be noted. The mucous membrane as
a whole may appear red and velvety.
Where no cause can be found in the
bladder, it is well to catheterize tiie
ureters separately to locate the seat
of the disease.
Treatment. — In the early stages, if
it is possible to build the patient's
health up by generous feeding, tonics,
suitable climate, etc., the disease may
be arrested and healing follow. The
urine should be kept as healthy as
possible with a urinary antiseptic and
by the free use of milk and water.
Creosote, balsamics, and alkalies may
all l)e of value. In early cases local
treatment is to be avoided. Later the
gentle introduction of a small quan-
tity of a 10 per cent, mixture of iodo-
form in sterilized olive-oil or glycerin
every few days may be tried. It may
be preceded by irrigation of the blad-
der, but if any e\'idences of irritation
follow, this should not be repeated.
Irrigations of bichloride of mercury,
beginning with 1 : 5000, are highly ex-
tolled by Guyon. For relieving vesi-
cal spasm, Keyes has found mercury
bichloride, guaiacol valerianate, and
thallin most useful. The first is in-
stilled daily in 2- to 10- minim (0.12
to 0.6 c.c.) amounts of a very dilute
solution, at first 1 : 25,000, then in-
creased according to tolerance. Guai-
acol valerianate is used in 25 to 100
per cent, solutions in olive oil, and
thallin sulphate 3 to 12 per cent,
aqueous solutions, 2 or 3 times
weekly. For frequent pain, tenesmus,
and urination, suppositories of opium
and belladonna may be used.
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 733
When the pain and frequency of ous, painless, and profuse. It is prac-
urination become unbearable and fail tically uninfluenced by rest or drugs,
to respond to treatment, it will and may be continuous or typically
i)e necessary to perform suprapubic cease spontaneously. If there be any
cystotomy for the purpose of drain- relationship of the hemorrhage to
age. At the same time it is occasion- micturition, it tends to occur at the
ally possible to remove the disease, if terminaion of the act. The urine con-
superficial, with curette, knife, or tains blood-clots and, in malignant
cautery. The rest afforded by pro- cases, pus, mucus, and at times frag-
longed drainage of the bladder is one ments of tumor. Only occasionally is
of the most potent therapeutic fac- hemorrhage not the initial symptom,
tors. In some instances good results, being preceded by pain and dysuria,
and even cure, are obtained by irri- frequent urination or cystitis.
gating the bladder through the cys- The pain in malignant cases may
totomy wound with iodoform, bi- be lancinating and very severe. Pain
chloride, or guaiacol solutions. It is may also arise from cystitis, the pass-
always difficult to decide when the age of blood-clots, or urethral ob-
suprapubic opening may be allowed struction. In some instances acute
to close in cases that progress favor- or chronic retention of urine occurs,
ably. In general, this should not be from obstruction either by a blood-
until the evidences of cystitis have clot or the growth itself. Cystitis,
disappeared. once established, is manifest in a
TUMORS OF THE BLADDER, peculiarly severe form, and, unless the
— Varieties. — Most bladder tumors inflamed tumor be removed, is likely
are at first papillomatous, later under- eventually to extend to the kidneys,
going malignant degeneration. Much Etiology and Pathology. — Bladder
less frequent are fibromatous and tumors constitute about 4 per cent, of
myxomatous polypi, sarcoma, mixed all cases of genitourinary disorder in
tumors, adenoma, myoma, angioma, the male. In the female they occur
chondroma, nevus, and cysts, the only one-fifth to one-half as fre-
Intter dermoid, hydatid, or epithe- quently as in men. They are met
lial. A condition of epidermization of with usually in the elderly, though the
the Ijladder analogous to leukoplakia rare sarcomatous and myxomatous
of the tongue, resulting from pro- tumors are peculiar to the young,
traded chronic inflammation, has also Carcinoma is by far the. commonest
been observed. bladder growth, occurring about .S
Symptoms. — Ucnign tumors of the times as often as papilloma, wiiich
bladder often produce no symptom comes next, and about 30 times as
l)ut liemorrhage, seldom causing blad- often as myxoma.
(Kt irritation or cystitis. In malig- About one-third of all bladder
nant growths hematuria is likewise tumors are multiple. They almost
the chief symptom, which, however, always start at tiie base of the organ,
is sooner or later accompanied by generally in the vicinity of the ure-
])ain and difficulty of urination and tcral openings, less often near the
signs of cystitis. TIic hemorrhage of neck of the bladder. The papilloma-
bladder tumor is typically spontane- tons growths consist of a series of
734 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
delicate, finger-like masses which villfms tumors may cause no hemor-
float out in the urinary fluid like rhage. liimanual examination with a
marine plants, and are provided with finger in the rectum will reveal the
definite pedicles. Microscopic exam- tumor if distinct infiltration of the
ination of the base of the growth base of the organ has already oc-
sometimes reveals a carcinomatous curred, but pai)illomas or small ses-
structure- but even the ordinary pap- sile growths will not 1)e detected;
illoma often has malignant proclivi- such examination will, in addition, ex-
ties, tending to recur unless removed elude general hypertrophy of the
early and inoculating itself into ad- prostate.
jacent tissues by mere contact. Cystoscopy with the irrigating in-
Carcinomas other than those origi- strument, care being taken to exam-
nating in papilloma are in the major- ine minutely each surface of the blad-
ity of cases secondary to cancer of der for growths in order that none
the rectum, prostate, or uterus. The may be overlooked at operation, is
primary carcinomas are sessile, fun- the chief procedure in positive diag-
gating, ulcerating growths, which nosis. If necessary, general anesthe-
penetrate deeply in the thickness of sia may be induced for the special
the bladder-wall and spread by infil- purpose of cystoscopy. Where the
tration as well as by contact. Metas- latter is entirely impracticable, some
tasis occurs to the iliac lymph-glands direct information may be gained by
and later to the lumbar glands, the use of a stone searcher if the
Malignant tumors of the bladder, as growth be large or hard or if it can
a whole, progress far more slowly, be readily made to bleed, the lat-
however, than cancer of the prostate, ter observation suggesting papillae,
and produce death by cystitis and as- Suprapubic cystotomy may also be
cending infection rather than by car- performed, with the additional inten-
cinosis. tion of excising the tumor if any
Sarcoma of the bladder may be of exists,
one of a variety of simple or mixed Prognosis. — Any untreated blad-
types, and is a sessile or infiltrating der grow^th finally proves fatal, owing
growth. It progresses rapidly. to the infection sooner or later super-
Diagnosis. — Hemorrhage which is added. Papilloma always turns event-
copious, little or not influenced by ually into carcinoma. Before cystitis
exercise, painless, associated with the sets in the general health may remain
passage of large clots, and which may good in spite of the hemorrhages,
be brought on by the insertion of When the infection does occur, the
a catheter or other instrument, is health is more rapidly undermined,
strongly suggestive of a vesical Yet the' patient with bladder carci-
growth. Pieces of growth easily mis- noma is likely to live several years.
taken for blood-clots are likely to be Treatment. — Early surgical removal
passed where there is papillomatous of bladder tumors is, unless the con-
tissue; or, groups of cancer cells or dition be already an inoperable one,
pieces of a fibroma may be found ; always indicated. If cystitis does not
otherwise the urine ofifers little that yet exist, great care should be taken
is diagnostic. Non-ulcerated and non- not to infect the bladder before the
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
735
operation is carried out. Urinary
antiseptics should be given for pro-
phylactic purposes. If hemorrhage is
troublesome the patient may be put
to bed and alum in the form of
Squibb's Surgical Powder, a heaping
teaspoonful suspended in 500 c.c. (1
pint) of hot water (Keyes), injected
into the bladder. A hot solution of
gelatin, or a dilute solution of silver
nitrate, or one of antipyrin, may be
substituted. For the evacuation of
clots Keyes recommends irrigations
through a large woven catheter or
repeated irrigations and aspirations
with the Bigelow evacuator (see sec-
tion on Stone in the Bladder).
For the elimination of papilloma-
tous bladder growths the high-fre-
quency current (fulguration) has been
highly recommended. Where this
method is not availed of, if the growth
is a papilloma or benign tumor, re-
moval through a suprapubic incision,
followed by cauterization of the base
of the tumor, is the procedure of
choice.
Where, however, the growth is
sessile or infiltrating, this method is
inadequate, and must be replaced,
when the growth is situated high up
or laterally, by resection of the por-
tion of the bladder bearing the growth.
When, as is usually the case, the
tumor is at the base of the bladder,
such partial resection becomes ex-
ceedingly arduous, the ureters, nearly
always involved, having to be cut off
and transplanted into the remaining
part of the bladder, and preservation
of the function of the urethra b"eing
also necessary. In many instances
total cystectomy, though a most seri-
ous operation, is therefore preferred.
This procedure should be preceded by
bilateral lumbar nephrostomy; or the
ureters may be implanted in the rec-
tum or vagina.
The mortality of total cystectomy
being somewhat over 50 per cent., the
operation is of relatively little value,
and in such cases, as well as in those
more advanced in which over one-
third of the bladder is already in-
volved in the tumor, a palliative oper-
ation, suprapubic cystotomy, is by
many considered preferable. Often
the tumor can simultaneously be re-
moved in part with the knife or
curette, and its base be carefully cau-
terized. Marked symptomatic relief
is thus frequently obtained, though
the operation is not a curative one.
Suprapubic cystotomy is also an op-
eration of last resort in obstinate
bleeding and cystitis. Barringer and
Schmitz ( 1918) have reported grati-
fying results from radium treatment
in bladder carcinoma. According to
the former, its effects are quite equal
to those of surgery.
ULCER OF THE BLADDER.— Blad-
der ulcerations other than tho^e arising
from tuberculosis and malignant disease
may occur from injury, simple cystitis,
gonorrhea, or may very rarely be "idio-
pathic." The traumatic ulcers are due to
injury b-y a stone in the bladder or to
crushing of the bladder-wall during child-
birth. According to L. E. Schmidt, gon-
orrhea, while usually manifest merely as a
relatively mild inflammation of the trigone,
occasionally causes a multiple ulceration
attended with marked pain and hematuria.
The same author finds a solitary, sharply
defined ulcer common in anemic women,
while Fenwick describes an idiopathic ul-
cer occurring usually between the ureteral
orifice and the median line, and giving rise
to symptoms similar to those of bladder
tuberculosis, though benefited by irriga-
tions. Uunner (1915) has described an
obscure and painful form of ulcer occur-
ring in the vertex or free portions of the
bladder. It appears as a white, scar area
beside a red spot, and requires excision.
736 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
Diagnosis. — The presence of bits of
bladder-tissue, with blood and clots, in the
urine indicates ulceration. In some kinds
of ulcer cases, however, the urine may be
limpid. A more definite diagnosis is
reached by cystoscopy or exploratory su-
pra-public incision.
Treatment. — Antiseptic irrigations of
the bladder maj' be practised, urinary anti-
septics given internally, and the ulcers
curetted through the operating cystoscope.
In the anemic cases iron should be given.
If the ulcers are extensive it maj- be ad-
visable to curet through a suprapubic
opening and drain. If perforation should
occur, treatment as for rupture of the
bladder ((/. z:) should be instituted.
VARICOSE VEINS OF THE BLAD-
DER.— This is an uncommon condition,
manifesting itself in sudden copious hem-
orrhage from the bladder. The diagnosis
has been made only by cystoscopy or an
exploratory operation.
Treatment. — Cauterization or suture of
the bleeding point after suprapubic cystot-
omy is required if the hemorrhage fails
to stop of itself.
FISTULA OF THE BLADDER.—
Among the most important varieties of
fistula of the bladder is the vesicointestinal
fistula. This is rarely congenital. The ac-
quired type is usually a vesicorectal, less
frequently a vesicosigmoid channel, and
may be due to malignant disease, tuber-
culosis, ulceration of a sigmoid divertic-
ulum, ulcer of the rectum, stone in the
bladder, trauma, or one of various other
causes. It is manifested in the passage of
gas and later feces from the urethra, wnth
resulting cystitis, and by the passage of
urine through the anus. The diagnosis
may be clinched and amplified by the in-
gestion of carmine, which will appear in
the urine; by the injection of methylene
blue into the bladder, the stain appearing
in the feces; by the ingestion of a bismuth
meal and subsequent X-ray examination;
by cystoscopy, and, if the fistula enters the
rectum, by the finger in the rectum or in-
spection through a rectal speculum.
Vesicovaginal, vesicouterine, and hypo-
gastric fistulas are also met with.
Treatment. — In vesicointestinal fistula
daily irrigation of the bowel and the blad-
der may, with advantage, be practised.
Surgical correction of the trouble may be
tried by celiotomy; evacuation, clamping,
and liberation of the loop of bowel adher-
ent to the bladder; repair of the opening
in the bowel, with or without excision of
a diseased section, and closure of the blad-
der opening with mattress sutures, to be
followed by drainage to the area of blad-
der suture, continuous catheterization and
maintenance of a tube in the rectum for a
few days. Where the condition is an in-
curable one, a palliative colostomy may be
performed.
Vesicovaginal fistula is treated as de-
scribed in the article on Vagina and
Vulva, Diseases of, in this volume.
In vesicouterine fistula, radical correc-
tion consists in dissecting out the fistulous
tract and suturing the surrounding tissues
either through and through — exclusive of
th^ vesical mucosa — or in layers. If all
attempts of this tj^pe fail, the uterine cer-
vix may be entirely closed up, after re-
moval of its mucous membrane, while the
fistula connecting with the uterus is al-
lowed to remain.
In hypogastric fistula spontaneous firm
closure will often take place eventually,
provided obstruction in the urethra has
been overcome. If such obstruction has
been only in part relieved a permanent
catheter in the urethra may greatly favor
closure of the fistula. In cases persistently
refractor}', the fistulous tract should be
excised, the bladder liberated from the
parietes, and the opening in it closed with
mattress reinforced by Lembert sutures.
Drainage from the wound should be pro-
vided for and a catheter kept in the ure-
thra to reduce strain on the bladder
sutures and facilitate healing.
DISEASES OF THE SEMINAL VES-
ICLES.
ANOMALIES of these organs are rare,
and seldom unassociated with abnormali-
ties of other genital organs. Absence of
one vesicle has been recorded. Anomalies
of the ejaculatory ducts sometimes occur,
these ducts discharging at the external
urinary meatus or into the ureters.
WOUNDS of the seminal vesicles are
almost invariably operative, the ducts be-
ing often injured in perineal operations on
the prostate or bladder. Obstruction of
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD).
737
rectal fossa is noted, the abscess may
open from the rectum or perineum.
CHRONIC SEMINAL VESICU-
LITIS usually develops insidiously
in subacute or chronic gonorrhea, but
may follow acute vesiculitis. It is a
frequent, but inconspicuous compli-
cation of prostatic hypertrophy.
Chronic prostatitis always coexists.
Symptoms. — The symptoms grreatly
reseml)le those of chronic urethritis
itself, including' an irregular gleety
discharge and frequent micturition.
Disturbances in the sexual sphere
are, however, likely to be more
marked, sexual weakness, nocturnal
emissions, and blood-stained semen
being especially noted. A character-
these ducts, spermatic fistula, or seminal
vesiculitis may result. Occlusion of a
duct does not lead to dilatation of the cor-
responding vesicle.
CONCRETIONS not infrequently oc-
cur in the seminal vesicles in old men,
and occasionally give rise to spermatic
colic, — a sharp, colic-like pain felt chiefly
near tiie anus or bladder-neck and occur-
ring either at the orgasm or during
sleep. The obstruction in the duct which
causes it, viz., impacted concretion or
dried semen, is often soon removed,
though at times pain persists for a num-
ber of minutes.
Treatment. — The immediate treatment
for spermatic colic is a hot rectal douche
(see Treatment of Chronic Urethritis);
enduring relief is obtained by massage of
the vesicle concerned.
ACUTE SEMINAL VESICULI-
TIS is usually a complication of istic symptom is vesicular colic, ex-
acute gonococcal urethritis, but may perienced in the region of the vesicles
also occur from infection with the and occurring spontaneously or in-
common pyogenic organisms. Pros- duced by defecation, ejaculation, or
tatitis always accompanies it. erection. Keyes has observed cases
Symptoms. — These may be lack- of apparent typical renal colic due to
ing until suppuration begins, when and relieved by treatment of vesicular
painful and frequent micturition, very disease.
painful defecation; and pains in the Diagnosis. — Rectal palpation may
anus and rectum, perineum, and hips reveal dilatation or localized indura-
or back are likely to be complained of. tions of the vesicles. From pro-
Priapism and bloody ejaculations tracted inflammation they may attain
may be noted. True abscess forma- 2 or 3 times their ordinary size. If
tion is rare. the expressed seminal secretion con-
Diagnosis. — The enlarged, tense, tains but little pus, it may be distin-
and tender vesicles are palpated from guishable from prostatic discharge in
the rectum at the sides of and behind that most of it floats on urine while
the prostate. (Normal vesicles are the prostatic secretion sinks. Since,
not palpable unless markedly dis- however, the secretion of the inflamed
tended.)
Treatment. — Local treatment of
the coexisting gonococcal urethritis
should be interrupted, and the treat-
ment for acute prostatitis (q. r.) ap-
plied. In the rare cases in which
abscess of the seminal vesicles de-
velops and a tendency to extension
or rupture in the rectum or ischio-
vesicle, when examined, usually con-
tains much pus, distinction between
the two types of discharge is gener-
ally impracticable.
Treatment. — The coexisting pos-
terior urethritis should be dealt with
as usual. The chief direct measure
is massage of tlic vesicles, \vhich
should be carried out even if these
8—47
738 URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD),
organs appear normal on palpation.
With the patient bending over the
back of a chair, the 'surgeon's finger,
covered with a lubricated finger-stall,
is inserted in the rectum and carried
as high as possible on one of the vesi-
cles. Pressure is made at that point
and the finger then drawn down
slowly, either directly or by a zigzag
route, until the prostate is encoun-
tered. If the vesicles are impalpable,
6 of these strokes on each side are
sufficient ; if tense or hard, additional
strokes should be given until, prefer-
ably, the bulk of the vesicles has been
manifestly reduced. Massage of the
prostate is then usually superadded
(see Chronic Prostatitis). The pro-
cedure may be carried out 2 or 3 times
weekly, and should be followed by
micturition and antiseptic irrigation
of the urethra and bladder.
TUBERCULOSIS OF THE SEM-
INAL VESICLES.— This condition is be-
lieved to be usually preceded by tuber-
culosis of the prostate or testicle, but
may be primary. It is at first unilateral,
the process sometimes extending later to
the opposite side through the prostate.
Symptoms. — Loss or increase of sex-
ual desire and blood in the semen are oc-
casional symptoms, but in most instances
there are no direct manifestations of the
vesicular disease, the symptoms being
rather those of tuberculosis of the pros-
tate or epididymis.
Diagnosis. — One-half the cases of vesic-
ular tulierculosis occur in subjects less
than forty years of age. The exist-
ence of the condition may be assumed
when tuberculosis of the prostate or epi-
didymis exists and the vesicles prove ab-
normal on palpation. The process starts
as a nodular hardening near the outlet of
the vesicle which may later extend to
other portions of the organ, and is fol-
lowed by caseation and softening. Upon
palpation the vesicle may thus present a
series of somewhat tender nodules; but
frequently there is to be found merely a
dilated organ indistinguishable from that
of simple chronic vesiculitis. After a time
the process may invade adjoining struc-
tures, including the peritoneum. Excep-
tionally, the condition is spontaneously
recovered from through walling off by
fibrous tissue.
Treatment. — Vesicular massage and hot
rectal douches do more harm than good
in this condition, tuberculous epididymitis
often suddenly following. The customary
general hygienic and dietetic treatment of
tuberculosis will, however, often yield
good results, whether the vesicular tuber-
culosis be primary or secondary. If the
disease progresses to diffuse softening or
fistula formation, however, vesiculectomy
is indicated. This is probably best per-
formed through the same perineal incision
as is u;ed by Young in extraurethral pros-
tatectomy (see Hypertrophy of the Pros-
tate). The rectum having been so sep-
arated from the urethra and prostate as
to afford access to the vesicles, the sheath
of each vesicle is split, and the latter lib-
erated as well as possible by blunt dissec-
tion, divided at the surface of the prostate,
and removed with a portion of the vas
deferens. If the entire organ cannot be
freed owing to adhesion, the remainder is
cauterized or curetted. The wound is then
closed, drainage being afforded by a cig-
arette drain, for which a small tube may
later be substituted.
TUMORS of the seminal vesicles are
nearly always secondary to growths in the
prostate, rectum, or bladder. Excision,
where circumstances permit, is indicated.
DISEASES OF THE SPERMATIC
CORD.
ANOMALIES of the vas deferens are
occasionally met with, the canal being
absent entirely or in part. (See also
Hydrocele of the Cord, next page.)
WOUNDS of the spermatic cord cause
atrophy of the corresponding testicle if
complete section has occurred. Mere sec-
tion of the vas results in obstruction to
the passage of spermatozoa through it.
Much hemorrhage may attend wounds of
the cord owing to section of the spermatic
artery or the pampiniform plexus.
Treatment. — The vas, if cut, should
be reunited with fine-silk sutures. Not
URINARY AND GENITAL SYSTEMS, SURGICAL DISEASES (WOOD). 739
infrequently restoration of the canal
follows.
TORSION of the spermatic cord is an
occasional acute complication of malposi-
tion of the testicles. (See Penis and
Testicles, Diseases of, vol. vii.)
INFLAMMATION of the vas deferens
may be associated with gonorrheal or tu-
berculous epididymitis. Tenderness along
the cord is likely to be noted. An abscess
of the intrapelvic part of the cord, upon
rupturing, may induce peritonitis.
Treatment. — If an abscess is detected
in that part of the cord which courses
through the scrotum, an evacuating in-
cision should be made.
HYDROCELE OF THE CORD
may be of the encysted or the diffuse
(midtiloctdar) variety. The former
usually occurs where there has been
partial failure of obliteration of the
funicular process of peritoneum
which passes into the tunica vagi-
nalis surrounding the testicle. The
funicular process being closed above
and below, but open in its interme-
diate portion, a sac is formed in
which serous fluid may accumulate.
Occasionally 2 or more sacs- in a
row may be formed, the hydrocele
being, therefore, multiple. The con-
dition is usually encountered in chil-
dren. The hydrocele is situated
above the testicle, and cannot infre-
quently be worked upward and out-
ward into the inguinal canal. Occa-
sionally it is situated in the latter.
Its physical features — translucency,
etc. — are, in genral, like those of the
commoner hydrocele of the tunica
vaginalis (see Penis and Testicles,
Diseases of, vol. vii).
Less frequently, encysted hydro-
cele of the cord is actually a hydrocele
into the sac remaining after reduction
of a hernia, the neck of the sac having
become obliterated.
Diffuse hydrocele of the cord is
usually an edema of the tissues of and
surrounding the cord, or may be a
multilocular cyst resulting from sub-
division of an encysted hydrocele,
ecliinococcus disease, or the presence
of cysts of fetal remains such as the
Wolfifian body and Miiller's duct. It
is distinguished from encysted hydro-
cele by its indefinite outline and
boggy consistency. It may, however,
be fluctuating in places. A slight im-
pulse on coughing may be observed.
Treatment. — If dififerentiation of
the encysted hydrocele from hernia
has not with certainty been made, the
treatment should be incision. The
margins of the sac having been sutured
to the skin, its interior is swabbed
with pure phenol and drainage insti-
tuted. Where the diagnosis is not in
doubt, the sac may be punctured and
its inner surface scarified with a
needle. If this fails, especially in the
case of a relatively large cyst, the
hydrocele should be thoroughly emp-
tied by aspiration and 5 to 15 minims
(0.3 to 1 c.c.) of pure phenol at once
injected into it and rubbed around in
its interior. Another aspiration—
without injection — may 1)e required
about ten days later if the tendency to
refill has not been overcome by that
time (Keyes).
Diffuse hydrocele of the cord
may be incised or, frequently better,
permitted to undergo spontaneous
recovery.
SOLID TUMORS of the spermatic cord
include especially lipoma of the cord, with
which a fibromatous or myxomatous com-
ponent may Ijc mixed. Sarcoma, myoma,
and fiI)roma of the vas deferens have also
been met with. Generally the diagnosis
from inguinal hernia is only made at
operation.
A. C. Wo(M\
Philadelphia.
"40
UROBILINURIA.
URTICARIA.
UROBILINURIA. -Urobilin is re-
garded as a normal constituent of the
urine, being its principal coloring matter.
In excess, it imparts a red-brown color.
Urobilinuria occurs in fevers, in hepatic
diseases, after hemorrhagic effusions; in
purpura; and in progressive pernicious
anemia and chlorosis. It is said to show
that the liver is the cause of the disturb-
ance. For its detection spcctroscof^ic cx-
amination will reveal a marked absorption-
band between Fraunhofer's lines / and b,
fading off from the green into the blue.
Schlcsinger's test has already been given
(vi. 496); also Ehrlich's benzaldehyde test,
and others (iii. 306; vi. 380). Edehnann's
test makes use of two reagents, viz., a 10
per cent, alcoholic solution of mercuric
chloride, and a 10 per cent, solution of
zinc chloride in aniylic alcohol. The re-
action, when positive, is a red-green
fluorescence. S.
URTICARIA.-DEFINITION.-
Urticaria is a mild inflammation of the
skin, characterized by the sudden appear-
ance of wheals, which are ephemeral and
marked by stinging, pricking, or burning.
SYNONYMS.— Hives, nettle-rash.
SYMPTOMS.— An attack is usually pre-
ceded by lassitude, slight headache, epi-
gastric oppression and various gastroin-
testinal symptoms, a coated tongue, a
slight rise in body temperature.
The eruption appears abruptly, and may
reach its maximum in a few minutes. It
consists of wheals, in size from a split pea
to a silver dollar or larger, firm and
slightly elevated. Their number varies
from four or five to one hundred or more.
They are generally round or oval, but may
have an irregular outline. They vary in
color from white to pink, or bright red,
but generally have a white, elevated spot
in the center, with a more or less marked
areola, are often isolated, but may coalesce.
The lesions may appear in the mouth,
pharynx, or upon the epiglottis, and give
rise to symptoms of asphyxia; or on the
tongue, when the organ suddenly swells.
The eruption is accompanied by burn-
ing or stinging. Scratching gives but
temporary relief, and only increases the
number and size of the wheals. The
eruption may attack different portions of
the body in succession, remaining only a
short time in each. Usually running an
acute course — a few hours to one or two
days — it may, however, become chronic
unless the existing cause is removed.
Urticaria Papulosa (Lichen Urticatus).
— This occurs in young children that are
poorly nourished or improperly fed. It
occurs as a numl)er of small, isolated
papules, appearing suddenly, remaining for
a da^' or two, and gradually disappearing;
in size from a pin's head to a split pea,
and developed around the hair-follicles.
Tliey are bright red in color, pale or white
at the center, and generally appear upon
the limbs. Itching is usually intense.
Urticaria Bullosa. — A rare form, charac-
terized l?y bulke as well as by large
wheals. The wheals may be gradually
converted into bullie, the upper layers of
the wheal being raised into a bleb by the
subjacent serum, and becoming so large
as to resemble those formed in pemphigus.
Severe itching and burning are present.
Urticaria Nodosa (U. Tuberosa). — Very
rare, and also known as giant urticaria.
Large tubercles or nodules are suddenly
developed in the skin and subcutaneous
tissues, in size from a chestnut to a small
egg. hard to the touch, elevated, and sel-
dom appearing on the face. The itching
and burning are intense, but generally dis-
appear in a few hours. Incidentally we
mention angioneurotic edema, also known
as Quincke's disease, giant swelling, or
acute circumscribed edema (see volume ii,
page 201), which resembles this form, to
call attention ":o the fact that it differs in
that it chiefly attacks the face.
Urticaria Hemorrhagica. — Usually ob-
served as a complication of purpura, and
caused bj- a hemorrhage into the wheal.
Urticaria Intermittens. — In this variety
the eruption appears regularly every two
or three days, or on a certain day in each
week. It remains a short time, disappears
only to reappear again at tlie end of the
same interval. Fever may be present.
Urticaria Persians. — Known also as
chronic urticaria, when the lesions tend
to persist for days or w-eeks, or recur at
regular or irregular intervals for months
or years, until the source of irritation is
discovered and removed. A fresh crop
may appear daily.
URTICARIA.
741
Urticaria Pigmentosa. — Known also as
xanthelasmoidea, in which buff-colored,
wheal-like nodules, with or without itch-
ing, appear usually in the first six months
of infancy, and are most abundant upon
the neck and trunk. The nodules, or
wheals, are split, pea-sized, with pinkish
areolfe. The nodules later become yellow,
and may remain stationary for years, some
undergoing involution leaving brownish
stains. Itching may be severe or absent.
This variety resembles xanthoma tubero-
sum, except in the occurrence of ordinary
wheals and its onset in early infancy.
DIAGNOSIS. — The sudden appearance
of the characteristic wheals, their brief
duration and disappearance without des-
quamation, and the itching and burning
will make diagnosis easy. Various para-
sites and insects — bedbugs, fleas, mos-
quitoes, etc. — maj' produce wheals, but a
central punctiform hemorrhage or blood-
crust marks these cases.
ETIOLOGY.— Acute urticaria is usually
produced through some alimentary disor-
der, the result of mechanical irritation of
the stomach or bowel, or a toxemia. In-
testinal parasites and undigested food act
as mechanical irritants; substances capable
of producing toxemia may be primarily
toxic or may become so through putrefac-
tive changes within the intestines. Idio-
syncrasy to certain foods and drugs is an
active cause. Among the foods most apt
to cause urticaria are: crabs, lobsters,
mussels, caviar, shrimps, salted fish, clams,
oysters, cheese, buttermilk, sausage, scrap-
ple, pork, veal, strawberries, raspberries,
cucumbers, mushrooms, grape-skins, etc.
Urticaria may follow the use of various
drugs: quinine, cubebs, copaiba, salicylic
acid and salicylates, potassium iodide,
morphine, turpentine, chloral, valerian,
glycerin, arsenic, and many of the coal-
tar preparations. Antitoxic sera — used in
diphtheria, tetanus, streptococcus infec-
tion, tuberculosis, etc. — frequently induce
an urticarial eruption. Irritation of the
uterus or adnexa may precipitate an at-
tack. Rupture or puncture of hydatid
cysts, or of pleural effusions, may be
causal agents.
Urticaria may occur in connection with
malaria, rheumatism, Bright's disease, the
eruptive fevers, pertussis, asthma, and
various nervous and gastrointestinal dis-
orders. It is a frequent complication of
scabies and pityriasis, and has been ob-
served as a sequel of arsenical poisoning.
Finally, direct local irritation — sting of
nettle, bite of jelly-fish, mosquito, bee,
wasp, etc. — may produce the disease.
PATHOLOGY.— Direct or reflex irri-
tation of the cutaneous vasomotor nerves
causes spasmodic contraction of the cuta-
neous vessels, followed by dilatation and
exudation of serum. In consequence of
this spasm a stasis of the local lympli^tic
circulation ensues. The superficial and
deep vessels of the corium are involved.
Migration of white corpuscles takes place.
The cutaneous muscular fibers remain in a
state of contraction and, by forcing the
blood toward the periphery, produce the
pale center and hyperemic areola of the
wheal.
PROGNOSIS.— The prognosis is gen-
erally favorable. Suffocation may threaten
when the lesions are located in the mouth
and larynx. Acute cases can be promptly
relieved and frequently subsides spon-
taneously. Relapses, when they occur,
are as easily relieved as the primary
attacks.
Chronic urticaria may resist treatment
for months, but it disappears on the re-
moval of the causal irritation.
TREATMENT.— As nearly all cases
arise from gastrointestinal irritation,
emetics are indicated in acute cases if
seen early. If seen later saline purges —
Rochelle or Epsom salt — will be useful to
rid the alimentary canal of any undigested
or fermenting food. Intestinal antiseptics
— salol, phenacetin, acetanilid, sulphurous
acid, sodium thiosulphate — are beneficial
in both acute and subacute cases.
In chronic cases the cause must be dis-
covered and, if possible, removed. Care-
ful attention must be paid t<> diet, exercise,
sleep, etc. Arsenic by mouth, and atoxyl
(sodium arsenanilate) l)y hypodermic in-
jection on alternate days, yield good re-
sults. Extract of belladonnna, ^/j to ]f3
grain (O.OI to 0.02 (ini.) may be given in
pill, three times daily.
In cases of nervous origin cimicifuga acts
well. The itching of urticaria may lie re-
lieved by local treatment — a hot bath con-
taining a handful of washing soda, on re-
742
UTERUS, DISEASES OF (ini-ORD).
tiring, will be soothing; >'i warm bath may
agree better, or a hydrochloric acid tub-
bath — y2 to 1 ounce (IS to 30 mil.) of acid
to each gallon (4 liters) of water. Many
drugs are rcconinifuded for internal ad-
ministration: calcium chloride, 15 to 60
grains ( 1 to 4 Gm.) in milk, daily, or cal-
cium lactate, one or two tablespoonfuls of
a 5 per cent, solution before each meal;
dilute hydrochloric acid, in medium doses
to remove digestive errors; extract of
pilocarpus, 15 to 30 minims (1 to 2 mil.)
given three times daily, has given great
relief.
Urticaria pigmentosa and U. papulosa in
nursing infants have been successfully
treated by giving the mother mercury bi-
chloride, 1/^2 grain (0.002 Gm.), three
times daily.
Pain and itching are met b}^ a 1 : 1000
solution of adrenalin; lime-water; potas-
sium hydrate or carbonate in 8: 1000 solu-
tion (applied with a small piece of
sp Mige) ; and benzoin tincture and glyc-
erin, of each 1 part to 16 parts of rose-
water. Acetanilid, plain or diluted with
talc, may be used as a dusting powder, or
menthol in 5 per cent, ointment. A favor-
ite of J. V. Shoemaker was phenol, 5 to
10 drops; sublimed sulphur, ]/(, dram
(2 Gm.); camphor, 10 grains (0.6 Gm.);
zinc ointment, 1 ounce (30 Gm.), applied
frequently to irritable surfaces. Phenol,
tar, camphor, and other antipruritics are
useful. Finally soft linen, cotton, or silk
undergarments are advised. W.
UTERUS, DISEASES OF.—
MALFORMATIONS. — Rudiment-
ary Uterus. — The rudimentary uterus
may be of any size, from a cylinder-
shaped body an inch long down to a
slight thickening of tissue on the
posterior surface of the bladder at
the junction of the rudimentary Fallo-
pian tubes. It is usually solid, but
rarely a membranous sac. One or
both ovaries may be present, usually
also in a rudimentary state. The va-
gina may be developed, but is ordi-
narily represented by a shallow, blind
pouch. The vulva is apt to be normal.
Absence of the Uterus. — This con-
dition is rare, a slight rudiment nearly
always being found post mortem,
though impalpal)lc during life.
EMBRYOLOGICAL MALFOR-
MATIONS.—About the end of the
eighth week of fetal life Miiller's
ducts begin to unite, the united lower
portions forming the uterus and va-
gina, the upper ununited portions the
Fallopian tubes. Because of faulty
development during this union, which
is complete at the end of the third
month, malformations occur.
One-horned Uterus. — This indi-
cates an arrested development of one
of Miiller's ducts. The organ is
more or less fusiform in shape, and
curves toward the corresponding
Fallopian tube. The other side usu-
ally shows a rudimentary horn.
Two-horned Uterus. — This defect,
due to imperfect union of the ducts,
may involve the fundus only or cause
a flattening (uterus plaiiifundiis) or
slight depression of the fundus, or it
may extend downward any distance
toward the cervix (uterus bicornis
nnicoUis), or into the cervix {uterus
bicornis bicallis). Sometimes a sep-
tum divides the uterus (sometimes
the vagina) below the junction.
Double Uterus. — Here union of the
ducts has not taken place above the
vagina. The two sides are entirely
distinct, but the vagina may be single
or double or septate.
Two-chambered Uterus.— Such a
uterus is more or less normal in size
and shape, but the septum persists,
and may not extend as far down as
the internal os (uterus subscptus), or
it may divide the whole uterus and
cervix, forming two cavities, or the
septum may extend to the internal os
only (ute rus sep tus u nic o II is ) ,
UTERUS, DISEASES OF (BYFORD).
743
After complete union of Miiller's
ducts the following may result : —
Fetal Uterus. — The body is small,
cylindrical, and may be solid. The
cervix measures about one inch, and
twice as long as the uterus. The
papillary folds of the cervix extend
throughout the cavity.
Infantile Uterus. — The uterus re-
mains about the same as at birth.
The body is but little over half the
length of the cervix. The vaginal
cervix is short, and the vagina and
external genitals usually small.
Puerile Uterus. — Here the body is
as long or a little longer than the
cervix, and the external genitals
small. The conditions previous to
puberty persist.
Puerile Cervix.— ^The corpus is
about normal in size, but the cervix
is small and conical, with an ex-
tremely small external os. Ante-
flexion and stenosis may be present.
SYMPTOMS AND DIAGNOSIS.
— The symptoms of one- and two-
horned uterus, and of double and
two-chambered uterus do not usu-
ally attract attention until puberty
or marriage, when dysmenorrhea,
amenorrhea, sterility, dyspareunia, or
the signs and symptoms of atresia of
the vagina, with retention, develop.
The shape and size of the uterus
are determined best by the bimanual
rectoabdominal examination. If the
vagina and cervix be well developed,
the cervix can l)e pulled down within
better reach by a vulscllum, and the
character of the interior of the uterus
also determined with the sound.
If the diagnosis be difficult, it may
be possible, with the aid of anesthe-
sia, to introduce a fmger into the
bladder; then the uterus, tubes, and
ovaries can be palpated between it
and a finger of the other hand in the
rectum. When the uterus is rudi-
mentary, slightly resisting cords, rep-
resenting the Fallopian tubes, can be
felt, joined on the posterior surface
of the bladder and leading outward
to the rudimentary ovaries, if such
exist. If the uterus be one-horned,
its fusiform shape can be palpated,
extending laterally upward, and also
the rudimentary horn on the opposite
side. The two-horned uterus is
easily recognized by the depression
in the fundus, and the double uterus
by the presence of two elongated
hard bodies merging in the vagina
below.
The fetal, infantile, and puerile
uterus and cervix may be associated
with atresia vaginae or stenosis of
the cervix (q. i'.). The prognosis is
unfavorable except for puerile cervix.
TREATMENT.— In the presence
of one- or two- horned uterus, and
of double and two-chambered uterus,
there is little to do in developing or
improving the organ ; irremediable
symptoms may call for removal of
the ovaries or uterus, or both. Preg-
nancy in a rudimentary horn usually
causes rupture and calls for removal.
Where either fetal or infantile
uterus, or puerile uterus or cervix
exists, some benefit may be derived
from intra-uterine bipolar faradiza-
tion and persistent periodical dilata-
tion of the cervix if treatment is
commenced soon after puberty. Di-
vulsion by means of bladed dilators
under anesthesia, with packing of the
uterus for thirty-six hours, may be
followed by repeated packings, pro-
vided the endometrium is douched
out each time with an efficient anti-
septic ; afterward the cervix may be
kept dilated by conical round dilators
744
UTERUS, DISEASES OF (BYFORD).
twice weekly. Pelvic massage and
movements adapted to dexelop the
pelvic musculature and blood-supply
are somelimes used.
STENOSIS OF THE CERVIX.
— This condition consists in a lack
of development or atrophy of the
part sufficient to interfere with
uterine drainage. The contraction
may be at the external or internal
OS, or exceptionally throughout the
canal, and is often connected with
flexion of the uterus. It may be due
to puerility in the nullipara, to cica-
tricial contraction following cervical
laceration in the parous woman, and
to atrophy in the senile woman.
Symptoms. — Colicky dysmenor-
rhea, as in cases of anteflexion, last-
ing from a few hours to a day or
two, is the most common syn.ptom.
Colicky pains in the vesical region
are sometimes felt between periods ;
discharge of mucus, blood, or pus
may follow. In old people long re-
tention of secretions, which usually
become offensive and purulent (senile
endometritis), may stretch the uterus
until it resembles a bag. Endome-
tritis is present in long-standing
cases.
Sterility, which is often relieved by
a dilatation of the cervix, is common.
Diagnosis. — When the stenosis is
located at the external os, the orifice
mjay be scarcely visible, or appear as
a small dimple. If at the internal os,
a small probe w'ill demonstrate the
partial or complete closure of the
canal. If the cervix be small and
flexed, the stenosis is probably re-
lated to imperfect development and
displacement ; if large and perhaps
lacerated, it is due to induration and
contraction of the mucous and sub-
mucous tissues at or near the internal
OS. In the latter case the internal os
is apt to be quite sensitive to the
scjund, and may bleed a tritle upon
its withdrawal. Thick cervical mucus
will, as a rule, be visible.
Prognosis. — Patency of the cervical
canal is usually obtainable, but is
often hard to maintain in the virgin
or old woman without occasional
dilatation. The sterility can usually
be relieved in quite young people;
but, when hyperplasia or endome-
tritis is established, sterility is apt
to persist. In married women with
stenosis and sterility, who do not
apply for treatment for several years,
the sterility is seldom relieved by
dilatation.
Treatment. — In ordinar^r cases of
partial stenosis presenting symptoms,
and in young women with small cer-
vix, dilatation with graded sounds
twice weekly will cure stenosis of
the external os in a short time.
Stenosis of the internal os may re-
quire the dilatation twice weekly for
three or four months, then once
weekly for a year. The cervix is
thus also caused to develop. The
vaginal fornices and endometrium
should be disinfected with a 5 per
cent, carbolic acid solution through
the speculum, and the uterus disin-
fected by tincture of iodine, ichthyol,
etc. If it is done at the office, the
patient should take a douche of nor-
mal saline solution before coming.
In old cases the cervix will prob-
a])ly require forcible dilatation by
bladed dilators. The uterine cavity
and cervix should be packed tightly
for twent3^-four hours after the op-
eration, and the cervix kept dilated
with a large sound or bougie (No.
18, American scale) two or three
times monthly for several months.
UTERUS, DISEASES OF (BYFORD).
745
Incision of the cervical canal is al-
most never required, except for cica-
tricial contraction or rigid anteflexion.
In the latter case incision of the pos-
terior wall of the cervix in the
median line to the vaginal junction
(Sims's operation) and a doubling in
of the ends so as to obliterate the raw
surfaces (Dudley's operation) may
facilitate cure of stenosis of the in-
ternal OS, but is seldom necessaiy.
LACERATION OF THE CER-
VIX.— This ordinarily results from
abnormal conditions that interfere
with the natural course of labor, such
as large head, small or diseased cer-
vix, malpresentation, premature rup-
ture of menxbranes, precipitate labor,
artificial dilatation of cervix, etc.
Unilateral and bilateral lacerations
are most common, though posterior,
anterior, multiple (stellate), diag-
onal, and annular ones occur. They
may extend into the vaginal vault.
Symptoms and Diagnosis. — The
symptoms are those of the inflamma-
tions and displacements. The fissures
and flaps of the lacerated cervix can
best be discovered by a digital ex-
amination, and by inspection with
Sims's speculum. The bivalve specu-
lum opens the fissures wide, and may
deceive as to their size or existence.
Pathology. — Many moderate lac-
erations heal by adhesion, although
the majority of deep ones cicatrize
and contract with a cicatricial plug
in the angle. Often mucous mem-
brane seems to extend over raw sur-
faces, nothing but the fissure re-
maining.
Infection of the wounds is likely,
with consequent cervicitis, parame-
tritis, perimetritis, and perhaps pelvic
abscess. The infection may also
spread to the cervical, corporeal, and
tubal mucous membrane and the ov-
ary and pelvic peritoneum. The cerv-
ical mucous membrane becomes hy-
perplastic, and pushes the lower ends
of the cervical flaps outward, produc-
ing eversion (ectropion). All varie-
ties of cervical inflammation, erosion,
and degeneration are found related
to and probably originating in lacer-
ations.
Retroversion and lateral displace-
ments of the cervix may result from
the cicatricial contraction that at-
tends those extending into the vag-
inal vault, and other displacements
and fixations may follow peritonitis.
Treatment. — Extensive lacerations
should be sutured immediately after
labor if the conditions are favorable.
The cervix should be carefully pulled
down to the vulva by means of a vul-
selLum, shreds trimmed from the torn
edges, and the wound-surfaces united
in their original relation by hardened
catgut sutures. If there is any
doubt about the possibility of subse-
quent cleanliness, silkworm-gut su-
tures will givQ better results.
Old lacerations generally require
applications of carbolic acid, or other
disinfectant and astringent, to the
eroded and hyperplastic mucosa, for
the diseased surface can be much
better treated before being turned
into the cervix than after. Closure
before curing the cervical endome-
tritis often results in agsrravation.
In Emmet's operation, a tenaculum
is hooked into the lower, or distal,
end of the cervix at one side of the
fissure and the mucous or cicatricial
surface of the latter cut oflF, com-
mencing under the tenaculum and
going up into the angle and beyond
the cicatricial plug. The other side
of the fissure may then be denuded
■46
UTERUS, DISEASES OF (BYFORD).
from the angle down, or from below
upward as on the first side. If the
laceration is bilateral, the fissure on
the other side is similarly denuded,
and then both wounds are sutured
with hardened catgut or silkworm
gut. It is well to place the first
suture at the distal end of the flaps.
Two per cent, phenol douches twice
daily keep the catgut hard and clean.
When the lacerations are bilateral
or multiple and extensive, and the
cervical follicles extensively diseased,
Schroder's operation should be per-
formed to remove the diseased mem-
brane and restore shape of the part.
Schroder's operation consists in
lateral incisions through the cervix,
or cicatricial plugs, on both sides, ex-
posing all of the diseased cervical
mucous membrane. The sides of the
tears are denuded from these incis-
ions down to the end of the cervix.
Instead, now, of sewing up the parts,
as in Emmet's method, the endocer-
vical mucous membrane is dissected
ofl between lines drawn across from
the upper and lower ends of the raw
lateral surfaces. The low'er ends of
the cervical flaps are then folded in
until the mucosa reaches that of the
cervical cavity above the denudation,
and are sutured to it. Then the
wounds left on either side are
trimmed, if necessary, and sutured
to close the lateral fissures. Before
closing the cervix, applv tincture of
iodine to the endometrium.
DISPLACEMENT OF THE
UTERUS.
The uterus is normally located in
the central and anterior portions of
the pelvis. The cervix is suspended
by the pelvic connective tissue (pubo-
uterine, sacrouterine, and broad liga-
nicutsj just behind and often a trifle
to the left of the axis of the pelvic
cavity. Its range of mobility is
small. The corpus leans over the
bladder in slight anteflexion, the
flexure varying with the fullness of
the l)ladder and rectum. The former,
when distended, lifts the fundus and
straightens the uterus, while the lat-
ter, when loaded, pushes the cervix
forward and increases the flexion.
The main factors in malposition
are variations in the relative develop-
ment of the pelvic organs and con-
nective tissue, and injuries or other
causes that diminish, destroy, or
modify connective-tissue support.
Pathological alterations in the uterus
constitute a less important cause.
ETIOLOGY.— When the uterus is
poorly or late developed, the connec-
tive tissue about the rectum and
vagina oft'er relatively more sup-
port, and the uterus may be held up
at the pelvic brim in a position called
elevation. This is the position of the
rudimentary and fetal uterus. Or, it
may be held forward by the connec-
tive tissue at the base of the bladder
in antcposition. This is often the
position of the puerile uterus. An
imperfectl}^ developed vagina aids in
maintaining this form of displace-
ment. As the corpus uteri and pelvis
grow% the connective tissue of the
broad and sacrouterine ligaments
may, as the result of constipation,
debility, hard work, etc., be wanting
in tone and fail to support the cervix
firmly. Then, when the uterus is
pushed backward by the distended
bladder, the round ligaments, w^hich
nearly always share the flabby and
immature nature of the corpus, do
not draw^ the fundus forward, and
abdominal pressure may turn the
UTERUS, DISEASES OF (BYFORD).
747
temporarily retroposed organ back
into retroversion, or, if the connective
tissue about the cervix is firm
enough, bend the corpus backward,
producing retroflexion.
Normally strong sacrouterine con-
nective tissues draw the upper part
of the cervix backward, so that retro-
version cannot occur, while a short,
imperfectly developed fetal vagina
may pull the vaginal portion forward
causing a congenital anteflexion. The
corpus is small ; the cervix may be
elongated by the vaginal traction.
A\'hen the vagina is well developed,
the anterior wall is 2^ inches long;
the bladder connective tissue does
not draw the cervix too far forward.
If the uterus develops late or re-
mains small in an otherwise vigorous
girl, the cervix is apt to be drawn by
the vigorous sacrouterine folds back-
ward and upward nearer the rectum
and sacrum than normal, while the
fundus is drawn by gravity, and
pushed by abdominal pressure, down-
ward in front of the cervix, be-
coming anteflexed. Some atrophy
and shortening of the anterior uterine
wall is likely to take place, because
the filling bladder does not lift the
fundus sufficiently to straighten the
corpus, nor is the dorsal position —
normially bringing the fundus back-
ward— ^able to do so. The flexion then
becomes permanent, or irreducible.
Thus, many uterine displacements
are errors in development due to in-
heritance of an imperfect physique, or
to modes of living in early life that
fail to insure symmetrical develop-
ment. After puberty congestion and
local inflammations modify or per-
petuate these conditions. Thus, a
hardening or rigidity of the uterus
may render the flexion permanent.
As a result of the increased weight,
and of relaxation in the sacrouterine
tissues, the cervix may be carried by
abdominal pressure toward the vag-
inal outlet — anteposition. If ante-
flexion is permanent, we have both
anteflexion and anteposition; or if the
sacrouterine ligaments are greatly
relaxed, the body of the uterus is
tipped backward by the bladder and
abdominal pressure, and we have both
anteflexion and retroversion. If the
uterine rigidity is due to puerperal
metritis in an anteflexed organ, the
flexion may be prevented from re-
turning and the corpus will tip for-
ward without bending — aniez'ersion.
General relaxation of the pelvic
connective tissue due to pelvic dis-
ease, general debility, and increased
intra-abdominal pressure from ascites
or tumors allows the uterus to de-
scend to the vaginal outlet, either
with the uterine long axis in co-
incidence w^ith the pelvic axis, con-
stituting prolapse, or with the fundus
in the cul-de-sac of Douglas, con-
stituting prolapse and retroversion.
Injury, overstretching, laceration,
and subsequent cicatricial contrac-
tions may, as they affect dift'erent
parts, allow the cervix to sink toward
the vaginal outlet, or draw the cervix
from its normal location and cause
the above-mentioned displacements
in a previously normal uterus.
Inflammation and exudates may
fix the uterus in its malposition, or
may push or draw it to an abnormal
location. Lateral positions or irersions
are usually caused in this way. and
often tiie posterior deviations.
The same conditions that produce
prolapse may cause protrusion of tlic
uterus through the vulva. Whcti the
conditions are those of relaxation the
748 UTERUS, DISEASES OF (BYFORD).
cervix protrudes first, and inverts the When the uterus is retroposed, as
vagina. This is the meclianism in is usually the case when the parts
the virgin and nullipara. When pro- are well developed, the cervicovaginal
trusion results from lacerations about junction is found well back in the
the vaginal outlet, the vagina appears pelvis, making an acute angle an-
first at the vulva, dragging the uterus teriorly. With the tip of the index
after it. The bladder protrudes with finger touching the junction of the
the uterus, and at times the rectum. cervix with the anterior vaginal wall,
When the uterus is fixed in the the subpubic arch should normally be
pelvis by adhesions the traction of against the finger at or beyond the
the vagina upon the cervix is apt to middle of the third phalanx (over two
produce elongation, and some hyper- and one-half inches). The posterior
plasia, of the cervix, and only mod- fornix is unusually deep, and the pos-
erate descent of the fundus, causing terior surface of the cervix may be
prolapse, or protrusion, of the cerznx. felt to be convex in its long diameter.
ANTEFLEXION AND ANTE- The angle of the anterior uterine wall
VERSION. — Symptoms.— The most formed just above the vaginal junc-
common symptom of permanent or tion can usually be felt and some-
irreducible anteflexion is dysmenor- times the fundus itself. If antiseptic
rhea, due to interference with the preparations have been made, a sound
drainage and circulation of the uterus, may be passed to locate the uterus
The pain may commence with the and differentiate from a tumor or ex-
first menstrual period or not until udate that might be mistaken for it.
some years later. It is a cramping In anteversion the anterior vaginal
pain in the lower abdomen felt about wall is about three inches long as
the time the menstrual discharge ap- measured on the finger, but the os
pears, and if there be no complication uteri is still farther back, and points
ceases when the flow is well estab- toward the coccyx or sacrum. The
lished. Since utero-ovarian conges- cervix extends backward, and the
tion and hyperplasia gradually super- corpus forward over the anterior va-
vene, the pain, after a time, lasts ginal wall, and is in a straight line
longer and is more continuous. Sore- with the cervix. The organ is usually
ness in the lower abdomen, iliac and larger and harder than is usually the
lumbosacral regions may then per- case.
sist throughout. Between the periods Treatment. — The treatment of ante-
the symptoms are those of ovarian flexion sufficient to cause symptoms
and uterine hyperemia. should be a systematic dilatation of
In retroversion, backache and the the cervix with graded conical sounds,
other symptoms of the causative in- or a rapid dilatation. After the lat-
flammatory conditions are present. ter, dilatation should be maintained
Diagnosis. — The diagnosis is made by means of the occasional passage of
by the bimanual examination. When a large sound under the strictest anti-
the uterus is in the front part of the septic precautions. The endometritis
pelvis, the fundus, often small, is felt may require treatment, or measures
over the anterior vaginal wall and may be indicated such as are recom-
the cervix toward the perineum. mended elsewhere for puerile uterus.
UTERUS, DISEASES OF (BYFORD).
749
RETROFLEXION AND RE-
TROVERSION. — Symptoms. —
These, like other uterine displace-
ments, cause no symptoms unless
connected with inflammation or in-
terfering- with the menstrual flow or
the uterine circulation. If dysmenor-
rhea is present, it often commences
with cramping pains in the lower ab-
domen, as in anteflexion, but the
pains do not usually cease as soon as
the flow begins, and may continue
throughout. Backache is common,
and is apt to increase during the
period. Bladder traction may cause
persistent vesical irritability. Symp-
toms of pelvic inflammation are often
present.
Diagnosis. — In retroversion the
cervix is within two inches of the
vaginal entrance and points toward
the pubes, while the body can be felt
to extend nearly straight backward
into the hollow of the sacrum. In
retroflexion the angle formed by the
posterior walls of the cervix and cor-
pus can be felt, and the body of the
uterus is in or over the cul-de-sac of
Douglas. To avoid mistaking it for
a tumor or exudate, the absence of
the former from its normal position
can be readily demonstrated biman-
ually. If necessary, a sound may be
introduced.
Treatment. — If adhesions are pres-
ent with exudate or diseased ovaries,
these should be treated. Interference
of the flexion with drainage may
necessitate forcible dilation.
If, after the pathological conditions
have been as far as possible corrected,
the patient still sufl'ers, the uterus
should be replaced and kept in posi-
tion by a pessary or by an operation.
Replacement of the uterus : With
two fingers in the vagina push the
cervix and posterior vaginal wall
backward, and press the external
hand doiwn into the pelvis just below
the promontory of the sacrum, and
push the fundus, which is raised by
the backward pressure against the
cervix, forward to the pubes. If this
cannot be done, two fingers in the
rectum may be made to push the fun-
dus up out of the hollow of the sac-
rum so that the hand on the abdomen
may pull it forward over the pubes.
In the genupectoral position the
weight of the uterus and abdominal
organs may be made to assist. Kiist-
ner draws the cervix down toward
the vulva with a vulsellum until the
fundus is drawn out of the cul-dc-sac
of Douglas, and then turns the handle
of the instrument up toward the
pubes externally and pushes the cer-
vix back toward the sacrum where
the fundus had lain.
The replaced uterus may be held a
few months by a pessary. The
retroversion will usually recur when
it is removed, but the symptoms may
not.
The Albert Smith or Emmet are
the best forms. They are introduced
with the short curve turning upward
behind the uterus.
When pessaries fail to relieve the
symptoms, operations are indicated.
If the uterus can be perfectly re-
placed and the fundus remains tem-
porarily near the anterior vaginal
wall after being released, and the
parametrium feels soft, Alexander's
operation of shortening the round
ligaments through the inguinal canal
may be relied on. If there arc adhe-
sions to be separated or ovaries to be
resected, or if tlie uterus immediately
retroverts after being- replaced, a
vaginal or abdominal incision should
750 UTERUS, DISEASES OF (BYFORD).
be made, patholot^ical states of the and elongated the uterine sound will
ovaries and tul)cs (</. z'.) be attended usually penetrate four or more inches,
to, and the round lij^aments be The rectal examinations inform us
shortened throut^h the incision. The that the fundus is only moderately
latter and slii^ht peritoneal adhesions prolapsed, while the cervix is long
of the fundus to the peritoneum over and thin. When the elongation is
the bladder witli catgut sutures con- just above the level of the anterior
stitute all that is ordinarilv re(|uircd. vaginal junction, the anterior vaginal
PROLAPSE AND PROCIDEN- wall comes down with the cervix and
TIA. — Symptoms. — llackache, drag- the posterior vaginal fornix retains
ging sensations about the pelvic more or less of its depth. When the
outlet, and difficulty in urinating and elongation is in the upper part of
defecating are common symptoms, the cervix aljove the posterior va-
in procidentia, ulceration of the pro- ginal junction, the posterior fornix de-
truding vagina or cervix, cystitis, and scends. When both of the fornices
urethritis may be troublesome. Leu- remain deep it is mainly the vaginal
corrhea and other symptoms of pel- portion of the cervix that is elon-
vic hyperemia, neurasthenia, debility, gated. Supravaginal elongation is
indigestion, etc., often complicate. usually merely a stretching of the
Diagnosis. — In prolapse the cervix cervix,
will be found near or at the vaginal Treatment. — Operative treatment
entrance, with or without a protru- is, as a rule, necessary for the cure
sion of the anterior or posterior of protrusion. However, in many
vaginal wall or both (anterior and cases without distressing symiptoms
posterior colpocele), carrying, per- the patient may prefer palliation,
haps, the bladder (cystocele) or The patient can ordinarily push the
rectum (rectocele) with it. A recto- parts back and retain them during
abdominal, bimanual examination re- the daytime by introducing large cot-
veals the fundus either in the cul-dc- ton or wool tampons, or a rubber
sac or low down behind the pubes. inflatable bag. A soft-rubber elastic
In protrusion the cervix uteri can ring-pessary or a hard-rubber globe
be seen, and will admit the uterine pessary can sometimes be introduced
sound. Rectal palpation reveals the every morning and removed every
absence of the uterus from the pelvis, night. Soft-rubber pessaries should
and perhaps the projection of the an- never be worn continuously. A hard-
terior rectal wall into the vulvar tu- rubber or large Albert Smith pessary
mor. A catheter introduced through can be worn continuously with great
the urethra will show whether the comfort in some cases. The prolapse
bladder is up behind the pubes or returns when the pessary is removed,
external to the vulva. In complete When the prolapse is the result of
procidentia its posterior wall usually lacerations during childbirth it is usu-
follows the cervix out of the pelvis. ally necessary to repair the laceration
The parts can be pushed back into or amputate the enlarged cervix, per-
the pelvis and be palpated in their form anterior and posterior colpotomy
normal relationship. and perineorrhaphy, as well as re-
in case the cervix only is prolapsed move any hemorrhoids or protruding
UTERUS, DISEASES OF (BYFORD).
751
anal folds. If the fundus uteri sinks
into the hollow of the sacrum as the
cervix is pushed within the pelvis, it
is best to perform Alexander's opera-
tion. In case the patient is at the
change of life, vaginal fixation, or
uniting the anterior wall of the uterus
to the anterior vag-inal wall, may
accomplish the same purpose.
In extreme cases the uterus has
been removed by abdominal hyster-
ectomy and the stumps attached
to the abdominal incision. Vaginal
hysterectomy, supplemented by a nar-
rowing of the vagina and perineor-
rhaphy, has also proved successful.
INVERSION OF THE UTERUS.
— Inversion signifies a turning of the
corpus uteri into the cervix (partial)
or through it (complete). The uterus
turns inside out. It only occurs when
the uterus is (1) enlarged and (2)
partly or completely relaxed. These
conditions are found in the puerperal
state and in polypoid or submucous
uterine tumors (usually myomas).
The causes in the puerperal state
are pressure upon the fundus uteri or
traction upon the umbilical cord, or
both, during the third stage of labor.
Adherent placenta and a short cord
favor it. After a partial inversion
has taken place, abdominal pressure
may complete it, or the projecting
fundus or tumor may be caught in
the cervix and be expelled into the
vagina by the contractions above it.
Symptoms and Diagnosis. — Sudden
complete inversion occurring during
labor is often accompanied by fatal
hemorrhage unless immediate reduc-
tion is effected. If the patient escapes
death, septicemia is apt to follow.
More often the onset is gradual
and hemorrhage is more or less con-
tinuous and abundant. Leucorrhea
and metrorrhagia, with the symptoms
of metritis, anemia, and nervous ex-
haustion, are the chief symptoms.
An inverted uterus may be differ-
entiated from a fibroid polyp as
follows : —
The inverted uterus in recent cases
is darker, softer, and more sensitive,
and the cervix is represented by a
shallow depression all the way
around. A fil)roid can be twisted
slightly without carrying the cervical
rim with it. The cervical rim can
sometimes be made to disappear
by traction on the fundus, inverting
the entire organ. The Fallopian ori-
fices can sometimes be detected and
the relations thus determined.
Bimanual rectoabdominal examina-
tion demonstrates the absence of the
fundus from the pelvis, a cup-shaped
depression, and in old cases the
ovaries at the edges of the depression.
When the uterus is completely in-
verted by a polypus, the deviation of
the polypus from the size, symmetry,
and evenness of surface of the uterine
body, and a depression at the level of
the attachment may aid diagnosis.
A shallow incision, which can be
quickly sutured, will reveal the
tumor structure and existence of a
capsule.
The fundus may be (1) merely in-
dented, or (2) the entire corpus may
project through the cervix, or (3) the
cervix and corpus may be inverted.
The first and third conditions exist,
as a rule, only temporarih^ and dur-
ing traction upon the corpus; hence
the second one constitutes the type.
liefore involution, the peritoneal
cup in the cervix is large, containing
tile tul)cs and ovaries. Rig-ht after
lal)or the fundus projects into the
vagina as a large, soft, purplish,
752
UTERUS, DISEASES OF (BYFORD).
spong-y mass. This gradually l)e-
comes smaller, harder and smoother.
The discharge, at first bloody, sooni
becomes a bloody mucus, and the
membrane assumes the characteris-
tics of hyperplasia.
After involution the body becomes
hard and pear-shaped, and the ova-
ries and tubes are no longer con-
tained in the peritoneal cup. The
muccms membranes atrophy, al-
though in places glandular pockets
form. Gangrene of the fundus is
very rare.
Prognosis. — Hemorrhage, local dis-
comfort, leucorrhea, etc., may lead to
anemia and exhaustion. In the puer-
peral state immediate death from
hemorrhage or inflammation, or per-
haps later from sepsis, may occur.
Treatment. — At once after labor,
the knuckles should be pushed stead-
ily against the projecting mass until
it recedes through the relaxed cervix.
Then use ergot hypodermically, judi-
cious massage over the fundus, or
— if necessary — a hot intra-uterine
douche or antiseptic gauze packing.
In recent cases beyond the puerpe-
rium taxis may suffice. Prolonged
traction upon' the cervix with a vul-
sellum combined with attempts to
enlarge the cervical ring by eccen-
trical pressure, and compression of
the corpus uteri with the hands or
padded forceps, may be followed by
an attempt to indent one of the horns
by the fingers formed into a cone,
while the traction is being kept up.
Counter-pressure with the index
fingers in the bladder and rectum,
while the thumbs in the vagina press
against the fundus, may succeed.
In older cases the gradual method
is the best. The fundus is pushed
back toward the sacrum, and a rub-
])Qv bag is introduced between it and
the coccyx and sacrum, and inflated.
By pressure toward the jiclvic brim
resistance of the uterine tissue is thus
gradually overcome. The vagina is
thoroughly douched before each in-
troduction of the bag, which is
cleaned every forty-eight hours. Two
or three days, or as many weeks,
may be required for the reduction.
When all other methods fail, an
operation will usually succeed. The
posterior uterine wall may be incised
longitudinally in the median line, and
the cervix stretched by means of di-
lators introduced into the peritoneal
cup through the incision. If the con-
striction ring dilates sufficiently, the
incision is sutured and the fundus
pushed up through the dilated parts
(B. Bernard Brown).
In case the cervix does not yield
to the dilators, the incision can be
lengthened until it extends from the
fundus through the cervix into the
posterior vaginal wall. At its ex-
tremity a transverse incision is made
across the posterior vaginal fornix
into the cul-de-sac of Douglas, and
the uterus is easily turned right side
out and sutured in the vagina. Then
the fundus is pushed through the
posterior vaginal opening and up into
its proper position (Kiistner).
Because of the liability to retro-
version and adhesions after posterior
incision, it is best to incise similarly
the anterior uterine and vaginal
walls, separate the bladder, open the
peritoneal cavity, restore the uterus
to its normal shape, suture the
uterine incision, and attach the fun-
dus over the bladder, and — if neces-
sary— shorten the round ligaments
intraperitoneally, before closing the
vaginal incision.
,t3
X
<
c
11
UTERUS, DISEASES OF (BYFORD).
753
T. G. Thomas recommended celi-
otomy and dilating the cervix from
the peritoneal side. When this fails
Everke incises the posterior cervical
wall, and — if necessary — the anterior,
reduces the displacement, and then
sutures the uterine wound.
TUBERCULOSIS OF UTERUS
AND ADNEXA.
TUBERCULOSIS OF THE
BODY OF UTERUS may be caused,
primarily, by tuberculous semen, in-
strumental inoculation, etc., but is
nearly always secondary to tuber-
culosis in other parts. Although in
the corpus it may exist in any stage,
the miliary form is not recognizable
clinically, and hence the ulcerative
stage is the one usually encountered.
The disease commences as small mil-
iary tubercles, usually near the fun-
dus, and spreads diffusely throughout
the mucous membrane. In a few in-
stances it develops in the uterine wall,
constituting the interstitial form.
The Fallopian tubes are about as
frequently aft'ected as the uterus
itself; the ovaries are next in order.
Symptoms and Diagnosis. — The
early symptoms are those of endo-
metritis, sometimes with menorrha-
gia. Later the uterine walls are
thickened, and there is a grumous
discharge containing cheesy particles.
The menses are then apt to be scanty.
The diagnosis may be based on
uterine scrapings or inoculation of a
guinea-pig. Tubercles in other or-
gans, absence of foul-smelling, watery
discharges, and slow progress dis-
tinguish it from cancer or sarcoma of
the endometrium.
Treatment. — Removal of the uterus
and appendages should be practised
■per vaginam unless the condition is
secondary to advanced tuberculosis
elsewhere. If the appendages are
palpably affected, or if there be en-
cysted tubercular peritonitis, the ab-
dominal method is preferable.
If hysterectomy is contraindicated,
curettage and packing with iodoform
might retard the disease.
TUBERCULOSIS OF THE
CERVIX. — This consists of a round-
cell infiltration of the subepithelial
structures, containing tubercular nod-
ules. The glands show proliferation
and sometimes form papillary masses.
The vaginal portion is somewhat en-
larged, nodular, and partly covered
by a circular granular wound that
gives off a sticky, grumous discharge.
Symptoms. — These are at first
those of cervical endometritis. Later
the grumous discharge, containing
glandular matter, the local pain, and
the microscopic evidences from ex-
cised tissue serve for a diagnosis.
Prognosis. — The prognosis is usu-
ally bad because of disease else-
where. If discovered early, the area
of localization can be extirpated.
Treatment. — In the early stages a
high amputation of the cervix may
be depended upon unless uterine
scrapings show signs of tuberculosis
or decided inflammatory changes in
the endometrium. If the vaginal for-
niccs are affected, excision of the
vaginal wall should be done well be-
yond the disease and the wound
strewn with iodoform and sutured.
TUMORS OF THE UTERUS.
MYOMA OF THE UTERUS.—
Uterine myoma consists of one or
more masses of fibromyomatous tis-
sue. According to their location
til ere are several varieties.
The polypoid tumor develops near
8—48
754
UTERllS, DISIvNSI'-.S Ol' (l',\FORD).
or just under the mucous mem1)rane,
and, as it grows larger, projects into
the uterine cavity. It remains at-
tached by the mucous membrane and
a few connective-tissue fibers, which
form a pedicle of greater or less size
and density, according to the amount
of iibrous tissue. The snbiniicuiis
starts a short distance from the mu-
cous membrane and projects more or
less upon the surface. The uterine
cavity in these two varieties enlarges
as the tumor grows. The intramural
develops well within the uterine wall
and retains a thick covering of uter-
ine fibers. The uterine cavity en-
larges in proportion to the relation of
the tumor to the mucosa. The sub-
peritoneal variety is developed near
the peritoneal covering, and causes a
projection upon the serous surface
without increasing to a great extent
the size of the uterine cavity. The
pediculated tumor develops just un-
der the peritoneum and projects from
the surface. The intraliyamcntoiis
tumor projects into the connective
tissue of the broad or sacrouterine
ligaments. From 5 to 10 per cent,
develop in the cervix. Myomas may
be single or multiple, each with a
capsule, or several masses may be
developed in one capsule.
Symptoms. — In the polypoid, sub-
mucous, and interstitial varieties me-
norrhagia and metrorrhagia occur,
with or without mucous or watery
discharges between. The menopause
may be delayed beyond the fiftieth
year. Such tumors may cause pain-
ful uterine contractions either by
pressure on the cervix (acting like a
foreign body in the uterus) or from
obstruction of the cervix by the pro-
jection of a tumor growing near the
cervix. The interstitial and sub-
mucous varieties may cause ovarian
hyi)er])lasia, with its symptoms; or
painful ])ressure ui)()n the rectum,
bladder, or pelvic nerves; or even ob-
struction of one or both ureters.
Sterility, early abortion, and dysto-
cia are apt to be present. Anemia is
a common result of the loss of blood.
The subperitoneal and intraliga-
mentous growths have but few symp-
toms until large enough to press upon
the surrounding organs, when they
cause pelvic pain, vesical and rectal
distress, constipation, and, rarely,
serious impaction of feces in the
colon.
Diagnosis. — Single intramural, sub-
mucous, and polypoid myomata en-
large the uterus symmetrically, and
must be difl^erentiated from preg-
nancy, hematometra, flexions, car-
cinoma, sarcoma, and subinvolution.
The introduction of the sound when
pregnancy is excluded, and, in case
of large tumors, the introduction cf
the finger, reveals the increased size
of the cavity and perhaps the presence
of a polypoid or sessile growth. In
case of flexion the sound passes di-
rectly into the supposed tumor in-
stead of over or behind it. The
symptoms of the above-mentioned
conditions should be looked for.
Intramural multiple myomas pro-
duce a characteristic irregular en-
largement and hardening of the
uterus, with long, irregular cavity
that is difficult to sound. Adherent
ovarian tumor or inflamed appen-
dages present a^ distinct history of
inflammation, with a congested or
hyperplastic cervix, tenderness, and a
sulcus betw^een the uterus and the
projecting mass. The uterine cavity
may be but slightly enlarged. A my-
oma of the vaginal portion gives the
UTERUS, DISEASES OF (BYFORD).
755
OS a crescentic shape, with flattening
of the opposite lip. Carcinoma does
not thus alter the shape of the os, is
harder, and, if ulcerated, is excavated
and fissured. The tenaculum holds
in fibroid, but tears out of cancer
easily and causes free bleeding.
Very large soft myomas or cysto-
myomas of the corpus cannot al-
ways be satisfactorily diagnosed. The
myoma usually draws up and immo-
bilizes the cervix, and the uterine
cavity admits the sound farther than
normal. The uterine body can be
palpated, and the vascular murmurs
can be heard. Slow growth is
typical of uterine myomas and ova-
rian dermoids.
Etiology. — They are supposed to
develop from the walls of the
blood-vessels. Vascularity in connec-
tion with microparasitic development
would seem to be in line with the
recent discoveries in bacteriology.
Pathology. — The young tumor is
composed of fibrous and muscular
tissue irregularly interlaced in vari-
ous proportions. It presents a whit-
ish or yellowish-white, glistening sur-
face, unless much muscle exists,
when it is pinkish. The submucous
and polypoid tumors retain some of
the glandular structure of the mu-
cosa, while a variety called adeno-
myioma is partly composed of gland-
ular structure, and when cut pre-
sents the appearance of a coarse net-
work, instead of the ordinary smooth
sheen.
As they develop they usually de-
viate somewhat from the type. Those
which are surrounded by anemic tis-
sue, as the multiple and subserous,
grow slowly and become hard and
fibrous, and sometimes calcareous.
Those which are surrounded by
vascular tissue, as in the single in-
tramural and submucous, grow com-
paratively fast, but, having a poor
blood-supply within, tend to under-
go edematous, myxomatous, cystic,
fatty, and even sarcomatous and car-
cinomatous changes. The hard tu-
mors seldom grow very large, the
soft ones often do, while the cystic
may even destroy life by their great
size.
Prognosis. — Growing slowly and
tending to stop growing after the
menopause, they may prove com-
paratively benign, 3-et in young
people the persistence of the hemor-
rhages and gradual growth may seri-
ously impair health before the de-
layed menopause.
Treatment. — The best treatment
for growing myomas in women vui-
der 35 years of age is removal (enu-
cleation) of the tumor, with pres-
ervation of the uterus, if possible,
otherwise by hysterectomy with pres-
ervation of the cervix and ovaries.
Removal of the ovaries for fibroids
has now given way to myomectomy
or myomotomy. In older patients per-
sistent hemorrhage, pressure pains,
or rapid growth may call for radical
treatment unless palliative measures
are rapidly beneficial. Slowly grow-
ing tumors near the menopause with-
out symptoms require only palliative
treatment, and often no treatment
at all.
Polypoid or sessile intra-uterine
growths smaller than a child's head
at term can be removed tlirough the
dilated cervix, by morcellation. The
uterus usually contracts readily after
this; if not, a tight packing with
gauze, to be removed during the
second twenty-four hours, and ergot
internally, will prevent hemorrhage.
756 UTERUS, DISEASES OF (BYFORD).
Small subserous or intramural of l)road ligaments between H.gatures.
growths i)alpable on the antcri(jr ur Amputation of cervix at tlie internal
posterior uterine walls can be enu- os. Disinfection of cervix. Excision
cleated and the bed sutured through of a transverse, wedge-shaped piece
an incision in the anterior or pos- from cervix, leaving an anterior and
terior vaginal fornix (anterior or posterior flap. Paring out the cervi-
posterior colpotomy). Such tumors, cal mucous membrane. Suture of the
when larger than an egg, require ab- two cervical flaps with superficial
dominal section for their enucleation, catgut sutures. Suture of anterior
Polypoid and submucous tumors peritoneal flap over the stumps of
larger than a fetal head at term can broad ligaments and uterus.
be enucleated by abdominal section. Abdominal total hysterectomy is
The uterus can then be sutured with similarly performed until the uterus
catgut, and, if the bed cannot be ob- is amputated at the cervix. Then the
literated by sutures, it can be packed entire anterior cervical wall may be
with gauze that extends out through divided in the median line, or the an-
the vagina, and the peritoneal side be terior vaginal wall may be grasped
closed. When many intramural my- just in front of the cervix by forceps
omas are present the uterus may be and the vaginal canal opened between
amputated at the internal os (supra- the forceps and the cervix. An in-
vaginal hysterectomy) or be removed cision is then carried laterally around
with the cervix (total extirpation, the cervix guided by the finger passed
panhysterectomy). ^Multiple small through the opening made. When
fibroids with symptoms may be the cervix is cut out catgut sutures
treated by vaginal hysterectomy. and ligatures are put on the vaginal
Enucleation. — This is accomplished edges, and, if possible, all raw tissues
by making an incision across the tu- drawn together. If this is impossible,
mor, catching hold of it with a vul- the unapproximated surfaces should
sellum or hook, enucleating with the be packed with gauze that extends
fingers or blunt-edged instrument, into the vagina, and the peritorieum
and sewing up the bed with for- be united over it.
maldehyde or formalin catgut. Vaginal hysterectomy for fibroids
Abdominal supravaginal hysterec- is usually performed for tumors from
tomy is performed about as follows: the size of an egg to a fetal -head at
Trendelenburg's position. Incision in term. A curved incision is made in
median line extending from above the vaginal wall around the anterior
pubes to below umbilicus. Separa- edge of the cervix, and extending
tion of adhesions. Incision of cap- from the sides of the cervix straight
sule of any tumor that may be held out laterally for half an inch on either
down in pelvis, and enucleation of side. The bladder is pushed away
the tumor from its broad-ligament from the uterus, and the peritoneal
bed. Separation of the bladder from cavity opened, if possible, by tearing,
the uterus. Ligature of the ovarian A corresponding posterior vaginal in-
and uterine arteries, or of the broad cision is made, and the peritoneal
Hgaments down to the internal os, cavity opened just behind the cervix,
clamping next to the uterus. Section The bases of both broad ligaments
UTERUS, DISEASES OF (BYFORD).
757
are ligatured with strong catgut, and
the uterus cut loose from the broad
ligaments on either side as high as
the ligatures are placed. The cervi-
cal canal is then incised laterally and
the anterior wall of the cervix am-
putated. The anterior uterine wall is
then grasped with tenaculum forceps,
and a triangle is cut from its center.
Another is cut from either side ex-
tending higher up, and as tumors
are encountered they are cut up and
enucleated. Pretty soon the anterior
uterine wall and tumors are all re-
moved, and the posterior wall folds
upon itself, allowing the fundus and
uterine appendages to be pulled down
into the vagina. The remainder of
the broad ligaments are now ligated,
and all uterine tissue cut away. The
peritoneum is brought down with
forceps and stitched to the vaginal
walls before and behind, and then the
anterior and posterior vaginal walls
are brought together with sutures
that catch and hold the stumps.
Palliative treatment is used for
hemorrhage or pain and to check
tumor growth. Ergot is one of the
valuable palliative remedies. Occa-
sionally it expels polypoid and ses-
sile tumors througii the cervix.
Bleeding may be reduced and some-
times tumor growth arrested. Half a
dram (2 Gm.) may be given three
times daily for half or two-thirds of
the time, and be continued, if neces-
sary, for a year or more, or off and on
until the change of life. Fluidextract
of Hydrastis Canadensis (j/j dram — 2
Gm. — three times daily) has been
credited with properties of a similar
character.
The X-ray applied througii the va-
gina or skin may check Irmik )rrliagc
and retard the growth somewhat.
Radium introduced into the uterine
cavity has the same effect.
Curettage also acts beneficially
upon the endometritis, and thus upon
the hemorrhage.
Ligature of the vessels supplying
the uterus acts temporarily only.
Among 32 cases of fibroids sub-
jected to massive X-ray exposures on
account of severe menorrhagia, per-
manent amenorrhea resulted in 78
per cent, and temporary amenorrhea
in 22 per cent. Below 45 tlie X-ray
should be employed only when oper-
ation is inadvisable or refused. Be-
tween 45 and 55, it is the method of
choice. Hemorrhages due to fi1)roids
after 55 should raise a suspicion of
sarcomatous degeneration. Brettauer
(Amer. Jour, of Obstet., Sept., 1918).
CARCINOMA OF THE UTERUS=
CERVIX UTERI.— Carcinoma af-
fects the cervix uteri more often than
any other organ. It occurs at any
age after puberty, oftenest between
the thirty-fifth and sixtieth years.
Three varieties are met with, viz. :
the pavement-cell carcinoma and the
ulcerating and infiltrating (nodular)
forms of the cylindrical-cell car-
cinoma. The pavement-cell variety
starts, as a rule, on the vaginal por-
tion, and the cylindrical-cell within
the cervical cavity; but when, from
laceration, erosion, or other cause,
the endocervical epithelium becomes
squamous, or that of the vaginal por-
tion cylindrical, the place of origin
may correspondingly change.
Squamous-cell carcinoma com-
mences as a papillary growth covered
by thickened layers of epithelium.
The changes are largely confined to
the surface till they reach the vaginal
wall, by which time they invade the
deeper structures. It does not extend
to the cylindrical epithelium of the
758
UTERUS, DISEASES OF (PA'FORD).
cervix until late. The overproduction
of epithelial cells is surrounded by an
overgrowth of connective tissue, pro-
ducing- fingers that seem to project
in the deeper tissues. The surface
soon becomes fissured and necrotic,
and is covered by a grumous, sticky,
off'ensive discharge containing cell
debris.
Cylindrical-cell carcinoma starts as
a small nodule in the mucous mem-
brane that may spread superficially,
producing extensive ulceration. It
extends quite early into the uterus,
but is late in crossing to the pave-
ment epithelium of the vaginal
portion.
In other cases the cervical walls
are infiltrated before ulceration is
extensive, and the cervix is enlarged
and hardened, and exhibits the his-
tology of carcinoma. Later the proc-
ess of necrosis excavates the cervix
until nothing but a shell is left.
In all forms ulceration follows
sooner or later; the extension and
excavation may in time reach the
bladder, rectum, or ureters, and
finally open these organs, and may
convert the pelvic interior into a large
ulcerating cavity. Obstruction of the
ureters may be caused by infiltration.
Symptoms and Diagnosis. — Occa-
sional slight hemorrhages, becoming
more frequent and Later more abun-
dant and ofifensive, constitute one of
the first symptoms. A gray, watery
discharge, resembling dish-water and
increasingly foul, occurs between-
times. Pain is usually a late symp-
tom, and is a result of extension to
the surrounding tissues. A severe
pain extending into the iliac regioni
or hip is more often the earliest pain.
Later, pains due to cystitis, rectitis,
or peritonitis may become prominent.
Anemia, general debility, faulty di-
gestion, septicemia, and uremia oc-
cur from local inflammation and
sepsis.
Squamous-cell carcinomas give to
the examining finger the notion of an
induration or tumor of the cervix; in
early cases a mere projection of one
lip, later a large mushroom-shaped
growth. The surface, at first smooth
and hard, soon becomes fissured and
friable, and bleeds freely on firm
pressure. The os is seldom in the
center, as in laceration and eversion,
for the changes commence on one
part of the circumference, and afifect
that part first and most.
The surface, before ulceration, has
a purplish color, with grayish patches
of epithelial cells. The ulcerated sur-
face is irregularly fissured, has a
vascular border, and is mottled, due
to yellowish-gray necrotic areas sur-
rounded by vascular spots. A cheesy
substance can be pressed out. All
manipulations produce a persistent,
bloody oozing. If the odor is not
perceptible upon introducing the spec-
ulum, it will appear when discharge
is seen or the finger smelled.
Cylindrical-cell carcinoma without
infiltration does not alter the cervix
till advanced, unless eversion, exists.
The sound or dilator usually brings
out a thin, foul discharge, or gran-
ular matter and blood. If there is
eversion an irregular-fissured, ex-
cavated, yellowish-red ulcer, with
abrupt vascular edges, will be seen.
The infiltrated cervix feels hard
and globularly enlarged, the largest
portion being above the vaginal
junction. The vaginal portion may
he normal in color, but a tenaculum
hooked into it will tear out easily
and cause free bleeding — not in a
UTERUS, DISEASES OF (BYFORD).
759
hyperplastic cervix or one enlarged
by myoma. Just before ulceration
the cervix may present a yellowish-
pink, granulated, glistening surface
that in connection with the above is
quite characteristic. The tenaculum
easily tears out of a cystic cervix,
but the laceration tissue does not
bleed profusely, as in carcinoma.
If the surrounding parts are infil-
trated, glands will be felt beside or
behind the cervix, or indurated tissue
extending from the cervix under the
broad or sacrouterine ligaments, often
reaching to the walls of the pelvis
and immobilizing the uterus. When
the ulceration reaches the vaginal
junction, the parametrium is infected.
PROGNOSIS.— The only hope of
a cure is to remove the cervix or
uterus very soon after the com-
mencement of the disease. With the
vaginal walls or parametric glands
involved, cure is not to be expected.
TREATMENT.— The best treat-
ment is abdominal hysterectomy with
removal of as much tissue about
the cervix as possible. Emil Ries,
in this country, and Wertheim, in
Europe, developed the modern opera-
tion. In cases discovered previous to
ulceration or infiltration of the cer-
vix, a vaginal hysterectomy followed
by X-ray treatment or radium appli-
cations to the vaginal vault, as sooin
as healed, may be expected to cure.
But early diagnosis is rare.
Vaginal hysterectomy is performed
somewhat differently for carcinoma
than for myoma or inflammation, as
one must remove as much of the sur-
rounding tissue as possible. The dis-
eased tissue is curetted away and the
cervix and uterine cavity mildlv cau-
terized. An incision is made around
the cervix in tlic vaginal wall fully
half an inch from the diseased area.
After separating the bladder, pushing
it high up, and opening into the peri-
toneal cavity both before and behind,
heavy-silk ligatures are placed upon
the bases of the broad ligaments
about half an inch from the cervix,
and tied as tightly as possible, in
order that the tissue may afterward
slough off. The bases of the liga-
ments are then cut through, and the
upper portions tied. The uterus is
then cut loose, the peritoneum joined
with catgut to the anterior and pos-
terior vaginal walls, the stumps
united in the median line, and the
corners or sides of the vaginal wound
closed at the sides. The ligatures
are left long, and hang out from the
wound. Sterilized iodoform gauze is
packed into the wound and against
the stumps and in the vagina, and
left for four or five days, when it is
removed and an unirritating anti-
septic douche used. The patient is
kept in bed two weeks, given only
water the first twenty-four hours,
liquid diet during the second and
third days, and very simple, mostly
liquid, diet for the remainder of the
first week. The ligatures, if tightly
tied, will come off in two weeks.
Vaginal hysterectomy with forceps
diff'ers in that long-handled hemo-
stats are applied to the broad liga-
ments instead of ligatures, and are
left for thirty-six or forty-eight hours.
A ]iair is ])laced at the base of
each broad ligament, including the
sacrouterine ligament, and after the
cervix is cut loose another pair is ])ut
on the remainder of each ligament.
The connective-tissue vessels are se-
cured by lighter forceps. A gauze
packing is then placed bclween the
forceps and left for Uvo days after
760
UTERUS, DISEASES OF (BYFORD).
the forceps are taken off. The pa-
tient suffers greatly until they arc
removed.
When a radical operation is inad-
missible, the diseased area may be
thoroughly curetted and cauterized
with the strong solution of chloride
of iron or a 50 per cent, solution of
zinc chloride, applied on a pledget of
cotton held ag'ainst the wound for
twelve hours by a gauze tampon.
Bleeding and odor are, for a time,
controlled by strong astringent and
antiseptic injections. A 1 : 500 solu-
tion of chloride of zinc acts both
ways, as does permanganate of potas-
sium. The strength is limited by the
toleration of the vagina and vulva.
Anodynes should be given freely
for pain. X-rays and radium in in-
operable cases have been used.
Studj^ of 400 cases of uterine can-
cer in which radium was used. It is
more effective for the arrest of the
progress of the disease process than
any method hitherto used. It is more
eflfective in primary lesions than in
recurrences; will occasionally relieve
pain in the terminal stages, and will
relieve pain, heniorrhage, and dis-
charge, and restore the general
health in advanced lesions more
effectively than any other agent. It
will convert borderland lesions into
ones plainly operable. W. S. Stone
(Amer. Jour, of Obstet., Mar., 1918).
The application of heat of a tem-
perature that will harden but not de-
stroy the tissues destroys the cancer
cells, but does not penetrate as deeply
as the X-ray and radium (Percy).
CORPUS UTERI.— Three varie-
ties of carcinoma of the endometrium
have been described : adenocarcinoma,
malignant adenoma, and squamous-
cell carcinoma.
The adenocarcinoma is similar to
adenocarcinoma of the cervix, and af-
fects the mucous membrane quite ex-
tensiveh' before deeply infiltrating.
Malignant adenoma commences as
an enlargement and folding of the
gland-tubules, while still lined with a
single layer of epithelium. The folds
(if contiguous glands unite and form
anastomosing tubules filled with epi-
thelial cells, which begin to prolifer-
ate atypically, and gradually distend
and break through, to form the ordi-
nary nest-structure of cancer.
Squamous-cell carcinoma may be
primary where the epithelium of the
endometrium has become squamous,
or it is secondary to squamous epi-
thelioma of the cervix.
The uterine wall is slowly invaded,
and the glands of the broad ligament
and along the internal iliac vessels
become infected. Peritoneal adhe-
sions and infiltrations of the broad-
ligament connective tissue are formed.
SYMPTOMS.— Watery and bloody
discharges, gradually becoming offen-
sive and mixed with bits of broken-
down tissue, appear first. Pain is
prominent in advanced stages. If
discharges and disintegrating masses
of tissue are retained, it is colicky in
character, but in time the pains oi
chronic peritonitis assume promi-
nence. Pains shooting into the iliac
regions and down the limbs are also
troublesome when extensive infiltra-
tion exists.
DIAGNOSIS.— The characteristic
discharg-es beginning at or after the
menopause, the nature of the pains
and the progressive symptoms arouse
suspicion. Microscopic examination
of tissue brought out by a curette
should always be made.
PROGNOSIS.— The prognosis is
better than that of carcinoma of the
cervix ; the surrounding tissues are
UTERUS, DISEASES OF (BYFORD).
761
not as rapidly infected. An early
operation often effects a cure.
TREATMENT.— The only indica-
tion is hysterectomy. Abdominal
hysterectomy would seem to have the
perference, since affected glands of
the broad ligament and at the pelvic
brim can be seen and enucleated. If
the surrounding glands are affected
the disease may be expected to re-
turn, even though the visible ones be
removed ; hence the only benefit of
abdominal over vaginal hysterectomy
is that the return may be somewhat
slower. Therefore the former is only
to be chosen when the conditions are
such that the risk would be but little
greater : i.e., when the vaginal method
presents some unusual difficulties.
Vaginal hysterectomy is performed
the same as for carcinoma of the cer-
vix, except that the incisions can be
made close to the cervix, and that the
Fallopian tvibes and as much of the
upper portions of the broad ligaments
as possible should be taken.
Curettage is only palliative, and
should be done with a sharp curette
without pressure against the friable
uterine walls. Carbolic acid, the solu-
tion of perchloride of iron, or a 50 per
cent, solution of zinc chloride should
then be applied freely in the uterus.
When for any reason hysterectomy
cannot be performed, radium applied
to the endometrium, or heat, with
an electrode not quite hot enough to
destroy the uterine tissue, may be
expected to improve the local condi-
tion and reduce discomfort.
DECIDUOMA MALIGNUM.—
This disorder has been treated under
Abortion in the first volume, to
which the reader is referred.
Treatment. — The treatment con-
sists in early hysterectomy.
SARCOMA OF THE UTERUS.
— Sarcoma occurs as a papillary or
polypoid growth on the cervix, as a
difi:'use growth on the endometrium,
and as an interstitial tumor. It is
rare, and occurs at any age.
Sarcoma of the cervix contains
round and spindle cells. It is soft
and usually papillary, projecting
from the vaginal portion until it fills
the vagina and exerts pressure on, the
rectum and bladder. It spreads into
the cervix, uterine cavity, connective
tissue, and peritoneum about the
cervix.
Symptoms and Diagnosis. — The
symptoms are abundant hemorrhage
and irritating and offensive dis-
charges, retention of urine, difficult
defecation, and expulsion of dark-col-
ored, offensive masses. Anemia and
cachexia develop sooner or later, pel-
vic neuralgia and peritoneal pains
supervene, and finally death ensues
from exhaustion or peritonitis.
The diagnosis is made by the mi-
croscope, although youth of the pa-
tient, early bleeding, and numerous
dark, soft, polypoid masses hanging
from the cervix indicate the disease.
The hydatid mole does not break
down or bleed as easily, and can be
traced into the uterine cavity.
Sarcoma of the endometrium is
of the round-cell variety, usually
diffuse and papillary, and filling the
uterus with a soft, brain-like sub-
stance that may project into the
vagina. The uterine walls become
infiltrated, and finally the surrrunid-
ing organs also.
The symptoms are watery dis-
charges, and later profuse hemor-
rhage, becoming off'ensive and mixed
with pus. Anemia, septicemia, and
pelvic pains become prominent.
762
UVA URSI.
The diagnosis may sometimes he
made from the abundance of the
hemorrhage, character of the tissue
that can be scooped out of the uterus,
uterine enlargement, and general
symptoms of malignancy. Tissue
should be microscopically examined.
Interstitial sarcoma resembles in-
tramural myoma in appearance, and
consists of round and spindle cells,
largely of the latter. It may occur
as circumscribed nodules or as a
diffuse growth of spindle cells. The
submucous tumors sometimes become
polypoid. Some are supposed to have
been myomas that have undergone
sarcomatous degeneration. Rarely
they originate in the cervix.
Symptoms. — The symptoms are
similar to those of myoma uteri, but
they grow more rapidly and are at-
tended later by offensive discharges.
Early menorrhagia is apt to be less
prominent than in myomas. Pain
and general malignant symptoms are
tardy.
Diagnosis. — This is made from
myoma, on the one hand, carcinoma
or sarcoma of the endometrium, on
the other. It grows faster than
myoma, but does not become very
large before it causes symptoms of
malig'nancy. However, it enlarges
the uterus more than carcinoma or
sarcoma of the endometrium before
causing pain, cachexia, odor, etc.
The treatment of all forms of sar-
coma is hysterectomy according to
methods described for carcinoma.
Henry T. Byford,
Chicago.
UVA URSI.-Uva ursi, U. S. P.
Known also as Bearberry, Barren Myrtle,
Rockberry, and Mountain-box, is the
dried leaves of Arctostaphylos uva-ursi
(fam. Ericaceae). It is an evergreen
shrub i)caring white or purplish-white
flowers and five-seeded bright-red drupes.
Tlie leaves are gathered in the autumn.
The important constituents of uva ursi
are arbutin, ericoHn, ericinol, ursone, 5
to 7 per cent. f)f tannin, and a little gallic
acid, resin, and sugar. Arbutin, the active
alkaloid occurs as neutral, colorless, silky
needles, having a bitter taste, and freely
soluble in hot water and in alcohol, and
sparingly solulile ni ether. The mother
liquor, left after the removal of the ar-
butin, contains the yellow glucoside eri-
colin which yields the volatile oil ericinol.
Ericolbi occurs as a brownish-yellow,
odorless, bitter, and hygroscopic powder,
soluble in water, alcohol, and alcoholic
ether, nearly insoluble in ether, chloro-
form, and benzin. Ursolic occurs as silky,
tasteless, fusible, and sublimable needles,
insoluble in water, dilute acids and al-
kalies, sparingly soluble in ether and cold
alcohol.
PREPARATIONS AND DOSES.—
Uz'a ursi, U. S. P. (leaves). Dose, 20 to
60 grains (0.6 to 2 Gm.) in decoction or
infusion.
I'liiidc.vtractuni nvcc ursi, U. S. P. (lluid-
extract). Dose, 30 minims (2 c.c.).
Arbutin (non-ofificial alkaloid). Dose,
10 to 15 grains (0.6 to 1 Gm. ) per diem.
PHYSIOLOGICAL ACTION. — Uva
ursi has tonic, diuretic and astringent
properties. Diuresis is effected by the
stimulating action of the arbutin upon
the renal epithelium. A small portion of
the arbutin is decomposed into hydro-
quinone and glucose, the former exert-
ing an antiseptic and preservative action
upon the urine, and giving it a color vary-
ing from light green to dark brownish-
green, the coloration becoming accentu-
ated when the urine is exposed to the air.
In cystitis, where decomposition of the
urine takes place in the bladder, the urine
may be of a very dark green when voided.
In overdose it may cause nausea, vomit-
ing, and diarrhea.
THERAPEUTIC USES.— Uva ursi is
used in subacute and chronic inflamma-
tions of the urinary organs, being less
useful when the secreting renal epithelia
are diseased. It is, therefore, more effi-
cient in pyelitis and cystitis than in
nephritis. By retarding decomposition of
VAGINA AND VULVA, DISEASES OF (CURRIER).
763
the urine, and, possibly, by lessening the
sensil)ility of the mucous memlirane, it
relieves the incontinence, dysuria, and
stranguary. Tn chronic bronchitis and
leucorrhea it has also been used. W.
UVEAL DISORDERS See Iris,
Ciliary Body and Choroid.
UVULA. See Pharynx and Ton-
sils, Diseases of.
V
VACCINATION. See Varioloid
and Vaccination.
VAGINA AND VULVA, DIS-
EASES OF.
ACUTE VULVOVAGINITIS.—
This general term includes a variety
of inflammations.
Symptoms. — The vulvar symptoms
may be summarized into local irrita-
tion, throbbing-, pain, redness, swell-
ing-, heat, and increased secretion.
The labia minora may be sufficiently
swollen to close the vaginal orifice.
The inflamed tissues are first dry,
then moist. Painful and frequent
urination are very often observed
owing to contamination of the
urethra and bladder. The gonococ-
cus is often the pathogenic factor in
at first apparently benign cases.
Traumatic vulvovaginitis is not in-
frequent. If the skin or mucous mem-
brane is not broken, ecchymosis of
the vulva will mark the injured sur-
face. Pain is almost always promi-
nent, arising from pressure if blood
effusion renders the tissues tense.
The hemorrhage may be external
or internal and profuse. Swelling is
usually a conspicuous symptom, the
swollen tissue being soft and com-
pressible when the bleeding has taken
place, or hard and firm when due to
inflammatory exudate.
Suppuration occurs ncit infre-
quently, for the tissues are vascular ;
while the secretions of the vulvo-
vaginal glands, if retained, during the
inflammatory process readily undergo
degenerative changes. Uncleanness
and want of care in the treatment
predispose to suppuration here as
elsewhere.
The vaginal symptoms after trau-
matisms are similar to those of the
vulva : pain, swelling, local elevation
of temperature, and congestion. Even
moderate pressure, introduction of a
speculum, or violence of any kind
may cause great pain, and more or
less bleeding. The acute symptoms
may disappear in a few days with
judicious treatment. Asepsis is im-
portant, especially in cases with sup-
puration or sloughing.
Etiology. — With the exception of
the gonococcus, lack of cleanliness
exceeds all other factors as a cause
of vulvitis. This is particularly the
case in stout women, in whom the
defective circulation renders the vul-
var tissues unduly lia1)le to infection
and irritation, the latter being due
mainly to fatty acids developed from
excessive local secretion. Poorly
nourished and debilitated women are
also subject to infection in this re-
gion ; children likewise. In the lat-
ter, any of tlie infectious diseases
may cause it, complicated witli ul-
ceration. It may likewise be caused
by vaginal discharges, pediculi and
other parasites, pathogenic organisms
from the anus or urethra, neighbor-
764
VAGINA AND VULVA, DISEASES OF (CURRIER).
mg; cutaneous disorders, the nails in
scratchincf, excessive masturbation or
coitus, diabetic urine and the pruritus
accompanying' this disease.
Traumatic vulvovaginitis may be
caused in various ways — falls astride
a chair or fence, tlirusts from sticks
or implements of wood or metal,
caustic material (mineral acids, chlo-
ride of zinc, etc.), heat from boiling
water, from the flames of burning
clothes, etc., the horns of angry ani-
mals, bites and stings of insects of
other animals, etc. Prolonged or
complicated parturition, especially if
forceps are employed, may also pro-
duce it.
Intentional traumatisms often pro-
duce vulvitis. Among these are the
malpractice of abortionists, due to
violence and brutality, kicks, rapes,
violent coitus, self-inflicted injuries,
the latter often in the insane.
Treatment. — Vulvar cleanliness
should be insured by frequent v^^ash-
ing of the parts. A vulvar pad, se-
cured by a T-bandage and kept
moist w^ith the lead-and-opium lotion
(U. S. P.), may be used. A 4 per
cent, solution, of cocaine applied after
each washing will serve to assuage
the local pain. Excessive irritation
or burning is easily controlled by
means of a small ice-bag applied over
the labia. Absolute rest in bed is
imperative. The pain may also be
controlled and sleep insured by using
a suppository containing opium, 1
grain (0.06 Gm.), and extract of
belladonna, ^ grain (0.016 Gm.). If
the healing process is slow, local ap-
plications of a 25 per cent, solution
of argyrol will hasten it. Irrigation
two or three times daily with hot
saline solution (100° to 110° F.) or
with boric acid (10 per cent.), car-
boHc acid (2 per cent.), Thiersch's
solution, or peroxide of hydrogen will
favor the healing process. Abscesses
and retention cysts must be evacu-
ated under antiseptic precautions,
avoiding opening the venous plexuses
at tlie sides of the vulva.
As regards the vagina simple meas-
ures and gentleness of manipulation
will be helpful. Douches with hot
saline solution or weak solution of
lead and opium (U. S. P.), twice
daily, will serve the double purpose
of cleanliness and relieving pain. In
the interval a pad of absorbent cotton
may be secured against the vulva and
kept moist with the lead-and-opium
wash. The bowels must be kept open
with salines or any approved mild
cathartic. Rest in bed will hasten
the end of the inflammatory process.
If there should be elevation of
temperature (102° F.~38.9° C.— or
higher), quinine in 10-grain (0.6
Gm.) doses miay be given at night.
The diet must be composed mainly of
fluids. If these hygienic precautions
are observed the course of the disease
may not exceed a week. If the
malady does not yield to the above
treatment, a solution of zinc sulphate
or an application of protargol is
advisable.
CHRONIC VULVITIS. — This
disorder may follow the acute form,
but is milder as to swelling and red-
ness at first. Irritation and redness
gradually become severe, however,
with intense pruritus and burning.
After a time the vulvar tissues may
be edematous, parchment-like or hard.
In other cases there is present also: —
Follicular Vulvitis. — In this disorder
the sebaceous and sweat glands and
the hair-bulbs are inflamed and stand
out in small, red, elevated masses,
VAGINA AND VULVA, DISEASES OF (CURRIER).
765
above the more or less inflamed basal
tissues.
The follicular openings may close,
the follicles becoming distended ; or
they may form abscesses, which dis-
charge offensive pus.
Glandular Vulvitis. — Bartholinitis is
due usually to extension of an adjoin-
ing morbid process to both Bartho-
lin's glands. According to Sanger, a
reddish areola aroimd the openings of
the ducts in the fossa navicularis sug-
gests gonorrheal infection. When
pus is formed there is acute pain and
heat, the gland being enlarged and
red. When mere effusion occurs, a
cyst is formed.
The urethral crypts around the
meatus urinarius may also become
inflamed from the same causes, but
especially at menopause and coinci-
dently with senile vulvitis. Pruritus
and burning occur along with the
other symptoms of vulvitis.
Treatment. — The antiseptic and
surgical measures indicated for acute
vulvitis {q. v.) sometimes suffice.
Pruritus is so important and distress-
ing a symptom that a special section
is devoted to it (see page 778).
When these measures fail, removal
or cauterization of the affected glands
is necessary. Chronic suppuration
requires free incisions and iodoform
packing, the wound being allowed to
heal from the bottom.
In the senile form, Doleris advises
that cotton dipped in the following
be passed over the entire vaginal
mucosa : —
I^ Tinctura: indi 3iss (6 Gm.).
Glycerini '3v (20 Gni. ) .
M.
A cylindrical tampon covered with
the following ointment slmuld llien
be inserted into the vasrina : —
R Ziiici oxidi Siiss (10 Gm.).
Petrolati '3vj (25 Gm.) .
M. Fiat unguentum.
Each time the tampon is removed
an injection of the following is
made : —
B Liquoris plumbi sub-
acetatis diltiti 3vj (24 c.c).
Aqxtcc hull Oij (1000 c.c).
M.
The zinc oxide ointment and the
injections should be used daily,
and the iodized glycerin applications
made every two or three days.
GONORRHEAL VULVOVA-
GINITIS.— This condition, due to
gonococcus infection, is attended by
very acute inflammatory symptoms,
which are apt to come on suddenly,
in from one to seven days after ex-
posure. The tissues are hot, dry, and
swollen, and are the seat of sharp
burning pain, extending to the ure-
thra, which seldom escapes infection.
A common accompaniment is in-
flammation of the vulvovaginal
glands. The infective process ex-
tends from the duct, which is oc-
cluded in some instances, while in
others it is the avenue for the escape
of exuberant secretion. Suppurative
inflammation of the cellular tissues
and abscess of the vulva are common.
Gonorrheal infection, owing to
its remarkable tendency to spread
throughout the entire genitourinary
tract, is one of the most destructive
disorders to which woman is exposed.
The inguinal glands may also be in-
fected, and suggest syphilitic bubo.
A more or less marked chill, a rapid
pulse, etc., are common. The i)ain
soon extends to the deeper tissues,
the bladder, rectum, perineum, etc.
Diagnosis. — This should be based
upon microscopic examination of
766
VAGINA AND VULVA, DISEASES OF (CURRIER).
smears for the g^onococcus. The
gonorrhea complement-fixation test
(analogous to Wassermann test,
q. %'., page 385, fifth volume) is an-
other valuable method of detection.
Distinction from local sypliilitic le-
sions is important. (See also article
on Syphilis, this volume). In syphi-
litic ^'iili'ifis the initial lesion may be
on any portion of the skin or mucosa.
It may be very small and featureless.
It is often hidden within the navicu-
lar fossa or on tlie inner side of the
vulva, and may be overlooked. Acute
inflammatory symptoms apart from
those with the sore or sores are not
frequent, and may not appear in the
vulva at all. The neighboring in-
guinal glands are at times enlarged
and painful. The erythematous erup-
tion of syphilis is often seen upon the
vulvar skin, while the late ulcerative
lesions are relatively rare. Syphilis
and g'onorrhea not infrequently co-
exist.
Etiology. — Gonorrheal vulvitis, due
to the gonococcus, notable for its vi-
tality and power to remain inactive in
crypts and to resume activity when
communicated to another individual,
results almost solely from coitus.
Communication by means of towels
and water-closet seats is apt to be
questionable. Washing with infected
cloths or sponges, contact with hands
of nurses who have just handled in-
fected bandages, have also been in-
criminated. The disease may occur
at any age. I have seen it in the
little child and in the toothless dame
of three-score and ten. The tissues
of women between the ages of 20 and
30 are the; most susceptible to its in-
fluence. In very yovmg children the
poisonous agent is often conveyed by
the hand of the infected mother when
tlie child is washed or dressed, or
from contact with an infected father
or mother while in bed at night.
Treatment. — This should include
frequent al)lutions or douchings with
hot vs^ater (100° to 110° F.). For
local applications the best agent is a
solution of silver nitrate, the affected
surface being freely and often cov-
ered with it. Protargol has been
introduced as a substitute for the
silver salt, and is very effective.
For internal treatment a ferrugin-
ous tonic may be given or a com-
bination of quinine, strychnine, and
gentian. Vaccines have been tried,
but their value is still problematical.
Prophylaxis is important in infants
to prevent spread to deeper organs.
A good method is that of Chapin,
who found that by using vulvar pads
of cheesecloth on all girl babies in
wards, placing the soiled pads in
bags, to be immediately sealed and
burned, and employing individual
thermometers, gonorrheal vaginitis
ca'n be reduced to a minimum. The
eyes and other organs are rarely in-
fected. Most cures are spontaneous.
INFECTIOUS VAGINITIS.
— The venereal variety being treated
in the article on Syphilis, and in that
on the Urinary System (Gonorrhea)
in the present volume, this section in-
cludes onlv the remaining forms.
TUBERCULOUS VULVO-
VAGINITIS.—This is one of the
rarest forms of tuberculous disease,
rarely isolated, being usually an ele-
ment in disseminated tuberculous in-
fection. It may be communicated in
coitus from a tuberculous penis.
Symptoms. — On the vulva tuber-
culosis is characterized by a painless
ulcerative eruption of the labia, espe-
cially the labia majora, which shows
VAGINA AND VULVA, DISEASES OF (CURRIER).
767
the usual features of tubercular proc-
esses : sloughing-, want of tendency
to heal readily, and scarring and con-
traction after healing. It is probably
identical with lupus of the vulva.
In the vagina the morbid process
is that of miliary tubercle upon mu-
cosas in general, the tubercle being a
lenticular mass varying in size from
a pin's head to a pea, slightly raised,
grayish, breaking down and forming
a ragged ulcer with infiltrated walls.
Neighl^oring ulcers frequently coa-
lesce and show but little tendency
to heal. Tubercles may be few or the
vagina studded with them. They are
painful to the touch, secrete a sanious
discharge, which excoriates tissues,
and should be differentiated from the
ulcerative lesions of venereal vagini-
tis.
Acute local symptoms are usu-
ally wanting. The many avenues for
transmission to other parts must not
be forgotten, nor the ease with which
general infection may follow.
Treatment. — Constitutional treat-
ment embraces such means as are
usually administered in tuberculosis :
iron, oxygen, creosote, codliver oil,
alcohol, and an abundance of nour-
ishing food; local treatment includes
cleanliness, creolin douches (1 or 2
per cent.) twice daily, and local ap-
lications of a 10 per cent, solution of
silver nitrate, or of the mineral acids
in moderate strength. The object of
local applications is to stimulate the
tissues to healthy activity and pre-
vent spreading of ulceration, not to
cauterize the tissues. The following
formula will l)e found useful: —
Ti. Crrosoti,
Ichthyol aa 3ss (2 Gm.).
Ung. zinci ox Sj (30 Gm.).
M. Sig. : Apply freely.
DIPHTHERITIC VULVO-
VAGINITIS.— There forms a gray-
ish, sloughy, fibrinous false mem-
brane, attended with the usual
symptoms of acute inflammation. It
may occur either in children or in
adults. It has been observed in con-
nection with pharyngeal diphtheria,
with the eruptive fevers, and with
puerperal septicemia. It is a symp-
tom of grave import, indicating a
septic condition that is usually pro-
found and general.
Treatment. — The constitutional
treatment must be that of the general
disease. Antitoxin is indicated if the
bacteriological examination shows the
Lofifier bacillus. Helpful as support-
ing agents are : iron in an assimilable
form (Blaud's pills, the peptoman-
ganate, tincture of the chloride of
iron, etc.), strychnine, quinine, milk,
and broths. Locally, one should ob-
tain perfect cleanliness. When the
membrane begins to disintegrate or
exfoliate, it should be gently removed
with dressing-forceps, and hot anti-
septic douches (creolin, 2 per cent., at
about 100° F.) given twice daily.
In the diphtheritic vulvovaginitis
of cliildren and virgins it is desir-
able to avoid entering the vulva, but
a pad of absorbent cotton may be
kept constantly in contact with the '
vulva moistened with chlorine-water,
or a 10 per cent, solution of silver
nitrate, or a 5 per cent, solution of
hydrochloric or carbolic acid. For
puerperal women and multipar?e in
general, vaginal douches of creolin (2
per cent.) may be used, with great
gentleness, twice daily, while in the
intervals the vulvar ]x-id moistened
with the 10 ])er cent, solution of sil-
ver nitrate, or 2 per cent, solution
of protargol, should be applied.
768
VAGINA AND VULVA, DISEASES OF (CURRIER).
PUERPERAL VULVOVAGINI-
TIS.— This may follow injuries of
the vag'ina during- parturition, es-
pecially instrumental deliveries ; the
strangulation of tissues resulting
from ligatures applied during the re-
pair of tears ; cautery, and other
trauma. It may occur among rich or
poor, but especially in manifestly
dirty surroundings, and where doc-
tors or midwives are careless. It
sometimes occurs, however, when
precautions of doctor and nurse have
been most rigid and complete.
The infecting material may be re-
ceived in the vagina itself or in the
vulva or uterus. It may convey the
streptococcus or the mixed strepto-
coccus and staphylococcus, or the
enterococcus, as observed by G. E.
Shoemaker, or organisms of lower
virulence. The local vaginal symp-
toms may not be acute, for the dis-
ease is seldom limited to the vagina,
or there may be the symptoms of an
ordinary infectious vaginitis.
Treatment— The best is a 2:1000
solution of potassium permanganate
as douche, with local application of
20 per cent, argyrol daily, leaving a
small tampon wet with it in the
canal. A stronger solution may be
used to swab the latter if no tampon
is left in. Scrupulous cleanliness is
important.
The chronic granular vaginitis of
pregnant ivomcn is very refractory.
The utility of zinc-oxide ointments is
practically limited to relief from pain.
Treub advises injections of alum, 1
tablespoonful in a quart of tepid
water, or of 1 : 4000 solution of potas-
sium permanganate. Doleris recom-
mends that a diluted mercurial oint-
ment be applied to the vagina daily
on a gauze or cotton tampon : —
I^ Unguenti hydrarcjyri.. . . 3ij (8 Gm.).
Adil'is IcuKT hydrosi. . . . 3vj (24 Gm.).
M.
Where complete recovery from the
vaginitis has not occurred at the ad-
vent of labor, an iodine application
should be at once made to tlie cervix,
the vagina and vulva washed with
soap and tepid water, and antiseptic
vaginal irrigations conducted.
ECZEMATOUS VULVOVA-
GINITIS.— This disorder runs no
well-defined course. There is an acrid
watery discharge, which excoriates
the external genitals, causing distress
and persistent itching. The latter
may extend to the vulva and peri-
neum ; the vaginal mucosa may be
sensitive and congested, and attempts
to relieve it by friction often intensify
the irritation.
The discharge and irritation may
extend to the uterine mucosa.
Etiology. — The .condition usually
occurs after the menopause. It has
often been called senile vaginitis. It
is almost invariably associated Avith
eczema of the vulva, which is irri-
tated by an acrid vaginal discharge,
especially in cold weather and at
night. The itching in such cases is
almost intolerable — pruritus vulvcc.
Scratching and rubbing cause great
disturbance in the skin, which may
become dry and hard, like parchment,
or may exude an excoriating serum.
Probably germs from dirty finger-
nails are frequently communicated,
thus complicating the condition. The
suffering may cause hysteria or even
insanity.
In my experience it is quite a com-
mon disease, chiefly among those not
overparticular in personal habits.
Treatment. — Cleansing of the va-
gina with 10 per cent, solution of
VAGINA AND VULVA, DISEASES OF (CURRIER).
769
silver nitrate applied upon a swab of Symptoms. — While leucorrhea is a
cotton to every portion of the mucous symptom, it is also the direct expres-
membranc is required. An ample sion of a diseased condition, and pro-
tampon of cotton-wool moistened duces a variety of unpleasant results,
with a glycerin and bismuth paste The daily discharge may amount to
should then be placed in the vagina, several ounces. It may also produce
Applications must be made daily un- an intense irritation of the vulva and
til congestion and discharge have skin which it soils, causing almost
ceased, and sedative and astringent unbearable itching and pain,
douches should be used daily before Etiology. — Causes: (1) Conditions
the tampon is renewed. Any consti- in which the freedom of the pelvic cir-
tutional symptoms should likewise culation is impaired; e.g., pregnancy,
receive especial attention. new growths, and inflammatory con-
The entire inflamed surface of the ditions within the pelvis. (2) A re-
vulva should also be covered with
the bismuth and glycerin paste, ap-
plied freely and frequently, the va-
laxed and catarrhal condition of the
mucous membranes in general ; e.g.,
anemia, fatigue, and the catarrhal
gina being plugged with cotton-wool diathesis. (3) Frequent coitus,
moistened with it. This treatment, Treatment. — The treatment con-
in addition to vaginal douches suffi- sists first in cleanliness, the discharge
ciently astringent (tannic acid, alum being received upon absorbent-cotton
or Hydrastis combined with hot pads as soon as voided; next in re-
water), and cathartics at night (com- lieving the causative conditions; and,
pound cathartic pills, 1 or 2 ; or fluid- finally, using astringent douches.
extract of cascara, 1 dram \ Gm.), In the writers" treatment of leucor--
will usually succeed, and must be
continued as long as any symptoms
remain.
LEUCORRHEA.— By this term is
meant a liquid discharge, more or less
sticky and purulent, milk-like, vari-
able in quantity, and sometimes of-
fensive. It may occur at any age.
Vaginal discharges from conditions
already described are excluded. The
condition whicli causes the discharge
is not an inflammatory, but an irrita-
tive one, in which there is excess of
secretion from the vaginal epithelium,
and probably transudation of serum Gm.) of sodium carbonate, or local
and corpuscles froin the vaginal washings with a 1 per cent, borax
rhea, a tablet of lactic acid bacilli is
slightly moistened, inserted into the
upper vagina through a speculum,
and smeared over the surface. The
treatment is repeated at first weekly,
later once a month. Non-specific
vaginitis in children usually re-
sponded well to the treatment. Of
cases in women without a gross
pathologic condition, about one-half
responded well. Best results in senile
vaginitis. Block and Llewellyn (Jour.
Amer. Med. Assoc, Dec. 15, 1917).
In some cases of leucorrhea in
young girls bathing in tepid alkaline
water containing, e.g., y2 pound (250
blood-vessels, at least in some cases.
The discharge is the more profuse as
the tension in the blood-current is in-
creased: therefore just before and
after menstruation.
solution, or, if the inflammation is
severe, with a 2 per cent, decoction
of althea root, may suffice to give re-
lief. In women in whom these meas-
ures are not promptly effective.
8^9
770 VAGINA AND VULVA, DISEASES OF (CURRIER).
douching should be advised, either insignificant, while the vulvovaginal
with normal saline solution, if there glands lose their activity. This state
is no inflammatory process locally, or may also come prematurely as the re-
with the borax solution just men- suit of general failure of nutrition or
tioned, or a 1 per cent, decoction of removal of the ovaries. It is not a
saponaria root. Where greater as- customary result, however, of early
tringency is necessary, injections of removal of the ovaries.
oak bark (5 per cent.), krameria (3 HYPERTROPHY OF THE VA-
per cent.), or eucalyptus (1 per cent.), GINA AND VULVA. — Excessive
with sodium borate added, may be use causes hypertrophy of the vagina.
used. For very obstinate cases a 0.5 Its walls may merely be thickened or
per cent, solution of copper sulphate, be disposed in folds and ridges. The
1 per cent, solution of lead acetate, or condition may be due to excessive
the following combination, reoom- child-bearing, excessive coitus, or to
mended by Pringle, may be used: — an accumulation of fat and con-
U Zinci sulphatis, nective tissue, which is part of a
Aluminis ex aa Siiss (10 Gm.). general process. If unattended by
'^1^^ OJ (500 c.c). prolapse it may cause no symptoms.
Fiat solutio. Hypertrophy of the vulva is rather
Where more or less odor attends common. It may involve the labia
the leucorrheal discharge some prep- majora or minora alone, or both. In
aration containing sodium hypochlo- syphilis and chancroid it is frequent,
rite should be used, the labia majora being that more
ATROPHY OF THE VAGINA often implicated. The degree of en-
AND VULVA. — Atrophy of the va- largement varies; it may be mod-
gina is the result of age, but a dis- erate, or the vulva may be four or
eased condition when it occurs pre- five times its normal size. The skin
maturely, or as the result of other is hard and board-like to the feel,
diseased conditions. It occurs after Hypertrophy of the labia minor is
oophorectomy and premature meno- also very common. Among the ne-
pause; sometimes in connection with groes of Africa it is said that the
excessive obesity and wasting dis- enlargement is sometimes enormous,
eases, which cause atrophy of all the the labia hanging down in great folds
genitals. The vaginal lumen is con- and masses — often due to elephan-
tracted, the mucous membrane is tiasis.
pale, and its vitality as a functionat- A common cause is masturba-
ing organ is practically abolished, tion, the nymph?e being very sensitive
No particular treatment is indicated, and constant friction and traction)
its work as an organ being termi- causing elongation and enlargement,
nated. Treatment. — When hypertrophy is
Atrophy of the vulva also attends a source of great discomfort, owing
old age, the hair of the labia becom- to its location, operative removal will
ing sparse and straggling, the labia become necessary. When the tension
majora flabby or still somewhat of the skin is marked, shallow linear
prominent if the supply of fat is incisions, by depleting the tissues,
abundant, the labia minora small and will afiford relief; leeches likewise.
VAGINA AND VULVA, DISEASES OF (CURRIER). 771
PROLAPSE OF THE VAGINA, tion of the wound. Iodine collodion
— This condition of the vagina is usti- is then applied to the wound and
ally associated with hypertrophy, iodoform-gauze dressing in the va-
The anterior or the posterior wall, or gina. Upon rest in bed for ten days
both, may be prolapsed. The con- and perfect cleanliness, the wounds
ditions which cause hypertrophy are usually heal by first intention,
also usually the cause of prolapse. Hernial protrusion of the uterus.
Treatment. — Palliative treatment bladder, and tectum, either singly or
consists in the use of pessaries, in combination, has taxed the opera-
electricity, or astringent substances, tive ingenuity of gynecologists. Even
But the moment the treatment is after removal of the uterus there has
discontinued the unfavorable condi- been a recurrence of the cystocele.
tions will recur. Hence radical surg- G. M. Edebohls, after four other op-
ical measures are to be recommended, erations on the same patient, had
namely, the removal of superfluous failed to sustain tlie bladder within
tissue and the restoration of the va- the vagina, removed the whole va-
gina to its normal condition. For ginal mucosa, permanently closing
prolapse of the posterior wall the the vagina by columnization, and
sim.plest, oftenest applicable opera- cured his patient. Subsequently he
tion is Hegar's method. It consists, reported having had 8 successful
in brief, in the removal of a trian- cases ; Waldo had 3 cases, and Boldt
gular, or nearly triangular, strip of 2 cases. Gallant also had 2 cases,
mucosa, the apex of which is near the VAGINISMUS. — This term is ap-
os uteri and the base at the introitus plied to an excessive degree of hy-
vaginse. Its size varies with the pro- peresthesia, together with spasm of
lapse and width of the vagina. the muscles which form its outer
For prolapse of the anterior wall wall, and which render any contact
an operation devised by myself many with the vagina annoying or even
years ago is effective. In extensive positively painful. It may often be
prolapse, an elliptical strip of mucous referred to the sensitive remains of
membrane is removed from the long the hymen, which may not bear the
axis of the vagina, the vaginal wall slightest pressure or even suggestion
being depressed with a sound (as in of pressure without exciting painful
Hegar's operation on the posterior emotion and spasm,
vaginal wall) to determine the extent Treatment. — The induction of gen-
of removal. Then another ellipse, eral anesthesia, dilatation of the in-
sufficiently large, is removed at right troitus vaginae and excision of the
angles to the first, the plane of each ring of tissue which is the remnant
ellipse cutting that of the other at of the hymen will usually cure the
its middle. With suitable precau- trouble. Hemorrhage may be pro-
tions against hemorrhage, the edges fuse, and it is always desirable to tie
of each quadrant (or half-ellipse) in all bleeding vessels and insert a tam-
the denuded area are then united pon filling the entrance of the vagina,
from end to center with aseptic cat- A tampon moistened with a 10 per
gut, the ends being carefully tied to cent, solution of cocaine is useful to
close with neatness the central por- anesthetize the introitus temporarily.
772
VAGINA AND VULVA, DISEASES OF (CURRIER).
VAGINAL FISTULA. — Fistulie
may communicate witli the bladder,
uterus, ureter, intestine, rectum, or
pelvic connective tissue. Often the
result of prolonged, difficult labor,
they may also result from sepsis fol-
lowing surgical operations and pel-
vic inflammation. Ureterovaginal and
uretero-uterovaginal fistulse are rare ;
so also is uterovaginal fistula, the lat-
ter following rupture of the uterus.
Enterovaginal fistula may follow hys-
terectomy, removal of the appendix,
or any complicated pelvic operation
in which the intestine has been in-
jured. This form of injury has be-
come more frequent since the removal
of diseased structures by way of the
vagina became an approved pro-
cedure.
A vaginal fistula implies the pas-
sage of urine, feces, or pus into the
vagina by way of a canal connecting
with the bladder, intestine, or an
abscess within the pelvis. It is a
very distressing condition. Oblitera-
tion of this canal is usually difficult
and subject to frequent failures.
Treatment. — A cure will sometimes
result spontaneously ; if not, it is ob-
tainable only by surgical measures.
Two classes of cases may be con-
sidered : those in which the fistula
alone is to be regarded and obliter-
ated, and those in which this pro-
cedure alone will not suffice, the
organ, abscess, tissue communicating
with the vagina requiring separate
treatment or removal.
In the first class may be mentioned
the fistulas communicating with the
bladder, rectum, ureter, and some
with uterus, intestines, and pelvic
connective tissue. In the second
class are those which connect with
the tubes and ovaries, intestine, ap-
pendix, and pelvic tissue. The fi»'st
class of cases require that the mu-
cous membrane of the vagina be care-
fully and broadly denuded, the adhe-
sive attachment between the vagina
and the other injured organ being
usually maintained. The denuded
tissues are then brought into such ac-
curate apposition that no leakage can
occur. For suture material in such
. cases nothing, I believe, is equal to
fine, pliable, silver wire. Each suture
is carefully twisted so as to furnish
a splint to the healing tissues, but
care must be taken that it be not
twisted too tightly, thereby defeating
its object. The sutures are to be re-
tained from seven to ten days. In
vesicovaginal fistula it has always
seemed to me rational to keep a
catheter in the bladder for constant
drainage until the wound has healed.
In the second class of cases, not
only must the vaginal opening be
closed, but the abdomen opened and
the ofifending organ or tissue removed.
In some cases this removal will
suffice, the vaginal fistula being
closed by a subsequent operation
should it fail to heal. In either class
of cases a series of operations may be
required, and great patience and skill
demanded to obtain a cure.
Mayo's Technique. — C. H. Mayo
(Trans. A\'est. Surg. Assoc, Dec,
1915) has described the operation suc-
cessfully employed by him for the past
twenty years in the repair of small
vesicovaginal fistulae: An incision is
made through the vaginal mucosa
extending completely around the fis-
tulous opening for about a quarter of
an inch, or less, from its margins.
The vaginal mucosa is dissected to-
ward the opening, care being taken
not to break through at the margin.
I
VAGINA AND VULVA, DISEASES OF (CURRIER).
771
This makes a little cup or funnel-
shaped opening projecting into the
vagina. The circular dissection is
carried deeper around the fistula, ap-
proaching no nearer than one-eighth
of an inch to the margiuj its depth
penetrating to the mucosa of the blad-
der, but not through it. This leaves
a little bell- or funnel- shaped open-
ing with mucous membrane which is
connected with the mucosa of the
bladder and projects into the vagina.
A ligature carrier is passed through
the urethra into the bladder and
through the fistula into the vagina.
A suture is passed through both walls
of the funnelled mucosa on each side
of the ligature carrier. The two ends
of the silk suture are threaded into
the ligature carrier, which is with-
drawn from the bladder and urethra.
The ends of the suture projecting
from the urethra are drawn upon, and
with a little aid the fistulous tract
starts inverting. As soon as the mu-
cosa disappears a circular suture of
fine chromic catgut is aDDlied, a little
more traction is used on the ends of
the long suture, and a second purse-
string suture of catgut is applied.
The vaginal side is then closed either
by a circular suture of the chromic
catgut or by interrupted sutures as
seems best. This inversion turns the
mucous surface into the bladder and
leaves a healing surface within the
tube. One of the long ends of the
suture projecting from the urethra is
rethreaded and by a needle is sutured
to the skin of the labia. The two
ends are tied at this point, making
slight traction. A self-retaining ca-
theter (Pezzer type) is inserted into
the bladder, and the patient told to
rest on her side or face, to obviate
urinary pressure on the fistulous area.
After four days it is necessary to
watch the catheter carefully to see
that sediment or phosphatic deposit
does not obstruct its lumen. In some
cases irrigation is necessary. How-
ever, the long suture attached to the
inner side of the fistula and passing
through the urethra acts as safety
valve if the catheter becomes tem-
porarily plugged. After a week the
repair is usually solid, but it is better
to keep the patient on her side or
face for a few days longer, and during
this time keep a catheter in or pass
one at regular periods. The suture
from within the bladder either cuts
itself out with the slight traction or
it may be drawn out by cutting one
side where it is attached to the skin.
TUMORS OF THE VAGINA
AND VULVA. — Vaginal tumors
may be benign or malignant : —
Benign. — (1) Hernise. (2) Cysts.
(3) Hematomata. (4) Non-cystic
growths. (5) Foreign bodies.
Malignant. — (1) Carcinomata. (2)
Sarcomata.
HERNIA.— Prolapse of the va-
gina is often associated with one or
bo'th of two forms of hernia. Dis-
tinction between them is often over-
looked. These consist of hernia of
the rectum, or rectocele, determined
by the finger or sound in the rectum,
and hernia of the bladder, or vesico-
cele, similarly determined by a sound
within the bladder. Hernia at the
top of the vagina is determined by
the presence of a soft, painless, mov-
able tumor, which combined palpa-
tion proves to be a process of the
intestine.
Hernia witiiin the vagina may be
due to descent of the bladder, rectum,
or intestine. The first two are usu-
ally the result of parturition, and are
774
VAGINA AND VULVA, DISEASES OF (CURRIER).
common among- multipara who work
hard, and bear heavy burdens. In
the third form the intestine descends
through the top of the vagina after
the uterus has been removed, or an
incision has been made in the an-
terior or posterior fornix. In rare
cases a prolapsed intestine in Doug-
las's pouch has been forced through
tlie vaginal fornix by a sudden im-
pulse or by continued straining inde-
pendently of any surgical procedure.
Hernial tumor of the vulva may
result from prolapse of an ovary or
from descent of the intestine through
the inguinal or femoral canal into the
labium majus. The differentiation of
the causes of hernia is not always
possible, and when operating for this
condition it is well to remember the
desirability of returning a healthy
ovar\' to the pelvic cavity. The pro-
longed ovarian ligament may be
shortened by looping it upon itself
to prevent recurrence of the prolapse.
Hydrocele of the round ligament
will, in some instances, simulate in-
testinal hernia, and must be distin-
guished from it in the plan of treat-
ment. The contents of such a tumor
are, of course, to be evacuated and a
portion of the tumor-wall removed to
prevent possible recurrence.
Treatment. — Relief is surgical.
The measures mentioned under va-
ginal prolapse may be used for recto-
cele and vesicocele, while for the hernia
at the top of the vagina the patient
may be placed in the left lateral
posture with the hips elevated. The
tumor can then be reduced, if pos-
sible, with the finger. A sufficiently
large portion of the prolapsed vaginal
mucous membrane is then dissected
away ; the sac of the hernia opened,
cleared by careful manipulation of its
contents, if it has any, and cut away;
the edges of the peritoneal stump
brought to the edges of the vaginal
wound ; and the tissues all closed
with interrupted sutures, worm-gut
being preferred for this purpose. In-
stead of this procedure, one may fol-
low Thomas's method: open the ab-
domen, draw back the prolapsed
omentum or intestine out of the sac,
draw back and excise the sac, and
close the wound with silk or catgut.
After this the prolapsed portion of
the vagina may be excised and the
wound sutured. The Bassini opera-
tion offers good prospect of radical
cure for hernia in w^omen.
CYSTS. — Cysts of the vagina are
not infrequent. They may occur
singly or there may be several. They
may be retention cysts, containing
lymph or mucus to which blood may
be added by vascular rupture.
Purulent degeneration may follow.
An abscess and cyst of the vagina
may also result from a hematoma, or
from a tumor within the pelvis (pel-
vic abscess, cyst of the broad liga-
ment, etc.) which communicates with
the vasfina bv means of a sinus or
fistula.
These cysts seldom attain any great
size, and they are not usually painful,
except when connected with severe
lesions of the pelvic organs.
Treatment. — The uncomplicated
cysts may be ligated at their base
and' excised, or if too deep-seated for
ligation, they may be exposed by in-
cision in the vagina and dissected
out. If connected with a tumor of the
pelvis, this must first be removed.
HEMATOMATA. — Hematomata
of the vagina and vulva are rare.
Thrombosis in a vaginal vessel, with
rupture and blood-tumor, while con-
VAGINA AND VULVA, DISEASES OF (CURRIER).
775
ceivable perhaps as an accident of
labor, is at least improbable. As a
result of pressure or bruising, or vio-
lence with instruments during labor,
it is quite possible.
Other accidents may account for it,
e.g., violent coitus, masturbation with
wooden or metallic substances, falls
astride a fence or a chair, or a thrust
with any hard object. It is possible
also as an accompaniment of purpura
hemorrhagica. No age is exempt.
The tumor may be little more than
an ecchymosis or slightly elevated
effusion, or may occupy a large part
of the vagina. The causal hemor-
rhage is usually self-limited, owing to
pressure of the surrounding tissues.
Treatment.^There is little to be
done ; the fluid contents of the tumor
are usually absorbed if not disturbed.
Should purulent degeneration take
place, the tumor would require to be
treated as abscesses elsewhere. Rest
in bed will favor absorption, and
warm boric acid compresses favor
resolution.
MISCELLANEOUS GROWTHS.
— Benign neoplasms of this class are
most frequently fibroids or out-
growths from the mucous membrane.
Lipomata have rarely been reported.
Fibroids may be either sessile or
pedunculated. They are always ses-
sile in their early history. They may
be projected into the vagina from the
uterus or originate in the vagina, are
seldom larger than a walnut or small
€:gg, and are painless. They may be
pure connective-tissue growths or
contain muscle-elements. Little is
known as to their causation.
The mucous-membrane growths, or
polypi, are always pedunculated ; they
may be single or multiple, are always
painless, but may give rise to hemor-
rhage and a mucoid or mucopurulent
discharge ; they are seldom larger
than a pea.
Treatment. — This consists in liga-
tion and exsection of the polypi ; in-
cision and enucleation of the sessile
tumors.
FUNGOUS GROWTHS of the
vagina must be rare. Garrigues refers
to two forms, which usually occur
among pregnant women. They are
known as Leptothrix vaginalis and 0-
'idiiini albicans. The chief symptom
is itching, especially with O'idimn al-
bicans. The vaginal mucosa is red and
inflamed, and studded with small,
whitish growths similar to those in
the mouths of children afflicted with
the same fungus. The distinguishing
growths are determined microscopic-
ally.
Treatment. — A silver-nitrate solu-
tion (10 per cent.) or a 10- or 15-
per cent, solution of copper sulphate
or of lead acetate may be swabbed
freely over the vaginal mucosa daily
until it has returned to normal.
FOREIGN BODIES.— These may
become fixed in the vagina and be
more or less surrounded by new
tissue, and so become essentially
tumors. They may consist of hair-
pins, pieces of glass, pessaries long
neglected and overlooked, etc. They
are often introduced for the purpose
of masturbation, and sometimes from
mere perversity. Intense inflamma-
tion may result. They may form a.
focus from which malignant disease
develops.
Treatment. — Foreign bodies may
cause intense pain. In some cases
they may be removed with forceps ;
in others, dissection is necessary.
MALIGNANT GROWTHS. — Of
tliesc, sarcoma is rare. It consists in
776 VAGINA AND VULVA, DISEASES OF (CURRIER).
an infiltration of the vaginal wall, is prevented, the uterus can be reached
very painful, and its presence can by way of the rectum, and the blood
only be determined by excision of a then evacuated. In a case reported
portion and microscopic examination, by Fordyce (Edin. Med. Jour., Aug".,
Carcinoma is also, for the most 1^12), the menstruation appears to
part, an infiltration process. It may have found its way into the perito-
be an extension from carcinoma of the neum at regular intervals, and to
uterus; in fact, the disease rarely have undergone rapid absorption
originates in the vagina. The tissues therefrom. Having sufl^ered acute
involved may be hard or soft, and abdominal pain in one instance, the
bleed readily. The condition some- girl was operated on for appendicitis,
times results from irritation by a pes- The hemorrhage was traced to an un-
sary or a foreign body in the vagina. usually vascular Graafian follicle.
Leucoplakia of the vagina should A more scientific procedure is the
be classed among malignant tumors construction of an artificial vagina.
as it nearly always passes into cancer. It is essential to provide the artificial
Rhabdomyoma, occasionally met in vagina with a mucous membrane.
the vagina of infants as rapidly grow- The operative procedure devised by
ing polypoid masses, may also assume Baldwin, of Columbus, O., proved
a malignant type. eminently successful in his 6 cases.
Treatment. — This consists in early, A transverse perineal incision is niade
extensive removal with knife, scis- between the bladder and the rectum,
sors, or actual cautery. In some Dissection is carried up to the peri-
cases the diseased tissue can be re- toneum. Through an incision in this
moved only by scraping with the a piece of the small bowel about 25
sharp curette. Recurrence is almost cm. long, 30 cm. from the ileocecal
certain unless the entire growth is re- junction, is brought down, cut across,
moved in its incipiency. Radium has and the ends are inverted with a
been recommended. purse-string suture. The continuity
CONGENITAL ABSENCE.— of the rest of the bowel is re-estab-
This condition is rare ; it signifies ar- lished. The center of the detached
rest in the development of Miiller's loop of bowel is caught with a
ducts during embryonic life from clamp, and drawn down into the va-
causes of which we know very little, ginal canal, leaving the two ends
It may coexist with perfect develop- riush with the floor of the pelvis. The
ment of all the other genital organs, abdomen is closed, and the portion of
There are no troublesome symptoms bowel held by the clamp is opened
if there is also absence of the ovaries; and each side wiped out, and packed
nor before puberty, as a rule, nor with iodoform gauze, so as completely
after the menopause. Trouble is usu- to fill the vaginal space, and the edges
ally due to the accumulation of men- are attached to the margins of the
strual blood within the uterus. I perineal opening. Afer three weeks,
have seen the resulting tumor extend the septum between the/ two loops is
nearly to the umbilicus in a girl of 16. crushed, thus leaving but a single va-
Treatment. — When at puberty the ginal opening. Several surgeons have
elimination of the menstrual flow is resorted to Baldwin's method, all
VAGINA AND VULVA, DISEASES OF (CURRIER).
777
with success. All cicatricial contrac-
tion is also avoided.
.The lower end of the rectum, above
the sphincter, has also been used to
supply a vaginal canal. The possibil-
ity of complications from the colon
bacillus would, however, seem in-
creased.
Conversely, a double vagina may
occur and its presence be detected
only during parturition. This condi-
tion may be simulated by a longi-
tudinal vaginal septum. Such a sep-
tum may occur across the vagina, and
thus form a secondary hymen.
Adhesions. — Inflammatory disease
of the vagina (erysipelas, diphtheria,
sequelae of severe labor, etc.) may
cause extensive sloughing and ex-
foliation of the mucous membrane,
followed by complete adhesive union
of the anterior and posterior walls.
Acquired Occlusion. — Complete clos-
ure by surgical procedure has been
recommended, e.g., for extensive and
inoperable vesicovaginal fistula — the
menstrual fluid being discharged
through the bladder.
Acquired defects of the vagina may
also consist in narrowing or atresia
after unsuccessful operations, after
inflammatory diseases with sloughing
or necrosis, after severe labor, after
cauterization from heat, acids, etc., as
injuries or malignant infiltration, and
as the consequence of senile atrophy
or premature m.enopause.
Atresia from the last two causes is
usually irremediable. When due to
other causes it may sometimes be
overcome by judicious dilatation and
the cutting of bands and strictures.
VARICOCELE.— This sometimes
accompanies pregnancy. It implies
obstructed venous circulation. The
venous supply of the vulva is exten-
sive; hence any condition increasing
pelvic pressure may derange venous
circulation. Fibroid tumors of the
uterus, tumors of the ovaries and
tubes, pelvic abscess, pelvic perito-
nitis and cellulitis, and subinvolution
of the uterus may all cause enlarge-
ment in the veins of the vulva. In
the later months of pregnancy this
enlargement is sometimes enormous,
and rupture is constantly imminent.
Occasionally rupture does occur,
either just before or during labor,
and hemorrhage, phlebitis, or throm-
bosis occur, with grave possibilities.
Treatment. — Rest in bed and a
pressure bandage upon the enlarged
vessels. A pad of absorbent cotton
moistened with an astringent solution
(tannic acid, alum, or fluidextract of
Hydrastis) may be worn until the
cause of the pressure can be removed ;
the varicocele then usually disap-
pears.
PARASITIC VULVITIS.— Vari-
ous degrees of inflammation result
from vulvar parasites. In children,
worms (lumbrici, ascarides) whose
habitat is the rectum, sometimes mi-
grate to the vulva and cause much
uneasiness.
Pediculi pubis are common after
puberty, the hair-follicles upon the
labia and mons veneris being- at-
tacked. Intense itching, with conse-
quent scratching and rubbing, results.
The inflammatory reaction is very
decided, the vulva being sometimes
converted to a mass of suppurating
sores.
Treatment. — The treatment in-
volves cleanliness and great gentle-
ness of manipulation. Irrigation with
a 2 per cent, solution of creolin should
be practised twice daily. The hair of
the vulva should all be carefully
7/8
VAGINA AND VULVA, DISEASES OF (CURRIER).
clipped away, and the entire surface
freely anointed with mercurial oint-
ment (ung-uentum hydrargyrij. After
the parasites have been destroyed the
inflamed surface may be kept con-
stantly covered v^ith the oflicinal zinc
ointment until healing has occurred.
KRAUROSIS VULV^.— In this
rare condition, characterized by atro-
phic contraction of the vulva, the
latter appears dry, shrunken, tense,
and glistening-, resembling scar-tis-
sue. The surrounding hair becomes
thin and dry, and gradually drops out.
The vestibular skin is studded with
ecchymotic, reddish-brown, depressed
spots, although itself pale and defi-
cient in pigment, followed by abrasion
and cracking, and in some cases by a
purulent discharge. It is attended by
itching, burning, and sometimes much
pain. It may lead to local cancer.
Its causes are obscure. It is mainly
witnessed in elderly women, and ap-
pears related to senile involution.
It has also occurred, however, in
younger women, after removal of the
ovaries. Longyear found a band of
fibrous tissue in lieu of the subcutane-
ous connective tissue, and believes
that it impairs nutrition of the vulvar
tissues by strangulating their vascular
supply. It was formerly attributed
tc syphilitic infection, but the Wasser-
mann reaction has proved this to be
untrue. Nor can it be attributed to
gonorrhea or sexual excesses. In a
case of Balzer and Laadesmann it
was associated wnth lichen atrophicus.
Treatment. — Spontaneous recovery
is rarely witnessed. Removal of all
the superficial diseased tissues, in-
cluding the fibrous band referred to
above, is recommended by Longyear.
Case of kraurosis vulvae in which
the writer performed the following
operation: Commencing from above,
outsulc the diseased tissue, he dis-
sected away the whole diseased tis-
sue, excluding the hymen, the incision
starting on the right side and from
above. He came down upon the pos-
terior commissure and upon the left
side after the diseased tissue had
been removed. He dissected the pos-
terior vaginal and lateral wall for
about one inch, and cut partly through
the external perineal muscle so as
to have a large vagina. He then
sewed the vaginal mucous membrane
to the healthy skin. The patient
made a good recovery. C. F. Kivlin
(N. Y. Med. Jour., Jan. 20, 1912).
If operative measures are impos-
sible, physiological rest of the parts,
cleanliness, and treatment to relieve
the pruritus {q. v.) are indicated.
PRURITUS VULV^. — Though
but a symptom, vulvar pruritus causes
suft'ering so intense in some cases as
to have led to nervous breakdown,
insanity, and ever suicide.
Among- the causes are discharges
from the vagina and vulvar glands,
various uterine disorders, especially
fibromas, pregnancy, abortion, pe-
diculi, erythema, eczema, herpes, and
other cutaneous disorders, especially
in corpulent women, diabetic and
gouty subjects; irritation by fine
hairs on the inner aspect of the labia
majora; kraurosis vulvae, and other
atrophic changes attending senility,
physiological or normal menopause;
acidosis due to high living and alco-
holism, gonorrhea, syphilis, intestinal
worms, especially oxyuris, associated
with anal pruritus ; in infants, thrush,
and, finally, nervous disorders in
which the dread of vulvar pruritus
brings it through what has been
termed "pruriginous mnemodermia."
Treatment. — The modem treatment
consists of eradication of the cause
VAGINA AND VULVA, DISEASES OF (CURRIER).
779
while using palliatives. In all states
traceable to deficient metabolic ac-
tivity, especially when due to
senility or the menopause — physio-
logical or artificial — corpus luteum,
thyroid gland, or pituitary gland, all
in small doses, often prove efifective.
In 2 cases of pruritus vulvse asso-
ciated with the menopause, the itch-
ing was with great promptness re-
lieved by internal administration of
an extract of corpora lutea of preg-
nant cows. W. T. Dannreuther
(Jour. Amer. Med. Assoc, Jan. 31,
1914).
Toxemias of intestinal origin, shown
by indicanuria, should be met by in-
testinal antisepsis and free purgation
by salines. Abstention from shellfish
and alcoholic beverages sometimes
suffice in eczematous cases. In others
it is kept up by acid fruits, spices, etc.
Strawberries and green gooseberries
are not infrequent causes. Decayed
teeth may provoke vulvar pruritus,
doubtless through pyorrhea. The
nervous system should be quieted by
valerian, with a dose of the bromides,
and hot milk on retiring.
In pregnant women pruritus vulvae
is often sufficient as to entail loss of
rest and sleep, and to induce pro-
nounced nervous irritability. In some
cases the cause is without doubt the
presence of more or less well-marked
discharge, but the writer has found
sugar in the urine of all the pregnant
women who have complained of dis-
comfort and irritation of this part.
He permits no ingestion of sugar or
sweets, and prescribes for them
Vichy water as a drink. A local ap-
plication of hot water, with 10 Gm.
{2Y2 drams) o£ chloral, is made four
times a day, the parts being after-
ward treated with an ointment of
ichthyol 10 Gm. {ZYz drams) and
benzoin. A few days later a powder
made up of zinc oxide, bismuth, and
talc will be found useful. If there is
any leucorrhea a morning and even-
ing douche containing 20 Gm. (5
drams) of sodium borate is pre-
scribed. Rudaux (Brit. Med. Jour.,
Sept. 27, 1910).
[Carnot found that a tablespoonful of
fresh yeast in a quart (liter) of water ap-
plied as a lotion to the vulva and used as
a vaginal injection caused disappearance
of the sugar from the inflamed parts, ar-
resting the pruritus. — Ed.]
When medical treatment of pru-
ritus vulvae fails, nerve resection
gives good results. In a woman of
34 the author resected on the right
side the superior perineal branch of
the pudic nerve for a distance of 3
cm., back of the transverse muscle
of the perineum and on the left, in-
cising along the ascending ramus of
the ischium, the lower branch of the
perineal nerve for 3 or 4 cm. in front
of the transverse muscle. Pain and
discomfort disappeared the same day
and never returned. Mauclaire (Ann.
de gynec. et d'obstet., Sept., 1917).
Dechaux found efficient a pad of
absorbent cotton dipped in water as
hot as the hand can stand, containing
3 or 4 tablespoonfuls of good vine-
gar to the quart, then dusting with
talcum powder. In other cases, jets
of warm or cold water act better.
The X-rays are useful but cause
much dcpilation. Radium is best.
The constant current has been cura-
tive.
Operative measures include the ap-
plication of caustics or the cautery
to an erosion of the cervix; curet-
tage, if endometritis exists; divul-
sion, under anesthesia, of the vaginal
constrictors, with the introduction of
Sims's glass tul)e or a thick gauze
plug; removal of Bartholin's glands.
Evans (Clin. Jour., June 26, 1912).
Among the lotions proved useful
arc: camphorated brandy, chloro-
form water, potassium bromide (25
Gm. — 6M drams — to the liter — quart),
morphine, ichthyol (20 Gm. — 5 drams
— to the liter of water), and naphthol
(15 or 20 Gm. — 4 or 5 drams^ — to the
■80
VAGOTONIA AND SYMPATHETICOTONIA.
VALERIAN.
liter of water). Psychic treatment is
an adjuvant. Dechaux (Revue de
gynec, et de chir., June, 1914).
Where leucoplakia or kraurosis ex-
ists, excision of the pruritic tissues
is curative and wards ofi cancer. The
X-rays have been used with benefit.
Andrew F. Currier,
Mount Vernon, N. Y.
VAGINOPERINEAL INJU-
RIES. See Pregnancy and Par-
turition, Disorders of.
VAGOTONIA AND SYMPA
THETICOTONIA.-The vegeta
tive nervous system, which includes all
nerve fibers supplied to organs having
smooth muscles and glands, and to the
heart, is divided into a sympathetic sys-
tem proper and an autonomic system.
These 2 systems are antagonistic func-
tionally, 5'et both furnish fibers to each
organ. The most important autonomic
nerve is the vagus, filjers of which go to
the heart, stomach, bronchi, esophagus,
intestine, and pancreas.
Vagotonia has been conceived of by
Eppinger and Hess to denote a morbid
hyperexcitability of the autonomic or "ex-
tended vagus" side of the vegetative sys-
tem. The diagnosis of vagotonia can
always be established by a study of the
action of the various drugs which act on
the sympathetic or autonomic system.
Symptoms. — These include accommoda-
tion spasm, widening of the palpebral fis-
sure, mild convergence spasm, and epi-
phora. Salivation is exaggerated, and
svveating is common. The feet often be-
come cyanotic in cold weather. Derma-
tographia and pigmentation are noted.
Bradycardia, cardiac irregularity, and pre-
cordial pains are also mentioned. Asch-
ner's phenomenon, a bradycardia caused
by pressure upon the eyeball, likewise
occurs in vagotonia. Asthma may exem-
plify periodic vagus irritation. Anaphy-
laxis seems to occur especially in vago-
tonics. This applies also to eructations,
hyperacidity, sensations of fullness, pres-
sure, acute distension, pylorospasm, vom-
iting, etc. The intestinal symptoms are
spastic constipation, periodic diarrhea,
mucous colitis, and rectal tenesmus. Neu-
rotic genital symptoms may also be noted.
Pathology. — The internal secretions are
believed to be at fault. Vagotonia occurs
in the young and constitutionally inferior,
and may be related to status lymphaticus.
Treatment. — Atropine improves the spas-
tic states of vagotonia, but must be given
perseveringly in ascending and descending
doses (Sublinski). Arsenical waters were
also found useful. Atropine is very help-
ful in dysmenorrhea of vagotonic origin
(Spitzig). In some it produces flushing,
tachycardia and cerebral excitement, as in
a child observed by Boehm, but adrenalin
proved helpful, temporarily. As a matter
of fact, vagotonia rests merely on theo-
retical grounds. S.
VALERIAN.— Valerian is the rhi-
zome and rootlet of Valeriana officinalis
(nat. ord., I'alcrianacecc). It contains oil
of valerian, composed of esters of valeric
(valerianic) acid, chiefly borneol valerate.
PREPARATIONS AND DOSES.—
Valeriana, U. S. P. (valerian). Dose, 30
grains (2 Gm.).
Tinctura valeriance, U. S. P. (tincture of
valerian), a 20 per cent, preparation. Dose,
1 to 2 fluidrams (4 to 8 c.c).
Tinctura valeriance ammoniata, U. S. P.
(ammoniated tincture of valerian), made
from powdered valerian, 20 parts, and
aromatic spirit of ammonia, enough to
make 100 parts. Dose, 15 to 60 minims
(1 to 4 c.c).
Ammonii valeras, U. S. P. (ammonium
valerate or valerianate), occurring in
colorless plates, very soluble in water or
alcohol. Dose, 7^4 grains (0.5 Gm.).
Zinci valeras, U. S. P. (zinc valerate or
valerianate), occurring in white scales,
soluble in 58 parts of water and in 35 of
alcohol. Dose, 2 grains (0.12 Gm.).
Among related unofficial compounds are:
bromural (monobromisovalerylurea), 5 to
10 grains (0.3 to 0.6 Gm.), and validol
(methyl valerate), 10 to 15 drops.
PHYSIOLOGICAL ACTION.— Vale-
rian is held by many to exert a pronounced
stimulating effect on those cerebral cen-
ters which exert psychic control, thus
having the power to allay nervousness.
Valeric acid and the non-volatile vale-
rates exert little of the effect of the fluid
VARICELLA.
781
valerian preparations, and the effect of
the salts is practically limited to that of
the combined metals or alkaloids {e.g.,
quinine). The volatile valerates, such as
borneol valerate, seem to act largely like
valerian itself.
THERAPEUTICS.— Valerian is by
many held to be useful for the relief of
various forms of functional nervous dis-
turbance associated with overexcitability
or exhaustion of nervous tissues. It is,
therefore, administered in general nerv-
ousness, nervous insomnia; insomnia after
acute infections, nervous headache or tin-
nitus aurium; gastralgia, neurasthenia,
hysteria, nervous tachycardia, the cardiac
palpitation of smokers and alcoholics; vas-
cular, gastric, intestinal, and sexual neu-
roses; congestive dysmenorrhea, the vom-
iting of pregnancy, and climacteric dis-
turbances. Aromatic elixir and the oils
of gaultheria and peppermint are among
the best agents for disguising the un-
pleasant taste of valerian. The am-
moniated tincture of valerian is a useful
preparation where combined stimulating
and carminative effects are desired. S.
VALVULAR DISEASES OF
THE HEART. See Endocardium
AND Heart, Diseases of.
VARICELLA, —definition.— A
mild, contagious, eruptive disease, also
known as chicken-pox, occurring chiefly
during childhood and youth.
SYMPTOMS. — The incubation varies
from 10 to 15 days. Although the erup-
tion often appears first, there is generally
slight chilliness, a temperature rise of
2° or 3° F. (l.r or 1.8° C), restless-
ness and peevishness, slight pains in the
head and back, and general lassitude. In
24 or 2)6 hours a strictly vesicular erup-
tion appears, more upon the trunk of the
body, but some on the face and neck.
The fever continues, and new vesicles ap-
pear, especially on the face and scalp, for
3 days, after which the indisposition
quickly disappears. The vesicles have no
hard or indurated base, are mostly ovoid
in shape, and filled with a slightly turbid
scrum, which gives them a pearly hue.
They never become confluent. Each
vesicle begins to shrivel or dry up in 24
or 36 hours after it appears, and form a
thin, light-brown scab. Consequently the
first vesicles are often seen dry when the
later ones are just appearing. In 5 or 6
days the eruption has all become dry and
the scabs fall off, generally leaving no
indentations or permanent scars. In a
small percentage of the cases, however, a
very few distinctly pitted and permanent
scars have been left these probably re-
sulting from scratching or otherwise caus-
ing inflammation to extend deeper into the
cutis vera. The duration of the disease
from the first indications of fever to com-
plete convalescence is generally from 7 to
10 days. Very rarely the vesicles appear
in the mouth and fauces, and cause much
annoyance to the child in eating.
In some cases the appearance of ves-
icles on the skin is preceded a few hours
by small, red spots. Rarely the eruptoin
is hemorrhagic. Cases have also been
recorded in tuberculous, anemic, and
otherwise unhealthy children, and leaving
gangrenous — varicella gangrccnosa — phag-
edenic, or troublesome sores. Nephritis
and paralysis have also been noted. In
a few instances focal lesions of the cen-
tral nervous system (encephalomyelitis)
have been observed. Varicella occurring
in previously healthy children, however,
rarely is followed by any troublesome
complication.
DIAGNOSIS. — The sudden develop-
ment of the pearl-color'^d vesicles, the
trfling general symptoms, the early reso-
lution of the eruption, render the diag-
nosis quite easy. From rubeola varicella is
distinguished by the absence of cough
and catarrhal symptoms and the appear-
ance of the eruption on the second instead
of the fourth day. From scarlatina it is
distinguished by the mildness of the feb-
ril ; symptoms and the absence of intense
redness and soreness in the fauces; and
from both it and rubeola by the eruption
appearing in plain, scattered vesicles con-
taining fluid instead of mere red points or
exanthems. From variola it is differen-
tiated by the absence of 3 full days of
active fever and severe pain in the back
and head before the eruption appears.
The latter presents at once an oval vesicle
without any hard, elevated base as in
variola; and as it progresses it begins to
782
VARIOLA— SMALLPOX (MILLS).
shrivel, then dries up in two days, and
has disappeared before a variolous papule
would have completed its development
into a pustule.
ETIOLOGY.— Though very contagious,
there is no known cause of varicella. It
prevails chiefly among children, and, in
epidemic periods, only seldom attacking
persons during adult life.
PROGNOSIS.— Uncomplicated varicella
rarely, if ever, terminates fatally.
TREATMENT.— Rest, in clean, well-
ventilated rooms, at a comfortable tem-
perature, with a plain, digestible food, and
strict personal cleanliness, is all that is
required in a very large majority of cases
of varicella. If a case is met with during
the eruptive stage with scanty and high-
colored urine and inactive bowels, a solu-
tion of bitartrate of potassium in cold
water and rendered palatable by the addi-
tion of sugar, may be given in doses
suited to the age of the patient until the
kidneys act more freely and the bowels
are moved.
If the "esicles appear so numerous on
the face as to cause much heat or discom-
fort, they may be kept moist with an equal
mixture of glycerin and rose-water. D.
VARICOCELE. See Penis and
Testicles, Diseases and Injuries of.
VARICOSE VEINS AND
ULCERS. See Vascular System.
VARIOLA (SMALLPOX). -
DEFINITION. — An acute, infec-
tious and highly contagious disease,
characterized by severe constitutional
symptoms and the appearance on
about the fourth day of a multilocu-
lar, macular eruption, which subse-
quently changes to papules, vesicles
and pustules.
SYMPTOMS.— The period of in-
cubation is from one to three weeks,
usually about two weeks. The pro-
dromal symptoms, lasting three or
four days, are high temperature, rapid
pulse, malaise, headache, severe back-
ache, vomiting, chill, and sometimes
delirium or convulsions. It is at tliis
stage of the disease that young in-
fants frequently succumb. At this
time a scarlatinal rash may be pres-
ent, usually on the abdomen, arms
and legs, and at the same time small
red papues on the hard and soft
palate and other parts of the mouth.
The presence of this scarlatinal rash
and papular eruption in conjunction
with the constitutional symptoms is
very diag"nostic of smallpox before
the appearance of the true eruption.
After four days of the foregoing
symptoms the t3'pical macular rash
makes its appearance, which rapidly
becomes papular, presenting a shot-
like feel to the finger. This rash usu-
ally appears first on the forehead,
from which it spreads rapidly over
the entire body. At the time of its
appearance the temperature will fall
several degrees and the constitutional
symptoms quickly subside. Twenty-
four hours after the appearance of the
papular eruption a small vesicle will
be noticed on the summit of each
papule, which rapidly enlarges, and is
filled with a clear serum. Gradually
a central depression or umbilication
grows on each vesicle, and the vesicle
is converted into a pustule, the con-
tained fluid having a yellowish color.
At this time, which is usually about
the eighth day of the eruption — at
which timic it is distinctly pustular —
secondary fever develops. The pus-
tules are present for a number of
days, and then slowly begin to dry
with the formation of a brown scab.
Following the falling ofif of this
scab, the characteristic pitting will be
noticed.
Albuminuria is present in most
cases. Leucocytosis is the rule in
this disease.
VARIOLA— SMALLPOX (MILLS).
783
Special Forms. — A form which has
been named confluent smallpox is oc-
casionally met with, and is so called
because of the tendency of the ves-
icles to coalesce. This form is ac-
companied by considerable edema
and infiltration in the pustular stage,
resulting in such extreme disfigure-
ment of the face that the patient is
scarcely recognizable. In addition,
this form of the disease is accom-
panied by a never-to-be-forgotten
odor.
Another form called varioloid (de-
scribed in the next article) is a type
of the disease that has been modified
by vaccination.
DIAGNOSIS. — The diagnosis of
smallpox before the appearance of
the rash may usually be made with a
fair degree of accuracy, especially
when, in addition to the severe con-
stitutional symptoms mentioned, the
scarlatinal rash and the papular erup-
tion in the mouth are present. After
the skin eruption appears, the diag-
nosis is rarely difficult to make, the
only disease with which one would be
likely to confust it being chicken-pox.
During the invasion stage and before
the appearance of the prodromal rashes
the diagnosis, according to A. E. Thomas
as modified by H. W. Hill (Lancet-Clinic,
Jan. 1, 1912), must be made from the fol-
lowing diseases: —
Scarlatina. — With rash absent or "missed."
Condition of tongue, cervical lymph-
glands, tonsils, nose discharges, injection
of soft palate (enanthem), circum-oral
pallor, history of vomiting and sore throat.
Backache, absent or slight.
Measles. — Coryza, photophobia, lachryma-
tion, Koplik's spots, backache absent or
slight.
Typhoid Fever. — Although this has not an
acute onset, many cases when smallpox is
rife are reported as smallpox. Attention
should be paid to (a) gradual rise of tem-
perature at onset; "step ascent" on chart;
(fc) early epistaxis or deafness, not com-
mon; (c) Widal reaction; (d) tympanites;
(e) condition of tongue; spleen, stools.
Influenza. — Here the diagnosis may be im-
possible until the time interval for the
appearance of the rash has passed. The
muscular soreness and prostration are
both generally much more exalted in in-
fluenza than in smallpox. The history of
exposure and the presence of an epidemic
are of special importance here. The
bacillus may sometimes be isolated from
the sputum.
Meningitis. — The history, with the pres-
ence of a possible cause, e.g., suppuration
of the middle ear or tuberculous focus in
a lung, is important. The subsequent
course, with the attending palsies, gen-
erally soon clears up the issue. Backache
is uncommon.
Cerebrospinal Meningitis. — Retraction of
the head; rigidity of the neck muscles;
Kernig s sign; possible presence of the
bacillus in the nasal discharge or in the
fluid obtained by lumbar puncture.
ETIOLOGY. — In 1892 Guanieri
described a parasitic protozoa called
Cytoryctcs variolcc, which is now be-
lieved by some to be the specific mi-
cro-organism of smallpox, but the
question is far from settled.
The cytoryctes of Guarnieri, while
specific for smallpox, is not an organ-
ism, but a reaction product of the
cell, and can be demonstrated at
will in infant lymph. The cytoryctes
may sometimes be found to contain
a minute, coccoid, blue stained
(Giemsa) corpuscle in groups. These
may or may not be a form of the
actual microbic exciter, but at any
rate is commonly associated with the
supposed cause of the disease, which
does not stain with Giemsa, and
which passes through s Berkfeld
filter.
The bodies which the writer has
been studying for a number* of years
are in reality the causative agent of
variola and vaccine. They are very
small, round, sharply defined, coccus-
like objects, which divide directly.
On many of tliesc Iiodies one can see
784
VARIOLA— SMALLPOX (MILLS).
a very delicate, filamentous process.
Frquently the bodies are found in
pairs, which are united by a filament;
this appearance is even more striking
vifith dark illumination. The two
bodies seem to dance about, ap-
proaching and receding from one an-
other. As von Prowacek has shown,
this is Brownian movement. E.
Paschen (Deut. med. Woch., Oct. 30,
1913).
Smallpox is the most highly con-
tag-ious of all infectious diseases and
spreads through every known me-
dium of communication. The germ
Avill live for years if kept from light
and moisture. All ages are suscep-
tible, children slightly more so than
adults, but the degree of susceptibil-
ity varies according to the vital re-
sistance of the individual rather than
the severity of the infection.
PROPHYLAXIS.— The only pro-
phylactic measure of any value is
vaccination (q. r.) ; the disease may
undoubtedly be prevented by this
measure. Thus, during 20 years in
Prague, each 10,000 vaccinated per-
sons yielded 27 cases and 1 death,
while 10,000 unvaccinated persons
yielded 830 cases and 247 deaths.
TREATMENT.— Given a case of
smallpox during the stage of inva-
sion, the treatment would be largely
symptomatic. Later frequent bath-
ing will be much appreciated by the
patient; an ice-bag to the head and
hot-water bottle to the feet may be
used to reduce the temperature; the
bromides will be found of consider-
able benefit in view of the extreme
discomfort that accompanies this dis-
ease, and a diet that is nutritious and
easy of digestion should be employed.
One of the causes of the greatest suf-
fering is the intense itching that is
present, for which cold applications
or various inunctions, especially those
containing phenic acid, may be used
wiith considerable benefit. Stimula-
tion may be necessary in an emer-
gency, but should not be used as a
routine treatment. Sudden collapse
may at any time demand active stim-
ulation, and for this purpose alcohol
may be employed.
Dry plaster of Paris is the best ap-
plication for diminishing the sup-
puration and mitigating the subse-
quent pitting, as well as for allaying
the intense itching and overcoming
the loathsome odor of the diseasV.
Its good efifects are most noticeable
in severe cases of confluent smallpox,
which are prone to terminate in deep
cicatrices and actual deformity of the
face. I. Zdanovitch (Semaine med.,
July 15, 1908).
Ten grains (0.65 Gm.) of hydrar-
gyrum cum creta, 3 times a day by
mouth, continued for 6 days, pro-
duces no symptoms of poisoning in
smallpox (with natives of India).
The drug appears to have a marked
action in modifying and reducing the
severity of the disease. Nesfield
(Indian Med. Gaz., Oct., 1908).
The writer has treated 85 small-
pox patients with a mixture of 10
parts of iodine and 90 of glycerin, to
shorten the pustular stage. The
preparation was painted over the pus-
tules two or three times a day. The
results were the dr3nng of the lesions,
absorption of the toxin, arrest of tis-
sue destruction, and prevention of
subsequent pock-marks. All the
cases recovered. Their average stay
in the hospital was only 12 daj^s.
C. S. Rockhill (Jour. Amer. Med.
Assoc, Jan. 27, 1912).
The local application of aluminum
acetate in alcohol reduced the pain
and itching so much that the pa-
tients clamored for it. The writer
used SO parts of the aluminum ace-
tate to 1000 parts of alcohol recti-
ficatus; cotton dipped in this was laid
over the face and covered with oiled
VARIOLOID AND VACCINATION.
785
silk. The chest, abdomen and back
were also dressed with the same mix-
ture, alternately during three hours.
Pitting seemed to be materially
checked. Traeger (Therap. der Ge-
genwart, May, 1915).
In 64 cases of smallpox the writer
obtained a mortality of only 12.5 per
cent., compared with 21 per cent, in
134 cases treated by former methods,
by using a 10 per cent, solution of
spirit of camphor in 90 per cent,
alcohol as a local application several
times daily, followed by painting with
a mixture of iodine, 1 part, and glyc-
erin, 2 parts. Warm baths with lysol
solution were given daily besides,
neutralizing the fetid odor of the dis-
ease. T. Taboada (Cronica Medica,
Mar., 1916).
A form of treatment by the use of
light, which is filtered through red
glass, has been mentioned from time
to time to prevent suppuration, but
with very variable results.
Suppuration in the pustules of small-
pox will never be so intense if the
patients are treated with red light.
It is therefore customary in many
hospitals of the Far East to place
smallpox patients in wards with
windows of red glass. The writer
praises this treatment, but mentions
as serious drawback the difficulty of
ventilation when no artificial system
has been installed. Dreyer (Miinch.
med. Woch., Aug. 2, 1910).
The strictest isolation and quaran-
tine should be practised from the
very beginning; a bedpan should be
kept under the bed containing a solu-
tion of equal parts of chloride of lime
and strong vinegar. To prevent the
infection of outsiders by the phy-
sician, a dram (4 Gm.) each of
chlorate of potash and hydrochloric
acid should be mixed in an adjoining
room at the time of the physician's
arrival, in which room he should pre-
pare himself to leave the house by
w^ashing his hands and face in a weak
bichloride solution and thoroughly
brushing his clothes, if a gown and
cap is not provided.
H. Brooker Mills,
Philadelphia.
VARIOLOID AND VACCI-
NAXION. — Although varioloid is but a
mild form of variola, treated above, which
may occur in individuals who, though un-
vaccinated, may be endowed with insus-
ceptibility to the latter disease, it is also
met occasionally in subjects who have
been vaccinated. Hence its presence in
this article.
VARIOLOID— This is but a mild form
of smallpox (described above). While the
initial general symptoms are virtually the
same, an erythematous rash usually pre-
cedes the typical eruption. The latter is
quite scanty, appearing both on the face
and trunk, and proceeds only, as a rule,
to the vesicle stage. The vesicles may,
however, be found in groups here and
there, differing in this from smallpox.
They usually appear about the end of the
second day and continue until desiccation
begins — about the sixth day. What fever
there is usually ceases on the appearance
of the eruption, and does not recur. Com-
plications worthy of the name are prac-
tically never witnessed. The treatment is
the same as that for smallpox.
VACCINATION.— This term is applied
to a procedure through which, by inocu-
lating human subjects with lymph from
the vesicles of heifers or of human sub-
jects suffering from cowpox (vaccinia)
they are rendered more or less immune
to smallpox.
[I say "heifers" here, instead of "cows"
because a personal study of the subject
at the Institut Vaccinogene of Brussels,
Belgium, emphasized the importance of
employing only heifers not older than
seven months to obtain the lymph, if com-
plications, local and general, from this
source are to be avoided. Humanized
lymph is no longer used, owing to the
danger of transmitting disease, syphilis
in particular. S.]
TECHNIQUE.— That employed by the
War Department, which has been emi-
8—50
786
VARIOLOID AND VACCINATION.
nently successful, is described by Dr. E.
C. Cody, as follows, the vaccine used be-
ing- that available to the profession at
large, i.e., the lymph furnished by the
large manufacturers of the country: —
The area is cleansed with green soap,
then alcohol; dried with cotton or gauze;
abrasions made by scraping or scratching
on the selected area, three being made, 1
inch apart. Instrument, ivory point or
sterile scalpel. Dressing, sterile gauze,
preferably, sometimes vaccine shield.
Dressing changed as often as necessary
to keep it clean and in good condition; if
the vaccination is successful the second
dressing is always sterile gauze. If pri-
mary vaccination fails, the process is re-
peated in a reasonable time, and is again
repeated if the second attempt fails.
The U. S. Public Health Department
holds that the best method is the simplest;
hence, it uses scarification. Vaccination
shields are avoided and aseptic bandages
used. The arm having been dressed after
the operation, the patient returns in 7
days, or earlier, if constitutional or se-
vere local symptoms appear. The dress-
ing is removed in successful cases reveal-
ing "a section of a pearl on a rose leaf."
A bland ointment with sterile dressing is
then applied, to protect the lesion until
it is dry. If the vesicle has not matured
and a mere scratch remains, revaccination
a week or two later at the site of the first
attempt revives the latter, causing it to
run a short course synchronously with
the second inoculation.
The most commonly employed method
is to cleanse the skin — of the left arm
about the deltoid preferably, and not the
leg, which is more readily infected — with
alcohol and to express the contents of
the capillary tube on the cleansed area.
The latter is then scratched with a steri-
lized needle through the vaccine, but not
sufficiently deep to draw blood. The side
of the needle is then placed over the
scratches and the vaccine fluid rubbed
in. The slight wound is then dressed
aseptically.
According to many observers, and the
New York State Commissioner of Health,
the best possible cover for the little
wound is the dried vaccine matter and
clean unbroken scab or skin with which
nature covers the vaccinated spot. Some-
times a shield is put over it at first, l)ut
it had better be left off after a day or
two. If it is worn it should be removed
every day and the skin washed gently in
water tliat has been boiled, and with a
clean towel. When replaced the shield,
also carefully cleansed, should not inter-
fere with the circulation.
PREVENTION OF INFECTION.—
When soiled arms, such as those of im-
migrants, laborers, coolies, etc., are to be
vaccinated, the danger of infection is pre-
vented by the use of iodine, suggested by
Major E. E. Waters, of the Indian Med-
ical Service. The arm is painted with
tincture of iodine, and at the same time
the vaccinator, as he holds the arm, paints
his left thumb-nail. The lancet blade is
dipped in the tincture and" allowed to dry.
A sufficient quantity of lymph is extracted
from the tube with the now sterile knife
and placed either directly on the iodined
arm or on the left thumb-nail; vaccination
is then performed through the iodined
skin and no dressing is applied.
Isadore Dyer holds that the vaccination
injury should stop at the vesicle, that the
pustule is only a sign of local infection,
and hence should be prevented. There-
fore, he advises breaking the vesicle and
treating the vesicular lesion antiseptically,
and suppuration will thus be prevented.
Such a method prevents glandular en-
largements, erythemas, and other erup-
tions. Albert and Holden found that the
best antiseptic measure after opening the
vesicle was to apply tincture of iodine to
it as soon as possible after the latter has
formed, and repeating the application 2
or 3 days later. By this method they
succeeded in either preventing pustule
formation or so limiting it that the sev-
eral pustules which formed did not coa-
lesce. As a result, the vesicles would
soon dry up and form a small, dry scab.
In not one of 116 cases so treated was
there secondary infection with pus-pro-
ducing bacteria, whereas in those not so
treated about 30 per cent, were second-
arily infected.
Acupuncture Method. — This method, in-
troduced by H. W. Hill (1916), aims to
do away with the older methods, all of
which facilitate infection of the wound.
VARIOLOID AND VACCINATION.
787
The arm is washed with soap and water,
then with alcohol, and finally with ether.
A small drop of vaccine is deposited on
the clean surface. The vaccinator's hand
is closed on the arm from behind, so as
to draw the skin tight in front, and a
carefully asepticized sewing-needle point,
held slantingly nearly parallel with the
skin, is pressed against the skin through
the drop of vaccine. Then it is that
Mooo of an inch of the point sticks
through the upper layer of the skin,
carrying the vaccine with it. The needle
is instantly withdrawn and another punc-
ture exactly like the first is made close
beside it, until six punctures are made in
the space of Me of a square inch or less-
The whole process of puncture takes per-
haps fifteen seconds. At once, with a bit
of sterile gauze, the surface vaccine is
removed, and the sleeve drawn down.
SYMPTOMS. — After vaccination no ap-
preciable efifect is produced until the end
of the fourth day. Then, at the point of
introduction, will appear a small, hard,
elevated papule with a minute vesicle on
its apex, very closely resembling the in-
dividual papules of variola. The papule
continues to enlarge in all directions for
4 days, the vesicle becoming first flat-
tened, then indented in its center, and
filled with transparent lymph. During the
fifth day inflammation commences, indi-
cated by an areola of redness, swelling,
and a slightly turbid appearance of the
lymph in the vesicle. The swelling and
redness around the pustule continue to
increase for 3 or 4 days, accompanied by
slight symptoms of general fever, when a
dark-brown spot appears in the center of
the pustule now fully distended with
purulent fluid. From this time all feel-
ings of general fever disappear, the areola
of redness and swelling diminishes, and
the dry, brown spot increases until the
pustule has become replaced by a thick,
brown scab, under which cicatrization
takes place and the scab falls ofi, leaving
an indented or pitted cicatrix, or scar.
The process of desiccation usually oc-
cupies from 7 to 9 days, making the
whole time from the introduction of the
virus to the complete cicatrization of the
pustule about 3 weeks. As a rule, in vac-
cination, papules appear only at the points
where the virus has been introduced; but
in a very small percentage of cases a' few
papules have appeared on other parts of
the surface.
REVAC CI NATION. —Although the
protection afforded by vaccination has
been known to continue indefinitely in the
majority of cases, the period of absolute
immunity lasts, as a rule, but 10 or 12
years, the minority being mainly com-
posed of individuals in whom it lasts but
7 or 8 years. Thorough protection can
only be expected, therefore, by renewing
vaccination every 7 years, and when an
epidemic prevails. Repeated vaccinations
failing under these conditions, tends to in-
dicate that the rebellous subject is still
protected by his earlier vaccination. Even
should infection occur in such a person
the disease — though transmissible as
smallpox to an unvaccinated subject —
would prove relatively benign in practic-
ally every instance, constituting the syn-
drome described above: Varioloid.
Efficacy of Vaccination. — As may read-
ily be ascertained in any smallpox hos-
pital, recently vaccinated persons, includ-
ing children, can live in such an institu-
tion, wait on the patients therein, breathe
its contagium-laden air, and totally escape
the disease. As recalled by Gay recently
(Boston Medical and Surgical Journal,
April 6, 1916), smallpox caused, before
the discovery of vaccination by Dr. Wil-
liam Jenner, a tenth of the deaths in
ordinary times, one-half in epidemics, and
destroyed, maimed, or disfigured one-
fourth of mankind. The evidence that
vaccination practically prevents smallpox
at the present time is overwhelming.
Countries that are most efficiently vacci-
nated suffer least from the scourge. To
give but a few examples, Germany, where
vaccination is obligatory, has been free
from the disease for more than 40 years,
while the adjacent nations are never free.
Systematic vaccination by the surgeons of
the United States army in 6 provinces of
the Philippines, having an approximate
population of one million, reduced the
annual smallpox mortality from 6,000 to
nothing. During the succeeding 5 years
there was not a death from this disease
in this region of a vaccinated person. In
1885, smallpox broke out in Montreal; the
788
VASCULAR SYSTEM, DISORDERS OF (SAJOUS).
upper classes protected themselves by
vaccination and escaped; the ignorant
classes refused, and 3000 perished. If any
event in human afifairs has been demon-
strated beyond a reasonable doubt, it is
the great benefit to be derived from timely,
efficient, skillful vaccination against small-
pox. S.
VASCULAR SYSTEM, DIS-
ORDERS OF.— Several of the more
important disorders of this class, ar-
teriosclerosis, aneurism, angioma, an-
gioneurotic edema, etc., having al-
ready been considered, this section
will be devoted to conditions w^hich,
though not as frequently encoun-
tered, occupy a prominent position in
nosology.
RAYNAUD'S DISEASE. — This
malady, also termed in its advanced
stage symmetrical gangrene (see also
fourth volume, page 796), is the re-
sult of spasm of the arterioles, espe-
cially those of the extremities, which,
by impeding the arterial circulation
in the latter, provokes in them pallor,
coldness, tingling, pain, and cyanosis ;
and in some cases, when the vascular
obstruction is complete, gangrene.
Symptoms. — In the early stage
of the disease, the only symptoms are
such as would suggest slight freezing
of the fingers or toes, the tip of the
nose, the margins of the ears, etc.,
with their usual attendants, pallor
and numbness. After a few hours,
perhaps, or on returning to warmer
quarters, there is slight tingling and
hyperemia, soon followed by the res-
toration of normal conditions. Later,
similar phenomena recur, but this
time they may be more marked,
cyanosis, burning pain, followed by
pulsative congestion suggesting the
presence of severe chilblains — which
local disorder is closely simulated.
Such mild attacks may recur fre-
quently, or, perhaps, only once or
twice, but ultimately there occurs
one in which, after exposure to cold,
the blueness or cyanosis of the
fingers persists, and their projecting
portions, the pads or knuckles, or, per-
haps, the tip of the nose or margins
of the ears swell and become bluish
black, and finally slough off as necro-
tic tissue, leaving scars. Or, after
the preliminary pallor, coldness, etc.,
severe pain, extending perhaps to the
hand, occurs, and cyanosis and gan-
grene of one or more fingers or toes
follows, the first phalanges in marked
cases being lost. Similar attacks
may follow at weeks' or months' in-
tervals, but in the more severe cases
a hand or foot, or both upper or
lower extremities, require amputa-
tion, owing to appearance, finally, of
symmetrical gangrene. In such cases
the suffering may be acute.
Hemoglobinuria may accompany
the attacks or supplant them, and is
more common in children than in
adults. Urates are often found in the
urine ; sugar occasionally. The hem-
osflobinuria is doubtless due to in-
volvement of the renal vascular sup-
ply in the morbid process. The
latter may also affect the vessels of
any organ, even the cerebrospinal
system, and thus cause convulsions,
melancholia, hemiplegia, aphasia, and
finally death from exhaustion. In
some patients the disease ceases
spontaneously.
Etiology and Pathogenesis. — Ray-
naud's disease is uncommon, but
seems to be more frequent among
Hebrews than among other races,
the largest proportion occurring in
females, and between the tenth and
fortieth year, though the very young
VASCULAR SYSTEM, DISORDERS OF (SAJOUS).
789
or old are not exempt. A neuro-
pathic heredity or the presence of
neurasthenia, epilepsy, gout, mi-
graine, mental disorders, hysteria, or
other neuroses seem to predispose to
it; also arteriosclerosis, sexual ex-
cesses, syphilis, malaria, various in-
fections, lead and benzine poisoning.
As to the immediate causes, cold
weather, frequently recurring chil-
blains, frequent immersion of the
hands in cold or hot water, as in
certain occupations, and menstrua-
tion have been incriminated. Several
acute cases, in which fright and ex-
posure to cold and wet concurred,
were observed after the recent earth-
quake in the Abruzzi, Italy.
Raynaud, who, in 1862, gave the
disease its true place in nosology,
maintained that it was a neurosis of
central origin, what arterial or per-
ipheral nervous lesions he found be-
ing evidently secondary, gangrene
occurring without such lesions to ac-
count for it. That contraction of the
peripheral arteries accounts for the
local syncope has been shown by the
reduced caliber of the radial, retinal,
and other vessels, but the nature of
the process has remained obscure.
From my viewpoint, the arterial spasms
are due to two concomitant factors: 1.
Abnormal excitability of the cutaneous
fibers of epicritic and protopathic sensi-
bility— the former of which are not stim-
ulated by cold above 26° C. (78.8° F.)
and the latter by heat below 37° C.
(98.6° F.). 2. Abnormal excitability of
the spinal cells, probably sympathetic,
which govern the vasoconstrictor nerves
of the cutaneous arterioles. When the
cutaneous sensory terminals mentioned
are exposed to temperatures, cold or heat,
capable of exciting them, they stimulate
with abnormal violence the oversensitive
spinal cells and reflexly produce a periph-
eral vasomotor spasm to which the dis-
ease, is due. Personal experiments have
shown that when the skin of exposed
areas was covered with a substance, flex-
ible collodion, for instance, which pro-
tected its sensory terminals from contact
with air at a temperature capable under
ordinary circumstances of provoking a
spasm, the latter failed to occur.
Treatment. — Any underlying cause
of the disease (see under Etiology)
should, if possible, be eliminated. In
practically all cases removal to a
warm and equable climate affords
marked relief, and sometimes insures
a cure. Hot air has been recom-
mended by Bensaude ; radiant heat
baths, or the more convenient warm
poultice and warm bath tend to
arrest the attacks of local syncope
where cold is the spasmogenic agent.
Amyl nitrite inhalations occasionally
do so. To prevent their return when
the patient is obliged to be out in
cold weather I have used as adhesive
covering flexible collodion, which
does not crack, with excellent results,
in addition, of course, to the usual
warm gloves or stockings worn by
the patient as a rule. The collodion
is painted over the lingers and toes,
and thus coating the cutaneous sen-
sory terminals for cold. Beck found
a 10 per cent, solution of ichthyol to
afford marked relief.
To oppose the tendency to angio-
spasm thyroid gland has been used
by Battus and Osborne, but sodium
iodide in large doses is at least as
efficient and need not be closely
watched ; it may be given with so-
dium bromide to reduce the hyper-
sensitiveness of the spinal centers.
Nitroglycerin has been recommended,
but it fails in most cases; the spirit
of nitrous ether, 30 drops taken when
an attack is starting, sometimes ar-
rests it in patients given the iodides
and bromides, as stated above. Elec-
790
VASCULAR SYSTEM, DISORDERS OF (SAJOUS).
tricity, massage, or the Tourniquet
were recommended by Gushing-, but
such measures are often painful and
not always efficient. The treatment
indicated when gangrene occurs has
already been reviewed in the fourth
volume, page 799.
ERYTHROMELALGIA. — This
disease, also known as red neuralgia
and Weir Mitchell's disease, is char-
acterized by neuralgic pain, tender-
ness and congestion of the feet, and
sometimes of the hands when these
are dependent, and after severe exer-
tion or use of these extremities.
Symptoms. — Tenderness of the feet,
especially of the soles or palms, fol-
lowed by actual burning pain mark
the onset of most cases. The af-
fected extremity will then be found
to be the seat of a congestion, with a
local rise of temperature, and more
or less covered wMth irregular patches
of redness, the arteries pulsating ab-
normally. After a time, cyanosis
may appear, the affected extremities
becoming either purplish red or
pallid with bluish hue, and cold.
These symptoms are aggravated by
warmth (including warm weather),
the dependent position and exercise,
and eased by cold. The onset of the
symptoms may be more or less sud-
den and paroxysmal, their gravity in-
creasing up to a more or less marked
acme, which is follow^ed by an equally
gradual recession to normal. There
is no edema, and the local hyperemia,
even if it proceeds to cyanosis, does
not lead to gangrene. Paresthesia
and hyperesthesia of the affected re-
gion are usual. Otherwise the health
is normal, the disorder occurring onh^
when the affected member is depend-
ent, as in standing; the reflexes are,
as a rule, exaggerated.
Etiology and Pathology. — The dis-
ease occurs somewhat more . fre-
quently in males than in females.
Puberty, menopause and infectious
diseases may act as predisposing
causes. Cold and damp, frequent im-
mersion of the extremities in cold
water, excessive use of the limbs and
traumatisms proved to be exciting
factors in the relatively few cases re-
ported, the disease being rare. Its
pathology is still obscure, though be-
lieved by some to be much the same
as that of Raynaud's disease, i.e., a
vasomotor neurosis. In some cases
it seems to occur in association with
disorders of the spinal cord and
peripheral nerves.
This disorder is placed immediately
after Raynaud's disease because, from my
viewpoint it is to a certain extent its
antithesis as regards the influence of the
nervous system on the phenomena ob-
served. Briefly, we are dealing here with
a primary vasodilation instead of a pri-
mary vasoconstriction. Moreover, the
teachings of modern physiology tend to
indicate that it is the vasomotor system
and not the sympathetic (autonomic)
which underlies the morbid process
through excessive vasodilator impulses.
As is well known, destruction of the vaso-
motor center is followed by immediate
dilatation of all the vessels of the body.
But stimulation of certain afferent nerves
produces similar effects reflexly. In erj'-
thromelalgia — only from my viewpoint of
course — we are dealing with abnormal ex-
citation of the peripheral terminals of
such sensory nerves — epicritic or proto-
pathic, as the case may be — in persons
whose central vasomotor center is, as a
result of conditions mentioned above, ab-
normally ready to respond to such vaso-
dilator impulses, especially when their
occupation is such as to increase the mor-
bid process by constant exposure or
irritation.
Treatment, — The essential feature
of the treatment is to seek carefully
VASCULAR SYSTEM, DISORDERS OF (SAJOUS). 791
the cause and remove it. The pre- ally are also affected — they are paler
vailing treatment is rest with eleva- than usual and cold, their tempera-
tion of the limb from six to twelve ture being- reduced from ^° to 2° C.
weeks, daily massage to promote cir- (0.9° to 3.6° F.). Paresthesia is ob-
culatory activity, cold douches or served in some and anesthesia in
cold packs, and which prove grateful others. Rarely the head, face, chest,
to the patient. Rubber bandages back, and abdomen are involved,
have been used to facilitate locomo- Numbness and stififness of the hands
tion. Moleen has found adrenal are commonly observed. Friction,
gland useful, doubtless owing to its walking, or movement of the parts
influence on the central vasomotor tend to reduce the discomfort. The
tone, which effect the faradic current attacks of acroparesthesia may last
also tends to increase. Resection of but a few minutes and recur at long
the motor nerves to the affected area intervals ; in other cases they may
has been performed, but in view of last many hours and recur frequently,
the fact that spontaneous cure occurs and even, though rarely, may per-
often when the cause of irritation is sist continuously. Often they cease
removed, such a radical measure is when their cause is eliminated ;
not warranted. From my viewpoint otherwise they become progressively
adrenal gland, strychnine, digitalis, worse.
or, better, digitalin in full doses are Etiology and Pathology. — Of 200
indicated to promote the contractile cases studied by Lesem, 94.5 per
power of the arterial musculature cent, were in women, the majority
and thus enable it to oppose, with being in those whose occupations
greater efficiency, the vasodilator im- tended to expose them to wet and
pulses. Painting vulnerable surfaces cold, continuous hard use of the
with flexible collodion is efficient to hands, as in tailoring, etc. The
protect them against cold. Ichthyol majority of patients were between
painted on the congested areas when the ages of 30 and 40 years. Ivlen-
these persist favors their resolution, strual, puerperal, circulatory, and
ACROPARESTHESIA. — This gastrointestinal disorders appeared
disease is characterized by numbness, to be the chief predisposing causes,
tingling, and pain in the fingers and It has also, though rarely, followed
hands, also occasionally in other traumatisms.
regions, due in most instances to ex- Pathogenesis. — The pathology of
posure to cold and damp, hard usage the disease is admittedly unknown,
of the hands, etc., in a predisposed It has been attributed to defective
subject. peripheral venous circulation with
Symptoms. — The salient symptoms resulting serous infiltration of the
of the disease are tingling, "falling nervous terminals ; a vasomotor dis-
asleep," burning, itching of the hands turbance, etc. Oppenheim attributed
and arms, occurring either at night, it to extraordinary irritability of the
especially toward morning, or on vasomotor center as a result of which
using the hands, and increased by the arteries are contracted and the
heat. If any discoloration occurs in nutrition of the peripheral nerve
the fingers — or toes, which occasion- endings perverted.
792
VASCULAR SYSTEM, DISORDERS OF (SAJOUS).
Oppenheim overlooks the fact that
marked irritability of the vasomotor center
would manifest itself by hyperemia of the
surface, and not as in the present disease
by constriction of the peripheral vessels
as evidenced by the primary pallor, hypo-
thermia, numbness, etc., of the affected
areas. The sympathetic (autonomic) fac-
tor must be included to account for the
phenomena observed, much as is the case
in Raynaud's disease. It probably differs
from the latter, however, in being brought
about by abnormal irritation, through
cold, wet, pressure, etc., of the cutaneous
nerve endings of epicritic sensibility
which, as separate sensory terminals, en-
able us to make the finer discriminations
of touch and temperature. The spinal
autonomic centers, themselves irritable
through one of the systemic factors
enumerated, would find in the peripheral
irritation the factor necessary to incite
and perpetuate the disease.
Treatment. — The main indication
is to eliminate the external cause.
This is often a difficult matter where
a trade or other means of livelihood
must be abandoned. Yet it is usu-
ally possible to cause the sufferers to
modify the feature which is actually
harmful to the affected members.
Any pathological factor, whether cir-
culatory, gastrointestinal, menstrual,
puerperal, etc., must receive atten-
tion. On the whole, the measures
indicated are the same as those rec-
ommended for Raynaud's disease.
VASOMOTOR ATAXIA.— This
term, subsequently amplified to auto-
nomic ataxia, was first applied by
Solomon Solis-Cohen, in 1885, to an
abnormal condition of the sympa-
thetic (or autonomic) nervous sys-
tem, through which, as a result of
hereditary or of debilitating influ-
ences, it fails to carry on adequately
its visceral and especially its cardio-
vascular functions The circulatory
(vasomotor) aberrations, provoked
under the incidence of various excit-
ing causes and local detriments, may
be constrictive, dilative, or mixed, or
be local, diffuse, or general. Secre-
tory and visceromotor disorders of
various tyi)es may be produced simi-
larly. The chief excitants are heat
and cold, emotion (including worry
and shock) and toxic agents of en-
dogenous or ectogenous origin.
Symptoms. — The disorders built
upon autonomic ataxia are often
widespread, but their peripheral (cir-
culatory and trophic) manifestations
are those most readily observed.
Cutaneous marbling, angioneurotic
congestions and edemas, varices and
even angiomas are the external ex-
pressions of similar conditions of the
superficial or deeper internal struc-
tures. Not only the conjunctivae,
retinae, nose, lips, mouth, tongue,
pharynx, esophagus, cardia and py-
lorus, rectum, larynx, trachea, bron-
chi, but also the appendix, gall-ducts,
pancreatic ducts, ureters, uterus, and
other abdominal organs, and even the
brain, as shown by Hansell's studies
of the ocular fundus, may be the seat
of these vascular disturbances.
As a source of subjective phenom-
ena— usually paroxysmal, recurrent,
and painful — such hyperemias and
ischemias cannot but be prolific.
While the upper respiratory tract
may contribute hay fever or asthma,
or both, to the semeiology of the
fundamental disturbance, the skin
may offer urticaria, eczema, purpura,
and falling of the hair; the gastro-
intestinal canal, indigestion, cyclic
vomiting, colic, membranous enteri-
tis, serous diarrhea, hepatic or appen-
dicular colic (leading at times to un-
warranted operations), hematemesis,
and even gastric ulcer, etc. ; the urin-
VASCULAR SYSTEM, DISORDERS OF (SAJOUS). 793
ary system, renal colic (but not cal- Recurrent blood-losses from any or
cuius), g^lycosuria (from adrenal or all regions are not rare,
pancreatic disturbance), polyuria, al- Diagnosis. — Not only the imme-
buminuria, hematuria, etc. ; the geni- diate collation of symptoms but the
tal system, menstrual and other dis- fundamental (constitutional) liability
orders ; in the joints, rheumatism, of the patient is to be recognized,
angioneurotic swellings, simulating, Here family tendencies and history,
and gout. Arthritis deformans, gen- as well as the patient's previous
nine rheumatic disorders, and tuber- record, are important. The array of
culosis have an etiological rather than syndromes reviewed points to the
a symptomatic relationship with the underlying autonomic imbalance ; but
condition. Paroxysmal disorders in- various tests facilitate its recognition,
elude also migraine, pseudoangina (pec- Blushing, easily evoked, finds its
toris and abdominalis) "palpitations," ruder counterpart in the readiness
functional cardiac murmurs, tremors, with which hot water or counterirri-
muscular spasms, leg cramps, with tants provoke cutaneous hyperemia,
epileptic seizures as an occasional The converse is likewise true — the
surprise to emphasize the importance ready production of pallor and cya-
of the morbid process in point. All nosis and even blackness of the nails
these varied phenomena, to which by cold. The presence of vasomotor
many could be added, may, owing to ataxia is emphasized, moreover, by
the differing incidence in excitants the fact that plunging the cyanotic
and local determinants, supplement, member in ice-cold water will not
supplant, or complicate one another, only produce hyperemia, but also
The objective phenomena are no cyanosis in the parallel non-immersed
less varied. Besides the obvious member. Dermographism, either
dilatations or constrictions of the ischemic, hyperemic or mixed fac-
superficial vessels, we may have mas- titious urticaria, local or general pilo-
sive congestion of the dependent motor reflexes, all point in the same
parts, especially the hands, these be- direction. Excessive or peculiar
ing perhaps pink, red, blue, or leaden, (idiosyncratic) reactions to drugs, as
mottled, with the finger-tips enlarged quinine, epinephrin, thyroid prepara-
and the nails, perhaps, incurved, bi- tions, pilocarpine, and atropine, either
colored, tricolored, etc The whole administered as tests or taken pre-
gamut of Graves's disease may be- viously as medicines, give valual)le
come developed, even to the exoph- clues as to the particular portions of
thalmos, the Stellwag and Graefe the autonomic-sympathetic system or
signs, and the enlarged thyroid. Cer- endocrine gland system, chiefly or
tain cases present Raynaud's phe- exclusively affected,
nomena. Treatment. — Each case is a prob-
The usual low blood-pressure (circa lem unto itself and requires indi\idual
100 S. 80 D.) may, conversely, be- management. It may symbolize Ray-
come high during spastic paroxysms, naud's disease, Graves's syndrome,
Moderate anemia, with hemolysis, is erythromelalgia, hay fever, asthma,
mot uncommon, while in some cases migraine, etc., and call for the meas-
persistent eosinophilia is the rule, ures indicated in these disorders
794
VASCULAR SYSTEM, DISORDERS OF (SAJOUS).
(q. v.). Apart from such, however,
treatment addressed to the under-
lying abnormality — apathy or ere-
thism— .of the sympathetic or auto-
nomic system is necessary.
Erethism betokens central irritabil-
ity. Rest and avoidance of emo-
tional excitants, correction of eye-
strain and of anatomical maladjust-
ments such as visceral ptoses, uterine
displacements, etc., the prevention of
autotoxis by regulated diet, gastric
lavage, occasional purgation with
calomel as main agent and lactic
bacilli, hexamethylenamine, phenyl
salicylate, etc., as intestinal antisep-
tics, are prominent among the meas-
ures calculated to allay this central
erethism. As a corollary to these
measures, the cardiovascular tone, en-
feebled by aberrant stimuli, must be
enhanced ; in addition to hydrothera-
peutic and mechanical measures to
re-educate the vascular responses,
adrenal, posterior pituitary and thy-
mus preparations, digitalis, sparteine,
strophanthus, cactus, quinine hydro-
bromide and ergotin exemplify the
types of agent indicated, to which
galvanization, faradization, and the
static breeze are potent adjuvants.
When persistent sweating betokens
disorder of the sweat-glands, atropine
outstrips all other agents.
Conversely, we may encounter
high blood-pressure in such cases,
the heart laboring to overcome the
spastic constriction of the arterioles.
Here, mechanotherapy, hydrotherapy,
autocondensation, and high-frequency
currents, the nitrite group erythrol
tetranitrate, with amyl nitrite in
emergencies are indicated, with the
iodides and thyroid gland to relax
the contracted peripheral arteries and
sustain the effect, thus restoring the
circulatory equilibrium. Picrotoxin
as a central stimulant may be useful
in all cases, but especially in those
(the most frequent) showing mixed
phenomena.
TRAUMATIC NEUROSES.—
This collective term, which includes
those of railway spine, concussion of
the spine, concussion of the spinal
cord, railway brain, is applied to vari-
ous nervous disorders which may de-
velop subsequent to, and as a result
of, injuries, shock, concussion, fright
or other factors capable of producing
a violent structural disturbance of
the nerve-centers, cerebral and spinal
(including those of the ductless
glands) and manifesting themselves
in the form of vascular neuroses, of
which traumatic neurasthenia, trau-
matic hysteria, traumatic epilepsy,
and traumatic insanity and combina-
tions of these disorders are the main
expressions.
Pathogenesis. — The participation of
the ductless glands in the underlying
morbid processes modifies the older
conceptions of the pathogenesis of
traumatic neuroses
In 1903 ("Internal Secretions," p. 598
et seq.) I attributed to the posterior
pituitary the role of a central sensorium
(seiisorium commune), which reacted to
sensory impressions of external origin
"traumatism, surgical procedures, an ab-
normal mental state such as attends fear,
grief, or other emotions, etc." The mor-
bid effect being defined as a "molecular
jarring of the posterior pituitary body,
harmless when slight, pathogenic when
sufficiently intense, but fatal when a cer-
tain limit is reached." The influence of
the same organ upon the b.ody at large,
but particularly upon the functions of the
thyroid and adrenals, with which organs
it formed what I termed the "adrenal sys-
tem," was repeatedly emphasized through-
out the same work, and in the third edi-
tion (1909, page 606) I established for the
VASCULAR SYSTEM, DISORDERS OF (SAJOUS).
795
first time the direct connection between
the ductless glands and traumatic neu-
roses by the statement that "fright,
trauma — the cause of acromegaly in 19 of
130 cases (Hinsdale) — provoke various dis-
eases, exophthalmic goiter, acromegaly,
railway spine, and concussion, for instance.
. . ." In 1911 the brilliant researches of
Cannon and La Paz, and subsequently
those of Cannon himself, confirmed the
influence of fright and other emotions on
the adrenals, while Crile not only em-
phasized the role of the thyroid under
similar conditions, but through his "anoci-
association" (q. v., page 122, this volume),
introduced measures intended to control
the pathogenic influence of traumatic
stimuli upon the central nerve-cells.
It is through the sympathetic (or auto-
nomic) system that the vascular supply
of the ductless glands is co-ordinated, and
one has but to study even cursorily a
case of Graves's disease due to traumatic
shock, for instance, to realize that there is
a paretic dilation of the arterioles, not
only in the thyroid, but also throughout
the system at large. This applies, in my
opinion, to all the various syndromes of
traumatic origin witnessed.
Erichsen's view (1871), supported by
Erb, that a sufficiently violent concussion
caused molecular disturbance, has been
abundantly sustained by the experiences
of the present war, "cerebral and spinal
concussion" and "physical trauma," with
demonstrable cellular lesions, such as
those depicted in this country by Crile,
having been shown to prevail, even where
no structural trauma occurred, and as a
result of shell or mine explosions of great
violence. "When the shell explodes near
a sleeping person" writes Gaupp (Beitrage
z. klin. Chir., Apr., 1915) "it does not in-
duce the nervous and mental disturbances
otherwise observed. This throws light
upon the importance of fright as a factor"
— a graphic reminder of a fundamental
principle of traumatic neuroses. Again,
Mott (Lancet, Feb. 26, 1916) found that a
large proportion of 156 cases of shell
shock was in neurotics and that neuras-
thenia and hysterical phenomena pre-
dominated, some exhibiting amnesia,
mutism, and even epilepsy — all features
which, as we shall see below, are charac-
teristic of traumatic neuroses. From my
viewpoint, with the ductless glands as
features of the problem, the primary
molecular jarring caused by fright — a
psychic complex — manifests itself mainly
upon the most sensitive of the cerebro-
spinal cellular elements, the sympathetic
(or autonomic) cell aggregates beginning
with what I deem to be their main or
upper nucleus located in the posterior
pituitary body. Inasmuch as the thyroid
and adrenals (and also all other true duct-
less glandular tissues) are innervated by
the sympathetic, there occurs primarily, as
a result of the emotional, i.e., psychic ex-
citement, the excessive outpouring of
secretion demonstrated, as regards the
adrenals, by Cannon, but followed by ex-
haustion of the organs varying in intensity
with the violence of the pathogenic emo-
tion. It is this exhaustion of the ductless
glands which provokes the various phe-
nomena grouped collectively under the term
traumatic neuroses, by causing, among other
effects, atony of the arterioles (the tone of
which is sustained by the chromaffine sys-
tem), slowing of cellular metabolism through
lowered oxidation, and defective catabolism
of waste, and the resulting accumulation of
toxic intermediate products in the blood.
The bearing of these morbid phenomena
will appear under Symptomatology.
Symptomatology. — The symptoms
of the various syndromes awakened
by a traumatism, ph3'sical or mental,
correspond clearly with those of dis-
eases to which they have been as-
similated. Thus traumatic neuras-
thenia differs in no way from the
classic form {q. v.), but it is apt to be
more serious and disabling^; yet the
seriousness of a case may readily,
owing to the relative simplicity of
symptomatology, be exaggerated by
a claimant. Here the pathology is
virtually that of shock with vaso-
motor (autonomic) paresis, low
blood-pressure, and chromatolysis in
severe cases from deficient oxidation.
Traumatic hysteria tends likewise to
prove seiiious, but in proportion, as
796
VASCULAR SYSTEM, DISORDERS OF (SAJOUS).
the individual is predisposed to the
disorder. It is usually due to fright
and may thus fail to develop if the
traumatism is received during- sleep.
In males it is usually associated with
neurasthenia and may assume the
type of a hypochondriacal psychas-
thenia. Railway accidents, owing to
the sudden fright caused, not infre-
quently produce this form, which is
proportionate with the amount of
shock. The main result here is atony
of the arterioles : irregular tissue oxi-
dation sometimes spasmogenic through
the presence of toxic catabolic wastes
in the blood. Traumatic epilepsy may
develop from head injuries, and the
claim that the injured will suffer
from this disease is usually made. In
truth the proportion of instances in
which it develops is extremely small
— hardly once in two hundred head
wounds, including some in which
complete perforation of the brain had
taken place. Malingering is occa-
sionally resorted to in this connec-
tion. The malingerer is apt to over-
look the fact that the thumb con-
tracts inside the fingers and seldom
stands pin-pricks, ammonia vapor,
etc., with the equanimity that the pro-
found unconsciousness of epilepsy
permits.
In these cases the blood-pressure
is high during convulsions w^hich
have for their purpose the destruc-
tion of toxic wastes ; but low between
them — which indicates slowed metab-
olism and defective hydrolysis of
wastes.
Traumatic insanity is still more rare.
In the European war, notwithstand-
ing the many conditions, the terrific
shell fire, etc., which prepared the
nervous system for them, Oppen-
heim found mental affections infre-
quent and only where a history of
previous psychosis, alcohol or head
traumatisms clearly accounted for
tiiem. Even the latter seldom cause
insanity; it was observed in only 1^/2
per thousand head injuries during the
Franco-Prussian war. Amnesia, func-
tional or organic, may occur follow-
ing traumatisms of the head, but as
a rule it is transient; illusions of
identity and fabulation have been ob-
served. Lacerations or other gross
lesions of the brain in children may
entail traumatic dementia or idiocy.
The role of the ductless glands in
the various forms of insanity is given
in the seventh volume, page 657, to
which the reader is referred.
Besides these more prominent morbid
effects of traumatisms are others as varied
as they are numerous. Cerebral concussion
may awaken no immediate serious symp-
tom at first, but do so a few hours or days
later, their nature depending upon the
seat of the lesion. This applies also to
skull fractures, the prognosis of which is
usually serious. Spinal concussion is prolific
in morbid effects, even at times where the
traumatism is apparently slight, partic-
ularly in railway accidents. Locomotor
ataxia was formerly the main disorder at-
tributed to such accidents, but the Was-
sermann reaction, the reflexes, and other
modern tests now make it possible to
establish the true identity of the disease.
Chorea and paralysis agitans may be men-
tioned among the syndromes that have
been attributed to traumatism.
In determining the actual status of a
case, especially if the patient is involved
in a litigation, numerous factors, besides
the purely clinical features, must be taken
into account. Among these inay be men-
tioned: Cupidity as the basis of the claim
with malingering as possible consequence;
autosuggestion, the predominant factor
being an ideational complex in the com-
plainant's mind; worriment entailed by
the lawsuit as a factor in perpetuating and
even aggravating the case, — a feature
taken advantage of by corporation law-
VASCULAR SYSTEM, SURGICAL DISEASES OF.
797
yers. An early settlement is always ad-
visable.
Segregation of early cases of war
neurosis, each patient being in a
special tent or room, is of value, if
the patient is made to feel he has been
selected for special care. Cheerful,
mutual confidence and optimism
are essential. Symptoms produced
mainly by emotional shock or sug-
gestion are treated chiefly by psy-
chic methods; those due to physical
concussion or exhaustion, by rest,
massage, diet, electricity, etc. Those
due to intoxications are treated by
drugs, e.g., for tachycardia, insomnia,
etc. Other cases may require a men-
tal hospital. Stewart (Arch, of Neu-
rol, and Psychiatr., Jan. 1, 1919).
C E. DE M. Sajous,
Philadelphia.
VASCULAR SYSTEM, SUR-
GICAL DISEASES OF. -ACUTE
ARTERITIS.— Inflammation of an artery
occurs during repair of an injured vessel
or following embolism in the absence of
infection (acute plastic arteritis), but is
here applied to inflammation due to bac-
terial infection. It is often due to neigh-
boring inflammatory processes (acute sup-
purative arteritis). If the infection enters
through the connecting blood or lym-
phatic channels, the disease may start
with the inner vascular coat; from a sep-
tic wound, the process attacks the ad-
ventitia first. A thrombus from a distant
purulent process may not only impair the
lumen, but lead to sloughing and aneurism
formation or perforation. In some cases
of arteritis restoration of the vessel oc-
curs; in others, a fibrous cord results.
Symptoms. — These vary somewhat with
the degree of stenosis. There is pain over
the vessel, tenderness, and usually some
local loss of muscular power. If the ar-
tery is superficial, it is tense and cord-like.
Pulsation may be absent. When the col-
lateral circulation is not formed sufficiently
early there is danger of gangrene. Again,
from infectious thromboarteritis metastatic
abscesses may appear elsewhere.
Treatment. — Absolute rest is indicated,
with warmth of the part, opium to relieve
pain, and nourishing food and tonics.
Mercurial ointment, diluted with petrola-
tum, according to the age of the patient,
assists repair if applied with a cotton
pledget along the course of the artery.
Ammonium chloride, 5 grains (0.3 Cm.),
every three hours, is said to encourage dis-
solution of any thrombus present. Other
measures are suggested under Phlebitis.
PHLEBITIS.— Inflammation of a vein,
as here understood, involves direct en-
trance of bacteria into the vascular tissue.
Acute phlebitis usually results from
some injury accompanied by infection. It
is sometimes very grave, leading to py-
emia. . The subacute form, less grave, is
usually caused by some disease of the ves-
sel accompanied by thickening and nar-
rowing of the lumen.
- Symptoms, — Inspection may show a
dull-red line, with discoloration and edema
below the obstruction. There is great ten-
derness, and the vein is felt as a hard,
knotty cord. Pain and stiffness in the
limb are noted. An increasing pulse rate,
without fever (Mahler's symptom) is held
suggestive of beginning phlebitis.
In phlebitis of deeper veins deep-seated
pain and tumefaction are noted. Constitu-
tional symptoms are seldom serious unless
there is pyemia, due to detachment of
small septic emboli, when fever, rigors and
joint-pains may occur.
In the subacute form, if occlusion oc-
curs, an abscess may form. But unlike
arteritis, there is no hemorrhage. Acute
phlebitis may follow, however, through
rupture of the abscess into the vein. Py-
emia may thus also ensue.
Etiology, — Phlebitis may be caused by
varicose veins, traumatism, any inflamma-
tory focus near a vein, primary thrombosis
(thrombophlebitis), or constitutional states,
such as gout, rheumatism, syphilis, chloro-
sis, infectious fevers, and tuberculous or
cancerous cachexia. Postoperative phle-
bitis, believed usually of aseptic nature,
develops oftenest in the left femoral and
iliac veins, and occurs chiefly after ab-
dominal operations on the uterus and
ovaries, in anemic patients, and after
operations for varices.
Prognosis. — Phlcl)itis complicating any
severe constitutional disease, especially
pyemia, is very grave. Simple phlebitis
seldom results fatally, but detachment of
798
VASCULAR SYSTEM, SURGICAL DISEASES OF.
a large embolus resulting from aseptic
thrombosis may result in sudden death.
Treatment. — Absolute rest with eleva-
tion of the afTcctc-d liml) is imperative. A
wash of lead and opium, an ichthyol, mer-
cury and belladonna ointment (not to be
rul)])ed in), or hot fomentations should be
applied. Leeches often prove of value.
Any abscesses should be incised, under
strict antiseptic precautions. Suppurative
inflammation of the vein itself indicates
excision; if this is not possible, it should
be ligated above the affected portion, in-
cised, and disinfected. The diet should be
easily digestible and nourishing, and the
bowels kept open. After six or eight
weeks, gentle superficial massage and pas-
sive movements may help in restoring
circulation, and hastening absorption of
edema.
VENOUS VARIX, OR VARICOSE
VEINS.— This is a dilated and thickened
condition of the veins, especially the inter-
nal and external saphenous.
Symptoms. — Superficial varices appear
as tortuous, bluish, tumor-like masses.
Dull pain is often present, with some loss
of power and a feeling of weight in the
part, and at times muscular cramps. The
superficial veins are usually mainly af-
fected. Saphenous varices are bilateral in
over two-thirds of all cases. They may
extend to the scrotum; occasionally, the
superficial veins of the abdomen are all
involved, a thick, bluish, arborescent mass
of vessels projecting from the surface.
Arteries sometimes also become involved,
and the nearby nerves and muscles may
undergo interstitial inflammation.
Infiltration of tissues is frequent, espe-
cially after walking or standing, but soon
difil'ers from true edema, in that it does
not pit under slight pressure, because of
lymphangitis and hyperplasia of the sub-
cutaneous tissues. An eczematous erup-
tion often appears, followed by a varicose
leg ulcer. When ulceration involves a
large varicose vein, dangerous hemorrhage
may ensue. Another possible complication
is thrombophlebitis, which, in favorable
instances, may result in obliteration of the
vein and spontaneous recovery.
Deep varices are rare and difficult of
diagnosis, until the corresponding super-
ficial veins dilate.
Etiology. — Varicose veins are favored
by weakness of the venous walls, either
inherited or induced by phlebitis, and by
poor general health. Blockage of deep
veins favors varicosity of superficial ones.
The female sex is that more often af-
fected. Prolonged standing, heavy lifting,
tight garters, heart and lung diseases, and
enlargements of pelvic or abdominal or-
gans are determining factors.
Pathology. — The veins are lengthened
and tortuous. Their inner coat may pro-
trude in lobular masses through the
thinned outer coat. The greatest dilata-
tion occurs above the valves, which are
later often sclerosed or rendered insufii-
cient by the dilatation. Such insufficiency
is proven by noting an impulse on cough-
ing all along the vein, or by rapid filling
of the vein from above downward after it
has been emptied by recumbency and ele-
vation of the limb, pressure being tem-
porarily applied high up over the saphe-
nous vein while the patient resumes the
standing posture. Fibroid periphlebitis
may fix the veins to surrounding tissues.
Thrombi may lead to suppurative phlebitis
or turn into phleholiths ("vein stones").
Treatment. — Palliative measures include
treating the cause, building up general
health, attention to the bowels, rest in
bed with elevation of the limb, and light
massage if the skin is normal. Elastic
stockings or bandages are of value where
there is pain, decided discomfort or edema,
and should be applied and removed in re-
cumbency, the skin being rubbed with al-
cohol after removal and zinc stearate
dusted over the part before reapplication.
Hemorrhage is controlled by elevation
and pressure.
Radical treatment is indicated for marked
pain, threatening rupture and hemorrhage,
thrombosis, intolerance of elastic compres-
sion, insufficiency of the valves, obstinate
ulceration or eczema, and varices over the
tibial crest. • When the varicose condition
is unilateral and of small extent, excision
may be performed by ligating the vein or
veins above and below the varices, and re-
moving the latter. Any deep anastomotic
veins should be tied. Where the saphe-
nous vein in the thigh is affected, total
saphenectomy is advisable, either through
an incision from the saphenous opening
VASCULAR SYSTEM, SURGICAL DISEASES OF.
799
down to the ankle or by enucleation of
successive portions of the vessel through
short incisions. This operation is ex-
pedited by the Mayo "stripper," or by the
device of Babcock, who passes a long
flexible probe, acorn-tipped at both ends,
into and along the vein, exposes the distal
acorn and by traction on it tears out 20
or more inches of the vein, which becomes
firmly pleated against the large proximal
acorn. Marmourian's device consists in
passing in a long probe, fixing the vein
firmly to an eye in its distal end, and ex-
tracting the vein inside-out by traction on
its proximal end.
Trendelenburg's operation, less radical,
is useful only where the valves in the per-
forating veins connecting the deep with
the affected superficial vein are sufficient.
Insufficiency ©f these valves is shown by
a rapid refilling (in 30 seconds or less) of
the saphenous in the standing posture
when it is emptied in recumbency and
pressure continued over the upper ex-
tremity of the vessel. The operation,
which consists in excising about 4 inches
of the internal saphenous at the junction
of the middle and inferior thirds of the
thigh, is at times followed by recurrence.
Other useful procedures are those of
Schede, who makes a circular incision
round the leg at the junction of its middle
and upper thirds and ligates all veins then
visible; Phelps, who ligates the saphenous
at short intervals through 30 or 40 small
incisions; Friedel, who incises the leg
spirally, encircling it several times, from
foot to knee, ligating all veins; Cecca, who
sutures the deep fascia over the saphenous
vein,' and Katzenstein, who supports the
vessel by suturing the sartorius round it.
Varicose Ulcers. — If a varicose ulcer is
kept very clean with soap and water or 2
per cent, phenol and dusted with dermatol
night and morning, and a rubber — or, bet-
ter, elastic webbing — bandage is wrapped
round the limb ironx ankle to knee, it
often gradually disappears. Overlapping
strips of adhesive plaster, passing two-
thirds round the limb, are also very use-
ful. Over the ulcer itself 2 per cent, cop-
per sulphate or aluminum acetate, or spirit
of camphor, may be applied. To stimulate
granulations balsam of Peru or 2 per cent.
silver nitrate may be used. Rest, eleva-
tion, and massage of the surrounding tis-
sues are all of importance. In some cases
liberation of the ulcer margins from the
tissues beneath by curved incisions, or
excision of the entire ulcer, may become
necessary.
HEMORRHAGE.— This may be ar-
terial, when the blood comes in jets and
is bright red — except in asphyxia; venous,
when it flows in a continuous stream and
is dark in color, or capillary, i.e., an oozing,
which usually ceases on exposure to air.
Hemorrhage may also be divided into
primary, when it accompanies injury; re-
current, intermediary, reactionary, or con-
secutive, when it follows within twenty-
four hours, during the period of reaction,
or secondary, when it occurs any time after
twenty-four hours.
Symptoms. — A slight hemorrhage is usu-
ally recovered from promptly, unless gen-
eral health is impaired. In severe bleeding
the surface becomes progressively paler,
the lips white, the extremities cold, the
pulse increasingly feeble and rapid, and the
respiration frequent and sighing. Faint-
ness is experienced, with loss of voice,
buzzing in the ears, failing sight, and
pupillary dilatation. Often cold perspira-
tion is noted. Delirium, collapse, and even
death may follow.
Treatment. — This is constitutional and
local. The patient must be recumbent,
with the head as low or lower than the
body, — unless the bleeding be from the
nose or ears, when the upright position is
indicated. All clothes should be loosened
and the temperature maintained with
warm blankets and hot- water bottles. The
femorals and subclavians may be com-
pressed, or, better, the extremities band-
aged (autotransfusion). When the bleed-
ing has not been arrested, stimulants
should be given only in extremis. If it has,
1 pint or more of hot normal saline solu-
tion containing 15 or more minims (1 c.c.)
of 1:1000 adrenalin chloride should be
given by intravenous infusion or hypo-
dermoclysis. Hypodermic injections of
ether, atropine, strychnine, and digitalin,
with enemata of hot coffee and brandy, are
also of value. Blood transfusion is best
for saving desperate cases; next comes in-
fusion of 5 to 7 per cent, acacia solution.
For local treatment sec r.ext section.
800
VASCULAR SYSTEM, SURGICAL DISEASES OF.
INJURIES AND WOUNDS OF VES-
SELS.
A. Arteries. — Contusion of an artery
may not cause any special symptom, but
if it is badly injured its walls are apt to
slough, causing hemorrhage. Aneurism or
obliteration and gangrene may also result.
RuPTUKE is favored by atheroma. When
incomplete, it is associated with tearing of
the middle and internal coats alone. The
latter, curling up, may lead to thrombosis
and occlusion. Or, there may follow an
aneurism, or a hemorrhage due to erosion
of the outer wall. Even in complete rup-
ture hemorrhage ma^^ be scarcely notice-
able if the inner coats act as a barrier. If
there is no external wound the tissues be-
come infiltrated with blood or a diffuse
(false) traumatic aneurism results.
Punctured wounds, when large, may
cause considerable bleeding; they are apt
to be followed by traumatic aneurism.
Incised wounds, when transverse, often
cause profuse bleeding; where longitudinal
or oblique, hemorrhage is usually not
great.
B, Veins. — Injuries and wounds of veins
are not, as a rule, followed by results as
serious as in the case of arteries. Dififer-
ent from arterial bleeding, venous hemor-
rhage may be stopped by pressure on the
distal part of the injured vessel.
Treatment. — In addition to the constitu-
tional treatment already referred to, cold
in the form of ice, or heat in the form of
hot-water at about 120° F., locally applied,
often arrest hemorrhage. Elevation is of
some service in bleeding from extremities.
Pressure may be applied with the finger,
by compresses secured by bandages over
the bleeding point or main artery, or in
the flexure of a joint, and by firm gauze
packinig. Edema and gangrene must be
guarded against. In the extremities, a
tourniquet placed above the injury is im-
mediately dependable, but its removal
must not be long delayed.
The actual cautery, if used, must be a
very dull red.
Styptics include adrenalin, 1 : 1000 to
1:10,000, especially useful for mucous
membranes, alum, antipyrin, tannic acid,
silver nitrate, coagulin (animal blood
platelets), and thromboplastin (brain
emulsion). Internally, calcium lactate, styp-
ticin, ergot, turpentine, and dilute sul-
phuric acid may be used. Subcutaneously,
21/2 to 10 drams (10 to 40 c.c.) of human,
horse, or rabbit serum, or of diphtheria
antitoxin, t)r antistreptococcic serum, may
be given. Gelatin, in 1 to 10 per cent, solu-
tion, very carefully sterilized, may also be
administered by this route.
In applying acupressure, a harelip-pin or
needle is passed through the skin under
the artery and out on the opposite side,
when a figure-of-eight ligature is thrown
around the ends of the pin. Or, the pin
or needle may be inserted parallel to the
artery, next rotated until perpendicular,
then carried across and in front of the
artery, to be deeply inserted into tissues
of the opposite side.
Forcipressure, or vigorously crushing
with forceps, is useful, especiallj^ for small
vessels, but sometimes serves likewise for
large, — as a rule, before ligation.
Torsion is done by twisting with for-
ceps until there is no sense of resistance,
— without, however, twisting the vessel off.
Ligation is the best method for all ves-
sels visible with the naked eye. Silk or
catgut ligatures are to be preferred and
must be aseptic. A ligature should be ap-
plied to both ends if the artery is entirely
severed, and on both sides of the wound
if partially severed. If the distal end can-
not be found, the proximal end is tied and
a compress placed over the wound. Where
it is impossible to tie the vessel in the
wound, ligation in continuity is performed.
A suture ligature is one passed not di-
rectly around the vessel, but in a broader
loop through the tissues surrounding it.
It is used where there is danger of the
ligature slipping; where the vessel is fixed
in dense tissues; in necrotic tissues, and
where the vessel is atheromatous.
Angiorrhaphy (vessel suture), maintain-
ing the circulation through the injured
vessel, is frequently advantageous or even
imperative in wounds of arteries (or
veins) of the size of the radial or larger.
The risk of cutting through of the sutures
is held to be no greater than in the case
of a ligature (Stewart), and even if throm-
bosis should follow, extra time is given for
the establishment of collateral circulation.
The vessel having been shut of¥ above
with rubber-coated clamps or by external
VASCULAR SYSTEM, SURGICAL DISEASES OF.
801
pressure, in the case of a wound occupying
not over one-third the circumference of
the vessel, the margins of the injury are
smoothed, if necessary, with a sharp bis-
toury, and covered with petrolatum to
obviate drying. Guide sutures may be in-
serted at either extremity of the injury, to
render the later suturing easier. Very
fine needles and silk, sterilized in boiling
petrolatum, are used. A continuous suture
closing the wound is then inserted, special
care being taken to bring the opposite
margins of the intima in contact. A ves-
sel more extensively wounded is best com-
pletely divided, and an end-to-end union
accomplished after both extremities have
been cut ofi square. Three equidistant
guide sutures are placed through both ves-
sel ends, the margins stretched somewhat
by traction to reduce the chances of later
stricture, and a continuous suture around
the wound introduced. The vessel having
been closed, blood is gradually allowed to
run through from above, the line of suture
being pressed upon until hemorrhage from
the suture-holes is arrested. The vessel-
sheath, previously slightly retracted, is
next sutured, and then the fascia and skin.
Secondary Hemorrhage. — In secondary
hemorrhage from a stump, pressure and
elevation may arrest it. If not, the wound
is reopened and the bleeding vessel ligated.
If, however, the wound is nearly healed
and there do not seem to be many clots,
the hemorrhage is controlled by securing
the main artery just above the stump, and
either applying acupressure or cutting
down and ligating it.
Venous Hemorrhage. — A hemorrhage
from small veins usually ceases of itself.
Pressure on the distal side is of value for
veins somewhat larger. When large veins
are injured, however, ligation is indicated.
Sometimes this need only be a lateral liga-
ture, applied after drawing up the margins
of the venous wound in the shape of a
cone with forceps. Phlebitis and gangrene
seldom follow.
THROMBOSIS .—A thrombus is a
blood-clot forming in the heart, blood-
vessels, or lymphatics during life. In
thrombi of slow formation, or due to pro-
jections from the interior of vessels, red
cells may be absent and the thrombus
nearly colorless.
Varieties. — A thrombus situated where
coagulation began is a primary thrombus;
when it gradually extends, an extension or
induced thrombus. A thrombus adherent
to the vessel-wall is a lateral or parietal
thrombus; when it fills the vessel, an
occluding or obliterating thrombus. Subse-
quent changes allowing blood to flow
through, result iu a canalized thrombus.
Finally, a thrombus may be venous, arterial,
cardiac, capillary, or lymphatic, the first site
being most frequent.
Symptoms. — If a main venous trunk be
obstructed and collateral circulation not
rapidly established, there occur passive
hyperemia, venous dilatation, edema, oc-
casionally hemorrhage in the vicinity, and
in extreme cases moist gangrene. Accord-
ing to the situation, there may occur hy-
drothorax or ascites, anasarca of an ex-
tremity; hemorrhage from the stomach,
intestine, or kidnej'; cyanosis and edema
of the face and neck, etc. Thrombosis of
the mesenteric arteries or veins, attended
with sharp pain and melena, usually leads,
sooner or later, to gangrene of the bowel,
and is nearly always fatal without opera-
tion. The symptoms of arterial throm-
bosis in general are mainly those of ar-
terial embolism. (See Embolism, in the
fourth volume.)
Etiology. — Thrombosis may be due to
alterations in the intima, producing an ob-
struction or roughening, or to foreign
bodies or septic germs. Hyperinosis, or
excess of fibrin factors, and diminished
fluidity, as in cholera, may be predisposing
causes. Of all causes, however, retarda-
tion of circulation is most important.
The chief causes of venous thrombosis
are two. The first is injury, nature arrest-
ing hemorrhage by the formation of
thrombi. The thrombus may extend, caus-
ing occlusion of distant veins. The second
cause is inflammation, — though in many
cases of phlebitis, thrombosis is the pri-
mary lesion. Other causes are: pressure
on veins; dilatation; arrest of circulation
in the capillary district of the vein, from
embolism or inflammatory stasis; weak-
ened heart action, as in marasmus and
other exhausting diseases. In the latter
varieties thrombosis occurs mostly in the
lower extremity and pelvis, less often in
the sinuses of the dura mater.
8—51
802
VASCULAR SYSTEM, SURGICAL DISEASES OF.
Arterial thrombosis may be caused by
wounds and injuries, degeneration of the
intima, aneurism (by stagnation coagula-
tion), and any condition, as embolism,
producing circulatory arrest.
Cardiac thrombosis may be caused by
endocarditis or by imperfect evacuation of
the cavities due to valvular stenosis or
lack of myocardial tone.
Caf^illary thrombosis may occur by ex-
tension from veins and arteries, or be
primary.
Lymphatic thrombosis may be due to
abnormal coagulability of the lymph, to
tuberculous or other infection, or to can-
cer. It is mainly observed during puer-
peral fever, in the uterine lymphatics and
their continuations to the lumbar glands,
more rarely in the thoracic duct, or the
axillary or inguinal lymphatics.
Pathology. — The first changes in a
thrombus are shrinkage and decolorization.
It may dry up until leathery or even cal-
cified (phleboliths). Or, it may soften,
beginning in the center, forming a milky
fluid consisting of oily, granular detritus.
Suppuration occurs occasionally in venous
thrombi surrounded by. or leading from,
inflamed parts. The vein wall, in these
cases, is itself always inflamed. Such
broken-down thrombi are a common cause
of embolism.
Finally, the thrombus may organize, a
vascular reticulated connective tissue be-
ing formed. Dilatation of newly formed
channels gradually canalizes the thrombus,
which may eventually disappear.
Treatment. — This is mainly prophylactic.
Rigorous postoperative care of the patient,
with centripetal massage and active move-
ments of the limbs, are of prophylactic
value. Citric acid, 30 grains (2 Gm.), 3
times a day, may be administered, or so-
dium citrate, in the same amount, added
to each pint of milk. In actual throm-
bosis the part must be kept at rest until
organization or absorption has occurred.
Morris (1917) reported excellent results
in thrombosis during infections from in-
travenous injection of ^ pint (225 c.c.) of
0.5 per cent, sterile solution of sodium
citrate in normal saline. Further treat-
ment of thrombosis is largely that of
phlebitis and embolism. (Embolism; Fat
Embolism, and Air Embolism, Vol. IV.)
PHLEGMASIA ALBA DOLENS.—
Phlegmasia alba dolcns (milk-leg; white
leg; marble-leg) is a swelling of one or
both lower extremities, either ascending
from the ankle or beginning at the groin
and extending down the thigh, occurring
usually between the tenth and twentieth
days after confinement, or some days or
weeks after an abdominal operation.
Symptoms. — As a rule, slight fever pre-
cedes; exceptionally, the onset may be
announced by a distinct chill. Sometimes
malaise, with gastric disturbance, anorexia,
coated tongue, and constipation exist for
a day or two before pain in the limb is
complained of. Another possible premoni-
tory symptom is pain and tenderness in
the uterine region, especially on the corre-
sponding side. The first characteristic
symptom is a dull, dragging pain in the
limb, increased by motion. As a rule,
acute pain soon develops along the fem-
oral vein, in the calf, or above the ankle.
In these situations the thrombosed veins
can sometimes be felt. The pain and ten-
derness then extend all over the affected
parts. The pain is sometimes along the
internal saphenous vein.
Concurrently with the pain, or a day or
two after, swelling is observed, which
gradually spreads and hardens. This
swelling, when fully developed, is very
tense and resilient, and does not pit on
pressure. It may spread at once all over
the limb, but often either descends from
Poupart's ligament or ascends from the
ankle. Involvement of the upper or lower
part of the limb alone is rare. The swell-
ing affects the limb evenly, and rounds off
its figure, but does not destroy its form
as in anasarca. Coagulable lymph exudes
if the skin be pricked. An erythema is
occasionally noted over parts of the limb;
it may be confined to a narrow path along
a subcutaneous vein or lymphatic. Volun-
tary motion is almost completely abol-
ished. The temperature rarely exceeds
102° F. (38.9° C).
The ordinary termination is absorption
of the thrombus and restoration of cir-
culation. The rate of recovery varies
greatly. In a favorable case it may be
several weeks before the disease disap-
pears; in other cases further or even in-
definite delay may occur.
VENESECTION AND BLOOD TRANSFUSION.
803
Diagnosis. — From edema with phlebitis
or accompanying varicose veins the his-
tory will usually permit differentiation.
Etiology. — This disorder is oftenest ob-
served in the puerperium. It is probably
favored by the natural formation of
thrombi in the uterine sinuses after deliv-
ery. It may follow operation on an ab-
domen apparently free of infection. Other
predisposing conditions are convalescence
from fevers, especially typhoid, dysentery,
and disease of the rectum, fibroids, arrest
of the menses, and general malignant or
tuberculous disease. The disorder has
often been observed in the leg on the side
of a previously commenced pleurisy.
Pathology. — In some cases the disorder
may be considered the extension of an in-
flammation from the genitalia to the peri-
neum, nates, and upper thigh, secondary
thrombosis resulting. In others, throm-
bosis is apparently the initial lesion. It
may be spontaneous, from retardation of
the blood-current; varicose veins favor it.
The iliac and its tributaries, the tibial and
the peroneal veins are the vessels usually
involved, as a rule, on the left side. The
intravenous coagula may, however, take
origin at the placental site, and, extending
along the pampiniform plexus to the hy-
pogastric vein, thence occlude the iliac
vein to Poupart's ligament, or, passing up
by the spermatic veins, they may obstruct
the vena cava.
Complications. — Among the complica-
tions are inflammation and suppuration of
the pelvic joints, erysipelas, abscesses of
periphlebitic origin, cellulitis, and gan-
grene of the lower portions of the limb.
The more fatal complications are embo-
lism (sometimes cerebral), pyemia, and
septic pneumonia.
Sequelae. — The most frequent sequel is
persistent aching of the limb, increased by
cold, dampness, derangement of health,
and exercise. More or less persistent
edema of the ankles, motor weakness, and
muscular atrophy or contracture have been
observed. Exceptionally, great hypertro-
phy of the cellular tissue coexists with
muscular atrophy; it may be associated
with extensive and intractable ulceration.
Prognosis. — This depends on the cause
and complications. Death from pulmo-
nary embolism is always possible until the
thrombus has disappeared or become or-
ganized. Embolism has proved suddenly
fatal as late as 37 days after delivery.
Treatment. — The principal indications
are: Opium to relieve pain, cathartics for
constipation; quinine, iron, good food, and
other sustaining measures, and rest of the
swollen limb for 4 to 6 weeks. The latter
should be supported on a pillow raised at
the foot, with the bedclothes kept off by
a cradle. Cold should be used locally the
first day, followed by wrapping the limb
in cotton-batting sprinkled with equal
parts of belladonna and chloroform lini-
ment, with oil-silk outside and external
heat. Remedies for rheumatism or gout
should be given if indicated. Where the
vein is manifestly suppurating, the af-
fected portion should be excised or, if this
is not practicable, ligated above and be-
low, incised, and the infected clot washed
out.
If vesicles form, they may be punc-
tured and evacuated. When the swelling
is subsiding, and tenderness begins to di-
minish, absorption may be promoted by
gentle frictions with alcoholic lotions and
by applying a light, flannel, roller bandage
evenly over the entire limb. The patient
must not be allowed to leave bed until
every trace of tenderness and thickening
has disappeared. For some time the pa-
tient should wear a long elastic stocking,
as the limb will swell from standing or
protracted exercise. Rubbings, bandaging,
and faradization may be required to re-
lieve swelling, edema, and muscular weak-
ness. In applying frictions the danger of
dislodging a thrombus must not be over-
looked. D. and S.
VASOMOTOR NEUROSES.
See ^^\scuLAR Sy.stem, Disorders of.
VEINS, DISORDERS OF. See
Vascular System.
VENESECTION AND BLOOD
TRANSFUSION, -venesection,
or phlebotomy, fijrnierl}- u;^cd extensively
in therapeutics, has largely fallen into
disuse, yet in suitable cases is a measure
of great value.
Technique. — A large vein, usually the
median basilic, is made prominent by
804
VENESECTION AND BLOOD TRANSFUSION.
pressure above, either with the finger or
a bandage or bj- twisting a handkerchief
about the arm, care being taken not to cut
off the arterial supply. The skin over the
vessel is incised for lialf an inch and the
fascia carefully separated till the vessel it-
self, blue and shining, is exposed. A
small longitudinal incision is then made
into the vessel, the knife being held with
the cutting edge upward and care being
taken not to injure the posterior wall of
the vessel; or the vessel may be snipped
with a small pair of scissors. When
enough blood has been removed, usually
ascertainable by the pulse of the other
arm, the constriction is removed and a
sterile compress applied.
Indications. — Bleeding is useful in cases
of pneumonia, pleurisy, and meningitis
if the arterial tension is high, and in any
case in which there is congestion, local or
general, and arterial excitement. In
pneumonia with engorgement of the right
ventricle early bleeding will equalize the
circulation, relieve the laboring heart, and
dispel d3'spnea and cyanosis. Though
seemingly indicated in apoplexy, where
the pulse is hard and tense, Gushing holds
it inadvisable. In toxic conditions such as
septicemia, uremia, diabetic coma, and the
toxemias of the infectious fevers, bleed-
ing and saline hypodermoclysis or intra-
venous infusion simultaneously performed,
are often life-saving. Theilhaber (1916)
believes withdrawal of 400 or 500 c.c. of
blood twice a year does much to prevent
recurrence or metastases in cancer cases.
BLOOD TRANSFUSION.
Technique. — To obviate hemolysis or
agglutination, a preliminary test, the two
bloods being mixed in z'itro for 24 hours,
is advisable. R. I. Lee mixes on a slide
serum from the donor and blood from the
recipient dropped into 10 times the
amount of 1.5 per cent, sodium citrate
solution, and examines microscopically in
a few moments for agglutination. A fur-
ther device (1918) is the division of blood
samples into 4 definite groups differing in
their transfusion compatibilities and the
testing of prospective subjects with pre-
served standard specimens.
In Crile's method of direct transfusion
the donor's radial is brought in contact
with a superficial vein of the recipient by
means of a small, sterilized, silver tube
(Crile's tube) having two circular grooves.
The proximal end of the donor's vein is
passed through inside the tube (previously
dipped in sterile olive oil), cuffed out over
its end and tied to it by a ligature over
the second groove. The artery is then
drawn over the everted vein and tied in
the second groove. Brewer simplifies the
procedure by using a plain tube dipped,
after sterilization, in melted paraffin,
which, on cooling, prevents clotting and
permits of merely drawing the artery over
one end and the vein over the other and
fastening by ligatures. In each method
the radial artery is exposed under local
anesthesia, and the artery and vein are
cut between a ligature and a clamp. In
Fauntleroy's method a vein-to-vein (arm-
to-arm) transfusion is performed through
a semicircularly bent or S-shaped tube
(previously paraffined), according to the
relative positions of the donor and donee;
a constricting band is kept round the
donor's arm during the transfusion suffi-
cientl}' tight to maintain venous hyper-
emia in the forearm. In artery-to-vein
transfusion the flow is hastened by dilat-
ing the artery with a flow or compress of
warm normal saline solution over it. In
either method, when enough blood has
been transfused — usually- after 15 or 20
minutes, — or the donor's pulse begins per-
ceptiblj' to weaken, the tube is withdrawn,
the vessels are ligated, and the skin
wounds closed. Before this is done in the
case of the donor, however, saline solution
equal to the blood lost may be run in.
A later modification in the technique of
transfusion consists in making it indirect,
i.e., collecting the blood in a receptacle
before introducing it in the recipient. A
glass cylinder with side outlets at the
bottom and near the top is sometimes
used. It is sterilized and coated with
sterile paraffin. By the use of the sodium
citrate method, the blood can be either
administered forthwith or preserved for
later use at intervals up to four weeks,
and paraffin coating of the receptacles is
unnecessary. Xewell (1918) draws blood
into a 200-c.c. syringe containing 2 c.c. of
2 per cent, citrate solution and injects it
from the same sj-ringe.
VERATRUM.
805
With Queyrat's needle, 300 to 500
c.c. (10 to 18 ounces) of blood can
be withdrawn without any incision
and collected in a sterile receptacle,
meanwhile constantly shaken, con-
taining 0.1 Gm. (\y2 grains) of sod-
ium citrate for each 100 c.c. (3%
ounces) of blood. The blood is then
reinjected from a wash bottle with
rubber bulb. The blood can be kept
at 37° C. as long as four days. P.
Ameuille (Bull, de I'Acad. de med.,
Feb. 12, 1918).
In the average transfusion about 6(X)
c.c. of blood are transferred. For infants
from 90 to 120 c.c. of blood are transfused,
usually with the needle inserted into the
longitudinal sinus at the posterior angle
of the anterior fontanelle, exactly in Hne
with the sagittal suture.
Indications. — Blood transfusion is of
great value, as has been further proven
in the European war, after violent or pro-
longed hemorrhage. The blood not only
tends to arrest hemorrhage or prevent
secondary hemorrhage, but simultaneously
supplies a highly concentrated form of
nourishment; hemolysis, even upon using
a stranger's blood, is rare, and if it does
occur, half a pint of blood will not over-
whelm the recipient (W. R. Morrison).
In hemorrhagic disease of the newborn
transfusion has given very satisfactory re-
sults. It is useful in severe hemorrhage
in typhoid fever, and in hemophilic or
jaundiced cases with slow blood coagula-
tion requiring operation, and in cases of
exhaustion in general, is a valuable pre-
operative measure. In anemias, the re-
sults have been somewhat disappointing,
but transfusion is, nevertheless, sometimes
useful as an ultimate therapeutic means.
Precautions to avoid transmission of
syphilis or other infections from donor to
recipient are, of course, always advisable.
W. and S.
VENOMOUS BITES. See In-
dex-Supplement.
VERATRUM. — Veratrum viride is
defined (U. S. P.) as the dried rhizome
and roots of Veratrum viride (green or
American hellebore), of the family Liliace<e.
The white or European hellebore {Vera-
trum album) is no longer official (U. S. P.
IX). The chief constituents of the two
plants probably differ; that of veratrum
viride is held to be cevadine (C32H49NO9),
that of veratrum album, protoveratrine
(C32H51NO11). Each plant contains, in
addition, the lesser alkaloids, jcrvine and
ruhijervine, and an acrid, irritant resin;
veratruin viride also einbodies veratridine
and pseudojervine. Much of the veratrum
used in the United States has been derived
from veratrum album.
Veratrine, as officially recognized, is not
a single chemical substance derived from
veratrum, but a variable mixture of sev-
eral alkaloids — cevad'ue, cevadiUine, saba-
dine, sabadinine, and veratridine — obtained
from the seeds of Asagr-ra ofjicinalis (saba-
dilla or stavesacre), of the family Liliacece.
PREPARATIONS AND DOSES.—
Veratrum viride, U. S. P. (veratrum).
Dose, 1 to 2 grains (0.06 to 0.12 Gm.).
Fluidextractum veratri viridis, U. S. P.
(fluidextract of veratrum viride). Dose,
1^ minims (0.1 c.c).
Tinctura veratri viridis, U. S. P. (tincture
of veratrum viride), representing 10 per
cent, of the drug. Dose, 5 to 30 minims
(0.3 to 2 c.c); official dose, 8 minims (0.5
c.c).
Veratrina, U. S. P. (veratrine), occurring
as a grayish-white, amorphous powder,
practically insoluble in water, soluble in
2.2 parts of alcohol. It is odorless, but
causes irritation and sneezing even in
minute amounts, and has an acrid taste,
followed by numbness of the tongue.
Dose, Vm grain (0.002 Gm.).
A 2 per cent, oleate and a 4 per cent,
ointment of veratrine were formerly offi-
cial (U. S. P. VTII).
PHYSIOLOGICAL ACTION.—
Locally, all veratrum preparations are
very irritating to mucous membranes, in-
ducing violent sneezing and coughing
when inhaled, and a pricking and burning
in the mouth when orally taken.
Veratrine ointment applied to the skin
causes pricking and warmth locally, due to
excitation of the sensory nerve-endings
followed after a time by numbness and
cold.
General Effects. — The chief systemic
action of veratrum is seemingly exerted
on the vagal cardioinhibitory center in the
medulla, which, by large therapeutic doses.
806
VERATRUM.
is strongly excited, causing a marked
slowing of the heart rate and a corre-
sponding fall in blood-pressure. Accord-
ing to R. J. Collins, from 30 to 75 minims
(2 to 5 c.c.) of a 10 per cent, tincture of
veratrum album, in divided doses, is re-
quired to produce distinct effects of this
kind, i.e., a slowing of the rate by 12 to 42
beats per minute, a drop in the systolic
blood-pressure of about 39 mm. of mer-
cury, and in the diastolic pressure by 8 to
32 mm. Such doses are sometimes fol-
lowed, half an hour after the circulatory
effect reaches its maximum, by nausea
and vomiting, probably due chiefly to
medullary stimulation, perhaps coupled
with local gastric irritation. A tendency
to stimulate the vasoconstrictor center in
the medulla has also been attributed to
veratrum, but if this actually occurs, the
resulting vasoconstriction is insufficient to
prevent the fall of blood-pressure due to
slowing of the heart. According to Pil-
cher and Sollmann veratrum viride is with-
out direct action on the vasomotor center,
while according to Cramer it produces
vasodilation through a reflex action on the
vasomotor center. Cevadine and proto-
veratrine both stimulate striated muscle
tissue, the former probably slightly stimu-
lating the heart muscle in therapeutic
doses; in addition, cevadine in large
amounts, especially in the frog, causes a
characteristic slow relaxation and delayed
fatigue of striated muscle tissues.
UNTOWARD EFFECTS AND POIS-
ONING.— Large doses of veratrum may
cause, in addition to marked cardiac slow-
ing, fullness and throbbing in the head,
nausea, and vomiting. Frankly toxic
amounts induce also profuse sweating,
diarrhea, and dysphagia. The pronounced
bradycardia is suddenly replaced, in lethal
cases, by extreme cardiac acceleration, a
temporary rise in blood-pressure, followed
by collapse, sometimes convulsions, paral-
ysis, and death by respiratory failure.
Treatment of Poisoning. — The vomiting
so constantly and early provoked by large
amounts of veratrum tends to obviate dis-
astrous results from such amounts, the
drug being safer for this reason than
aconite. Where poisoning occurs the evac-
uation by vomiting may be assisted with
large draughts of warm water. Absolute
rest in recumbency, external heat, atropine
in full dosage hypodermically to release
the cardiac inhibition, and morphine hypo-
dermically or opium by rectum, for con-
tinued, exhausting vomiting are all im-
portant measures. To these may be added
cardiovascular stimulants, peripheral stim-
ulation Ijy rul)l:>ing with coarse towels or
mild flagellations, and artificial' respiration.
THERAPEUTICS.— The chief use of
veratrum is as a circulatory sedative in
conditions associated with high blood-
pressure. The dosage required for pro-
nounced effects has already been referred
to under Physiological Action. Such
amounts should be given in divided doses,
each dose with at least one glassful of
water, to reduce gastric irritation. The
effect of these amounts is likely to per-
sist at least six hours — diminishing grad-
ually meanwhile — after the last dose.
In puerperal eclampsia with high blood-
pressure tincture of veratrum in large
doses is extensively used, causing a
marked hypotensor effect and allaying
convulsions. If one adheres to the view
that veratrum lowers blood-pressure solely
by slowing the heart rate, combined use of
a nitrite, it would seem, might be of ad-
vantage to enhance the hypotensor action.
In uremic convulsions results similar to
those in eclampsia may be obtained with
large doses. According to Gilardoni one
may, by constant use of veratrum in mod-
erate dosage, secure a continuous depres-
sion of blood-pressure in such conditions
as chronic nephritis, arteriosclerosis, and
vascular hypertension of unknown origin.
For this purpose the drug should be given
at three-hour intervals. Pesci, in such
cases, gives 30 to 60 drops of the tincture
daily for nearly a week, next suspends the
drug for a few days and then resumes it;
he also reports good results from similar
doses in lead colic. In excessive cardiac
hypertrophy and in the irritable heart of
strong but overworked men, veratrum in
smaller doses, is by many considered of
value. In advanced aortic aneurism with
high blood-pressure, the drug may be
used with great care to reduce the pres-
sure and with it the chance of vascular
rupture. J. S. Todd warmly recommends
combination of Ij^ minims (0.1 c.c.) of
X'orwood's tincture with every dose of
VERONAL.
807
digitalis in cases where an undesirable
peripheral vasoconstricting effect of the
latter remedy is apprehended.
In acute, sthenic, incipient inflamma-
tions, including cases of pneumonia, bron-
chitis, hepatitis, salpingitis, etc., veratrum
has been used with asserted benefit. That
small doses of the drug, perhaps combined
with morphine and sweet spirit of niter
(Bates), will in such patients tend to
soften and slow the bounding pulse, and
moisten and relax the skin, seems clear.
Whether such effects will actually benefit
by reduction of congestion in the diseased
area is a question open to discussion.
Veratrum is contraindicated in the pres-
ence of marked depression or exhaustion,
as well as in cases in which harm from
possible vomiting, as in peritonitis or gas-
tritis, is apprehended.
Veratrine is used externally, usually in
ointments, for the relief of local neural-
gias and myalgias. Danger from absorp-
tion is said, however, to attend free use
of the oleate of veratrine. S.
VERONAL.— Veronal, diethylma-
lonylurea or diethylbarbituric acid, oc-
curs as a white, crystalline powder having
a faintly bitter taste, and soluble in about
150 parts of cold and in 12 parts of boil-
ing water. The sodium salt, veronal-
sodium, sodium diethylbarbiturate, or
medinal, dissolves in 5 parts of water. The
average dose of either preparation is 7^
grains (0.5 Gm.). Both drugs are best
taken on an empty and acid-free stomach
— on retiring. In some cases — cardiac
and bronchial asthma — veronal-sodium is
given per rectum, dissolved in a dram (4
c.c.) of water and injected with a small
rectal syringe. Subcutaneous injections —
75 minims (5 c.c.) of a 10 per cent, solu-
tion— are intensive rather than rapid in
effect, and are recommended only in spe-
cial cases — where patients refuse oral
medication, in threatened delirium tre-
mens, in antimorphine treatment, and in
grave insomnia.
PHYSIOLOGICAL ACTION.— In
normal individuals, or those suffering
from mild insomnia, veronal induces quiet
sleep in from 20 to 45 minutes. In ro-
bust patients, with more severe insomnia,
15 grains (1 Gm.) may be required. Sleep
lasts for 8 to 12 hours. A few, especially
elderly patients, experience slight vertigo
on rising, apparently due to a reduction in
blood-pressure. The pulse rate is low-
ered and the respirations are more shal-
low. The skin may become paler, but is
never cyanosed. As small a dose as 5
grains (0.3 Gm.) may produce dizziness.
After prolonged use patients may suffer
vertigo, weakness in the limbs; the urine
may be scanty and dark. In those suffer-
ing from delirium or mania, or in a state
of mental hebetude, there is a tendency
to ignore bodily functions, and occasion-
ally urinary retention occurs. Cumulative
effects are sometimes noted.
POISONING BY VERONAL.— Toxic
symptoms are : vertigo, diplopia, stagger-
ing gait; dark, scanty urine, sometimes
with retention; feeble pulse, shallow res-
piration, gradual coma, and death. Der-
matitis has been noted. The average lethal
dose is from 120 to 150 grains (8 to 10
Gm.). Veronal is contraindicated in
acute nephritis, in myocarditis and aortic
regurgitation, and in insomnia due to
pain. Clinically veronal is incompatible
with calomel if administered close to-
gether, great depression being caused.
Treatment of Poisoning by Veronal. —
No hot drinks should be given if it is
suspected that the stomach contains any
unabsorbed veronal, as these will hasten
absorption, but lavage of the stomach
with the stomach-tube is indicated. Hot
tea or coffee should then be given freely,
by stomach-tube, if necessary. The cen-
ters should be stimulated through the use
of caffeine, camphor, etc. Venous con-
gestion, especially in the a1)dominal area,
must be overcome by compressing the
abdominal vessels and raising the surface
temperature by the application of exter-
nal heat. Oxygen inhalations may be
used. When the acute syniptcMiis have
subsided, potassium acetate, spirit of ni-
trous ether, and other diuretics, will aid
in rc-cstaldisliing the renal function.
THERAPEUTIC USES. — Veronal is
useful in insomnia and excessive nervous
restlessness, especially as seen in neuras-
thenia, psychasthenia (cercliral neuras-
thenia), acute alcoholism, maniacal ex-
citement, epileptic mania, paresis with
excitement, grave melancholia, especially
808
VITAMINES.
with suicidal tendencies or refusal of
food, withdrawal treatment of morphin-
ism and cocainism, hysteria, seasickness,
severe chorea, and vomiting of pregnancy.
A patient took fourteen 5 grain bar-
bital (veronal) tablets in divided doses
over a period of 36 hours and slept
continuously for 7 days. This pro-
longed sleep from veronal suggested
its use in status epilepticus, with
happy results from 30 grains (2 Gm.)
in divided doses. Probably in other
mental conditions, as morphinomania,
etc., a week's sleep might eliminate
the suffering from drug withdrawal.
MacLeod (Med. Record, Dec. 11,
1920). W.
VITAMINES.— The outer coatings of
grain and the quality of freshness in fresh
vegetables have been shown to be of great
importance in bodily nutrition. To the
substances in the pericarp of rice counter-
acting beriberi, Casimir Funk, of London,
in 1912 applied the name vitamines. Simi-
lar substances have been shown to exist
in the pericarps of wheat, corn, rye, oat
and barley grains. Though vitamines are
present in only minute amounts, not a
single animal fed on vitamine-free food,
however varied and plentiful, was found
able by Funk to live more than a short
time. A given amount of vitamine will
take care in the body of only a certain
amount of carbohydrate food. In the ex-
perimental polyneuritis in fowls, even
starvation proves much less quickly harm-
ful than a diet only of polished rice. The
more polished rice taken, the greater the
certainty and severity of beriberi (Levene).
In the absence of vitamines, according to
Funk, metabolism goes w-rong, as shown
in a negative balance of nitrogen and of
inorganic constituents, e.g., Ca, P, and S.
In Seidell's experiments, pigeons with
severe paralysis due to a polished rice diet
plainly showed improvement within an
hour after an injection of vitamine, and
seemed entirely normal the next morning.
Vitamines, as shown by Shie, have a strik-
ing influence on the growth of young ani-
mals, which may be completely stopped
by vitamine deficiency. Marked changes
in the chemical composition of the brain
were found by Funk in animals fed on
shelled rice. The thymus gland, normally
large and persistent in pigeons, atrophies
completely under a polished rice diet.
Changes in the pituitary and decided
atrophy of the testes or ovaries also occur.
Diseases, other than beriberi now attri-
buted by many to insufificient vitamine
intake include scurvy. Barlow's disease,
pellagra, rickets, and osteomalacia. Infec-
tion is probably also favored, the experi-
mental animals suffering from an eye in-
fection which promptly disappears upon
addition of vitamine.
Less pronounced vitamine insufificiency
in infants may cause restlessness, irrita-
bility, and greenish stools containing
either mucus or curds (Fischer). Loss
of appetite is an earlj^ symptom of vita-
mine deficiency, and is thought especially
significant in children, chlorotics, and
convalescents. Vomiting, diarrhea, and
meteorism are other results.
If sterilization of milk becomes
necessary during an epidemic, vita-
mines should always be supplied in
some other form — meat-juice for
young infants, potato puree or egg
3'olk for older children. In digestive
disorders tlie diet must not be al-
lowed to get too poor in vitamines.
Desiccation destroys vitamines in
fruit and vegetables; hence the lassi-
tude from an antidiarrheic diet. A
surplus of vitamines reduces the de-
mand for calories. Vitamine deficit
is probably a factor in chlorosis,
anemia, neurasthenia, and vasomotor
disturbances, and in fevers and con-
valescence an ample vitamine supply
is imperative. Commercial infant
foods are free from vitamines. and
these must be added. E. Madsen
(Ugeskr. for Laeger, Apr. 18, 1918).
Liberal amounts of milk are neces-
sary' when milk is depended on for
an appreciable proportion of the
water-soluble vitamine in the diet.
In reinforcing the calories by dilut-
ing the top milk and adding milk
sugar, the food contains relatively
less of the water-soluble vitamine
than the original cow's milk; while
the child's appetite is normal, the
supply of vitamine may be sufficient,
but if the food intake is reduced, the
WATER (HYDROTHERAPY).
809
vitamine supply is lowered, and end-
less dietary trouble may set in. T. B.
Osborne and L. B. Mendel (Jour, of
Biol. Chem., June, 1918).
Ramoino reported gastrointestinal dis-
turbances, herpes, eczema, epistaxis, blu-
ish gums, malodorous breath, pains in the
joints, muscles, and head, loss of weight,
mental dullness, and melancholia as being
widely noticed among Italian troops as a
result of deficient vitamines in the rations;
when food rich in vitamines could be ob-
tained all these symptoms generally sub-
sided.
Cereals, meats, potatoes, fats, and
sugar probably furnish too small an
amount of vitamines to meet fully
the requirements of an adequate diet-
ary. Care should be taken not to
tindereat in green vegetables. Osborne
and Mendel (Jour. Biol. Chem., Jan..
1919).
At the present time too little is known
concerning the vitamines to warrant de-
cided assertions. As- stated in an edi-
torial in the British Medical Journal for
February 11th, 1922, fresh vegetables con-
tain an abundant supply of vitamines, while
a considerable quantity is present in milk
and meat, provided the animals from which
these are obtained were fed on fresh foods.
As the writer states: "A normal adult on
an o.-dinary diet containing a reasonable
proportion of fresh vegetables is, there-
fore, certain of obtaining a plentiful sup-
ply of vitamines." Yet, as stated by Men-
del and Osborne, preference should be
given to green vegetables. Commercial
infant foods are also lacking in them;
hence the need of orange juice, etc. S.
W^
WARTS.
Diseases of.
See Skin, Surgical
WATER (HYDROTHERAPY).
— Water as a remedial agent may be ap-
plied externally in solid, liquid, or vapor
form; either hot or cold, pure or impreg-
nated with mineral substances, carbon
dioxide, or sulphur dioxide; it may be ap-
plied in pools, tubs, jets, or sprays, with
or without pressure, or by means of
sheets, or compresses.
Reaction. — The effect, or action of
baths, either hot or cold, should be fol-
lowed by a reaction, or return of healthy
glow to the skin. This reaction is de-
layed in the weak and feeble; the reaction
may be hastened by the application of
cold after heat, by employing friction in
the bath, and by using chemical stimu-
lants, such as carbonic acid gas, and vari-
ous chlorides, etc., in the water. When
baths differ much in temperature from
that of the normal body, it is highly im-
portant to secure reactions.
Temperature of Baths.— Temperature of
water used in the various baths is as fol-
lows : Cold, 40°-65° F. (4.4°-18.3° C.) ; cool,
65° -75° F. (18.3°-23.8° C.) ; tef^id, 85°-95°
F. (29.4°-35° C.) ; warm, 9S°-10n° F. (35°-
37.7° C.) ; hot, 100°-110° F. (377°-43.3° C.) ;
very hot, 110°-120° F. (43.3°-48.8° C).
Where vapor baths are employed : Warm
vapor, 100°-115° F. (37.7°-46.1° C.) ; hot
vapor, 115°-140° F. (46.1°-60° C). Air baths
are still higher in temperature ; warm air,
n0°-120° F. (43.3°-48.8° C.) ; hot air,
120°-180° F. (48.8°-82.2° C), or more.
HYDROTHERAPEUTIC MEAS-
URES.— Many of these applications are
made while the patient reclines in bed,
which should l)e narrow, with woven wire
spring mattress. Marble slabs are con-
venient when the patient is to be rubbed
or shampooed, though a wooden table may
be used. In preparing the bed, a rubber
sheet is first spread, then a thick blanket.
The Cold Pack.— A sheet, saturated in
water at 70° F. (21.1° C.) is wrung out
slightly, and wrapped about the patient,
around each limb, and snugly about the
neck. A light covering may be used over
the patient. Five or six renewals at inter-
vals of five minutes may be necessary.
Cutaneous circulation is promoted by fric-
tion with the hands outside the sheet. In
fever patients the temperature falls.
Evaporation Bath.— Prepare the bed as
before, place a hot-water bag at patient's
feet and a cold compress on his head.
810
WATER (HYDROTHERAPY).
Cover the patient wholly with one thick-
ness of gauze moistened in water at 115°
F. (46.1° C). Adjust the gauze' closely to
the skin. The patient is now fanned and
the gauze is moistened, as evaporation
takes place, with water still at 115° F.
(46.1° C). During fifteen minutes about
one pint of water should be evaporated.
The temperature of the water may be
maintained by placing the basin used in a
larger one containing hotter water.
In the absence of ice or cold water,
cold applications may be made with am-
monium nitrate, Yz pound dissolved in 1
quart of water.
The Cold Bath.— This includes the cold
plunge and cold full baths.
In the cold plunge hath, vigorous friction
is made to the body while in the bath and
a large bath sponge is used to deluge the
head and shoulders. Friction is made
from one-half to three minutes. A quick,
thorough rub with coarse Turkish towels
and rapid dressing follow. This bath
tones up flabby abdominal muscles and
relieves gastrointestinal sluggishness, im-
paired nutrition, obesity, and autointoxica-
tion. It is also useful in mental torpor,
lassitude, headache, and listlessness.
Cold full baths at 50°-60° F. (10°-15.6° C.)
should last only a minute or less; if from
60°-70-' F. (15.6°-21.1° C), a little longer.
A large tub is used and the entire body is
submerged. A tonic effect is produced
and respirations are deepened as in the
plunge bath. The appetite and peristalsis
are increased, and constipation prevented
or lessened; it is useful in enteroptosis,
intestinal dilatation, and autointoxication,
and in typhoid fever (at 70^ F. — 21.1° C).
These baths are contraindicated in spas-
tic and mechanical constipation, acute in-
flammatory affections (appendicitis, peri-
tonitis, and gastritis), in severe anemia,
during gestation, in advanced life, and
where arteriosclerosis is present. Bron-
chitis, cardiac weakness and emphysema
are best relieved by hot sponge baths.
The best cures by cold baths follow the
temperate use of hot baths (Floyer).
The Half-bath of Priessnitz. — This is a
shallow bath, the water reaching to the
umbilicus, but used over the v/hole body.
It is applied with water at 65°-75° F.
(18.3°-23.9° C.) during from three to five
minutes, the water being 5 or 6 inches
deep. The patient enters from a warm
bed, or with circulation stimulated by ex-
ercise; the attendant rubs the chest vigor-
ously for a few minutes, and then both
limbs. The rubbing of the various parts
is repeated once or twice. This bath is a
powerful tonic and is useful in anemia,
many chronic diseases of the spinal cord,
in cardiac affections, and usually in those
cases of asthma which do not bear the
Turkish or Russian bath well, in constipa-
tion and chronic gastric affections. At
the higher temperatures it relieves sci-
atica and all painful affections of the pel-
vis and lower extremities.
The Spray Bath. — This consists in the
application through a large, perforated,
rose nozzle, of a continual fresh layer of
water in a finely divided state, with a cer-
tain mechanical impact, to the skin. This
removes secretions and is a marked seda-
tive to the nerves. This bath is especially
useful in simstroke, either alone or com-
bined with ice rubbing; in typhoid fever
the combination is especially efficient.
The Ablution or Wet-mit Friction. — In
this the water is applied with a wet bath
mitten. One portion of the body after an-
other is rubbed first with water at from
50°-75° F. (10°-23.8° C), and then with a
rough towel. Alcohol may be added to
the water if the circulation is poor. The
rubbing should be continued until the
skin of the part becomes red and warm.
This method is used in the treatment of
feeble and bedridden patients. When re-
action becomes prompt and good, douches
and other stronger measures may be used.
The Drip Sheet or Sheet Bath.— This is
best given late in the afternoon or
toward evening. For its application we
need a pail of water at 65° F. (18.3° C),
a foot-tub with water at 100° F. (37.8° C),
ice-water, two face towels, a bath towel,
a bed with an extra blanket, and protec-
tion for the floor. Place the sheet in the
bucket of water, allowing the corners to
hang out. The patient, dressed only in
one thin garment, stands in the foot-tub
containing the warm water. One face
towel is dipped into the ice-water, wrung
out and applied around the head. The
pail of cold water containing the sheet is
placed behind the patient, and the nurse,
WATER (HYDROTHERAPY).
811
standing in front, removes the wet sheet
by two corners and wraps it around the
patient, with vigorous, quick rubbing.
This process should take about two
minutes. The sheet is then dropped and
the patient wrapped in the dry blanket
and put to bed. If desired, the mechanical
irritation of the skin may be increased by
slapping the surface with the hand or a
wet towel. Water 10° F. (5.4° C.) colder
than the water used for the sheet should
be dashed over the head and shoulders
two or three times at short intervals, al-
ternating with slapping and friction for
from five to ten minutes. A moderately
sedative effect, with the abstraction of
considerable heat, is produced.
Sponging. — Have ready water at 80°-
90° F. (26.7°-32.2° C.) and also some at
60° F. (15.6° C). Before sponging take
the exact temperature of the patient. Re-
move all clothing from the patient, place
blankets over and beneath him and a hot-
water bottle at his feet. Arrange the
basins, sponges, and six soft towels on a
table near the bed. First sponge the face
and neck, applying a cold compress at
60°' F. (15.6° C.) to the head after spong-
ing. Sponge downward, exposing only the
part being sponged. After the whole body
has been gone over thoroughly dry the
patient, put on him a night dress, wrap
him in a warm blanket, and leave him un-
disturbed in bed for an hour or so. Take
the patient's temperature after each spong-
ing and at the end of the hour's rest.
Sensitive patients will better stand cold
sponging if they are previously sponged
with tepid water, 80°-90° F. (26.7°-
32.2° C). In stronger ones the arms,
back, and chest may be allowed to dry by
evaporation. Sponging usually causes a
decline of from l°-4° F. (0.54°-2.2° C),
according to the temperature of the water
used. Cooling by rapid evaporation is
favored by the addition of ammonia,
cologne-water, or vinegar to the water
used. If a suitable sponge is not at hand,
wring towels out of cold water so as not
to drip and place this about the body from
the neck downward. On reaching the feet,
again begin at the head, etc. Sponging is
beneficial in febrile conditions, especially
in typhoid fever when the temperature is
not above 102° F. (38.9° C).
An abdominal cold compress is some-
times applied to enhance the effect of the
sponging. Partly wring two towels out
of water at 60° F. (15.6° C), unfold them,
lay them over the abdomen, and retain
them with a thick Turkish-towel binder.
The Oil Rub. — After a warm or tepid
bath the skin is dried and the oil is ap-
plied; it should not be applied when the
skin is dry or unwashed. Pure olive,
cocoanut, or palm oil is best, although
cottonseed oil may be used. Animal fats
are not suitable. The oil should be well
rubbed into the skin and the surplus re-
moved with a soft towel. For a successful
oil rub the rubbing should be gentle and
not cause perspiration. This measure is
beneficial in sluggish cutaneous circula-
tion and in dry, scaly, skin affections. An
oil rub lessens the liability to chilling
after hot baths, and may be used, after the
latter, for cold feet or cold legs. In
marasmus oil rubs improve body nutrition.
The Scotch Rub. — This consists in wash-
ing a part of the body with hot water and
then rubbing with a towel wet in cold
water. It sometimes replaces cold spong-
ing, but its effects are milder and slower.
Salt Rub or Salt Glow. — A small hand-
ful of finely ground salt is dampened in
salt water at 104°-105° F. 40°-40.5° C), and
with it the patient is rubbed. After this
the patient is washed off with a warm-
water spray; the water is gradually cooled.
A full tub bath may follow or take the
place of the spray. A cocoanut-oil rub is
then given for 15 minutes.
Ice Rub or Ice Ironing. — Flat pieces of
ice, inclosed in gauze, are rubbed over
body and limbs. In conjunction with
sprinkling it has been advocated in sun-
stroke.
Alcohol Rub. — This is usually applied as
a terminal measure. It enhances the cir-
culation, is a tonic to the skin and, after
packs or douches, prepares the skin for
contact with the outer air. Only grain
alcohol, either pure or slightly diluted,
should be used, about four tablespoonfuls
being sufficient for an entire body rub.
DOUCHES. — These are useful in treat-
ing limited portions of the body. The
various forms are chosen according to re-
quirements, and may be short or pro-
longed, hot or cold, or alternately hot and
812
WATER (HYDROTHERAPY).
cold, and under more or less pressure,
i.e., varying from 10 to 35 pounds to the
square inch.
Cold applications, continued for one or
two minutes, are strongly stimulant in ac-
tion. The underlying tissues (vascular and
lymphatic) are affected in proportion to
the pressure used. Without pressure the
action is superficial, but may cause reflex
stimulation in some regions of the body.
Hot applications reduce the sensibility
of the superficial nerves of the skin. They
produce local and reflex sedative ef¥ects
when water is at 90°-100° F.(32.3°-37.8° C).
Needle Douche or Spray; Circular
Douche. — In this form there are usually
sixteen "roses" having minute perfora-
tions through which the water flows, ar-
ranged at different heights upon a circular
standard, the upper row being adjusted to
give a downward spray, so as to avoid the
face and head. A higher pressure may
be used than in the douches of larger size.
The many fine jets of water striking the
skin feel like needles. A preliminary hot-
air or electric-light bath is given to induce
perspiration. The duration of the douche
is usually one or two minutes, beginning
at 105° F. (40.6° C), gradually lowered to
90° F. (32.2° C), at 20 pounds' pressure.
Cold Douche. — This is a powerful stim-
ulant, and often used after the hot-air
bath and circular douche. It is contra-
indicated in asthmatic patients. A single
stream of water under pressure, through
a %- or y2- inch nozzle, and at a distance
of from 6 to 10 feet from the patient, is
used. Cold douches should follow hot ap-
plications; alternate heat and cold are also
used. Cold douches preceded by warm ap-
plications and followed by friction are used
against anemia, insomnia, and headaches;
acne, chronic constipation, autointoxica-
tion, and general malnutrition.
Spinal Douche. — A douche applied to a
limited portion of the spine, the water at
45°-60° F. (15.6°-72° C), and under 20 to
30 pounds' pressure, was used by Charcot
in hysteria with good results.
Alternating Hot and Cold Douches
(Scotch Douche). — This produces marked
excitation. It cannot be applied to the
head or the anterior thorax. Satisfactory
results are obtained with water at 105° F.
(40.6° C.) and 70° F. (21.1° C); in the
robust the extremes may be 110° and
55° F. (43.3° and 12.8° C).
Head Douches. — These should be cold
or cool, without pressure, and given from
a pitcher or dipper; the duration should
be only a few seconds. The primary
effect produced is a dilatation of the cere-
bral vessels; if long continued, a second-
ary contraction and chilling are induced.
They are used with the Brand bath or drip
sheet, always at a slightly lower tem-
prature and repeated once or twice. They
are useful in mental disease (melancholia,
hypochondria, etc.). In insomnia, mania,
and paresis, the temperature extremes of
the water are 80° F. (26.7° C.) and 95° F.
(35° C). In the case of women the full
bath or spinal douche is preferable, on ac-
count of the difficulty in drying the hair.
Rain Douche. — This is an elevation of
the ordinary shower bath. The pressure
and temperature are regulated by valves.
In brief applications and at moderately low
temperatures, a vigorous nerve stimula-
tion and strong circulatory reaction are
produced. It is valuable in neurasthenia,
hysteria, neuralgia, paresis, disorders of
nutrition, and weak circulation (non-or-
ganic). The tepid and warm rain douches
are sedative in their effects, and are used
in hypersensitive neurasthenia and hys-
teria. Alternating changes in the tempera-
ture are useful in anemia, chlorosis, and
skin diseases.
Fan Douche. — When the thumb is placed
over the nozzle delivering the jet douche,
breaking it into a fan-shape stream, it be-
comes a fan douche. This is used as a
terminal measure; it is given cool or cold.
Filiform Douche. — This is a very fine
douche, given at high pressure (60 pounds
or higher). It acts as a powerful counter-
irritant and stimulant. It is useful in
sciatica and other neuralgias; it is applied
for from one-half to two minutes. The
steam douche is a variation, live steam
being used.
Perineal Douche. — In this douche the
patient sits upon a stool with the center
cut out or a circular seat and receives on
the perineum a ^-inch jet or spray douche.
Low temperatures, 60°-80° F. (15.6°-26.7°
C.) are employed. Used in vesical atony,
chronic proctitis, sexual depression, psy-
chic impotence, and hemorrhoids. Dura-
WATER (HYDROTHERAPY),
813
tion is from three to ten minutes; the
force of the stream should be sufficient to
raise the water about 30 to 40 inches.
Aix Douche. — This is a combination of
the douche with vigorous massage (douche-
massage). It is a speciahy of Aix-les-Bains.
Affusions. — The patient, nude or covered
only with a sheet, lies on a cot protected
with a rubber blanket. Basins or pails of
very cold water are dashed on him from
a height of several feet, alone or with the
half-bath or Brand bath. They strongly
stimulate and aid in rousing an uncon-
scious patient; they are especially useful
in sunstroke.
CONTINUOUS BATHS.— The Warm
Full Bath. — In this the patient, having his
head covered with a cloth wet in cold
water, lies fully immersed in a large tub
nearly full of water at 95°-100° F. (35°-
37.8° C). The room should be warm
(80° F.— 26.7° C), and the water should
be maintained at its initial heat for from
ten to twenty minutes or more. In sur-
gical and skin cases the body is anointed
well with mutton suet, lanolin, or petro-
latum to protect the skin from peeling or
shrivelling. It is used in severe skin
eruptions like pemphigus, where it relieves
pain, reduces fever, and allows the patient
to pass safely through the eruptive stage.
Prolonged warm baths are advised for
patients with bed-sores, compression mye-
litis, locomotor ataxia, and paraplegia
with paralysis of the bladder and bowels,
inoperable cancer of the urogenital tract,
obstinate sciatica, muscular and articular
rheumatism, chronic meningitis, hemiplegia
contractures, and general hyperesthesia.
Warm baths of short duration are bene-
ficial in the fevers of infancy and child-
hood, in cerebrospinal meningitis, in acute
mania and other conditions due to excited
nerves. Friction is not usually required.
A half-hour bath, at 110° F. (43.3° C.) is
beneficial in amenorrhea and dysmenor-
rhea.
Atheroma and cardiac diseases contra-
indicate the warm bath.
The Hot Bath.— In these baths the
water is at 104°-115° F. (40°-46.1° C).
The effects vary according to their tem-
perature and duration, less nerve exhaus-
tion following their use because of less
demand upon the heat-producing centers.
and when followed by cold affusions there
is a feeling of increased vigor. The pa-
tient should then recline for at least half
an hour. This is used in cases of infantile
convulsions, though the hot pack is prefer-
able.
SPECIAL BATHS.— The Brand Bath.
— This was formerly used extensively in
typhoid fever. It is still recommended
by some observers. The technique sub-
mitted is that obtained from Brand him-
self by Simon Baruch (Am. Jour, of
Physiol. Therap., Sept., 1910). When the
axillary temperature taken for ten min-
utes registers 39.5° C. (103° F.), the pa-
tient is lifted into a tub two-thirds full of
water not below 18° C. (64.4° F.) nor
above 20° C. (70° F.) in which he is
rubbed gently for fifteen minutes. During
the intervals a compress of three folds of
old linen wrung out of water at 60° F. and
covered with thin flannel is placed over
the abdomen and held firmly in place by a
thin flannel band covering it completely.
This is renewed every hour if warm. The
bath is repeated every four hours when
the rectal temperature is 103° or over.
The Turkish Bath. — This is cleansing
and stimulating. The patient adjusts a loin-
cloth about the pelvis, takes a drink of
water and enters a room with dry air at
from 110°-130° F. (43.3°-54.4° C). Per-
spiration appears in ten or fifteen minutes.
The patient is superficially massaged to
increase the perspiration, and sometimes
a hot foot-bath, hot spray, or hot full bath
is given. When perspiring freely the pa-
tient enters another room, at 150°-20O° F.
(65.6°-93.3° C.) for a few minutes. He is
then rubbed vigorously with bare hands
and then given a soap shampoo, lying on a
marble slab. A cold douche, at 60° F.
(15.6° C.) is then given or, if perspiration
is still rather free, a rain douche, the tem-
perature being reduced in from one to
three minutes from 85' F. (29.4° C.) to
75° F. (23.9° C), or 60° F. (15.6° C). A
cold plunge in water at 60° F. (15.6° C.)
follows, and then he reclines until the skin
is dry and pulse normal. Finally, an alco-
hol rub is given, after which he rests.
In acute pharyngitis and suppressed
menstruation tlic Turkish bath gives re-
lief. It is beneficial in the treatment of
obesity, alcoholism, diabetes, chronic dys-
814
WATER (HYDROTHERAPY).
pepsia, anemia and chlorosis, and the gout
of the obese. Syphilitics, neurasthenics,
and insane patients, and certain patients
havinj^r neuritis and chronic myelitis are
improved. In cardiac dilatation, cardiac
asthenia, tachycardia, arteriosclerosis, high
blood-pressure, pulmonary congestion,
chronic bronchitis with emphysema, and
exophthalmic goiter; in advanced heart dis-
ease and Bright's disease,, in cases with a
history of apoplexy, and in skin diseases
with eruptions its use is contraindicated.
The Russian Bath (Diaphoretic). — In
this the patient lies on a marble slab in
a small, steam-filled room, being rubbed
at intervals to hasten perspiration. The
room-temperature is lower than in the
Turkish bath, the steam making higher
temperatures unbearable. After remaining
in this room from ten to twenty minutes
he takes a shower of cold water or a
plunge in a pool at 60° F. (15.6° C).
Vapor or Sweating Bath. — In this a
blanket on a rubber sheet is placed under
the patient, and he is wrapped in a blanket.
A cradle covered with a rubber sheet and
blanket is placed over him and the cradle-
covers are tucked closely around the neck.
An ice-cap or cold compress is placed on
his head. Steam is allowed to enter grad-
ually through a spout leading from a
kettle of boiling water. The duration may
be from 30 to 60 minutes, or longer. The
patient's temperature, pulse, and respira-
tion should be watched. When the steam
is stopped, the patient should be wrapped
in a dry blanket and allowed to rest.
Foot-bath. — This entails the use of a
small tub or pail of hot water and an ad-
ditional supply of very hot water. The
temperature is therewith gradually raised
from 110° F. (43.3° C.) to 115° or 120° F.
(46. P or 48.9° C). The duration of the
bath may be from 10 to 15 minutes; the
depth of the water may be 8 or 10 inches.
A little mustard may be added. A cold
compress should be placed on the head.
This bath is beneficial after the initial
chill of pneumonia, in sprains of the ankle
or foot, bruises, cramps in the legs, etc.
Medicated Baths. — Alkaline Bath. — Use 1
ounce (30 Gm.) sodium bicarbonate to
every 5 gallons (20 liters) of water.
Pine-needle Bath. — Pine-needle extract, 2
ounces (60 Gm.) to 40 gallons (160 liters).
Sulphur Bath. — Potassium sulphide, 1 ounce
(30 Gm.) to 7 gallons (28 liters) hot water.
PACKS.— Cold Wet Pack.— A narrow
bed and mattress protected with a rubber
sheet, and on this a large blanket, a hair
pillow covered with rubber cloth and a
pillow slip are prepared, and one or two
additional blankets, a sheet, four small
towels, a hot-water bag, half-filled with
hot water not over 120° F. (48.9° C.), a
foot-bath with water at 102°-105° F.
(38.9°-40.6° C.), a pitcher of ice-water, and
a bucket of water for the sheet at 65°-
70° F. (18.3°-21.r C.) are made ready.
The patient in a bath robe sits with his
feet in the bath of warm water, and with
a cold compress on his head. The at-
tendant wrings out the sheet from, the
cold water and spreads it evenly on the
bed. The patient removes all clothing and
lies on the wet sheet with arms extended.
The sheet on one side is wrapped over the
body and limbs; the hands are brought to
the sides and the other half of the wet
sheet covers in both arms and the lower
limbs. The feet are left uncovered by the
sheet, and the hot-water bag, covered with
a towel, is placed at the soles. The pa-
tient is now well covered with the under-
lying blanket, close adjustment at the neck
excluding all air. Another blanket, folded,
envelops the entire body. The turban of
ice-water is changed when warm.
Hot Wet Pack. — This is done similarly,
hot water being used instead of cold. It
is followed by a tepid or cool sponging,
and is used in anemia, in the sequelae of
scarlet fever, and in catarrh of the air-
passages in children. In infantile convul-
sions it equals the hot bath. In uremia,
especially of pregnancy, it is invaluable.
Dry Hot Pack. — Dry, hot blankets are
used after the warm douche or hot baths
in gout, rheumatism, syphilis, and obesity.
COMPRESSES.— Cold Compress.— The
material used is linen, eighteen inches
wide, covered by several layers of flannel
to prevent radiation. The water should
be at 50°-60° F. (12.8°-15.6° C.). The
linen is partly wrung out. laid evenly over
the afifected side, and is covered with a
flannel binder applied loosely. The com-
press should be renewed every hour. This
is useful in pneumonia, toxemia being re-
duced, crisis hastened, and pulse improved.
WOUNDS. SEPTIC, AND SEPSIS (LAPLACE).
815
Ice Compresses. — These are best ap-
plied in the form of ice-bags.
Hot Compresses (Fomentations). — Well-
soaked flannel is used, covered with suffi-
cient layers of dry flannel, and unless very
hot, in direct contact with the skin sur-
face, hyperemia is induced and internal
congestion relieved. Hot compresses favor
suppuration, hasten the absorption of ex-
udates, relieve pain, and loosen up stiff-
ened joints. They are used in rheumatoid
arthritis, arthritis deformans with pain and
swelling, sprains, bruises, cramps of the
extremities, in biliary, renal, and hepatic
colic, in affections of the bowels and pelvic
viscera, intercostal neuralgia, lumbago,
and sciatica.
Fomentations are contraindicated when
appendicitis threatens, in peritonitis due
to perforation or injury or when idio-
pathic, and in the onset of pneumonia. In
all these cases ice-bags, cold compresses,
and similar measures are preferable. W.
WEIL'S DISEASE. See Liver
AND Gall-bladder: Acute Infec-
tious Jaundice.
WEN. See Skin, Surgical Dis-
eases OF.
WHOOPING-COUGH. See
Pertussis.
WINTERGREEN. See Gaul-
theria.
WITCHHAZEL. See Hamamelis.
WORMS. See Parasites.
WOUNDS, SEPTIC AND
SEPSIS. — By septic wound is meant
a lesion in which the tissues have be-
come infected by pathogenic organ-
isms. Sepsis refers to an invasion of
the blood by these organisms or their
toxins.
PROPHYLAXI S.— The great
European war afforded abundant
material, unfortunately, for the study
of measures which tend most effect-
ively to thwart even the most ex-
treme risks of wound infection, and,
therefore, of general sepsis. As em-
phasized by Sir A. E. Wright, the
clothingf and skin of the soldiers are
usually in a foul condition. The pro-
jectile passing through a zone of filth
necessarily carries infection along its
path, often far beyond the reach of
antiseptics. This results in a pri-
mary infection, not only with strep-
tococci, but also with organisms
from the feces, particularly gas, teta-
nus, and colon bacilli. Death, there-
fore, may result from erysipelas,
gangrene, cellulitis, or tetanus. If
the wound is open and aerobic
conditions prevail, a secondary infec-
tion, with other pus organisms, no-
tably the Bacillus proteus, may fol-
low. Overshadowing the issue also
is the danger of general sepsis in its
various forms, with death as a prob-
able result. In no phase of the prac-
tical field, therefore, is prophylaxis
more important.
Commonly Used Antiseptics. — A strik-
ing feature of the first two years of the
war, in this connection, was that virtuall}'
all the older antiseptic agents were found
wanting. Phenol proved to be of low ger-
micidal power, especially in the presence
of serum, and, when sufficiently concen-
trated, damaged the tissues. Peroxide of
hydrogen had very little germicidal action
in the precence of tissue fluids on account
of its rapid decomposition by catalase
present in them. Roliert Morris, some
years ago, pointed out its morl)id influ-
ence on the processes of repair. Bi-
chloride of mercury rapidly lost much
of its antiseptic power in the presence of
albuminous fluids and was irritating to the
tissues even in very dilute solutions. Sil-
ver nitrate proved more valuable than bi-
chloride of mercury, but was also found
to be a violent irritant. The coagulation
of protein and its irritant properties re-
duced the value of iodine for use in
wounds, notwithstanding its great value
as a surface antiseptic. On the whole, the
virtues detailed elsewhere under the re-
816
WOUXDS, SEPTIC, AND SEPSIS (LAPLACE).
spective headings of these powerful
agents (q. r.) did not stand tlie test of
the extraordinar}' conditions the war
evoked, and imposed the necessity of
looking elsewhere for efificient agents.
Sodium Hypochlorite or Dakin-Carrel
Solution. — Of the various preparations
tried this afforded the best results. It
was introduced by H. D. Dakin to elimi-
nate the disadvantages of the older anti-
septics. As obtained in commerce, how-
ever, sodium hypochlorite, though highly
germicidal, is extremely irritating to the
tissues, owing to the presence of free
alkali and free chlorine. Dakin found
that boric acid overcame this defect.
The solution was then prepared as fol-
lows: 140 grams (4% ounces) of dry so-
dium carbonate, or 400 grams (13%
ounces) of the crystallized salt, are dis-
solved in 10 liters (quarts) of water, and
200 grams (6% ounces) of calcium chloride
of good quality are added. The mixture
is shaken and at the end of half an hour
the clear liquid is siphoned of? from the
precipitated calcium carbonate and filtered
through cotton. Forty grams (10 drams)
of boric acid is then added to the liquid
and the solution is ready for use. It is
important to add the boric acid after fil-
tration, not before. The solution will not
keep more than a week. Dakin then as-
certained that the best results were ob-
tained when it was used by continuous
irrigation; that it favored the dissolution
of necrotic tissue; that it was slightly
hemostatic, though not irritating to the
wound tissues.
Carrel then took up the question at the
Rockefeller Foundation Temporary Hos-
pital at Compiegne, France, in collabora-
tion with Dakin, the aim being to over-
come the terrible effects of infection. In-
deed, 80 per cent, of all amputations, 75
per cent, of all deaths after the first 24
hours, and 95 per cent, of secondary
hemorrhages were due to this factor, and
not to the gravity of the wound. Of all
antiseptics tried, Dakin's proved the most
satisfactory.
The following technique was employed:
After the w^ound had been thoroughly
though gently cleansed, foreign bodies and
all bits of bone removed, and the bleeding
controlled, a loose dressing was applied,
no impermeable substance ever being used.
Numerous rul)ber tubes, perforated with
many small holes, were then run down
into all recesses of the wound and allowed
to project out through the dressings.
Dakin's fluid was poured into them every
hour at first and less frequently later, with
continuous day and night irrigation, proved
even better. (See also page 193, this vol-
ume). This fluid could be applied for
days, or even weeks, without irritating the
tissues. It should not be used with al-
cohol, however, and should not be heated.
The process of healing was carefully
watched, and, if normal healing did not
ensue, the wound was examined for for-
eign substances, which might have inad-
vertently remained, and then irrigated
anew. But the removal of muscles or
bones not irreparably injured was not
practised on the first or second examina-
tions as frequently as had been the case
heretofore, and in this way parts were
saved which otherwise would have been
lost.
When the phenornena indicating infec-
tion had subsided and smears showed de-
creasing numbers of bacteria in the secre-
tions of the wound, and finally their com-
plete disappearance, the wound was closed.
This was usually possible from the fourth
to the tenth day. The infection having
been overcome, conditions were practically
the same as in a fresh operative wound,
and the tissues healed by primary inten-
tion when carefully coaptated.
Strips of adhesive plaster, from 2.5 to 5
cm. wide, were applied perpendicularly to
the wound to bring the tissues together
(or clips can be used); no suturing was
done unless circumstances compelled it.
This early closing of wounds got the pa-
tients up much earlier, and this in turn
aided in warding off stiff joints and
atrophy of the muscles.
While the original Dakin solution con-
tains 0.5 to 0.6 per cent, of sodium hypo-
chlorite, an improved solution subse-
quently prepared by Daufresne contains
0.45 to 0.5 per cent, and is free of boric
acid.
Danfresne's technique has beeH described
by Dakin as follows (Keen: "Treatment
of War Wounds," 1917): "Two hundred
Gm. (6% ounces) of good bleaching pow-
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
817
der are put in 12-liter (quart) bottles with
5 liters (quarts) of tap-water. The solu-
tion is shaken vigorously and allowed to
stand for at least 6 hours. In another
vessel 100 Gm. (3% ounces) of dry sod-
ium carbonate and 80 Gm. (2% ounces) of
sodium bicarbonate are dissolved in 5
liters (quarts) of cold water and then
added to the bleaching powder mixture.
The whole is shaken vigorously for a few
minutes, and the precipitate allowed to
settle. After half an hour the clear solu-
tion is siphoned out and filtered through
paper. With the most brands of Ameri-
can bleaching powder it is better to use
90 Gm. (3 ounces) of each salt. The
solution must invariably be tested for
neutrality by adding a pinch of solid
phenolphthalein to a little of the solution.
If the solution should react alkaline, 1 of
3 methods must be employed to correct it,
otherwise skin irritation will surely result:
(a) Pass carbon dioxide gas into the solu-
tion until a sample shows no alkalinity.
(b) Reduce the proportion of sodium car-
bonate and increase the bicarbonate, (c)
Add boric acid. The carbonate-bicarbo-
nate mixture possesses greater stability
and can be kept for several weeks with-
out much deterioration."
Following procedure described as a
rapid method of preparing Carrel-
Dakin solution. The materials: A
solution of chlorinated soda contain-
mg 2.8 to 2.9 per cent, of available
chlorine; one of sodium bicarbonate
of about 5 per cent, strength; and
some phenolphthalein powder. One
part of chlorinated soda solution is
diluted with 5 of water, and to this
25 c.c. (6^/4 drams) of the bicarbonate
solution is added for each liter
(quart). The whole is well mixed
and 20 c.c. (5 drams) removed and
tested with a little phenolphthalein.
If there is no red color the solution
is ready for use. If red appears, 10
to 20 c.c. (2y> to 5 drams) more of
bicarbonate solution is added, and the
test repeated until the red does not
appear.
The chlorinated soda solution is
readily obtainable, and keeps well. 1".
Rosengarten (Jour. Amer. Med.
Assoc, Sept. 29, 1917).
Describing Carrel's method, the
writer notes that tubes have been
found most practical to carry the
liquid to the wound. They are
lengths of rubber tubing of 4 milli-
meters interior diameter, 30 to 40
millimeters in length. They are
closed at one end by tying with
strong linen thread, and perforated
from the same end over a length of
5, 10, 15 and 20 centimeters by means
of a punch, making holes ^ milli-
meter in diameter, perforating both
walls 1 centimeter apart. The tubes
are so arranged in the wound that
the liquid may readily spread over the
whole surface. They are not applied
over gauze, but directly to the wound,
and compresses soaked in Dakin's
solution are laid over them. Gravity
plays a considerable part in distribu-
tion of the liquid. Covered tubes
with Turkish toweling are used in
cases of superficial wounds, vertical
setons and wounds of the posterior
aspect of the limbs. In superficial
wounds instillations may be made
through a looped perforated tube at-
tached to the skin above by adhesive
plaster. On inclined surfaces the
tubes should be applied to the upper
portion of the wound. All tubes are
connected by glass distributing tubes
with the irrigating flask. The latter
usually holds a liter and its inferior
orifice has a diameter of 7 milli-
meters. It is hung at a height of
from 60 to 100 centimeters above the
bed, according to the number of tubes
in the wound.
Every 2 hours the nurse releases
the pinch cock for a few seconds and
gives to the wound from 30 to 100
c.c. (1 to 3% ounces) of solution.
The total quantity per diem varies
from 250 to 1200 c.c. (SVg to 40
ounces). At the daily dressings the
skin is protected by squares of gauze
soaked in yellow vaseline. A pad of
absorbent aid non-absorbent cotton
covers the entire dressing, the ab-
sorbent layer being placed next to
the wound.
Smears are taken every 2 days from
the most infected parts of the wound
8—52
818
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
the instillation being stopped 2 hours
before. They are stained by carbol-
thionin and the bacteria counted.
With a Bausch and Lomb microscope
the No. 10 ocular and 1.9 millimeter
objective are used. The average
number of bacteria in a field is then
estimated and charted. When only 1
bacterium is found in 5 to 10 fields
surgical asepsis is obtained and the
wound can be sutured with safety.
Wounds of the soft parts, with ster-
ilization begun in a few hours, can
thus be closed after 2 days. In frac-
tures it is preferable to wait until the
wound has been surgically sterile for
4 or. 5 days. Where sterilization has
been begun after a period of sup-
puration, one should find the secre-
tions sterile for a week at least be-
fore suturing. G. Loewy (N. Y. Med.
Jour., Oct. 27, 1917).
The skin surrounding a wound treated
with Dakin's solution should be protected
with vaseline, otherwise painful and per-
sistent cutaneous irritation sometimes en-
sues. Care must also be taken that the
solution is of precisely correct strength,
too strong a solution proving more irri-
tating, while a solution weaker than 0.45
per cent, is insufficiently germicidal. One
of the main objects in the treatment is to
keep the solution constantly in contact
with all the wound surfaces. For this
reason dependent drainage is avoided.
Frequent renewal of the solution in con-
tact with the wound — every 2 hours — is
necessarj^ because the solution, in the
presence of the wound exudates, rapidly
loses its chlorine content.
The improvement in wounds treated
by the Carrel method is due rather to
the proteolytic action of the hypo-
chlorites on mortified tissues than to
any sterilizing action. The Dakin
solution is only feebly germicidal.
The more proteins it dissolves, the
more attenuated its antiseptic action.
Fiessinger and Clogne (Rev. dc chir.,
Sept.-Oct.. 1917).
In applying the Carrel-Dakin
method to wounds in private prac-
tice, care should be taken that the
solution is non-irritating. If the pa-
tient complains of continuous burn-
ing in or about the wound the solu-
tion has usually become alkaline, and
should be neutralized with a solu-
tion of boric acid. As it breaks down
readily, it should be kept in well
corked dark bottles. A preparation
more than a week old should be dis-
carded. The bacteriological status of
the wound should be determined
every few days. Good results are
obtained with the Carrel-Dakin out-
fits on the market. Gauze should
not be employed. The tubes should
not l)e allowed to remain in any one
position more than twentj-'-four hours.
The irrigations should be made at
two-hour intervals and enough used
to bathe the parts thoroughly. The
dressing should not become dry be-
tween treatments, nor should the
wounded part be allowed to lie in a
wet bed. P. J. Reel (Ohio St. Med.
Jour., Jan., 1918).
The Carrel method has given good
results in extensive superficial wounds.
In fractures the results differ accord-
ing to the bones involved. Thej- are
good in the case of the humerus or a
single bone of the forearm; slower
for both bones of the forearm or leg.
Complete sterilization is not obtained
in fractures of the femur. The
method fails in osteitis and osteo-
mj'elitis and subsequent sinuses; in
joint fractures, where it does not ob-
viate resection, and in purulent pleu-
risy. Careful hemostasis must be
established at once after the opera-
tion to avoid secondary hemorrhage,
which Dakin's fluid favors by dis-
solving blood-clots. The usual drain-
age at the lowest point should not be
omitted. A. Rendu (Lyon chir., July-
Aug., 1918).
Apart from the Carrel-Dakin solu-
tion and procedure a large variety of
other antiseptic agents came into use
during the European war. A number
of these have now passed into ob-
livion. Tlie remainder, such as
dichloramine-T, flavine, and sunlight,
will be referred to under Treatment.
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
819
The writer urges the value of dust-
ing war wounds thickly with a dry-
powder consisting of calcium hypo-
chlorite and boric acid in the propor-
tion of 1: 10. This prophylactic treat-
ment, particularly useful when the
wounded are coming in in large num-
bers, is renewed the next day, if
there is delay in getting the wounded
to the hospital. It has a powerful
sterilizing action and seems to ward
off gas gangrene. Vincent (Presse
med.. Mar. 29, 1917).
Starch iodide is recommended by
the writer in wounds of soft parts
due to abrasion, unassociated with:
sinuses or deep, inaccessilile tracts.
In deep wounds success was secured
by irrigations of starch iodide after
the Carrel method. The solution
consists of soluble starch, 25 Gm.
(4% drams); boiling water, 1 liter
(quart), and 1:1000 iodine-iodide
solution, 50 c.c. (1% ounces). This
fluid contains iodine in extreme sub-
division, and seems to possess anti-
septic power of the same order as
Dakin's solution. It is not irritating
to the skin and has no deleterious
action on clothing. A. Lumiere
(Presse med., Sept. 20, 1917).
In minor wounds, the writer first
covers the injury with cotton or
gauze wet with 1 : 2000 mercury cya-
nide solution. Then, under strict
aseptic precautions, the surrounding
skin is scrubbed with sterile water
and liquid soap, hair shaved off, for-
eign bodies and visible dirt removed,
bleeding vessels ligated, shreds of
flesh cut away, the wound irrigated
with hot, sterile water and sutured,
drained if necessary, and covered
with sterile cotton and bandages. If
near a joint, a splint is applied. A
dressing wet with Dakin's solution
is kept on for a few days until all
danger of infection is past. A. W.
Colcord (Internat. Jour, of Surg., 30,
312, 1917).
Iodine promotes the healing over
after tlie wound cavity has filled with
granulations. Plaster is swabbed on
the adhesive side with a 10 per cent,
tincture of io<Jine and when dry. cut
into narrow strips which are applied
to the edge of the wound, the strip
fitting for 1 millimeter on the epi-
thelial margin and the other 3 or 4
mm. on the granulation tissue.
Often the epithelium heals over as
promptly as if Thiersch grafts had
been applied. Taddei (Riforma med.,
Mar. 30, 1918).
In recent wounds, before active in-
fection appears, no mode of disinfec-
tion gives as good results as hot air. It
is not to be substituted for the cus-
tomary excision of dead or injured
tissue, but acts well in place of any
antiseptic liquid or powder. In a but-
tock wound contraindicating com-
plete excision, recovery was obtained
by carbonization with oxygen heated
to 1000° C. under pressure. In long-
standing obstinate wounds, air heated
to 55° or 60° C. proved useful both
in military and civil practice. M.
Vignat (Bull, de I'Acad. de med.,
Mar. 4, 1919).
Wound Excision and Primary Suture. —
The foremost surgical development of the
war as regards wound treatment was
probably the general recognition of the
principle of complete wound trimming or
excision (debridement), which introduced
the possibility of effecting immediate
(primary) closure of wounds even when
presumably infected. Through the Car-
rel-Dakin method, reasonably prompt
secondary suture of wounds already in a
manifest state of infection was rendered
feasible, but in wounds coming for treat-
ment early — within eight or ten hours
after injury — more rapid results than are
afforded by the Carrel method are desir-
able, and this desideratum has to a cer-
tain extent been supplied by the proce-
dure of wound excision, wliicli seems
destined to pass definitely from military
into civil practice for the treatment of
severe, presumably infected wounds. As
John T. Bottomley stated (1919), it is
logical to assume that as del)ridenient
comes more into vogue, the need of the
Carrel-Dakin method will be less urgent.
At the time of the beginning of stable
trench warfare after the first battle of the
Marne, the results from expectant treat-
ment of wounds — nearly all primarily in-
820
WOUNDS, SEPTIC, Ax\D SEPSIS (LAPLACE).
fected — became extremely unfavorable,
active suppuration. secondary hemor-
rhage, gangrene, septicemia, and linger-
ing illness being commonly ol)served.
Early in 1915 a numl^er of surgeons were
insisting not only on prompt wide incision
and drainage of wounds, but also on im-
mediate removal of all avascular tissue
and all structures manifestly dead or
about to undergo necrosis. By the middle
of 1915, both antiseptic treatments, such
as that of Dakin-Carrel, and the principle
of early suture after complete wound
cleansing, were in process of practical
trial. In France, Lemaitre, Tissier, Duval,
and Depage, and in England, Gray, were
among those who compelled recognition
of the principles of debridement and pri-
mary suture. At first tried only in fresh,
comparatively clean wounds — especially in
wounds of the knee-joint, scalp and brain,
lungs, and abdominal wall — the field for
primary suture was gradually extended to
more dubious cases.
The technique of wound excision
as commonly performed is as follows:
(1) Incision. This is usually made
either parallel to the muscle fibers or
to the large vessels and nerves; or it
may be differently placed to open up
the track of the projectile widely; or
it may actually connect the wounds
of entrance and exit. (2) The track
of the projectile is followed and all
diverticula opened and explored. (3)
Foreign bodies, clothing, projectiles,
and loose fragments of bone or skin
are removed, together with all tis-
sues already dead or avascular and
destined to necrosis. Important ves-
sels and nerves must be saved. (4)
Ilemostasis is completed, with liga-
tion of all visible bleeding points,
followed by gauze pack for a few
^ minutes and then by fixation of the
bacteria in the wound by tincture of
iodine. (5) Repair of the structures
is made by suture.
If because of poor general condi-
tion or other material circumstances,
excision is not completed, one must
effect their removal at a subsequent
dressing to avoid spontaneous elimi-
nation by necrosis and consequent
contamination of the wound.
Primary suture can be practised
only when proper surgical surround-
ings make aseptic conditions possible.
Advanced infection and impaired
local circulation are absolute contra-
indications to it. R. T. Vaughan
(Surg., Gynec. and Obstet., Apr.,
1919).
Where immediate suture was deemed in-
advisable, delayed primary suture was
frequently carried out two to four days
after the initial excision treatment, if the
wound seemed in good condition. Correct
results from this procedure were found to
be more easily obtained with the aid of
bacteriologic study of the wound secre-
tions. Carrel treatment may or may not
be applied during the interval between ex-
cision and suture. The so-called secondary
suture consists in closing the granulat-
ing wound later than four days after the
excision, after removal of the epithelial
margin and neighboring skin or a com-
plete excision of the scar tissue. Where
the wound is in a sufficiently unfavorable
condition to make delayed primary suture
inadvisable, the next object in view is to
carry out secondary closure when the
wound has become practically sterile and
contains no streptococci.
The principle of primary suture is defi-
nitely established, but opinions as to the
legitimate field for it remain at variance.
Clean wounds in civil practice are ob-
viously comprised in this field. Of the
army surgeons, some remain adherents of
the Carrel procedure, after primary ex-
cision, for practically all types of war
wounds.
[W. Wayne Babcock (1919) has des-
cribed a special method for the immediate
sterilization and closure of chronic infected
wounds of bones and soft tissues (see
under Treatment). En. J
Where primary suture is imprac-
ticable, the writer attempts second-
ary suture. After careful removal of
dead tissues, the wound is treated by
continuous or intermittent irrigation
or with a simple wet dressing of 12.5
per cent, magnesium chloride and
0.125 per cent, ammonium chloride.
This is preferable to Dakin's fluid,
which at times burns the tissues.
Complete arrest of suppuration and
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
821
descent of the temperature generally
occur in two or three days. The
wound is then cleansed with tepid
magnesium chloride solution, and
secondary closure effected with su-
tures or adhesive strips. Helio-
therapy accelerates repair. G. Pothe-
rat (Presse med., Dec. 20, 1917).
Report of experience with primary
suture in 2537 cases. It is not neces-
sary to excise any more tissue for
primary suture than with any other
method. Curved scissors are prefer-
able to the knife. The wound is next
dried with gauze, the tissues swab-
bed freely with 5 per cent, tincture of
iodine, and any excess wiped up.
Iodine is not needed for small
wounds with healthy tissues which
do not require excision, nor when
the devitalized tissues are removed
en bloc. The iodine somewhat re-
tards healing and delays removal of
sutures to the twelfth or thirteenth
day, but it offers the advantage that
delayed primary suture can be post-
poned till the eighth or ninth day or
even longer. The iodine fixation ren-
ders harmless the germs sown on the
surface of the wounds during the
operation. In the last series of 1891
wounds, primary suture was applied
in 79 per cent, and proved successful
in all but 0.84 per cent. In the com-
plete failures the streptococcus was
always found, but even the strepto-
coccus does not inevitably doom the
suture to failure. R. Lemaitre (Lyon
chir., Jan.-Feb., 1918).
Every war wound free of the strep-
tococcus should be sutured. Ful-
minating putrid infection always re-
sults from anaerobes plus the strep-
tococcus. At 37" C. its cultures are
characteristic in five or six hours.
Swabs should be taken from all por-
tions of the wound at the fourteenth
to the eighteenth hour and inoculated
in bouillon agar slants with lactose
litmus and in Veilloii agar. Strepto-
cocci were found in but 10 or IS '
per cent, of fresh cases, with anae-
robes in 6 or 8 per cent. But by the
time unsutured wounds reach the
hospitals at the rear, fully 80 per
cent, show streptococci. No anti-
septic should iie used except possibly
ether and iodoform-ether solution
for bone lesions. G. Gross (Paris
med., Feb. 23, 1918).
Regular healing takes place only
where all adhesion of dressings is
avoided. This is easily secured by
covering the wound with a layer of
tulle of 2 millimeter mesh, impreg-
nated with sterile vaseline. Simple
washing of wounds with normal
saline solution, i.e., aseptic treatment,
results in more rapid progress than
occurs with antiseptic ether solution,
the daily rate of healing rising to 1.2
or 1.3 mm. At times, however, heal-
ing under such treatment is suddenly
checked by bacterial contamination.
The best plan is to use dressings of
starch iodide, healing being thus ac-
celerated to over 1.6 mm. a day. A.
Lumiere (Bull, de I'Acad. de med.,
Mar. 12, 1918).
The writer's system of "reinforced
prophylaxis" for wounds comprises
primary excision plus deep disinfec-
tion by infiltration of the tissues with
solutions of quinine derivatives by
means of the hypodermic syringe.
Isoethylhydrocupreine, the quinine
derivative having the greatest des-
tructive action on the streptococcus
and staphylococcus, is used in
1 : 10,000 solution in normal saline
solution, filtered through cotton and
sterilized. Novocaine or adrenalin
may be added if required. Joint
wounds respond most favorably to
the solution, which is injected into
the joint as well as the surrounding
tissues. R. Klapp (Miinch. med.
Woch., May 7, 1918).
Sloughs from foul wounds do not
require chemical solvents for their
removal, l)ut can be eliminated by
tryptic ferment set free from disinte-
grated leucocytes. Liberation of this
ferment is greatly accelerated by
breaking down tlic leucocytes in the
discharges vvitli hypertonic saline
solution (5 to 10 per cent.). Notiiing
prevents a wound surface washed
quite clean of alliuminous matter
from being sterilized by a single ap-
•822
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
plication of antiseptics. A. E. Wright,
Fleming and Colebrook (Lancet,
June 15, 1918).
Primary suture is feasil)le even
twelve hours after injury when the
wound seems slightly if at all in-
fected. In 32 cases, the writer oper-
ated and sutured between the thirty-
fifth and forty-eighth hours in 12; on
the third day in 7, and from the fourth
to the eleventh day in 13. In only 3
did reopening of the wound become
necessary. In all the others the scar
was linear and soft as in +he most
successful early suture cases. Chalier
(Progrcs med., July 6, 1918).
No attempt should be made to ex-
cise a wound when the infecting
organisms have already invaded the
tissues, as this does not hasten re-
covery and materially increases the
risk of septicemia. The operation
should then be limited to free ex-
posure of the entire surface, includ-
ing all recesses. Comparison of sev-
eral methods: Carrel-Dakin with
early operation, 77.5 per cent, closed
by suture; without early operation,
53.5 per cent.; dichloramine-T in
eucalyptol, 43 per cent.; flavine, 22
per cent.; hypertonic saline, 12 per
cent. Early excision with primary
suture is the only method comparing
favorably with the Carrel-Dakin pro-
cedure. Dichloramine-T in eucalyp-
tol gives very fair results, but epi-
thelialization is somewhat slow, with
irregular scar tissue. J. T. Morrison,
Hartley and E. F. Bashford (Lancet,
Aug. 24, 1918).
In the first stage of wound healing
destruction of germs is imperative,
but when these are once conquered,
disinfectants serve only to injure the
delicate tissues forming during re-
pair.
A simple dry absorbent dressing on
a sterile wound leads to healing a
little more rapidly than the Dakin
method.
Systematic exposure to sunlight,
however, will greatly shorten the
period of healing, e.g., by as much
as two weeks. Tuffier and Desmarres
(Jour, de chir., Dec, 1918).
In Evacuation Hospital No. 1, in
France, between 500 and 600 battle
casualties were received in 8 weeks,
including mostly the more severe
wounds. Of these, 206 were closed
immediately; 93.5 per cent, of them
healed without a drop of pus or a
particle of infection. A number of
other cases, forming a second type,
were closed when clean and sterile
by delayed primary suture; 100 per
cent, healed without any infection.
The third group comprised those
known to be infected and in which
the Carrel-Dakin method was used;
85 per cent, healed without suppura-
tion. These results convey a good
idea of what can be done under
favorable conditions liy the newer
treatment of battle casualties. Brewer
(N. Y. Med. Jour.. Feb. 8, 1919).
GENERAL INFECTIONS; SEP-
SIS.— These conditions, popularly
known as "blood poisoning," are due
to the invasion of the blood by bac-
teria or their toxins from the seat of
injury. Three forms of general in-
fection have been identified : toxemia,
septicemia, and pyemia.
Toxemia or Sapremia. — These
terms are applied to a general disor-
der due to the penetration in the
blood of toxins only from a septic
focus, a gangrenous or sloughing
area, a putrefying blood-clot, a pla-
cental remnant, etc., containing pyo-
genic organisms. The first symptom
is usually a chill or several of them,
soon followed by a temperature rang-
ing from 100° to 104° F. (37.8° to
40° C.) and irregular in type. The
skin is dry and hot ; there is head-
ache, nausea, and vomiting, the
tongue being dry. These phenomena
may appear rather suddenly, i.e.,
within 24 hours, when the outflow
of toxin into the blood by way of the
lymphatics is copious, or when a
virulent infection of a previously
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE). 823
clean wound develops rapidly. The temperature rising- to 105° F. '(41.8°
pulse is usually rapid, but full at C.) or more, when a period of dan-
first, and the respiration somewhat ger is reached. In rare cases, how-
hurried. These phenomena subside ever, fever is absent, and, when the
promptly when local treatment of abdomen is the seat of the injury
the wound completely removes the (gunshot wounds, hernia, etc.), the
source of intoxication. temperature may even be subnormal.
If the intoxication is allowed to The pulse may be strong and rapid
proceed the erstwhile febrile symp- at first, but it gradually fails in power
toms are attended by increasing until it becomes easily compressible
weakness, which may proceed to ex- and weak, though rapid. After ab-
treme prostration, with jactitation, .dominal lesions the pulse may remain
tremor and delirium, most marked at extremely rapid, while the tempera-
night. The disorder then assumes ture is subnormal. When acute
the typhoid type, the tongue becom- peritoneal septicemia is present seri-
ing dry and brown, the lips studded ous symptoms develop within 12
with sordes, the skin even showing hours after the injury, and death may
petechial hemorrhages, at times, and occur within 36 hours. Lesions
more or less jaundice. Diarrhea in- found after death in such cases, ac-
creases in intensity until the stools cording to Hartmann, are dilatation
are passed unconsciously. The urine, of the intestines and fine arborescent
which at first was scanty and high- vascularity of the peritoneal coat,
colored, may then be found to con- Diarrhea is frequently observed,
tain albumin, hyaline casts, etc., and but it is seldom as violent as in cases
also be voided unconsciously. As the in which the general toxemia is due
morbid process progresses, the pulse to the ingestion of toxic foods. It is
becomes weak, rapid, and irregular, often protective, in that it aids in the
the temperature subnormal, and elimination of pathogenic substances,
coma supervenes, with death on the bacterial and organic. Vomiting also
fourth or fifth day of the febrile occurs, but is rarely severe. The
process, unless the course taken be spleen is enlarged in most cases,
truly typhoid in character, when life The lymphatic glands may also show
is somewhat prolonged, death occur- a marked tendency to become infil-
ring from exhaustion, trated and enlarged. The urine usu-
Septicemia.— In this condition, due ally shows considerable albumin and
to the presence of bacilli and their casts.
toxins in the blood and tissues from The blood undergoes rapid de-
the focus of infection — even though terioration, owing to the bacteremia,
this be very small, the symptoms As a result, the skin becomes pale
develop less rapidly than in toxemia, and yellowish, and shows a punctate
They consist of chills, sometimes eruption — minute areas of cutaneous
persistent, fever, anorexia, headache, hemorrhage — sufficiently like that of
vomiting, diarrhea, great prostration, scarlatina to suggest the presence of
mental torpor, and the general ty- the latter disease. Other cutaneous
phoid state observed in toxemia. manifestations may also suggest such
The fever increases suddenly, the diseases as roseola, herpes, superficial
824
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
edema, etc. At first the skin is hot,
dry, and rough ; g-radually it becomes
doughy, bathed in perspiration, arid
often cold and clammy.
In the later stages, complications
may occur. Endocarditis may de-
velop very insidiously, being some-
times far advanced when discovered,
althoug"h the physical signs are less
marked than is usually the case.
Gradually the sallow hue of the skin
•deepens, the mental torpor lapses
into stupor, and dulling- of the senses
becomes perceptible in every way.
The tong-ue becomes dry and thickly
furred; the urine, at first scanty, be-
comes concentrated, and sometimes
has to be drawn with the catheter.
Delirium is replaced by coma, soon
followed by death.
The local manifestations varv : in-
deed, none may appear. This is espe-
cially the case when the disease runs
a very acute course. On the other
hand, a severe local inflammatory
process may develop, accompanied by
sloughing and rapidly spreading gan-
grene. This may be observed in con-
nection with slight injuries, such as
those to which surgeons are exposed.
In such cases the wounded finger be-
comes inflamed and painful, red
streaks appear on the arm, and the
lymphatic glands of the member
swell. This is well shown in the
annexed illustration.
In accidents involving crushing,
general septicemia may follow con-
tamination from the dead tissues,
traumatic gangrene with putrefactive
inflammation of the neighboring un-
injured tissues ensuing. Moist gan-
grene, the rapidly spreading gan-
grene (gangrene foudroyante, with
evolution of gas"), may thus act as
foci which rapidly bring on death.
Alany such cases have been wit-
nessed in the great European war.
There is great swelling, with local
emphysema with crackling sounds,
tlie mass giving ofif a very foul odor.
Sucli tissue l^ecomes totally decom-
posed if the patient lives long
enough.
Some cases, as previously stated,
run their course without fever ;
others progress in the usual way and
then cease, — the abortive form., —
even after the temperature has ap-
proximated 103° F. (38.2° e.). Such
cases are not rare.
Blood-cultures in 50 cases of septi-
cemia showed 57 per cent, were
positive, the streptococcus being the
prevailing organism. Of 23 patients
with a positive blood-culture, 74 per
cent, died and 26 per cent, recovered.
Of 17 patients with a negative blood-
culture, 35 per cent, died and 65 per
cent, recovered. Ordinarily in this
series a low leucocyte count indi-
cated a bad prognosis. The differ-
ential count is of the greatest im-
portance. When the polymorphonu-
clears approach 90 per cent., particu-
larly when the count is low, the
prognosis is grave. Abderhalden
(Amer. Assoc, of Immunologists;
Jour. Amer. Med. Assoc, July 15,
1916).
Pyemia. — This condition, charac-
terized by the formation of multiple
metastatic abscesses in various parts
of the body, including the endo-
cardium, joints, etc., is due to the
absorption of pyogenic organisms,
and, in some instances, of the pneu-
mococcus, the gonococcus, the colon,
and typhoid bacilli.
The initial symptoms, a chill more
or less marked, slight fever, increased
sensitiveness of the wound, usually
come on a week or ten days after the
injury was received: i.e., when sup-
puration has been fully established.
Pyogenic Infection of Lymphatic Gland.
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
825
After this first chill, a period of
quiescence occurs of perhaps an en-
tire day. As a rule, another chill
occurs the second day, followed by
another on the third, and so on, until
the chill is observed to be irregularly
periodical or intermittent: a charac-
teristic manifestation of pyemia. The
same irregular intermittence is ob-
servable in the temperature-curve,
which, after marked elevation, — 105°
F. (40.6° C), suddenly falls to normal
or below, remaining there until the
next exacerbation. The intermissions
vary in length — sufficiently long some-
times to suggest recovery. Suddenly
another occurs, and another period of
high temperature supervenes with
sweating. The pulse does not follow
the temperature; though its rapidity
is increased when there is pyrexia, it
is never normal as long as pyemic
infection is present. The constitu-
tional symptoms, which correspond
with those observed in septicemia,
may be very severe.
The second period is that dur-
ing which metastatic abscesses are
formed. The lungs, the spleen, the
liver, the kidneys, and the joints are
the sites of predilection for these ab-
scesses, the first two organs espe-
cially. A sharp pain in the side
with dyspnea — the attending signs
roughly suggesting pleurisy, hemop-
tysis, etc. — indicate that the lung
has become the seat of the abscess,
with perhaps septic efifusion into the
pleura. If the liver be invaded,
jaundice, a common symptom in py-
emia, becomes marked, and the phys-
ical signs indicate hepatic involve-
ment. Hematuria, the presence of
many casts and much albumin in the
urine, points to pyemic nephritis.
The brain mav also be the seat of
abscess, and show signs correspond-
ing with the region involved. The
joints are not infrequently the seat of
abscesses, and the parotid gland also.
The general symptoms are charac-
teristic, but unlike those of septice-
mia. The mental condition, unless ai
brain-abscess develop, is totally dif-
ferent ; instead of apathy, there is
usually clear perception of suffering,
which may become quite severe
through the involvement of nerves
and joints in the inflammatory proc-
ess. The skin is usually dark or
yellowish and erythematous, and
sometimes pustular eruptions may
greatly increase the discomfort. The
tongue is thickly furred. Marked
weakness, emaciation, and exhaus-
tion are the rule, especially in cases
of long duration. In the later stages
delirium may appear, especially in
acute cases, followed by coma.
ETIOLOGY AND PATHOL-
OGY.— Toxemia or Sapremia. — The
morbid process may be initiated from
an area of putrefaction or from le-
sions in any part of the body, the
surface, the viscera, sinuses, uterus,
etc. The poisons elaborated by the
bacteria in situ, and which penetrate
the blood-stream, are poisonous pto-
maines, toxins, etc., the quantity oi
which determines the severity of the
case. The poison — that contained in
a drop of blood, for instance — does
not communicate toxemia to another
subject unless sufficient quantities
penetrate the blood of the latter.
Toxemia is apt to occur when putrid
fluid; blood-clots, etc., are retained in
a wound, a joint, amputation flaps,
etc., by pressure. Briefly, toxemia, in
the surgical sense, means an ill-
drained wound. If its cause is not,
or cannot, be removed, the case as-
826 WOUNDS, SEPTIC, AND SEPSIS (LAPLACE),
sumes the pathological type of septi- composition begins soon after death,
cemia, from which it can hardly be Hemorrhagic areas may occur in
distinguished post mortem. There is the skin and internal organs — to
marked congestion of all the viscera, such a degree, at times, as to have
including the brain, and also hemol- warranted the term hemorrhagic scp-
ysis. ticemia. Cloudy swelling is found in
Septicemia, Sepsis, Septic Infec- practically all organs, the spleen be-
tion.— Any wound, no matter how "ig more or less swollen, though at
diminutive, may become the starting times greatly softened,
point of this disease. Hence its com- Pyemia. — This disorder is brought
parative frequency among surgeons about mainly by the passage, from
who, through a scratch, a slight the infected area to the blood, of clots
abrasion, or a post-mortem wound, either infected with pyogenic bacteria
due to a slight prick of the scalpel or saturated with the toxins of these
used, etc., introduce the pathogenic organisms. Pyemia may also be
organism beneath the protective in- caused in the absence of a wound,
tegument. No wound may be dis- such as that attending middle-ear
covered; the focus of infection may disease. The pathogenic thrombi
then be a middle-ear disease, tonsillar tend to break up in fragments which,
suppurations or infected crypts, den- on reaching vessels whose lumina are
tal caries, pyorrhea alveolaris, sup- too small for them, cause obstruction
purative appendicitis, etc. The bac- and secondary metastatic or second-
teria, once in the blood, multiply ary abscesses. The lungs, heart,
therein and produce continually in- liver, kidneys, spleen, and the brain
creasing quantities of toxins. While, are the organs most frequently af-
as we have seen, a drop of blood in fected in this manner. These ab-
toxemia will not communicate the scesses do not differ from those
disease, the same procedure with the witnessed in the peripheral tissues,
blood will, in septicemia, do so, be- being composed of a central mass of
cause it introduces bacteria which pathogenic organisms, a layer of
proceed at once to multiply, reaching necrotic tissues, another of leuco-
the blood by way of the lymphatics, cytes and the granulation tissue.
Hence the swelling of these glands, which separates it from the surround-
due to the accumulation therein of ing normal structures. In the liver
defensive phagocytes. the abscesses may be multiple, and
Staphylococci, streptococci, pneu- are due, in most instances, to appen-
mococci and colon bacilli are the chief dicitis.
pathogenic organisms. Being solu- PROGNOSIS.— The prognosis in
ble, the bacterial products are carried ^11 forms of sepsis depends greatly
to all parts of the body, unless they ypo^ the powers of resistance of the
have a special affinity for cells, as the patient. In toxemia and septicemia
tetanotoxin has for the nervous sys- the prognosis is favorable both in
tem, the typhoid toxin for endothelial surgical and obstetrical cases when
cells, etc. The blood loses its coagu- the focus of infection can be ade-
lating power; the red cells are de- quately treated early. The time
stroyed in large quantities and de- elapsed before this is done greatly
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE). §27
inflviences the result. The kind of are numerous or involve important
micro-organism present influences organs, the likelihood of an early
materially the prognosis. It is rela- fatal issue is great. The disease is
tively favorable when staphylococci often linked with septicemia, the
predominate, less favorable if pneu- manifestations of both forms being
mococci are found, and least favor- mingled, and the progress of the case
able still if streptococci are present, toward a fatal ending is correspond-
land also in mixed infection. The ingly hastened. Erysipelas, which
bacteriological examination of the may occur as an accompaniment of
blood points to the source of infec- pyemia, also reduces the slight
tion. Thus, if we find pneumococci, chances of recovery. In the form of
the respiratory tract is to be looked pyemia attending gonorrhea the mor-
upon as its source; if the bacterium bid processes caused by the gono-
coli, the intestines, biliary passages, coccus do not vary greatly from those
or a cystitis, etc. caused by pyogenic bacteria.
When the source of infection— a TREATMENT.— Whether the sur-
large septic mass or an infecting sur- geon be dealing with a simple or a
face, etc. — can be reached and judi- severe wound, as soon as fever at-
ciously treated, the chances are tends an injury or an operation,
greatly improved and the symptoms nowadays, suspicion is immediately
sometimes clear up immediately, aroused that a septic condition of the
This is especially the case in sapre- exposed surface has appeared,
mia; but, it is always difficult to -^^^^i Measures.— The sooner the
ascertain whether we are dealing ^^^^-.^ ^nd any accessible secondary
with this condition or with septice- ^bs^ess is opened, drained, and ren-
mia, the information obtainable on ^^^^^ absolutely aseptic, an infective
this score being rather scant. placenta removed, etc., the better.
The rapidity of the course affords -p^jg j^ probably best effected by the
some idea of the chances the patient godium hypochlorite solution of
has, and the prognosis may be said to j^^j^jj-^ ^^^^ Carrel, described on page
be favorable if the symptoms show g^^ Qr, a bichloride solution, 1 to
but slow aggravation. The rapid ^OOO, may be used after carefully
forms of septicemia are usually mor- clearing of anv discharge or blood
tal. Important is the fact, already ^i^^^ ^lay be present. In injuries of
stated, that cases of "abortive" septi- ^j^^ extremity, the latter mav l)e left
cemia are often met with, the symp- j^^ ^ i^^^^h of sodium borate, 20 grains
toms receding after a short period of (j 3 q,^,^ ^^ ^^g ^^^^^^^ ^30 QmO. for
progress. In septicemia occurring several hours, if need be, after clear-
as a complication of celiotomy, the i^g and disinfecting the wound.
chances of recovery are slight. tt j ^ j-« -j -it j •
-^ ^ Hydrogen dioxide, widely used in
The duration of pyemia varies the treatment of infected wounds, dis-
greatly ; it may last from a week to solves catgut and may cause repetition
several months. The prognosis of of hemorrhage, especially if the liga-
,, J. • r 111- tare has been placed in a section of
the disease is unfavorable, however , , , rr ,
vessel that has suffered contusion.
When the intervals between the Hydrogen dioxide should therefore
chills are short and the metastases not be chosen where vessels have
828
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
been ligated with catgut; silk should
be used instead of a ligature. E.
Delorme (Presse med., Oct. 8, 1914).
Good results obtained in treating
desperate cases of infected railway
wounds by 4-hourly irrigation with
hot peroxide solution (2 ounces — 60
c.c. — to the liter — quart) followed in-
stantly by hot phenol lotion (1/2
ounce — 15 c.c. — to the liter — quart),
and the application of hot bichloride
of mercury fomentations (wrung
dry). A septic cavity or cavities
should be converted into 1 large
open sore. When feasible, submer-
sion in warm peroxide lotion once or
twice daily is a useful adjunct.
O'Conor (Annals of Surg., Apr.,
1917).
Lacerated industrial wounds heal
rapidly when treated as follows:
The surrounding skin is cleaned with
gasolene and painted with tincture of
iodine, full strength. Paraffin wax
(see Burns) is immediately applied
to the wound, which is dressed daily
for the first few days, but without
touching the wound proper. An
electric blower is used as a drier.
The writer calls the procedure the
"serum-retaining dressing." It is a
rapid healer. Excessive granulations
and sluggish wounds never occur. F.
R. Williams (Boston Med. and Surg.
Jour., Apr. 4, 1918).
Stitches should be removed in or-
der to reach every sinus that may
serve as a nidus for infectious agents.
When a cavity cannot be reached
conveniently, a syringe may be em-
ployed to wash it out. The safest
method is to irrigate the wound with
the sodium hypochlorite solution
referred to al)ove. • These measures
are sufficient, as a rule, to arrest an
uncomplicated toxemia, since the fo-
cus which supplies the toxins is
eliminated.
The artificial nutrient fluids, such
as Ringer's and Locke's, afford the
best conditions for repair of wounds.
Schiassi's serum is especially useful,
as it contains calcium and potassium
to strengthen the cells, sodium to
combat acidosis, and sugar as a tonic
and nutrient. The formula is 6.5 Gm.
(100 grains) sodium chloride; 0.3 Gm.
(5 grains) potassium chloride; 1 Gm.
(15 grains) fused calcium chloride;
0.5 Gm. (7y> grains) sodium bicar-
bonate; 1.5 Gm. (23 grains) glucose,
and 1000 Gm. (1 quart) distilled
water. Soubeyran (Paris med., Nov.
27, 1915).
For suppurating wounds the writer
recommends the following antiseptic
and healing dressing: Camphor, 5
Gm. (lyi drams); balsam of Peru,
10 Gm. (Zyi drams) ; gomenol, 25
Gm. (6Vi drams) ; ether and liquid
petrolatum or almond oil, of each
500 c.c. (1 pint). This is highly dif-
fusible and prevents adhesion of
dressings. Healing is accelerated.
G. Duchesne (Bull, de I'Acad. de
med., Apr. 3, 1917).
For drainage all that is necessary
is to put something into the tissues
which will keep a passage open,
without leaving an open drain. A
soft piece of folded rubber in an ap-
pendix abscess will allow pus to
come away but will not leave an
open drain by which secondary in-
fection can gain entrance. The two
main principles of civil surgery
taught by the war are, early and
complete operation, and that secon-
dary or mixed infection is worse than
primary infection. Hathaway (Brit.
Med. Jour., June 29, 1918).
During the F.uropean war the
Dakin-Carrel method, applicable to
the treatment of infected, wounds
was devised. (See under Prophy-
laxis). Shortly after its introduction,
Dakin produced a series of substances
which, while highly bactericidal, are
not irritating to the tissues, viz., the
chloramines. Favorable results have
been obtained with these substances
in civil practice.
Dichloramine-T (tolueneparasul-
phondichloramine) was originally
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
829
used in a 5 or 10 per cent, solution in
chlorinated eucalyptol or chlorinated
liquid petrolatum.. Eusol is a pre-
paration of hypochlorous acid first
made by Lorrain Smith, of Edin-
burgh.
Preparation of dichloramine-T by
the Cliattmvay method described as
follows: Chlorinated lime (from 350
to 400 Gm.— 11% to 13V3 ounces) of
good quality is shaken with 2 liters
(quarts) of water on a shaker for
half an hour, and the mixture allowed
to settle. The supernatant fluid is
siphoned off and the remainder fil-
tered. Powdered tolueneparasulpho-
namid, 75 Gm. (Zj/j ounces) (the
crude product may be used), is then
added to the whole of the hypo-
chlorite solution and shaken until
dissolved. The mixture is filtered, if
necessary, placed in a large separat-
ing funnel and acidified by gradual
addition of acetic acid (100 c.c. — 3%
ounces). Chloroform (about 100 c.c.
— SVs ounces) is then added to ex-
tract the dichloramine, and the
whole well shaken. The chloroform
layer is tapped ofif, dried over calcium
chloride, filtered, and allowed to
evaporate in the air. The residue is
powdered and dried in vacuo. The
product sold as chlorazene may be
substituted for the tolueneparasul-
phonamid. Keen ("Treatment of
War Wounds," 1917).
The Edinburgh preparation known
as eusol is made up as follows: To a
liter (quart) of water 12.5 Gm. (3%
drams) of bleaching powder (chlo-
ride of lime) are added and shaken
vigorously. Then 12.5 Gm. (3%
drams) of boric acid powder are
added, and it is again thoroughly
shaken. Upon standing over night
and filtering it is ready for use. The
solution contains hypochlorous acid
0.54 per cent., calcium l)il)orate 1.28
per cent., and calcium chloride 0.17
per cent. It should Ije kept well
corked in dark-colored bottles, and is
effective for 1 month.
The preparation is non-toxic, keeps
the wounds bathed in lymph which
contains antibodies, is practically
painless, dissolves necrotic tissue,
causes wounds to lose their fetid
odor, and is hemostatic. It has been
given intravenously in some cases.
C. H. Gilmour (Can. Jour, of Med.
and Surg., Feb., 1917).
The author's oily solution of dichlo-
ramine-T is held by him to give as
good results in infected military
wounds as, and to have several advan-
tages over, older methods. Thirty-
five c.c. (1% ounces) sufficed to dress
42 wounds. Its use eliminates the
Carrel tubes and reduces the fre-
quency of dressings to once in 24 to
48 hours. It greatly reduces the
amount of cotton and gauze required,
as well as the soiling of bed linen.
J. E. Sweet (Jour. Amer. Med. Assoc,
Sept. 29, 1917).
In extensive experimentation, a
chlorinated parafifin wax oil proved
the most satisfactory solvent for di-
chloraniine-T. It is commonly called
chlorcosane. It is readily prepared
from cheap constituents, has a vis-
cosity between those of olive oil and
castor oil, is bland, dissolves dichlo-
ramine-T up to 10 per cent., and the
solution retains its activity for two
months if stored in amber bottles.
The solution is suitable for use on
wounds and can be nebulized by a
power spray. Dakin and Dunham
(Brit. Med. Jour., Jan. 12, 1918).
The chloramines present all the ad-
vantages of sodium hypochlorite,
which they set free, besides being
much less irritating to the skin and
acting for a longer period. They are
inferior only in their power to dis-
solve necrotic tissues. Chloramine-T
is but slightly toxic, and as a bac-
tericidal agent is 4 times as strong
as sodium hypoclilorite.
In infected wounds a 2 per cent,
solution may be used by intermittent
irrigation every two hours; clean
wounds are thus rai>i(Ily sterilized,
but wounds witli dead tissues, much
more slowly. As a collyrium a 2 to
4 per cent, solution may lie used; in
urethritis, copious irrigations with
a 0.5 per cent, solution; in mouth in-
830
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
fections, washings and gargling with
a 1 per cent, solution, and for the
disinlection of germ carriers, spray-
ing of the nose with a 0.5 per cent,
solution. A 5 per cent, chloramine
gauze, appplied dry, is serviceable.
A paste containing 8.5 per cent, of
sodium stearate and 1.5 per cent, of
chloramine-T exerts a detergent
action in wounds covered with dead
tissue and sterilizes the wound sur-
face. Dichloramine-T is likewise a
powerful antiseptic, but its oily solu-
tion is unstable. Halazone, a third
chloramine product, was prepared by
Dakin for the sterilization of drink-
ing water. One or two tablets of it,
added to a liter of water, sterilize it
rapidly and leave no taste. Guillot
and Daufresne (Paris med., May 4,
1918).
The dichloramine-T oil method of
wound treatment is simple of appli-
cation and the results from it, even
when judged by modern standards,
are not to be disregarded. It is, how-
ever, not indifferent to granulation
tissue nor to the skin edges of wounds,
but has, especially if used for a long
time, a deleterious action on both.
The oily menstruum does not alto-
gether prevent adhesion of dressings
to the surface. On the whole, di-
chloramine-T oil has not yielded the
improvement on Dakin's solution that
was anticipated. Morrison, Hartley
and Bashford (Lancet, Aug. 24, 1918).
Report on 19,040 cases in civil sur-
gical practice treated with dichlora-
mine-T. Its use has definitely im-
proved the results in the primary
closure of traumatic wounds of the
soft tissues, bones, and joints. In
superficial accessible afifections it
uniformly gave better results than
any other germicide. The best re-
sults can only be obtained when
actual chemical contact with the in-
fecting organism is maintained. Un-
like the aqueous hypochlorite (Dak-
in's) solution, dichloramine-T has no
disintegrating effect on catgut. As a
deodorant dressing it is of great
value. Packing putrid, sloughing,
malignant tissues lightly every 6
hours with gauze saturated with a 5
per cent, solution of it overcomes
odors entirely and controls wound in-
fection. (Milit. Surgeon, Sept., 1918).
Experiments showed that the chlo-
rinated antiseptics have no power to
penetrate blood clots and destroy
bacteria therein contained. The fibrin
is probably the resistant substance,
as the plasma and blood cells are
easily dissolved by these antiseptics.
Taylor and Stebbins (Jour, of Exper.
Med., Jan., 1919).
Another innovation introduced
through war practice was the em-
ployment of antiseptic dyes, such as
flavine and brilliant green, in wound
treatment.
Acrifiavine is more active than pro-
flavine and is markedly selective in
its action on streptococci and less so
on staphylococci, while almost with-
out effect on certain other organisms.
It has a toxic action on tissues, but
this is not such as to make its use
inadvisable in solutions of about
1:4000 strength in infections with
streptococci and staphylococci. Its
application should follow thorough
cleansing of the wound with a rap-
idly acting antiseptic such as Dakin's
solution, followed by normal saline.
W. P. Morgan (Lancet, Feb. 16,
1918).
Brilliant green in 1 : 500 solution in
Yi per cent, chloretone used in severe
wounds received for treatment within
two to eight hours after injury. The
dye stains all damaged tissues more
than the healthy and thus aids in de-
termining just how much tissue
should be excised. The drug pro-
duced exuberant, vascular granula-
tions, was painless, rapidly removed
edema and inflammation, and exerted
a favorable antiseptic action. R.
Massie (Lancet, May 4, 1918).
In using flavine in septic injuries,
all affected parts should be reached.
The writer always tries to introduce
the solution by means of a hypoder-
mic or dental syringe. The flavine-
soaked gauze should always be ap-
plied as wet as possible and any cavi-
WOUiNDS, SEPTIC, AND SEPSIS (LAPLACE).
831
ties filled up with the solution. If
applied continuously, a yellowish pel-
licle appears on the wound surface in
a few days. A change should then be
made to eusol, brilliant green, or
magnesium sulphate about the fourth
day, and subsequently a return to
flavine made once every three days.
This method gave great satisfaction.
Savery (Brit. Med. Jour., Sept. 14,
1918).
Humphrey's formula of an emulsi-
fied preparation of acriflavine recom-
mended as a wound dressing: Acri-
flavine, 0.1; thymol, 0.005; white wax,
4.0; liquid paraffin, 76.0, and distilled
water, 20.0. The emulsion is sealed
in small sterile bottles. The addition
of thymol ai^ords better results in
cases with mixed infection. In broken
down tuberculous glands, after scrap-
ing, a little of the emulsion is intro-
duced before the wound is closed.
Stowell (Brit. Med. Jour., Mar. 1,
1919).
Rutherford Morison's bismuth
iodoform ("Bipp") paste is intended
to gradually asepticize wound cavi-
ties and reduce the frequency of re-
dressings. Fairly good reports from
its use have appeared, but it seems
to have been the cause of a number
of cases of bismuth intoxication.
The writer treats infected war
wounds as follows: Under an anes-
thetic, usually open ether, cover the
wound with gauze wrung out of 1:20
phenol, and clean the skin and sur-
rounding area with the same lotion.
Open the wound freely, sparing
nerve trunks and muscular branches
of nerves. Cleanse the cavity with
dry sterile mops, Volkmann's spoon,
etc., and remove all foreign bodies.
Mop the skin and cavity with
methylated spirit. Rub bismuth
iodoform ("Bipp") paste well into all
parts of the wound witli dry gauze,
removing any gross excess: Iodo-
form, 16 ounces (480 Gm.); bismuth
subnitrate, <S ounces (240 Gm.); liquid
paraffin, 8 lluidounces (240 c.c.) or a
sufficient quantity to form a paste
Rub down the paste, in small quan-"
tities at a time, on a slab with a spat-
ula, to insure freedom from grit, etc.
Dress with sterile gauze, and cover
with an absorbent pad. This dress-
ing requires no change for days or
weeks if the patient is free from
pain and constitutional disturbance.
Should discharge come through, the
stained part must be soaked in alco-
hol, and a gauze dressing wrung out
of the same applied as a furthei: cov-
ering. In redressing, the wound is
covered with cotton soaked in alco-
hol, and the discharge wiped off the
surrounding skin. The paste in the
depths is clean and is not disturbed.
Rutherford Morison (Brit. Jour, of
Surg., Apr., 1917).
Two thousand cases of recent
wounds seen in civil practice, with
less than 1 per cent, of infections.
The procedure followed was similar
to that of Morison. Hemorrhage is
controlled by pressure with dry gauze
and twisting off small spurting vessels.
The skin is then cleansed with Y^. per
cent, iodine in benzine, the wound
laid open, dirt removed, and ragged
edges trimmed. Bipp paste is then
applied freely and rubbed thoroughly
into the tissues, the surplus wiped
away, and the skin edges brought to-
gether and held until bleeding ceases.
Buried catgut sutures are avoided and
the edges coapted with adhesive
strips if they gape widely. M. L.
Emerson (Jour. Amer. Med. Assoc,
Jan. 12, 1918).
Following formula for Bipp recom-
mended: Bismuth subnitrate (C. P.,
arsenic-free), 10; petrolatum or white
wax, 10; iodoform, 4; olive oil, 15,
more or less, to suit the wound. The
oil and petrolatum are heated to boil-
ing, the bismuth stirred in, the mix-
ture cooled to 70° C, and the iodo-
form added. Before using, heat again
to 70° C. This paste never proved
toxic. E. Calandra (Policlinico, Aug.
11, 1918).
Among other varieties of wound
treatment which were applied with
more or less success during the war
832
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
and are doubtless destined to 1)e of
some value in civil practice were
hypertonic salt solution, magnesium
compounds, and heliotherapy.
Recent infected wounds, with dead
tissues excised, and opened out Hat,
can be sterilized by sunlight in 48
hours. The first period of insolation
lasts Yz hour, and the second 2'/>
hours. After 6 days such a wound
could be sutured. In deep wounds
and fractures, sterility was ol)tained
in 4 to 6 days. Where the sunlight
is subdued the wounds can be safely
exposed for a long time; where bright
and hot, small progressive doses are
indicated, not exceeding 15 minutes
on the first few days. Leriche (Presse
med., May 24, 1917).
A 1.5 per cent, dilution of Javel
solution (liquor sodae chlorinatae),
containing but 0.042 per cent, of
sodium hypochlorite (12 times less
than the Dakin or Daufresne solu-
tions) was used by the writers in 510
cases of infected wound, including 155
compound fractures and 286 deep
wounds of soft tissues. In the whole
series there were but 3 deaths, includ-
ing 1 from tetanus and 1 from grave
icterus. The diluted Javel solution
showed greater bactericidal power
than Dakin's solution without its irri-
tating property. Cazin and Krongold
(Presse med., Nov. 1, 1917).
Following paste recommended for
infected wounds: Dried magnesium
sulphate, 1^ pounds (700 Gm.);
glycerite of phenol (10 per cent.) or
glycerin, 11 ounces (330 Gm.). The
latter is placed in a hot mortar and
the finely powdered magnesium sul-
phate slowly stirred in. The paste is
very hygroscopic and is kept in tight
jars. It is packed into all crevices of
the wound and a dressing of cotton
and gauze applied. Profuse serous
discharge occurs. When the dressing
is removed after three to eight days
the discharge is seropurulent and the
wound covered with bright red,
healthy granulations. A saturated
aqueous magnesium sulphate solution
is then used and the wound later
closed or grafted. A. E. Morison
(Brit. Med. Jour., Mar. 23, 1918).
Infected wounds healed up very
quickly under hypertonic salt solution
in 120 cases. The indications for it
are infected, infiltrated walls in the
wound cavity. Permin (Hospital-
stid., Apr. 3, 1918).
At all seasons direct sunlight rays
have a positive therapeutic value.
Not to use them is a waste in the
treatmen.t of the wounded whose beds
receive the sunlight. The wound
should be exposed, the window
opened, and a coarse wire screen
used to keep off flies from the wound.
The exposures are for fifteen min-
utes to two hours. The sunlight acts
like a drain, the edematous tissues
pouring out septic fluid, droplets of
which become visible in ten to twenty
minutes. Leo and Vaucher (Paris
med., July 27, 1918).
Hepatic lipoids are prepared by
hashing up liver tissue, dryin-g it well
at 70° C, reducing it to a powder,
and placing it in a Soxhlet apparatus
for ether extraction. With the
lipoids thus obtained, a 5 to 10 per
cent, emulsion in sterilized olive oil
is aseptically prepared. A few mils
of ether are added from time to
time. Before use it is slightly
warmed in hot water and" well shaken.
The emulsion is applied to wounds
every other day, after cleansing with
sterile saline solution. In sinuses
and suppurating cavities it is intro-
duced with a gauze wick or syringe.
Small uninfected wounds heal in
three to five days. Pain and burning
are immediately allayed. In broad,
suppurating wounds, the lipoids soon
arrest suppuration and lead to com-
plete healing in eight or ten days. E.
Savini (Paris med., Aug. 17, 1918).
Good results in wound disinfection
from passing over the wound an air
current laden with antiseptic vapors
such as ether, phenol, camphor, and
oil of geranium. The air is passed
through a flask containing the anti-
septics and introduced into the deep-
est part of the wound through a
rubber catheter. The gaseous injec-
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
833
tion is kept up both day and night.
Infected wounds are completely trans-
formed in 24 to 48 hours, even where
ordinary treatments have failed. The
cost is very slight, and the annoy-
ance of having the bedclothes wet
from continuous liquid irrigation is
avoided. Lavenant (Presse med.,
Dec. 19, 1918).
Specific treatment of infected
wounds by means of serums and
vaccines has been attempted. The
French serum of Leclainche and
Vallee, used locally, seems to have
given especially gratifying results in
this connection.
Specific serum prophylaxis in in-
fected wounds recommended. Poly-
valent serums are used in the form of
dressings or hypodermic injections.
In the hands of Bazy, Quenu, and
others this treatment has given ex-
cellent results. According to Quenu
it checks suppuration and promotes
epidermization. In the case of the
B. pyocyatieus, however, a weak silver
nitrate solution is best. Leclainche
and Vallee (Presse med., Apr. 2.
1917).
Normal beef serum used in the
treatment of wounds. Gauze soaked
with it should touch every part of the
wound and be packed into blind
pockets with dressing forceps. The
dressing should be kept moist. In
dififuse cellulitis, irrigation is prac-
tised by means of a syringe into the
rubber tissue or tubings used in the
dressing. In burns, dressings are
moistened in situ, and changed only
once a day. Fresh wounds are
cleansed, irrigated with serum and
sutured, where it is possil)le to ap-
proximate the skin edges, and a
serum dressing applied externally,
not to be disturbed for three or four
days, unless evidences of sepsis ap-
pear. Serum controls septic proc-
esses. It is harmless to normal tis-
sue, valuable as a prophylactic in
fresh wounds, a marked stimulant of
granulations, and causes no anaphy-
lactic reaction. Shortell, Cotting, and
T. Leary (Boston Med. and Surg.
Jour., Nov. 1, 1917).
A sensitized autovaccine proved
very useful in war wounds. A loop-
ful from the depths of the wound is
incubated on agar for 48 hours, and
all the colonies formed then scraped
off and suspended in 5 c.c. (80 min-
ims) of polyvalent serum. The re-
sulting vaccine has the rapid im-
munizing properties of a prepared
serum and also the durable immuni-
zation of a vaccine. The emulsion is
incubated for lJ/2 hours, centrifu-
gated, the sediment rinsed twice with
saline solution, heated twice for an
hour to 50° or 60° C, and the prep-
aration adjusted to 50 million per c.c.
One c.c. (16 minims) is injected in
the scapular region. Interminable
suppurations are arrested by this
treatment. Julien and Tholozan
(Presse med., Feb. 6, 1919).
Babcock's Method. — -This is a procedure
devised for the immediate sterilization and
closure of chronic infected wounds of
bones and soft tissues. Its technique is
given below (N. Y. Med. Jour., June 21,
1919):—
1. Skin Preparation. — If possible the
wound area should be prepared by daily
shaving, washing with soap and water, re-
moval of all scabs and crusts, and the ap-
plication of 2 per cent, yellow oxide of
mercury ointment for three days preceding
the operation.
2. IVoiind Sterilization. — On the operat-
ing table, the skin is (a) Thoroughly
scrubbed with "B" solution (Liquor cre-
solis comp. 2, turpentine 10, and gasolene
88). ((')) Painted with 3 per cent, solution
tincture of iodine, (c) Sterilized by a sat-
urated zinc chloride solution, thoroughly
injected under pressure into all sinuses
and cavities, applied to all unhealed and
granulating surfaces, and rubbed over the
scar and adjacent skin. Five minutes are
allowed for penetration of the zinc
solution, and great care is taken that every
recess of the wound is reached.
3. Color Delineation. — The following anti-
septic staining solution is then thoroughly
applied to all eroded surfaces and injected
under pressure into all cavities and sinuses:
s— R3
834 WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
Saturated alcoholic solution of be neutralized hy a 10 per cent, solution of
iiiethyloie blue 20 sodium bicarbonate. This is rarely neces-
Caustic potash 3 sary. Voluminous, very wet boric alcohol
Phenol 3 dressings are applied until all tissue re-
Ether, to make 100 action has subsided and healing occurred.
As soon as this has evaporated, the ex- General Measures.— When, notwith-
posed granulating surfaces are left dark ^^^^^,y judicious local measures,
blue black, dry, bloodless on manipula- , . ^ .
.; „ 1 „4. -1 T-1 1 • 4. * general miection, septicemic or p\>-
tion, and sterile. Ihe colormg penetrates ^^ > / ^ / .v
to 3 millimeters. Outside of this is a ^^i<^> occurs, efforts should be made
much wider zone of a vascular, grayish to enhance the autoprotective func-
white tissue, sterilized by the zinc tions of the body at large.
chloride. c ^ ^^ r a.'
. r7 ■ • ^ J ^ . , A rr., bome surgeons speak well of anti-
4. hxctswn of Infected Area. — The entire . ...
field is again painted with tincture of Streptococcic serum, mjectmg 10 c.c.
iodine and a very free skin incision made, (2^^ drams) or more into the w^all of
planned for later closure, and well outside the abdomen, and repeated several
of all scars and sinuses, which are to be times a day. It can do no harm., but
excised as nearly as possible en bloc. The -. . i i • j u^ j i
. , ^ ^ ^ , J , , . Its actual value is doubted bv many.
mstruments are now changed, the skm . -.
margins separated from underlying tissues VaCCines have also been tried, but
by sharp retractors, and dry towels or even Sir A. E. Wright States that
gauze clipped in position to protect all "in cases in which septicemia has
skin margins. The incision is now deep- supervened the results are scarcely
ened to the bone;, the periosteum is freely encourag-ing- "
incised, retracted, protected by towels or °'
gauze, and, beginning some distance from Septicemics should be given plenty
the disease, with sharp chisels the infected <^f fresh air and should be fed as
bone is freely excised with the attached liberally as possible without derang-
overlying skin, scars, and sinuses. Care is ^"^ ^^e digestion. The hot pack is
taken not to divide completely the bone. indicated in septicemia marked by
A blue color indicates that all infected ^'g'^ temperature and erythema and
areas have not been excised, and the in- »" the absence of more serious com-
cision is to be continued. The operator plications, with stimulation before
should work outside the septic focus and ^nd after the pack. Quinine should
use very sharp knives, gouge, and chisels. ^e given in small doses and often,
rather than curettes. If possible, all soft Apparently good results have been
tissues and bone should be removed to at obtained by hypodermoclysis. The
least 1 centimeter external to the blue continued use of autogenous vaccines
coloration. The bone incisions should 's justified. Spinal puncture is indi-
leave smooth, vascularized surfaces with cated for meningismus. Abderhalden
no holes to form "dead spaces." (Amer. Assoc. Immunologists; Jour.
5. Wound Closure.— The muscles and soft Amer. Med. Assoc, July 15, 1916).
tissues are sufficiently freed from the skin, Case of a man wounded in the
bone, and each other, to fit into the bone shoulder, in whom septicopyemia de-
defects. Bleeding is carefully controlled veloped. Blood cultures revealed
with the smallest amount of plain catgut. streptococci, and the patient soon be-
If necessary, a few fine catgut sutures came cachectic. Peptone injections,
unite the deeper tissue layers, and the skin as advised by Depage and Nolf, were
is closed with silkworm gut. In very then given. After the twelfth injec-
large wounds, 1 or 2 small tube drains may tion of 10 c.c. (2^4 drams) on alter-
be left between stitches to drain the nate days, fever completely subsided,
depths of the wound for the first 24 or 48 A 10 per cent, solution of pure, bac-
hours. Only a dry technique is employed. teriological peptone is made in sterile
Excess of zinc chloride may, if necessary, water and heated to 120° C. The re-
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
835
suiting flocculent precipitate is fil-
tered off on a hot filter and the
residual solution put up in 10 c.c.
ampules which are sterilized again in
the autoclave. Subcutaneous injec-
tions are safe. For the first injection
the solution should be diluted. Intra-
venous injections, if used, should be
given very slowly. Potel (Presse
med., July 12, 1917).
Favorable report from intravenous
injection of isotonic sugar solution in
septicemia. The leucocytes jumped
from 5000 or 7000 up to 25,000 in less
than half an hour, remained thus for
two or three hours, and even then did
not decline below 16,000. The re-
action resembled that occurring after
colloid metals — slight fever, chill, and
sweating. The solution also provides
nourishment and brings on diuresis.
The isotonic solution is of 4.76 per
cent, strength with glucose; 10.35 per
cent, with saccharose, and 10.89 per
cent, with lactose. P^rom 300 to 500
Gm. (10 to 17 ounces) are injected at
a dose, up to 1000 or 2000 Gm. (1 or
2 quarts) a day in grave cases.
Enough is injected to keep the leuco-
cytes at about 25,000. The procedure
is also applicable in erysipelas and
rheumatism. Audian and Masmonteil
(Presse med., Nov. 8, 1917).
Attention called to the striking dis-
crepancy between the slow agglutina-
tion of bacteria i>i vitro and their
usual immediate disappearance when
injected into the blood stream. Ex-
periments showed that the bacteria
quickly become adherent to the blood
platelets, which themselves likewise
become agglomerated and diminish in
number. Natural im.munity to a germ
arises merely from this property of
the. platelets. In vitro, platelets show
selective power, promptly separating
staphylococci injected into the circu-
lation from pneumococci, which re-
main free and separate. The various
non-specific agents at times used suc-
cessfully in septicemias, such as col-
loid- metals, peptone, non-specific
scrams, and dead bacteria, all induce,
when injected intravenously, agglu-
tination of the blood platelets and a
leucopenia. P. Govaerts (Presse
med., Nov. 25, 1918).
Twenty-nine cases of proved sep-
ticemia treated with arsphenamine,
with 17 recoveries. The treatment
was beneficial when used early in
septicemias associated with primary
foci easily accessible to surgical inter-
ference. In endocarditis and other
conditions in which secondary local-
izations had become firmly estab-
lished, its use was disappointing. S.
R. Haythorn (Med. Soc. State of
Penna.; Med. Rec, Nov. 23, 1918).
PUERPERAL SEPSIS.
Any of the following septic condi-
tions may develop in the puerperium :
Septic vulvitis, vaginitis, metritis and
endometritis (including sapremia),
salpingitis, oophoritis, or peritonitis
(local or general) ; pelvic cellulitis
(including pelvic abscess) ; septic
thrombosis, and septic pyemia. By
far the most frequent and important
of these, however, are metritis, peri-
tonitis, and pelvic cellulitis.
SYMPTOMS.— The earliest symp-
toms of septic infection appear, as a
rule, about thirty-six hours after the
termination of labor. The initial chill
is frequently mild and overlooked,
but the pulse and temperature afford
more distinct indications. When the
former increases in rate and the latter
rises above 99° to 100° F. at this period,
septic disease may be suspected, and
the suspicion is strengthened if a
laxative fails to eliminate the distur-
bance. If the pulse rises to 120 or 140
in the presence of the temperatures
just mentioned, the condition is likely
to be a severe and dangerous one,
being frequently attended with gen-
eral purulent peritonitis. A temper-
ature of 103° to 104° with a pulse
rate of 115 to 120, even if persisting
for days, indicate rather a septic in-
fection contincd to the pelvic organs.
836
WOUNDS, SEPTIC, AND SEPSIS (LAPLACE).
Along with the clianges in pulse
rate and temperature the lochial dis-
charge may diminisli or completely
cease ; it may also acquire a foul odor.
If the arrest of lochia is due merely
to stenosis at the internal os, the ex-
amining finger may find the body of
the uterus flexed on the cervix and
the constitutional symptoms lessen
upon straightening out of the flexion.
Lochial fetor indicates sapremia, and
is not a necessary accompaniment of
infected uterus. It usually results
from a decomposing portion of plac-
enta, membrane, or blood clot in the
uterus, but may instead arise from
a slougiiing pelvic floor or cervix.
The uterus is relatively large.
Pain is generally not present in
early sepsis, though tenderness on
pressure over a septic uterus will be
noted. Pain becomes pronounced as
the peritoneum becomes involved.
Sharp and radiating pain results from
an exudate in the pelvis, and phlebitis
likewise induces sharp pain.
Where endometritis exists in the
absence of sapremia, the initial chill
is followed by a rise in both the pulse
rate and the temperature, and the
lochial discharge, at first reduced or
suppressed, is likely to become free
or even profuse later on, as the en-
dometrium undergoes necrosis and
sloughs oft'. Tympanites appears
early, pain late, and where treatment
is inadequate, multiple thrombosis and
embolism may follow. Apparent con-
valescence may be interrupted by ex-
tension to the tubes or peritoneum.
Pelvic cellulitis is often an asso-
ciate of peritonitis, but may occur in-
dependently and run its course with-
out inv^olvement of the tubes and
ovaries. In puerperal cellulitis fol-
lowing laceration of the cervix, there
may be a slight chill about the third
or fourth day after labor, and upon
local investigation, a boggy condition
of one or both of the lateral vaginal
cul-de-sacs is noted. The tempera-
ture and pulse rate rise and remain
elevated from a few days to a week.
If suppuration then sets in, the cul-
de-sac softens and the temperature
may drop, while the pulse remains
high. If peritoneal infection coexists,
there may be tympanites and the
pain may radiate over the abdomen.
Severe tubal and ovarian infection
from the uterine cavity may pass into
peritonitis within a few days. If of
a lower grade, the acute symptoms
may soon abate and a chronic sal-
pingitis and oophoritis ensue.
ETIOLOGY. — Puerperal sepsis has
been held to be always exogenous
i.e., due to the introduction of infec-
tion from without. Many now be-
lieve, however that it may be due to
autoinfection from the vaginal secre-
tions. The germ most frequently
causative is the streptococcus, and
next to it come the gonococcus and
staphylococcus. Many other less fre-
quently present organisms, including
the colon, diphtheria, typhoid and
^Velch's gas bacilli, have been found.
DIAGNOSIS.— Apart from the
clinical diagnosis based on the symp-
toms already referred to, bacterio-
logical examinations of the vaginal or
uterine discharges, as well as of the
blood, are of considerable value.
Potocki (1918), in 196 cases of puer-
peral infection, found blood cultures
positive in 91, or 46.4 per cent., in 93
per cent, of the positive cases a single
organism, the streptococcus, was
found. Increasing numbers of an or-
ganism in the blood may warn of an
impending fatal termination.
XANTHOMA.
837
TREATMENT. — The treatment
depends upon the nature of the infec-
tion present. Where there is digital
or other evidence of the retention ot
secundines or clots, the blunt curette
or, if possible, the finger may be used
to remove the offending- material. In
the absence of such retention, rest,
promotion of elimination, and the use
of vaccines or serums to enhance im-
munity are the chief initial indica-
tions. Cold may be applied to the
abdomen in the acute stages and later
hot applications to favor absorption
of exudate. Intra-uterine douches of
antiseptic agents are, as a rule, no
longer considered valuable. Where
infected lochia are being retained,
however, aseptic irrigation of the
uterine cavity is advised. Fresh air
day and night, feeding to the limit of
gastric tolerance, and the use of
stimulant and supporting drugs such
as ammonium carbonate and digitalis
are recommendable. Water should
be given freely by mouth and bowel.
Autogenous vaccine seems to have
been particularly useful in colon
bacillus infections. In extraperi-
toneal pelvic abscess, with fluctua-
tion, the indication is to incise through
the . vagina and treat the condition
aseptically. For an exudate under or
witliin the broad ligament, frequent
hot douches may be tried at the start.
In thrombophlebitis, ligation of the
pelvic veins has sometimes yielded
good results. Peritonitis is treated
by the usual means. (For addi-
tional constitutional measures, see
ante, Treatment under Septicemia.)
Ernest Laplace,
Philadelphia.
WOUNDS, VENOMOUS.
Index.
See
X
XANTHOMA— Xanthoma, xanthe-
lasma, or vitiligoidea, is a connective-tis-
sue growth, in the form of circumscribed,
flat or slightly raised yellowish patches
or tubercles, commonly located on the
eyelids. Two varieties are noted, the
macular (xanthoma planum) and the tu-
bercular (xanthoma tuberosum).
Xanthoma planum is usually found on
the eyelids, in pea-sized or larger, soft,
smooth, flat or slightly elevated, circum-
scribed patches the color of chamois-
leather. The favorite seat is near the
inner canthus. Its development is slow.
Xanthoma tuberosum is usually found
upon the neck, body, or extremities, oc-
curring in patches or tubercles, pin-head
to pea sized or larger, rounded and yel-
lowish. They are slightly elevated and
may be large. Closely set aggregations of
smaller nodules unite to form the larger
patches. The favorite seat of the disease
is upon areas subject to pressure as the
elbows, knees, knuckles, palms, soles, and
buttocks, although occasionally found
upon the face, neck, chest, and other lo-
calities, and more rarely the mucous
membrane of the mouth, pharynx, esoph-
agus, and respiratory tract. Nodules in
the liver occasion jaundice.
The two forms may be present at once,
and when the lesions are numerous the
disease is known as xanthoma multiplex.
ETIOLOGY.— Xanthoma usually oc-
curs in middle life, rarely in childhood.
Women are more often affected. Occa-
sionally there is a hereditary history. In
other cases hepatic disease, rheumatism,
and other metabolic diseases are factors.
PATHOLOGY.— S. Pollitzer differen-
tiates, pathologically, xanthoma of the
eyelids which is a product of a peculiar
degeneration of the muscle-fibers, the only
resemblance to the rarer widespread form
838
X-RAYS AND RADIUM (BIRD).
being the presence of a large amount of
fatt}- sul)stance.
PROGNOSIS.— The lesions tend to be
stationary after reaching a certain size.
TREATMENT. — The disease yields
sometimes to applications of monochlo-
racetic acid; when inefifectual the patches
may be removed by means of the knife,
galvanocautery, or electrolysis; recur-
rence- is rare. Radium and the high-fre-
quency spark have been used with success.
XANTHOMA DIABETICORUM.—
This disease occurs in diabetic patients
and is unrelated to other varieties. It oc-
curs as numerous pin-head to pea-sized
obtusely conical, orange-red papules or
tubercles, located upon the extensor sur-
faces of the extremities, upon the neck,
loins, buttocks, etc., with itching and burn-
ing. The center of the lesion is gener-
ally yellow, with a small reddish areola.
The development of the eruption is com-
paratively acute. It may disappear sud-
denly and reappear later. Obese, florid,
middle-aged men are most subject to it.
PATHOLOGY.— These lesions, accord-
ing to Johnson, are produced by an exu-
dative inflammation with proliferation of
fixed tissue elements (fibroblasts and en-
dothelial or epithelioid cells), in the lat-
ter of which fatty change occurs (xan-
thoma cells), whilst free fat infiltrates the
tissues. Sherwell believes that this dis-
ease is not a true xanthoma, but an in-
flammatory condition resembling it.
PROGNOSIS.— This is generally favor-
able. The lesions tend to recur, but this
depends on the glycosuria.
TREATMENT.— The treatment is that
of the unckrlying glycosuria. I'roper
dietetic and medicinal treatment will cause
disappearance of the eruption. W.
X-RAYS AND RADIUM. -The
therapeutic uses of radioactive agents
having been reviewed in the articles
on the various diseases in which they
are indicated, and also in the Index-
Supplement, this section will be de-
voted mainly to their mode oi action
and the general principles governing
their therapeutic use.
X-RAYS.— Physiological Action.—
The application of the Rontgen rays
in therapeutics is based upon the fact
that living tissues which have been
subjected to the rays undergo certain
definite metabolic changes. These
changes pass successively through
the stages of stimulation, irritation,
degeneration, and destruction, de-
pending upon the amovmt of rays ab-
sorbed by the tissues, and upon the
selective action of the rays for certain
tissues.
In addition to the local effects of
the rays, there seems to be, in some
instances, a constitutional effect as
well. As an instance of this we often
see, in the treatment of certain skin
diseases, improvement of lesions sit-
uated at a part of the body remote
from the area which is being treated.
This is probably due to formation of
antibodies or vaccines.
The X-rays have a selective action
on pathological tissues, and this is
the keynote of Rontgen therapy. The
object is to throw a dose of rays
into the tissues which will cause the
greatest destruction possible to path-
ological tissue, with a minimum of
reaction in the normal tissues. The
more closely the cells of pathological
tissue approach the embryonal type,
the more susceptible are they to the
rays.
At the time a treatment is given,
no sensation, whatever, is caused by
the rays. A slight sensation of
warmth, noticed by some patients, is
due to high frequency discharge from
the tube. A single mild dose causes
no visible changes in the skin. A
somewhat heavier dose will, in the
course of a few days, set up a slight
erythema, probably accompanied by
itching. This irritation is usually
X-RAYS AND RADIUM (BIRD). 839
very transient. If a succession of spoken of as an "erythema dose."
similar doses be applied at intervals This represents the limit of safety to
of a few days, the skin reaction w^ill which a single treatment may be
go on to a stage of bronzing and pushed, and this skin area must be
desquamation. This condition, like- carefully avoided in subsequent treat-
wise, will usually disappear if treat- ments for a period of three or four
ment is discontinued soon enough. weeks, until all reaction has subsided.
Untoward Effects. — After a dan- Apparatus. — Prior to the last three
gerously heavy dose of the rays, in years there was little uniformity in
the course of a few days, a more the apparatus used by different ront-
intense erythema is noted, followed genologists. Some used the indue-
by the formation of vesicles, later by tion coil for the production of their
bullce and, finally, by necrosis and electrical energy, others the high-fre-
ulcer formation, with deep destruc- quency coil, and some few clung to
tion of the tissues. These ulcers, or the static machine. The tubes used
X-ray burns, are very painful, and with these different forms of appa-
show very little tendency to heal, ratus were of many types and ex-
This is explained by the fact that the ceedingly unstable as to vacuum and
intima of the blood-vessels is thick- penetration. At the present time,
ened and swollen, there is prolifera- however, rontgenologists in this
tion of the endothelium, and the country, at least, are practically all
lumen may be completely blocked, doing their treatment work with one
It is a case of starvation of the part of the standard types of interrupter-
by loss of blood-supply. less transformer and the Coolidge
An important feature of the X-rays tube.
is that their effects are cumulative, The Coolidge tube, named for its
and much the same result as the inventor, Dr. William D. Coolidge,
above may follow a succession of of Boston, a physicist, has revolu-
small doses, none of which is in itself tionized the technique of radiothe-
harmful. If such a cumulative action rapeutics. This tube is devised to be
did not exist, and the effect of each entirely free of gas, and has a
dose passed off rapidly, mild expo- vacuum 1000 times greater than the
sures continued over a considerable ordinary tube, so that it is impossible
time would accomplish nothing. to pass a current through it in the
Therapeutic Dosage. — Inasmuch as ordinary way, even with the most
many pathological conditions are ag- powerful apparatus. Both anode and
gravated rather than benefited by too cathode are made of tungsten. The
small a dose of X-rays, it is our ob- cathode consists of a spiral tungsten
ject to give as heavy doses as pos- filament, which, when electrically
sible without crossing the danger line heated by a storage-battery circuit,
and producing a severe reaction. As gives off the stream of negative elec-
the skin is the most sensitive normal trons required for the generation of
tissue to the effect of the rays, the the X-rays. A molybdenum sleeve
maximum dose that can be thrown around the spiral filament is used to
into the tissues and produce simply focus the cathode stream upon the
a mild and transient erythema is target. The number of electrons
840
X-RAYS AND RADIUM (BIRD).
given off from the cathode is reg-
ulated by changing the temperature
of the tungsten spiral. This is done
bv means of a rheostat in the storage-
battery circuit.
The technique of operating one of
the Coolidge tubes is as follows :
The primary current from the stor-
age battery is turned on and the
tungsten tilament in the cathode is
allowed to heat up. While in this
condition the high-tension current
from the interrupterless transformer
is delivered to the tube terminals in
the usual way. By regulating the
degree of heat in the tungsten spiral,
bv means of a rheostat in the battery
circuit, anv degree of hardness and
any quality of rays may be obtained.
One mav be working one minute
with the tube so soft that the blood-
vessels in a baby's arm will show in
a radiogram, and by a quick adjust-
ment of the rheostat, rays so hard
and penetrating are obtained that a
radiogram of a skull may be made to
appear as though entirely devoid of
soft parts. The remarkable advan-
tage of this tube to the rontgenolo-
gist lies in the immense output for
deep therapeutic work. It is quite
practicable, with this tube and a good
transformer, to give a full erythema
dose of rays in one minute. A\'ith
this tremendous reduction in the time
required to give a full treatment,
however, the danger of producing X-
ray burns is much greater, unless
extreme caution be used in estimat-
ing proper dosage.
Estimation of Dosage. — ]\Iany
methods have been introduced for
accurately determining the dose of
X-rays absorbed in a given case.
The parallel spark gap and the mil-
liamperemeter reading are invaluable
guides as to the hardness of the
tube, but they do not estimate the
dosage of rays absorbed by the tis-
sues. Ingenious methods to gauge
this dosage have been introduced
by Holzknecht, Sabouraud, Kienbock,
Bordier, Hampson. and others.
The method most used in this
country is that introduced by Sabou-
raud and X'^oire, and modified by
Hampson. The principle depends
upon the action of the X-rays upon
a disk of paper coated with platino-
barium-cyanide. These disks are of
an apple-green color when fresh, and
under the action of the rays they
change to a yellow, ^ orange, and
finallv a brown color. The Hampson
radiometer, designed for the pur-
pose of reading these various color
changes, consists of a wheel, around
the periphery of which is arranged a
row of disks, 25 in number, of differ-
ent tints. The initial or zero tint is
the color of an unexposed Sabouraud
pastille. Each higher number repre-
sents one of the tints assumed by a
pastille under the continued action of
X-rays. This wheel revolves back of
an outer case, in which is cut a small
aperture through which the tints can
be successively viewed, one at a time,
and compared with a pastille which
has been laid on the skin of a patient
in the direct path of the X-rays dur-
ing a treatment. This comparison
must be made In^ artificial light,
either a gas-jet or an incandescent
carbon light. A full erythema dose
is obtained when a pastille has turned
four divisions of the Hampson scale.
In using this technique the tube is
brought to a distance of about six
inches from the patient's skin. Pro-
jecting from the diaphragm of the
tube-holder is a cylinder of lead glass
X-RAYS AND RADIUM (BIRD).
841
about two inches in diameter and
three inches long-. This serves to
confine the rays to a skin area two
inches in diameter. By moving- the
tube-stand after an erythema dose
has been given, a fresh skin area is
brought under the outlet of the cyl-
inder and a second erythema dose
administered. A series of treatments
may be given in this way, being care-
ful that the circular areas treated do
not overlap. In deep uterine therapy,
for instance, 10 or 12 times the ery-
thema dose may be directed to the
uterus by moving the tube-stand to
cover as many two-inch circles, and
changing the angle of the apparatus
each time, so that the rays are cross-
fired from each area treated to their
common destination.
Filters. — If the soft, non-penetrat-
ing rays, are filtered out, a much
larger dose may be administered with
less danger to the skin, and much
experimentation has been carried out
to determine the best substances for
this purpose. A combination which
has been found very efficient in this
respect is a plate of aluminum, 3 mm.
in thickness, placed in the tube stand
immediately beneath the tube, and a
pad of sole leather, about 10 mm. in
thickness, placed immediately on the
skin surface.
Therapeutic Uses. — In this connec-
tion and as stated by Pirie (Int. Abst.
of Surg., Aug., 1915) all cells can be
stimulated, reduced in function or in
growth, or destroyed, and we must
decide which action of the rays is the
one we desire to use. Under these
three headings can be classified the
diseases influenced by X-rays as fol-
lows : —
Diseases which benefit by X-ray stim-
ulation: Arthritis deformans (early),
eczema, leukemia, lung tuberculosis,
lupus, neuralgia, pruritus, psoriasis,
sciatica, and tuberculous glands.
Diseases zchich benefit by reduction
of tissue arf/T';7v.- Acromegaly, car-
cinoma, exophthalmic goiter, high
blood-pressure, hyperidrosis, hyper-
trophied prostate, hypertrophied thy-
mus, menorrhagia, myoma uteri,
ringworm, and rodent ulcer.
Diseases ti'hich benefit by destruction
of cells: Carcinoma, hyperidrosis, hy-
pertrichosis, myoma uteri, nevus,
rodent ulcer, sarcoma, and warts.
The reader is referred to each in-
dividual disease in the general vol-
umes and in the Index-Supplement
for additional details and indications.
RADIUM. — The property of radio-
activity was discovered by Professor
Hen+y Becquerel, of Paris, in 1896,
while conducting a series of in-
vestigations on the phosphorescence
of uranium salts. Two years later
Madame Curie, also of Paris, iso-
lated from pitchblend, a substance
which she called radium. Radium
possesses to a higher degree than
any other known substance the prop-
erties known as radioactivity. These
properties are four in number,
namely : —
1. Liberation of heat.
2. Liberation of light.
3. The power of ionization.
4. The production of certain rays
which pass through opaque bodies,
make impressions on photographic
plates and produce various biological
eft'ects.
Physiological Action. — The biolog-
ical eft'ects of radium are similar to
those of the X-rays, and the same
underlying principle governing the
therapeutic use of X-rays applies in
radium therapy, namely, that patho-
842
X-RAYS AND RADIUM (BIRD).
logical tissues having an inferior re-
sisting power, are attacked more vig-
orously by the rays than are the cells
of normal tissue. Jn cases where the
value of X-rays and radium are equal,
the enormous cost of the latter makes
it the less desirable therapeutic agent.
Therapeutic Uses. — Tlie chief
points which influence the choice ot
radium are: (1) The convenience
with which it may be applied to sev-
eral of the internal organs. (2) The
ease with which it may be applied to
the interior of a tumor mass. (3)
The fact that it can be used with pa-
tients who are not in a condition to
be moved to a special X-ray depart-
ment.
The bulk of radium is so small that
it is possible, by the aid of various
forms of applicators, to introduce it
under the eyelid, in the auditory
canal, in the nose, mouth, throat,
esophagus, stomach, rectum, vagina,
and uterus. There are times when
pathological conditions in these loca-
tions can be treated by radium when
it would be difficult for the X-ray to
produce the same therapeutic result
without great destruction of tissue.
In malignant tumors the same prin-
ciple obtains, and sterile tubes of
radium can be introduced into the
tumor mass through incisions.
As regards the results obtained
they are fairly represented by A. E.
Pinch's report based on 860 cases
treated in one year of various disor-
ders at the Radium Institute of Lon-
don. Epithelioma if flat, superficial,
and accompanied by little or no ulcer-
ation yields satisfactor}^ results. The
results are also quite good in the
ulcerating forms, but require much
longer treatment and leave consider-
able scar formation. Treatment of
epithelioma of the mucous surfaces,
on the other hand, is usually disap-
pointing, though some temporary re-
lief may follow. According to some,
in skin cancer galvanic cauterization
should precede the use of radium.
In inoperable carcinoma of the
uterus radium will often bring
about results which cannot be ob-
tained by any other mode of treat-
ment, checking the rate of growth, or
arresting it, and in some cases even
converting the case into an operable
one. In cancer of the rectum radium
relieves the symptoms and usually re-
tards the rate of progress. In car-
cinoma of the breast also there are
encouraging results, especially in the
sclerotic forms of growth. Of all
forms of malignant disease rodent
ulcer is by far the most amenable to
the action of radium. Superficial
naevi are usually quite successfully
treated by radium, as is also the case
Avith tlie cavernous forms. Keloid
responds with most admirable results.
Parotid tumors are also particularly
amenable to treatment, even when
malignant. Lichenification of the
skin and some forms of pruritus are
quickly cured, while psoriasis is also
cured, but shows a tendency to later
return. Lupus vulgaris does not re-
spond to radivmi as well as it does to
Finsen light. Lastly, the drinking of
solutions of radium emanation is fre-
quently very beneficial in arthritis de-
formans.
GusTAvus C. Bird,
Philadelphia.
YAWS.
YELLOW FEVER.
843
YAWS. — Yaws is a tropical specific
infectious and contagious disease caused
by a Treponema {T. pertenue), and charac-
terized by papules, tubercles, and tumors
having the appearance of raspberries.
SYNONYMS.— Yaws (Br.), pian (Fr.),
bubas (Venezuela and S. A.), frambcesia
tropica (Ger., Ital.), etc.
SYMPTOMATOLOGY. — Three stages
are recognized.
The Primary or Prodromal Stage. —
After a period of incubation, varying be-
tween 2 and 4 weeks, marked by malaise,
rheumatoid pains, headache, and moderate,
irregular fever, the primary lesion appears
at the seat of the inoculation, which is al-
ways extragenital. The primary lesion is
a papule, becoming moist after 1 week,
and developing a yellowish secretion
which forms a dry crust. The papules
may be multiple and coalesce. The crust
removed, an ulcer, with clean-cut edges
and a granulating fundus, is left. This
ulcer may heal, leaving a whitish scar,
which may become pigmented; or it may
become a granulomatous mass, resembling
the granulomata of the secondary stage,
but frequently larger. This large, single
nodule is called "mother yaw," "maman
pian," or "buba madre," and may be sur-
rounded by several smaller granulomata.
The primarj^ sore is never indurated; it
may be painful at first, but later is quite
painless. The neighboring lymphatic
glands may become enlarged and indu-
rated, but they do not suppurate. The
primary lesion may heal before the gen-
eral eruption begins, but not as a rule.
The Secondary or Granulomatous Stage.
— The general eruption usually begins 1
to 3 months after the appearance of the
primary lesion, being preceded by malaise,
headache, and severe pains in the joints,
muscles, and bones. There may be fever
of intermittent type. Minute, rounded
papules, pin-head in size, appear on vari-
ous parts, persist for many weeks and
then disappear, leaving occasionally some
furfuraceous patches; others become en-
larged, coalesce, and acquire a dark areola
in natives, a reddish one in Caucasians.
The tertiary stage is marked by gum-
matous-like nodules and deep, ulcerative
processes, which may develop in any tis-
sue. Osseous nodes and muscle contrac-
ture are common.
INFECTION.— Yaws is usually con-
veyed by direct contact. Insects, espe-
cially flies, maj^ carry the disease. The
disease is apparently not hereditary.
TREATMENT. — Potassium iodide,
atoxyl, sodium cacodylate, quinine caco-
dylate, and mercury have been used with
some success, but salvarsan and neosal-
varsan are best; cure often follows a single
dose. These remedies may be given by
intramuscular, subcutaneous or intraven-
ous injection, or by the mouth in alkaline
solution. Castellani recommends the in-
tramuscular and intravenous injections.
The intramuscular injections are given
in the buttocks, after painting with iodine.
The adult dose of salvarsan is 0.30 to 0.50
Gm. (5 to 7y2 grains); in children, 0.03
to 0.04 Gm. (^ to % grain) for each year
of age, or 0.008 Gm. (% grain) for each
kilogram (2.2 lbs. av.) of weight. The
injection, in the same dose, may be re-
peated after 2 or 3 weeks. For the man-
ner of preparation of the solution to be
injected, see Dioxydiaminoarsenobenzol,
vol. ii.) A suspension of the drug in olive
oil (sterile) may be given subcutaneously
in the interscapular region. The intra-
venous injections are made as in sj'philis,
in dose somewhat smaller than those
mentioned above.
PROPHYLAXIS. — Abrasions of the
skin should l)e properly treated with anti-
septics. Patients with yaws should be
isolated until cured, their skin lesions be-
ing properly dressed, so as to prevent
them from spreading infection. The dwell-
ings should be thoroughly disinfected.
YELLOW FEVER.-Time having
fortunately sustained the view of I'inlay,
that the mosquito was the intermediary of
infection of this disease, a fact ultimately
demonstrated by the labors of Reed, Car-
roll, Agramonte, and Lazear, it is fittingly
relegated to an inferior position, from the
standpoint of relative importance, in the
nosology of disease.
844
YELLOW FEVER.
Having taken a small part in its
undoing, I find it the source of great-
est satisfaction to witness the final
passing away of this terrible scourge.
A. Agramonte (Sanidad y Beneficen-
cia, January, 1916).
SYMPTOMATOLOGY.— As given in
preceding editions by Surgeon Murray, of
the United States Public Health Service,
the symptomatology of yellow fever is as
follows: —
The patient may complain of headache
and malaise, with some gastric distress.
A chill, or chilliness, is usually complained
of. Distress in the early morning is a
rule. Fever of 101° to 103° F. (38.3° to
39.4° C), with pulse of 110 to 120; cutting
pain through the forehead, with aching
eyes; fullness of the latter with some pain
and suffusion, generally with injection,
may be observed. The back and thighs
are painful in a severe case; there is some
soreness in the mildest cases. Severer
cases will also have pain in the back of the
neck and in the calves. By pressing firmly
and deeply over the region of the gall-
bladder, one will generally elicit a sound
resembling a squeak.
The face is full and less mobile than in
health, with a fullness of the upper lip.
The cheeks are more or less dusky, the
hue depending also on the patient's
color; they are sometimes faintly purplish.
Sweating diminishes these facial signs in
a few hours. There is congestion of the
sclerotics, which increases, until after 36
hours, when they tend to become yellow-
ish; in children, the eyes remain pearly.
Frequently pressure on the eyeballs will
cause pain, especially in bad cases.
Primary complete constipation or semi-
constipation is always present. The su-
perficial circulation is abnormal and slug-
gish; the skin may be streaked by passing
the finger over it or paled for a quarter
of a minute by pinching; this is a good
sign, especially after the disease has pro-
gressed 36 hours. The skin is moist, as a
rule, and stays so to the end, whether
drugs are given or not. Yellowness of the
skin is not to be looked for early. Unless
there is nausea or headache, the patient
lies quietly.
There is less rapidity of the pulse than
the febrile condition present warrants,
judging from lung disorders and enteric
fever. An inveterate smoker's pulse may
become reduced when the amount of to-
bacco used is diminished. After 2^ or
3 days the pulse falls below 70 and later
on lower yet, being out of all proportion
with the temperature (Faget's sign); fright
and irritation cause the slowness to pass
unobserved. The pulse should be counted
without the patient's knowledge.
The above signs are sufficient to warrant
isolation, even if there is no known case
of the fever within many miles.
After 60 hours there should be some
albumin in the urine, but it may be absent.
Anuria may exist, but in women this is not
a reliable sign, while in children the urine
is sometimes difficult to obtain. Albumin
should not be confounded with mucin.
Other symptoms should not be treated
lightly because no albumin is found in the
urine. At this stage some brown mucus,
or black discharges, or "bismuth" stools
may be looked for: early in mild cases —
late sometimes in severe ones. Mild cases
sufifer from distaste for usual food only,
there being anorexia from the beginning.
The vomiting of the last food taken is
usual, and bile is voided early if the early
nausea is not checked, but no bile will be
vomited during the 36 hours following
proper bowel movements.
After vomiting the last food taken and
a little bile, the vomit usually becomes
white, and remains so until blood oozes
into the duodenum or stomach: the source
of the black vomiting. Hiccough and
retching appear, and the black fluid may
be heard regurgitating through the pylorus
into the stomach.
Fulminant Cases. — Sometimes the symp-
toms appear in such rapid succession as to
suggest that the attack will be necessarily
fatal. Walking cases are also common.
Murray refers to the case of a man who
suflfered from headache 3 days while on
duty, black vomit occurring while he was
on the stairs on the way to his death-bed.
DIAGNOSIS.— The diagnosis of yellow
fever is usually easy; no febrile disease
has as many pathognomonic signs. The
early albuminuria, epigastric tenderness;
the disparity between the rise of tempera-
ture and the pulse, the latter remaining
low, and even declining {Faget's sign)
YELLOW FEVER.
845
when the jaundice occurs and the black
vomit are all typical. Castellani and
Chambers state that the most important
diseases from which it is to be differen-
tiated early are dengue, which may be
recognized by the absence of albuminuria,
the preliminary rash and leucopenia; suh-
tcrtian malaria, identifiable by the parasites
in the blood and, in some cases, the typical
4-hourly temperature chart; hlackzvater
fever, characterized by hemoglobin in the
urine and the increase in mononuclears;
relapsing fever, recognized by the parasites
in the blood and the leucocytoses.
ETIOLOGY.— The natural habitat of
yellow fever may be said to be the west-
ern coast of Africa, the West Indies, Cen-
tral and South America down to the 40°
of latitude. It does not prevail in Japan,
China, or India, or anywhere in Europe,
nor does it naturally occur anywhere on
the mainland of the Northern Continent
of the Western Hemisphere. Yet it may
be carried almost anywhere. Of all ports,
Havana was, for a long time, the most
dangerous to the United States, both be-
cause of its propinquity and because, under
the Spanish rule, all sanitation was disre-
garded. During the American occupancy,
however, subsequent to the Spanish-
American War, Havana was freed from
this disease by active sanitary and quaran-
tine measures.
This great step, which has saved more
lives already than the Spanish-American
War (styled by Mr. Taft when President,
the "medical war") itself cost, was mainly
due to the discovery of the role of the
mosquito as agent of transmission of the
disease. This fact, urged for many years
(1881) by Carlos Finlay, of Havana, was
ultimately confirmed experimentally in
19(X) by Walter Reed and James Carroll,
of the L^nited States Army; Aristide Agra-
monte, of Havana, and Jesse W. Lazear,
who died of yellow fever after an experi-
mental bite from an infected mosquito.
Briefly, the causation of the disease proved
to be an ultramicroscopic animal parasite
capable of living in the blood of man and
in the body of Stegomyia fasciata, which
this insect could, through its bite, transmit
to man. All but the very young are sus-
ceptible to the disease; indeed, it is through
the latter that it is perpetuated, since im-
munity is conferred by the first attack.
Negroes and Creoles are comparatively im-
mune, however, without acquiring the dis-
ease. Aliens or strangers visiting a con-
taminated area are particularly liable to
infection.
PATHOLOGY AND PATHOGENE-
SIS.— Surgeon Eugene Wasdin has well
shown that post-mortem findings are not
sufticiently distinctive to warrant a diag-
nosis from them alone. Some clue to its
identity is afforded, however, by the mixed
hepatogenous and hemorrhagic jaundice,
the red-tinted serum due to destruction of
erythrocytes, the diffusion of the hemo-
globin in the plasma, and the fatty de-
generation and necrosis between the hep-
atic cells. We have here, from by view-
point, the main clues to the nature of a
morbid process which can hardly be dupli-
cated in any other acute febrile infection:
a rapidly progressive hemolysis and au-
tolysis due to an intense autoprotective
reaction incited and perpetuated by the
specific virus of the disease.
[This view, which I advanced in 1907
("Internal Secretions," p. 1873, vol. i), has
recently, as far as autolysis of the hepatic
cells is concerned, been advocated by
Colonel Hunter. See A. Balfour, Lancet,
May 20, 1916. S.]
PROGNOSIS.— This depends upon the
intensity of the morbid process and the
resisting power of the patient. The high-
est mortality averages 87 per cent. Alco-
holism, squalor, excessive fatigue, star-
vation, and other debilitating conditions
enhance the mortality. Fortunately, the
discovery of the mosquito has afforded the
means of preventing the transmission of
the disease, as it has, for instance, in the
Isthmus of Panama, thanks to the labors
of Surgeon-General Gorgas.
PROPHYLAXIS.— This reduces itself
to adequate protection against mosquito-
bites. It consists in: screening of the bed,
verandas and windows; destruction of
tnosquitoes by removal of breeding places,
oiling of surface waters, screening of cis-
terns, Inish clearing; drainage flushing, ab-
solute clealiness of all backyards, streets,
cellars — imposing severe fines if necessary;
isolation of cases, suspected cases, and
contacts, in screened quarters; prompt dis-
semination of literature concerning the
846
YOHIMBINE.
disease and individual protection against
infection.
TREATMENT.— Although the general
impression prevails that nothing will abort
the disease, it is probable that the use at
the earliest possible moment of the late
Surgeon-General Sternberg's advice to
give mercuric bichloride, Kjo grain (0.001
Gm.), and sodium bicarbonate, 7^ grains
(0.5 Gm.), every hour, will do so by en-
hancing, when it is still time, the autopro-
tective resources of the body. A hot mus-
tard foot-bath and saline purgative do
much to relieve the distressing headache.
Calomel is preferred by some. Antipyrin
may also be used for the same purpose, or
acetphenetidin, if needed. The gastric
irritability may be oflfset with cerium
oxalate, but if persistent, cocaine hydro-
chloride, in doses of J4 grain to ^ grain
(0.016 to 0.03 Gm.), every hour or two,
often proves efficient. Small quantities of
carbonated beverages, as Vichy or very
dry champagne, administered ice cold, will
often prove of service. Creosote carbonate
has also been highly recommended. Con-
siderable relief is also derived from the
application to the epigastrium of a lini-
ment composed of olive oil and menthol.
It is preferable to withhold food or give
only cracked ice at first, then to begin
with milk and Vichy, followed by a bland
diet when the patient is better able to take
nourishment. Hunter, and more recently
Balfour {Lancet, May 20, 1916), hold that
the autolytic destruction of liver-cells
calls for a supply of protein (peptonized
enemata of beef-tea, eggs, etc.), and sugar
given by mouth or enema in 5 to 10 per
cent, solution to compensate for the
hepatic failure. When I pointed out, in
1907, that autolysis was the active patho-
genic factor in the process, I urged the
use of saline solution intravenously to in-
crease the fluidity of the blood. This
would not only enhance the elimination of
the pathogenic toxin, but the antitoxin
process as well. It may also be used for
high enemas. Spw^nging and cool baths are
also recommended. S.
YOHIMBINE. -Yohimbine (CosH.-io-
X2<^^4) is an alkaloid found in the bark
of the yohimbehe tree, indigenous to Ger-
man West Africa. It occurs in silky
needles, readily soluble in alcohol and
ether, almost insoluble in water. Its hy-
drochloride, being water-soluble, is mostly
used, in doses of M2 grain (0.005 Gm.),
.!^i\en 3 times daily.
PHYSIOLOGICAL ACTION. — In
large doses the drug first stimulates and
then paralyzes the central nervous sys-
tem, especially the cardiac and respiratory
centers. The kidneys are unafifected.
Smaller doses produce a dilatation of the
blood-vessels of the skin and mucous
membranes. Coincidently, the sexual ap-
paratus becomes congested and erections
ensue, probably caused by a direct stim-
ulation of the erection center in the lum-
bar cord; a sensation of heat and tension
in the testicles and scrotum is noticed.
UNTOWARD EFFECTS.— After large
or frequently repeated doses, vertigo oc-
curs, with congestion of the ocular ves-
sels, salivation, weakness, chilliness, and
sweating. D'Amato reports cardiac palpi-
tation and sleeplessness; these occurring
without erections. Loss of appetite, gas-
tric pain, and intestinal colic, and after
very large doses a condition of excite-
ment, resembling that due to alcohol, with
talkativeness, have been noted.
THERAPEUTIC USES. — Yohimbine
possesses anesthetic properties. In a 1
to 2 per cent, solution the hydrochloride
has been used in ophthalmology, rhinology
and otology.
Its chief use has been in sexual neuras-
thenia and impotence in the male, and in
female disorders marked by a conditio;! of
pelvic anemia, as well as in cases of steril-
ity due to genital infantilism. It should
be used with care in nervous persons and
kidney affections, and is contraindicated in
chronic inflammations of the pelvic or-
gans, endometritis, and chronic prostatitis.
ZINC (WITHERSTINE).
847
ZINC— Zincum (U. S. P.) is me-
tallic zinc in the form of thin sheets,
in globules (the size of No. 7 shot
for arsenic test), granulated pieces,
thin pencils, or as zinc dust.
Acetate of zinc occurs in white,
lustrous plates, soluble in 2.7 parts of
cold and in 1.5 parts of boiling water,
and in 36 parts of alcohol.
Carbonate of zinc (precipitated) oc-
curs as an impalpable, white powder,
of variable composition and insoluble.
Chloride of zinc (butter of zinc)
occurs as a white, deliquescent pow-
der, and is soluble in 0.3 part of
water, in alcohol, and also in ether.
The official solution of zinc chloride
occurs as an astringent, sweetish acid
liquid, containing 50 per cent, by
weight of zinc chloride. Canquoin's
paste is made by mixing zinc chloride
with flour and water in a ratio of
1 part of the chloride in 6 parts
(weakest) to 1 part in 3 (strongest).
When used, 10 or 15 drops of water
are added. The stronger paste may
be cvit into pointed strips or arrows
and dried before being used (Maison-
neuve).
Oxide of zinc occurs as a white,
amorphous powder, having the prop-
erty of absorbing carbon dioxide from
the air. It is soluble in dilute acids,
ammonia, and in ammonium carbo-
nate. The official ointment contains
20 per cent, of zinc oxide.
Phenolsulphonate (sulphocarbolate)
of zinc occurs in transparent prisms,
which are soluble in 1.7 parts water
and in alcohol. Tt is antiseptic, as-
tringent, and is employed externally
in 0.5 to 1 per cent, watery solution.
Stearate of zinc occurs in very fine
white powder, insoluble in water, al-
cohol, etc., but readily miscible with
oil and fats. Used as an antiseptic
powder and to make the ointment.
Sulphate of zinc (white vitriol ;
zinc vitriol) occurs in colorless, rhom-
bic crystals, having an astringent,
metallic taste ; they effloresce in dry
air. It is soluble in 0.6 part of cold
and in 0.2 part of boiling water, and
in 3 parts of glycerin. Villate's solu-
tion for treating caries consists of:
sulphates of copper and zinc, of each,
15 parts; solution of subacetate of
lead, 30 parts; vinegar, 300 parts.
Valerate of zinc occurs in white,
glistening laminae, having a valeri-
anic acid odor and a sweetish taste,
and decomposing on exposure. It is
soluble in 40 parts of alcohol and in
100 parts of water.
PREPARATIONS AND DOSES.
— Irritant (Soluble). — Ziiici acctas,
U. S. P. (acetate of zinc). Dose, 2 to
6 grains (0.13 to 0.4 Gm.).
Zinci chloridum, U. S. P. (chloride
of zinc).
Liquor cinci chloridi, U. S. P. (solu-
tion of zinc chloride — 50 per cent.).
Zinci phcnolsnlphonas, U. S. P. (sul-
phocarbolate of zinc). Dose, 2 grains
(0.125 Cm.).
Zinci sulphas, U. S. P. (sulphate of
zinc). Dose, 1 to 3 grains (0.065 to
0.2 Gm.) ; emetic, 15 grains (1 Gm.).
Zinci valeras, U. S. P. (valerate of
zinc). Dose, Y^ to 2 grains (0.03 to
0.13 Gm.).
Mild (Insoluble). — Zinci oxidum;
U. S. P. (oxide of zinc). Dose, 1 to
5 grains (0.06 to 0.3 Gm.).
Ungucntuin cinci oxidi, U. S. P.
(zinc ointment ; zinc oxide 20 per
cent.).
Ungucntum zinci stcaratis, N. F.
(zinc stearate 50 per cent.).
Zinci carhonQ'S prcrcipitatus, U. S. P.
848
ZINC (VVITHERSTINE).
(precipitated carbonate of zinc).
Dose, 1 to 2 grains (0.06 to 0.13 Gm.) ;
emetic, 10 to 20 grains (0.6 to 1.2
Gm.).
Ziiici stcaras, U. S. P. (stearate of
zinc) ; used externally.
Zinciim, U. S. P. (metallic zinc).
PHYSIOLOGICAL ACTION.—
The common action of the soluble
salts of zinc is astringent and irritant.
The chloride, on account of its high
diffusion power and great affinity for
water, is the most energetic of all.
When the cuticle is removed, it pene-
trates the tissues and destroys them
for a considerable depth, producing at
first warmth, then burning pain for
seven or eight hours, by which time
a white eschar is formed which sep-
arates in seven to twelve days
(Ringer). The chloride is a corrosive
poison, and is strongly disinfectant.
The sulphate has a more superficial
action upon the tissues. In small
doses it increases for a time the ap-
petite and digestion, but later causes
catarrh, nausea, and anorexia.
The soluble salts of zinc form in-
soluble compounds with albumin,
condense the tissues, and contract the
blood-vessels. They are stimulant
and astringent, lessen secretions, and
promote reparative action.
The carbonate and oxide, almost
insoluble in the animal fluids, are but
slightly astringent.
The carbonate in large doses pro-
duces some nausea and vomiting.
The sulphate, in full doses, acts more
speedily, is a safe emetic, producing
little prostration or nausea, and, as it
generally empties the stomach in
one complete evacuation, is the best
emetic in cases of poisoning (Ringer).
It excites vomiting even when in-
jected into the blood or mixed with
albumin. In large doses it is an
irritant poison. The oxide, being in-
soluble, exerts but little action upon
the stomach.
Zinc salts are eliminated slowly
by the urine. The chief part may be
recovered from the feces, being prob-
ably excreted by the intestinal mu-
cous membrane and with the bile.
Experimenting in rabbits, the auth-
ors found the gastrointestinal tract to
be the chief organ of elimination of
zinc. From Yz to Yz the amount given
was recovered from its contents and
the feces in two to three days. Ap-
preciable amounts were recovered
from the liver. It may be either stored
in the skin or eliminated through it.
Salant, Rieger, and Treuthardt (Jour.
of Biol. Chem., May, 1918).
ACUTE POISONING BY ZINC
SALTS. — The chloride is an irritant
poison, causing heat and a sense of
constriction of the throat, a strong
metallic taste, a burning pain in the
stomach, nausea, vomiting, profound
pulse depression, cold clammy sweats,
cramps of the leg-muscles, etc. Oc-
casionally nervous symptoms follow.
Zinc sulphate in large doses causes
vomiting, colicky pains, diarrhea, etc.
Case of a young Il-para with
chronic endometritis. In 5 days the
physician in charge swabbed out the
uterus three times with a 10, 15, and
30 per cent, alcoholic solution of zinc
chloride. Abdominal symptoms then
developed, vomiting, nausea, pain, in-
somnia, twitchings and symptoms of
nephritis; after various remissions,
she succumbed, 63 days after the cau-
terization. Buttersack (Monats. f.
Geb. u. Gynak., Jan., 1909).
CHRONIC POISONING.— This is
uncommon. The symptoms are mus-
cular palsies, neuritis, and cachexia
(Hare). Zinc-smelters, according to
Schlockow, rarely live beyond 45, and
ZINC (WITHERSTINE).
849
die, some of bronchial or gastrointes- chronic diarrhea of children and
tinal catarrh, others of a peculiar adults in doses of from 2 to 10 grains
nervous affection which commences (0.13 to 0.6 Gm.). The phenolsul-
with burning superficial pains, ex- phonate is given internally to produce
alted sensibility, and reflex activity in gastrointestinal antisepsis in diarrhea
the legs, and afterward puts on still particularly with fetid stools. In
more clearly the features of myelitis, typhoid fever this remedy renders the
A. Sacher found that the intravenous
injection of very large doses of zinc
salts produces paralysis of the volun-
tarv muscles. Gimlette reported an
stools less offensive and tends to
check the diarrhea, in doses of 2 to 3
grains (0.13 to 0.20 Gm.) in pill, 4 or
5 times daily. Combined with cas-
epidemic of zinc poisoning among the cara sagrada, it is useful in cases of
soldiers stationed at Pahang, caused
by drinking w^ater collected from
roofs covered with galvanized iron.
Gastric symptoms predominated over
the nervous phenomena.
Treatment of Acute Poisoning. —
Alkalies and their carbonates, tannic chronic diarrhea and dysentery it
acid, and albumin, are the chemical may be given with opium and ipecac,
constipation with flatulence and auto-
intoxication. The sulphate has pro-
duced beneficial results in that form
of dyspepsia which gives rise to
oxaluria, when given in doses of Yi to
(0.03 to 0.13 Gm.). In
1 g-rams
antidotes. Siphon out stomach sev-
eral times with solution of sodium
bicarbonate, or give emetic of mus-
tard, 4 drams to 4 fluidounces (15
Gm. to 120 c.c.) of water, or hypo-
dermic of apomorphine hydrochlo-
ride, 2 to 4 minims (0.12 to 0.25 c.c.)
of a 2 per cent, solution. Give
1 grain (0.06 Gm.) of each in a pill.
The sulphate is much employed as
an emetic in cases of narcotic poison-
ing; a moderate dose, 6 to 10 grains
(0.4 to 0.6 Gm.), well diluted with
water, may be given every 15 minutes
until emesis occurs.
Respiratory Disorders. — The night-
abundance of white of egg and milk, sweats of phthisis are often amenable
Give tannic acid, 30 grains in 1 fluid- to a pill containing 3 grains (0.2 Gm.)
ounce (2 Gm. in 30 c.c.) of water, of zinc oxide and Yi grain (0.03 Gm.)
Relieve abdominal pain with mor- of extract of belladonna, given at bed-
phine, y^^ grain (0.016 Gm.) ; laud- time. The oxide has been recom-
anum, 15 to 20 minims (1 to 1.3 c.c), mended as a serviceable prophylactic
or hot fomentations. Further treat- in spasmodic asthma and as a remedy
ment will be synii)tomatic. in pertussis, comljined with bella-
THERAPEUTICS. — Gastrointes- donna.
tinal Disorders. — Zinc oxide is an Nervous Disorders. — Zinc has ])een
excellent remedv for gastralgia, and used in epilepsy and chorea. Epilep-
in the summer diarrhea of children tiform vertigo and epileptiform angina
Yi \o \ grain (0.03 to 0.06 Gm.) may pectoris, when they arise from some
be combined with 5 to 10 grains (0.3 gastric disorders, are sometimes cured
to 0.6 Gm.) of bismuth subnitrate and by the oxide of zinc. The valerate
2 to 5 grains (0.13 to 0.3 Gm.) of may be used in nervous headaches,
saccharated pepsin, to be given every nervous cough, hysterical aphonia,
4 to 6 hours. It is also useful in the ovarian neuralgia, etc.
850
ZINGIBER.
Cutaneous Disorders. — In lupus,
epitheliomata, and unhealthy ulcers
the dried sulphate of zinc may be
freely dusted over tlie parts for its
caustic action. For the destruction
of malignant growths the chloride in
its various forms — as solution, Can-
quoin's paste, or Maisonneuve's "caus-
tic arrows" — may be employed. Zinc
oxide, carbonate, and stearate are
useful for their astrini^ent action in
weeping eczema, impetigo, herpes, in-
tertrigo, bums, seborrhea, and ery-
thema. The ointment of the oxide is
soothing and astringent. Zinc oxide
is contraindicated when the skin sur-
face is dry ; when the eruption is
moist it is useful. Zinc stearate is
applied as a dusting powder for
burns, either alone or combined with
acetanilide (5 to 1). As emphasized
by Chaput, peroxide of hydrogen is
not durable, and after the oxygen has
been liberated nothing remains but
water, and water is destructive to the
cells. Zinc peroxide is free of these
■drawbacks.
Catarrhal Disorders. — In catarrhal
disorders weak zinc solutions serve
after acute symptoms are past. Sub-
acute conjunctivitis is relieved by
either the acetate or sulphate, 1 to 2
grains (0.06 to 0.13 Gm.) to the ounce
(30 c.c.) of water. The same solution
is valuable as an injection in the
subacute stage of gonorrhea, grad-
ually strengthened up to 20 grains
(1.3 Gm.) of the acetate to the ounce
(30 c.c.) of rose-water, until the dis-
charge ceases. Zinc stearate is ap-
plied in substance, or combined with
menthol (2 per cent.) in urethritis
and gonorrhea, in the form of a pow-
der to be insufflated or in bougies.
C. Sumner Witherstine,
Philadelphia.
ZINGIBER. —Zingiber, or ginger, is
the dried rhizome of Zingiber officinale
(fani. Ziiigiberaceae). Ginger contains a
volatile oil, to the extent of from 1 t(j 3
per cent., which is the source of the odor
and flavor of the drug, and gingerol, which
is very pungent, hut not volatile or aro-
matic, in about one-half the amount of
the oil. The volatile oil occurs as a thick-
ish greenish-yellow liquid, very slightly
soluble in alcohol (50 to 100 times its
weight).
PREPARATIONS AND DOSES.— Zm-
gibcr, U. S. P. (the root). Dose, 10 to 30
grains (0.6 to 2 Gm.).
Fluidcxtractmn c'lngtheris, U. S. P. (fluid-
extract of ginger). Dose, 5 to 20 minims
(0.3 to 1.3 c.c).
Oleoresina zingiberis, U. S. P. (oleoresin
of ginger). Dose, Yz grain (0.03 Gm.).
Syrtipiis zingiberis, U. S. P. (syrup of
ginger). Dose, 1 to 4 drams (4 to 16 c.c).
Tinctura zingiberis, U. S. P. (tincture, or
essence, of ginger, 20 per cent.). Dose,
20 to 60 minims (1.30 to 4 c.c).
Pulvis rhei compositus, U. S. P. (com-
pound powder of rhubarb — rhubarb, 25;
magnesium oxide, 65; ginger, 10 parts).
Dose, 10 to 60 grains (0.5 to 4 Gm.).
Pulvis aromaticus, U. S. P. (aromatic
powder — cinnamon, 35; ginger, 35; carda-
mon, 15; nutmeg, 15 parts). Dose, 10 to
30 grains (0.6 to 2 Gm.).
Fluidextractum aromaticum, U. S. P. (aro-
matic fluidextract). Dose, 10 to 30 minims
(0.6 to 2 c.c).
PHYSIOLOGICAL ACTION.— Ginger
is a warm, stimulating carminative. It in-
creases secretions and peristalsis. It is a
mild diuretic, and acts as an irritant to the
bladder and urethra. Externally it is
rubefacient and counterirritant.
THERAPEUTIC USES. — Ginger is
useful in atonic dyspepsia, especially in
elderly persons. It relieves flatulence and
diarrhea. It is a useful addition to bitter
tonics. As a rubefacient it is made into
a cataplasm, either alone or in combina-
tion with other spices (spice plaster) for
neuralgia, myalgia, headache, and colic. S.
ZONA. See Herpes Zostjer.
■■
RC
Sajo-Qs, Charles Euchariste de
a
M^dicis
S3 5
Analytic cyclopedia of
V.8
practical medicine
9th rev, ed.
Biological
«
& Medical
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