Diseases of Middle Life THE PREVENTION, RECOGNITION AND TREATMENT OF THE MORBID PROCESSES OF SPECIAL SIGNIFICANCE IN THIS CRITICAL LIFE PERIOD COMPRISING TWENTY-TWO ORIGINAL ARTICLES BY VARIOUS EMINENT AUTHORITIES EDITED BY FRANK A. £RAIG, M.D. Associate Director of the Clinical and Sociological Department of the Henry Phipps Institute of the University of Pennsylvania IN TWO VOLUMES ILLUSTRATED VOLUME TWO PHILADELPHIA F. A. DAVIS COMPANY, Pumjshers 1923 COPYRIGHT, 1923 BY F. A. DAVIS COMPANY Copyright, Great Britain. All Rights Reserved. PRINTED IN U. S. A. PRESS OF F. A. DAVIS COMPANY PHILADELPHIA, PA. CONTRIBUTORS ANTHONY BASSLER, M.D., F.A.C.P. Consulting Gastroenterologist, St. Vincent’s, People’s, Jewish Memorial, Christ’s IN. J.), and Fifth Avenue Hospitals, New York City; Formerly Professor of Gastroenterology, New York Polyclinic Medical School and Hospital, and the late Fojdham University Medical School EDWARD J. G. BEARDSLEY, M.D., L.R.C.P. (London). Assistant Professor of Medicine, Jefferson Medical College, Phila., Pa.; Assistant Physician to the Jefferson Medical College Hospital. CLIFFORD B. FARR, A.M., M.D. Medical Consultant, Department of Health, B. F. Goodrich Co., Akron, Ohio; Former Professor of Gastroenterology, Graduate School of Medicine, University of Pennsylvania. JULIUS FRI EDEN WALD, A.M., M.D., Professor of Gastroenterology, University of Maryland. FRANCIS G. HARRISON, M.D. Assistant Professor of Urology, Graduate School of Medicine, University of Penn- sylvania; Assistant Genitourinary Surgeon of the Presbyterian Hospital, Philadelphia. EMERY R. HAYHURST, Ph.D., M.D. Professor of Hygiene, Ohio State University: Consultant, Industrial Hygiene, Ohio State Department of Health, Columbus, Ohio. HAROLD HAYS, M.D., F.A.C.S. Consulting Otologist and Laryngologist at Sing Sing Prison and Sanitarium for Hebrew Children; Associate Laryngologist and Otologist, at City Hospital, New York City. GUY HINSDALE, M.D. Member of the International Society of Medical Hydrology; Former President of the American Climatological and Clinical Association; Fellow of the College of Physicians of Philadelphia. T. B. HOLLOWAY, M. D. Associate in Ophthalmology, University of Pennsylvania. FRANK C. KNOWLES, M.D. Professor of Dermatology, Jefferson Medical College, Philadelphia, Pennsylvania; Dermatologist to the Dispensary of the Pennsylvania Hospital; Member of the American Dermatological Association. JOHN A. LICHTY, M.Ph., M.D. Associate Professor of Medicine, School of Medicine, University of Pittsburgh, Pennsylvania. IV CONTRIBUTORS. F. A. L. LOCKHART, M.B., C.M., M.D. Clinical Professor of Gynaecology, McGill University; Formerly Professor of Surgical Gynaecology, University of Vermont; Gynaecologist to the Montreal, Canada, General Hospital and to the Protestant Hospital for the Insane, Verdun. J. RAYMOND LUTZ, B.S., M.D. Assistant Attending Physician to St. Bartholomew’s Hospital and Clinic, New York City. JAMES HUFF McCURDY, A.M., M.D., M.P.E. Professor of Physical Education and Director of Teachers’ Courses, International Y. M. C. A. College, Springfield, Massachusetts; Editor, American Physical Education Review. HJENRY K. MOHLER, M.D. Demonstrator of Medicine, Jefferson Medical College; Medical Director, Jefferson Hospital, Philadelphia, Pa. THEODORE H. MORRISON, M.D. Associate in Gastroenterology, University of Maryland. O. H. PERRY PEPPER, M.D. Assistant Professor of Medicine, University of Pennsylvania. GEORGE MORRIS PIERSOL, M.D. Professor of Medicine in the Graduate School of Medicine of the University of Pennsylvania; Professor of the Principles and Practice of Medicine and Clinical Medicine in the Woman’s Medical College of Pennsylvania; Physician to the Philadelphia General Hospital, the Hospital of the Graduate School of Medicine of the University of Pennsylvania, the Methodist Episcopal Hospital of Philadelphia, and to the Woman’s College Hospital; Consulting Physician to the Chestnut Hill Hospital. JOSEPH SAILER, Ph.B., M.D. Professor of Clinical Medicine, University of Pennsylvania, School of Medicine. JAMES E. TALLEY, M.D. Professor of Cardiology, Graduate School of Medicine, University of Pennsylvania; Visiting Physician, Presbyterian and Methodist Episcopal Hospitals, Philadelphia. BENJAMIN A. THOMAS, M.D., Professor of Urology, Graduate School of Medicine, University of Pennsylvania; Genitourinary Surgeon to the Presbyterian Hospital, Philadelphia. I. CHANDLER WALKER, M.D. Associate in Medicine, Peter Bent Brigham Hospital; Assistant in Medicine, Harvard Medical School, Boston, Mass. NATHANIEL S. YAWGER. M.D. Consulting Neurologist to the Norristown State Hospital and to the Pennsylvania Eastern State Penitentiary; Member of the American Neurological Association: Formerly Neuropathologist to the Pennsylvania Epileptic Hospital and Colony Farm, and Assistant Neurologist to the Philadelphia General Hospital. CONTENTS Volume II. PAGE Gastric Disturbances of Middle Ltfe, 3 By Julius Friedenwald, A.M., M.D., and Theodore H. Morrison, M.D. Foreword, 4. Etiology. Focal Infections, 4; Infectious Diseases, 5; Degenerative Changes, 0; Arteriosclerosis, 7; Toxemia, 8; Syphilis, 9; Diseases of Other Organs, 11; Indiscretions in Diet, 12; Disturb- ances of the Nervous System, 13; Disturbances of the Endocrine Sys- tem, 15; Trauma, 18. Gastric Secretion and Motility in Middle Life, 19. Incidence of Diseases of the Stomach in Middle Life, 22. Descrip- tion of the Diseases of the Stomach as Revealed in Middle Life. Acute and Chronic Gastritis, 23; Ulcer, 32; Cancer, 40; Dilatation of the Stomach, 55; Gastroptosis, 58; Syphilis, 61; Secondary Gastric Affec- tions, 63; Nervous Gastric Affections, 69; Visceral Arteriosclerosis, 96. Diseases of the Intestines, 105 By Anthony Bassler, M.D., F.A.C.P. Constipation. Foreword, 105; Etiology, 106; Diagnosis, 110; Treatment, 110. Diarrhea. Foreword, 118; Necrotic Ulcerative Processes, 118; Inflammatory Ulcerative Processes, 120; Infective Ulcerative Processes, 125. Chronic Excessive Intestinal Toxemia. Foreword, 142; Etiology, 143; Pathology, 144; Relation of Bacterial Metabolism to Certain Foods, 149; Symptoms, 150; 'Treatment, 160. Cirrhosis of the Liver, 183 By Anthony Bassler, M.D., F.A.C.P. Portal Cirrhosis. Etiology, 184; Pathology, 185; Symptoms, 186; Physi- cal Signs, 188; Diagnosis, 191; Prognosis, 192; Treatment, 193. Bili- ary Cirrhosis. Etiology, 196; Pathology, 197; Symptoms, 197; Pro- gnosis, 198; Treatment, 199. Diseases of the Liver, Gall-bladder, and Pancreas . 203 By J. Raymond Lutz, B.S., M.D. Foreword, 203. Diseases of the Liver and Gall-bladder. Jaundice, 205; Congestion of the Liver, 208; Acute Perihepatitis, 213; Chronic Hyper- plastic Perihepatitis, 215; Degenerative Conditions of the Liver, 217; Liver Abscess, 218; Acute Yellow Atrophy, 222; Lues Hepatis, 227; Tuberculosis of the Liver, 229; New Growths, 230; Echinococcus of the Liver, 235; Epidemic Catarrhal Jaundice, 238; Acute Catarrhal VI CONTENTS. PAGE Cholangitis, 244; Acute Suppurative Cholangitis, 246; Acute Chole- cystitis, 248; Acute Catarrhal Cholecystitis, 250; Suppurative Chole- cystitis, 252; Acute Phlegmonous Cholecystitis, 253; Chronic Chole- cystitis, 255; Cholelithiasis, 256; Tumors of the Gall-bladder and Biliary Fassages, 265; Diseases of the Pancreas. Acute Hemorrhagic Pancreatitis, 266; Acute Suppurative Pancreatitis, 269; Pancreatic Hemorrhage, 271; Chronic Interstitial Pancreatitis, 271; Tumors of the Pancreas, 279; Cystsi of the Pancreas, 281; Pancreatic Calculi 284. Diseases of the Male Genitourinary Tract, . . . 289 By Benjamin A. Thomas, M.D., and Francis G. Harrison, M.D. Infection. Balanitis and Balanoposthitis, 289; Herpes Progenitalia, 290; Penis, 290; Urethra, 291; Epididymitis, 301; Spermatocystitis, 303; Prostate, 304; Bladder, 311; Ureters, 317; Kidney, 319; Hydrone- phrosis, 324. Calculus. Renal, 325; Ureteral, 329; Vesical, 332; Urethral and Prostatic, 334. Tumors. Kidney, 335; Bladder, 337; Prostate, 340; Testicle, 341; Urethra, 342; Penis, 343. Tuberculosis, 344. Malformations, etc., 348. Hydrocele, 350. Varicocele, 351. Syphilis, 352. Chancroid, 358. Gynecology, 363 By F. A. L. Lockhart, M.B., C.M.. M.D. Menopause, 363; Haemorrhage, 366; Pruritus Vulva*, 369; Esthiomfine, 370; Tuberculosis Vulvae, 371; Tumours of the Vulva, 372; Injuries from Childbirth, 375; Uterine Displacements, 381; Inflammatory Af- fections, 386; Extra-uterine Gestation, 395; Carcinoma of the Vagina, 404; Carcinoma of the Uterus, 406; Carcinoma of the Tubes, 420; Car- cinoma of the Ovary, 421; Sarcoma of the Vulva, 422; Sarcoma of the Vagina, 423; Sarcoma of the Uterus, 424; Sarcoma of the Tubes and Ovaries, 425; Uterine Fibroids, 426; Tumours of the Ovary, 442. Nervous and Mental Diseases, 453 By Nathaniel S. Yawger, M.D. Introduction, 453. Functional and General Diseases. Neurasthenia, 455; Psychasthenia, 460; Hysteria, 461; Epilepsy, 467; Fibrositis, 470; Headache, 472; Migraine, 474; Vertigo, 476; Disorders of Sleep, 477; Multiple Cerebrospinal Sclerosis, 480; Paralysis Agitans, 482; Tetanus, 484; Rabies, 485; Sunstroke, 486. Diseases of the Peripheral Nerves. The Neuralgias, 488; The Paralyses, 494; Neuritis and Multi- ple Neuritis, 500; Herpes Zoster, 504; Cervical Rib, 505. Diseases with Pronounced Muscular Manifestations. Progressive Muscular Atro- phy, 505; Myasthenia Gravis, 507; Progressive Bulbar Paralysis, 508. Diseases of the Spinal Cord. Myelitis, 509; Hematomyelia, 512; Lan- dry's Paralysis, 512; Caisson Disease, 513: Syringomyelia, 514: Lateral Sclerosis, 516; Amyotrophic Lateral Sclerosis, 516; Combined Scler- osis, 517; Spinal Meningitis. 519; Hypertrophic Cervical Pachymenin- gitis, 521; Tumors, 522; Fracture-Dislocation Syndromes, 523. Vaso- motor and Trophic Diseases. Ravnaud’s Disease, 525; Intermittent Claudication, 526; Angioneurotic Edema, 526; Erythromelalgia, 527; Scleroderma, 527; Spondylose Rhizomelique, 528. Syphilis of the Nervous System. Tabes Dorsalis, 531; Paresis, 535; Syphilis of the CONTENTS. VII PAGE Brain and Cord, 53S. Diseases and Disorders of the Brain. Epidemic Encephalitis, 541; Apoplexies, 547; The Aphasias, 550; Tumors, 552; Delirium, Confusion and Stupor, 555; Hypochondria, 559; Manic-de- pressive Psychosis, 561; Paranoia, 565; Traumatic Psychosis, 572; Psy- choses Incidental to Childbearing, 573; Toxic Psychosis, 576; Heredi- tary Chorea, 578. Diseases of Inebriety. Alcoholism, 579; Morphin- ism, 583; Cocainism, 585; Caffeinism, 587; Nicotinism, 589. Psycho- pathic Personalities, 590. Sexual Anomalies, 592. The Endocrino- pathies, 595. The Inflammatory Arthropathies, ...... 611 By John A. Lichty, M.Ph., M.D. Introduction, (ill. Classification of the Diseases of the Joints, 613. Arthritis in Acute Infectious Diseases, 614. Acute Rheumatic Fever, 618; Incidence, <519; Etiology, 619; Morbid Anatomy, 622; Symptoma- tology, 625; Complications, 626; Prognosis, 627; Diagnosis, 627; Treat- ment, 628. Arthritis Due to Chronic Infection, 634. Etiology, 635; Pathology, 646; Symptomatology, 648; Diagnosis, 652; Treatment, 654. Gonorrheal Arthritis, 665. Syphilitic Arthritis, 674. Tuberculous Arthritis, 679. Gout. 689 By Edward J. G. Beardsley, M.D., L.R.C.P. (London). Historical, 689; Geographical Distribution, 695; Incidence, 696; Etiol- ogy, 697; Pathology, 705; Symptoms, 716; Diagnosis, 720; Prognosis, 722; Treatment, 723. Obesity, 735 By Guy Hinsdale, M.D. Foreword, 735. Formation of Fat, 737; Relation to the Endocrine Sys- tem, 740; Relation to Diabetes Mellitus, 742. Life Expectancy and Mortality in the Obese, 744. Instances of Extreme Obesity, 747. Treatment. Prophylactic, 751; Metabolism in the Obese, 752; Dan- gers of “Antifat Cures,” 755; Popular Reduction Cures, 759; Use of Water, 764; Dietetic Treatment, 766; Class Treatment of Overweight, 772; Circulatory Disorders in the Obese, 780; Mechanical and Elec- trical Devices, 782; Exercise, 785, Hydrotherapy, 786. Diseases of the Skin, 797 By Frank C. Knowles, M.D. Foreword, 797; Toxic Erythema, 797; Erythema Multiforme, 798; Ery- thema Nodosum, 799: Urticaria. 800; Lichen Planus, 802; Psoriasis, ' 803; Eczema, 804; Herpes Simplex, 806; Herpes Zoster, 807; Pemphi- gus, 808; Diphtheria of the Skin, 809; Hyperhidrosis, 810; Derma- titis Dysmenorrheica, 811; Raynaud’s Disease, 812; Dermatitis Medi- camentosa, 812; Dermatitis Factitia, 813; Purpura, 814; Scleroderma, 816; Chloasma, 817; Argyria, 818: Vitiligo, 818; Xanthoma Diabeti- corum, 819; Pruritus, 819; Leukemia Cutis, 819; Furuncle, 820; Ery- sipelas, 821; Keratodermia Blennorrhagica, 821; Tuberculosis Verru- cosa Cutis, 821; Erythema Induratum, 822; Leprosy, 823; Blastomy- cosis, 824; Acne Vulgaris, 825; Acne Rosacea, 826; Hypertrichosis, 826; Alopecia Areata, 827; Leukoplakia, 828; Syphilis, 828. VIII CONTENTS. page Diseases of the Blood, 837 By Joseph Sailer, Ph.B., M.D. Foreword, 837. Classification of the Diseases of the Blood, 839. Second- ary Anemia, 841. Hemorrhagic Diathesis Due to Hypertension, 846. Progressive Pernicious Anemia, 847. Leukemia, 854; Chronic Myelo- genous Leukemia, 856; Chronic Lymphatic Leukemia, 859; Acute Mye- logenous Leukemia, 860; Acute Lymphatic Leukemia, 861; Treatment of Leukemia, 861. Polycythemia with Splenomegalia, 865. Purpura Hemorrhagica, 868. Diseases of the Eye, 873 By T. B. Holloway, M.D. Foreword, 873. Presbyopia, 874. Retinal Vascular Changes Associated with Hyperpiesia, Arteriosclerosis and Nephritis, 878; Hyperpiesia, 881; Arteriosclerosis with High Tension, 881; Renal Disease, 883; Diabetic Retinitis, 885. Cataract, 886. Glaucoma, 895; Acute Con- gestive Glaucoma, 898; Subacute Congestive Glaucoma, 900; Chronic Non-congestive Glaucoma, 900. The Gastric Disturbances of Middle Life BY JULIUS FRIEDENWALD, A.M., M.D. Professor of Gastro-enterology, University of Maryland AND THEODORE H. MORRISON, M.D. Associate in Gastro-enterology, University of Maryland The Gastric Disturbances of Middle Life. FOREWORD. The gastric affections of middle life are worthy of the most careful consideration. It is only by means of a comprehen- sive study of these conditions that the various factors leading to the development of senile changes can be definitely deter- mined, and much may be accomplished by the early recog- nition of such influences in the prevention and amelioration of these diseases, and in the prolongation of life. It is in middle life when the most serious forms of gastric disturbances first begin to manifest themselves, frequently appearing with symptoms so mild and insignificant that their importance is completely overlooked until late in their course —often only after alarming signs have already developed. Many of these disorders have their origin in youth, at that period often in an apparently unimportant form, while others drag along from youth to old age with exacerbations and re- missions only presenting serious manifestations in middle life when the transition from benign to malignant states is so commonly observed. Again attention must be directed to the fact that the in- cidence of nervous gastric affections is greater in the young while organic affections are more common in older individu- als. One need only remember that in youth the tissues are resilient and less vulnerable to insults, so that ordinary influ- ences make but little impression upon the gastric mucosa; whereas in older individuals in whom degenerative changes have already begun to manifest themselves, these same fac- tors often bring about marked pathological changes. On comparing the gastric disorders of youth and of middle life, one is at once impressed with the fact that the acute types are more frequently observed in the young, while the more chronic forms are more frequent in adults. This may 4 GASTRIC DISTURBANCES OF MIDDLE LIFE. be due to the fact that the causative factors leading to the disease have not been sufficiently potent to as yet make seri- ous inroads into the younger patient’s health, until the in- fluence has become so continuous as to produce organic manifestations. Finally it is always important to hold in mind that in order to make any advance in the amelioration and prevention of gastric disorders in middle life, all causa- tive factors bearing upon the etiology of these affections must be taken into consideration and not until these are definitely recognized can we hope to make any material advance in the prevention and cure of these diseases. ETIOLOGY. The various factors concerned in the production of the gastric disorders of middle life may be grouped as follows: Focal infections. Infectious diseases. Local degenerative changes. Arteriosclerosis. Toxemias. Syphilis. Influence of diseases of other organs (liver, heart, lungs, kidneys, nervous system, genito-urinary system). Indiscretions in diet. Disturbances of the nervous system. Disturbances of the endocrine system. Trauma. FOCAL INFECTIONS. It is a well established fact that focal infections may play an exceedingly important role in the production of certain gastric disorders of middle life. The primary foci may be localized in various portions of the body; as in the teeth, tonsils, sinuses, gall-bladder, appendix, intestine, genito- urinary tract or other organs. There can be no question, for example, but that the cause of a certain proportion of ulcerations is a hematogenous in- fection with special strains of streptococci absorbed from certain foci of infection. Rosenow’s work brought this out conclusively and has thus materially altered our views re- INFECTIOUS DISEASES. 5 garding the etiology of ulcer in these cases; and consequently it is now generally maintained that previous to instituting treatment all sources of focal infection should, as far as pos- sible, be removed. According to this investigator, peptic ulcer may be produced experimentally in animals by the intravenous injection of certain strains of streptococci, and he has been able to isolate these strains from the ulcer base in man and has shown that they have an elective affinity for the stomach wall of animals when injected intravenously. The method of production of the ulceration is an infection of an embolic streptococcic type in the submucous layers of the stomach with the production of hemorrhagic areas in the surrounding tissue; in consequence of which anemic nec- rosis takes place followed by the digestion of the mucous membrane above by the gastric secretion. Depending upon the extent of the infection, either healing may take place or chronic ulceration ensue. INFECTIOUS DISEASES. Beaumont first called attention to the fact that in febrile states there is a diminished secretion of gastric juice together with a lowered digestion of food. It is therefore not uncom- mon to observe symptoms of indigestion accompanying many of the infectious fevers occurring during middle life. The symptoms of dyspepsia are more pronounced in certain of these affections than in others, for example, one commonly finds gastric upsets in the form of nausea, vomiting and dis- tention in typhoid fever, tuberculosis, influenza and pneu- monia. In these infectious fevers the appetite is always diminished, and in many instances there is marked anorexia. The symptoms of indigestion may not only be present during the entire course of the fever, but may continue on during the stage of convalescence. Gastritis may be produced both directly and indirectly by infections. Thus thrush due to the growth of schizomycetes may extend directly into the stomach, developing as a part of the general infection. Rosenheim has reported a case of this disease associated with violent gastric symptoms in a woman of sixty years. Dieulafoy has also called attention to certain unusual cases of pneumococcic infections of the 6 GASTRIC DISTURBANCES OF MIDDLE LIFE. stomach, leading to gastritis and ulceration. Finally, it is important to note that the role played by infectious diseases in the production of gastric disturbances is not only im- portant on account of the immediate effects, but that long after the infection has disappeared, definite gastric manifes- tations may still remain as the result of the inroads made by the infection upon the stomach. The degenerative changes of middle life are observed in the form of weakness of the muscle fibers of the stomach; giving rise to atony of the glands, to a diminution of the gastric secretions and atrophy of the mucous membrane. Due to these degenerations there occurs a weakened motility of the stomach with retention of its contents, together with a decrease in digestive power. These changes frequently lead to the most distressing gas- tric discomfort, often so severe as to simulate malignant dis- ease. The symptoms arise, however, as a rule, far more gradually and frequently extend over a long period of time. Fenwick has graphically described the progressive degen- erations affecting the secretory structures of the digestive tract in advancing years. He points out that although after the age of fifty these changes are quite constant, careful ob- servation will frequently reveal their presence at a far earlier period of life, even at times at the age of forty. Microscopically, the pyloric end of the stomach appears attenuated, the rugae no longer being marked and the mucous membrane appearing very smooth, pigmented and adherent to the adjacent muscular layer. The pyloric orifice is some- what contracted. On microscopic examination, the pyloric area presents an increase of connective tissue, which surrounds the tubular glands, resulting in their attenuation. In the early stage of the disease one observes that the columnar epithelium cover- ing the surface of the mucous membrane and of the ducts has disappeared and that the cells of the glands no longer present their normal outlines but are granular in appearance. In a more advanced stage the continued growth of the con- nective tissue compresses and distorts the glandular tissue DEGENERATIVE CHANGES. ARTERIOSCLEROSIS. 7 until nothing but minute cysts remain. These finally dis- appear and the mucosa is converted into a thin layer of connective tissue. While these changes are progressing in the mucous mem- brane the submucous layer becomes affected with a similar but less marked form of connective tissue change associated with an obliterative endarteritis, and as a result of compres- sion the intervening muscularis mucosa is destroyed. At the onset the muscular coat presents signs of hyper- trophy but finally interstitial changes manifest themselves and the muscle fibers undergo fatty degeneration or atrophy. These connective tissue changes are rarely observed beyond the central zone of the stomach. At times degenerative changes are observed in the vessels of the stomach itself, leading to rupture with hemorrhages of a more or dess severe type, which are not unfrequently most difficult to distinguish from those occurring in ulcera- tions. The degenerative changes having their origin in mid- dle life are usually mild and often progress extremely slowly, so that they may be entirely overlooked until the onset of old age, when they become more fully developed. ARTERIOSCLEROSIS. Arteriosclerosis is a most important factor in the produc- tion of gastric disturbances of middle life. It is observed in one of two distinct types: 1st. Those instances in which the arteriosclerotic changes are primarily in the stomach itself. 2d. Those in which the manifestations are secondary to a general arteriosclerosis. Both conditions play an important role as causative factors leading to gastric symptoms of varying degrees. A study of the arteries of the stomach, in this condition, shows that due to the primary changes in the media and adventitia there is a thickening of the intima which finally involves the media and adventitia. As a result of the arteriosclerotic changes a definite form of abdominal angina may be produced, associated with parox- ysmal attacks of pain of a rather severe type. Harlow Brooks has called attention to the fact that the disturbed visceral 8 GASTRIC DISTURBANCES OF MIDDLE LIFE. function, with occasional elevation of blood-pressure which cannot otherwise be accounted for, may lead to the suspicion of some localized area of arterial disease and especially when associated with anginal pain located in the abdomen. Attention has already been directed to the gastric hemor- rhages not occasioned by ulceration but produced by degen- erative changes in the vessels of the stomach. A frequent cause of these hemorrhages is found in the miliary aneurisms due to arteriosclerosis of the small gastric arterioles. As arteriosclerosis plays an exceptionally important role in the production of the gastric disturbances in middle life, as well as of old age, this condition will be taken up for further consideration in another section. (Page 96.) Toxemias associated with gastric disease are not uncom- mon and may be either of exogenous or endogenous origin. The exogenous forms are caused by the ingestion of con- centrated mineral acids or alkalies, or by such poisons as phosphorus or arsenic, or by food infected with certain patho- genic microorganisms. Due to these toxic substances an intense inflammatory state of the stomach is produced, which is more severe when the poison is swallowed in the fasting state. The parts af- fected frequently become necrotic, producing varying degrees of sloughing of the mucous membrane, and at times pene- trating the submucous and peritoneal coats, occasionally producing perforative peritonitis. In less severe types a swelling of the mucous membrane takes place with superficial necrosis and hemorrhagic areas, and the epithelium of the glandular tubules undergoes a fatty degeneration. The endogenous variety of gastric toxemia is far more common than the exogenous form and may have its origin in a great many different causes. Of special interest are those forms observed in certain affections of the stomach itself; next, those of intestinal origin; and finally, those due to disease of distant organs. Among the gastric affections in which this condition may be especially noted are dilatation of the stomach, both of the TOXEMIA. SYPHILIS. 9 acute and chronic variety, carcinoma and certain forms of chronic gastritis. Gastric toxemias are not uncommonly produced by intes- tinal disease. A very striking instance of this condition is to be found in the vomiting due to intestinal obstruction. It may also occur associated with the intestinal toxemias, due to constipation or diarrhea, and in the various forms of in- testinal affections, as in dysentery, stasis, mucous colitis and malignant disease. Gastric toxemias are also frequently observed associated with diseases of distant organs, as the kidneys, genital or- gans, liver, as well as in diabetes, certain forms of anemia (pernicious anemia, chlorosis), and in pregnancy, and even in endocrine dysfunction. The effect of disease of other organs upon gastric function is a subject of the greatest importance, to which further attention will be directed in a subsequent section. SYPHILIS. Syphilis of the stomach is not an infrequent affection in middle life. According to Gerster, in a series of 1603 cases of gastric disease, 1.6 per cent, was found due to syphilis; and according to the combined statistics from a number of sources the proportion varies between 1.25 and 1.50 per cent. In the largest proportion of instances the cases have occurred during the tertiary stage of the disease, though secondary syphilis is frequently accompanied by symptoms of indiges- tion due, as a rule, to a toxemic gastritis. Tertiary syphilis may, according to Fenwick, appear in three forms: (1) gum- matous formations; (2) in the form of endarteritis; and (3) as chronic inflammation of the mucosa. 1. Gummata. Large gummata have not been frequently noted in the stomach, Chiari having observed but three in- stances. This tumor is usually found in the pyloric area near the lesser curvature, and is frequently multiple. In its growth it often undergoes softening, producing ulceration. The gummatous ulcer can usually be distinguished from the simple form, as it is irregular in shape, its edges over-hanging, its walls and base are soft, dry and bloodless and frequently covered with an adherent slough, and perigastric adhesions 10 GASTRIC DISTURBANCES OF MIDDLE LIFE. are not uncommon. The mucous membrane adjacent to the ulcer presents indications of chronic inflammation, and is often studded with minute gummata. It is rare to observe perforation of the stomach in this affection and the usual manifestations of syphilis are present in other abdominal organs (liver, spleen and pancreas). 2. Endarteritis. Obliterative endarteritis occurring in the blood-vessels of the stomach is frequently noted in syphilis, though it need not necessarily be indicative of the presence of this disease, for it may occur as well in simple ulcerations and in arteriosclerosis. Syphilitic endarteritis is usually as- sociated with gummata in the liver, spleen, and pancreas, and frequently affects the minute branches of the pyloric vessels in the submucous and subserous connective tissue; as the result of the interference with the nutrition of the wall of the stomach, ulceration may ensue. 3. Chronic Gastritis. Chronic gastritis may occur as a direct or indirect effect of syphilis. As a result of the inter- ference with the circulation of the stomach from luetic dis- ease of the liver, spleen, kidneys, etc., a secondary gastritis may be induced. In the luetic gastritis, the mucous mem- brane is dull and opaque and is usually thickened, due to an increase in the connective tissue between the glands. The gastric glands are frequently observed to be distorted and disorganized by a round cell infiltration, which is usually profuse in the submucosa and glandularis. The syphilitic origin of the disease is indicated by the miliary granulations, which are observed throughout the en- tire thickness of the mucosa, and at times even in the sub- mucous tissue there are small areas which are minute gum- mata which coalesce. Another characteristic feature of syphilitic gastritis is the marked accumulation of oval, round and spindle cells around the vessels forming concentric rings, encroaching upon the vascular walls and increasing their thickness to a greater or less degree. The lumen of the vessels is at times markedly occluded and a subendothelial proliferation is not uncommon. In con- sequence of the cicatricial obstruction about the pylorus, stenosis with gastric dilatation may be produced. DISTURBANCES OF FUNCTIONS OF STOMACH. 11 Clinically, syphilis of the stomach may be classified, ac- cording to Einhorn, into the following groups: 1, Luetic ulceration of the stomach; 2, syphilitic tumor; 3, luetic steno- sis of the pylorus. A clinical study of this exceedingly important disease of middle life will follow in a subsequent section. DISTURBANCES OF THE FUNCTIONS OF THE STOMACH IN DISEASES OF OTHER ORGANS. In a study of the diseases of middle life, it at once becomes apparent that in a large proportion of instances, disturbances of the stomach functions are encountered as the result of diseases of other and often distant organs. At times, espe- cially in the more chronic cases as well as in afebrile forms, the gastric symptoms may present the most marked features, while the actual disease producing the gastric disturbance is only recognized with great difficulty and, therefore, errors in diagnosis not uncommonly occur. It is on this account that in all dyspeptic conditions, a thorough investigation should always be made into the func- tions of all of the important organs of the body, as well as the stomach itself, lest an incorrect conclusion be reached. The cause of the disturbed stomach function due to dis- ease of other organs lies either in some disturbance of the circulation, nervous system, or is due to a special toxemia. In diseases of the heart and liver, portal obstruction is recog- nized as the cause of the gastric disturbance; in nervous affections there is frequently an alteration of the gastric secretion; while in febrile states, kidney disturbances, tuber- culosis, diabetes, and anemia, changes occur in the gastric mucosa due to toxemias specific to the individual disease. In many instances the gastric disturbance is reflected as a purely nervous manifestation, as is not infrequently observed in the form of pylorospasm occurring in instances of chronic appendicitis, or in cardiospasm in gall-bladder affections. Among the most important diseases exercising a secondary effect on the stomach during middle life are those of the in- testines, lungs, heart, liver, genito-urinary organs, diabetes, pernicious anemia, febrile and nervous affections, a clinical study of which can be found on page 63. 12 GASTRIC DISTURBANCES OE MIDDLE LIFE. INDISCRETIONS IN DIET. Indiscretions in food and drink, in addition to the abuse of tobacco, are often potent factors in the production of the gastric disturbances of middle life. These errors in diet may consist in the consumption of food in excessive amounts, often imperfectly masticated and too rapidly bolted, taken too hot or too cold; food over-rich, highly spiced, or fer- mented or decomposed, introducing microorganisms into the stomach; unripe or overripe fruits; too cold drinks; excessive use of condiments, and over-indulgence in alcohol, coffee, or tea. There are certain individuals who are affected with so- called “weak or delicate digestion,” in whom any variation from a strict diet is at once followed by gastric upsets. In such persons sweets, fatty foods, shell-fish, coffee, alcohol, or tobacco, are quite apt to produce acute gastric catarrhal conditions. There can be no question but that the lower classes are endowed with better digestion than the better classes, due to the fact that the former are accustomed to eat less diges- tible food with considerable more residue than the latter, in consequence of which the stomach is trained to digest larger quantities of not readily digestible foods without difficulty. The acute upsets brought about by the ingestion of ex- cessive quantities or improper food usually causes an acute gastritis, while food taken very hot is believed to be a fre- quent cause of ulcer and, as W. J. Mayo has pointed out, is a possible factor in the production of cancer of the stomach. On the other hand, Wegele attributes the dyspepsia of many Americans to the taking of ice-cold water and other cold drinks. When food is consumed too rapidly or is insufficiently mas- ticated the masses entering the stomach are difficult to dis- solve in the gastric secretion and act as irritants and may produce acute or chronic gastritis. It is well to call attention to the fact that the largest pro- portion of cases of hyperchlorhydria are induced by indiscre- tions in diet, abuse of alcoholic drinks and tobacco. In an analysis of 542 cases of hyperchlorhydria studied by us, 186 were brought about by these conditions, of which fifty-seven, DISTURBANCES OF NERVOUS SYSTEM. 13 or thirty per cent., occurred between the ages of thirty and fifty years. The following table, taken from Fenwick, presents the relative frequency of errors in food and drink in the produc- tion of chronic gastritis: Alcohol 60.0 per cent. Errors of diet 17.9 per cent. Drugs 13.3 per cent. Tobacco 8.8 per cent. DISTURBANCES OF THE NERVOUS SYSTEM. The importance of the nervous system, in its relation to affections of the stomach in middle life cannot be over- estimated. Much attention has been directed to disturbances of the digestive system by the more recent studies of the physiology of the nervous system. Through the researches of Langley, Meyer and Gaskell, as well as others, it has been demonstrated that the involuntary nervous system supplies two sets of nerve fibers to every organ, the one functioning as activator, and the other as inhibitor nerves, the two com- bined, exhibiting a regulating mechanism, controlling the interactivity of both groups. Through Eppinger and Hess the theory has been advanced that disturbances of the autonomic system leading to in- creased and decreased tonus or excitability may be the cause of certain pathological changes. According to this theory, the symptoms of nervous dyspepsia are due to disturbances of the internal secretions in consequence of which changes in the excitability or tonus are transmitted through the autonomic system to the stomach. These writers have evolved a clinical symptom-complex according to this idea, which is based on the excitability or tonus of the autonomic system and is termed by them vagotonus and sympathetico- tonus. Increased vagotonus produces an increase in gastric secre- tion (hyperacidity and hypersecretion) and peristalsis (ner- vous vomiting, cardiospasm, pylorospasm). As forms of in- creased sympatheticotonus may be mentioned atony of the stomach, achylia gastrica and nervous anacidity. 14 GASTRIC DISTURBANCES OF MIDDLE LIFE. It is further known that certain drugs have a definite stimu- lating effect on the vagus and are therefore vagotonic, while others have an inhibiting effect. There are in addition drugs which are sympatheticotonic. Gastric nervous affections may be primary or secondary: they are primary when the seat of the nervous disorder is inherent in the stomach itself, and secondary when the ner- vous mechanism of the stomach is reflexly affected either from the brain, spinal cord, or some other organ, such as the liver, kidneys, etc. Thus a severe pain such as kidney colic may reflexly affect the stomach, causing vomiting. It has been demonstrated by Gould that severe eye-strain may also have a marked influence in this regard. Dock has recently called attention to the fact that focal infections may be the cause of certain functional disorders, and that exhaustive treatment in a case of bulimia, by re- moval of infected teeth and the treatment of nasal and sinus disease, resulted in a cure. On the other hand, a gastric neurosis may in turn reflexly affect other organs, and we may find’symptoms, such as headache, palpitation, and insomnia, due to this condition. According to our experience, fifty-five per cent, of all gas- tric disturbances can be classified as neuroses, while forty- five per cent, represent organic diseases. In order that a gastric neurosis may exist there must be present some pre- disposition, that is, a neurotic tendency in the individual. This is frequently first manifested by nervous symptoms di- rected to other organs, the stomach only becoming involved later. Heredity plays an important role. The manner of development of these affections is often peculiar. At times they begin suddenly, often without any apparent cause or error in diet, persist for a longer or a shorter period of time and then perhaps terminate abruptly; at other times they come on slowly, progress rapidly, and terminate when least expected. Most of the gastric neuroses are observed more frequently in females than males, and more often in the upper than the lower classes. The chief factors in males are overwork, worry and excesses, especially overindulgence in drink. The chief causes in women are disorders of menstruation, reproduction, anxiety, sorrow, and DISTURBANCES OF ENDOCRINE SYSTEM. 15 disappointment. The neuroses rarely begin in old age. They occur more frequently in middle life, between the twentieth and fortieth years. The following, taken from Friedenwald in Osier’s Modern Medicine, presents the incidence of gastric neuroses at various ages: Years No. of cases Percent. 1 to 20 232 14.5 20 ” 30 354 22.5 30 ” 40 404 25.0 40 ” 50 339 21.5 50 ” 60 175 11.0 60 ” 70 88 5.5 Forty-six per cent, of this number occurred between the thirtieth and fiftieth years. The neuroses occur as frequently in the robust and well nourished as in the broken-down and enfeebled individual. After persisting for some time, however, these affections in- terfere with the general health, often producing emaciation. Through the knowledge obtained from the researches of Eppinger and Hess, it is now established that the glands of internal secretion are controlled and regulated through the autonomic nervous system, while on the other hand the activ- ity of this system is, in a measure, dependent upon the secre- tions of the endocrine glands. According to this theory, therefore, the symptoms of nervous dyspepsia are due to disturbances of the internal secretions, in consequence of which changes in excitability or tonus are transmitted through the autonomic system to the stomach. This relation has been well illustrated in the experiments of Rogers on dogs. By means of subcutaneous injections of certain extracts of the thyroid, or parathyroid, he was able to produce a marked increase both in the flow of the gastric secretion and in gastric motility, which could be inhibited by means of an injection of atropin. Not only will atropin inhibit this reaction but a similar effect can be brought about by the injection of an extract of the adrenal gland. Rogers explains the latter reaction as due DISTURBANCES OF THE ENDOCRINE SYSTEM. 16 GASTRIC DISTURBANCES OF MIDDLE LIFE. to a stimulation of the sympathetic by the extract of this gland. According to Barker, the relations existing between the endocrine glands and the digestive system may be classified under two main heads: A. The relation of the digestive apparatus to endocrine organs outside of itself. B. Internal secretions originating within the digestive apparatus itself. A. Relation of the Stomach and the Thyroid Gland. In Graves’s disease the appetite is usually increased, especially in the early stages and there is frequently polyphagia. As the disease progresses the appetite becomes diminished and at times there is complete anorexia. In myxedema, the ap- petite is usually diminished and there may be complete anorexia, especially for meats. In Graves’s disease the gastric secretion is usually dimin- ished, yet at times a rise of acidity does occur. Vomiting is not uncommon, especially of a paroxysmal type, usually bears no relation to food and frequently is not associated with nausea. In myxedema the gastric secretion is also re- duced in quantity and not infrequently a complete achylia exists. Relation of the Stomach to the Parathyroid Gland. Trousseau was the first (in 1851) to describe the clinical symptoma- tology of tetany, which is associated with a disturbed func- tion of the parathyroid glands and is also seen in certain gastric disturbances. There are two groups of cases of this affection: one in which tetany develops in individuals who are affected with chronic gastric disturbances, and another in which the gas- tric affection occurs about the time of the onset of tetany. The gastric condition most frequently observed in cases of tetany is dilatation. Barker and Estes have described a syndrome in which chronic dilatation of the stomach exists with tetany and hematoporphyrinuria. The condition occurred in a family of three sisters. Relation of the Stomach and Hypophysis Cerebri. The symp- toms related to the stomach in disturbed hypophysial func- DISTURBANCES OF ENDOCRINE SYSTEM. 17 tion are but few. Dilatation and enlargement of the walls of the stomach have been observed with the polyphagia so often noted in acromegaly. In diabetes insipidus there is a marked polydipsia. The subcutaneous injection of pituitrin leads first to a de- crease followed by an increase in the motility of the stomach. Relation of the Stomach and the Chromaffin System. Adre- nalin, when injected into the blood-vessels, stimulates the sympathetic fibers in the glands, inhibiting peristalsis and causing a contraction of the pylorus. The relation of the adrenals to the production of ulceration of the stomach is extremely interesting. It was noted by Gibille in 1909 and Fenza in 1913, that animals dying after removal of both adrenals, were observed to have ulcerations of the stomach. Fenza also demonstrated that if after removal of the adrenals, adrenalin was injected into the circulation, the gastric mucous membrane remained unaffected. More recently Friedman, from both clinical and experi- mental evidence, has concluded that these ulcerations are due to disturbances of the internal secretion affecting the nerves supplying these areas. During the past few years a number of reports bearing upon the relationship between peptic ulcer and disturbances of the adrenals have been published. Relation of the Stomach and the Intcrrcnal Glands. Digestive disturbances are prominently observed in Addison’s disease in the form of a diminished and capricious appetite, eructa- tions, hiccough, fullness after meals and frequently anorexia, nausea and vomiting. Gastric pain is at times present, which is sometimes paroxysmal and may be localized or diffuse. The examination of the gastric secretion in this affection usually reveals an absence of the hydrochloric acid and there is a diminution in the motility of the stomach. B. The Hormone of the Pyloric Glands (Gastrin). The sub- stance known as gastrin (Edkins), or gastric secretin (Bay- lin), has the power when injected into the circulation of exciting the secretion of the gastric glands at the fundus of the stomach. 18 GASTRIC DISTURBANCES OF MIDDLE LIFE. Edkins, with an extract of the pyloric mucosa of a fasting cat, was able to produce a secretion of gastric juice contain- ing hydrochloric acid and pepsin when this substance was injected into the circulation of another fasting animal. Similar results were obtained with meat extracts, and to a less degree, with extracts of glucose or peptones, while extracts prepared from other glands of the stomach excited no secretion. TRAUMA. The part played by trauma in the production of the gas- tric affections of middle life is not of marked importance; yet there is a definite relation, in a small proportion of in- stances, between this condition and the incidence of certain diseases of the stomach. For a long period of time it was generally held that trauma of the stomach would so far dis- turb the gastric mucosa as to produce the formation of gas- tric ulceration. This theory, however, cannot be entirely correct, for Beaumont demonstrated on Alexis St. Martin, that the stomach is markedly resistant to trauma and that repair takes place extremely rapidly. It has also been demon- strated in animals in which destruction of the gastric mucous membrane has been produced, that the mucosa heals rapidly without the production of ulceration; in fact, the healing of injuries of this character is even more rapid than in other regions of the body. This is probably due to the great vascularity of the stom- ach, as well as the power of the mucous membrane of con- tracting, and thus partly covering over and protecting the injured area. On the other hand, falls, blows, and foreign bodies, have produced massive hemorrhages from the stomach, without, however, the formation of ulceration. There can be but little question that traumatism, under certain conditions, may be a factor in the production of ul- cerations. In a study of one thousand cases of ulcer of the stomach and duodenum reported by us, a definite history of trauma was elicited in twenty-three cases, in ten of which there had been blows upon the abdomen. Fifteen of these occurred in males and eight in females. GASTRIC SECRETION AND MOTILITY. 19 The following table presents our twenty-three cases of ulcerations due to trauma, observed in males and females according to age: Years Males Females 20 to 30 1 30 ” 40 3 40 ” 50 3 50 ” 60 1 Total 15 8 Of the twenty-three cases sixteen occurred in individuals of middle age. According to Richardiere, traumatic ulcerations may be divided into two groups: 1. The acute forms which heal rapidly. 2. The forms which heal slowly and which run the course of chronic ulcerations. It is quite possible to conceive that traumatic factors, such as direct blows on or severe compression of the abdomen, may cause an injury and destruction of the mucous mem- brane of the stomach, especially at such times when the mucous membrane of the stomach is congested with blood during digestion and the stomach contains considerable quantities of food. Attention should also be directed to those instances of ulceration occurring in women who employ corsets compress- ing the stomach, and shoemakers and tailors who are sub- jected to continuous pressure on the upper abdomen. THE GASTRIC SECRETION AND MOTILITY IN MIDDLE LIFE. It has been definitely noted that the general changes that take place as individuals advance in years are similarly ac- companied by changes in the gastric secretion and motility. Both Ewald and W. Fenwick have pointed out the occurrence of atrophic changes in the stomach as well as the tendency to the disappearance of free hydrochloric acid, as individuals grow older. Karjaard was the first to systematically investigate this problem. He studied the functions of the stomach in four 20 GASTRIC DISTURBANCES OF MIDDLE LIFE. individuals who were over fifty years of age and who did not complain of any gastric disturbance. He found .an absence of free hydrochloric acid and concluded that the hypochlor- hydria is related to and proportionate to the degree of arterio- sclerosis. In a further investigation upon seventy individuals of mid- dle life and old age, Seidelin observed that free hydrochloric acid was constantly absent in twenty-eight (fourteen per cent.). In only six (ten per cent.) was there a normal per- centage of free hydrochloric acid. Of forty-five females, fif- teen (thirty-three per cent.) presented an entire absence of free hydrochloric acid, while in twenty-five males, thirteen (fifty-five per cent.) revealed the same condition. In forty- eight cases of marked arteriosclerosis there were twenty-four with an entire absence of free hydrochloric acid, while in twenty-two cases without apparent arteriosclerosis there were but four without free hydrochloric acid. Seidelin concluded that in a large proportion of individuals of middle life and old age there is an absence of free hydro- chloric acid in the gastric contents, there being a special re- lation between this condition and the degree of arterio- sclerosis. Liefschutz examined the gastric contents of sixty individu- als of middle life and over; of these, twenty-five showed a constant absence of free hydrochloric acid. He also found achylia gastrica present in thirty-seven per cent, of his cases and concluded that the gastric secretion has a distinct ten- dency to diminish at this period of life, and that an absence of the free hydrochloric acid is not an uncommon condition in old age. In 1908 Friedenwald reported his observations on twenty- seven cases in elderly individuals; in no instance did any case present symptoms indicating the presence of any gastric dis- order. Free hydrochloric acid was constantly absent in twelve of the twenty-seven cases (forty-four per cent). In only five was there a normal percentage of free HC1 (eighteen per cent.) ; of nineteen males, eight (forty-two per cent.) pre- sented an' entire absence of free HC1, while of eight females, four (fifty per cent.) presented this condition. In eighteen cases of marked arteriosclerosis there were ten with an en- GASTRIC SECRETION AND MOTILITY. 21 tire absence of free IICl, and six with a subnormal amount of free HC1, while in nine cases without arteriosclerosis there were but two without free HC1. As a further evidence of the fact that the gastric secretion has a tendency to diminish as individuals grow older, Liefschutz draws attention to the fact that thirty-seven per cent, of his cases of achylia gas- trica occurred in individuals over the fiftieth year of age. According to our own observation, this percentage is forty. The following table, taken from Friedenwald in Osier’s Mod- ern Medicine, indicates the number of cases of achylia gas- trica at various ages among one hundred and twelve cases: Years Males Females up to 20 1 1 20 ” 30 5 8 30 ” 40 10 9 40 ” 50 18 15 50 ” 60 15 20 60 ” 70 6 4 From our former observations, as well as from those of Liefschutz and others, it is evident that the gastric secretion has a tendency to diminish in advancing years and in a degree proportionate to the arteriosclerosis, and it is, therefore, un- wise to attach too much importance to the absence of this secretion in individuals advanced in years, in the diagnosis of cancer of the stomach. From more recent investigations of the gastric secretion and motility in individuals of middle life our former observa- tions have been confirmed. examinations were made by means of fractional analyses on one hundred patients af- fected with various gastric disturbances taken in regular order, and compared with a similar number of cases in young individuals under like conditions. Table Comparing the Acidity and Motility in One Hundred Patients of Middle Life with a Similar Number of Young Individuals. Y ears Normal acidity cases Hyper- acidity cases Sub- acidity cases Anacidity cases Normal motility cases Hyper- motility cases Hypo- motility cases 20 to 40 45 34 12 9 55 29 16 40 to 55 39 28 15 18 35 22 43 22 GASTRIC DISTURBANCES OF MIDDLE LIFE. From these observations it is evident, that while in youth hyperacidity is more frequent than subacidity, that in middle life hyperacidity is of less frequent occurrence, and subacidity and anacidity are more common. On the other hand, hypermotility is more frequent in youth and atony in middle life. THE INCIDENCE OF DISEASES OF THE STOMACH IN MIDDLE LIFE AS REVEALED BY AN ANALYSIS OF 500 CASES. In order to establish the incidence of the various gastric affections in middle life an analysis of the records of five hundred cases, taken in rotation, was made and the results tabulated. Diseases No. of cases Per cent. Acute and chronic gastritis, including achylia gastrica 55 11.0 42 8.4 69 13.8 Dilatation 35 7.0 69 13.8 Syphilis 10 2.0 Secondary gastric affections 99 19.8 Nervous gastric affections 74 14.8 Visceral arteriosclerosis 33 6.2 Unclassified 14 2.8 Total 500 100.0 Incidence of the Gastric Disorders of Middle Life Arranged According to Age and Sex. Diseases Acute and chronic gastritis Ulcer Cancer Dilatation Ptosis Sex M. F. M. F. M. F. M. F. M. F. Ages in years 40 to 45 7 4 14 7 5 6 5 4 9 16 45 to 50 13 6 8 3 8 17 5 3 10 12 50 to 55 11 14 6 4 18 15 10 8 8 14 Total 31 24 28 14 31 38 20 15 27 42 ACUTE AND CHRONIC GASTRITIS. 23 Incidence of the Gastric Disorders of Middle Life Arranged According to Age and Sex (continued). Diseases Syphilis Secondary gastric affections Nervous gastric affections Visceral arteriosclerosis Sex M. F. M. F. M. F. M. F. Ages in years 40 to 45 1 0 10 13 12 15 5 2 45 to 50 3 2 19 12 10 11 9 4 50 to 55 4 0 26 19 11 15 7 6 Total 8 2 55 44 33 41 21 12 According to the classification above noted the secondary gastric affections form the largest proportion of the gastric affections of middle life, 19.8 per cent; next in number are the nervous gastric affections, 14.8 per cent.; followed closely by cancer, 13.8 per cent.; ptosis, 13.8 per cent.; chronic gas- tritis and achylia gastrica, 11.0 per cent.; ulcer, 8.4 per cent., and visceral arteriosclerosis, 6.2 per cent. DESCRIPTION OF THE DISEASES OF THE STOM- ACH AS REVEALED IN MIDDLE LIFE. ACUTE AND CHRONIC GASTRITIS. In our five hundred patients of middle life, fifty-five (or eleven per cent.) were afifected with gastritis. Arranged ac- cording to age and sex these individuals may be classified as follows: Ages in years Male Female 40 to 45 7 4 45 ” 50 13 6 50 ” 55 11 14 Total 31 24 Of the fifty-five cases, ten represented the acute form, while forty-five were cases of chronic gastritis and achylia gastrica (atrophic gastritis). 24 GASTRIC DISTURBANCES OF MIDDLE LIFE Etiology. Acute gastritis is not uncommon in middle life, occurring among individuals whose digestion is impaired and in whom proper mastication is prevented by the absence of proper dentition. It not infrequently occurs as the result of errors in diet, food taken too hot or too cold, too highly spiced or fermented, unripe or decayed food, or over- indulgence in alcohol. Acute gastritis is not uncommonly observed as secondary to acute infections. Pathology. In acute gastritis there is an acute inflamma- tion of the superficial layers of the mucous membrane with an increased secretion of mucus and a desquamation of the glandular epithelium. The mucous membrane is reddened and swollen. While at the onset the gastric secretion may be normal in quantity or increased, it is soon diminished. The superficial epithelial cells undergo cloudy swelling and the principal and parietal cells can no longer be distinguished and are in a state of cloudy swelling and fatty degeneration. Round cells are found in the interglandular tissue and the capillaries are dilated. There are at times slight hemorrhages in the mucosa, and bacteria of various types are not infre- quently observed. Symptoms. The symptoms vary according to the inten- sity of the attack. In most instances there is discomfort in the abdomen, loss of appetite, nausea and vomiting; though the vomiting may be absent. In more severe cases there is pain in the region of the stomach, excessive nausea and vomiting, headache, and temperature of 100° to 103° F., the tongue becomes furred and the pulse rapid. The vomitus has often a rancid odor and consists first of food and then of mucus and finally bile. The vomited matter contains no free HC1 but lactic and other organic acids are present. The duration of this affection is short, lasting from three or four days, to a week. Inasmuch as certain infectious diseases, such as typhoid fever, as well as cholecystitis, appendicitis and enterocolitis, have in their onset identical signs as one finds in acute gas- tritis, one should constantly be on the watch for such affec- tions, otherwise grave errors may occur. Simple Acute Gastritis. ACUTE AND CHRONIC GASTRITIS. 25 Treatment. The treatment should be directed to a thor- ough evacuation of the stomach, which is usually promptly brought about by vomiting, but if this does not take place the stomach should be quickly emptied, preferably by means of the stomach tube, or if this is impossible, by means of emetics. The patient must be given complete rest in bed and starvation practiced until nausea has entirely abated. Hot stupes should be applied to the abdomen and calomel given in minute doses at half hour or hour intervals until one to two grains have been taken. If acid eructations are disturbing the patient, bicarbonate of soda or milk of magnesia can be administered. No food should be allowed until vomiting has entirely ceased. But bits of ice will often relieve the nausea and vomiting, when milk, to which lime water has been added, may be given in small quantities and food gradually increased according to the condition of the patient. Toxic Gastritis. Etiology. Toxic gastritis occurs as the result of chemical poisons, as the swallowing of strong alkalis or mineral acids in concentrated form, or is produced by such poisons as arsenic, corrosive sublimate, or phosphorus. Pathology. The result of these poisons is a destruction of the parts attacked, causing a varying degree of necrosis of the mucosa, at times the submucous layer or the entire wall of the stomach is involved with a resultant perforative peri- tonitis. Hemorrhagic areas are commonly produced with a granular and fatty degeneration of the glandular tubules. Symptoms. These vary with the degree of involvement. There is intense pain and burning in the epigastrium and esophagus with nausea and vomiting; the vomitus being streaked with blood and filled with ropy mucus. There is marked salivation and dysphagia. The abdomen is tender and distended, and intense thirst is a prominent symptom. Collapse is not uncommon, the pulse becoming small and rapid and the respirations shallow, and death may ensue in coma or convulsions. Treatment. Of prime importance is the rapid removal of the poison from the stomach, which can be best accomplished 26 GASTRIC DISTURBANCES OF MIDDLE LIFE. by immediate lavage. The poison should as far as possible be diluted and neutralized. In case of acid poisoning alkalis are indicated in the form of milk of magnesia or soda; in alkali poisoning acids such as dilute citric or acetic acids are indicated. An ice-bag should be placed over the stomach and cracked ice given by mouth, and morphin must be adminis- tered hypodermically for the relief of pain. Phlegmonous gastritis is a rather rare affection. It is ob- served as a purulent inflammation of the gastric walls, having its origin in the submucosa and gradually involving the other layers. Etiology. The cause is often difficult to determine. It has been observed as the result of trauma, small-pox, puerperal fever and pyemia. In some manner the gastric wall loses its resistance and a focus of infection by streptococci de- velops. The affection may appear as a diffuse phlegmonous gastritis or may be circumscribed (abscess of the stomach). Pathology. The most marked change is observed in the submucosa, which is thickened and covered with a purulent secretion, while the muscular coat presents a degeneration of the muscle fibers; the serous coat may also be involved. The pyloric area of the stomach is most frequently affected. Secondary involvement is not uncommon, suppurative splenitis, purulent peritonitis, pericarditis and liver abscess being among the lesions which have been noted. Symptoms. The symptoms are extremely alarming. There is always present a violent gastritis associated with pain, nausea, vomiting and high temperature; in addition, rapidity of the pulse, extreme weakness and prostration and marked toxemia are observed. This affection is ordinarily fatal in a few weeks and at times even in a few days. Treatment. The treatment is mainly symptomatic though surgery is indicated if the disease can be recognized reason- ably early. From a medicinal point of view but little can be accomplished. The stomach must be spared all food and the patient should be fed by means of rectal enemata. Morphin must be administered hypodermically. Phlegmonous Gastritis. ACUTE AND CHRONIC GASTRITIS. 27 Membranous Gastritis. But little need be noted regarding this very rare affection, which is caused by the formation of a diphtheritic membrane upon the mucosa of the stomach, due either to the diphtheria organism, pneumococcus or streptococcus. Treatment. The treatment of this condition is symptom- atic unless the diphtheria organism be noted as the cause, when diphtheria antitoxin should be utilized. Chronic Gastritis. Chronic gastritis may be a primary or secondary affection. The secondary form will be fully described under that special group known as secondary gastric disorders. As a primary disease it has occurred in forty-five of our five hundred cases of middle life. We have embodied in this division, however, fifteen cases of achylia gastrica due to chronic atrophic gastritis. Etiology. Chronic gastritis may occur as the result of a prolonged or recurrent acute gastritis; and often appears in association with other affections of the stomach, as cancer, ulcer or dilatation. The most frequent causes are, errors in diet, the too rapid ingestion of coarse and indigestible food which is not thoroughly masticated, as well as the abuse of alcohol and tobacco. It is not unlikely that neglect in the care of the mouth, infected tonsils, and decayed and ab- scessed teeth, or sinus infections may be potent factors in the production of this affection due to the chronic bacterial invasion and intoxication. The following table illustrates the thirty cases of chronic gastritis in our series, arranged according to age and sex: Ages in years Male Female 40 to 45 3 2 45 ” 50 7 1 50 ” 55 7 10 Pathology. The involvement is not limited, as a rule, to the superficial layers of the mucosa, but extends to the glandular layer and interstitial tissue. The epithelial layer is early involved and covered with mucus. 28 GASTRIC DISTURBANCES OF MIDDLE LIFE. The glands undergo degeneration in the form of cloudy swelling or atrophy, and there is both parenchymatous and interstitial inflammation present, it being impossible to dis- tinguish between the principal and parietal cells. There is also present a marked round cell infiltration and connective tissue proliferation, choking many of the lumina of the glands and thus interfering with their normal func- tion. At first the glands elaborate an excess of secretion, but as the disease progresses it becomes lessened in amount until atrophy occurs, when the secretion entirely disappears. The mucous glands continue to pour out large quantities of mu- cus and at the same time this secretion is increased by a mucoid degeneration involving the tubules as well as the fundus of the peptic glands. The connective tissue increases in quantity, especially about the pylorus, so that even stenosis of the pylorus may be produced (stenosing gastritis). In more severe forms of this disease even the muscular layer of the stomach may become involved in the connective tissue proliferation to such a degree as to cause a reduction in size of the stomach, interfering with its motility. By the progressive increase of the connective tissue com- plete destruction of the glandular area may be brought about, leading to a complete achylia gastrica. In the aggravated forms of the disease, bacteria (strepto- cocci, staphylococci, and other organisms) may be found in the glandular and interstitial layers of the stomach. In a small number of instances in middle life in individuals presenting the signs of arteriosclerosis, these sclerotic changes involve the gastric arteries, producing chronic gastritides of the mucous type. Symptoms. The symptoms of chronic gastritis appearing in middle life dififer but little from those occurring at other ages, in fact, the manifestations are frequently extremely vague and not distinctive, much resembling those observed in other gastric disturbances. The usual signs are, loss of appetite, often anorexia, dis- agreeable taste, coated tongue, fetid breath, and eructations. Not uncommonly nausea is present and patients complain of fullness and pressure after meals, palpitation, vertigo, head- ACUTE AND CHRONIC GASTRITIS. 29 ache, and constipation, or constipation alternating with diarrhea. In a certain group of these cases, especially in patients of middle life, one notes relief from gastric distress after meals, with discomfort several hours after meals (hunger sensation). Allan A, Jones has called attention to this condition, and our observations are entirely in accord with his. It is quite likely that notwithstanding the absence of free hydrochloric acid in these cases, the hyperesthesia of the gastric mucosa due to inflammation produces this condition. According to our experience the symptoms of these patients are aggravated by the administration of acids. Many patients tolerate this affection extremely well and present no untoward symptoms, while others lose in weight and strength, and complain constantly of discomfort. In the alcoholic subject the morning vomiting of large quantities of ropy mucus is familiar to many. On physical examination of patients affected with chronic gastritis one notes usually a grayish coated tongue, although this organ may be entirely clean, an offensive breath and a moderate tenderness over the entire region of the stomach, with some distention of this area. The diagnosis of chronic gastritis cannot be made from the symptoms already noted without the finding of large quan- tities of mucus. The presence of the mucus can be ascer- tained in the vomitus or in the gastric contents obtained through the tube. This mucus is ropy and thick and contains large numbers of cells, free polymorphonuclear leucocytes being especially significant. In the early stages of chronic gastritis there is often a hyperacidity, frequently called acid gastritis, but this condition is rarely observed in middle life, for with the progress of the disease as the patient reaches this period of his life the acidity has diminished below normal and anacidity is usually present. With the diminution of the free HC1 the pepsin and rennet are reduced in amount, and finally that stage of the disease occurs when there is a com- plete atrophy of the secreting glands, the stage at which restitution is no longer possible. Prognosis. The prognosis of chronic gastritis is favorable, providing the causative factors can be eliminated. The prog- 30 GASTRIC DISTURBANCES OF MIDDLE LIFE. nosis must, however, be guarded, for notwithstanding the material relief which may be obtained in most instances, relapses are not uncommon. Atrophic Gastritis (Achylia Gastrica) Einhorn introduced the term achylia gastrica to denote an absence of gastric secretion. There are two distinct varieties of this affection. The one form a result of chronic atrophic glandular gastritis and the other a neurosis. We are here only considering the former affection, the latter condition be- ing referred to later on in the section on gastric neuroses. Cases accompanied by a complete atrophy of the gastric mu- cous membrane, such as were first described by Fenwick and such as have been observed in pernicious anemia, are included in this group. In this affection we observe the final stage of a chronic anacid gastritis with atrophy of the glands. There is a senile form of achylia gastrica, often occurring in middle life in arteriosclerotic subjects, in whom senile atrophy occurs following a chronic atrophic gastritis. Achy- lias of this form also occur in carcinoma of the stomach, at times in chronic cholelithiasis and in pancreatic diseases. The following table illustrates the fifteen cases of achylia gastrica in our series, arranged according to age and sex: Ages in years Male Female 40 to 45 2 1 45 ” 50 4 3 50 ” 55 3 2 Etiology. In order to determine the presence of achylia gastrica a fractional analysis of the gastric contents accord- ing to the Rehfuss method is extremely important, as only by employing this method is it possible to differentiate the true from the spurious forms. In true achylias, free hydro- chloric acid is absent in every specimen and the total acidity is low. We also observe degenerative changes in the small fragments of the mucous membrane that are broken off by the stomach tube, indicating the anatomical basis of this affection. Symptoms. The symptoms of achylia gastrica are vari- able. They may resemble those of chronic gastritis or may ACUTE AND CHRONIC GASTRITIS. 31 be referable to other organs than the stomach. The gastric symptoms are, nausea, vomiting, eructations, discomfort after meals, and anorexia; these manifestations may, however, be entirely absent and the patient may only complain of diar- rhea. A fair degree of health may often be maintained as long as the intestine functions normally; should diarrhea, however, set in, extreme emaciation and weakness will ensue. The symptoms of this affection are often very indefinite and the disease may only be recognized after test meal examinations. Treatment of Chronic Gastritis and Achylia Gastrica. The treatment of both of these conditions is essentially the same; that is, mainly dietetic. Although it is necessary to restrict the diet, it is essential to insist on the ingestion of sufficient nourishment, as many of these patients are weak and have lost flesh. An attempt should be made to increase the gen- eral nutrition, and on this account the motor function of the stomach should as far as possible be maintained in its normal state, and any disturbance of the intestinal canal should be guarded against. It is important to arrange the diet so that it can be digested easily by the intestinal juices. The food must be broken up into as fine particles as possible and should to a large extent be given in liquid and semi-solid form. Of the liquids, broths such as barley, rice or chicken, are to be recommended. Vegetables are usually well borne and should be eaten after the removal of the cellulose. Peas and beans, strained and taken in the puree form, are especially useful. Potatoes and rice should be eaten cooked with broth or milk or as a mush. Eggs are best taken soft boiled. Meats must be given in the most digestible forms, i.e., scraped beef, brains, boiled sweetbreads, and these only in small amounts. Raw oysters and boiled white fish are permissible. Milk is badly borne at times, and cream, koumiss, or matzoon, may be sub- stituted. Butter may be eaten liberally on stale bread or toast. Cocoa may be allowed as well as weak coffee or tea. Lavage is to be recommended in those instances in which there is marked increase in the mucus secretion, fermentation or impairment of gastric motility. Drugs are only of secondary importance, though in some instances, especially those characterized by an absence of 32 GASTRIC DISTURBANCES OF MIDDLE LIFE. HC1, full doses of dilute hydrochloric acid are useful, its efficacy being increased by the addition of pepsin. In many instances of achylia gastrica pancreatin in com- bination with bicarbonate of soda serves as a useful digestant. For the anorexia bitter tonics, such as strychnin or nux vom- ica with gentian or cinchona, are recommended. ULCER. Ulcer of the stomach is a common disease in middle life. It is characterized by more or less destruction of the mucous membrane of the stomach. This lesion exhibits no tendency to heal and is attended, as a rule, with definite symptoms. Etiology. In the study of our five hundred cases of gastric disturbances of middle life, there were forty-two instances of gastric ulcer, or 8.4 per cent. Arranged according to age and sex, these cases may be classified as follows: Ages in years Male Female 40 to 45 14 7 45 ” 50 8 3 50 ” 55 6 4 Total 28 14 This table illustrates that gastric ulcer occurs more fre- quently in males than females, during middle life. In a clinical study of a thousand cases of ulcer of the stom- ach and duodenum reported by us, this affection occurred in 357 instances between, the thirtieth and fiftieth years of age, that is, 35.4 per cent., which indicates the great prevalence of this disorder during middle life. The following table, taken from our study, illustrates the incidence of ulcer in males and females, according to age: Age Cases Per cent. 0 to 10 2 0.20 10 ” 20 162 16.20 20 ” 30 345 34.50 30 ” 40 229 22.90 40 ” 50 128 12.50 50 ” 60 93 9.30 60 ” 70 38 3.80 Over 70 3 0.30 ULCER 33 Etiology. The etiology of ulcer has not yet been entirely satisfactorily established, and it is probable that a combination of factors contribute to its formation. As has already been noted, under the heading of Trauma, ulcerations may be pro- duced by injury, yet blows on the abdomen are rarely the cause of this condition. Inasmuch as the largest proportion of gastric ulcers are situated on the lesser curvature, near the pyloric area, that portion which is subjected to the great- est irritation, it is possible that the trauma produced by the mass of gastric contents, before it has become thoroughly liquefied, is a factor in the production of this affection. A further explanation has also been noted, founded on dis- turbances of the circulation; due to vagatonia constriction of the small vessels in special areas, destruction of the mucosa by the acid chyme occurs. The cause of a certain proportion of ulcerations is a hema- togenous infection with special strains of streptococci ab- sorbed from certain foci of infection. Rosenow’s work has materially altered our views regarding the etiology of ulcer in these cases, for he has been able to isolate these strains from the ulcer base in man, and with them has shown that they have an elective affinity for the stomach wall of animals when injected intravenously. The method of production of the ulceration is an infection of an embolic streptococcic type in the submucous layers of the stomach with the production of hemorrhagic areas in the surrounding tissue; in consequence of which anemic necrosis takes place, followed by the*digestion of the overlying mucous membrane by the gastric secretion. The ulcerations found in man differ materially from those produced in animals in that in the former there is a marked retardation of the healing process, while in the latter healing occurs rapidly. Sippy has attributed delayed healing to the corrosive effect of the acid gastric juice and notes that by constant neutraliza- tion of the acid chyme, healing may be brought about. Pathology. Gastric ulcers vary in size from small areas the size of a pea, to extensive processes involving large por- tions of the stomach. They are round or oval in shape, and in the large proportion of instances involve the posterior sur- 34 GASTRIC DISTURBANCES OF MIDDLE LIFE. face of the lesser curvature at the pyloric area. The localiza- tion of gastric ulcers, according to Sippy, is noted as follows: Lesser curvature 35.0 per cent. Posterior wall 30.0 ” ” Pylorus 12.0 ” ” Anterior wall 9.0 ” ” Cardia 6.5 ” ” Fundus 3.0 ” ” Greater curvature 3.5 ” ” Anterior and posterior wall 1.0 ” ” In the largest proportion of cases, ulcers are single, though two or more have been noted. Due to the tendency of ulcers to penetrate deeply, the base may be found in the muscular or serous coat. In the perforating type, the base is formed by the adjacent viscera. Ulcers are usually funnel shaped, appearing as excavations in the stomach wall, with the submucous, muscular or serous coat as the base. Surrounding the ulcer is a callous base, which at times undergoes carcinomatous degeneration. Due to cicatrization of an ulcer situated at the pylorus, stenosis of the pylorus may be produced. In some instances, necro- sis may proceed rapidly, producing a sudden perforation or a blood-vessel may become eroded, causing hemorrhage. Symptoms. The symptoms of gastric ulcer depend largely upon its size, depth and location. At first the symptoms are indefinite, manifesting themselves by slight discomfort after food, with signs of hyperacidity. Soon, regurgitation, nausea, or vomiting, may develop and finally, the typical evidence of pain presents itself. This appears soon after, or an hour or more after the ingestion of food, and is aggravated by certain types of food. Acids and the heavy vegetables and fruits increase the pain; while on the other hand, proteins, in the form of milk and eggs, relieve it. As a rule, liquids are better borne than solids. The pain is often of a paroxysmal type and may become intense. On account of the pain, patients of their own accord become disinclined to eat and in conse- quence lose flesh and strength. In some instances the pain is of the hunger type, appearing some hours after meals and is relieved by the ingestion of food. This phase, however, is far more characteristic of du- ULCER 35 odenal ulcer. Relief may be afforded, not only by food, but also by rest and by the administration of alkalies. The pain is usually localized in the epigastrium, below the ensiform cartilage. This area is tender to pressure. Boas has called attention to a dorsal tender area, to the left of the median line, between the tenth and twelfth dorsal vertebne. Vomiting may occur, sometimes after meals; usually at the height of pain, after which the pain is relieved. In many instances, vomiting does not occur, though nausea is an evident symptom. Hemorrhage may be slight and consequently may remain unobserved for a considerable time. When present in the “occult form” chemical tests will reveal its presence, either in the vomitus or stools. When the hemorrhage is profuse, other symptoms are evident, i.e., faintness, dizziness, thirst and pallor. Finally, the finding of blood in the stools reveals the exact condition. According to our experience, hematemesis occurs in twenty- two per cent, of cases, while melena occurs in fifty-one per cent. On the other hand, occult blood was determined in the feces in eighty-six per cent. Perforation occurs, according to Patterson, in about seven per cent, of all cases of peptic ulcer; it occurred in only one per cent, of our cases. It is the most serious manifestation of gastric ulcer and one of the most frequent causes of death. Perforation is evidenced by excruciating abdominal pain, ap- pearing suddenly and associated with signs of collapse, syn- cope, weakened pulse, absence of hepatic dullness, and other evidences of peritonitis; only early operation will save such patients. In the more chronic forms of perforation, in which a plastic exudate has been produced, adhesions are formed to neigh- boring organs, preventing the escape of the gastric contents into the abdominal cavity. Diagnosis. The diagnosis of gastric ulcer is arrived at from the symptoms of hematemesis, melena or appearance of occult blood in the stools; pain, vomiting, from the gastric analysis, x-ray signs, and Einhorn’s string test. While hematemesis occurs in twenty-two per cent, of all cases, it appears in thirty-one per cent, of the ulcers of middle 36 GASTRIC DISTURBANCES OF MIDDLE LIFE. life, indicating that hemorrhage is more frequent at this period of life, and of the five hundred and fifteen cases with melena of our one thousand cases of peptic ulcer, one hundred and fifteen (or twenty-two per cent.) occurred during middle life. The presence of occult blood in the stools is of great value in diagnosis, being present in eighty-six per cent, of cases; its continued persistence indicating the non-healing of the ulcer or the presence of carcinoma, while its gradual disap- pearance is indicative of cicatrization. The significance of pain and vomiting has already been described. The presence of pain together with a tender epi- gastric area and a tender dorsal area is of importance in diagnosis. It is also of importance to note the periods of intermission of pain as well as of the other symptoms, varying often from one to twelve months or more, as significant signs in the clinical course of this disease. Hyperacidity is usually noted in gastric ulcer. According to our observations of eight hundred and ten cases, normal acidity was observed in forty-six per cent.; hyperchlorhydria in thirty per cent.; hypochlorhydria and anacidity in twenty- three per cent. These values were obtained with the one- hour extraction after an Ewald meal. From our recent in- vestigations in ulcer cases by means of fractional analysis, we have arrived at the conclusion that it is unusual not to observe hyperacidity some time during the digestive period, and that hyperchlorhydria occurs far more frequently than was formerly supposed. This, however, pertains to individu- als of all ages. In our forty-two instances of ulcer of middle life, normal acidity was observed in thirty-five per cent., hyperacidity in forty-two per cent., and subacidity and anacidity in twenty- three per cent., indicating that there is a tendency even in middle life to a general reduction in acidity, a condition which we have already pointed out. The roentgen ray renders important aid in the diagnosis of gastric ulcer. From a study of seven hundred and forty- three cases reported by Baetjer and Friedenwald, the follow- ing conclusions were drawn: ULCER. 37 The x-ray offers most valuable aid in the diagnosis of pep- tic ulcer and although this method is not yet sufficiently well developed to be relied upon alone without entering into the clinical aspects of the disease, it is of the greatest diagnostic help in obscure cases. Positive x-ray findings are noted in about eighty-four per cent, of cases of peptic ulcers and in seventy-nine per cent, of cases operated upon. The String Test of Einhorn. This test is extremely valuable in determining the presence and location of an ulcer. It is especially useful when x-ray signs are doubtful or after opera- tions on the stomach, the distortion of the stomach often rendering the x-ray signs difficult to interpret. Complications. Of the important complications the follow- ing may be noted: pyloric obstruction, hour-glass stomach, perigastric adhesions, hemorrhage, subphrenic abscess, per- foration, and secondary carcinoma. Treatment. The treatment of peptic ulcer during middle life varies but little from that at other ages. Inasmuch as this disease is at least in some instances due to focal infection, previous to instituting treatment all sources of focal infection should as far as possible be removed. Aside from removing all focal infections, much can be done prophy- lactically by means of a carefully selected diet, in preventing the onset of ulcer of the stomach. As soon as the first symptoms appear the patient should be placed upon an ex- clusive milk diet. The temperature of the food should be regulated so that it be given not too hot and not too cold. Anemia and hyperchlorhydria must as far as possible be overcome. Certain advances have been made in the medical treat- ment of gastric ulcer in the past few years. According to the older plan, the Leube treatment was almost constantly followed. This consists in placing the patient at complete rest in bed for fourteen days or more, upon a liquid diet consisting mainly of milk. Upon such a diet the patient frequently loses much flesh as well as strength. On this account Lenhartz advises against the strict abstinence cure, even in those instances in which there is hemorrhage. In the Lenhartz cure an absolute rest in bed for at least four weeks is maintained. On the first day, even though 38 GASTRIC DISTURBANCES OF MIDDLE LIFE. there be hematemesis, two hundred cubic centimeters of iced milk are given in teaspoonful doses with two ice-cold beaten up eggs. The milk is increased one hundred cubic centimeters daily and an additional egg added; raw scraped beef is added on the sixth day, and on the seventh and eighth days the patient is given rice and softened zwieback. More recently Sippy has evolved a method of treating peptic ulcer, which, according to our observations in a large number of cases, has yielded the most gratifying results. Inasmuch as it is generally admitted that a peptic ulcer heals if its surface is not continuously exposed to the diges- tive action of the gastric juice, Sippy’s treatment consists in protecting the ulcer from the acid corrosion until it is healed by shielding it from the corrosive effect of the gas- tric secretion. He accomplishes this by maintaining a neu- tralization of the free hydrochloric acid, from early in the morning until late at night, usually from 7 a.m. to 10.30 p.m., or during the entire period when food or gastric secretion is in the stomach. If an excessive secretion is present at night, this is re- moved by aspiration until the secretion has disappeared. The neutralization is effected by frequent feedings and the administration of alkalies given freely and at frequent in- tervals. Nourishment is given from the onset of the treat- ment; preliminary starvation and administration of nutrient enemata common to other forms of treatment are of little value. The patient remains in bed for three to four weeks. Three ounces of a mixture of equal parts of milk and cream are given every hour from 7 a.m. to 7 p.m. After a few days, soft eggs and well cooked cereals are gradually added, until in ten days the patient receives three ounces of milk and cream mixture every hour, three or four boiled eggs, and nine to twelve ounces of cereal each day. Cream soup of various kinds, vegetables, purees, and other soft foods, may be substituted now and then as desired. There can be no question but that a large proportion of ulcer cases recover under this plan of treatment. Of four hundred and three cases of ulcer reported by us, eighty-six per cent, recovered under the Sippy cure. ULCER 39 In those instances in which the ulcer is of a severe type associated with excessive vomiting, pain or hematemesis, food by mouth should be withheld for three to five days and the patient fed by rectum. A Murphy drip, consisting of normal salt solution and containing glucose, is especially to be recommended. In case of hemorrhage an ice-bag should be placed ov£r the epigastrium and morphin must be given hypodermically; thirst is to be overcome by small bits of crushed ice. But little effect is obtained by means of the usual hemostatics. The writers have, however, ob- served splendid results by means of blood transfusions. Of the greatest importance in the treatment of certain cases of ulcer, especially those of a severe type, accompanied by excessive vomiting and nausea, is the method devised by Einhorn, known as duodenal alimentation. By means of this method, food can be introduced directly into the duodenum. Of the remedies employed in the treatment of gastric ulcer, atropin appears to have an almost specific effect in some instances; by depressing the vagus fibers it decreases the secretory and motor functions of the stomach and thus promotes healing. Bismuth preparations, scarlet red, nitrate of silver, and olive oil, have been recommended. Surgical Treatment. Simple uncomplicated gastric ulcers do not require operations. Operation must only be con- sidered when there are complications, or when the ulcer has resisted a thorough medical treatment; especially is opera- tion indicated in those cases accompanied by severe and persistent pain, vomiting, or hemorrhage, or in pyloric ul- cers accompanied by stenosis. In ulcers situated at other parts of the stomach, operation gives but slight relief unless radical procedures (resection or excision) are undertaken. Operation should be promptly practiced in all cases of per- foration, and ulcers of the stomach accompanied by tumor formation always demand surgical intervention. The char- acter of the surgical procedure to be selected is of the great- est importance. This, of course, must vary according to the situation and extent of the ulcer; thus the beneficial effect of gastroenterostomy is dependent upon the proximity of 40 GASTRIC DISTURBANCES OF MIDDLE LIFE. the ulcer to the pylorus—the closer to the pylorus, the better is the prognosis. According to Finney and Friedenwald, the results of pyloroplasty and pylorectomy are far better than gastro- enterostomy. There were 90 per cent, of immediately suc- cessful recoveries and 86.6 per cent, of satisfactory end re- sults following pyloroplasty, while there were but 82 per cent, of satisfactory immediate recoveries and 77.2 per cent, of satisfactory end results following gastroenterostomy. Healing of Ulcers. Attention must be directed to the ques- tion as to what means we possess of determining whether an ulcer has really healed, other than that indicated by the relief of symptoms. Baetjer and Friedenwald were among the first to call attention to the fact, and other clinicians have since corroborated this finding, that the degree of heal- ing can be determined by means of the x-ray, i.e., by making roentgen ray observations over a long period of time during the course of treatment, we are enabled to determine the progress of healing and note when the ulcer has healed. This method has been utilized by us to great advantage in many instances. After-treatment of Ulcers. There can be but little ques- tion that relapses are frequently due to indiscretions in diet following the cure, when the patient is no longer under the control of his physician. The patient should be placed upon a carefully regulated diet free from acids and indigestible foods; intermediate feeding should be prescribed and alka- lies be administered for some months following the cure. CANCER. Cancer of the stomach is a common disease of middle life, According to W. H. Welch, next to the uterus, the stom- ach is most frequently the seat of this disease. In an analy- sis of 30,000 casesi he finds the stomach involved in 21.4 per cent. In a clinical study of 1000 cases of cancer of the stomach made by us, this affection occurred in 9.6 per cent, of patients afflicted with various gastric disturbances, while peptic ulcer only appeared in 7.8 per cent. W. J. Mayo maintains that nearly one-third of all cancers occur in the stomach. In a Census Bureau report it is estimated that CANCER. 41 of a total of 140,088 deaths from cancer, the stomach and liver combined constituted 36.4 per cent. The incidence of this disease varies in different countries; Griesinger main- tains that it never occurs in Egypt, while it is extremely prevalent in the United States, Germany and Switzerland. Welch observes that three-fourths of his cases occurred between the ages of forty and seventy. In our study of 1000 cases of cancer of the stomach, the maximum liability of the disease lies between the fortieth and sixtieth years (sixty-five per cent.), the greatest number of cases occurring between the fiftieth and sixtieth years. In an analysis of 150 cases of cancer of the stomach reported by Osier, sixty- two (41.3 per cent.) occurred between the ages of forty and fifty-five years, while fifty-eight per cent, occurred between forty and sixty. In our study of 500 cases of the gastric disturbances of middle life, cancer of the stomach occurred in sixty-nine cases (13.8 per cent.); of these there were eleven between the ages of forty and forty-five; twenty-five between forty-five and fifty, and thirty-three between fifty and fifty-five. The disease is slightly more frequent in males than fe- males; according to Welch, 1233 males to 981 females, and according to Osier, 126 males to 24 females. In our 1000 cases there were 588 males and 412 females. The following table, taken from our clinical study of 1000 cases of cancer of the stomach, illustrates the number of cases observed in males and females, according to age: Years Males Females Total 20 to 30 3 1 4 30 ” 40 23 14 37 40 ” SO 125 136 261 50 ” 60 249 146 395 60 ” 70 143 75 218 70 ” 80 45 40 85 Total 588 412 1000 The study of our cases of middle life reveals the following incidence: 42 GASTRIC DISTURBANCES OF MIDDLE LIFE. Ages in years Male Female 40 to 45 5 6 45 ” 50 8 17 50 ” 55 18 15 Total 31 38 ' Cancer of the stomach is more frequent in the white than the colored race. According to the statistics of our 1000 cases, there were 948 whites to 52 colored—that is, 94.8 per cent, whites and 5.2 per cent, colored. Of the fifty-two cases in the colored race, ten occurred in males, and seven in females, during middle life. Etiology. The part played by heredity as a predisposing cause of cancer has not yet been definitely established, though it is now more generally believed that this factor plays but a subordinate role. The following tables, abstracted from our 1000 cases of cancer of the stomach, are interesting in this regard. An hereditary history of cancer appearing in various por- tions of the body occurred in 104 of the 1000 cases (9.4 per cent.). Of these there were: With a family history of cancer of the stomach Cases 22 yy yy yy yy yy ” ’ uterus 37 )> yy yy yy yy yy ” ” breast 24 yy " ” ” ” yy ” ” throat 5 » yy yy yy yy ” ” ” rectum 11 yy yy yy yy yy yy ” ” face 5 Total 104 The following table indicates the ages of the cases pre- senting a family history of cancer, showing that the largest proportion of cases occur in those years in which the great- est number of cases of cancer of the stomach occur—that is, in middle life: Age Cases 4 Cases with family history of cancer 3 30 ” 40 37 33 40 ” 50 261 44 50 ” 60 395 22 60 ” 70 218 5 70 ” 80 85 Total 1000 104 CANCER. 43 Trauma has been noted as a cause of cancer of the stom- ach. Osier reports but one case, while Coley refers to a number of instances. In our cases a history of trauma was elicited in nineteen, in six of which there had been blows on the abdomen. Previous disorders of digestion bear a detinite relation to this disease. In the 1000 cases of cancer there was a history of some previous digestive trouble in 232 cases (23.2 per cent). Of the 232 cases, 109 had slight attacks of indigestion for a period of five years or more preceding the present gastric disease, while twenty-five had slight attacks only during the last five years preceding the present disease. Of the remaining 123 cases, thirty-two had chronic indigestion more or less all their lives, of which twenty-nine had chronic indigestion mainly during the last five years preceding the present illness. Seventy-three cases gave a definite history of former gastric ulcer. It is therefore evident that of these 1000 cases, but twenty-three per cent, presented a history of any previous digestive disturbance whatever, even in the slightest degree, and that but 7.3 per cent, gave a direct history of ulcer. If, therefore, all of the former digestive disturbances be considered as due to ulcer, the formation of gastric cancer from ulcer could not have taken place in more than twenty-three per cent.; if all of these cases with slight digestive disturbances be disregarded in our series, this per- centage is reduced even to 12.3 per cent. Wilson has con- cluded that practically all carcinomata develop on the site of a previous ulcerative lesion of the gastric mucosa, though this is not in accord with our clinical experience. Some clinicians consider chronic inflammations of the mu- cosa as predisposing factors in the production of cancer, especially when present in the polypoid form. Finney and Friedenwald have reported three cases of gastric polyposis with carcinomatous degeneration. Excesses in food and drink have an etiological bearing on this affection. A his- tory of former indiscretions in diet was obtained in 32.1 per cent, of our cases, but only in 13.7 per cent, did the patient attribute his disease to some specific error in diet. A history of alcoholism was obtained in 15.2 per cent, of our cases. 44 GASTRIC DISTURBANCES OF MIDDLE LIFE. Infectious Diseases. A history of syphilis was obtained in seventy-nine instances; tuberculosis of the lungs was present in forty-eight instances. Cardiovascular Changes. Chronic endocarditis was present in 11.4 per cent., arteriosclerosis being observed in 69.6 per cent, of all cases, as may be noted in the following table: Age Cases Cases with arteriosclerosis Per cent, of cases with arteriosclerosis 20 to 30 4 0 0 30 ” 40 37 0 0 40 ’ 50 261 89 12.7 50 ’ 60 396 321 46.1 60 ’ 70 218 201 28.7 70 ’ 80 85 85 12.5 Pathology. Cancer of the stomach originates in the gland- ular structure of the mucosa and consists of an atypical pro- liferation of the glandular epithelium. It soon infiltrates the submucous, muscular and serous coats and extends into the lymphatic glands- which become enlarged. The growth has a tendency to ulcerate, sometimes deeply and at other times superficially, and at times involves the blood-vessels, causing hemorrhage. As the disease progresses metastatic nodules appear in the liver, omentum and other organs. Metastases were noted in 672 (67.2 per cent.) of our cases, distributed as follows: 255 (37.9 per cent.) occurred in the glands. 222 (33.0 per cent.) ” ” ” liver. 54 ( 8.0 per cent.) ” ” ” peritoneum. 45 ( 6.6 per cent.) ” ” ” pancreas 41 (6.1 per cent.) ” ” ” intestines. 14 ( 2.0 per cent.) ” ” ” lung. 12 ( 1.7 per cent.) ” ” ” spine. 2 ( 0.3 per cent.) ” ” ” skin. 27 ( 4.0 per cent.) undetermined. It is evident that over seventy per cent, of the metastases appeared in the glands and in the liver. Location of the Growth. Cancer of the stomach is most frequently located in the pyloric region. According to Welch, of his 1300 cases, 791 were at the pyloric area, 148 on the CANCER. 45 lesser curvature, 104 at the cardia, 68 on the posterior wall, 61 involved the greater part of the stomach, 45 were multiple tumors, 34 were found on the greater curvature, 38 on the anterior wall and 19 on the fundus. According to our ob- servations in 284 cases determined at operation or autopsy, the location of the growth was as follows: Number Per cent. In the pyloric area 166 58.4 ” ” cardiac ” 19 6.6 ” ” lesser curvature 23 8.1 ” ” greater ” 12 4.2 ” ” fundus 8 2.8 General involvement 56 19.7 The most common forms of cancer of the stomach are: I, Scirrhous. II, Adeno-carcinoma. Ill, Medullary. IV, Colloid. I. In scirrhous carcinoma one observes large amounts of connective tissue, producing a firmness in the growth which at times is almost cartilaginous in character and on section presents a pearly or yellowish appearance. This growth has but a slight tendency to ulcerate except late in the course of disease; it is slowly progressive, metastases being infrequent. This growth is most frequently noted at the pylorus and on account of the contraction of the fibrous tissue is apt to pro- duce stenosis. When this tumor is diffuse and involves a large portion of the stomach it is apt to lead to the condition known as linitis plastica. II. Adeno-carcinoma of the stomach occurs, as a rule, in the form of soft tumors of the polypoid type. It is most com- monly found near the pylorus and eventually ulcerates. III. Medullary carcinoma consists of soft spongy tumorous masses involving all of the coats of the stomach, forming cauliflower-like projections into the mucous membrane. As a rule it metastasizes early, and ulcerations and hemorrhage are not infrequent. IV. Colloid Carcinoma. This form of cancer is formed from a colloid degeneration of the cells of a malignant growth in the stomach. It invades all of the coats of the stomach and metastases are frequent. 46 GASTRIC DISTURBANCES OF MIDDLE LIFE. Carcinoma of the stomach is usually primary, though sec- ondary growths have been noted in the stomach. In our series secondary cancer of the stomach occurred in 0.9 per cent. Three were secondary to breast cancers, two to rectal cancers, and four to uterine cancers. Complications. Among the complications which may arise as a result of carcinoma of the stomach are: dilatation of the stomach due to pyloric stenosis; adhesions to neighboring organs; perforation; hemorrhage; and subphrenic abscess. In our series of 1000 cases, dilatation of the stomach occurred in forty-six per cent., the largest number being noted between the fiftieth and sixtieth years. Symptoms. The recognition of carcinoma of the stomach is exceedingly difficult in its early states. For it is a well recognized fact that the earlier the stage of the growth, the less positive are its manifestations. If one analyzes a series of cases of cancer of the stomach, one finds that the patients developing this affection are not as a rule chronic dyspeptics, and, excepting in those instances in which the disease has developed from a previous gastric ulcer, have usually been in good health with a normal digestion until the onset of this disorder. This fact is well illustrated in the 1000 cases of cancer of our own, in which there was a history of some previous di- gestive trouble in but 232 cases (23.2 per cent.). Of the 232 cases, 109 had slight attacks of indigestion for a period of five years or more preceding the present gastric disease, while 25 had slight attacks only during the five years pre- ceding the present disease. Of the remaining 123 cases, 32 had chronic indigestion more or less all their lives, of which 29 had chronic indigestion mainly during the five years pre- ceding the present illness. Twenty-three cases gave a definite history of former gastric ulcer. It is, therefore, evident that of these 1000 cases, but 23 per cent, presented histories of previous digestive disturbances, even in the slightest degree, and that but 7.3 per cent, gave direct histories of ulcer, while in 77 per cent, of the cases the onset was sudden and acute. The fact that the onset of this affection is sudden in a large proportion of cases is a sign of great value in the early diagnosis of this disorder. CANCER. 47 In our endeavor to arrive at an early diagnosis, the most important signs and symptoms must be taken into considera- tion. Of these the following are most characteristic: Loss of flesh. Pain. Anorexia. Vomiting. Dysphagia. Hematemesis. Melena and the presence of occult blood in the stools. The presence of a palpable tumor. Dilatation of the stomach. Ascites and edema of the extremities. Changes in the gastric secretion. Certain roentgenological findings. Loss of Flesh. Loss of flesh is a sign of very considerable importance. It occurred in 98.5 per cent, of our cases, in which there was a loss of flesh of from five to seventy-eight pounds. We have observed, however, that thirty per cent, of our cases presented periods of improvement in weight and in general conditions, with an increase in flesh of from five to twenty-five pounds. These periods of improvement oc- curred, in the greatest number of cases, from one or two months (that is, in seventy-nine per cent, of all cases) after the beginning of treatment. While, therefore, loss of flesh is a sign of importance as an early sign of cancer, periods of improvement with gain of flesh are not uncommon in the early period of this disease, and this should be kept in mind in the diagnosis of gastric cancer. Pain. Of our cases, pain was present in 93.1 per cent.; in 56 per cent, of these cases pain extended more or less over the entire abdomen; it was limited to the epigastric region in 22.9 per cent.; in 68 per cent, to the lower abdomen; in 6.2 per cent, to the back, and in 1.1 per cent, to the chest. It was present as an early sign in 84 per cent, of our cases, but because of its variation as to location and extent, its diagnostic value as an early sign of gastric cancer is lessened. Anorexia. Anorexia is a very prominent symptom of gas- tric cancer, and was present in over 89 per cent, of our cases. It varies markedly from a slight loss of appetite to an abso- 48 GASTRIC DISTURBANCES OF MIDDLE LIFE. lute aversion to food. It was slight in 23 per cent, of our cases, moderate in 30 per cent., and variable in, 7 per cent. It is usually a very early symptom, but is present in so many other affections that, unless taken in connection with other signs, is of but little significance. The aversion for meat, which frequently occurs early in the disease, is of diagnostic importance. Vomiting. Vomiting is also of frequent occurrence in gas- tric cancer, appearing in 89 per cent, of our cases, in 67 per cent, of which it was in no way associated with the ingestion of food. This symptom is exceedingly frequent, but presents such slight relationship to food that it can be accorded only minor importance in diagnosis. Dysphagia. Dysphagia existed in 6.9 per cent, of our cases; that is, in those instances in which the growth involved the cardiac orifice. It appeared as an early sign in 78 per cent, of these cases, and according to our experience, when mani- festing itself in patients over forty years of age, is a sign of great significance. Hcmatemcsis. Gastric hemorrhage occurred in 22.7 per cent, of our carcinoma cases, of which 88.7 per cent, were multiple and 10.8 per cent, single hemorrhages. It appeared as an early sign in 21 per cent, of these cases, and as a late sign in 79 per cent. The hemorrhages were small in 66.5 per cent., profuse in 27.3 per cent, and variable in 6.1 per cent, of these cases. It was coffee-ground in 88.9 per cent, of all the cases with hemorrhage, bright red in 7.9 per cent, and variable in 3.1 per cent. Inasmuch as gastric hemorrhage appears early in only a small proportion of cases, it can only rarely be relied upon as an early sign of this disease, but when it oc- curs, especially in the coffee-ground form, it presents addi- tional evidence in the diagnosis. Melena. Tar-colored stools appeared in 18.9 per cent, of our cases, much less frequent than hematemesis, but in only a small proportion of these cases did it appear as an early sign (that is, in 14 per cent.), while it appeared late in 86 per cent. The stools were examined for occult blood in 642 of our 1000 cases. A positive reaction was obtained in 92.5 per cent. When occult blood is once observed, it can usually be found CANCER. 49 at any time afterward. Of the 642 cases, 216 were early cases. Of these, 93 per cent, presented occult blood, indicat- ing that the presence of occult blood is a very constant as well as an early sign of gastric cancer. Presence of Palpable Tumor. While the presence of a pal- pable tumor is the most valuable diagnostic sign of gastric cancer, yet this sign is usually a late manifestation of the disease. According to our observations, in only 30 per cent, of our cases could a mass be palpated within six months after the first appearance of symptoms, while in 70 per cent, it was present only after six months, from which it is evident that the appearance of a palpable mass is over twice as com- mon after the first six months after the first appearance of symptoms than before that period, and cannot, therefore, be relied on as an early sign of this affection. Dilatation of the Stomach. Dilatation of the stomach due to pyloric stenosis occurred in 47 per cent, of our cases, and this condition, when present early, is of the greatest diagnostic value. It occurred as an early sign in 52 per cent, of our cases of gastric cancer. As Baetjer and Friedenwald have pointed out recently in a paper “On the Diagnosis of Incom- plete Forms of Pyloric Stenosis by Means of the X-ray,” beginning obstructions of the pylorus occur early as partial obstructions, which gradually increase in degree until com- plete stenosis is produced. Partial obstructions often begin early in the course of the disease, and can usually be easily recognized by means of roentgen ray examinations. Partial stenosis, when ulceration can be excluded, is of the greatest significance in the early diagnosis of cancer. Ascites and Edema of the Extremities. Ascites or edema appeared in 21.1 per cent, of our cases. Ascites appeared alone without edema in 4.4 per cent.; edema appeared without ascites in 10.4 per cent.; edema and ascites appeared together in 6.3 per cent. Of the 211 cases with ascites or edema, but 24.6 per cent, presented these signs before the first six months after the appearance of symptoms, while 74.7 per cent, pre- sented these signs after the first six months, indicating that both ascites and edema are late manifestations in gastric cancer. 50 GASTRIC DISTURBANCES OF MIDDLE LIFE. Changes in the Gastric Secretion. In 89 per cent, of our cases there was an absence of free hydrochloric acid. The absence of free hydrochloric acid is an early sign in many instances, appearing in 81 per cent, of our early cases, and when taken in conjunction with other symptoms, is a sign of real im- portance ; and yet an absence of hydrochloric acid .is so fre- quently observed in affections other than cancer that this sign loses much of its significance. In this connection it must not be forgotten that after the fiftieth year of age there is a natural tendency to a diminution in the gastric secretion, and that it is not uncommon to observe this condition as a manifestation of middle life. There should not be too much stress, therefore, placed upon this finding as an evidence of cancer. Lactic acid was present in 82 per cent, of our cases. It was present only in any appreciable amount in those in- stances in which there was a complete absence of free hydro- chloric acid. It appeared as an early sign in 76 per cent, of our cases. The diagnosis of cancer is greatly strengthened when, in the absence of free hydrochloric acid, lactic acid is found. The Oppler-Boas bacilli were observed in 79 per cent, of our cases. They were found only in those instances in which lactic acid was observed, and appeared as an early sign in 74 per cent. This finding when accompanied by the presence of lactic acid and an absence of free hydrochloric acid, is a sign of great diagnostic importance. We have utilized the Wolff-Junghans test in 106 of our cases of gastric cancer. In all of these cases there was an absence of free hydrochloric acid. According to the observa- tions of Wolff and .Junghans, the gastric contents in cancer present large quantities of soluble albumin, while in non- malignant achylias but little albumin is obtained. By means of simple dilutions of the contents, and precipitating the soluble albumin by means of a phosphotungstic hydrochloric acid mixture, the variations in this reaction can readily be observed. In 89 cases (83.9 per cent.) there was a positive reaction obtained. Of these. 18 were early cases, and the reaction was positive in 13 (72.2 per cent.). This test is an extremely CANCER. 51 valuable sign when positive in the early diagnosis of gastric cancer, especially when there is an absence of free hydro- chloric acid, and when lactic acid is present in the gastric contents. Certain Roentgenological Findings. The roentgen ray exami- nations have been of great help in many instances in the diagnosis of gastric cancer. Inasmuch as the largest pro- portion of cancers have their seat at or around the pylorus, early obstruction is not infrequent. In the early stages of this disease, as we have already pointed out, the obstruction is incomplete, and it is only by means of the x-ray that be- ginning or partial obstructions of the stomach can be deter- mined. In the early stages of this condition we have active contractions of the stomach, with a slow elimination of the stomach contents. Another very significant sign is the fact that we frequently observe that a portion of the stomach just within the pylorus, on the greater curvature in the pyloric region, shows a tendency to bulge. This condition is pro- duced by the active contractions of the stomach forcing all of the food towards the pyloric region. The pylorus not being patent, the prepyloric region becomes dilated under this constant pressure, so that the plates present the pylorus not at the end of the stomach, as it were, but the prepyloric region extends farther to the right than the pylorus, the pylorus resting on the top of the stomach and pointing to the splenic region. The prepyloric bulging is dependent largely upon the duration of the afTection. In the early stages it is very small, but, as the condition advances, the prepyloric bulging may reach the size of a hen’s egg. As the condition advances, dilatation begins to take place, and after a time practically the entire fundus yields, so that a typical sac-like formation is produced, and the entire bismuth rests in the bottom of the fundus. In this state the examination will present a retention of contents of from ten to twenty hours. The most important x-ray evidence, however, of cancer is a filling defect, which remains constant in all of the plates. When the disease has been present for some time (that is, in advanced cases) the defect is large and very irregular, and there is an absence of peristalsis at this area. In the early cases, however, there is but a slight thickening at the cancer 52 GASTRIC DISTURBANCES OF MIDDLE LIFE. area with weakened peristalsis, which frequently makes the diagnosis exceedingly doubtful or even at times impossible. While, therefore, the roentgen ray examination is exceed- ingly useful and presents important aid in the diagnosis of gastric cancer, it is of value only in certain instances in the early stages. Special Tests. The only special tests that need here be considered are: 1, Abderhalden’s serum test, and 2, the blood-sugar tolerance test. I. Abderhalden’s Serum Test. Dr. Charles E. Simon has tested this reaction in a number of our cases of gastric carcinoma, and finds that the reaction cannot be considered specific for this disease. This cannot be explained on the basis of faulty technique, as the utmost care was taken in carrying out the test. It may be due to the fact that we are dealing with various cellular types in carcinoma, and that, for instance, a serum from a patient afifected with a squamous-celled carcinoma may not react to the serum of one afifected with a cylindrical-celled carcinoma. Fulchiero found that in thirty-six cases of carcinoma there was a posi- tive reaction in only twenty-one (that is, in sixty per cent.), and that in forty-five serum controls in cases of various kinds (not cancer) there was a positive reaction in five cases (12.1 per cent.). This indicates that there may be a variation in two directions, as there may be failure to get the reaction in undoubted cases of malignancy, and on the other hand, there may be obtained a positive result in con- ditions which are not malignant. II. Blood-Sugar Tolerance Test. Friedenwald and Grove have described this test as rather characteristic of carcinoma of the stomach and intestines, providing diabetes, nephritis, tuberculosis and thyroid disturbances can be excluded. In cancer of the stomach this curve presents a high sugar con- tent even in the fasting state, followed by an initial rise up to 0.24 per cent, or even higher within forty-five minutes after the ingestion of the dextrose, remaining at this level or higher for at least two hours, and at no time falling below 0.20 per cent. In drawing our final conclusions concerning the sig- nificance of the various signs and symptoms of gastric can- CANCER. 53 cer, it is quite evident that many are general manifestations frequently present in other gastric affections, and not char- acteristic of this condition alone, while those which are more characteristic are usually late developments. On this ac- count the late diagnosis of cancer is rendered exceedingly simple while, on the other hand, the early diagnosis is exceedingly difficult. In reaching definite conclusions it is therefore important to rely not upon a single sign or symptom, for there are no pathognomonic signs of early cancer, and only after a criti- cal review of the history, physical examination, and study of the symptoms, including examination of the gastric con- tents and stools, can definite conclusions be drawn. We take into the consideration, in our diagnosis, the age of the patient, the history of the affection (that it, its onset in the midst of good health), the anorexia, vomiting, pain, hemat- emesis, loss of flesh and strength, and early dilatation of the stomach. In addition, we have the evidences afforded by the examination of the gastric contents; that is, the absence of free hydrochloric acid, and the presence of lactic acid, Oppler-Boas bacilli and blood. A positive Wolff-Junghans reaction, manifestations of gastric retention, and the persistence of occult blood in the stools, are evidences of additional value. But we rarely have all of these signs present in early cancer, and usually there are so few that the diagnosis is impossible. It is most important, too, to remember that gastric cancer usually appears at the age in which arteriosclerotic changes have already manifested themselves, on account of which there are retrogressive changes and impaired metabolism with loss of strength, with symptoms often akin to those of cancer. There is at this period of life, as we have observed some years ago, a tendency even to a diminution of the gas- tric secretion with an absence of free hydrochloric acid, and this, too, may further complicate the diagnosis. Further difficulties often arise by the occurrence of gastric cancer in patients suffering with some preceding affection, such as dia- betes, chronic Bright’s disease, cardiac affections, and chronic infections, on account of which there are often marked ema- ciation, loss of strength, and indigestion; the presence of a 54 GASTRIC DISTURBANCES OF MIDDLE LIFE. carcinoma may, therefore, easily be entirely overlooked. Finally, there still remains another group of cases, known as latent cancers, in which symptoms are not revealed until late in the course of the disease, and, at times, not at all. Inasmuch as surgery offers the only cure for gastric cancer, and then only when the diagnosis is made early, the question of early diagnosis is of the greatest importance. How can this be made? As yet it is impossible to reach very definite conclusions at the early stage, except in rare instances. But it behooves us to carefully observe all of our cases of gastric disturbances most critically, and to view with suspicion all patients over forty years of age who show no improvement after a short course of medical treatment. Inasmuch, therefore, as our means of early diagnosis of cancer of the stomach are exceedingly insufficient, and until more certain methods of diagnosis are available, exploratory incisions should be urged upon all individuals over forty years of age having gastric symptoms which are not relieved after a few weeks of treatment. Especially is this the case if the patient presents a history of rather abrupt onset, some loss of flesh, an absence of free hydrochloric acid in the gas- tric contents, and occult blood in the stools. Even under these conditions many cases will be operated on too late, for there can be no question but that gastric can- cer may be present for some time and may assume consider- able proportions even before marked symptoms of indigestion are manifested. Differential Diagnosis. In the differential diagnosis the fol- lowing conditions must be taken into consideration which are also apt to occur in middle life. Of these we have grave anemias of the pernicious type, syphilis, cirrhosis of the liver, ulcer of the stomach, and achylia gastrica; and occasionally some form of nervous gastric affection. Treatment. The treatment of cancer of the stomach is surgical, but unless the diagnosis is made early the results of surgery are most disappointing, rarely accomplishing more than relief and never cure. Of the entire number of our cases, operations were performed in two hundred and sixty- six instances. Of these, fifty-one per cent, were exploratory. DILATATION OF THE STOMACH. 55 Gastroenterostomies were performed in thirty-six per cent.; gastrostomies in seven per cent., and pylorectomies and gas- trectomies in three per cent. Thus far the results have not been encouraging. In the further treatment of this disease internal treatment is only palliative, in which diet plays an important role. Food should be given in small quantities, should be very nutritious and easily assimilated. When there is obstruction either at the cardia or pylorus, the food should be either liquid or semisolid. Of the liquid foods, milk, but- termilk, koumiss, and broths, are to be recommended. Fruit juices, vegetable juices, and eggs, are also useful in this dis- ease. Fat should be given in the form of butter and olive oil. Meat, which is usually distasteful to these patients, can be prescribed scraped or given as meat jelly. Vegetables must be taken in puree form, and bread should be thoroughly toasted or taken as zwieback. Inasmuch as this disease is incurable, too great a restriction should not be placed upon the diet and monotony should be avoided. In the further treatment of the patient, lavage is of great value, especially if there be a motor insufficiency at hand. The use of drugs in this affection is purely palliative, inasmuch as no remedy is known that can exert the slightest beneficial affect upon the course of the disease. Codein and morphin must be prescribed for pain, and bitter tonics may be given as stomachics. DILATATION OF THE STOMACH. In dilatation of the stomach there is always present a marked motor insufficiency; a motor insufficiency of a less degree producing atony. We, therefore, distinguish between motor insufficiency of the: first degree (atony) and motor insufficiency of the second degree (dilatation). Both of these conditions are important factors in the study of diseases of middle life. Atony is characterized by relaxation of the mus- cular wall of the stomach and has been variously classified; and will be discussed further on under the gastric affections of the sympatheticotonic group. In dilatation of the stomach we recognize a chronic state in which the stomach is no longer able to expel its contents, in consequence of which there is a stagnation of food. 56 GASTRIC DISTURBANCES OF MIDDLE LIFE. Etiology. Dilatation of the stomach may be due to one of two causes. Either atony, which by becoming more aggra- vated, is gradually transformed into this condition, or to stenosis of the pylorus. It is rare, however, to observe dila- tation due to atony. The main conditions leading to dilata- tion are: the cicatrization of gastric ulcers, the contraction of cicatricial tissue from cholecystitis or following operations on the gall-bladder, and the occlusion of the pylorus by carcinoma. Other but less important factors are: the forma- tion of polypi at the pylorus, hypertrophy of the muscles surrounding the pylorus in certain forms of chronic gastritis, long continued pylorospasm, and pressure from abdominal growths. In our series of the five hundred cases of middle life, dila- tation occurred in thirty-five instances. Fourteen of these were due to ulcer, and twenty-one to cancer. The following table illustrates our cases of dilatation due to ulcer and can- cer, arranged according to age and sex: Years Number of males Number of females Ulcer Cancer Ulcer Cancer 40 to 45 4 1 3 1 45 to 50 2 3 1 2 50 to 55 2 8 2 6 Symptoms. The symptoms first manifested are, distention, fullness and pressure, which finally give rise to pain; the pain being due to the attempt of the stomach to empty itself and overcome the obstruction. Finally symptoms of stagnation occur, which are manifested by the vomiting of large quan- tities containing the remains of food eaten on a previous day. The vomitus is of the well known three-layer variety. On standing in a glass it separates into a lower layer of solid particles, with a middle layer which is fluid and cloudy, and a top layer containing mucus filled with gas bubbles. On microscopic examination of the fluid, sarcinae and yeast spores are present in abundance. In the vomitus associated with the stenosis produced by cancer, the material is thick, contains a great quantity of mucus and is much decomposed. As the DILATATION OF THE STOMACH. 57 disease progresses the thirst becomes intense, the urine is diminished and constipation is marked. The appetite gradu- ally diminishes and emaciation may become extreme. These patients are much weakened and complain of dizziness, lassi- tude, and headaches. The diagnosis is definitely determined by the symptoms already noted, by the visible peristaltic movements and x-ray signs of stenosis, which are extremely definite presenting at least a twelve to eighteen hour reten- tion. The examination of the gastric contents reveals food remains of the previous day, and the characteristic three layered contents. In non-malignant stenosis the gastric con- tents is acid due to HC1 and organic acids, and sulphuretted hydrogen is frequently present. In stenosis due to carcinoma HC1 is usually absent, but the presence of lactic acid and Oppler-Boas bacilli are important aids in diagnosis. Treatment. The treatment of this affection is mainly sur- gical, though at times when taken early this condition may be overcome by medical means. Diet plays an important role in treatment. This should consist largely of semisolids and should be given in small quantities at frequent intervals. Proteins should be prescribed in the form of chicken, chops, or beef, but only in the minced or scraped forms. Green vegetables must be given in the puree form and carbohydrates only in small amounts. Liquids should be restricted in amount as far as possible, best given as milk. Cohnheim has advised the administration of olive oil in these cases. In order to allay the thirst, bits of crushed ice may be allowed and water given by rectum. In those instances in which food is constantly vomited, rectal alimentation in the form of the drip method, with glucose, should be practised. Much relief is often obtained by means of lavage, or perhaps better still, by expressing a portion of the contents of the stomach at times, according to the recent method advised by Boas. The use of drugs is of but little value in this condition. In malignant forms with the absence of free HC1, dilute hydro- chloric acid should be administered with pepsin. In the non- malignant forms, alkalies with atropin are indicated. In all well defined cases of stenosis of the pylorus with stagnation, operation is indicated. In stenosis due to ulcer, our most favorable results have been obtained by means of Finney’s 58 GASTRIC DISTURBANCES OF MIDDLE LIFE. pyloroplasty and when this cannot be practised gastroenter- ostomy or perhaps pylorectomy should be done. In stenosis due to carcinoma the most favorable results are obtained by means of pylorectomy. At times gastroenterostomy is the only means open for relief. There is a complication which at times is associated with gastric dilatation known as tetany, to which attention must be drawn. This condition is characterized by paroxysmal or constant bilateral tonic spasm of the extremities. In all of these cases operation is indicated. Moynihan reports four- teen cases in which gastroenterostomy was performed, with cure. Acute Dilatation of the Stomach. Acute dilatation of the stomach is an extremely serious affection, noted especially after abdominal operations, trauma, dietetic errors, and tox- emias from infections, as in pneumonia or typhoid. The characteristic feature is an enormous distention of the stom- ach, merging into the paralytic state. This affection is often the first stage of an arteriomesenteric ileus. The symptoms of this condition are, pain of an intermittent type, continuous vomiting, difficulty in obtaining bowel movements, and signs of collapse. In the treatment of this affection lavage plays an important role. This is best accomplished by allowing the Einhorn tube to remain continuously in the stomach and washing constantly. No food should be administered by mouth and pituitrin should be given hypodermically in an attempt to reestablish normal peristalsis. Frequent rectal irrigations are indicated. Gastroptosis, a displacement of the stomach extremely common in middle life, is usually complicated with a similar condition of the intestine and other abdominal organs. It is also frequently associated with other abdominal affections, at times exerting evident influence upon the symptomatology of such disturbances. We have only included here those cases of gastroptosis of middle life in which the symptoms mani- fested were almost entirely due to this affection. There are two types of gastroptosis: the congenital,and acquired forms. In the congenital form, the prolapse is due GASTROPTOSIS. GASTROPTOSIS. 59 to an inherited constitutional weakness. It is quite possible that the endocrine glands may exert some influence in this regard. In the production of the acquired form mechanical factors play an important role; of these, childbirth, trauma, tight-lacing, and overexertion, are especially to be mentioned. Etiology. Due to the relaxation of the ligaments and mesenteric attachments or to the disturbed intra-abdominal pressure, producing a loss of tone of the abdominal muscles, varying degrees of prolapse may ensue. Gastroptosis is most commonly observed in middle life, although it may occur at a much earlier period. It is far more common in females than males. In our study of the five hundred cases of diseases of the stomach in middle life, this affection occurred in sixty-nine instances (13.8 per cent.). The following table presents our cases arranged according to age and sex: Ages in years Male Female 40 to 45 9 16 45 ” 50 10 12 50 ” 55 8 14 Total 27 42 Attention must be called to postural defects in their bear- ing on ptosis. According to the observations of Goldthwaite, Bryant, Mandell and Koenig, posture is of the greatest im- portance, both as a cause as well as a means in the' correction of this affection. Symptoms. In many individuals affected with this con- dition, no annoying symptoms are noted. On the other hand, it not infrequently occurs that the symptoms accompanying a gastroptosis are relieved without a correction of the dis- placement. In many instances patients are affected with lassitude, fatigue, headache, general malaise, loss of flesh and with frequent disturbances of the circulation, the pulse rate increasing when the patient is in a standing posture. Gastric distress is often present in the form of fullness, nausea, eruc- tations and occasionally pain. The appetite is variable and symptoms of hyperacidity are at times observed. Constipa- tion is a very frequent manifestation and backache is not uncommon. Associated with the constipation mucous-colitis 60 GASTRIC DISTURBANCES OF MIDDLE LIFE. often occurs. The gastric secretion presents a variable de- gree of acidity, though according to our experience sub- acidity is most frequent. In our sixty-nine cases the acidities were as follows: Normal acidity 22 Hyperacidity 16 Subacidity and anacidity 31 Total 69 Diagnosis. The characteristic appearance of the patient— the habitus enteroptoticus—is well known. The thorax pre- sents a narrow and elongated appearance and the abdomen reveals a distention of the lower part in the upright position, which usually disappears when the patient is in the reclining posture. The well known “Stiller sign”—the movable tenth rib—is present in a large proportion of cases. The position of the stomach can usually be located by means of ausculta- tory percussion or inflation of the stomach, but the x-ray presents the most accurate method of determining the loca- tion as well as motility of this organ. Aaron has presented us with a valuable sign of the pres- ence of gastroptosis. The pain occasioned by deep pressure over the celiac plexus is relieved when the patient’s abdomen is elevated by passing both arms about him and elevating the abdomen. Treatment. While the possibility of a permanent replace- ment of the stomach is not particularly favorable, the symp- toms occasioned thereby may be greatly relieved and at times entirely overcome.by appropriate treatment. As prophylac- tic measures in the prevention of this disorder, care should be taken in having patients remain in bed sufficiently long after childbirth and in the adjusting of a proper abdominal support, and by strengthening the abdominal muscles by massage and proper exercise in individuals prone to this af- fection. In the general treatment of these patients attention should be especially directed to improving their general nutrition and strengthening of the muscles of the abdomen. Of primary importance is the care in diet. In this regard the'state of the gastric secretion affords the best guide. Inas- SYPHILIS. 61 much as many of these patients are undernourished, forced feeding may become necessary. This is best accomplished by placing the patient in bed, the foot of the bed being elevated. A rest cure of this form may require four to six weeks to bring about satisfactory results. In other patients whose physical condition is not in need of a rest treatment, physical training, together with the adjusting of a properly fitting abdominal bandage may be all that is required. Hydrotherapy and abdominal massage are usually ex- tremely beneficial adjuvants in the treatment of this affec- tion. The constipation which is usually a marked feature of this condition, is often greatly relieved by the measures al- ready noted. Purgatives as far as possible should be avoided. The regulation of the bowels can usually be brought about by means of such simple remedies as mineral oil and agar- agar. In the treatment of the mucous-colitis so frequently asso- ciated with this condition, the use of high oil enemata is to be recommended. The general nutrition of the patient can be often improved by means of the hypodermic injections of cacodylate of soda and iron. SYPHILIS, Gastric syphilis is a rather rare affection, though it appears most frequently in middle life. According to Mills, one case occurs in every one hundred cases of gastric organic lesions of all sorts, and in our five hundred cases of gastric disturb- ances of middle life, it appears in ten instances (two per cent.). It occurs much more frequently in males than females. The following table presents our cases arranged according to age and sex: Ages in years Male Female 40 to 45 1 0 45 ” 50 3 2 50 ” 55 4 0 Total 8 .... 2 In the largest proportion of instances the cases have oc- curred during the tertiary stage of the disease, though secon- 62 GASTRIC DISTURBANCES OF MIDDLE LIFE. clary syphilis is frequently accompanied by symptoms of indigestion due, as a rule, to a toxemic gastritis. Pathology. The various gastric lesions appearing in tertiary syphilis have already been described, pages 9 to 11. These appear as (1) large gummatous formations; (2) in the form of endarteritis, and (3) as chronic inflammation of the gas- tric mucosa. There is a tendency to terminal contractural cicatrization in syphilitic disease of the stomach which re- sults either in hour-glass formation or general contraction of the stomach. Symptoms. Clinically syphilis of the stomach may be classified according to Einhorn, into three groups: (1) Luetic ulceration of the stomach, (2) syphilitic tumor, and (3) lu- etic stenosis of the pylorus. 1. The syphilitic ulcer is the most frequent form of gastric lues. It may arise as a result of endarteritis causing a necro- sis of a circumscribed area of the stomach or as the result of the destruction of a gumma. The pain which occurs in this condition is much like that of gastric ulcer, though relief is not so frequently afforded by food and alkalies. It appears usually immediately following meals and is relieved by vom- iting. Hemorrhage is not frequent in this affection and the appetite remains good. Great loss in flesh is usual. 2. Specific tumor is manifested by a mass in the gastric area in a syphilitic subject. This is accompanied by pain, vomiting and loss of flesh, and gives rise to the suspicion of carcinoma. 3. In specific stenosis of the pylorus, pain, nausea and vomiting are prominent symptoms. The vomiting is of the retention type and emaciation is rapid. Diagnosis. The Wassermann reaction is positive in most instances and in doubtful cases a provocative test is always indicated. The gastric secretion usually presents an achylia, even in instances of luetic ulceration. Achylia was present in all our cases. Roentgen ray evidence is of great importance in diagnosis. According to Mills the salient x-ray features are: “First, that of a general but locally accentuated contour defect; second, a general diminution in area of the gastric shadow; third, that of motor impairment of either the obstructive or SECONDARY GASTRIC AFFECTIONS. 63 more usually the residual type; and fourth, though less im- portant, atypical peristalsis.” Syphilis of the stomach must be distinguished from car- cinoma and the crises of locomotor ataxia. Treatment. The prognosis is quite favorable providing the treatment be undertaken reasonably early. Where hour- glass contraction or stenosis of the pylorus has occurred, surgery is indicated. Under all conditions thorough anti- syphilitic treatment should be undertaken in all cases. SECONDARY GASTRIC AFFECTIONS. Attention has already been directed to the very frequent occurrence of the disturbances of the functions of the stomach in diseases of other organs. In youth such affections are rather unusual, but as individuals advance in years the inci- dence gradually increases, so that even in middle life they comprise the largest proportion of gastric disturbances of that period. In the study of our five hundred cases of the gastric affections of middle life, the secondary disturbances number ninety-nine (19.8 per cent), occurring more frequently in males than females. The following table presents our cases arranged according to age and sex: Ages in years Male Female 40 to 45 10 13 45 ” 50 19 12 50 ” 55 26 19 Total 55 44 The cause of these secondary gastric affections lies, as we have already pointed out, either in some disturbance of the circulation, nervous system, or is due to toxemia. The dis- eases in which disturbances of the gastric functions are par- ticularly conspicuous during middle life are tabulated as fol- lows, together with their incidence in our ninety-nine cases: Acute febrile diseases 4 Diseases of the intestines 11 Diseases of the liver and gall-bladder 13 Diseases of the pancreas 4 Diseases of the kidneys 20 Diseases of the heart and blood system 22 Diseases of the lungs 17 Diseases of metabolism 5 Diseases of the nervous system 3 64 GASTRIC DISTURBANCES OF MIDDLE LIFE. Functions of the Stomach in Acute Febrile Diseases. The gastric disturbances in acute febrile diseases, such as typhoid and pneumonia, are accompanied by diminution and in some instances with an absence of free HC1; there is also a weak- ened motor function. During convalescence an increase in secretion is again noted. Functions of the Stomach in Diseases of the Intestines. These affections comprise largely chronic constipation, ileo- colitis, intestinal obstruction, chronic appendicitis and peri- tonitis. There were eleven cases due to these conditions in our series. Gastric symptoms frequently arise from chronic constipa- tion, consisting largely of nausea, loss of appetite, distress and occasionally of vomiting. In ileo-colitis and dysentery there is often present anorexia, nausea, vomiting, gastric dis- tention and pain. In intestinal obstruction fecal vomiting, with abdominal distention, is usual. Chronic appendicitis is frequently the cause of gastric distress and in fact without discomfort in the region of the appendix itself. The gastric manifestations of chronic appendicitis are pressure, discom- fort and eructations, and are largely induced reflexly by pylorospasm. In peritonitis the symptoms of pain, nausea, vomiting and distention are too well known to require further description. Functions of the Stomach in Diseases of the Liver and Gall-Bladder. There were thirteen cases of these affections in our series. Of these, four were due to liver disturbances and nine to gall-bladder affections. The stomach is not in- frequently affected secondarily as the result of diseases of the liver and gall-bladder. Obstruction of the circulation, due to disturbances of the liver, occasions congestion of the stomach and may lead to a gradual reduction in the gastric acidity; while enlargement of the liver may displace the stomach, causing interference with its motility; again, any inflammation of the liver or gall-bladder may result in ad- hesions to the stomach, with consequent interference with the gastric functions. Atrophic cirrhosis of the liver is al- most always associated with a chronic gastritis, often of the interstitial or glandular type, which is followed by venous congestion due to the portal obstruction, and hemorrhage SECONDARY GASTRIC AFFECTIONS. 65 may ensue from the rupture of the varicose veins surrounding the cardia. In cholecystitis and cholelithiasis the gastric symptoms may be so prominent as to render the diagnosis difficult; these may consist of pain, nausea, and vomiting, and the pain may be localized in the epigastrium instead of over the region of the gall-bladder. In gall-stone disease pylorospasm is fre- quent and the production of adhesions between the gall- bladder and pylorus often leads to interference in motility. In the early stages of gall-bladder disturbances hyperacidity is usually present—sixty per cent., with anacidity in eighteen per cent, and normal acidity in twenty-two per cent.—but as the disease advances toward middle life, anacidity is usually observed. Functions of the Stomach in Diseases of the Pancreas. Acute pancreatitis is usually associated with gastric symp- toms in the form of severe nausea, vomiting, intense pain located above the umbilicus, while in the chronic forms and in carcinoma of the pancreas there is nausea, vomiting, eruc- tations and distress following the ingestion of food. In our series there were four cases of cancer of the pancreas, pro- ducing gastric symptoms. Functions of the Stomach in Diseases of the Kidneys. Nephritic affections are usually accompanied by symptoms referable to the stomach. These are largely due to the tox- emia produced by the renal lesion, caused by the excretion of urea and other poisons through the gastric mucosa, as well as to the cerebral irritation from the poison. When the lesion is extensive or of long duration, marked changes may take place in the gastric mucous membrane: first in the form of acute inflammation of the gastric tubules with swelling, irregularity and granular degeneration; in the later stages as a chronic inflammation of the glandular structures, the peptic cells undergoing fatty infiltration; and finally, as an inflammatory thickening of the interglandular tissue In rare instances hemorrhage takes place in the mucous membrane of the stomach and superficial ulcers of variable size may be formed. The character of the gastric secretion varies according to different observers. According to Biernaki, the free HC1 is 66 GASTRIC DISTURBANCES OF MIDDLE LIFE. diminished in proportion to the excretion of albumin, reduc- tion in quantity of urine excreted and extent of edema. Free HC1 is usually observed in the early stages but in extensive and chronic lesions of the kidneys achylia is usu- ally noted. The pepsin and rennet ferments are always diminished and are frequently entirely absent; the motor function is usually increased. In the early stages of chronic nephritis the gastric symp- toms are often so prominent that unless careful urinary examinations be made erroneous conclusions may be reached. The gastric symptoms accompanying nephritis are: nausea, vomiting, discomfort after meals, loss of appetite, and flatu- lency. The vomiting in renal disease occurs immediately on arising in the morning and is associated with much retching; the vomitus consisting of mucus mixed with yellow bile and saliva. When vomiting occurs later, it may appear immedi- ately or an hour or two after meals, and the ejected matter then contains undigested food with mucus. In uremia the vomiting takes place at frequent intervals and especially upon any attempt at nourishment; the vomited matter consisting of mucus which is bile tinged. In obstructions to the passage of the urine due to pros- tatic enlargements the symptoms associated with the gastric digestion, in the form of loss of appetite, nausea, vomiting, distention and loss of flesh, are frequently so prominent that the question of gastric carcinoma cannot always be ruled out at once. Functions of the Stomach in Diseases of the Heart and Blood System. In heart affections in which compensation is present the gastric functions are usually normal but when compensation is interfered with the portal system becomes congested, in consequence of which stasis and hyperemia of the gastric mucosa takes place. After long continued con- gestion of the stomach due to heart disease the mucous mem- brane becomes filled with hemorrhages; there is intense con- gestion of all of the veins and capillaries, the gastric tubules becoming irregular or compressed, and the central and parietal cells swollen. The gastric secretion in the early stages of this affection is usually normal but gradually diminishes in its acid content; the pepsin and rennet fer- SECONDARY GASTRIC AFFECTIONS. 67 ments decrease and in advanced cases gastric motility is much impaired. The gastric symptoms noted in cardiac disease are, dis- tention pressure, fullness and palpitation after meals; anor- exia becomes marked, and nausea and vomiting ensue. The vomitus consists of bile stained mucus, often containing traces of blood; rarely hematemesis may occur. On palpa- tion of the abdomen the region of the stomach is found markedly distended and tender on pressure. In pernicious anemia, anorexia, nausea and vomiting fre- quently occur and the gastric secretion ordinarily presents a complete achylia. In chlorosis and secondary anemia, gastralgia, anorexia and hyperchlorhydria are usually noted. Functions of the Stomach in Diseases of the Lungs. The disease of the lungs which sooner or later gives rise to gas- tric symptoms is tuberculosis. The various changes observed in the stomach in this affection are, atonic dilatation, ulcera- tion, and the various forms of gastritis. The gastric dis- turbances of pulmonary tuberculosis ordinarily noted may be divided into two groups: First, the'dyspepsias observed in the initial stage of the disease, and second, the dyspepsia of the final stage. In the initial stage of the disease gastric symptoms are manifested, according to Samuel Fenwick, in eighty-three per cent, of cases, and according to Saltou Fenwick, in seventy-nine per cent.; being much more common in females than males—that is, eighty-four per cent, of females to fifty- two per cent, of males (Fenwick). The symptoms often appear very insidiously, frequently even before the pulmonary signs have become sufficiently marked to be noted by the patient. These consist of pain or discomfort following immediately upon meals or several hours afterward; vomiting especially appearing in the early morning, preceded by cough or irritation in the throat, the vomited matter consisting of mucus from the pharynx, bron- chi and stomach; loss of appetite; flatulency, and acidity. In this stage the gastric secretion is normal or hyperacidity may exist; the motor function being normal or slightly reduced. 68 GASTRIC DISTURBANCES OF MIDDLE LIFE. In the terminal stage of this affection the dyspeptic symp- toms are extremely marked. Of 316 cases of advanced pul- monary tuberculosis, Fenwick observed that forty-two per cent, were affected with dyspepsia. This condition is more common in females than males; sixty-two per cent, of females to twenty-five per cent, males (Fenwick). The symptoms manifested at this stage are: anorexia, flatu- lency, discomfort in the epigastrium usually unaffected by the ingestion of food; nausea and vomiting frequently pro- duced by coughing. The gastric secretion gradually shows a lessened acidity and in very advanced cases there is a true achylia; the motility of the stomach being also reduced. Functions of the Stomach in Diseases of Metabolism; Dia- betes. The digestion in diabetes is often normal. On the other hand, patients affected with this disease are liable to indigestion; chronic gastritis and atrophy of the gastric mu- cosa have been noted in a few instances. The gastric symp- toms manifested are, bulimia, polyphagia, abdominal discom- fort, distention, and eructations. Occasionally when an at- tack of gastritis arises, pain in the epigastrium is produced followed by nausea and vomiting. Violent pain may ensue, preceding the development of coma. The gastric secretion in this disorder is variable, and nor- mal, hyperacid, and achyliae states may be observed. The gastric motility may be normal or hypermotility may be present. Functions of the Stomach in Diseases of the Nervous System. Organic diseases of the brain and spinal cord are usually accompanied with gastric symptoms. In tumors of the brain, in cerebral abscess or hemorrhage, vomiting is a prominent symptom; it is usually projectile in character and preceded by headache and is in no way related to the inges- tion of food; the vomitus consisting largely of hyperacid gastric secretion containing bile. Locomotor ataxia produces gastric symptoms in the form of crises. These crises are manifested by sudden attacks of acute pain in the epigastrium, radiating into the abdomen, back, and limbs. The pain is of the girdle type and vomiting frequently occurs at the onset of the pain. The vomitus con- sists of the contents of the stomach and then of mucus tinged NERVOUS GASTRIC AFFECTIONS. 69 with bile. Hypersecretion is usually present during the attacks. The Treatment of Secondary Gastric Affections. In the treatment of secondary gastric affections, attention must be directed to the primary disorder, as in no other way can recovery be expected. It not uncommonly occurs that by the compensation of a failing heart or by the relief of a dis- turbed kidney function, gastric disturbances are at once over- come without further treatment. On the other hand, much can often be accomplished for the patient’s comfort in these affections by direct treatment to the stomach itself. This can often be best brought about by means of diet, which must be of such a nature as to avoid over-taxing the embarrassed digestion and at the same time prevent fermentation. We have already referred to the great importance of the nervous system in its relation to affections of the stomach in middle life and to the frequency of these disturbances. Of all gastric affections, fifty-five per cent, may be classified as neuroses, while forty-five per cent, represent organic disease. The gastric nervous disorders rarely have their onset in old age; they occur more frequently in youth and middle life; forty-six per cent, between the thirtieth and fiftieth years, according to Friedenwald (Osier’s Modern Medicine). Of our five hundred cases of gastric disorders of middle life, there were seventy-four cases of gastric nervous affec- tions (14.8 per cent.). The following table presents our cases arranged according to age and sex: NERVOUS GASTRIC AFFECTIONS. Ages in years Male Female 40 to 45 12 15 45 ” 50 10 11 50 ” 55 11 15 Total 33 41 Symptoms. The symptoms of a general neurosis are usu- ally present, that is, irritability, lassitude, insomnia, depres- sion, and a feeling of malaise. Hyperesthesia or anesthesia often exist in certain parts of the body. The subjective symptoms are changeable and capricious, exhibiting protean 70 GASTRIC DISTURBANCES OF MIDDLE LIFE. changes in rapid succession. The digestion is usually in a state of labile gastrointestinal function (Boas). The digestive complaint is frequently independent of the quantity and qual- ity of food ingested, and frequently bears no relation what- ever to meals. Periodic attacks of discomfort often alternate with unaccountable periods of well being. Frequent and sudden changes take place in the secretory or motor function of the stomach, or in both, so that a superacidity may quickly give way to a subacidity, and a motor insufficiency to a hyper- motility. The pain which may be present is diffuse and often bears no relation to the ingestion of food. Gastrointestinal neuroses are usually polysymptomatic, more rarely monosymptomatic, in character; in the first form there is a multiplicity of symptoms, while in the latter but one symptom is observed. A monosymptomatic neurosis is not infrequently converted into the polysymptomatic form. Diagnosis. This may be very often difficult, as similar symptoms may envelop certain organic diseases, the nervous manifestations being so much more prominent that the actual disease becomes entirely masked. In order to establish the nervous character of a gastric disorder, organic affections must be excluded, which is frequently a difficult task. Func- tional gastric disease is frequently either characterized by peculiar periodical or paroxysmal attacks, with many unac- countable periods of well being, or by an absence of subjec- tive symptoms, even upon the ingestion of indigestible food. A further difficulty arises from the fact that organic dis- orders are often accompanied by nervous symptoms, and most careful investigation may therefore be necessary. A nervous dyspeptic himself often indicates the diagnosis of his condition, and one need only listen to his story attentively. Objective signs may be absent or when present may be misleading. In the diagnosis of these conditions, the onset of the attacks without apparent cause and the intervals of well being are most striking. The fact that as a rule the complaints of the patient bear no relationship to the quality and quantity of food ingested, but are mainly dependent upon overtaxation, mental disturbance, and excitement, is of great value in the diagnosis. By frequently testing the motor and secretory functions of the stomach, and constantly finding NERVOUS GASTRIC AFFECTIONS. 71 these normal, is alone sufficient evidence to indicate the neurotic nature of the disorder. Prognosis. The prognosis of the gastric neurosis is not unfavorable provided the cause be discovered and removed and treatment be instituted promptly. Treatment. It is necessary to remember that one is dealing with patients whose imagination is easily influenced in direc- tions other than normal; for this reason the personal influence of the physician himself will have a great bearing on the patient’s recovery. A change of scene is often imperative, and specific regulations as to the mode of living and diet should be insisted on. In some instances a rest cure in a sanitarium is most desirable. The diet deserves particular attention, for most of these patients are undernourished and their nutrition may have to be stimulated by fdrced feeding. A gain in body weight is very desirable; in many instances a simplified method of in- creasing the patient’s nutrition is to add four to eight ounces of milk to each meal and an equal amount between meals. This quantity can gradually be increased until the patient is taking ten to twelve ounces at a time, or as much as two quarts a day. Eggs may be given in increasing numbers in addition to the milk or alone when milk is not well borne. As many as one dozen eggs can be taken a day. The patient’s appetite should be humored, and he should be allowed to eat any food he can digest. All stimulants should be forbidden, and the use of tobacco, tea, and coffee, is interdicted. To aid nutrition and stimulate elimination of waste prod- ucts certain physical methods of treatment are most service- able. Of these the most important are hydrotherapy, mas- sage, the application of stupes and electrotherapy. Cold and warm sponges, swimming, and the various forms of baths serve useful purposes. The efficacy of tepid packs, producing sleep, is well known. Gastric and duodenal lavage may be practiced, the latter yielding especially gratifying results in cases of intestinal stasis. A cure at some mineral spring is often beneficial. Massage at the beginning of treatment should be carried out gently and superficially,, and only for a short time each day. Cocoa butter or olive oil and alcohol rubs are used with much benefit. Electricity is a helpful 72 GASTRIC DISTURBANCES OF MIDDLE LIFE. adjuvant to treatment if used properly, and psychotherapy carefully practiced is useful. Occupational therapy may be utilized to great advantage, especially in many cases follow- ing rest cures. Such activities as book binding, weaving, knitting, etc., materially aid in bringing about relaxation and prevent introspection. The nervous dyspeptic should be taught to rely more upon hygienic measures than upon drugs, as but few drugs have any marked influence in these cases. Of the remedies that have been employed the bromides, preparations of valerian, iron, and arsenic, have been found most useful in the treatment of these affections. The hypo- dermic administration of the cacodylate of soda and iron are especially valuable. Following a rest treatment the patient should be encouraged to take a vacation at the seashore or the mountains. The following classification of the functional gastric affec- tions according to their relationship with the autonomic ner- vous system has been abstracted from our paper in Nelson’s Loose Leaf Medicine: Vagotonic Group. Cardiospasm Pylorospasm Peristaltic Unrest Pneumatosis Nervous Vomiting Eructatio Nervosa Rumination Regurgitation Gastralgia Hyperesthesia Bulimia Parorexia Gastromyxorrhea Hyperchlorhydria Gastrosuccorrhea Sympatheticotonic Group. Atony Incontinence of pylorus Acoria Anorexia Achylia gastrica Hypochlorhydria While any of the various gastric neuroses may occur dur- ing middle life, only the most important will be described. Cardiospasm. Cardiospasm is characterized by a spasmodic contraction of the cardia, not due to organic disease. Diffuse dilatation of the esophagus frequently follows as a result of this con- NERVOUS GASTRIC AFFECTIONS. 73 dition. This affection is observed at times accompanying neurasthenia and hysteria; it occurs after swallowing food which has not been sufficiently masticated or which has been too highly seasoned; occasionally it is produced by worry or excitement. Symptoms. This affection may occur in two forms, either as the acute or chronic variety. The acute forms last but a few days. The attack appears suddenly and is accompanied by dysphagia, pressure and pain beneath the sternum, and a burning sensation in this region. The food accumulates in the esophagus and great effort must be exercised to force it into the stomach; when this is impossible, it is regurgitated. At times it becomes impossible to swallow any food for hours or even days; however, as soon as the food is regurgitated, relief is afforded. These acute attacks appear periodically; between the attacks the patient suffers no inconvenience. In the chronic variety dysphagia is the most prominent symp- tom. Great effort is required to force food into the stomach. Liquids and semisolids are most easily swallowed. After a shorter or longer period of time a diffuse dilatation of the esophagus begins to manifest itself, in which considerable quantities, of food may be retained. Food is retained in the dilated esophagus and is regurgitated after a time; vomiting, however, is impossible in these cases due to the spasm. On introducing a.bougie a resistance is discovered, which is more plainly felt with a large than with a small sized bougie. With gentle pressure the resistance yields and the bougie enters the stomach. Diagnosis. The diagnosis of the acute type is arrived at by noting the varying degrees of dysphagia, by the introduc- tion. of the bougie, which passes without difficulty, by the inability of the patient to vomit, and by the absence of the second deglutition murmur. In the chronic type the dys- phagia extends over a long period of time and the symptoms of dilatation of the esophagus become prominent. A large bougie enters the stomach more easily than a small one. When dilatation of the esophagus has taken place, the diag- nosis may be confirmed by fluoroscopy and esophagoscopy. Treatment. In acute forms attention should be especially directed to the nervous system, and the general health of the 74 GASTRIC DISTURBANCES OF MIDDLE LIFE. patient. Large bougies should be introduced into the stom- ach, and should be allowed to remain for a few minutes at a time, if possible. The bromides, valerian, and belladonna, may be administered with a variable degree of success. In the chronic forms, the*diet should be restricted to liquid and semisolid food. When deglutition becomes very difficult food must be given through a tube. Large bougies should be introduced and allowed to remain in position for some time. It is necessary in these cases to produce forcible dila- tation of the contracted area of the esophagus and cardia by means of special dilators. In pylorospasm there is a spasmodic contraction of the pylorus not due to organic disease. The etiology of this affection is, however, frequently so obscure that various theories have been suggested in explanation of its occurrence. It is a well known fact that this condition may be wholly of a nervous type, or it may be caused by some disease of the stomach, or be manifested as a reflex affection from disease' of some organ either near or at some distance from the stomach itself, i.e., gall-bladder, appendix, kidneys, etc. In pylorospasm we possess another evidence of vagatonia, inasmuch as this condition can be produced experimentally by stimulation of the vagus and inhibited by stimulation of the splanchnics. Pylorospasm occurs more frequently in females than in males. Symptoms. Usually at the height of digestion a spastic contraction of the pylorus occurs, accompanied with moderate or intense pain, nausea, eructations, and vomiting. In the early stages, the spasm occurs occasionally but later it may become almost continuous, leading to a spastic contraction with subsequent dilatation of the stomach and retention. When this occurs, the food vomited possesses all the features that are observed in dilatation. After vomiting, great relief is afforded for from one to more days, when there is recur- rence of the attack. As this disorder progresses there fol- lows marked emaciation, loss of strength, and severe consti- Pylorospasm. NERVOUS GASTRIC AFFECTIONS. 75 pation. During the attack the contraction of the pylorus may often be revealed by a firm protruding mass in the abdomen, which gradually disappears. The gastric secretion is usually hyperacid during the attack, but subsequently in the interval between the attacks becomes normal. Finally, the x-ray signs are usually distinctive and frequently clear up the actual cause of the spasm. Treatment. The treatment of pylorospasm consists pri- marily in properly overcoming the underlying neurasthenia. On this account changes of scene, massage, electricity, or a rest cure, may be found advisable. The diet should be care- fully regulated; all irritating food should be avoided. In certain instances an ulcer cure with the patient in bed for from three to four weeks under a Sippy treatment, has af- forded us very satisfactory results. During an attack the hypodermic administration of morphin or codein and atropin gives relief from pain. Sodium bromide and chloral have been recommended in some instances, and olive oil has been found to be a useful remedy. Hot applications to the abdo- men and a thorough lavage usually afford great relief from the pain. The drug which is most helpful in the treatment of this condition is atropin prescribed in full doses. Pneumatosis. Pneumatosis is characterized by an excessive distention of the stomach with air, the expulsion of which is impossible, causing an unpleasant expansion, with dyspnea. This con- dition is most frequently induced by a combined cardio- and pylorospasm. As soon as the air escapes, relief is at once brought about. Pneumatosis occurs as a primary neurosis accompanying neurasthenia; it may occur secondary to other affections, as atony, dilatation, and as a result of paralytic ileus. Pneumatosis is observed more frequently in males than females. It appears in an acute, type intermittently, causing serious symptoms of dyspnea, collapse, arrhythmia, tachycardia, and cyanosis. The region of the stomach is much distended, the patient being unable to relieve himself by eructating. In the less acute forms the attacks appear either immediately after meals or later, or after exertion. The symptoms are similar to those of the acute forms but far less 76 GASTRIC DISTURBANCES OF MIDDLE LIFE. alarming. The diagnosis can be readily made from the above noted symptoms. The treatment should be directed toward the nervous sys- tem. Change of scene, massage and hydrotherapy are indi- cated. By means of the introduction of the stomach tube immediate relief can be obtained from the acute symptoms. Nervous Vomiting. Vomiting may be due to some fermentation or abnormal condition of the ingested food; to disease of the stomach itself, or to a disturbance of the nervous system. The latter condition is the one with which we are here concerned. There are three forms of nervous vomiting: (1) Nervous vomiting proper, i.e., vomiting due to neurasthenia or hysteria; (2) re- flex vomiting; (3) cerebrospinal vomiting due to functional or organic disease of the central nervous system. ■ The characteristics of nervous vomiting are as follows: The ease of vomiting; its non-dependence upon the quantity and quality of the food ingested, the capriciousness with which very bizarre articles of food are retained to the ex- clusion of others; the occasional elective vomiting; the ease with which patients bear this condition, even for a long period of time; the very slight degree of inanition produced by habitual vomiting; the extraordinary influence of the slightest external or internal causes that react on the patient’s temperament; the occurrence of vomiting, frequently even on a fasting stomach, and the appearance of this condition in- dependently of the meals, the presence of other nervous symptoms associated with the vomiting or alternating with it. Nervous nausea is closely related to nervous vomiting. It may be purely a functional condition due to neurasthenia or hysteria, or due to affections of other organs. It may be intermittent or continuous, and bear no relation to the inges- tion of food. It may persist for days, and is sometimes slight, at other times so intense as to cause vomiting; marked emaciation is not an infrequent result. Prognosis. The prognosis of nervous vomiting and nausea depends largely upon the causation. In the cerebrospinal forms it is bad; while in that variety due to neurasthenia, the prognosis under favorable treatment NERVOUS GASTRIC AFFECTIONS. 77 is good, though occasionally a fatal outcome occurs due to the exhaustion and acidosis produced by the continued nausea and vomiting. Treatment. Whenever possible the cause must be over- come. In the mild forms, change of scene, avoidance of ex- citement, and rest, will bring about relief. In severe cases, rest cures under rigid isolation in a hospital or sanatorium should be insisted upon. Liquid diet, given in small quan- tities, should be at first prescribed. In severe cases, rectal alimentation should be practiced by means of the Murphy drip method. Saline solutions with glucose may be utilized for this purpose. In some cases under our care, duodenal alimentation according to the Einhorn method has been most beneficial. At times solid food is better borne than liquids. Good results are obtained at times from lavage with solutions of nitrate of silver. Drugs have but little influence on this condition. Eructatio Nervosa (Aerophagia). Eructatio nervosa is characterized by periodic or paroxys- mal attacks of noisy belching. It commonly occurs in neu- rasthenic and hysterical individuals. The gas which is ex- pelled in this condition is swallowed. Aerophagia occurs as a voluntary act produced to relieve an uncomfortable sensa- tion in the stomach, the air is forced into the esophagus or stomach and by contraction of the esophagus the accumu- lated air is expelled with a loud noise. The affection is more commonly observed in females than males. It is usually a primary gastric neurosis produced by excitement or worry, yet it may occur as a result of some gastric disorder, as catarrh, gastroptosis, or may be secondary to disease of other organs, as the heart, intestine, or genitourinary organs. Symptoms. This affection develops suddenly, as a rule, and is accompanied by noisy eructations varying in duration and intensity; the paroxysms lasting from a few hours to days. The attacks disappear suddenly, and cease while the patient is asleep. Treatment. This condition can usually be controlled by psychotherapy. Special attention must be paid to the patient’s nervous system. This can be best accomplished by 78 GASTRIC DISTURBANCES OF MIDDLE LIFE. means of rest and change of scene. A well regulated rest cure accomplishes much in many instances and relief is some- times afforded by the use of the bromides. Rumination or Merycism. Rumination is characterized by the regurgitation of food into the mouth, which is again masticated and swallowed, or spat out. This condition is not accompanied by nausea but with a rather pleasurable sensation; it is comparable to a similar condition observed in animals. Neurasthenia is an important factor in the production of this disorder. It is frequently due to worry and excitement and often to too hasty eating. It is observed at all ages, and is not uncom- monly found in intellectual individuals of middle life, and is at times acquired-by imitation. Rumination usually has its origin as a voluntary disorder; the food at first regurgitated producing a pleasurable sensation is again reswallowed and finally the condition is established as an involuntary process. It usually occurs during the early period of digestion, for as soon as the food becomes acid and unpleasant, it is either quickly swallowed or ejected. Merycism occurs alone or may accompany other gastric affections; it is at times associated with atony and dilatation. The treatment is essentially one of autosuppression and the patient can be taught to overcome this disease in many instances. Regurgitation. Regurgitation is characterized by the expulsion of small quantities of food from the stomach into the mouth, which are then ejected. The condition occurs in nervous individu- als, and is much like rumination except that the food is not again masticated; rumination, however, may develop from long continued regurgitation. The condition is at times voluntary but as the habit becomes fully established it be- comes involuntary. Regurgitation may be occasioned by nervous excitement or shock, or it may. be secondary to some gastric disturbance, as catarrh, hyperacidity, or dilatation. It is observed frequently at middle life in males and in indi- viduals following intellectual pursuits. NERVOUS GASTRIC AFFECTIONS. 79 Symptoms. The onset is gradual, manifesting itself by the regurgitation of food soon after meals, and persisting during the entire period of digestion. Nausea is not present; at first the food regurgitated has the same taste as when swal- lowed, later it becomes acid from the admixture with the gastric juice. The process can be suppressed at times; at times this is impossible. The treatment should be directed to the associated neuras- thenia. The patient should be taught voluntary suppression. Psychotherapy has been of great help as an aid in suppress- ing this condition, in some of our cases. Gastralgia Nervosa. By gastralgia is indicated an affection accompanied by periodic or spasmodic pain in the stomach occurring without relation to the ingestion of food and not dependent upon organic disease. Gastralgia must be considered as a neurosis of the vagus and is produced as a result of vagatonia. Ein- horn divides gastralgias into five groups. Those of (1) gas- tric origin; (2) central origin; (3) neurotic origin; (4) of constitutional origin; and (5) reflex origin. (1) Gastralgias of gastric origin. The gastralgic pains oc- curring in ulcer and cancer of the stomach are included in this group. (2) Gastralgias of central origin. In this group are found the pains observed in the gastric crises of locomotor ataxia and in cerebral tumors. (3) Gastralgias of neurotic origin. This condition is found in hysteria and neurasthenia. (4) Gastralgia of constitutional origin. This condition is one observed in lead poisoning, anemia, and gout. (5) Gastralgia of reflex origin. This condition arises as a reflex from the generative, urinary or other organs. Symptoms. The attacks of pain occur suddenly and are at times preceded by nausea, vomiting and headaches. The pain is of a boring, tearing, cutting or gnawing type and is felt in the epigastrium, radiating at times throughout the ab- domen and into the back, with such intensity as to cause exhaustion and symptoms of collapse, producing a weak and thready pulse, cold extremities and perspiration and pallor. 80 GASTRIC DISTURBANCES OF MIDDLE LIFE. The pains are relieved frequently by pressure and are often accompanied by nausea, vomiting and nervous manifesta- tions, as nervous chills, headaches and globus hystericus. Treatment. It is important to treat the underlying cause. In the form due to anemia, iron and arsenic should be ad- ministered ; those due to malaria require quinine. In the re- flex forms of gastralgia, the primary affection must be treated. Those forms due to neurasthenia and hysteria should be treated by change of scene, rest and massage. When the patient is much debilitated a systematic rest cure is indicated. For the attacks of pain, hot applications or poultices should be applied to the abdomen and codein or Hoffman’s anodyne be prescribed. Belladonna and chloroform water, phenacetin and aspirin have been found useful in some instances. If the pain is intense, hypodermic injections of morphin must be administered. Hyperesthesia Gastrica. At times the gastric mucous membrane is unusually sensi- tive, even to its normal contents; this condition is termed gastric hyperesthesia. There is neither secretory nor motor disturbance at hand and yet the lightest forms of food will cause discomfort in the form of pain, fullness, or sensations of cold or heat. In some cases not only does the food cause discomfort but the normal hydrochloric acid content will produce pain. Hyperesthesia is observed in neurasthenia and hysteria, and occurs in anemic individuals. Symptoms. The symptoms produced in this condition are mild discomfort, fullness and burning after meals, which dis- continue as soon as the stomach becomes empty. Solid food at times produces less discomfort than liquids. Symptoms of hyperacidity are at times manifested, though the gastric contents may reveal no excess of acid. In such cases the discomfort appears some time after meals, and is relieved by alkalies. Treatment. It is well in most instances to place a patient affected with this condition in bed, at first on a liquid diet, and best on a systematic rest cure on a gradually increasing diet scale. Cold compresses to the abdomen frequently af- NERVOUS GASTRIC AFFECTIONS. 81 ford relief. Nitrate of silver, given in solution in doses of from y8 to % grain three times a day, or administered by means of the stomach tube, has been of help in some in- stances. The bromids, valerianates, and sumbul, have been frequently found efficacious. Bulimia, Bulimia is characterized by an abnormal increase in the sensation of hunger. This condition has also been termed hyporexia, cynorexia, and lycorexia. According to Cannon, the sensation of hunger is produced by tonic contractions of the empty stomach. Bulimia may occur as a pure neurosis or it may be sec- ondary to other affections. As a primary neurosis it is observed in neurasthenia and hysteria. It occurs in cerebral tumors, hyperthyroidism, diabetes, syphilis, pulmonary tuber- culosis, as well as in ulcer of the stomach. Dock has called attention to the fact that it may be due in some instances to focal infection. Symptoms. Bulimia occurs usually in attacks appearing at irregular intervals; or it may occur periodically and extend over a long period of time. It manifests itself as a violent sensation of hunger after meals, on account of which the patient is much exhausted, becomes faint, and suffers with vertigo, and cold extremities. As soon as food is taken these sensations disappear. At times but small quantities of food are required to overcome this condition for a shorter and longer period of time; at other times very large quantities of food are needed to relieve it. The inordinate quantity of food is apt to cause other digestive disturbances, such as atony, gastritis, and disturbances of the bowels. The gastric secretion is usually normal in bulimia. Bulimia must be differentiated from acoria and polyphagia; while there is an abnormal desire for food in bulimia, the desire can be satisfied, while in acoria there is an entire ab- sence of the sensation of satiation. In polyphagia or glut- tony, while the appetite continues good, the feeling of satis- faction is delayed so that there is a constant desire for more food. The prognosis of bulimia depends upon the cause. The primary form due to neurasthenia may be of long dura- 82 GASTRIC DISTURBANCES OE MIDDLE LIFE. tion or may disappear suddenly, while the secondary form depends largely upon the nature of the underlying disease. Treatment. The treatment must be directed toward the primary disorder. All focal infections should as far as pos- sible be removed. In the primary forms due to neurasthenia, attention should be especially directed to the treatment of the nervous system. In most instances, rest, change of scene, hydrotherapy and psychotherapy, are the important measures for counteracting this affection. Hyperchlorhydria or Hyperacidity. Hyperchlorhydria is that condition characterized by an in- crease in the secretion of the hydrochloric acid produced during the period of digestion. Inasmuch as the excess of acid is simply a symptom, the question arises whether hyper- chlorhydria should be considered a distinct disease; yet the symptoms associated with this condition are so distinctive and so often embrace all subjective manifestations, that we are forced to treat this condition as a special clinical entity. While hyperchlorhydria definitely manifests itself in many instances as a secretory neurosis, in a certain proportion of cases it is associated with some definite lesion. The question as to what is meant by an excess of hydrochloric acid has not been fully established, for what might be taken as an excess in one individual may be a normal acidity in another. Although many authors have considered an amount of acid above 0.2 per cent, as representing a hyperacidity, many cases are met with having a greater acidity than this quantity with- out symptoms of hyperacidity. On the other hand, symp- toms of hyperacidity may exist even in cases of hypochlor- hydria. Much has been learned in recent years regarding the question of hyperchlorhydria by the studies of Rehfuss and his coworkers, by means of fractional analyses extend- ing throughout the entire period of digestion. It is now known that while hyperacidity may exist, that this may occur at any time during the period of digestion; so that at the end of an hour after a test meal we may find an entirely normal or even a lowered acidity, yet either before or after this period the acidity may be exceedingly high. By means of these examinations we have learned that the very same NERVOUS GASTRIC AFFECTIONS. 83 amount of acid may indicate a hyperacidity in one individual, and not in another, indicating that individual variations may exist in the normal percentage and that we cannot draw a sharp line between the normal and hyperacid state. Hyperchlorhydria occurs very frequently. It is most usu- ally observed in young and middle-aged persons, while it is rarer in older individuals. It is slightly more frequent in females than in males. It is more frequently observed among the wealthier classes than among the poor. The following etiological factors are important: 1. Mental strain, overwork, prolonged worry, are important factors in its production; neurasthenia and hysteria are also important causative factors. 2. Gastrointestinal atony is a marked etiological factor, especially when associated with chronic constipation. 3. Indiscretion in food, such as the use of food of a very indigestible character; the abuse of alcohol and tobacco, are the causes of the largest proportion of cases of hyperchlor- hydria. 4. Among the diseases bearing an etiological relationship to this affection are, ulcer of the stomach, chlorosis, chole- lithiasis, appendicitis. Symptoms. The symptoms manifested are, acid eructa- tions, heartburn, pain and burning in the stomach. The acid eructations usually occur at the height of the paroxysms of pain and afford relief from the pain. When the acid secre- tion is eructated the mucous membrane of the esophagus becomes irritated and heartburn develops. This symptom usually appears after taking acid foods, and is relieved fre- quently by the ingestion of milk, eggs or meats. The pain may vary from a severe pressure to an acute pain in the stomach, and may extend into the back between the shoulder blades and pass under the sternum to the pharynx (pyrosis hydrochlorhydria). It appears usually two or three hours after meals, depending upon the food taken. In a moderate number of cases the pain appears immediately after food. The symptoms of hyperchlorhydria continue for a variable period of time, disappearing for an hour or more or persisting for many hours. Pain is much more quickly produced by starchy foods than by protein foods, more quickly by light 84 GASTRIC DISTURBANCES OF MIDDLE LIFE. meals than by heavy meals, and is relieved by the ingestion of food or by neutralizing the acid by means of alkalies. Usually the pain disappears at night during rest and does not occur again until several hours after breakfast. The severe gastralgic pains are not usually found after every meal, and are somewhat relieved by the acid eructations, and by vomiting of the acid secretion which burns the throat and numbs the teeth as it passes over them. A sensation of burn- ing in the stomach is frequently observed, which is felt in the epigastrium, and may extend to the back. It is relieved by means of food and alkalies. The appetite is good, the thirst increased, and the bowels usually constipated. The exami- nation of the stomach contents after a Rehfuss or ordinary test meal, reveals a normal motility or hypermotility. The gastric juice presents a high degree of acidity; the starch digestion is imperfect, and rather large quantities of amidulin are found; the protein digestion and peptonization is more rapid than under normal conditions, so that none or but few undigested meat fibers are observed in the gastric contents. Treatment. Diet plays a most important role in the treat- ment of this affection, it being essential that the food should be given in such a form as not to produce any irritation of the mucous membrane of the stomach. As the gastric hyper- esthesia is mainly responsible for the hyperacidity, the treat- ment should be directed to this condition. This would in- clude the removal of all causes of irritation, the prohibition of alcoholic stimulants, all acids, all spices and' condiments. All foods to which vinegar or lemon juice have been added should be interdicted p all hard substances, such as nuts, should be avoided. Food should be thoroughly masticated, and should not be taken either too hot or too cold. A liberal mixed diet, consisting of proteids, fats, and carbohydrates, is to be preferred. In patients consuming but little nourishment, food should be given at frequent intervals; if large meals are consumed, it is advisable to permit only three meals a day, allowing the stomach to rest in the intervals. In severe forms of nervous hyperchlorhydria a purely vegetable, or milk and vegetable, diet have been recommended; the vegetables should be eaten in puree form. In advanced cases with pronounced nervous NERVOUS GASTRIC AFFECTIONS. 85 manifestations a complete or modified rest cure will accom- plish excellent results. Whenever patients affected with this condition present symptoms of fatigue they should be required to rest, either away at the country, sea shore, or mountains; physical exer- cise, out-of-door life, and cold sponge baths, are frequently serviceable. Lavage of the stomach is rarely necessary in the mild cases, though it is of great benefit in the severe and obstinate forms. Alkalies are utilized to neutralize the excess of acid. Of these, sodium bicarbonate, calcined magnesia, magnesium car- bonate, and phosphate of soda, are most frequently utilized. The dose of the alkali should be as far as possible propor- tioned to the heaviness of the meal, as well as the degree of hyperacidity. The alkalies should be administered when the discomfort begins to manifest itself, i.e., about two hours after meals. Gastrosuccorrhea or Hypersecretion of Gastric Juice. Gastrosuccorrhea is a condition characterized by a con- stant excessive flow of gastric juice. The stomach pours out secretion even when free of food, so that large amounts of gastric juice are-found in the morning, even before the inges- tion of nourishment. This affection is found in three forms: (1) Gastrosuccorrhea continua periodica; (2) gastrosuccor- rhea continua chronica, and (3) digestive succorrhea. Gastrosuccorrhea Continua Periodica. In. this condition, in addition to the appearance of acute attacks with a constant secretion of gastric juice, severe gastric pains and vomiting are present. Periodic hypersecretion may occur as a simple gastric neurosis or as a reflex neurosis secondary to disease of the brain and spinal cord, as in progressive paralysis, tabes dorsalis, or myelitis. The causes are various, among which may be mentioned excessive mental strain, excitement, anger, overindulgence in food and abuse of alcohol and tobacco. Symptoms. The characteristic signs of this condition are not only the paroxysmal attacks beginning in the midst of good health, but also the special character of the gastric con- 86 GASTRIC DISTURBANCES OF MIDDLE LIFE. tents and vomitus. The attacks begin early in the morning with lassitude, headache, and loss of appetite, thirst, and pain in the stomach which becomes intense and is accom- panied by heartburn and acid belching. The pains are spas- modic and intense, and finally there is vomiting of acid mat- ter containing only food at first, and finally only gastric juice. The attack may thus disappear, or after a short time others may set in extending over a period of a few hours to several days. The quantity of vomitus is usually large in amount, frequently from 200 to 500 cubic centimeters, containing food particles and finally pure gastric juice tinged yellowish or greenish with bile. The vomited matter is very acid and may contain traces of blood. During the attack, in addition to the pain there is loss of appetite, great thirst, and general feeble- ness ; the pulse becomes weak and the patient presents the appearance of suffering; he is pale and debilitated. The urine becomes scanty, of high specific gravity, and the bowels are constipated. The attacks vary both as to intensity and dura- tion. Between the attacks the patient is in good health, usually having but little or no gastric discomfort. The gas- tric analysis at this time presents usually a hyperacidity. There is a condition known as gastroxynsis which only differs from periodic hypersecretion in that the headaches are more persistent and prominent. Treatment. The treatment, whenever possible, should be directed to the cause. If due to' anxiety or mental strain, these should be overcome by change of scene; physical ex- ercise should be ordered, and the overindulgence in food and drink prohibited. Relief in some instances has been afforded by means of intragastric electricity. For the attack itself, the treatment advised by Einhorn has been found serviceable; that is, the administration of a moderate dose of bromide immediately at the onset of the attack. As soon as the attack sets in, lavage of the stomach should be practiced with an alkaline solution which should be repeated at varying intervals. For the severe pain, hypodermic injections of morphin must be administered. During the attack, the patient should be al- lowed but small quantities of fluids, water, milk, and albu- min ; bits of ice may relieve the throat. NERVOUS GASTRIC AFFECTIONS. 87 Gastrosuccorrhea Continua Chronica. This condition is known as Reichmann’s disease, or chronic hypersecretion. There is present in this affection a chronic continuous secre- tion of gastric juice, even in the fasting stomach; it may be primary or secondary. It is primary as a gastric neurosis, and secondary when it is due to some other gastric disturb- ance, as ulcer, dilatation, or atony. Inasmuch as continuous hypersecretion is usually associated with gastric dilatation, and inasmuch as the symptoms of both conditions are very similar, many deny the existence of this condition as a dis- tinct entity and consider it a form of gastrectasia. There have been cases, however, reported by Reichmann, Riegel and Pickardt, in which this disease existed as a pure neurosis in which careful investigation failed to reveal any organic disease of the stomach. The causes ■ are much like those of intermittent gastro- succorrhea, namely, worry and excitement, indiscretions in food and drink. Secondary continuous hypersecretion is fre- quently the result of pyloric stenosis and ulcer. The primary condition is rare; it is not as frequently observed as the inter- mittent form. Symptoms. The most frequent symptoms of chronic hyper- secretion are, burning in the stomach, pain, heartburn, acid eructations, nausea, and vomiting of large quantities of gas- tric juice. The onset is extremely gradual and many patients complain of mild dyspeptic symptoms for months before the true nature of the disease is revealed. At first there is but a slight burning in the epigastrium, and heartburn, which gradually increases; the pain appears several hours after meals, which is relieved by the ingestion of food. This affec- tion is especially observed in attacks at night; after the pain has existed for some time vomiting sets in consisting of large quantities of acid gastric juice. These symptoms are mild in some instances and severe in others; they are apt to appear for a time and disappear to recur again after weeks. In severe forms the symptoms are constant, vomiting occur- ring five or six times daily, on account of which the patient loses much flesh and strength. The attack can at times be subdued by the ingestion of protein food, such as milk or 88 GASTRIC DISTURBANCES OF MIDDLE LIFE. eggs. Constipation is usually present and the urine is dimin- ished and of a high specific gravity. On examination the gastric secretion reveals a marked hyperacidity and there are excessive quantities of gastric juice in the fasting stomach. The protein digestion is good, while the starch digestion is poor. In most instances 100 cubic centimeters, or more, of gastric secretion are found in the fasting stomach. Treatment. Diet plays a most important role in the cure of this affection. The meals should be small but frequent, given at intervals of from three to four hours. The patient should eat slowly and masticate his food thoroughly; all ir- ritating substances, such as pepper, spices, and highly sea- soned foods, should be forbidden. The diet should consist largely of proteins, which are best borne, while the carbo- hydrates must be given in small quantities, in the most easily digestible forms. Lavage of the stomach is the most efficient means of reliev- ing pain and irritation and should be practiced in the morning before the ingestion of food. Boas advises the simple empty- ing of the stomach in the fasting state by means of the tube, while Reichmann recommends lavage with nitrate of silver solution, 1 to 2: 1000. Digestive Gastrosuccorrhea, or Alimentary Hypersecretion. This condition is characterized by the secretion of large quan- tities of a thin watery hyperacid gastric secretion obtained in the extracted test meal. The large amount of contents do not depend upon a delayed motility, but upon an increased gastric secretion. In this condition the increased secretion is dependent upon the act of digestion in contradistinction to continuous hypersecretion in which gastric juice is obtained in the fasting stomach. Atony is characterized by a loss of tone of the muscular walls with a resultant motor insufficiency, in consequence of which the stomach is unable to pass its contents into the intestine at the normal rate. Most writers classify this con- dition as a neurosis, while by others it is considered a form of gastrectasia. Atony of the Stomach. NERVOUS GASTRIC AFFECTIONS. 89 Atony may be either primary or secondary. Primary atony is observed in nervous individuals who have been the subject of fright, worry, excitement or mental depression. It occurs as a result of the habitual ingestion of indigestible food; the excessive use of fluids is said especially to predispose to this disorder. It is frequently secondary to disease of the brain and cord, typhoid fever, and tuberculosis. It originates frequently dur- ing the period of puberty, on account of the precocious appe- tite at this period of life leading to the inordinate consumption of indigestible food. Atony appears as frequently in males as in females. Symptoms. The appetite is usually impaired, the first in- gesta causing in many instances a feeling of satiety; occa- sionally it may be normal. Fullness and pressure is constant after meals. The discomfort may be so intense as to continue with severity for hours after meals, and increase when food is again ingested. The symptoms appear immediately or shortly after meals and usually disappear as the stomach becomes empty. The emptying of the stomach is usually delayed, though this is not always thQ case; for while peris- talsis is usually slow in the beginning of digestion, when it is once begun a full meal may be emptied from the stomach at the normal rate. The full meals distend the stomach and thus cause an increase in tonus and peristalsis becomes ac- tive. There is present in addition, headache, pyrosis and eructations, but vomiting is exceedingly rare. Constipation is common, and headaches, vertigo, palpitation and dyspnea are symptoms which are not infrequently noted. On physical examination the stomach is found usually en- larged, the greater curvature reaching below the umbilicus. With but small quantities of fluids (250 to 300 cubic centi- meters) a splashing sound can easily be produced in the region of the stomach. In atony there is not only an enlarge- ment of the stomach, but its motor function is impaired, the food not being propelled into the intestine at the normal rate; food remains being still present in the stomach for from six to seven hours after meals. On the other hand, if the con- tents of the stomach be expressed in the morning before the 90 GASTRIC DISTURBANCES OF MIDDLE LIFE. ingestion of food, the stomach will be found empty of all food remains. This test distinguishes atony from gastrectasia. The test meal reveals large quantities of solid contents, the chemical examination of which points to a normal acidity in most instances. Treatment. Inasmuch as atony is frequently produced by injudicious and too rapid eating, individuals with feeble di- gestive powers should exercise special caution to eat slowly, masticate thoroughly, and avoid indigestible food. Patients affected with atony of the stomach should eat small quan- tities of food at regular and frequent intervals. The quan- tity of fluids should not exceed one and one-half liters per day. The diet should be varied according to the nature of the acidity. The treatment of the chronic constipation associated with this affection should be mainly dietetic, such foods should be given as excite intestinal peristaltic movements. Massage of the abdomen is to be recommended, to strengthen the abdominal walls, and to increase peristalsis. Duodenal feeding has been of great service in a number of our cases and a well regulated rest cure may become nec- essary in protracted cases with great loss of flesh. In regard to the medicinal treatment, preparations containing strychnin are indicated. Anorexia. Anorexia is a condition in which there is a marked decrease or entire absence of the sensation of hunger combined with an absolute loss of appetite. It may be primary or secondary. As a primary disturbance it is observed in hysteria and neu- rasthenia. It may be secondary to cancer of the stomach, chronic gastritis, and acute febrile disorders. Anorexia nervosa usually has its onset after mental excite- ment and anxiety. Symptoms. After great mental strain, loss of appetite manifests itself, which may become so marked that a repug- nance for food is produced and in consequence of which the patient loses weight and strength, and becomes pale and ane- mic. In addition, nervous symptoms present themselves in the form of excitability, restlessness, and insomnia. When NERVOUS GASTRIC AFFECTIONS. 91 the disease is most marked the patient presents the appear- ance of tuberculosis, and death may ensue due to exhaustion or some secondary infectipn. Treatment. In mild cases one should insist that the patient take sufficient nourishment; for this reason the patient’s taste should be consulted and the food varied as much as possible. By means of psychotherapy much can be accom- plished in this direction. The bitter tonics are sometimes of great help. Of these, gentian, quinin and strychnin are fre- quently beneficial. Lavage with a bitter infusion or with a normal salt solution has been recommended. The nervous system should be treated by change of scene, rest, massage, and hydrotherapy. In all serious cases the patient should be isolated in a hospital or sanitarium and given a rigid rest cure. This method of treatment together with feeding by means of the Einhorn duodenal tube, the writers feel con- fident, has saved the lives of a certain number of their patients affected with this condition. Achylia Gastrica or Anacidity. Einhorn introduced the term achylia gastrica to denote that affection in which there is an absence of gastric secretion. This term, however, simply designates a symptom, the under- lying cause being a severe form of chronic gastritis, or gas- tric atrophy, or a purely neurotic condition. Cases accom- panied by a complete atrophy of the gastric mucous mem- brane, such as were first described by Fenwick and as are observed in pernicious anemia, have been described else- where. The term achylia gastrica is best restricted to those forms to which Einhorn first applied it. In these there is an absence of gastric secretion which persists for years with- out ending fatally, and at the same time the general health of the patient remains normal; there are frequently no sub- jective symptoms whatever, and a varied diet may frequently be taken without producing discomfort, the small intestine vicariously assuming the function of the stomach. In one of our cases the affection persisted for twelve years, with gain in weight and with but few attacks of intestinal indigestion. Etiology. In order to determine the presence of achylia gastrica, a fractional analysis of the gastric contents accord- 92 GASTRIC DISTURBANCES OF MIDDLE LIFE. mg to the Rehfuss method is extremely important in all cases, as by means of this method we are enabled to differentiate the true from the spurious forms. This differentiation is important, inasmuch as many of the false achylias present a high hydrochloric acid index, sometimes marked hyperacidity, and are in fact really cases of delayed hyperacidity. In the true achylias free HC1 is absent in every specimen and the total acidity is low. Achylia gastrica is observed in neurasthenic patients. It may remain latent without making serious inroads into the general health, especially in those patients in whom the mo- tility of the stomach remains normal, and the intestinal func- tions are undisturbed. From the observation of certain patients for at least fifteen years, Stockton believes that, in the absence of or with a low standard of gastric secretion, individuals are always found to have impaired health even with relatively good intestinal digestion. Achylia gastrica is usually observed after the thirteenth year of life and increases in frequency in middle life. It occurs with equal frequency in males and females. Symptoms. Einhorn divides achylia gastrica into three clinical groups: (1) Individuals presenting no gastrointestinal symptoms whatever and who are in good general health. (2) Patients presenting more or less gastric discomfort. (3) Patients having apparently no gastric symptoms but who present marked intestinal disturbances. In the first group are found the smallest proportion of cases. The individual presents no loss of flesh, subjective symptoms are absent, and the diseased condition is usually noted by accident. The largest proportion of cases are observed in the second group, in which the symptoms are mainly gastric. These consist of loss of appetite, discomfort and pressure in the region of the stomach, and occasionally merely burning with pressure after meals and persisting for some time. In some instances there is no pain whatever, while in others it occurs with great severity. Nausea and vomiting are rare. The vomited matter usually contains un- digested food remains. Eructations and pyrosis are occa- NERVOUS GASTRIC AFFECTIONS. 93 sionally observed, and at times symptoms are present which are not unlike those observed in hyperchlorhydria—that is, pain appearing two hours after meals, relieved by the inges- tion of food; nervous symptoms are frequently noted. The third group contains those patients having apparently no gastric disturbances, but presenting intestinal symptoms. The most frequent symptom is diarrhea, which is at times associated with gurgling in the bowels, and intestinal colic. Not infrequently constipation alternates with diarrhea. The gastric content obtained after a test meal is moderate in quantity, with a small amount of fluid with bits of un- digested bread. The contents are neutral or slightly acid, the total acidity varying between 2 and 10; hydrochloric acid is not present, and pepsin and rennin are entirely absent, although the rennet zymogen may still be present; the test for propeptones and peptones is negative, and there is an absence of mucus. Fragments of mucous membrane often appear in the contents, indicating the great vulnerability of the mucous membrane. The motor function of the stomach is usually increased. Treatment. This is mainly dietetic and although it is nec- essary to restrict the diet materially, it is important to insist on the ingestion of sufficient nourishment, as many of these patients are weak and have lost flesh. An attempt should be made to increase the general nutrition of the patient. For this reason the motor function of the stomach should as far as possible be maintained in its normal state, and any dis- turbance of the intestinal canal should be guarded against. It is important to arrange the diet, so that it can be acted on easily by the intestinal juices. The food must be broken up into as fine particles as possible and should to a large extent be given in liquid and semisolid form. Lavage is to be recommended in those instances in which the gastric motility is somewhat impaired. Drugs are not required; in some cases dilute hydrochloric acid may be administered, well diluted, in 15-drop doses three or four times at intervals of fifteen minutes, after meals, with benefit. For anorexia, strychnin combined with bitter tonics is recommended. 94 GASTRIC DISTURBANCES OF MIDDLE LIFE. Hypochlorhydria or Subacidity. By subacidity or hypochlorhydria is meant that form of neurosis in which the acidity, as well as the other constituents of the gastric secretion, are lessened. One can only make a positive diagnosis of this affection by utilizing the Rehfuss fractional method of analysis. Hypochlorhydria is commonly observed in certain organic diseases of the stomach, as in chronic gastritis and cancer. In the nervous forms, however, there is no evidence whatever of organic disease. This affec- tion is frequently found in neurasthenia or hysteria. Many cases are observed which present no symptoms for a long period of time; this is especially true when the motor function of the stomach remains normal, but as soon as this function is impaired, fermentation sets up in the intestines and distention takes place. The symptoms of this affection are not positive and the diagnosis can only be arrived at by an examination of the gastric contents. A symptom which may lead one to suspect the presence of this affection is a persistent diarrhea, which is due to a disordered intestinal function following the hypo- chlorhydria, in consequence of which the patient becomes emaciated and weakened. The diagnosis is arrived at by an examination of the gastric contents by means of the Rehfuss method of fractional analy- sis, when a constant diminution of hydrochloric acid is ob- served in every specimen of gastric juice obtained; at the same time neurasthenic and hysterical symptoms must be present. The treatment is largely dietetic; the food should consist mainly of carbohydrates. Meat must be given in the most digestible forms and finely divided. Attention should be given to the general health and nervous system of the patient; hydrochloric acid should be administered in from 10- to 20-drop doses after meals, and lavage should be practiced provided the motor function of the stomach is disturbed. Nervous Dyspepsia or Neurasthenia Gastrica. In nervous dyspepsia a combination of gastric neuroses occurs, which is characterized by the presence of a multi- NERVOUS GASTRIC AFFECTIONS. 95 plicity of symptoms and yet no organic changes are observed. In this affection all the functions of the stomach—motor, sensory and secretory—may be disturbed at the same time. As causative factors in the production of nervous dys- pepsia are, worry, anxiety, overwork, sexual and alcoholic excesses, and the abuse of coffee, tea, and tobacco. Nervous dyspepsia is characterized by a multiplicity of symptoms varying in their mode of onset and intensity. Gas- tric discomfort is usually present after meals, though this condition is in no way dependent upon the quality and quan- tity of food ingested but rather upon mental strain and excite- ment. At times the most digestible food causes discomfort while indigestible food produces none. The gastric distress is in the nature of eructations, pressure, fullness, distention, nausea, and heartburn. Other manifestations of neurasthenia develop, as headache, vertigo, depression, and insomnia. The appetite is capricious—often good, followed by severe anorexia. The patient’s general health is not usually impaired, though at times the emaciation may be so extreme as to suggest some serious organic affection. Alternation of periods of well being with those of discomfort, as well as the variations in intensity of the symptoms at short intervals, are not uncommon in this disorder. The gastric secretion ordinarily presents a normal acidity, although at times hyperacidity or hypoacidity may occur. The diagnosis is arrived at by the absence of any indication of organic disorder together with the associated neurasthenic symptoms and is more fully confirmed by the finding of normal motor and secretory functions of the stomach. Treatment. The treatment must be so constituted as to aid in the general building up of the nervous system of the patient; drugs are rarely indicated, and recovery can only be brought about by following a proper mode of living and hygienic laws. If possible, it is important in all instances to determine the cause, which must be relieved; i.e., excitement and worry must be overcome and physical causes corrected. The diet is of great importance; this should not be too restricted but should be strengthening and given in liberal 96 GASTRIC DISTURBANCES OF MIDDLE LIFE. quantities. The patient’s appetite should be humored, espe- cially if the food desired is nourishing. The most beneficial results are obtained from rest cures, forced feedings, and duodenal alimentation. VISCERAL ARTERIOSCLEROSIS. Visceral arteriosclerosis occurring during middle life, as associated with the digestive tract and especially the stomach, has hitherto not been accorded sufficient attention, according to our experience, this condition occurring much more fre- quently than is usually acknowledged. Of our five hundred cases of gastric disorders of middle life, arteriosclerosis appeared in thirty-three instances (6.2 per cent.), almost twice as frequently in males as in females. The incidence according to age is as follows: Ages in years Male Female 40 to 45 5 2 45 ” 50 9 4 50 ” 55 7 6 Total 21 12 As individuals advance in years and arteriosclerotic changes slowly make their appearance, disorders of digestion become more common and indigestion can then only be avoided by care in diet. Samuel Fenwick has noted that twenty-one per cent, of all elderly individuals suffer more or less from chronic indigestion. On the other hand. W. Saltau Fenwick notes that of every hundred cases of chronic indigestion in elderly individuals, sixty-six are secondary to organic dis- ease of some important organ of the body, while the remain- ing thirty-four owe their symptoms to a progressive de- generation of the secretory structures of the stomach and intestines. As has been previously noted, arteriosclerosis leading to gastric disturbances may be observed in one of two distinct types: 1. Those instances in which the arteriosclerotic changes are primarily in the stomach itself. 2. Those in which the manifestations are secondary to a general arteriosclerosis. VISCERAL ARTERIOSCLEROSIS. 97 An etiological factor concerned in the production of this condition is the natural wear and tear of life, as manifested in the changes in the blood-vessels with advancing years. In many instances these changes may not be noted until the onset of old age; while in others they appear early, already being fully developed in middle life. There can be but little question that the early onset of this condition is frequently due to such factors as overwork, mental overstrain, over- indulgence in food and drink, syphilis, other infectious dis- eases, and toxic factors such as gout, lead poisoning, alcohol and intestinal toxemias. Heredity often plays an important role, as one frequently observes early arteriosclerosis in members of the same family. Pathology. The pathological change is degenerative in character, affecting both the arteries and also the walls of the stomach. The arteries may be partly or almost wholly occluded, due to the increase in connective tissue in the inter- mediate layer, as well as to the proliferation of the endo- thelium. The new connective tissue formation may occur diffusely or in circumscribed areas in the larger vessels, the endothelium often proliferating or undergoing fatty degenera- tion. Cystic degeneration often takes place in the newly de- veloped connective tissue, producing the well known “athero- matous cysts”; these, extending into the vessel’s lumen, may produce emboli, or ulcerations with thrombotic formation. Calcification may take place in the newly formed fibrous tis- sues of the intima, and atrophy and calcification in the muscularis and adventitia. Symptoms. The main clinical gastric manifestations recog- nized in middle life as the result of general arteriosclerosis and of arteriosclerosis of the abdominal arteries may be divided into three groups: 1. The dyspepsia due to general arteriosclerosis. 2. Abdominal angina. 3. Gastric ulcer, with or without hemorrhage. The Dyspepsia Due to General Arteriosclerosis. These symp- toms usually begin insidiously and are principally manifested in the form of flatulency, fullness, distention, nausea, eructa- tions, dizziness, palpitation, and shortness of breath. 98 GASTRIC DISTURBANCES OF MIDDLE LIFE. At first but a few of these symptoms are noted, and then only on awakening in the morning, and are often relieved by eructations of gas. The appetite for breakfast gradually diminishes and the patient finally is unable to eat until the noon meal. While the noon meal may be taken with relish, the symptoms above noted are apt to return in the afternoon and epigastric distress is not uncommon. As time goes on, the general abdominal distention, distress, and eructations, are constantly at hand. Nausea and retching after meals are not infrequent, but vomiting is rarely noted. Tachycardia, dyspnea, tightness of the chest, are not uncommon, adding further to the distress of the patients. The flatulency at times increases in severity, especially at night, and the patient is forced to sit up in bed in great discomfort, making efforts to eructate and often suffering with marked dyspnea. The night attacks are frequently increased by the evening meal, and on this account the patient frequently places him- self upon a liquid or semisolid diet. The symptoms just noted may exist with varying degrees of intensity for years and may even disappear for a short period of time, often to return with great severity. At this period, however, the dyspnea, flatulency, and epigastric dis- tress appear, on slight exertion, even without the influence of food. Intestinal flatulency and distress now manifest themselves and the patient loses weight and strength, the symptoms progress, and the patient may die either from an intercurrent cerebral, cardiac, or renal complication, or from exhaustion. Abdominal Angina. Abdominal angina occurs frequently as the result of an abdominal endarteritis. These changes of an inflammatory and degenerative character set in slowly in the abdominal aorta and its branches, are progressive and are also the cause of ill defined though often severe abdominal pain. This pain is usually of a paroxysmal character, is often increased on exercise, is relieved by rest and is associated with tenderness on pressure along the aortic plexus and with lancinating pains extending along the course of the iliac and femoral vessels. Harlow Brooks has called attention to the fact that the disturbed visceral function often associated with pain and VISCERAL ARTERIOSCLEROSIS. 99 elevation of blood-pressure, which cannot otherwise be ac- counted for, is frequently the cause of some localized area of abdominal arterial disease. The pain caused by arteriosclerotic changes in the abdom- inal aorta may be observed in the epigastrium, thorax, or lower abdomen. Like angina pectoris, it is ordinarily in- creased on exertion or excitement and is accompanied with tachycardia and hypertension. The pain is often transmitted into the dorsal and lumbar regions of the spine, and disap- pears under the influence of rest and the administration of the nitrites. According to Allen Jones, “it may be termed ab- dominal claudication and is accompanied by a consciousness of heavy, hammering, intra-abdominal pulsation, which rivets the patient’s attention, is somewhat alarming, and prompts him to seek immediate physical and mental relaxation.” When the gastric branch is involved in this condition, epi- gastric pain, often of a severe type, is induced by a full meal, which is not entirely relieved until the stomach has entirely emptied itself; light meals producing but moderate discom- fort. Gastric Ulcer, With or Without Hemorrhage. The character of the formation of these ulcerations has already been de- scribed. They are definitely due to degenerative changes as a result of marked ischemia of certain parts of the gastric wall, caused by an arteriosclerosis (often a thrombo-angeitis) of a branch of the gastric artery. A frequent cause of the hemorrhage is found in the rupture of the miliary aneurisms in the small gastric arterioles. The diagnosis of ulcers of this form is mot always easily accomplished, for they may be mistaken for simple ulceration inasmuch as the symptoms occasioned are not unlike those observed in that disorder. When in individuals at middle age, with evident manifesta- tions of arteriosclerosis, the usual signs of ulcerations occur, one should always suspect the presence of this affection. On the other hand, inasmuch as carcinoma may have its onset in a similar manner, the diagnosis may become even more complicated. When hemorrhage occurs with this form of ulceration the diagnosis becomes much less difficult, though, as has already 100 GASTRIC DISTURBANCES OF MIDDLE LIFE. been noted, hemorrhages do occur, even of a massive type, as a result of the rupture of the arteriosclerotic vessels in the stomach. Cases of this character have been reported by Simon and a number have been under our observation. The following case illustrates this condition : A male patient of sixty years of age, affected with general arteriosclerosis but without any gastrointestinal symptoms whatever, was awak- ened one night with a sudden massive hetyorrhage, from which he died within a few hours. At the autopsy a rupture of a small artery in the stomach, which had undergone marked sclerotic changes, was noted. Diagnosis. In order to arrive at a correct diagnosis, a thorough general examination of the patient should be made and not too much reliance should be placed upon the mere symptoms of indigestion. In a patient during middle life complaining of flatulency, distention, and with epigastric pain and dyspnea which are relieved by eructations, especially when these symptoms are aggravated at night, a careful examination into the cardio- vascular system should be made. Not infrequently there will be revealed a marked hypertension, with an enlarged heart, with an accentuated second aortic sound or a murmur over the aorta, pulsation in the episternal notch, discomfort on pressure along the abdominal aorta, together with an in- crease in the urine, which is of a low specific gravity and contains albumin and casts. These findings point directly to the arteriosclerotic changes as causative factors in the pro- duction of the ga,stric affection. Treatment. In the treatment of visceral arteriosclerosis special attention should be directed toward the general health of the patient. All foci of infection should as far as possible be removed, and improvement in the patient’s general health brought about by means of hygienic and dietetic, as well as medicinal measures. Among the hygienic measures to be recommended in the treatment of these patients are, moderate exercise, warm baths, and fresh air. Excitement should as far as possible be avoided, and sufficient mental and physical rest should be insisted upon. VISCERAL ARTERIOSCLEROSIS. 101 The dietetic treatment is of primary importance. While the food should be nutritious, it must be easily digestible, and above all the evening meal should be limited in quantity and so constituted as to avoid as far as possible the formation of gas. In general, a lacto-vegetable diet is to be recom- mended. Protein food, especially of the animal variety, should be greatly restricted; and tea, coffee, alcohol and tobacco be allowed only in limited amounts. The white meats and fish are allowable in minimal quantities, and in some instances it may become necessary to mash and strain the vegetables. Cereals and well toasted bread are to be recommended in liberal quantities. It is important under all conditions to restrict the use of salt, and in aggravated instances the food must be cooked free of salt. The remedies to be utilized in the treatment of this affec- tion are much like those ordinarily administered in general arteriosclerosis. Of the drugs to be recommended are the nitrites, either in the form of nitro-glycerin or sodium nitrite, sodiosalicylate of theobromine, potassium iodide, sajodin and benzyl- benzoate. Thyroid extract has been utilized with great bene- fit in many of these patients affected with an associated obesity. Diseases of the Intestines and the Cirrhoses of the Liver BY ANTHONY BASSLER, M.D., F.A.C.P. Consulting Gastroenterologist, St. Vincent’s, People’s, Jewish Memorial, Christ’s (N. J.), and Fifth Avenue Hospitals; Formerly Professor of Gastroenterology, New York Polyclinic Medical School and Hospital, and the late Fordham University Medical School. Diseases of the Intestines and the Cirrhoses of the Liver. CONSTIPATION. FOREWORD. Constipation is merely a symptom and occurs in many disorders and diseases. As a symptom this is the commonest of disorders of the human being and much has been written on it even in ancient times. Various opinions as to its im- portance are held by different observers, some believing that it is a common cause of serious conditions that may arise in the body and others that its importance has been over- estimated. Keeping in mind the irregularity of bowel movements it is not easy to be dogmatic as to what these should be, in intervals of time, to be considered normal. It must be mani- fest, with the presence of stasis in the ileum or whatever cause may bring about a delay, when the debris from a meal taken as previously as forty-eight or more hours occurs in a movement; these taking place daily and apparently no constipation existing. Taking examinations of numerous normal people as a standard, it may be said that an individual is constipated in whom the debris from a meal eaten thirty- six hours previously is not present in the rectum ready to be evacuated or the evacuation having already occurred. Of course it is manifest that when the bowels do not move for a number of days, then definitely the thirty-six hour time has elapsed and that individual is constipated. It may fur- ther be standardized that if a person has regular movements of the bowels at the same time each day the latter part of the stool being mushy or semi-solid, that this individual is not constipated. This also holds true in those who have more than one stool a day. Another important point is that where no constipation exists there is a feeling of complete satisfaction and emptying of the rectum after each evacuation. 106 DISEASES OF THE INTESTINES. ETIOLOGY. The causes of chronic constipation are numerous and in each instance all possible factors should be investigated and if possible corrected. Among these in their head lines are the following: Habits. There is no doubt about it that ignorance, lazi- ness and false modesty are largely responsible for constipa- tion. By ignorance I mean that state of mind found most often in women, particularly in the younger ones, in whom the necessity or importance of regular movements of the bowels has never been inculcated—and if so, was not be- lieved. It is a well-known fact, in rectal work as well as in vaginal examinations, that the average woman has feces collected in the rectum, which is not commonly the case in a man. Men are more particular about having efficient move- ments of the bowels, and are observant in this connection, whereas women have a fashion of not talking about their movements in these terms and are not really very observant as to whether the stool passed seems to be a complete evacu- ation, or whether a sense of being empty after the stool takes place. By laziness is meant a carelessness in responding to the call of nature and holding back, waiting for a more favorable time and place, which practice if continued long enough will eventually increase the constipation. There usually is a complete lack in these individuals of any effort to maintain a regularity of movement of the bowels, and commonly the slightest reason is taken advantage of for deferring this act. Among the worst offenders in this connection are the people of the wealthy class rather than the working people, and these individuals are those in whom the largest percentage of sedentary life exists. In this same connection may be mentioned false modesty, although it has been my observa- tion of late years that women and men are getting away from this, usually having the faculty of departing from the company of others under some subterfuge long enough to retire to the toilet. The study of people also suggests that those who live in cities are not more constipated than those in the country CONSTIPATION. 107 districts. While I have no statistics of positive data, it is my impression that the people of country districts are even more constipated than those in the cities. Diet. There is no doubt that faulty diet is largely respon- sible for habitual constipation. The factors which have to do in bringing this about are many. Some people do not eat enough for bulk in the intestines to stimulate sufficient peristalsis for evacuation. Others eat too much of the kind of food in which the native proteins predominate, and a large protein content in the intestinal canal means a low stimu- lating power on the peristalsis. There is no doubt about it, that bulk of food is necessary for what may be termed regular daily movements. The constantly growing habit of partaking of larger and larger amounts of cane sugar is a constipating factor. The same may be said of starches and flours, particularly those which have been prepared. The modern breakfast foods, of the instant and ten-minute varie- ties, have a low stimulating power on peristalsis. In the polishing and preparation of most of them the hull and chaff have been taken away, and while they have been rendered more palatable to the taste the stimulating elements in them have been removed. The demineralization of other foods is also a factor, as is excessive intake of vegetables high in cellulose and fruits high in the lower grades of sugars. Very often individuals are met with who do not take sufficient fruit in the course of a day. Water is one of the best in- testinal stimulants we have, and while excessive drinking is wrong, too little drinking is also wrong, because then the emunctories of the body have difficulty in carrying on their normal functions. Another factor of importance is eating at irregular times. If one keeps in mind the mass pendulent movements of the colon stimulated by the taking of food, the importance of stated hours for the taking of meals is readily seen. Defecation Position. With the advent of the house as a human abode it is surprising that the builders of early out- houses did not recognize the fact that before they had houses the normal position of defecation was much lower than that possible to be brought about by the high shelf used to sit upon. In modern buildings the height of the average toilet 108 DISEASES OE THE INTESTINES. seat is 18 inches, and the only position possible for the lower extremities, with the feet resting on the floor, is approxi- mately that in the average chair. The proximity of the thighs to the abdomen reinforces the abdominal muscles and causes a distinct relaxation of the lower pelvic outlets. With the average toilet seat, correct position can be brought about in one of two ways, either by leaning the body forward so that the abdomen presses upon the thighs, or with the body in the normal upright position and the feet raised by a stool or some such arrangement, so that the same effect is brought about. The former is distinctly more preferable, since no added means is necessary. Functional Disturbances of Intestines. Among the more common causes of constipation the following are presented: Atony of the colon; dry colitis; deficient function. In these conditions constipation is usually present. There are often prolapsed organs with more or less atony of the right colon or deficiency of the haustral contractions in the left. To diagnose these, x-ray examinations of the colon must be made, as well as proctoscopic examinations of the mucous membrane of the rectum and rectal dome. These conditions are usually found in the indolic and mixed types of chronic excessive intestinal toxemia, and the constipation is there- fore symptomatic. It is probable that the constipation is responsible for the drying of the mucous membrane, because I have observed that when it is possible to bring about normal movements of the bowels the mucous membrane takes on a much more healthy appearance—this usually requiring three or four months of time. Spastic Constipation. Hyperfunction. There are many cases of constipation due to irregular spasm found in the left half of the colon, and I have not infrequently seen the left colon, from the sigmoid to the contracted down so that the barium shadow represented but a thin line. An x-ray examination is necessary to diagnose this. It is believed that this type of constipation is bound up in some endocrine disorder and largely in the condition that is called vagotonia. While this may be so, because these factors do exist in a number of such patients at the same time, it is my belief that the spasm is due to the presence of irritative CONSTIPATION. 109 contents in the intestine which affects the musculature in spastic ways; and the commonest cause of this state is a saccharobutyric intestinal toxemia, in which the anaerobes are the prominent factor, the stool being highly acidulous in reaction. That this must be true is proven by the fact that when the biology and chemistry can be changed to approxi- mately normal the spasm area no longer exists. Flexure Defects. Malposition. Not uncommonly one sees marked constipation in cases which have a definite falling forward of the hepatic flexure, sometimes the flexure being so low that it almost occupies the ileocecal region, the ascending colon doubling up on itself. There are many instances of incomplete rotation of the colon in which all of the abdominal viscera are in normal position excepting the hepatic flexure. The hepatic flexure anatomically should be at a fixed point in the posterior wall of the abdominal cavity. Senile Constipation. Exhaustive Function. In advanced years constipation is a common condition. Such individuals are usually no longer robust, but deficient' in vitality, living sedentary lives, and have not only deficiency in the motor power of the hollow viscera of the abdomen but in the secre- tions of the gastrointestinal canal as well. Strictures. Strictures, both benign and malignant, provid- ing there is no ulceration, are common causes of chronic constipation. Such strictures usually bind down the struc- tures of the gut wall, perhaps bridging across and usually occluding its lumen. In rare instances tumors within, but most times without, the gut wall press upon its lumen and in that way obstruct the transit through. Stomach Conditions. In diseases and conditions of the stomach, such as hypochlorhydria, ulcer, cancer, dilatation, and achylia gastrica, constipation may be present. The same is true in an obstruction to the entrance of bile into the intestine or deficiency of bile. Diseases of the heart, lungs, liver and kidneys bring on an intestinal hyperemia and con- gestion of the portal system which may retard the peristalsis. In quite a few chronic diseases of the pancreas, constipation is met with, the same being true in diabetes, anemia, and 110 DISEASES OF THE INTESTINES. arteriosclerosis, and many diseases of the brain, spinal cord, and nervous system. Acute febrile conditions are usually accompanied by constipation due to deficiency in the secre- tions. Rectal Conditions. Constipation may be caused by hyper- trophied O’Beirne’s sphincter, in which the feces collect in the sigmoid flexure and are therefore prevented from reach- ing the rectum, owing to the frequent and persistent con- traction of the sphincter as soon as the stimulus reaches it. Hypertrophy of the rectal (Houston’s) valves, generally a result of chronic colitis, ulceration, and other affections of the lower bowel, may cause constipation. Occasionally one meets with constipation due to hypertrophy of the levatores ani muscles. When present they can usually be felt as thick, rigid bands at the sides of the rectum, about two inches above the anus. Hypertrophy and spasm of the anal sphinc- ter are not unfrequent causes of obstinate constipation. In rare instances coccygeal deviation and perhaps foreign bodies may cause constipation. A common type of constipation is that due to atony of the rectum in which the viscus acquires a voluminous shape, the caliber sometimes being as wide as four or five inches. Lastly constipation may be present in anal fissures and hemorrhoids, particularly of the internal variety. DIAGNOSIS OF CONSTIPATION. In the presence of a history of chronic constipation a search for a cause should be engaged in. This may be found in the life custom of the individual, his habits or his diet. X-ray examination of the colon should always be made as part of the routine. Following this a proctoscopic examina- tion is called for. When careful diagnostic work is done to ascertain the cause of constipation, the relief of this symptom without medicinal means is usually brought about. TREATMENT. As has already been stated, constipation is a symptom and thus the cause of the constipation should be searched for and treated. With people who are habitually constipated, CONSTIPATION. 111 with a movement every second or third day, and in good state of general health, it might be wiser not to engage in any method of treatment. But while the subject of chronic constipation has been largely overdone in its significance in medicine, it yet has an important bearing in the accomplish- ment of results possible by treatment, results which are favorable to the individual’s health and sometimes most beneficial. Ignorance and false modesty, as well as slow response to the rectal reflex for evacuation, often call for stern advice. The hygienic method of living, proper out-of- door life and exercise, and the diminution of strain and worry, are often called for, and as few purgatives as possible should be employed. Regularity should be taught, which means that a patient should repair to a toilet at a regular time each day, preferably before breakfast, and should remain sitting on the toilet for five or ten minutes, even if there is no desire for the bowels to move. If then nothing is accom- plished a glycerin suppository or small enema of cold water may be used. By persisting in this, regularity may in some instances be brought about. Diet. Water should be taken in considerable quantity before breakfast, and after meals through the day, and several times between meals. Foods to avoid are, too much protein food, too much cane sugar and a diet too rich in carbo- hydrates or fats. Milk, red wine, tea, chocolate, and cocoa, are constipating with some people. The diet should be largely vegetables and fruits, with, perhaps, the liberal use of olive oil. Apples in the evening before retiring are some- times beneficial. The plan of the diet is to eat three meals a day with nothing between times. The food should be of the normal kinds and simply cooked. Drink at least five glasses of water a day, preferably be- fore meals and between them, not during the meal. Any of the customary foods can be eaten, but do not take more than two eggs in a day, and take meat, fish and fowl but once a day, and this once in very small quantity. Milk, tea, or sour wines, are forbidden, and no foods con- taining pits or seeds are allowed. Fruits, raw or cooked, should be eaten morning and evening, the liberal use of 112 DISEASES OF THE INTESTINES. honey and the use of milk sugar instead of cane sugar on foods is advisable. At breakfast each morning instead of a cereal, or with oatmeal, eat a handful of finely cut agar-agar with fresh cream. Agar-agar may be purchased from the local druggist. During the course of the day eat one to three of the following gems, which should be baked twice a week: Bran Gems. Two cups of bran, 1 cup of flour, 1 cup of milk, % cup of molasses, y2 teaspoonful of baking soda (dis- solved in hot water), y2 teaspoonful of butter, y2 teaspoonful of lard, salt to taste. Bake in a slow oven 45 minutes. If it is not possible to take the bran gems, take one or two tablespoonfuls of wheat bran cooked in milk with cream and sugar. At dinner or before retiring, take a dish of stewed prunes cooked in milk sugar or honey. It may be found that apple sauce sweetened with milk sugar will work as well as the prunes. If so, alternate this with the prunes, eating one on one day and the other the next. At certain times each morning and evening make an effort to stool. This should be persisted in even if no success is obtained in the beginning. Its object is to establish a regu- larity in time. However, at any other time when the desire for stool conies on respond to it at the earliest possible moment. Very often one has to write an individual diet to fit the individual condition of a person who is constipated. In this instance any of the above anti-constipation additions may be added to the diet, although the following serves admirably as an additional diet—that is, anti-constipation additions which may be added to any diet: Measures to encourage the bowels to move in a normal way are the fol- lowing: Begin by taking three of the following bran gems during the course of the day, and if you cannot get them, take in place of them a good- sized dish of pettijohn bran, or from 1 to 2 tablespoonfuls of wheat bran mixed with oatmeal or shredded wheat biscuit for breakfast. Bran Gems : One-half teaspoonful of soda, saleratus, dissolved in % cup of hot water. Add, when dissolved, % cup of molasses, then a tablespoonful of butter, salt to taste, 2 cups of wheat bran, 1 cup of bran meal, 1 cup of milk. Mix all the ingredients together, put in muffin pans and bake 45 minutes in a slow oven. CONSTIPATION. 113 If the above does not move the bowels, retain the bran method which you are employing, and as an additional method take a dish of stewed prunes cooked with milk shgar or honey, or molasses, at the evening meal or before retiring If the foregoing two methods are not sufficient, take the prunes at the evening meal and.a tablespoonful of petroleum jelly or vaseline, before re- tiring. With the institution of this take from 3 to 6 glasses of water during the course of the day, in the intervals between the meals and on arising and before retiring. If then the bowels are not moving, add a few senna leaves to the prunes which are being taken, these being put in at the time of stewing. If still the bowels do not move, drop the use of the bran, both in the biscuits and at breakfast, and substitute a handful or ounce of finely cut agar-agar, eaten with cream and sugar at breakfast. This may be mixed with a cereal but not cooked with it. The foregoing methods should be followed, beginning with the first and adding one thing after the other until the desired result is accomplished. Do not become alarmed if the bowels do not move in the beginning, or if a day goes by during the time of the above additions. The use of agar-agar has been resorted to by some prac- titioners for a considerable number of years and there is no question that it has distinct benefit. In my experience, how- ever, it cannot be depended upon alone and I rarely use it alone excepting- in the diarrhea cases where constipation also exists. By that I mean where a number of movements of the bowels have taken place in the course of the day and there still remains back in the colon considerable dry feces. For the reason that agar-agar is not efficient it has been mixed with various drugs. A proprietary combination going under the name of Regulin, a combination of agar-agar and cascara, is an efficient preparation. The same is true of agar mixed with phenolphthalein. Bran, which takes up water, is indigestible and therefore it increases the roughage in the intestinal content and con- tains some intestinal stimulant and often serves to good purpose. It may be mixed with various foods, such as shredded wheat biscuit or cooked in various forms of bread and cake. Baker’s yeast, of which I have used considerable, serves to good purpose for chronic constipation with some individuals. While we do not know why, it does occasionally serve to regulate the bowels. 114 DISEASES OE THE INTESTINES. For a long time various preparations of mineral oil have been used for the alleviation of constipation, and while in some instances it does excellently, in the majority it is not to be recommended. Ofttimes the oil comes away without carrying any stool and we are told in this instance we are giving the oil in too large a quantity. While this may be true, nevertheless the giving of smaller quantities has often been disappointing to me. I believe that a better preparation than the fluid forms of oil is the soft form of paraffin, which is best employed in the form of petroleum jelly (vaselin), which is readily taken in the same way as mineral oil. It may be warmed so that it can be drunk. Lastly it should be mentioned that prunes cooked with any of the “dog sugars” are quite stimulating to peristalsis. For this purpose milk sugar, glucose, honey or molasses answers well. Sometimes the cooking of a few senna leaves with the prunes is all that is necessary for just one addition to any diet to overcome a moderate degree of constipation. Massage. Various forms of massage have been engaged in to overcome constipation. My experience has been that while they are helpful, they are rarely ever in themselves sufficient to overcome the condition. For a long time, the use of a three- or five-pound cannon ball rolled well over the abdomen and the coils of the colon and small intestine in a spiral manner, the patient in a dorsal position, was recommended. This procedure I object to, as well as I ob- ject to all forms of mechanical massage which the individual uses himself. It is very liable to make him too introspective and self-centered upon the condition. Electricity. Of considerable value is the use of the sinus- oidal current with a large electrode fore and aft on the abdomen. Various other types of current have been em- ployed, sometimes with benefit but most .often not so. Exercise. In my opinion one of the most valuable meth- ods of overcoming chronic constipation is the use of regular exercises. Of these there are none better than the United States army setting-up exercises, engaged in for ten or fif- teen minutes each morning. Not a few of my patients have accomplished regular movements of the bowels by drinking CONSTIPATION. 115 one or two glasses of cold water on arising and then engaging in the setting-up exercises. Dilatation. Hirschmann believes that the direct stimula- tion of the atonic rectum and sigmoid by means of mechan- ical dilatation has, up to the present time, given the best results in cases of chronic constipation. For this purpose he used a rubber bag with a stem, which is slipped over the distal end of a Wales bougie, 3-5, this bougie being canaled. Compressed air at a low pressure is allowed to enter the bag slowly and distention to any desired extent is produced. I have employed this method and I do not see any benefits from it. Enemata. Enemata with hot saline solution, given at the temperature of 110° to 120° F. for fifteen minutes three times a week alone, or combined with electricity or with the alter- nating cold douche, about 60° F., may prove of service in very obstinate cases. Of course the old-fashioned soapsuds enema, which is somewhat irritating, or that containing glycerin, especially when taken in the knee-chest position, most invariably empties the colon. This, however, is not a method of treatment that is advised, excepting perhaps in the senile cases where its use twice or three times a week may be necessary. Occasionally the instillation of warm oil into the rectum at night (4 to 6 ounces), using Russian or the common forms of sweet oil, serves to accomplish a movement of the bowels in the morning. Suppositories. Quite a few individuals, particularly those in whom there is no rectal reflex, can be stimulated by the use of glycerin or gluten suppository, or a small quantity of warm water containing one of these substances in solu- tion. Soper suggests the use of magnesium sulphate solu- tion, a twenty-five or thirty-three per cent, applied directly to the rectal mucosa or to the valves at the dome of the rectum in cases of spastic constipation, or the use of the same strength solution of sodium sulphate in the atonic type. Medication. It is my rule to use only the mildest laxa- tives and they are used only in a temporary way. For the spastic form with fecal impaction belladonna may be of value. This is given as a tincture in large doses and usually pushed until the physiological symptoms are apparent. 116 DISEASES OF THE INTESTINES. Among the mildest laxatives is fluid extract of cascara, the aromatic fluid extract being the most pleasant to take but only about one-third as potent as the bitter variety. Phenol- phthalein, in doses of from 1 to 5 grains at bedtime, may justify a trial. In my belief the combination that comes nearest to a physiological laxative is the following tablet, which goes by my name: Ext. cascara sag 2 gr. Podophyllin H2 gr. Ext. belladonna lie gr. Strychnia sulph lioo gr. Sig.: Take one or two at bedtime. The dose of cascara sagrada should be just enough to be a mild intestinal stimulant and not large enough to cause distinct colicky pain. There are some individuals who are distinctly idiosyncratic to cascara sagrada. They are usually the ones who are obstinately constipated and require very large doses to accomplish the purpose. The author feels that it serves no advantage to include a long list of various purgative tablets or pills, most of which are well known to all members of the profession. It may be said, though, that rhubarb is an excellent drug and that the various saline purgatives which are resorbed by the stomach and upper intestinal canal and excreted by the sig- moid and upper rectal mucous membrane, may be necessary for a brief period. Surgery. It must be remembered by the reader that the writer believes that constipation is due to some error and that he is very conservative in all matters of surgery. Sur- gery is never permitted in his cases unless there is a definite diagnosis of something seriously wrong, of which constipa- tion is merely one of the symptoms. Surgery is then en- gaged in to relieve the condition and not for the purpose of relieving the constipation. He is not at all in favor of Lane’s teachings which, while helpful in a few instances, are erroneous in by far the greatest majority. Such a thing as doing colectomies, partial or complete, because of ob- stinate constipation or autointoxication, is almost like be- heading an individual to cure a headache. CONSTIPATION. 117 I believe that there are instances of acute flexures or angulations of the colon or sigmoid which are important in the causation of constipation and fecal retention. I have seen a shortening of the mesentery hy inflammation or adhesion, or the fixation of the gut by adhesions, cause angulation which would narrow and even obliterate the in- testinal caliber. Marked redundancy of the sigmoid flexure, especially where there has been years of progressive con- stipation, may give rise to symptoms varying from exag- gerated constipation to actual obstruction, and surgery may be required here, regarding which the restop operation of Kellogg is worthy of serious study. Developmental anoma- lies are certainly at the bottom of many cases of chronic constipation, and ptosis is also a factor. It must be remem- bered that the various suspension operations, while valuable in properly selected cases, are disappointing in the majority. At best these fixation points that are made are unstable. Of course, where marked adhesions binding down the gut or other definite factors like that exist, constipation as well as all the other symptoms are often benefited by surgery. Surgery may be called for in the various rectal causes of constipation. When irritability of a hypertrophied sphinc- ter exists, the irritability of the muscle is due to ulcera- tion or catarrhal inflammation, and much can be done by the application of hot fomentations to the lower, abdomen, and the daily injection into the bowel of hot oil containing bismuth or a solution of hydrastis, boric acid, etc. Where the O’Beirne’s valves are hypertrophied to such an extent that the bowel is considerably occluded their dilatation is indicated, which in my hands is best done by a large procto- scope. Where the Houston valves are markedly thickened and rigid, nothing short of a division will effect a cure. This is easily done by the use of cutting clips which divide the valves by pressure necrosis. Usually the valvotomy is fol- lowed by an immediate relief. It may be said that if the relief is not complete after doing the valvotomy alone, and resort to the employment of diet, massage, electricity or vibratory treatment is called for, the operation was not in- dicated. I have seen several cases of hypertrophied levatores ani muscles requiring surgery. Sometimes in hypertrophied 118 DISEASES OE THE INTESTINES. sphincter muscles a divulsion or dividing of the muscle is necessary. I believe, however, that the simple forms of rectal dilators answer almost as good a purpose in the majority of individuals. If the result is not accomplishable, forcible divulsion performed under nitrous oxide anesthesia is called for. DIARRHEA. FOREWORD. There are a number of simple conditions which can cause diarrhea. Among these may be mentioned, acute dyspeptic diarrhea due to eating markedly irritating food substances, or perhaps the exposure of the abdomen to cold, low grades of catarrhal processes in the lower end of the small intestine and right colon, the diarrheal condition which sometimes accompanies achylia gastrica, etc. These are not considered in this connection. Those presented belong to the necrotic, ulcerative or infective processes of the intestine. NECROTIC ULCERATIVE PROCESSES. The usual form of simple duodenal ulcer will not be con- sidered in this connection. It has perhaps a special etiology and peculiar clinical features which differ distinctly from the other types of necrotic ulcerative processes. Duodenal Ulceration Following Extensive Cutaneous Burns. No very satisfactory explanation of the relationship of these two phenomena has ever been presented. Why ex- tensive ulcerations are found in the duodenum is perhaps best explained on the basis that following burns toxic sub- stances are secreted with the bile, which, on coming in con- tact with the duodenal mucous membrane, induce ulceration. When they occur these ulcers differ in many features from the common peptic duodenal ulcer. There may be one or several. Usually they are located in the inferior horizontal portion of the duodenum. Mostly they are irregular in out- line and they develop from the fifth to the twelfth day after the burn. They have occurred as early as the second day and as late as the seventeenth. They are met with generally in young subjects and more frequently after burns of the DIARRHEA. 119 trunk rather than of the extremities. They are almost in- variably fatal, and according to the Fenwicks they occur in 6.2 per cent, of all fatal burns. Embolic and Thrombotic Ulcers. The intestines are sub- ject to changes dependent upon alterations of their blood supply, just as are other tissues of the body. If a large vessel is occluded so as to alter materially the blood supply in a considerable portion of the intestines, some degree of gangrene is usually the process that takes place, but if smaller branches of the intestinal vessels be blocked, especially those running in the intestinal wall itself, ulceration will ensue. Perhaps the common cause of such ulcers is sclerotic changes in the intestinal wall, although occasionally they may be caused by an embolism resulting from valvular disease of the heart, or abscesses or thrombosis elsewhere in the body. In the beginning of the involvement the area becomes swol- len, firm, and gray or grayish-red, and the tissues of the area soon become necrotic and the mucous membrane, with more or less of the underlying tissues, is cast off and an ulcer results. If the occlusion has been such that the entire thick- ness of the gut wall is involved, the ulcer is deep and may perforate although most times the ulcers are of small size and involve only the mucous .membrane and submucosa. Generally they are multiple. Amyloid Ulcers. Amyloid disease of the intestines results from the same causes that produce amyloidosis elsewhere. The condition is most often found in chronic tuberculosis, syphilis, chronic suppuration, and the various cachexias. The entire intestinal tract may be involved, but at times only the ileum is the seat of the disease. Usually all the tissues of the intestinal wall are encompassed in the process. The in- testines then present a pale, shiny, translucent appearance, and on application of iodin give a typical amyloid reaction by turning brownish-red, and when subsequently treated with sulphuric acid become blue or violet. Ulcers are not uncommon, those present varying from the size of a pin- point to that of the large areas involving the entire circum- ference of the intestine in a girdle-like fashion. 120 DISEASES OF THE INTESTINES. SYMPTOMS AND TREATMENT. It is plain that the above mentioned types of ulceration are essentially secondary processes. They are characterized by one constant feature—diarrhea—and the character of the diarrhea in any one of them is not distinctive in suggesting the presence of the particular form. The stools may be frequent and watery, and usually blood is present. In the embolic and thrombotic types bleeding is not common, and in the amyloid ulcer it must be expected that when blood is present perhaps some other form of ulceration than amyloid exists. There is very little that need be said to control the diar- rhea in these conditions. Opium may be given, either in the form of morphin subcutaneously or opium powder by mouth. Ice-bags are occasionally helpful. After the diar- rhea has been on for a short time the patient loses in strength and vitality very quickly and then the sustaining measures are in order. In the embolic and thrombotic types, as well as amyloid ulcers, the treatment of the condition resolves itself into the treatment of the primary disease, and an at- tempt to control the diarrhea, which is best accomplished by mineral and vegetable astringents and opium. INFLAMMATORY ULCERATIVE PROCESSES. Catarrhal Ulcerations. The term “catarrhal ulcers” is in- appropriate, but it expresses well enough the nature of a condition of ulceration occurring in conjunction with an apparent catarrhal inflammation, seen most often in catar- rhal enteritis of rather long duration, and more frequently in children and young adults than in those of middle age or older. The ulcers are present in both the small and large intestine, are minute, round with very slight undulating edges. They usually involve only the mucous membrane, perhaps not going through its entire depth. In my opinion such types of ulceration are generally due to infection of the intestinal contents, often certain strains of Bacillus coli, not dysenteric in type; or streptococcus and even staphylo- coccus. DIARRHEA. 121 Simple Ulcerative Colitis. The condition mentioned in the above division and this one are essentially the same except that simple ulcerative colitis is a more pronounced condi- tion. It is because no organisms of the dysenteric forms a;re present that this term is used. In my opinion the condition is due to a form of Bacillus coll communis, and, as former writings of mine on this subject strongly suggest, present forms of such Bacillus coli may become parasitic in nature and distinctly infectious when gaining entrance to the tissue of the mucous membrane. This pseudodysenteric type of organism is not the only one that can cause ulceration of the simple type. There are conditions, such as are repre- sented in the saccharobutyric type of putrefaction, wherein ulceration is due to the high anaerobes, mainly the Bacillus aerogenes capsulatus. Sometimes those which are grouped un- der the Streptococcus fecalis seem to be the infecting or- ganisms. Follicular Ulcers. Follicular ulceration occurs as a result of the same condition that produces catarrhal ulceration, namely by means of the infecting organisms. Here we see solitary lymphatic follicles mainly involved in the process, which begins as an inflammation, inducing a hyperplasia of the elements of the follicles which later undergo central softening, and the production of an ulcer. When present such ulcers are often numerous, at times giving a typical honey-comb appearance to a part of the bowel. If seen be- fore ulceration has occurred the follicles appear on the mu- cosa as small shot-like yellow areas. Perforation seldom occurs. The colon and lower ileum are usually the portions of the intestines affected, and the condition is quite as com- mon in children as it is in adults, those of middle age being most often affected. Colitis Polyposa. This is not a distinctive form of colitis with ulceration, although in some of the instances ulceration has secondarily ensued and symptoms of diarrhea developed. It is probable that these polypoid growths begin in the mucous membrane which has first been affected with a gen- eral colitis and that of their funnels, local undermining ulcers similar to those mentioned in the above conditions. Finally the polypoid growths occur as a result of a healing process. 122 DISEASES OF THE INTESTINES. Such growths when large enough may in themselves cause ulceration again. Stercoral or Decubital Ulcers. These ulcerations result from the irritative action of fecal masses on the intestinal wall. They occur purely as mechanical results, or what is more probable, the mechanical injury to the mucosa and an ingression of pathogenic organisms. The condition is found in the large intestine and especially at the point where stag- nation of the fecal current occurs—namely at the hepatic and splenic flexures, or in the rectum, sigmoid, cecum, and ap- pendix. The ulcers usually are simple and have an inflamed suppurating base. The condition is more frequently met with in elderly people, especially those subject to constipa- tion. Perforation of these ulcers has been known to occur. Not infrequently they cicatrize with the production of steno- sis. Such stenoses have been mistaken at times for carcinoma or stricture. SYMPTOMS AND TREATMENT. The symptoms of these types of ulceration may be pre- sented in toto, diarrhea being the main one to draw attention to the condition. There is usually considerable abdominal pain, the stools increasing in frequency, finally with mucus and blood in them. As a rule the ordinary remedies have no effect upon the diarrhea and the patient rapidly loses in weight and strength. The number of stools vary, and usually contain fecal matter. One of the surprising features of these cases is that food passes through the alimentary canal with surprising rapidity, sometimes appearing in three hours after its ingestion. Another characteristic symptom is that the symptoms are variable, at times present in an acute form, at other times quite subsided. Much depends upon the progress of the disease and the extent of involvement in the gut wall, and particularly in its depth. Usually, however, the condition is chronic, extending over years of time. It must be remembered that there are a number of types of ulcerative colitis in which the symptoms are never severe and the patient is able to go about, although frequently troubled with loose movements. Sometimes there is an elevation of one or two degrees of temperature and the DIARRHEA. 123 production of what seems to be a mild degree of septic poisoning. Usually there is a feeling of general discomfort in the abdomen, especially when the diarrhea is on, perhaps more or less colicky pains before each stool. In the stercoral type of ulcer the history of constipation is obtained, followed by a diarrheal condition, generally with considerable pain and tenderness on the left side representing the sigmoidal region, or at the flexures. It is probable that some of our cases of massed adhesions of the hepatic colon and also those of ad- hesions of the pelvic colon on the left side are due to ulcers having been present which have healed with stenoses or peri- colonic adhesions, and the mucous membrane at the same time presenting a low degree of inflammation and perhaps ulceration. What is very important in these cases is to examine the stools bacteriologically to see whether, on the one hand Ameba histolytica are present, and on the other whether the well-known form of Bacillus dysentericus exists. With these being absent the endoscopic examination of the rectum and lower sigmoid, when possible, is important. In the proc- tologic examination some idea may be gained of the size and depth of the ulcer and the character of the inflammatory process, that is, as to whether it is entirely superficial or whether perhaps it has extended through the mucosa, repre- senting the more resisting type. Careful examinations of the stools should be made, especially as to the bacteriology which characterizes the subject of the indolic and saccharo- butyric types of chronic intestinal toxemia. Where a high anaerobic infection exists a meat diet is in order, such as is represented by the following: This diet is a temporary one. Take mostly meats—all forms of beef with the exception of cuts from the shoulder, kidneys and liver. The same is true of lamb. These meats should be fresh and taken in a broiled or roasted state. Mutton is permissible, but no pork nor veal. May take any kind of fish broiled or boiled with the exception of shad roe and shell fish. May eat eggs in any form. Butter and whole milk are allowed, together with any form of simple cheese of the cream variety, such as Philadelphia, Neufchatel and cream cheese. Eat as much gelatin foods as possible. Oatmeal and rolled oats are allowed. May have breads or crackers made of gluten or rye flour. Lentils and dried peas are per- 124 DISEASES OF THE INTESTINES. missible. There is no objection to an occasional orange, pineapple or straw- berries. The best drink would be chocolate or cocoa. When on the other hand the condition is due to the pseudo- dysenteric type of colon bacillus or due to the streptococcus, a vegetable diet represents the best form of constant treat- ment. It is advisable in some of these cases to roughen the diet with considerable cellulose and treat the case as one of constipation. I am not speaking now of stercoral ulcer, in which such diet would be definitely indicated, but of the coli infective forms. It is best to begin the treatment by a. rest in bed and the use of large doses of bismuth subgallate. During" this time the diet should be bland, consisting essentially of a lacto- farinaceous dietary. At times small doses of an opiate are useful, the best form being Dover’s powder. After many years’ use of the various forms of rectal irri- gation and the use of different solutions, including those of various silver preparations, I have quite given up this entire line of treatment. In such cases, however, I am not averse to the use of transintestinal lavage for the purpose of clean- ing out the irritating content of the intestinal canal, in which a hypertonic solution of sodium sulphate and sodium chloride is employed, the irrigations being given twice or three times a week. Of late, also, I have used the various dyes—gentian violet in the high anaerobic infections, mercurochrome 220 at times, and neutral acriflavin in those due to the Bacillus coli infections. Much benefit at times may be accomplished with the use of the Bacillus coli subcutaneously, preferably the autogenous type. When these are employed it must be remembered that to effect the colon beneficially, large doses are necessary. Patience and time are important essentials to remember in the handling of these cases, because often they are as discouraging to the attendant as they are to the patient. Sometimes when one considers the local condition improved an acute manifestation may take place which changes the happiness all around. It may take years of careful attention before the individual is entirely well. Care should be taken that they do not eat injudiciously, do not become chilled in the summer or get too cold in the winter; that they have INFECTIVE ULCERATIVE PROCESSES. 125 frequent sojourns in the country, and that they live normal lives without excesses and so on. These people usually possess a lower vitality and a very susceptible colon. Even after the ulceration is healed and has remained healed for a length of time, there is a friability of the mucous mem- brane which seems to be ready to break down on the slightest provocation. Therefore, it is well to apprise these people of the fact that they should not be discouraged even at an acute exacerbation, and that it sometimes takes a long time before a cure can be brought about. In my experience when marked follicular ulcerations have existed which have undermined the mucous membrane or when polypi are present, a cure is practically never accom- plished by medical means alone. It is in these types of cases that appendicostomy or cecostomy, in addition to the above- mentioned methods of treatment, are usually required. After irrigation, for a number of months many of these colons take on quite a normal aspect. But again it should be mentioned that after the fistula has healed and no further irrigation from the head of the colon downward is possible, we not uncommonly see a return of the condition. Thus it serves to good purpose here to remember that the medical measures of treatment should be carried out even though an operation has been performed. INFECTIVE ULCERATIVE PROCESSES. TUBERCULOUS ULCER, STENOSING TUBERCULOUS ENTERITIS AND CHRONIC HYPERPLASTIC TUBERCULOUS ENTERITIS. Tuberculous ulceration of the bowel may occur as a primary infection, although it is most often secondary. Evidently tuberculosis of the digestive tract is more common in chil- dren than in the adult, and it is not uncommonly found left from other infectious diseases, particularly fevers. Most of the instances in which intestinal tuberculosis is met with are those of pulmonary tuberculosis, the intestinal lesion usually resulting from the swallowing of the bacillus-bearing sputum. The most common lesion of intestinal tuberculosis is ul- ceration. It occurs most often in the ileum, just above the 126 DISEASES OF THE INTESTINES. ileocecal valve, although they may occur as high as the duodenum and as low as the rectum. These lesions begin as a small gray nodule just below the mucous membrane. This nodule enlarges and undergoes caseating degeneration in the center. Observed microscopically, it will be seen to consist of a number of typical tubercles composed of giant, epithelioid and lymphoid cells, or of a diffuse caseating mass. Finally, the nodule breaks through the overlying mucous membrane, the caseous material is discharged into the bowel and tuberculous ulcer results. The extent of the ulceration varies greatly in different cases. Ulcers of varying size and age will be found in the same case. Complete healing with the disappearance of all tubercles is an unusual occurrence. Not infrequently, however, the ulcers undergo partial or- ganization, so that while some ulceration remains, a moderate degree of stenosis is also present. Most practitioners are aware of the well-known form of ischiorectal abscess pre- senting in tuberculous individuals. In these instances it is probably due to an ulcerating process causing an abscess external to the coats of the rectum. While the occurrence of an ischiorectal abscess should not be taken in any sense as diagnostic of the presence of tuberculosis, the clinical fact remains that an association between ischiorectal abscesses and tuberculosis has been established. Of course in this instance tuberculosis was present before the ischiorectal abscess occurred. Symptoms and Diagnosis. The symptoms of ulcerative, tuberculous enteritis do not differ materially from those of simple enteritis or of other forms of ulceration of the bowels, excepting in the fact that they are chronic. The most con- stant and characteristic symptom is diarrhea; although this is by no means always present even when the ulceration is extensive. When present, the stools are soft and unformed, or they may be thin and watery. Mucus is usually present in small masses or as strings or shreds. Not uncommonly there is an admixture of blood in small quantities, and not uncommonly small hemorrhages take place. There is prob- ably no one condition that causes a more rapid emaciation of a tuberculous patient than the establishment of a tuberculous enteritis with diarrhea. The individual loses strength rapidly INFECTIVE ULCERATIVE PROCESSES. 127 and not uncommonly takes on quite a septic look, this being distinct even though a pronounced pallor also exists. A striking feature in these cases is a soreness, localized tender- ness which usually is not very marked and which generally exists in the right iliac fossa. In every case of marked tuber- culosis of the lungs where there is a tendency for looseness of the bowels or the establishment of a diarrhea, the move- ments of which are generally preceded by attacks of ab- dominal pain, the abdomen taking on a rounded contour and perhaps some bulging on the right side, always suspect the presence of ileocecal tuberculosis, because it is a clinical fact that it is present in perhaps fifty per cent, of pulmonary tuberculosis cases, whether abdominal symptoms are present or not. At the same time it must be recalled that amyloid disease of the intestines, the most prominent symptom of which is diarrhea, is a common complication of tuberculosis. In amyloid disease there is usually a more watery discharge from the bowels than in instances of tubercular enteritis and it is less commonly associated with occult or visible blood. Treatment. The prevention of intestinal tuberculosis is to some extent possible in the way of controlling the swal- lowing of infected sputum in tuberculosis cases. It is for this reason that the so-called sputum cup has become so popular, because it is a well-known fact in sanitariums that when patients develop ileocecal tuberculosis the end is usu- ally not far off. Once the condition has occurred, the main purpose of the treatment is to save the patient’s strength by controlling the diarrhea and as far as possible the ulceration itself. As has been stated before, there is some tendency of these ulcers toward healing, although usually with our best efforts very little can be accomplished in positive ways. It has been suggested that the diet should be regu- lated and that this is an essential part of the treatment. In my experience it makes no difference what the diet is, and I have tried all forms but have never been able to convince myself that any form possesses any value worth while in these cases. It is a wise thing, however, to remember that raw milk usually does increase the abdominal distress, whereas, on the other hand, milk which has been thoroughly boiled does not do this and seems to act in a beneficial way. 128 DISEASES OF THE INTESTINES. As far as medication is concerned, I have never been able to satisfy myself that except in the use of opium and large doses of the various bismuth salts much worth while is accomplished. There have been some cases in my practice that have done well on small sized doses of beechwood creo- sote taken in the form of enteric pills after the meals, usually two grains at a dose. Sometimes small doses of dilute hydro- chloric acid in conjunction with essence of pepsin given before the meals, serves to some value. The majority of these individuals have a gradual loss of gastric juice, due to the effect of the fever upon the secretory apparatus of the stomach, this fever being due to the pulmonary tuber- culosis. An occasional irrigation of the colon, sometimes a transduodenal lavage with acriflavin, will work very mag- ically for a short period of time. It must be manifest to the reader that the control of the abdominal condition is very largely subservient to such benefit as can be brought about in the control of the tuberculosis in a general way. This requires attention to those things which are beneficial in tuberculosis, namely rest, sufficient food, fresh air, sunshine, isolation from business, etc. SYPHILITIC ULCERS In acquired syphilis a low degree of enteritis occurs at times. This may go on to the establishment of considerable pathology of the gut, due to multiple gummata with the pathology mentioned in the foregoing in connection with the various types of ulcers. Perhaps the most frequent situation of syphilitic ulceration of the intestines is in the rectum, and these ulcers are distinguished from those of dysentery by their smooth, gray base and the tendency to induration of the edges and extensive stenosis. It is probable that stenosing tuberculous ulcers of the rec- tum have been frequently taken for syphilitic lesions, and vice versa. The symptoms are those of intestinal ulceration or stric- ture and permit a probable diagnosis only on the basis of the history or the associated findings of syphilis, and per- haps their response to the therapeutic test, or to the Was- sermann reaction. Always suspect in a young woman who INFECTIVE ULCERATIVE PROCESSES. 129 has a stenosis existing low in the rectum that the lesion is syphilitic in nature. The treatment of syphilis of the intestines is directed to the general infection and to the control of the diarrhea. The latter often persists in spite of ordinary treatment and even after active antisyphilitic remedies have been employed. In my experience the best remedy to use in syphilitic involve- ment of the gut is salvarsan or neosalvarsan in intravenous injections. Mercury and the iodides may be used in addi- tion. The point to keep in mind is that the treatment must be active and most energetic, or no results will be accom- plished. In the presence of stenosis operation may be in order. SPRUE (DIARRHEA ALBA). The true etiology of this disease is still somewhat in doubt, although it seems to be settled by Ashford, who in 1915, under the term of Monilia psilosis, described an organism which seems to be the offender. It is an old disease, having been known as far back as 1776. Usually it is found in tropical countries and it is characterized by the passage of large, frothy, pultaceous, light-colored stools, associated with atrophy of the mucous membrane of the alimentary canal and later of the liver, and raw or ulcerated tongue and mouth, commonly ending fatally after a running and pro- tracted course. The most important changes are met with in the intestinal canal, where the mucous membrane of the small bowel is thinned, and on section shows extensive atrophy of the villi and tube glands, together with small round celled infiltration. The condition seems to be due to a chronic infection of the whole lining of the alimentary canal going on to atrophy of the mucous membrane. Symptoms. This disease is common in the latter part of the year, particularly after the conclusion of a rainy season, although it is met with at all times. It occurs in individu- als most often between thirty and fifty years of age, and it may therefore be said to be a disease of middle life. It is more common among the whites than the mulattoes, and among the true negroes it seems to be rare. 130 DISEASES OF THE INTESTINES. The onset of sprue is usually that of a severe type of indigestion, regarding which the diagnoses of gastroenteritis, acute • duodenitis, gaseous indigestion, represent the largest number made. Almost a third of the cases, however, have no symptoms at the beginning. In other cases the symp- toms may run along for a while, there being no suspicion of the condition, Gradually, however, a chronic fermentative type of indigestion occurs in which the intestinal symptoms take place, usually preceding an infection of the tongue and mouth. The first sign of the disease is usually an irregu- larity of the bowels, thought to be due to some simple form of diarrhea, but tending later to occur in the morning and to become chronic, while the stools become light-colored and bulky, and the dyspeptic symptoms increase. A steady loss of weight now occurs with perhaps an occasional temporary improvement, a sallow complexion and in the latter stages anemia ensues, and after a longer or shorter course a large proportion of the cases eventually terminate fatally or in chronic invalidism, predisposing to the supervention of ter- minal acute infections. These usually take years to bring about. Diagnosis. The diagnosis of sprue is not difficult in the typical case, although it is very difficult in the early stages. The success of treatment depends upon early diagnosis and it is well to look upon any case in a sprue country, that has chronic diarrhea with light-colored stools, deficient in bile, as likely to be that of the early stage of the disease. Of course when the mouth symptoms are present they have special diagnostic importance, but their prolonged absence in no way negatives a diagnosis of sprue. The character of the stools usually enables the disease to be detected early, whereby appropriate and timely treatment can be adopted and perhaps the disorder cut short before the patient be- comes a confirmed chronic case. It is stated that in the chronic cases at least two-thirds receive no benefit from whatever form of treatment, whereas, those treated carefully in the first six months of the disease yield much better re- sults. This is important because the rate of mortality in sprue is high—as much as eighty per cent, in the chronic cases. INFECTIVE ULCERATIVE PROCESSES. 131 Treatment. The treatment of a well-established case of this condition is unsatisfactory. Many remedies have been advocated for it, none of which can be relied upon to give uniformly good results. Of value, however, is the regulation of the diet, and in some cases the fewer medicines by mouth the better the chances of improvement. All irritating forms of medication usually do more harm than good. Some bene- fit is found by the use of small doses of ipecacuanha, % to % of a grain of emetin hydrochloride, hypodermically given once a day. The most important item of the treatment is the regulation of the diet. A purely milk dietary is generally most useful, gradually increasing the quantity until four to six pints are consumed in the twenty-four hours. The milk may be diluted with various substances. In other cases a meat diet is more successful and should be substituted for milk if the latter is found after a careful trial not to suit the patient. Owing to the deficiency of carbohydrates in meat it is necessary to push the quantity up to two pounds in a day, including as little fat as possible, as the latter is not easily digestible. Beef and mutton are the best forms, but chicken has often been relied upon in certain locations. In advanced cases extracts of meat and raw meat juice are necessary. As im- provement in the stools takes place and weight is gained, the diet may be cautiously increased by the addition of eggs, fish and some fruit. In certain parts of the world fruit, in addition to milk, has been strongly suggested as a dietary in sprue, grapes having been given much on the continent. The difficulty in all dietetic treatments of sprue is to induce the patients to continue them long enough to allow for full recovery of the damaged mucous membrane, and until the stools remain formed and contain sufficient bile, weight has been gained, and the symptoms subsided. It is also advis- able for a patient to be taken to a cold climate, preferably one which is dry. BACILLARY DYSENTERY. Distinctly a disease of middle life is this condition of world-wide distribution and is apt to occur in epidemics, thus differing from amebic dysentery. Marked epidemics of 132 DISEASES OF THE INTESTINES. this condition have occurred in the sixteenth, seventeenth, and eighteenth centuries, and from time to time it is met with in various parts of the world. It is very common in Egypt and is often found in America, particularly in the southern part of the country. In recent years investigation has proven that dysenteric infections occur in the young, but these are usually in a modified form although the organisms are identical with those infecting the adult human being. Etiology. Agata, Shiga and Kruse proved that the bacillus was a specific one, which now is known as the Bacillus dyscntcricc of Shiga and Kruse. Shiga found it in almost pure culture in the blood-stained mucus passed in the early stage of acute dysentery, and he showed that on recovery it disappeared. He also demonstrated it in post-mortem lesions in an agglutination reaction of the blood serum, and he was enabled to produce dysentery in animals by inocu- lation with this bacillus. Kruse substantiated these results with his bacillus. Soon after that Flexner also isolated a bacillus in the United States which was the same as the Shiga bacillus. Since that time the dysentery bacillus has been found in various parts of the world and has been described by various observers under various names. Organisms have been isolated which have been given, the name of paradysentery or pseudodysentery bacillus. It must be remembered, however, that slight differences do not necessarily mean different organisms. They may be only races, and it further has been shown that by prolonged sub- cultures new sugar fermenting properties can be developed, such differences being usually taken to be- characteristic of new species. The bacilli taken, as a whole are somewhat* short and thick, being about 1 to 3 (i long. They may show variation in shapes according to the culture medium employed and the age of the culture, involution cocci-like forms occurring. None of these organisms produce’ gas. This differentiates them from the coli group. Their action in splitting up the various sugars serves for differentiation among themselves as a group. In a bouillon they all produce turbidity, and after two or three days a precipitate is formed. The growths on agar present appearances similar to gelatin cultures, be- INFECTIVE ULCERATIVE PROCESSES, 133 ing white, moist, and more or less iridescent. Maftnite is the most important sugar, as it divides the bacilli into two groups, the mannite fermenters which form the greater num- ber, and the mannite non-fermenters, represented almost exclusively by the Shiga-Kruse bacillus, which is thus clearly differentiated from the others. The following is a table showing the principa4 sugar reactions of the four important bacilli: Mannite Maltose Saccharose Dextrose Shiga-Kruse o o o o Flexner Manilla F F F F Strong His’s Y F ? F O F 6 O o F stands for “ferments” and O for “does not ferment.” After a certain number of days from the commencement of the disease, specific agglutinins appear in the blood, and by means of the Widal reaction a diagnosis of bacillary dysentery can' be made, and not only of dysentery but of the particular variety of bacillus- as well. This reaction usu- ally does not take place before the seventh day, and it is not often delayed beyond the twelfth day, though in some cases it may not be found before the. third week. Shiga, in his researches obtained from agar cultures a toxin which produced lesions in the intestine, as a rule: without diarrhea, and which produced, in addition, wasting and paralysis. It has been found that a powerful antitoxin could be prepared by the immunization of horses either with the soluble toxin or with the bodies of the bacilli. This toxin is comparatively stable, and is not destroyed by heating at 70° C. for one hour. The difference in the susceptibility of different ani- mals to the toxin is very striking. Antitoxin is most readily produced by the Shiga-Kruse bacillus, and, as but little toxin is produced by the Flexner type, this < organism probably does no>t lend itself to the antitoxin treatment, although there are some who believe that it does. A passive immunity can be produced by the injection of an antitoxin but an active immunity is only produced by a vaccine. It is by such a proceeding that the antitoxin sera are produced. Thus 134 DISEASES OF THE INTESTINES. it is that Ludke, bearing in mind Wassermann’s experiments with autolysed typhoid bacilli dried and kept in vacuo, which were found to keep well, produced a high degree of immunity with the bacillus of dysentery without much pain or reaction. He prepared a vaccine which he considered superior to the sensitized vaccine. Pathology. In the acute form of bacillary dysentery the whole of the large intestine may be involved and the dis- ease may attack the lower part of the small intestine as well. Generally the mucous membrane as a whole becomes swollen, red and very vascular. It may be covered by a whitish mucoid exudation, this exudation sometimes resem- bling the membrane of diphtheria. The edges of the folds may show superficial ulceration or erosion; in a more ad- vanced case the mucous membrane may become gangrenous and large areas take on a greenish-black appearance, and on the separation of the sloughs serpiginous ulcers are formed. There is this radical difference between the amebic and bacil- lary dysentery, that in the former the disease is essentially one of the submucosa and isolated ulcers appear with healthy areas of mucous membrane between them, whereas in the latter the involvement is from the surface and healthy areas are not seen between the lesions. In convalescent cases healing ulcers are found which leave in many instances a pigmented scar. The disease may in some cases, instead of being completely cured, become chronic; under such circum- stances, the lower part of the large intestine, and rectum are chiefly involved. The ulceration may last for months, and may end in stricture of the gut, although in my experience it usually continues as a subacute condition. The lesions are best discovered clinically by sigmoidoscopic examination. Symptoms. The incubation period is generally short, three to six days being the average. The onset is sudden, the patient being seized with severe pain and colic in the abdo- men. This is quickly followed by a constant desire to defe- cate. The motions quickly become small and may consist after a while of slight evacuations of blood and mucus. They may number twenty or more in the twenty-four hours. The tenesmus may be very severe owing to the early involvement of the rectum in this form of dysentery. The abdomen may INFECTIVE ULCERATIVE PROCESSES. 135 be uniformly tender. With such a typical acute case there is usually a rapid rise in temperature. The thermometer may register 104° F. This temperature may persist for several days with fluctuation and it is seldom as steady as it fs in typhoid fever. Toxic symptoms usually rapidly appear, the patient becoming drowsy and listless, especially in the case of children, and exhaustion may set in quickly from the constant pain and tenesmus, the patient being very unhappy unless he is constantly on the bed-pan. The pulse rises, the tongue becomes coated and may become dry. Al- bumin may appear in small quantities in the urine. In bad cases vomiting sets in. If the disease persists in this acute form the patient becomes very feeble, with pinched features, dry, inelastic skin and a small rapid pulse. In favorable cases the symptoms gradually disappear. The temperature becomes normal, and in ten days to a fortnight convalescence is established. Relapses may occur. In a few cases the condition may become chronic. In this last instance, the typical dysentery bacillus may disappear, and other forms— such as the streptococci or groups of the Bacillus coli— become semiparasitic in the gut. Chronic bacillary dysentery, as identified by obtaining the specific organism in the stool, is rare in ordinary civil life but does occur. That most often seen is a direct sequel to the acute form. This is in contrast with the amebic type, which may be chronic from the beginning. There is little or no temperature, but the stools continue to be somewhat frequent. There may be tenesmus with blood and mucus. Emaciation is a frequent sign. It may persist for years and eventually cure may result, but with a strictured gut and a ruined constitution. The stools sometimes contain in this form bodies like frog-spawn or sago-grains. In its more chronic form bacillary dysentery is much less characteristic than in its early acute manifestations. Some- times it is impossible to differentiate it from amebic dysen- tery by purely clinical appearance. As a general rule bacil- lary dysentery terminates in either death or recovery in a few months, and comparatively rarely lingers on with longer or shorter remissions for from one to several years, as is not uncommonly the case with inadequately treated amebic 136 DISEASES OF THE INTESTINES. disease. Nor are the remissions so complete and lengthy in the bacillary type, the disease tending to run unchecked until the patient eventually develops some immunity to the in- fection and slowly recovers. More often, however, the patient becomes worn out by his sufferings and the steady loss of albuminous fluids in the bowel discharges, and suc- cumbs to exhaustion. Extreme emaciation with a retracted abdomen is a striking feature of the clinical picture, but in the terminal stages it may be partly masked by dropsy due to cardiac weakness, atrophy of the general muscular tissue, and anemia. Severe hemorrhage from the bowel is less common than in the amebic form. The two most common complications of bacillary dysentery are hepatitis and arthritis. Hepatitis goin£ on to suppura- tion is a very common remote complication of amebic colitis, and it might at first sight be expected that acute and chronic bacillary ulceration of the large bowel might frequently re- sult in infection of the liver through the portal system. Com- paratively it is very rare. Portal pyemia with multiple small abscesses of the liver may occur as a complication of bacillary dysentery, but this also rarely happens. The complications of bacillary dysentery are not numer- ous. Hemorrhage from the bowel is rare. Heart affections may occur as the result of the toxemia, dilatation of the heart may occur, myocarditis has been recorded, and ir- regularity of the heart’s action with tachycardia is not uncommon. Joint affections, usually taking the form of a troublesome synovitis, usually of the knee, is a late toxic manifestation. Iridocyclitis may exist. Neurasthenia may result but other nervous manifestations, such as poliomye- litis, are extremely rare. Perforation of the bowel and peri- tonitis are also rare, and so is liver abscess. If abscess occurs it is of pyemic origin. Treatment. Unfortunately we have no drug with a specific curative action on bacillary dysentery such as ipecacuanha has on the amebic disease, so, apart from diet, the serums, vaccines, and use of the various dye solutions, the treatment is largely empirical. In the acute cases coming early under observation, the first thing to do is to clear out the bowels with a purge, INFECTIVE ULCERATIVE PROCESSES. 137 of which castor oil is the best. After the purgation the patient is kept on a fluid diet, composed mainly of citrated milk, during which time the stools are examined bacterio- logically. In very mild cases of dysentery treated as soon as the first symptoms appear, it is surprising how quickly all traces of mucus disappear from the watery yellow stools, while at the same time relief is afforded to the abdominal pain and tenesmus. Opium is often necessary if the stools continue to be frequent and distressing, and especially help- ful if abdominal pain is present in the intervals between the evacuations. It is best given in the form of an enema but may be taken with calomel. Solutions of permanganate of potash which are supposed to have an immediate action on the toxins produced by the Shiga bacillus, oxidizing them into harmless substances, have been advocated. Rogers sug- gests the use of the calcium salt of permanganate as prefer- able to the potassium one, as the former is less irritating to the bowel. Since bacillary dysentery is largely an infection of the colon it seems reasonable to expect a benefit from the use of the transintestinal lavage in which a hypertonic solution of sodium sulphate and sodium chloride is employed. This should be given early and repeated each day, until a thorough purgation and a flushing of the bowel has taken place. After the subsidence of the acute symptoms, to prevent the chronic form from occurring of that diarrheal condition that is due to the organisms of a mixed infection, the use of the hyper- tonic solution may be discontinued and neutral acriflavin used. This may be employed in plain solution usually in quantity of about five hundred to one hundred cubic centi- meters, and if the amount given is large enough the fluid is voided by rectum in about from one to two hours. Dye solutions may be used, such as mercurochrome 220 and gentian violet, but my experience has been that in subacute dysentery, as well as in those forms due to a mixed infection, neutral acriflavin acts to the best purpose. Of late much interest has been attached to the use of serum in the treatment of this disorder, especially in the acute stages. It is made by repeated injections of the Shiga bacillus toxins in gradually increasing doses into horses over 138 DISEASES .OF THE INTESTINES. a long period. The main difficulty with regard to this treat- ment is that there are a number of varieties of dysentery bacilli in different countries, and different outbreaks in the same country. Thus, Ruffer and his colleagues found it necessary to make a polyvalent serum with the aid of dysen- tery bacilli isolated from cases from different sources, and with it they obtained remarkably good results in the severe and neglected cases among the Mecca pilgrims, in which the death rate in bacillary cases was reduced from over sixty- four per cent, to slightly over ten per cent. This serum is said to be most effective when administered intravenously. It is obtainable in the American market and has only been employed subcutaneously in my practice. My experience with it has been limited and I am not prepared to make any statements as to its value. I do know, however, that in the latent infection following dysentery the serum is of no value. In established chronic bacillary dysentery the treatment is much more difficult and unsatisfactory than in the earlier stages. The reason for this is because the bacteria have worked their way into the depths of the mucous membrane, the organism culturizing there. Frequent transintestinal lavage, with perhaps dye solutions, answers to good purpose here. It is in this form of bacillary disease that the astrin- gent enemata are most valuable, the best being a solution of silver nitrate of about one pint, the strength of the solu- tion being about one-half to one and one-half grains to the ounce. Copper sulphate, in a strength of one grain to the ounce, is often of great value. Shiga first injected the dead dysentery bacilli as a prophy- lactic against the disease. Other observers have used similar procedures. The value of vaccine treatment in bacillary dis- ease is still a debatable ground, although the consensus of opinion of those who have had the most experience with it is in its favor. The vaccine most often used is that known as Forster’s. The initial dose for an adult should not exceed one lethal dose for a rabbit. In the chronic forms of the disease dieting is very im- portant. The patient should be kept in bed, or at least free from activity, the diet to be largely a milk diet for a space of time, the milk preferably being boiled. By this, with INFECTIVE ULCERATIVE PROCESSES. 139 large doses of bismuth by mouth (the subgallate salt being preferable), the stools are generally rendered pasty. Slowly the farinaceous foods may be added, preferably those that have been well-boiled, then the large carbohydrate-bearing vegetables, and, with the stools continuing satisfactory, small quantities of scraped meat or picked fish are to be added. One should be very careful not to add largely of cellulose to the diet and not to resort to protein feeding too quickly. The patient should be kept comfortable and under the best hygienic conditions possible. A prolonged sojourn in the country where the atmosphere is cool and the conditions favorable is often most advisable. There should be freedom from work, excesses of all kinds, mental strain, etc. Great care should be taken that the abdomen does not become chilled, or the general body overheated. Under ideal con- ditions the patient usually improves, often with small re- missions which are easily controlled, and after a few years appears to be well. It is important to remember, however, that many of these individuals seem to have a friability of the colon, and under the merest provocation therefor have a remission. PHLEGMONOUS ENTERITIS. This disease is probably never met with as a primary process. The organism most commonly found in phlegmon- ous gastritis and enteritis is a streptococcus. CHOLERA ASIATICA. This is an infectious disease, caused by the comma-bacillus, and characterized by violent diarrhea and rapid collapse. The cases are mostly met with in eastern countries but the condition has been known to occur in America. The disease is due to a specific organism described for the first time by Koch. In the characteristic case they do not occur in the vomitus, but are met with in post-mortem examinations in enormous numbers in the intestines. They are found in the depth of the glands and in the still deeper tissues. The bacteria have toxic properties, even in dead culture, and the symptoms, which occur very rapidly, are no doubt also due to an absorption from the intestine when 140 DISEASES OF THE INTESTINES. the epithelial layer has been injured. It is propagated chiefly by contaminated water used for drinking, cooking and wash- ing; its dissemination is due to so-called cholera carriers which are probably even more numerous than typhoid carriers. Symptoms. After a period of incubation for from two to five days, the disease sets in with a preliminary diarrhea, and colicky pains in the abdomen with looseness of the bowels, perhaps vomiting, headache and depression of spirits, without fever. This diarrhea increases or it may set in acutely without preliminary symptoms until profuse liquid evacuations succeed each other rapidly. Exhaustion and collapse soon occur, with extreme thirst, the tongue becomes white, and cramps of great severity occur in the legs and feet. Within a few hours vomiting sets in and becomes incessant. The patient goes into collapse, the extremities are cyanosed, and the appearance is that of a dehydration of the body. Usually the surface temperature is below normal while that of the internal parts may be as high as 103° to ■104° F. At first the feces are yellowish in color, but soon become grayish-white and look like turbid whey or rice-water, whence the term “rice-water stools.” In such discharges there are numerous small flakes of mucus and granular matter, and at times blood. The reaction is usually alkaline. As a rule this stage usually lasts for from twelve to twenty-four hours. If a patient survives the collapse, a gradual return to normal condition takes place, although some of them go into a con- dition known as cholera-typhoid, in which death occurs with coma, the symptoms being attributed to uremia. Diagnosis. The only infection with which Asiatic cholera could be confounded is with cholera nostras, a severe choleraic diarrhea which occurs during the summer months in tem- perate climates. The absence of an epidemic, the extreme collapse and vomiting with rice-water stools, the cramps, the cyanosed appearance, may be helpful, although in severe cases of cholera nostras most of these symptoms may be present. The main distinction, however, is by bacteriological methods in the discernment of the specific organism in the bowel discharges, there being no specific organism as a cause of cholera nostras. INFECTIVE ULCERATIVE PROCESSES. 141 Treatment. Preventive measures are all-important. The isolation of the sick and disinfection of discharges have eventually prevented the disease entering various countries, and accomplished its control in countries in which it was endemic, such as India and the Philippines. All fluids should be boiled, errors of diet avoided, and digestive disturbances treated promptly. The patient should be kept at rest in bed, warm, and given a simple diet, boiled milk, whey, and egg albumin. Large quantities of water should be given, as well as hypodermoclysis, to overcome the dehydration due to the diarrhea and vomiting. Calomel and opium are the most efficient remedies to control the diarrhea and pain. GASTROINTESTINAL INFLUENZA. This is a pandemic disease occurring at irregular intervals, characterized by the large number of people attacked. It is supposed to be due to a special organism, namely, the Bacillus influenza although of late the specificity of this or- ganism has been questioned. Numerous pandemics since the sixteenth century have occurred. The disease is highly contagious, and seen in its most severe forms in the cold season of the year. Symptoms. The period of incubation is from one to four days, the onset abrupt with fever and its associated phe- nomena. It is not the purpose here to describe the respiratory, nervous, or so-called febrile forms, but simply the gastro- intestinal. This occurs with an onset of fever and more or less vomit- ing and nausea, or the nausea and vomiting may not be present, the attacks being ushered in with acute abdominal pain, profuse diarrhea and collapse. In some epidemics, jaundice, probably due to an extension of a catarrhal process up the common bile duct, has been a common symptom. Usually there is an enlargement of the spleen depending chiefly upon the intensity of the fever, and while this form is supposed to be rare in the United States, I have met with it often enough to say that in an epidemic it is more common than believed. Treatment. Isolation should always be practiced, even with gastrointestinal form, and while no work has been done 142 DISEASES OF THE INTESTINES. to recover the characteristic type of bacillus from the stool, it is best to consider the discharge as infective, and thus its sterilization is in order. From the onset the treatment should be supporting, the patient kept in bed, carefully fed and nursed. The bowels should be kept open by the use of calomel, and Dover’s powder may be employed to control the distress and diarrhea. The patient should be kept well warmed, and if the fever be high, aspirin given. Where car- diac weakness occurs, stimulants freely given are in order, and during convalescence strychnin in full doses, or the use of thyroid extract. Even after the gastrointestinal cases the convalescence may be protracted into weeks or months be- fore full health is restored. Thus a good nutritious diet, change of air, and pleasant surroundings, are essential. Low spirits and general weakness following this disease is one of its characteristic features. CHRONIC EXCESSIVE INTESTINAL TOXEMIA. (PUTREFACTION, INDICANURIA, AUTO-INTOXICATION, OR INTESTINAL FOOD-BACTERIA TOXIC STATES.) FOREWORD. In diseases of middle life there are no more important conditions which are etiologic in the production of disease or strongly contributing factors in them than chronic in- testinal toxemias. These conditions present, perhaps, the most important of all subjects we have to consider and they are especially interesting when found associated with dis- eases that ordinarily are classified as of obscure origin. Leaving out of consideration the effects of syphilis, heredi- tarily acquired endocrine disorders, various chemical tox- emias (such as plumbism, chronic alcohol or nicotine poison- ing), the conditions and diseases of obscure origin are the most common we have to deal with in middle life. Long- standing infections, such as focal, tuberculosis, etc., assuredly may bring on destructive effects in the protoplasm of the parenchymatous cells of various highly specialized organs, but the largest and most common source of focal infection CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 143 in the human economy is the intestinal canal, a portion of medicine so large and significant that it is a wonder that it is so little touched upon by scientific and practical phy- sicians. This is especially surprising in that the most com- plete mortality records show that in the last twenty years the only reduction that has taken place is in infancy and childhood, and not at all in the middle decades of life. Mid- dle age, the most important of all stages of life from economic and progress standpoints, deserves that biologic errors of intestinal digestion receive more attention from the profes- sion than they have given to them. Much of the work that has been done in this connection has been of the rash as- sumptive order, usually based upon some simple laboratory procedure. These have been applied to practical medicine with a degree of enthusiasm not warranting the clinical re- sults possible of attainment, and the same may be said of the many physical treatments, especially the enemata and irrigations of the colon. ETIOLOGY. In 1887 Bouchard advanced his theories on auto-intoxication of the intestinal canal in an interesting work which is now quite out of date. Following him, Metchnikoff, who may be considered the real founder of what may be called the school of intestinal toxemias, drew attention to the colon being a breeding place for pathogenic bacteria and advanced the Bulgarian bacillus method for treatment. In 1907 Christian Herter, who had been working for several years on the sub- ject, engaged in a series of laboratory observations, and wrote a small-sized textbook on the subject. Following this was the work of propaganda carried out by Sir Arbuthnot Lane on stasis, ptosis and toxemia as having to do with the clinical condition, and suggested operative interference for their alleviation and cure. Various other writers engaged in the presentation of the subject, and in 1913 Kellogg pub- lished papers attempting to demonstrate practically all of the list of diseases which Lane claimed to be due to intestinal toxemias were due to incompetency of the ileocecal valve. In 1913 Martin, of Philadelphia, and myself proved that Lane and Kellogg were wrong and that no operative interference 144 DISEASES OF THE INTESTINES. was warranted on the intestines in these conditions unless bona fide obstruction existed. Goldthwaite advanced the anatomic and mechanistic causes of practically the same list of disorders that Lane had given. Of much interest in this connection, however, were the writings of Adami in 1899, on “Latent Infection” and “Subinfection,” in which he drew attention to the fact that submucosal infection could exist, it being an old observation of mine as well as of E. E. Smith, of New York City. In 1910 I advanced a method for the treatment of intestinal toxemias by means of rectal adminis- tration of autogenous Bacillus coli. This was added to by Satterlee, who suggested their subcutaneous use in the ordin- ary forms of vaccines. In 1920 the various bacterial methods which I employed were then given to 'the profession in the text-book on intestinal diseases. PATHOLOGY. It can be deducted and believed that chronic excessive intestinal putrefaction and fermentation may be divided into two classes, the primary and the secondary. The primary ones are those which are due to definite infective conditions running chronically in the intestinal content and in the gut wall, while the secondary ones are those which are due to disorders which unfavorably influence the status of affairs in the intestinal canal and bring on the toxemia in a sec- ondary way. From bacterial changes in primary intestinal toxemias there develops a degeneration in the sympathetic fibers between the muscle planes which may extend into the sympathetic paths extra-enterically, even as high as the sym- pathetic plexuses in the back of the abdomen. When enough degeneration has taken place, dilatation of the viscus which is supplied by these sympathetics occurs, and atony with stasis is the result. Such may cause a sagging of heavy organs which further add an item of delay. Toxins formed in the bowel may conceivably be of four types: First, products of disintegration of foodstuffs by the digestive juices; second, products of disintegration of food- stuffs by bacterial activity; third, the ectotoxin discharged by the intestinal bacteria; and fourth, toxins from the dead bodies of bacteria. In regard to the first type, peptones, CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 145 proteoses, etc., from proteid digestion are toxic only when introduced directly into the blood or tissues. It has been stated that these could not act as toxic bodies and that if they were introduced, which is not possible since they are not absorbed unchanged by the healthy bowel, only anaphy- laxis could result. It is well to remember, however, that in the presence of acids various monamino acids and di- amino acids or hexone bases are formed and these may easily gain entrance into the general circulation. Somewhat the same bodies are formed in laboratory digestion of al- buminous substances. In the simple action of pepsin upon the albuminous molecules we have, in addition to the non- crystalline bodies, ammonia and the diamino acids, mon- amino acids, also the aromatic series such as is represented in tyrosin, tryptophan and phenylalanin, and the fatty series, leucin, glycocoll, alanin, glutamic acid. In the microbic de- composition of albuminous molecules, in addition to non- crystalline bodies is a long string of fatty series, and finally fatty bodies, such as butyric, caproic, valerianic, various ptomaines and bodies of the aromatic series such as oxyacid group, the phenol products, the indoxyl products and various gases, all of which are toxic. Albuminous putrefaction oc- curs mostly in the large intestine, in which the reaction is more or less alkaline. Hence it is that normally the fer- mentation of the carbohydrates takes place in the small in- testine and the putrefaction of the nitrogenous bodies occurs in the large. Whenever the fatty acids accumulate in the blood, there results an acid intoxication, or acidosis, which is character- ized by a diminution in the alkaline bases of the blood. This acidosis is supposed to occur only when the fatty acids are formed in excess, and this rarely happens except under the influence of the breaking up and fermentation of the ternary bodies, and the fats in particular. For a complete presenta- tion of the subject of the various toxins that are formed in the intestinal canal the reader is referred to my work on the subject. Intermingled with these factors of food and secretory activity is the influence of aerobic and anaerobic conditions in the digestive tract, and the nature of the bac- terial activities which occur there. The initiation of putre- 146 DISEASES OE THE INTESTINES. factive decomposition in the digestive tract depends very largely, but probably not exclusively, on the activities of obligate anaerobes, and a portion of the digestive tract is at all times under anaerobic conditions. If the stomach exodus is slow the chances for anaerobic development are good, and hence we frequently find that there are evidences of putrefactive decomposition of food that has been unduly retained in the stomach—namely, the presence of sulphureted hydrogen, mercaptan, butyric acid, etc. On the whole, however, in the average case of intestinal toxemia which we see, no gastric condition can be ascribed as a contributing cause, in fact many gastric conditions are secondary to intestinal toxemias. While in a few cases of intestinal toxemia it can be proven that putrefaction takes place in the lower end of the small intestine, the usual thing is that it takes place in the colon, where anaerobic conditions are more perfect. In the colon the anaerobic conditions are well maintained throughout its entire course and here we find the greatest number of anaerobes and the most pro- nounced evidence of putrefaction. There is, however, a gradual fall in the number of living bacteria beyond the ileo- cecal valve so that in the rectum the numbers of cultivable bacteria are very much less than in the ascending colon. There is evidence to prove that under certain conditions the restraint against bacteria which would be inimical to the host may be overcome by errors in diet, depressed general conditions, or alterations in the secretions of the digestive tract, and that thus definite infection by the hemiparasitic bacteria that are present becomes possible, that is, infection of the intestinal content and perhaps secondary infection of the mucosa itself. Toward adult life great dififerences exist in the habits of different persons, and these are in a degree reflected in the nature of the bacterial processes of the digestive tract. In adult life there are the individual experiences, new responsi- bilities, new dangers, an enhanced emotional life, and often a greater proportion of indoor and sedentary habits. The dietary is apt to undergo an alteration in the direction of increased and frequently injudicious liberty and the use of tea and coffee, etc. Also the use of tobacco and alcoholic CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 147 drinks is either increased or begun. It is not unusual to find people who are over fifty years of age and apparently robust and well, who possess a slight degree of inability at work, and at times feel tired. With such persons it is not unusual to demonstrate the presence of increased numbers of putrefactive anaerobes in the intestines. These persons, though in good health, are not really robust. A period of sustained hard work is followed by considerable mental and physical fatigue. Dining out and the use of alcoholic drinks are indulgences quickly followed by unpleasant consequences. Exercise out of doors becomes more and more of a necessity, and the individual becomes conscious of having to live within certain conditions compatible with the performance of his duties. In my opinion the classification of intestinal toxemias ad- vanced by Herter is the best, namely: (1) The indolic of chronic excessive intestinal putrefaction.. This is marked by striking indicanuria and probably due to members of the Bacillus coli group. (2) The saccharobutyric type of chronic excessive intestinal putrefaction which seems to be initiated chiefly by the anaerobic forms. In its simplest examples there is very little indol in the gut. (3) A combined type, or cases resembling the characteristics of (1) and (2). In the indolic type the members of the Bacillus coli form indol in considerable quantities and often they probably in- vade the small intestine in large numbers. The bacterial cleavages seem largely to replace normal tryptic digestion. These individuals are largely among those that are consid- ered clinically as having intestinal toxemia. They are usually under-nourished, of low blood-pressure, usually with con- siderable neurologic symptoms, often ptosis of the abdom- inal organs, a marked fatigability, are constipated and have more or less dilatation and atony of the various abdominal organs. The examination of their stool will usually show that it is dark in color, hard, alkaline reaction; and a Gram differential stain will display an increased number of the Bacillus coli bacteria beyond the sixty-three per cent, which is normal. The examination of these stools in the fermenta- tion tests displays the presence of ammonia, sulphureted hydrogen and methane gas, which total gas result is usually 148 DISEASES OF THE INTESTINES. abundant in the fermentation tubes. The urine usually shows an increased amount of indican and a high ethereal sulphate partition. Usually it is more concentrated than normal and often quite high in urates. The saccharobutyric type is due to the activity of the strictly anaerobic butyric acid producing bacteria, of which the Bacillus a'crogcncs capsulatus and Gram-positive coccal forms are mostly responsible. To these, however, may be added the Bacillus putrificus and sometimes the bacillus of malignant edema. The abundance of putrefactive anaerobes, especially the Bacillus a'crogcncs capsulatus, gives a peculiar character to the intestinal contents. The organisms attack carbohydrates and proteins vigorously and butyric acid is formed from both, together at times with propionic, caproic or valeric acid. These acids give the peculiar odor to the stool. As a result the feces have a low specific gravity and often a decidedly light color. The Schmidt test with mercury bichloride usually gives a strong pink reaction. The stools have an acid reaction and are usually quite soft in character, with a result that these people are rarely constipated. Gram differential stain of these stools shows a marked increase in the Gram-positive organisms. These sometimes comprise the entire bacteriology.that is met with. Stools which con- tain more than one-third of Gram-positive organisms are significant in the direction of this type of toxemia. On fermentation these stools surprisingly usually generate but small quantities of gas and this gas is usually of an acid character. The urines of these individuals rarely display anything that is significant, although not uncommonly uro- rosein is found in abundancy. The same may be said of oxalic acid and uric acid, and the presence of various amounts of sugar is not uncommon. The combined indolic and saccharobutyric type is a mixture of the above. It is the most difficult to diagnose from a laboratory standpoint because characteristics of one type, diametrically opposite from the other, usually combine with the other to present a more or less normal picture. In these instances it is only by very careful culturizing of the in- testinal bacteria that it is possible to make a definite diagno- sis, although usually the urine will display large quantities CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 149 of indol as well as urorosein to give various indices of an intestinal toxemia. RELATION OF BACTERIAL METABOLISM TO CERTAIN FOODS. It is a well-known fact that perfectly wholesome foods may be prepared and sold in an apparently sound condition and yet contain within themselves the elements of their own destruction in the form of included bacteria, and also bacteria which would be inimical to the human being. It is a well- known fact that Bacillus coli grown in media containing only protein or protein derivatives will produce indol, phenol, hydrogen sulphide, ammonia and other products indicative of protein decomposition. It is apparent then that the or- ganism of necessity utilizes the protein substances. Putre- faction is the result, because the medium becomes progres- sively alkaline, foul odors develop, and the resulting products are not only disagreeable to the senses, but are quite unfit for food. This is bacterial putrefaction. The same organism in the same protein medium, containing in addition sugar which the colon bacillus can utilize now, produces an entirely different kind of decomposition. In place of the products of putrefaction now appear lactic acid, small amounts of fatty acids, as well as carbon dioxide and hydrogen, w'hich are characteristic of the breakdown of carbohydrate. The re- action now is permanently and progressively acid, the odor not offensive, and the products formed are innocuous and inoffensive. This is bacterial fermentation. It will thus be seen that in the presence of protein and sugar, most organ- isms utilize the sugar in preference to the proteins. This is because the carbohydrates are more easily metabolized than proteins, and because in the presence of protein they abstract only a small amount of nitrogen for their develop- ment. Whenever bacteria are presented simultaneously with protein and utilizable carbohydrate in the same medium, the structural needs are largely derived from the proteins, and the fuel requirements from the sugars. This fact of bacteria in sparing the proteins and using the carbohydrates is im- portant in connection with the treatment of putrefactive conditions in the intestinal canal. The object of a diet rich 150 DISEASES OF THE INTESTINES. in carbohydrates is twofold: physiologically, to provide the patient with a readily assimilable food requiring the mini- mum amount of digestive energy to prepare it for the tissue needs, and bacteriologically, to shift bacterial metabolism from the destruction of body tissue for their food require- ment to the utilization of carbohydrates for at least the major part of their dietary needs. This does not directly result in annihilation of the invading bacteria but it certainly ap- proaches their metabolic reformation. The shifting of metab- olism to sugar appears to deprive these organisms of one of their most potent weapons of defence and forces the parasite to act on the defensive, and theoretically at least, permitting the host to rally and strengthen his defensive and even his offensive powers earlier in the battle. While the above is true in the main, there are many cases of intestinal putrefaction in which no changing of the diet to the carbo- hydrate basis prevents the formation of putrefaction in the content of the intestinal canal. Whenever such is met with in spite of the diet, either a pathology is present which has been overlooked, additional or different bacterial methods of treatment are required, or the abnormal bacteriology is definitely facultative in the toxic way on any form of treatment. SYMPTOMS OF CHRONIC EXCESSIVE INTESTINAL TOXEMIA. It is a difficult task to describe the symptoms of intestinal toxemia. On the one hand they may be outlined about as broadly as is the field of medicine, on the other, they may be described in detail, both locally in the abdomen, and generally in the body. Then again, they may be considered entirely from the laboratory, and conditionally from the x-ray standpoint. Attempt will here be made to classify the clinical symptoms so that a semblance of order will be presented. Fatigue. The victim of a long-standing intestinal toxemia presents certain characteristics. In the first place the matter of fatigue is conspicuous, and many of these individuals after engaging in moderate amounts of work and mental effort CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 151 become quite exhausted and perhaps must rest a while be- fore they can recuperate their sense of well-being. This factor of fatigue is quite characteristic in all, and in women it is generally accompanied by more or less headaches, pains in the back and perhaps down the limbs, certain neuralgic manifestations together with circulatory ones, such as cold hands and feet, sweating of the palms, and various vaso- motor factors. As a class, such individuals not only seem fatigued on exertion, but have a constantly running fatigue which brings them closely to more or less inherent devitality in the nervous system. Not uncommonly there may be a mental inability to continue with their efforts after three or four o’clock in the afternoon, and ofttimes such men will drink alcohol in the evening, or perhaps coffee, for the pur- pose of keeping their well-being until it is time to retire. It is not unusual for them over Sunday to acquire quite a reserve stock of vitality and to engage in work on Monday morning with vim and zest. Perhaps then the feelings of fatigue will not be manifest again until Tuesday afternoon or Wednesday, and toward the end of the week they are quite exhausted, perhaps even the mornings being interfered with so that they cannot conduct their business to their satisfaction. Dizziness is commonly present (indolic and mixed forms). Anemia. Chronic anemia is a factor in a large number of cases; particularly is this true among the young and the women and those who are more or less' housed during the winter time because of sedentary work. This anemia is never pronounced; it is of moderate grade and of the simple type. It is more pronounced where the sulphate partition of the urine is high and a condition of indicanuria exists. This is probably due to reduction of the red blood cells from resorbed sulphureted hydrogen gas from the intestine (indolic forms). Anorexia. This is commonly present, such individuals rarely having a sharp appetite. They go along from day to day eating moderate amounts of food and very often they get along with very little food. Particularly is this the case where symptoms of distress on eating are present. In this instance they usually begin to ascribe the indigestion to vari- 152 DISEASES OF THE INTESTINES. ous foods that they eat and eliminate certain articles of diet, so that after a time they are eating less than is required to maintain a fair state of health. At other times their appetite may be good for two or three days, and perhaps longer, then suddenly it will drop off again into the chronic condition of loss of appetite and more or less anorexia (indolic and mixed forms). Insomnia. Insomnia is quite a characteristic symptom of intestinal putrefaction. It is surprising to see how long many of these individuals continue taking various hypnotic and soporific drugs for the purpose of mastering a persistent insomnia the cause of which has not been corrected or even handled intelligently. Generally those individuals who have eaten three meals a day are considerably more toxic at the end of the day than in the morning, and it is not uncommon for them to lie awake in the early part of the night, getting to sleep when quite exhausted along toward the small hours of the morning, and in the morning they are generally quite sleepy and it is difficult for them to arise. The urine at the time of the insomnia generally contains a high sulphate partition, whereas in the morning it may be sulphate low. It is almost as if the toxic bodies absorbed from the intestinal canal stimulate the central nervous system so that normal sleep is not possible (indolic and mixed forms). Skin. In addition to the characteristic skin which some of these individuals have, namely, a staining particularly manifest under the arms, in the groins, and around the neck, there may be certain forms of skin manifestations of a der- matological order. Eczema in children with intestinal tox- emia, and also in adults, is most common. This eczema is generally of the eczema rubrum type. It may be that the eczema itself is nof directly caused by the gastrointestinal condition, but it generally does aggravate the condition markedly so that the individual is more eczematous than would be the case if he did not have an intestinal toxemia. It is not uncommon when this has been cleared up, for an eczema which has been standing for years to entirely dis- appear, or practically become minimized to such an extent that the individual pays no further attention to it. Another common finding is the irritative rashes such as are repre- CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 153 sented in urticaria and erythemia. Recurring urticaria is particularly a symptom of the saccharobutyric form, but it may also exist in the mixed, or even the indolic forms. Angioneurotic edema may exist. Another cutaneous erup- tion caused by toxemia is acne. While acne may be caused by overeating or eating indigestible foods, indulging in al- cohol. smoking, coffee, etc., there is no doubt that in many of the intractable forms the acne is due to the elimination of irritating substances from the intestinal canal in the skin. Lichen planus, which usually yields more readily to a vege- table diet, is due, in my opinion, to a chronic indicanuric or chronic putrefactive state of affairs in the intestinal canal rather more than to any other factor that is known (the three types). Nervous System. There is absolutely no doubt about it that a distinct relationship exists between mental and ner- vous conditions and these disturbances of the intestinal tract. While certain nervous disorders may cause symptoms in the gastrointestinal canal, by far the largest majority of these functional disorders are brought about the other way. The most common of these is the so-called neurasthenia, or ner- vous exhaustion (complete neurosis). While it is true that certain conditions can bring on this disturbance in the ner- vous system, it is nevertheless true that the most common result of complication in intestinal toxemia is the so-called neurasthenia. The majority of these people have been treated from a neurological standpoint, sent away and so on, and many of them get over the major symptoms of the neuras- thenia, but have a neurasthenic condition chronically present. This is due to the fact that the intestinal condition has not been corrected. In over 9000 cases of intestinal toxemia which I have treated, at least one-third have had sanitarium experiences for so-called neurasthenia. The nervous system is almost invariably affected in whole or in part by the toxemia. In every case of toxemia an examination of the gastrointestinal tract should be made, and also a search for the cause of the neurasthenia, because it is not normal for an individual of middle age to become neurasthenic without a cause. Of course, this cause may be something other than an intestinal condition but in the majority of instances it 154 DISEASES OF THE INTESTINES'. cannot be, as is proved by the fact that these individuals do not become well until the intestinal condition has been cor- rected, and it is not uncommon for people who have been in more or less of a semineurasthenic state for years to be- come entirely well after the intestinal condition has been cleared away. In this same connection may be mentioned those who are sluggish of mentality, have a dullness and stupidity, a loss of concentration, loss of memory and in- coordination. In the psychic group are irritability, lack of confidence, excessive and useless worry, exaggerated intro- spection, hypochondriasis, photophobias, depression, melan- cholic state, impressions, illusions, etc. In a psychasthenic individual who has also an intestinal condition, the above mentioned symptoms are invariably intensified. Sensory polyneuritis of a mild grade and pronounced condition of irritative vagal disturbance (vagotonia) are commonly due to intestinal toxemia. What patients describe as ‘‘rheuma- tism,” consisting of pain without any apparent manifestation in joints or muscles, is common among these people. The pains may be transitory, or last in the same location for days. They apparently are more myalgic or myositic in character, or due to nerve involvement in the muscle planes or perhaps in the sheaths or capsular ligaments about the joints. Mental Diseases. Ross reports on the examination of urines the following statistics: In ninety-one apparently healthy individuals, 7.69 per cent, showed positive urines without the O-agent, and 21.37 per cent, positive with the O-agent. He claimed that among the insane the indolacetic acid test was most frequent, the results obtained being over forty-three per cent, positive compared to 21.37 per cent, positive in apparently healthy individuals. Eye Symptoms. Among these individuals are found cho- roiditis, iritis, and various functional disturbances. The probabilities are that various types of color blindness and also various spots in the vitreous are largely due to intestinal conditions (indolic and mixed forms). Asthma. In the absence of a hereditary history and when a renal and cardiac condition can be excluded, not a few cases of chronic essential asthma are due to intestinal tox- emia. Some of the most striking results that I have achieved CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 155 Tests of Urines of Insane Patients. Type of Mental Disorder No. of Cases Test without O-agent Test with O-agent V > o Ph 6 25 Per cent. Positive No. Positive Per cent. Positive Organic brain disease (not differ- entiated) 7 i 14.29 2 28.58 General paralysis of the insane 21 2 9.52 4 19.04 Senile dementias 16 2 12.50 10 62.50 Infective exhaustive psychoses 3 1 33.30 3 100.00 Intoxication psychoses (alcohol and morphine) Chronic 14 1 7.14 4 28.57 Acute 6 1 16.67 2 33.33 Total 20 2 10.00 6 30.00 Dementia precox group Hebephrenic group 42 4 9.52 15 35.71 Katatonic 12 5 41.66 10 83 33 Paranoid 18 2 11.11 10 55.55 Not differentiated 102 8 7.84 48 47.06 Total 174 19 10.92 83 47.70 Manic depressive group Depressed 16 1 6.25 6 37.50 Excited 17 2 11.76 4 23.52 Remission 2 0 0 Total 35 3 8.57 10 28.57 Involutional melancholias 5 0 2 40.00 Psychoneuroses 2 0 2 100.00 Paranoic states 4 1 25.00 3 75.00 Psychopathic personalities 3 0 1 33.33 Epileptic psychoses 42 3 7.14 15 35.71 Defective mental development 26 3 11.54 15 57.70 Unclassified cases of insanity* 132 18 13.64 65 49.24 Tuberculosis in insane individuals! . 26 3 11.54 10 38.46 Very inactive insane individuals .... 25 4 16.00 13 52.00 Total insane individuals tested 490 55 11.22 211 43.05 have been in cases of chronic asthma, particularly those that occur in the late part of the winter, from the middle of January on, before the warmer weather sets in (saccharo- butyric and mixed forms). Myocarditis. In middle life, in the absence of syphilis, alcohol or other toxic factors as the cause, and in the presence of a marked status of intestinal putrefaction, this disease * Old cases which are largely cases of dementia precox undoubtedly, t These individuals were also included in the different psychosis groups. 156 DISEASES OF THE INTESTINES. may be due to these intestinal states. As a rule, however, when the heart condition is distinct, although a general bene- fit in health may be brought about by the treatment of the intestinal condition, the heart condition does not clear up. The same may be said of vascular and renal conditions. There is no doubt that intestinal toxemia is a factor of much importance in connection with arteriosclerosis in middle age. When syphilis, lead, alcohol, and various other factors can be eliminated, a chronic intestinal condition must be taken into consideration as a possible cause. While with the im- provement brought about in the intestinal condition, and perhaps even a complete cure, the stiffness in the vessels always continues, at the same time it does not seem to pro- gress and many of the symptoms of increased pressure, when it exists, and others, are distinctly benefited by treatment of an intestinal state (saccharobutyric and mixed forms). Joint Conditions. Arthritis deformans is, in my opinion, based upon the successful treatment of over seventy-five cases, largely due to an intestinal condition as the main cause. Some of the most striking successes I have had have been in cases of arthritis deformans. The relapses of the attacks have been stopped and distinct amelioration in the already affected joints has taken place. I do not agree with Pemberton in his conclusions that the successful treatment of arthritis deformans is a matter of diet and hygiene, and that the intestinal bacteriology is not an important factor. In my opinion, the most important factor in connection with the cause of this condition is an intestinal toxemia and the treatment in the individual case may not be a matter of diet so much, but may be of vaccine entirely (indolic and mixed forms). Esophagus. Not a few of these individuals complain of substernal distress which on esophagoscopy shows that there is no pathology or congested condition of the esophageal mucous membrane. In my opinion various substernal dis- tresses, probably esophageal in origin, are due to reversed peristalsis taking place through the cardia and stomach of individuals who have intestinal toxemia (all forms). Hyperacidity and Hypersecretion. The textbooks on dis- eases of the stomach, for a long time have described these CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 157 conditions as entities without giving any causes beyond in- discretion in diet and drinking, and ulcer. The truth is that by far the largest number of cases of hyperacidity are due to chronic intestinal toxemia, generally of saccharobutyric type. It is not uncommon to find a hyperacidity existing at least for a while in the early stage of putrefaction in the intestine. But generally the picture in the putrefaction case is one of a lowered amount of secretion all the way to an achylia, which is due to an atrophic gastritis, the most com- mon cause of an achylia we have (all forms). Atony. Those states of loss of tone in the musculature of the stomach as well as diminution of peristaltic power, in my opinion, are due to an effect upon the Auerbach and Meissner plexuses by resorbed intestinal toxins. Such are not as manifest in the stomach as they are in the colon, because in intestinal toxemia any section of the gastro- intestinal canal can be relaxed due to a degeneration in the sympathetic plexuses (all forms). Hyperesthesia Gastrica. By far the largest number of cases of hyperesthesia gastrica are due to indiscretions in diet, but not a few occur as a result of a long-standing in- testinal toxemia, and these often are best treated by con- sidering them as intestinal in origin (saccharobutyric and mixed forms). Pyloritis. A condition hitherto not described in which the symptoms may be marked and which may simulate the presence of an ulcer or a carcinoma is an inflammatory dis- order of the distal one-third of the stomach, generally a primary congestion which may even go on to an inflamma- tion and more or less organization of tissues. These instances are due to a local infection, generally in achylic stomachs, but may also occur in intestinal toxemia, and they may be so bad as to require operation for stenosis and other reasons (all forms). Ileal Stasis. By far the largest number of cases of putre- faction in the intestine have an ileal stasis. These represent just as definite a degree of stasis as when there is pathology in the region of the ileocecal valve. This stasis which seems manifest in the six-hour place by a roentgenographic ex- amination may not be a stasis after all. It may be due to 158 DISEASES OF THE INTESTINES. an interference of the neuromuscular apparatus of the in- testines clue to a granular degeneration of the sympathetic plexuses, the sympathetic fibers and plexuses extraenteric in situation (indolic and mixed forms). Appendix. It must be perfectly logical to anyone to con- sider that the large number of cases of acute and chronic disease of the appendix must have its origin in the bacteri- ology of the intestinal canal. My belief is that the main cause of chronic appendicitis is an intestinal toxemia, and this explains why it is that often after appendices are removed the symptoms continue just as before; because re- moval of the appendix does not cure intestinal toxemia. There is a feeling nowadays that in an instance of intestinal toxemia and diseased appendix, the removal of the appendix will have a beneficial efifect upon the intestinal toxemia. This is true in only the minority of instances; the great majority of cases are the other way, namely, that the in- testinal toxemia is primary and not removed by operation, and the removal of the appendix merely removes a resulting condition and not the actual cause (all forms). Megacecum. This condition in the idiopathic type com- monly is a resulting condition of intestinal toxemia. It is brought about, as mentioned before, by a resorption of toxic bodies from the interior of the gut and a gradual degenera- tion and shrinking of the cytoplasm of the cells in the Meissner and Auerbach plexuses in the right colon. Gen- erally there is more or less of a catarrhal condition present at the same time—a so-called right sided colitis (all forms). Chronic Colitis. Chronic colitis is often a resulting con- dition from an intestinal toxemia of long standing. Gen- erally there is disease of the mucous membrane of the right side of the colon with perhaps more or less atrophic changes in the lower end of the colon and sigmoid as well. Generally there is more or less dilatation of the colon in these cases. Usually there is a distinct change in the mucous membrane to the extent of a hypertrophic inflammation or an atrophic destruction, dry in type. The hypertrophic type (generally due to a saccharobutyric toxemia) is usually accompanied by more or less spasm, which is commonly expressed as spastic constipation since constipation usually exists in these CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 159 cases. The atrophic form has generally a dilated gut with a dry mucous membrane. Adhesions. It is not uncommon to find pericolonic ad- hesions in these cases. Adhesions may be found in the right colon or in the descending, perhaps only in the region of the brim of the pelvis on the left side. They are due to migration of bacteria through the mucous membrane and walls of the gut, and, gaining the peritoneal surface, causing a plastic and adhesive form of a low degree of peritonitis with adhesion formation, the original condition being in- testinal toxemia (all forms). Ptosis. In about one-half of all the cases of ptosis a primary intestinal toxemia exists which, if not removed, usually causes the symptoms to reappear. Cases of ptosis plus toxemia must be divided into two groups: those with secondary and those with primary intestinal toxemia. In those that have a secondary intestinal toxemia, due to the ptosis, the treatment will be that for ptosis, after which the intestinal toxemia generally disappears. One-half of all cases of ptosis, however, have a primary intestinal toxemia. To benefit the ptosis and relieve the symptoms by the incor- poration of all of the methods of treatment that are known for ptosis, benefits for a short time only, with a resumption of symptoms later. This is because the original primary toxemia has been left, eventually again causing symptoms in the abdomen. Gall-bladder Condition. It is a well-known fact that in some individuals, particularly those who have intestinal toxemia, the bacteria may reach the general circulation, in which instance the liver may act as an organ of elimination, the bacteria gaining the bile and collecting in the gall- bladder and ducts may infect it with the production of chole- cystitis, all the way from the strawberry type to that of the fibrous form, and when the gall-bladder is enough dis- eased, as in individuals who have a cholesteremia, there can occur a production of gall-stones. It may here be mentioned that intestinal toxemia is an active cause of cirrhosis of the liver. It is a well-known fact that many alcoholics do not get cirrhosis of the liver, and that others who drink do. It is also known that cirrhosis of the liver is not an uncommon 160 DISEASES OF THE INTESTINES. finding in the operating-room with people who have never drunk alcohol. In investigating this subject I have come to the conclusion that it is not the alcohol that causes cir- rhosis of the liver, but the drinking of alcohol and malt fluids brings about a change in the bacteriology of the small in- testine and this change is capable of producing cirrhosis of the liver, due to resorption of toxins (saccharobutyric form). LABORATORY EXAMINATION. All that pertains to the various tests of the urine, the significance of the sulphate bodies, oxalic acids, ammonia, bile pigment, tests for functional renal capacity, tests for function of the liver, examination of the feces in intestinal toxemia, the x-ray examination, need not be entered into here. TREATMENT OF INTESTINAL TOXEMIA. It is a well-known fact that the bacteriology of the human intestinal canal is quite facultative, and therefore in putre- factive conditions a carbohydrate and fat diet may be given which in the course of time turns the character from a putre- factive to a fermentative state of affairs; due to the encour- agement that the change in diet brings about in the growth of such bacteria, perhaps of quite opposite groups. Then, too, organisms can actually change their metabolism and accommodate themselves to protein and then to a complete carbohydrate regime. These changes consist essentially of alteration between proteolytic and gas-forming bacteria on a protein diet and acid-forming bacteria on a carbohydrate regime. Often for a time, however, the absence of carbo- hydrate prevents the development of acid-forming bacteria on a protein diet, and the excessive amounts of acid by the fermentation of sugar prohibit the growth of the proteolytic aerogenic forms in the carbohydrate regime. From these facts it is readily seen that the character of the foods taken in the alimentary canal will very profoundly alter the bacterial flora and the toxins of the canal. It might also be added that there are many cases in which, whatever the diet, whether protein or carbohydrate, the bacteriology continues in spite of the character of the food, and it should CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 161 also be remembered that bacteria may become facultative and may be quite as injurious in a fermentative sense as in a putrefactive. Intestinal Antisepsis. For a good many years the medical profession has attempted by means of medication to accom- plish an ideal which is not possible considering the many factors which are found present in the intestinal tract. The germicidal effect of drugs in the intestinal canal is an ostrich proposition. The substances used for this erroneous purpose have been many. Myriads of drugs and methods have been advanced, none of which have stood the test of time. It must be manifest that in a canal of intestines over twenty feet long, in which a number of phenomena take place, such an idealism as accomplishing intestinal antisepsis by any single method is entirely out of the question. A great array of drugs has been tested culturally, and reports pro and con have been expressed by the authors. There is a great difference in the proportion of a dis- infecting agent required to destroy microorganisms and that needed to restrain development. For example, the germi- cidal strength of creosote is about one to three hundred, but it is distinctly inimical to bacterial growth when present in the proportion of one part to four thousand. The following table gives the generally accepted strengths in which some of the intestinal antiseptics are positively efficient, and the dose this would represent for a volume of six thousand cubic centimeters: Antiseptic strength Dose required Beta-naphthol 1 to 10,000 9 grains Copper sulphate 1 to 1,100 80 grains Chlorine water (U. S. P.) 1 to 16 12 fluidounces Creosote 1 to 3,000 30 minims Phenol 1 to 700 3 drams Salicylic acid 1 to 1,000 90 grains Phenyl salicylate 1 to 800 . 115 grains’1' Solution of formaldehyde (U. S. P.) 1 to 2,800 31 minims Resorcinol 1 to 2,(XX) 45 grains Thymol 1 to 1,500 60 grains * This figure is based on calculations from the amounts of phenol and salicylic acid in this compound. Bouchard found by actual experiment that it required 75 grains. 162 DISEASES OF THE INTESTINES. These figures are based on the supposition that all of the drug administered will remain as such in the intestinal tract, which of course is contrary to the fact. In the experiments which Sucksdorff conducted, an effort was made to influence the number of bacteria in the ali- mentary canal by plating a weighed sample of the stool and counting the number of colonies in the usual manner of esti- mating bacteria and administering one of the following in the table that he gives: Weight of Bacteria. Case Without drug With drug Drug 1 7.44 grams 3.26 grams Bismuth salicylate 2 5.0 grams 1.15 grams Bismuth salicylate 3 2.74 grams 1.17 grams Bismuth salicylate 4 2.23 grams 0.90 grams Beta-naphthol 5 2.51 grams 1.44 grams Beta-naphthol 6 1.69 grams 3.51 grams Beta-naphthol From the above, three substances turned out as being efficient in doses that are within the limits of safety. These are beta-naphthol, formaldehyde and creosote. It is prob- able, however, that formaldehyde is taken up with great rapidity, so that a practical intestinal antiseptic action would not be useful. Creosote, on the contrary, is absorbed with a fair degree of rapidity. It is possible by enteric coating to delay the absorption from the intestinal canal. Beta- naphthol is rather an insoluble substance, probably somewhat more soluble in the content of the bowel than in pure water. It is evident, however, that a substance which is so sparingly soluble as this, must go into solution in the intestines very slowly, and therefore linger in the bowel for a considerable length of time. For this reason, as well as for the fact that even in very dilute solution it exercises an antiseptic influ- ence, it would seem to be the remedy of choice in cases in which we wish to influence bacteria in any part of the intestinal tract below the upper duodenum. General Medicinal. Fatigue would have to be controlled by means of the well-known methods of rest, sufficient feed- ing, perhaps a sojourn in the country, tonics of various sorts, CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 163 and those which are metabolically constructive, as malt, the oils, hyperphosphates, etc., and the hematinic forms of tonic. The anemia is controlled by means of hematinic tonics, of which the best forms are the inorganic forms of iron, hypodermically administered. Usually this is required but for a short time. A diet heavy in organic iron (such as meats), or a heavy iron-bearing vegetable diet and fruits, would answer the purpose in different instances. Anorexia is controlled best by the use of elixir tinctura, ferri chloride and gentian well diluted before meals. Other forms of hematinic tonics might be in order for the purpose. Of course, the patient should be encouraged to eat sufficient amounts of food. Insomnia, which is often a distressing factor in these con- ditions, had best not be controlled by hypnotic substances, excepting perhaps for a few days at the beginning of treat- ment. The insomnia usually disappears more or' less as the intestinal condition improves. Of some value is the well known hot spinal douche before retiring, it usually taking about fifteen minutes until complete relaxation of the ner- vous system has taken place. Occasionally bromides are in order and perhaps a mixture of bromide and valerian through the day may encourage better sleeping at night. Various skin conditions would require the necessary lotions and oint- ments. States of neurasthenia require special attention, per- haps a rest in bed treatment, although those who are up and about and not distinctly exhausted would be benefited by the use of the various tonics hypodermically given, especially those containing glycerophosphites. Hydrotherapeutic and mechanical measures, such as baths, electricity, massage, etc., may be employed. Such procedures are required to build up the general tone of the body, and where the means are not at hand, it may be necessary to send the individual to an institution equipped with apparatus for the purpose. In these instances there is often a complete mental diversion from business and family cares required; and those patients who have been depressed, upon becoming interested in golf, touring, music, reading, etc., which, bring- ing a more cheerful atmosphere, derive a beneficial effect from them. Very important, however, in their daily routine is 164 DISEASES OE THE INTESTINES. exercise. In the saccharobutyric cases the individuals are often quite obese, and exercise and dieting for the obesity would be in order. Such exercising should be of the heavy type so as to put as much strain on the muscular system as possible. In the indolic and mixed forms there is usually so much fatigue, devitality, etc., that strenuous exercising is contraindicated. In such instances, however, some exer- cise should be carried out and the system that I would recommend is a combination of massage and exercise at the same time, the various motions being as follows: (1) Rub each foot on top with the other, at the same time rubbing the neck with the hand. (2) Stroke each arm alternately, from the shoulder on the upper side down to finger tips, continuing underneath up again to armpit, then down same side of chest, and give a short stroke behind shoulder under armpit. (3) Without bending the knees, bend the trunk forward and stroke from ankle up front part of legs, stomach and chest to the neck, at the same time raising the trunk; then stroke down chest to diaphragm; now bend trunk forward and grab around the back, with hands on each side of spine, as far as possible, and stroke from there down over lower back, continuing down back part of legs to heels. (4) Stroke with both hands from each side of knee alter- nately, up over side of hip and loin, then straight across the abdomen with the one hand, and the diaphragm with the other. (5) Press the arms and hands alternately with a swing- ing movement from behind down on something in front and on a level with the chest, at the same time giving the trunk a quarter turn to the side, and rubbing the kidneys and lower back with the back of the other hand. (If swinging and pressing with the right arm and hand, turn to the left and rub with the left hand, and vice versa.) (6) This is similar to No. 5, but here swing the one arm sideways and press sideways on something in front of you, at the same time rubbing the left and right side alternately with the other hand. When rubbing the left side with the left hand from hip up over diaphragm, the trunk is turned CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 165 to the left, and the sideway swinging and pressing is done with the right arm and hand, and vice versa. (7) Lift the knees alternately up to chest, then while legs go down stroke both sides of legs from ankle up over ab- domen and chest to neck; then go down the spine with the back of one hand. (8) Bend the trunk to right and left, at the same time stroke both sides from side of hip up to armpit with each hand alternately (heels together). (9) Jerk the trunk to right and left, at the same time rub- bing both hands across the chest. (10) A rolling of the body at the hips, the hands making pressure on the abdomen on the relaxed side. Practice a breathing exercise between each massage ex- ercise except in No. 8, when legs remain stationary and feet are kept at least a foot apart and nearly parallel. Do not exercise for at least one hour after a meal. As a special breathing exercise: Inhale as deeply as possible with hands placed on loins, and elbows and shoulders thrown back, at the same time rising up on toes and bending the knees so that the heels touch the seat. Exhale the air through the mouth while rising up on legs and toes and down again on heels. Intestinal Irrigation. Intestinal disinfection has been tried by means of the transintestinal lavage method, using vari- ous solutions for the purpose. What is accomplished here is a duodenal lavage and the benefits obtained are un- doubtedly due to] the washing of the intestinal content on- ward, and not to the various solutions which are used. Jutte uses a combination of saline cathartic with phenolphthalein. Other men claim benefit from the use of a solution of mag- nesium sulphate. There is no doubt that these methods accomplish a thorough cleansing of the lower end of the small intestine and all of the large, and it is my belief that such results as are accomplished have been brought about by the mechanical use of the water plus a purgative effect from the salts in solution, and not from any bactericidal action. In this sense they are worth the while, particularly in the saccharobutyric cases where there is a high anaerobic content, a large amount of Welch bacilli, and perhaps Gram- 166 DISEASES OE THE INTESTINES. positive diplococci or single coccal growths. In my experi- ence the use of the transintestinal lavage method of washing the small and large intestine is also worth while in those instances of saprophytic infection, both of the Gram-negative and Gram-positive types. Colonic Irrigation. Numbers of men that I know of are engaged in irrigating the colon in instances of colitis, in- testinal toxemia, etc., and I have yet to see the case (after an extensive study of this method) that has been benefited by it. There are not a few individuals who believe that they have been benefited, the effect being entirely one of purgation and mental suggestion, and not due to actual cura- tive benefit brought about by the method. Of course, an emptying of the intestinal canal has been accomplished but this can be done quite as well by any patient using an enema and taking it lying on the left side or perhaps in the knee- chest position. No physician, nurse, high rectal tube, or any definite solution employed is worthy of consideration in these cases as a method of treating intestinal toxemia while under a physician’s attention. It does not pay for the time and effort the medical man puts in on the effort, nor the patient for such as they have to pay for the treatment. In my work I do not use any form of rectal irrigation, either accumulative or by recurrent tube. It is my belief that the human intestinal canal is not made for the purpose of withstanding large quantities of water. Many times dis- tinct harm is done, and such results as may be brought about by a benefit in the pathology of the gut are so few that they are not worth the while, and could quite as well—in fact, much better—be accomplished by means of an anticonsti- pation diet, with perhaps the addition of slight purgative assistance which would insure the bowels moving normally. The use of vegetable purgatives, particularly the drastic ones, should be entirely discouraged in cases of intestinal toxemia. It is my observation that they do more harm than good. Intestinal Putrefaction and Water Drinking. Data is on hand which indicates a marked decrease in the output of bacteria in the feces when normal persons were caused to increase their water ingestion to thirty-four hundred and CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 167 fifty cubic centimeters per day, the water being taken with meals. That the use of water is worth while is evident, but in cases where there is ptosis or in which there are marked states of atony, the use of large amounts of water may be contraindicated. Water-drinking, however, cannot cure an intestinal toxemia, or even materially benefit it, if it is distinctive. Dietetic Treatment. In the three types of toxemia, one must avoid continued reinfection that follows the ingestion of putrefactive bacteria with the food, promote prompt di- gestion and rapid absorption from the small intestine, and reduce the number of putrefactive anaerobes in the ileum and colon. To avoid the infection and reinfection, the mouth must receive scrupulous care. Carious teeth and gingivitis must be treated carefully by the intelligent use of toothbrush and of washes containing peroxide of hydrogen, campho- phenique, or a weak solution of camphenol. Gastric lavage may be necessary in addition, perhaps best conducted in the morning. Oral sepsis requires strict attention. The preparation of food and ordinary cleanliness is very effective; it is probably better to use cooked food as much as possible. Fruit is not above suspicion, for on the surface of most raw fruits bacteria swarm. The bacillus of malig- nant edema, for instance, being commonly present on the banana peel, and the Bacillus putrificus on grape skins. Pas- teurization, or the ordinary boiling, kills the lactic acid form- ers in milk but does not harm the spores of the putrefactive organisms. Cheese contains many putrefactive forms and is best avoided, particularly important because many of these patients lack the protective action of a normal amount of hydrochloric acid in the stomach. With rapid digestion and prompt absorption little pabulum for the putrefactive organisms reaches the colon. These processes are often facilitated by means of the secretory and motor functions of the stomach. Chief in importance here is proper mastication, which largely determines the ability of the body to utilize food. When large masses of meat are swallowed they commonly appear in the feces. It is a good general rule to follow that putrefaction in the intestines is directly proportional to the amount of pro- 168 DISEASES OF THE INTESTINES. teins in the food. This is obtained from meats and from vegetables. The vegetables are comparatively safe, however, this being due to the fact that vegetable proteins are not so accessible either to the alimentary or bacterial enzymes, and therefore are not so readily decomposed, and also to the fact that bacteria utilize the carbohydrate substances in preference to protein. There is some difference in the effect of carbo- hydrate foods. Bread, sugar, potatoes, and legumes, often give rise to most of the organic acids and gases, whereas on the other hand, rice, sago, tapioca and arrowroot give rise to comparatively little fermentation. So much has been written upon the subect of diet in con- nection with intestinal toxemia, and so little is worth while, that I beg to be excused for not quoting from the literature of the past, and will undertake to present only my own views. In a word, there is no definite method of dieting for intestinal toxemia, and it may also be added that there is no definitely indicated diet which would be helpful in all instances of the same type of condition. The best rule is to plan a diet according to the type of intestinal bacteriology that is present, the designation being according to whether the toxemia is putrefactive, fermentative, or of the mixed form, and then not to depend upon the diet alone or con- tinuously. The rule I follow is to plan a normal diet, keep- ing the quantity of total protein down to not more than sixty to ninety grams in a day, roughing up the diet so as to overcome the element of constipation and the presence of a colitis if it exists, adding calories in the shape of fats when there is distinct debility or loss of tissue, the use of a high protein diet in saecharobutyric infections, and the employment of a diet which gives the minimum amount of food, allowing a general selection in cases of the mixed types. By following this plan I have been fairly successful in diet- ing instances of intestinal toxemia, not having the bother of making out an individual diet for each patient, or selecting various foods for this or that case. After making out in- dividual lists along general lines for years I have come to the conclusion that I have largely hoodwinked myself. I now go upon the findings in the laboratory and x-ray ex- aminations and make up a diet according to the type of CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 169 toxemia, the abdominal and general requirements of the individual, always encouraging the taking of sufficient amounts of food. The type of diet I use in putrefactive cases where putre- faction is marked, is somewhat on the order of the following: Albuminous Drinks. Egg broth Eggnog Junket eggnog Albuminized water Albuminized clam water Junket Grape juice Grape juice and egg Malted milk and egg Kumyss Zoolak Rice milk Mutton broth Nutritious beef broth Broth with grains Egg broth Cocoa Malted milk cocoa Soups. With or Without Noodles, Crackers or Croutons. Cream of celery soup Celery soup (gum gluten) Asparagus soup Corn soup Tomato soup (with broth) Mock bisque soup Green pea soup Rice soup Victoria soup (with broth) Flour gruel Porridge Cracker gruel Barley gruel Barley gruel with broth Arrowroot gruel Indian meal gruel Cereals. Rice, farina and oatmeal gruel Gum gluten breakfast food Corn meal mush Flominy mush Rolled oats Steamed rice Boiled rice, farina, tapioca, sago Fruits. Pineapple, Baked Banana, Steamed Rhubarb, Baked Apples and Apple Sauce, Stewed Prunes. Pastry. Rolls, any kind; Bread, any kind; Cake or Crackers, any simple kinds. Shell Fish. Raw oysters, with lemon only Pan roast oysters Creamed oysters Scalloped oysters Clam bouillon bisque Oyster stew and soup Broiled oysters Soft boiled Steamed or baked Golden rod eggs Egg nests Eggs (4 a day). Plain omelet Foamy omelet Bread omelet Poached eggs plain 170 DISEASES OF THE INTESTINES. Fish. Creamed Fish, Baked or Boiled Fish (Plain Sauce). Vegetables. Boiled potatoes Riced potatoes Mashed potatoes Creamed potatoes Baked potatoes Peas 1 Beans >• Lentils J in puree form Spinach Desserts, Banana, peach, or apple custard Soft custard Meringue or floating island Chocolate Malted milk or baked caramel custard Gum gluten pudding Rice pudding, peaches and rice Steamed and boiled rice Rice meringue Cream of rice pudding Bread and cracker puddings Junkets, custard, cocoa, coffee, plain Gelatin Souffles Cornstarch pudding Cornstarch, fruit jelly Chocolate or cocoa blanc mange Plain or tapioca cream Pineapple cream Pineapple, apple or raspberry tapioca Jellies (fruit and cereal) Fruit whips In most instances, however, more or less use of protein is allowed, for many of these individuals require protein and can take it, providing it is in such form that it is readily digested and quickly absorbed so as not to accumulate in the colon. A copy of such diet, with constipation additions, together with the necessary increase in fats to encourage an increase in weight and strength, is the following: General Rules.—Care should be taken that all of the foods are fresh, cleanly cooked and served, and that no foods that have been standing some hours in a cooked condition are partaken of. The mouth should be cleansed with plain water (preferably with a little bicarbonate of soda dis- solved in it) before and after the meals and when possible at other times. A thorough cleansing of the teeth and a correction of such dental con- ditions as may exist and the use of dental floss is advisable. Adopt the plan of taking either four meals a day, moderate in amounts, or three meals a day with supplemental meals between them and before retiring. Thorough cooking, cutting foods finely on the plate or mashing them, complete mas- tication and slow eating are advised. Foods should not be eaten under conditions of fatigue, mental excitement or depression and a rest for an hour after each meal is desirable. No condiments such as sauces, mustard, pepper, lemon and so forth are allowed, and all foods should be plainly cooked and never in made up dishes. The use of salt is allowed. When there is distress in the stomach drink a glass of warm flaxseed water be- fore meals, and no fluids, including soup, milk, water and so forth are allowed with the meals, although these may be taken in the meal intervals; drinking of a glass of cool water about an hour after the meal is sufficient. CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 171 Foods Allowed.—Bouillon, broth, consommes purees. Any of the well cooked cereals served with milk sugar and fresh cream. Eggs in any form but not more than two a day. Breads, rolls, zwieback, biscuits and crackers. All foods made of gelatin, not more than two ounces of meat, poultry, game and fish in a day. Take a half pint of fresh cream and as much unsalted butter and olive oil as possible each day. Any of the vegetables may be taken, except potatoes, tomatoes, asparagus and canned vegetables, but they must be cooked to softness; peas, beans, and lentils be- ing the most wholesome. The green vegetables and salads are allowed. Other foods of value are: custards, egg and milk, peeled fruits, jellies, marmalades, apples, pears, green chicory and spinach. Eat at least three of the following bran gems, well buttered, during the course of the day. Bran Gems.—One-half teaspoonful soda, saleratus, dissolved in cup hot water. Add, when dissolved, % cup molasses, then a tablespoonful of butter, salt to taste, 2 cups wheat bran, 1 cup bran meal, 1 cup milk, mix all the above ingredients together. Put in a muffin pan and bake 45 minutes in a slow oven. Two added measures of moving the bowels are to take a dish of stewed prunes sweetened with milk sugar instead of cane sugar, or from a tea- spoonful to a tablespoonful of white vaselin before retiring. If then the bowels do not move, inject about a half a tumblerful of olive oil into the rectum at night. It may be found that apple sauce, sweetened with milk sugar instead of cane sugar, may be more efficacious than the prunes. If such is the ex- perience, apple sauce may be used instead or they may be taken alternately, eating one on one day, and the other the next. Where distinct fermentation exists I use a high protein diet. A number of years ago the use of the beefsteak and water diet for the correction of intestinal toxemia had quite a vogue, and there is no doubt that considerable benefit was brought about by it. Such cases as improved were un- doubtedly those of the saccharobutyric fermentation form and not the indolic or mixed forms, which manifestly would not be improved or even would be made worse by a diet high in proteins. A practical diet high in proteins is the following: This diet is a temporary one. Take mostly meats—all forms of beef with the exception of cuts from the shoulder, kidneys and liver. The same is true of lamb. These meats should be fresh and taken in a broiled or roasted state. Mutton is permissible but no pork nor veal. May take any kind of fish broiled or boiled with the exception of shad roe and shell fish. May eat eggs in any form. Butter and whole milk are allowed, together with any form of simple cheese of the cream variety, such as Philadelphia, Neufchatel and cream cheese. Eat as much gelatin foods as possible. Oatmeal and rolled oats are allowed. May have breads or crackers made of gluten or rye flour. Lentils and dried peas are per- 172 DISEASES OE THE INTESTINES. missible. There is no objection to an occasional orange, pineapple or straw- berries. The best drink would be chocolate and cocoa. As was stated before, too much dependence should not be placed upon diet in the treatment of intestinal toxemia. Some benefit can be brought about, of course, but the cure of the condition on the basis of altering the bacteriology is quite temporary, idealistic, and not steadily useful. Some benefit can be brought about in this way, but it is only transitory because ofttimes when a definite absence, low or full protein diet is indicated, after a course of time it will be noted that the bacteriology present in the individual has become facultative and has now changed the type of the toxemia from one to another. Those cases always suggest that an infection is present in the gut contents and mucous membrane of the small and large intestine and perhaps no dieting will be of use, or again that a definite pathology is present and therefore no diet will avail, or that there may be some error in the secretions and the individual is toxic more from the mucous membrane than from the content of the gut or from an infection in the mucous membrane. How- ever, the plan as mentioned above, the absence of protein diet, that in which the protein is low, and the one in which the protein is high, and these based upon the study of the case in the nature of the process in a biochemical way is the most advisable that I know of. Vaccine Treatment. It is necessary here to consider whether the infection is simply of the intestinal content— namely, a true intestinal toxemia, or whether in addition to that there is an infection of the mucosa—namely, a distinct infection. When local pathology exists an infection of the mucosa is always present. It is probable in the toxemia due to infection of the content, wherein the mucous membrane and submucous tissues are in a resisting state, that very few if any general or constitutional symptoms are present. The treatment of these cases is essentially along general lines, together with proper dieting, the use of intestinal treatments, and so forth. But where distinct infection exists, the vaccine theory ofifers a means well worthy of employment. When infection of the tissues has taken place, distinct constitu- tional symptoms are also present. My belief is then that CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 173 whatever may be clone in a simple way, unless vaccines are resorted to, but little if any benefit be accomplished. Of course, the dietetic means of controlling the infection within the content of the gut are in order however much pathology there may be present. For centuries it has been known that following an attack of certain acute infectious diseases there remains a certain loss of susceptibility to the contraction of a second attack of the same disease. Early in the eighteenth century this experience was utilized in vaccination against small-pox. This successful immunization can now be accomplished against cholera and typhoid fever, as well as conferring more or less benefit in other conditions. . Sir Almroth E. Wright, in his introductory address de- livered before the Royal Society of Medicine on May 23, 1910, gave his conception of the rationale of vaccine therapy as the exploitation, in the interest of the infected tissue, of the unexercised immunizing capacities of the unaffected tis- sues. There exists a correlation between the vaccine and the antibacterial defenses of the body. This can easily be demonstrated by the opsonic index, which accurately meas- ures the opsonic power of the blood, that is, the antibacterial defenses of the body. It has been generally accepted that the immune bodies are produced almost wholly by the blood-making (hemapoietic) organs, and thence delivered into the blood stream. This theory fails to take into account the special immunity which certain tissues exhibit against infection, which in the in- testines is definite. The most obvious objection to the use of vaccines in general infections is that the patient is undergoing extreme intoxication and that the injection of vaccines will but add to this intoxication. This is not so in intestinal work. Another objection offered to the use of vaccines in general infections is that vaccines stimulate the production of bac- teriolytic substances and that these substances may kill many bacteria and set free their toxins, thus overwhelming the body with toxic products. I have never seen reported harmful results relative to the sudden setting free of their toxins. 174 DISEASES OF THE INTESTINES. Christian Herter’s work on the bacterial infections of the digestive tract appeared in 1907. Some time between that and 1910 Allen and others wrote on vaccine therapy. Recog- nizing the possibility of being able to favorably affect the intestinal infections in man by means of vaccine methods of treatment, I engaged in the clinical application of autoge- nous bacteria according to the infection I believed existed in intestinal toxemia, carefully noting the results. All of the first work done was by the use of autogenous colon vac- cine, administered both subcutaneously and by way of the rectum. Chvostek had given colon vaccines by mouth, and when some very remarkable results by injection of autoge- nous colon bacillus vaccine had been accomplished by me (New York Medical Record, September 24, 1910), Turck suggested their use. In 1910 I had treated one hundred and twenty-seven cases of distinct intestinal toxemia by means of autogenous colon vaccine, with a number of strik- ing results, some indifferent results, and a few failures. I suggested that it might be possible to influence the cases better by use of autogenous colon vaccine administered by rectum and using the viable form, employing much larger doses than possible by subcutaneous injection, the initial dose of which is limited to between twenty-five million and fifty million organisms, given every fourth day, and gradually increased. The colon route was also deemed advisable be- cause of some very severe reactions, local and general, in the subcutaneous injection method. It was observed by me that as many as from five trillion to thirty trillion viable colon bacteria could be given by rectum without much re- action, and that a leucocytosis was possible of accomplish- ment in the same way. Also that the resulting leucocytosis was more steady than that by subcutaneous injection, and if the vaccine could be kept up for three or four months the results were quite as good—in fact, were better than by the cutaneous route. Since that time, Satterlee has reported good results by the use of colon bacillus vaccine given subcutaneously. The original use of the colon vaccine by me was suggested by the conclusions drawn by Herter, that the colon bacillus was capable of initiating the toxic process in the intestine, CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 175 although it usually did not finish the putrefaction, this being accomplished by other forms of anaerobic growths. It is a well-known, fact that many strains of the Bacillus coli are beneficial in the intestinal canal and inhibit putrefaction and fermentation rather than initiate or encourage it. The whole question is bound up in the strains of the coli, and it has been my experience that there are essentially four patho- genic types in the seventeen different strains. It is a well known fact, for instance, that the colon bacilli recovered from the human intestinal canal is the most virulent of any. Having concluded that the Bacillus coli have to do with the production of symptoms in the case, and decided upon a subcutaneous administration, the process of treatment is simple. The patient is given a dose of castor oil, and the third or fourth stool following is taken to make the vaccine from. As many colonies and strains as possible should be used to make the vaccine, which would be a polyvalent autogenous emulsion and perhaps the infecting strain given. Depending upon the age and clinical conclusion as to the vitality of the individual in the subcutaneous method the initial dose is from about fifteen million to twenty-five mil- lion of dead bacteria. The dose is repeated every four to seven days, and a gradual increase of about twenty million bacteria each time until the maximum of two hundred million or three hundred million bacteria is reached. One does not see much, if any, improvement until several doses have been given, and in fact it may be necessary to go on for two or three months before any results are accomplished. There should be a reaction after each dose, which consists of local redness and swelling, with perhaps a considerable spreading until a large area is involved. Because of the failure in many instances of the use of autogenous coli vaccine subcutaneously administered, I be- lieved that the rectal route would be more worth a trial, and so far as I know, I was the first one to use the subcutaneous and the rectal routes for influencing conditions of intestinal toxemia by the administration of coli vaccine. I desire to quote from the article published on the rectal instillation method, which holds almost as true today as it did in 1910, and after about twenty-two hundred cases have been treated: 176 DISEASES OF THE INTESTINES. “My interest in the use of a direct bacterial method of treatment was suggested by the uniformity of the different bacterial pictures seen in examining specimens of normal and abnormal stools stained by the Gram differential method; the fact that the coli bacilli grow only for a certain time in bouillon, when, probably because of their generation of thermostabile and thermolabile substances allied to phenol, their proliferation is inhibited and they become quiescent or resting but not killed (the latter was a confirmation of Conradi and Krupjurveit observations with the Bacillus coli communis and the Bacillus lactis aerogcnes, the last of which organisms probably suggested the use of the Bulgarian form as a germicidal bacteria against all others), and also, the fact that colon bacillus was most numerous in stools of nor- mal individuals, but was diminished or absent in some cases of excessive chronic intestinal putrefaction, having excess of indican in the urine, even when the intestinal contents have somewhat rapidly passed through the colon. “I have come to the following conclusions: In cases of chronic intestinal putrefaction wherein carcinoma, colonic obstruction, abnormal organic disease of the pancreas or stomach, or gastrointestinal atrophy, etc., are not responsible for the condition, much benefit can come from raising the content of Bacillus coli communis in the gut by instillation either of the autogenous mixed forms or strains from other individuals; whether this is due to a real antagonism be- tween the toxins of the Bacillus coli and the other putrefac- tive organisms, these toxins being existant in the cultures injected (which bacteriologists claim is slight in amount with the Bacillus coli), or whether the Bacillus coli so injected are directly toxic to those other bacteria, I am not prepared to say. (We know that the dead as well as the living Bacillus coli are very toxic.) But it is certainly true that an indi- vidual who has high Gram-positive stools can, by the au- togenous mixed or Bacillus coli instillations, quickly have the running proportion between the Gram-negatives and Gram- positives raised to a proportion equivalent to normal, this being due to a raising in the Bacillus coli and also to a diminution in the putrefactive Gram-positives as the first become more numerous. With this more equal proportion CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 177 between the two types of organisms, the conjugate sulphate of the urine diminishes and the cases make substantial im- provement in the general body. Whether this raising of the Gram-negatives is only due to the Bacillus coli or only to the Bacillus lactosus aeroyenes (both being antitoxic to other bacteria), or to both together, is not always possible of de- termination, since both are much alike in their morphology and are Gram-negative in character. But the cultural meth- ods of distinguishing these forms from each other and the results obtained when only the Bacillus coli were used in the injections incline me to believe that these disorders are due to a shortage or inactivity of the Bacillus coli, and that the latter are the most powerful agents in the human alimentary canal against the development of putrefactive conditions, and, that while outside of the intestine they are destructive and pyogenic, inside of the canal they commonly are welcome hosts. As regards the permanency of the benefit brought about, it is apparent that about half of the cases which do not respond to simple treatments clear up inside of from one to three months on this treatment, but that the other half may not remain substantially benefited even when the instillations are kept up for longer periods. These latter show relapses when the instillations have been stopped for a week or more, quickly responding again when the injec- tions are reestablished and some eventually clear up. It is probable that in the relapsing cases some permanent ana- tomical mischief preventing the establishment of a normal bacterial intestinal condition is present, which is either the cause of the development of the condition in the first instance and then its prolongation, or that there is present some anatomical or permanent functional change affecting normal secretions and motility of the digestive canal in asthenic ways. Cases of putrefactive conditions when in doubt may first be treated by the routine methods of treatment (diet, hygiene, tonics, etc.) before instituting the instillations. Then if no benefit is noted on the Bacillus coli alone the Bacillus lactosus aerogenes may also be added to them, the two grown together in the single media, and these tried for a length of time. And if after these, no sustained or ap- parent benefit is achieved, the other vaccines or antagonisms 178 DISEASES OF THE INTESTINES. should be tried, and should it then be that no benefit is accomplished, we have present some anatomic and permanent complication affecting the function of the gut, and the best we can hope for is a resort to surgery in some of the cases, or a longer interval continuation of instillations of whatever form of culture has shown the best results in the particular case.” After numberless attempts to administer rectally the in- nocent forms of coli vaccine, I have come to the conclusion that not only do they act in a beneficial way by inhibiting the processes of fermentation and putrefaction by such effect as they exert upon the bacteria present in the intestinal canal, but they produce a leucocytosis or a stimulation of leucocytes in the walls of the intestine with the generation of more or less of an antibody formation which acts as a means to elevate resistance against bacteria in a general way. I cannot explain the results accomplished along any other line than that there must be this leucocytic antitoxic body forma- tion, because the individuals remain permanently well and are singularly free from infections of all kinds for some years. It may be, after all, that the results accomplished by my method are distinctly along the vaccine immunity line, and not along the line of increasing the number of colon, bacilli in the intestinal canal, or any local effect of that sort. The choice between the two methods—namely, subcutane- ous of dead bacteria which have been killed by heat (and if required, by means of any phenol substance), or the viable autogenous rectally instilled—is a matter according to the individual case. After a length of time, one instinctively can draw distinctions as to which is the wiser method to pursue, whether by vaccination, on the one hand, or for an- tagonistic effect, on the other. This is somewhat of an art that comes only from experience and cannot be described in words. There are some instances where it is wise to use both methods at the same time, but this is not a good prac- tice because it is not possible to state which one of the methods brought about the beneficial results. It is better to use one, then the other, or, better yet, to decide when possible on which is the best one to use according to the CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 179 individual case. In a general way, infections of the intestinal content are best controlled by means of the rectal adminis- tration, while those of the true toxemia wherein there is invasion and infection of the mucosa or tissues of the body, by the subcutaneous. Many cases have both an infection of the content and infection of the tissues and therefore may require both methods of . attack eventually. The method of taking innocent forms of bacteria by mouth, the subcutaneous immunity vaccine method, and the rectal instillation of Bacillus coli has failed me at times. This is sometimes due to fault in the selection of the cases and at other times due to improper vaccine employed—occasionally to improper laboratory procedure in estimating the patho- genic forms present in the individual. Ofttimes it is nec- essary to reexamine the case, go over the stools carefully again, particularly from a bacteriological standpoint, and do a restudy of the sedimentary culture fields. It is not un- common that a conclusion which was drawn in the first instance, was distinctly different from the conclusion that is drawn in the second or third examination. The colon bacilli are great complicators of the work, and not uncom- monly an underlying or overlying bacteriology is of very much more importance in the production of the symptoms than the simple presence of the organism. In these instances no results, or only very mild ones, would be brought about by the use of the coli vaccine, and as my work multiplied, the number of cases in which other vaccines were more desirable constantly increased until now over two thousand cases have been treated with other than Bacillus coli. It is not advisable to give a long dissertation on the pros and cons on the elaborated vaccine side of the subject, par- ticularly in the matter of ideally selecting the bacteria for the case. This can only be accomplished by careful labora- tory work. The following, then, in toto, is the plan of the work I now follow when I employ the vaccine immunity methods of giving the infecting organisms, and the two methods of administration of the vaccine. A single bacterium is always employed in the vaccine used. 180 DISEASES OF THE INTESTINES. Rectal and Subcutaneous Routes. Vaccine Immunity Methods. B. aerogencs capsulatus Gram-positive diplococci (rectal; rarely) Saccharo-butyric Gram-positive single cocci (rectal) B. bifidus (rectal; rarely) B. putrificus (rectal; rarely) (rectal) Identification of which of B. coli communis the 17 varieties, and that one used, (skin) B. mysentericus (rectal) B. liquefaciens (rectal) Indolic B. proteus Gram-negative streptococci (skin) Staphylococci (skin) Combinations of above according to predomination of fermentation or putrefaction, and types of organism. Mixed The rectal method is used here altogether, and effort is made to get reactions and a leucocytosis of from 10 to 20 thousand within eight hours after the injec- tions. Bassler’s Bacterial Treatments in Primary Toxemias. After all that has been said in connection with the diet, general care and vaccines, there still can be found instances where there is no result worth while, either such as can be proven in the laboratory or results which the individual shows in a state of improved health. In these instances it has been my custom, after an extensive study of bacterial antagonisms, to use the following method of administering bacteria, all the work then being done either by rectal ad- ministration or administration through the duodenal tube, usually the first. After seven years’ experience in the study of bacterial antagonisms to meet such cases as fail to respond to the vaccine immunity plan, the following represents the plan I now follow. It must be remembered here, however, that the results may not be as substantial as those accom- plished by means of the vaccine immunity method: Not a few of the cases have been treated along a line which I have designated as biochemical alteration. In these instances the infecting bacterium is employed differently from the vaccine method, in which the organism employed is gained in as pure culture as possible in the shortest time after the stool specimen is on hand. By the biochemic altera- CHRONIC EXCESSIVE INTESTINAL TOXEMIA. 181 Bassler’s Bacterial Treatments in Primary Toxemias. Rectal and Subcutaneous Routes. Bacterial Antagonism Methods. B. coli (many differ- ent strains and per- haps collected from different sources). For the first two the o, for the sec- ond two the b, strains are best. B. aerogenes capsulatus Saccharo-butyric Gram-positive diplococci (Heavy protein diet.) Gram-positive single cocci B. bifidus B. acidophilus B. bulgarius B. lactis aerogenes G. P. diplococci G. P. cocci Indolic B. coli (Low protein and B. mysentericus high carbohydrate and Gram-negative streptococci hydrocarbon diet.) Gram-negative staphylococci B. proteus vulgaris (B. Welch) B. cloaca (B. coli, polyvalent strains) B. pyocyaneus (B. coli, a strains) B. putrificus (B. coli, b strains) Mixed (Least possible amounts of food, no cheese, peelings of fruits, mostly boiled foods.) No action on antagonisms possible by rectal or subcutaneous methods excepting when a predomin- ant type of bacteria is present. The difference between the a and b strains of B. coli is that the a does not produce gas in saccharose; the b does. The effects are the same on all the other sugars and on the coagulation of milk. tion method, the vaccine used is that in which the organism has been grown in successive subcultures, these averaging about five. According to the organism, the medium is changed, sometimes at each inoculation, the idea being to change it both morphologically and in chemical ways. This often robs it of its specificity and toxicity, and at the same time it may answer for vaccine effect on the organism in- fecting the host. It is only possible by the study of the individual case and then perhaps after more or less instillation experience to decide whether the biochemic alteration would be the best to employ either all the way through the bacterial treatment in total time or in a part of it. The list of this method is the following: 182 DISEASES OE THE INTESTINES. Bassler's Bacterial Treatments in Primary Toxemias. Rectal Route. Biochemical Alterations. Occasionally infecting bacteria can be changed biochemically by growing under different media and these used in the effort to substitute those present in the body. Successful examples of this have been found in cases of in- fections with the B. coli, aerogenes capsulatus, mysentericus, and putrificus. Surgical Treatment of Intestinal Toxemia (Stasis). Watch- ing a number of baneful results that have been brought about by surgeons who have followed the propaganda of Lane and others, I am pleased that I have not worshipped at the altar of the surgical treatment of intestinal toxemia for the pur- pose of changing the biology of the intestinal canal. I am satisfied that the surgical therapy of drainage (which would have to do with pus, urine, etc.), or the removal of diseased tissue, are surgical fundamentals that should be continued. But, these conditions of toxemia are a biologic state and one cannot change the biology of the intestinal canal in satisfac- tory ways by changing the fecal current. Deaver was per- fectly right about that. To remove an appendix, or to relieve a kink which is causing a distinct obstruction, may in individual instances be a justifiable surgical procedure. There are a few cases of reconstruction of the right side of the colon in which it was indicated. But the removal of the colon, or to do an anastomosis where there is not a distinct intestinal obstruction is improper surgical procedure and it is only necessary to follow a number of these cases which have been operated upon by enthusiastic surgeons to prove this. It is unfortunate that the biology of this subject is not as well understood by surgeons as it should be, but it is plain to me that of late they are not engaging in as much exploitation in this field as several years ago, evidently be- cause they did not accomplish results which were substantial, or none at all, or because the rate of mortality from excision was too high. It is not uncommon to see patients improve for a while after such surgical procedures, but usually in the course of six months or a year, almost always by the latter period, they are quite as bad as they were before; simply because their intestinal toxemia still exists. And it is not uncommon, even when the entire colon has been removed, CHRONIC INTERSTITIAL HEPATITIS. 183 to see a condition of affairs which is worse than the state of the individual before the operation was performed. The more experience I have, the fewer the operations of ques- tionable sorts are advised, and when the case is simply one of an intestinal toxemia, however much pathology there may be in the right half of the colon, it is never promptly con- sidered surgical, but always treated medically for a while. In a word, for the treatment of intestinal toxemia in all stages, surgical procedure is not indicated; if a definite ob- struction exists, yes, but for the ordinary case, no. There may be a resulting pathology in the appendix, gall-bladder, etc., that requires surgery, but for the toxemia or such stasis that is not due to definite obstruction, never. CHRONIC INTERSTITIAL HEPATITIS (CIRRHOSIS OF THE LIVER.) The so-called cirrhosis of the liver has been much and variously classified, but the term was first employed by Laennec to describe the yellowish “hobnails,” which he re- garded as new-growth. There are two types of chronic diffuse disorder of the liver, attended by fibrosis, to which the term cirrhosis may be limited. The first is a common disorder, usually due to the misuse of alcohol, and is charac- terized by a moderate enlargement of the liver which in late stages may be reduced in size, by phenomena of portal obstruction, by the absence of jaundice, and after the de- velopment of symptoms it usually runs a comparatively short course. The second of these is more rare and is character- ized by marked and persistent enlargement of the liver and spleen, by chronic jaundice, periodic attacks of abdominal pain and fever, by the absence of manifestations of portal obstruction mainly ascites, and runs a comparatively long course. This latter is classified as biliary, Hanot’s, or hyper- trophic cirrhosis. As a rule the so-called alcoholic cirrhosis cases are those of the Laennec type, although Hanot’s cirrhosis sometimes occurs. The terms atrophic and hypertrophic cirrhosis of the liver should be discarded. The reason of this is because 184 THE CIRRHOSES OF THE LIVER. in the hypertrophic liver atrophic areas are found and in the atrophic liver hypertrophic areas are usually present. Perhaps the best classifications of these two cirrhoses of the liver are portal and biliary; portal (Laennec’s) because the etiological factor is perhaps always transmitted by the portal circulation and the obstructive symptoms are those of portal obstruction; and biliary (Hanot’s) because the essential lesion is a radicular cholangitis, and the conspicu- ous clinical feature is jaundice, due to obstruction to the free flow of bile. PORTAL CIRRHOSIS. This is a chronic degenerative and inflammatory disease erculosis, and is usually unilateral. Bilateral tuberculosis in the majority of cases begins on the two sides at different times, with an interval of years be- tween the time of infection of the other organ. When but one kidney is infected, the other is in danger from two sources; first, the tuberculous infection, and second the development of a nephritis as a result of toxins eliminated from the other kidney. It has been observed repeatedly that the func- tion of the good kidney has improved after the infected one has been removed. There are no symptoms as long as the renal substance alone is affected, but the syndrome of pain, hematuria and pyuria develop when the abscess ruptures into the pelvis. Frequently the kidney symptoms may be masked by the general infection or its complications and the original source of the trouble overlooked. This is true of a severe tuberculous cystitis, when all the symptoms point directly to the bladder, TUBERCULOSIS. 345 and occasionally when an epididymitis is the first warning to the patient. It is often difficult to make a diagnosis in early renal tuber- culosis. It may be found in the corpulent individual as well as the lean and recently a tuberculous kidney was removed cystitis, when all the symptoms point directly to the bladder, from a nurse who weighed well over two hundred pounds. With marked involvement of the bladder, the trained cystos- copist needs but little else to make the diagnosis, the next thought being which kidney is the seat and whether both are involved. The presence of tubercle bacilli in the urine de- pends upon how assiduously the examination is conducted, and should be found in a large percentage of cases. Indigo- carmin plays its stellar role as a functionable kidney test in renal tuberculosis, as it is poor technic to catheterize the unaffected ureter in the presence of vesical tuberculosis. With the diagnosis of tuberculosis established, and one functionally sufficient kidney, nephrectomy is indicated. In the bilateral cases, except in acute miliary tuberculosis, pallia- tive treatment in conjunction with tuberculin gives the best results. The presence of a pulmonary tuberculosis is not a contraindication in itself to operation, unless manifesting ac- tivity. The avoidance of ether as an anesthetic is probably a matter accorded too little consideration in nephrectomy for tuberculosis. Untreated the ultimate prognosis of renal tuberculosis is bad. A few cases may heal, constituting the so-called closed renal tuberculosis, but these are so rare as to be unworthy of consideration. The progress is usually very slow, but more destruction is going on all the time and toxins are being ab- sorbed which gradually decrease the vitality. It is not proper to delay operation in the hope that the administration of tuber- culin will bring about a cure, this is only an adjunct when the source of the infection has been removed and is used in con- junction with the general hygienic measures that constitute a good anti-tuberculous regime. The prognosis in unilateral renal tuberculosis is good in proportion to the promptness with which the diseased kidney is removed. The operative mortality has in recent years decreased from thirty per cent, to less than three per cent. Over eighty per cent, of persons 346 DISEASES OF THE MALE GENITOURINARY TRACT. with this condition are cured or improved by nephrectomy and seven and five-tenths per cent, permanently. It has been stated that about ten per cent, of patients who die after nephrectomy do so during the first two years and only about three per cent, die of tuberculosis thereafter. Tuberculosis of the ureter is secondary to tuberculosis of the kidney or bladder. The ureteral orifices become rigid and present the so-called golf ball type. The treatment is directed to the primary focus and as much of the ureter as possible is removed at nephrectomy. Primary tuberculosis of the bladder is extremely rare, being usually secondary to renal tuberculosis, though it may in a minority of cases become involved from the epididymis, sem- inal vesicles or prostate gland. It produces very distressing symptoms of which frequency of urination is most marked. The bladder symptoms may be so severe that they overshadow any symptoms that might be referable to the kidney, and unless this is borne in mind the original focus may be overlooked. The majority of patients with urinary tuberculosis will have bladder involvement when they present themselves for examination, if they have not the post-operative convalescence is much quicker, because a tu- berculous cystitis persists a long time, perhaps a year or more after the focus has been removed. Indeed vesical irritation is the chief and only symptom of renal tuberculosis in ninety per cent, of patients. When the primary focus cannot be re- moved, only palliative measures are employed in treatment. It is characteristic that a tuberculous cystitis will not tolerate silver nitrate. With the focus removed general hygienic meas- ures are indicated and the cystitis may be benefited by injec- tions of 6 per cent, phenol or gomenal oil 10 to 20 per cent. The reaction following such an injection should have thor- oughly subsided before the next is attempted. These patients have considerable distress no matter what is done for them and the danger remains that as long as the tu- berculous cystitis is present, the other kidney may become in- volved due to an ascending infection. With the original focus removed, the prognosis is good. Tuberculosis of the prostate occurs in the prime of life along with vesiculitis, epididymitis and cystitis. While occasionally TUBERCULOSIS. 347 a spontaneous cure may take place through sclerosis, the prog- nosis is regarded as poor. The presence of bloody ejaculations leads one to suspect there may be tuberculosis of the seminal vesicle, and is seen in association with other tuberculous lesions as prostatitis and epididymitis. As a rule when a tuberculous epididymitis be- comes demonstrable, the vesicle in the affected side is palpably involved. Palliative treatment is usually employed in conjunction with tuberculin and surgery should be avoided if possible. Some cases have been reported cured after a vesiculectomy while others clear up after the original focus, as an epididymis, has been removed, otherwise the prognosis is poor. Involvement of the testicle and epididymis may occur at the same time, or more often primarily in the epididymis. In a small percentage of cases this may be the primary seat in the urinary tract or it is dependent upon a renal tuberculosis with a cystitis. Many cases come under observation that have had some operation on the testicle, without removing or rec- ognizing the primary focus in the kidney. There may or may not be any symptoms, with the patient often discovering a lump in the epididymis as the first indica- tion. It makes but little difference whether it be located in the globus major or globus minor. There is marked tendency for its development in patients with a tuberculous family history. Often there is difficulty in making, a diagnosis and the tuberculin test, applied diagnostically with O. T., is a reliable guide. Before attempting any treatment, it is essential to ascertain that there is no focus higher up in the urinary tract, as a kid- ney. Bilateral cases call for palliative measures. The forma- tion of free pus demands surgery and excision of the involved epididymis, or even orchidectomy when the testicle is in- volved is urged by some. The conservative operation and treatment is indicated, due to the great tendency to become bilateral. The young seem to have a better chance with tu- berculin combined with a careful anti-tuberculous regime. The tuberculous nodules may break down, form a fistula or become encapsulated and absorbed, leaving a mass of fibrous tissue to mark their position. This does not necessarily mean 348 DISEASES OF THE MALE GENITOURINARY TRACT. that a permanent cure has been established, as under favoring circumstances a tuberculous focus may again become active and with greatly increased virulence. Yet spontaneous cure may result from such a process. The prognosis is unfavorable in the cases of rapid development, being better in the slow and indolent variety. The greater the involvement, the less chance of cure. The tendency to become bilateral is unfavor- able as is the association with a diffuse urinary tuberculosis. When the process is located solely in the epididymis or tes- ticle and is removed promptly by surgery, the outlook is fair, with associated involvement of other structures, the pal- liative method is indicated and the prognosis is guarded. In the slow and indolent variety, the patient is able to be around and attend to his affairs, reporting regularly for tuber- culin therapy and usually do well. As it is possible for in- fection to take place during coitus, sexual relations should be avoided. MALFORMATIONS, ETC. The urinary tract is subject to congenital malformation and anomalies, which while not producing any immediate effect upon life in themselves often potentially are factors in pro- ducing disease. Abnormalities of the kidney are found once in every two hundred and eleven cases and comprise single, supernumerary, horse-shoe and pelvic varieties. Males are affected more frequently than females. The left kidney is affected more than the right. Infection occurring in such individuals is obviously not borne as well as in normal cases and the important fact of determining that a man has one functionating kidney before removing the other is too well known to emphasize. Movable kidney is seven times as frequent in women as men. At most from five to ten per cent, of women and one-half to one per cent, of men have abnormally movable kidneys. In twenty per cent, of cases both kidneys are abnormally mov- able. The left kidney alone is rarely affected. The greater frequency (80 per cent.) with which the right kidney is in- volved is explained by its relation to the liver and greater length of its artery. It is prevalent between twenty and fifty years. MALFORMATIONS. 349 A wide range of motion may cause neither symptoms nor pathological change, whereas a small displacement may oc- casion considerable trouble and be difficult of diagnosis. This may be explained by a kinking or obliteration of the lumen of the ureter. Nephroptosis is often associated with a general ptosis and relief cannot be obtained without treatment to the latter condition. Neurasthenia is also commonly associated. The prognosis is bad where the condition has produced some pathology of the kidney with changes in the urine. When the pain is slight and occurs only at long intervals and the kidneys can be kept in position by a belt or appliance, the out- look is favorable. Sooner or later a movable kidney, which begins to degenerate, profoundly alters general nutrition often producing a condition of melancholia or neurasthenia. The gastrointestinal symptoms progress until the mechanical cause is removed. Nephropexy is advised where there is pain in the kidney region, Dietl’s crises or urinary disturbance, and in fifty per cent, of cases is attended with good results. The operative mortality is less than one per cent. When it has been un- successful and the symptoms are severe and progressive, nephrectomy is justified. Exstrophy of the bladder is commoner in males and usually consists in the absence of the anterior wall. It is often as- sociated with bilateral inguinal hernia, rudimentary prostate and ectopic testicles. The seminal vesicles are either absent or atrophied. The great danger in such a condition is an as- cending infection to the kidneys, and patients exhibiting this deformity are of poor physical development in other respects and often perish before attaining middle life. In the male there is sterility and in the female, while pregnancy may occur, it is beset with many difficulties. Such abnormalities are difficult to cure and the prognosis is always guarded. Diverticula of the bladder presents a poor prognosis unless they are small enough for radical excision. Infection, which is dif- ficult to eradicate plays the chief role and septic absorption renders the patient a chronic invalid. Improper descension and ectopy of the testicle predisposes to malignant degeneration. Hernia and inflammation are also associated. Abdominal cryptorchidism is difficult to remedy 350 DISEASES OF THE MALE GENITOURINARY TRACT. and it is a question whether anything should be attempted except possibly repair of a hernia if it is present. The tes- ticle is better off in the abdominal cavity, even though it may undergo degeneration, than it is in the inguinal canal or pos- sibly removed. In inguinal cryptorchidism, the gland is either brought down into scrotum and anchored there or else re- moved. This is best done before puberty. The testicle which has remained undescended usually atrophies, but may increase greatly in size to normal after operation. Hypospadias and epispadias produce no symptoms nor cause any discomfort if they are confined to the glans, but more proximal than this may be of serious inconvenience to the pa- tient, although not affecting the general health. Procreation is usually impossible and even urination may greatly incon- venience the patient. The operative cure of these cases is difficult and can only be obtained after a series of operations extended at times over many months. HYDROCELE. Hydrocele is most common in infancy and old age. Acute hydrocele, due to inflammation, is associated with disease of the epididymis, as epididymitis, and is mainly seen in young adults. The symptoms are produced mainly by the disease which causes the hydrocele and the patient has to keep to his bed. Acute hydrocele usually undergoes resolution, or it may become chronic, constituting the usual form of hydrocele. Suppuration occasionally takes place. Chronic hydrocele is the ordinary type and is mostly a dis- ease of old age. the average being sixty-seven years. The right and left sides are affected about equally, and in about thirty-three per cent, of cases is bilateral. While mostly as- sociated with inflammatory disease of the epididymis and testicle the etiology is not definitely known. The important feature of the diagnosis is the translucency to light, which may be lacking due to a chronically thickened wall. We have observed such a case in which no light was transmitted, the walls of the sac being about one-half inch thick. Spontaneous cure may take place in infants, but is very rare in adults. Hydrocele in itself is not dangerous to life, but it VARICOCELE. 351 encourages the development of hernia and may lead to tes- ticular atrophy and occasionally suppurates. It may rupture into the tissues of the scrotum as a result of traumatism. By its presence and size it may render a man unfit for work be- sides producing a tumor in a region that is rather difficult of concealment. Simple tapping may produce a cure especially in infants and the inflammatory variety. In the chronic hydrocele there is mostly a reaccumulation of fluid, which may be removed from time to time as indicated by distention. The radical operation is usually advised and permanent cure is usually attained. VARICOCELE. Varicocele is most common in young adults, being most fre- quent from the fifteenth to twenty-fifth year, it is rare in in- fancy and in old age is usually a moderate development and causes little inconvenience. A moderate degree of varicocele is said to exist in about ten per cent, of male subjects, a marked degree is much less frequent. In about ninety-seven per cent, of cases the left side is affected, while the right is only affected in about three per cent, of cases. Bilateral cases exist in about two per cent. In most cases varicocele tends to improve and eventually disappears spontaneously and it is very rare in old age. Ob- served in young men subject to prolonged and ungratified sex- ual excitement it is usually cured by marriage, or, at least, it ceases to give trouble thereafter. If moderate in degree it has no marked tendency to increase, causes little pain and does not appreciably alter the nutrition of the testicle. Only when varicocele is so pronounced that circulation is materially in- terfered with does atrophy of the testicle result. In poorly nourished individuals and those given to mental anxiety, ach- ing pains are frequent and the condition assumes an exag- gerated importance and hypochondriasis may develop. Where palliative measures of cold douches, suspensory, etc., do not relieve the patient, radical operation is indicated and in a majority of cases no further trouble is experienced after the operation. 352 DISEASES OF THE MALE GENITOURINARY TRACT. SYPHILIS. There is no disease which has a greater tendency to hasten middle life, bring on premature old age and early death than syphilis. The importance of syphilis to life insurance risks has demanded in recent years additional consideration. This has arisen by virtue of the discovery of the Treponema pal- lidum and the advent of the Wassermann reaction, whereby further evidence substantiates the recognition of syphilis as the cause of paresis, tabes, and aneurism, and one of the chief factors in other types of arterial and cardiac disease, particu- larly in patients under fifty years of age. The studies of para- syphilis and the so-called luetic sequelae have clearly shown that these are misnomers, and that in truth we have to deal with a definite syphilitic process in the lesions of which living treponemata can be demonstrated. The incidence of syphilis has been estimated by various observers, but can not be determined accurately. The result obtained from the Wassermann reactions of a certain group of cases is not reliable for the population as a whole. Various figures from Germany would indicate that about twenty per cent, of the adult population are infected. Fournier estimated that fifteen per cent, of the adult population of Paris have syphilis. In the United States, the findings have been from twelve to twenty per cent, among the insane, and in a gen- eral hospital from ten to twenty per cent, of all patients ex- hibit signs of the disease. It has been estimated that the per- centage for the negro race is about twice that of the white race, but the female is infected in the same proportion as the male, while in the white race men are infected about three times as frequently as women. Conservative estimates would place the number of syphilitic individuals in the United States as five to eight millions. The autopsy findings are at variance with these figures. Symmers found from a study of gross anatomy in 4880 autop- sies performed at Bellevue Hospital, six and five-tenths per cent, showed evidence of syphilis. Warthin, pointing out that the gross anatomic study as done at the autopsy table is not enough to establish a diagnosis of syphilis in the majority of cases, found evidence of syphilis in three hundred cases in SYPHILIS. 353 seven hundred and fifty autopsies. According to Graves, post-mortem Wassermann reactions confirm the ante-mortem report in nine per cent, of cases. Our conception of syphilis in relation to middle age is two- fold : The morbidity and mortality of syphilis incident to deep seated visceral disease speedily threatening the life of the in- dividual, and the influence on vital resistance predisposing the victim to the acquisition of all other diseases, notably tuber- culosis. The mortality charts of the large life insurance com- panies give reliable data. Most of the large companies will not issue a policy to an individual, who admits he has had syphilis. In thousands of deaths among insured lives, the minimum death rate due to syphilis is five and two-tenths per cent.; the maximum being fifteen per cent. (Tiselius, Solomonsen, Blaschko, Kleinschmidt, Runeberg, Weber, Bramwell, Andry). Thus syphilis ranks higher than pneu- monia as a cause of death and stands second only to tuber- culosis. Kleinschmidt finds the average age at death of syphilitic policy holders to be forty-five years, the average duration of insurance to be ten to fifteen years, and the aver- age length of time between infection and death to be twenty- one and five-tenths years. This with non-syphilitic policy holders shows a decrease in longevity of three and five-tenths years, and in duration of insurance of approximately one and five-tenths years. Gollmer estimates that the average extra mortality among syphilitics is sixty-eight per cent, over other insured men at all ages. This series was made up almost exclusively of diseases of the central nervous sys- tem, the heart, the vessels, and the kidneys. Five thousand, three hundred and eighty-five policy holders in American in- surance companies, admitting syphilitics, showed a death rate of thirty-three and three-tenths per cent, above the expecta- tion. It will be borne in mind that the mortality is, further- more, powerfully influenced by age, climate, race, alcohol and most of all by treatment. In addition to the number of deaths that directly result from this infection, syphilitic women do not bear the number of living children they otherwise would. Many miscarriages are directly traceable to syphilis, as are many deaths among the newborn. 354 DISEASES OF THE MALE GENITOURINARY TRACT. It has been estimated that the total economic loss is nearly half a billion dollars a year to the United States alone (Hazen). In addition to this financial loss there is an im- mense amount of suffering, both among the innocent and guilty, many separations in families and losses in many other ways. Pathology. Syphilis is caused by a specific motile organism, the Treponema pallidum, discovered by Schaudinn in 1905 and quickly confirmed by Hoffman and Metchnikoff. In the acquired form the initial lesion is upon the genitals in ninety- four per cent, of cases, the infection being the result of sexual intercourse. The remaining six per cent., are classified as extragenital and occur most frequently on the lips, tongue, breast, tonsils, hands, etc., and while the infection may be contracted innocently—so-called, yet it may result from per- verted sexual habits. The incubation period is generally regarded as twenty-one days—although some observers claim that it is nearer four weeks. The primary lesion is called a chancre and may be multiple in from ten to fifteen per cent., but is usually described as a single sore. The commonest site in the male is the coronal sulcus. In the female Fournier reports the following distri- bution of chancre: Location Cases Greater lips 114 Lesser lips 55 Fourchette 38 Cervix 13 Introitus vaginae 9 Urinary meatus 17 Superior vulvar commissure 2 Vagina 1 Several clinical types of chancre have been described such as erosive,' ulcerative and papular, all having certain char- acteristics in common. They are usually painless, in- durated, ulcerated, and exude a serous fluid. In size they vary from three millimeters to nearly two centimeters in di- ameter. A chancre may be absolutely atypical and last but a day or two and the patient not be aware of it, and again it may persist until after the appearance of secondary lesions. A point SYPHILIS. 355 that can not be too strongly emphasized is that all genital sores are regarded as potential chancres until proved other- wise. There is usually a bilateral inguinal adenitis, which does not suppurate. A mixed infection may be present, i.e., chancre and chancroid and the diagnosis of chancroid does not neces- sarily rule out the diagnosis of chancre. The diagnosis of chancre is made first from the history, second from the clinical findings, and third and most important from the laboratory findings. The indurated sores located at the coronal sulcus or at either side of the frenum, which produces a characteristic “flop” when the foreskin is retracted, or which produce an irretractable phimosis and bilateral in- guinal adenitis, do not escape diagnosis by the trained ob- server, but the atypical ones can only be diagnosed by the lab- oratory aids. The dark field illuminator reigns supreme for this diagnosis and the practitioner who fails to have all sus- picious lesions examined by this method is guilty of moral malpractice. The sore should be carefully cleansed with nor- mal salt solution, and in those cases where some local caustic has been applied, a continuous wet salt solution dressing should be applied. Some of the serous fluid is expressed from the ulcer and drawn up in a papillary pipette, care being taken to exclude the blood. This examination if carefully performed should yield ninety-five to one hundred per cent, positive findings in untreated chancre. The findings are less con- stant as the duration of the lesion increases. In suspected cases, the examination should be repeated on successive days, especially in those cases where caustics have been employed. The finding of a single Treponema pallidum is pathogno- monic. Puncture of the inguinal lymph nodes and demonstration of Treponema pallidum by the dark field has been employed in those cases where the use of caustics has rendered the direct examination negative. It is well known that the application of various antiseptics and mercurials such as calomel powder and ointment, blue stone, etc., destroy the treponemata on the surface and render the dark field examination negative until they have been re- moved several days. In an attempt to make the diagnosis as early as possible, Baeslack and Keane suggested that tre- 356 DISEASES OF THE MALE GENITOURINARY TRACT. ponema could be demonstrated by culture. Our findings would indicate that while the method is easy to employ, the patients resent a section being taken and the low percentage of positive results make the procedure of questionable value. The patient’s blood should be subjected to the Wassermann reaction—even should the diagnosis of chancre be established by the dark field, because a negative reaction should offer a better prognosis. The Wassermann results in the initial stage of syphilis as given by Craig are as follows: Week after appearance Total number Total positive Per cent. of chancre examined reactions positive First 65 10 27.6 Second 122 62 50.8 Third 123 79 64.2 Fourth 134 98 73.1 Fifth 39 31 79.4 Thus it will be seen there is a gradually increasing curve up to the sixth week, or advent of the secondary lesions, when the Wassermann reaction should be one hundred per cent, posi- tive. Therefore, passively to await the advent of secon- daries to confirm the diagnosis should be sufficient ground for a suit for malpractice. A reliable laboratory should be picked out for the perfor- mance of the Wassermann reaction—preferably one connected with a hospital. A trained worker, who is given neither to fads nor short cuts nor modifications, is indispensable. The experienced clinician will desire to know what method is em- ployed and what antigens are used, for some are more sensi- tive than others and may be therefore liable to false positives. We believe it is better to miss an occasional case of syphilis with a not too-sensitive antigen, rather than one that is liable to give false positives and thereby brand an innocent indi- vidual as a syphilitic. Treatment. Syphilis from its conception is a constitutional or tissue disease and the treatment should be given as early as possible. The sheet anchor in the treatment of syphilis is no longer mercury, but arsphenamin or its substitutes. It is of paramount importance, however, that the injections of ar- sphenamin in the beginning be administered as early as pos- sible and intensively in full doses commensurate with the phy- SYPHILIS. 357 siological tolerance of the patient, not scattered indefinitely over months, interspersed here and there with a Wassermann test. In view of the possibility of immediate cure by this drug, properly administered in the primary if not in the secondary and latent stages of the disease, the treatment of syphilis, par- ticularly in the chancre period, prior to the advent of a positive Wassermann, becomes an emergency operation in many in- stances, no less imperative than appendectomy. Our experi- ence dictates as a reliable routine in the chancre stage, before the Wassermann becomes positive, to give a series of from four to six injections of full size dosage if the patient’s condition warrants, once a week or every five days. If the serological test is positive the full size injections are given in weekly in- tervals for six weeks and then a rest period for three weeks followed by a Wassermann test. If this be positive another series is given until it becomes negative. The patient is then advised to have the test repeated every three months the first year, every six months the second year, and yearly thereafter. An individual whose blood has been positive is advised to have a spinal puncture and the spinal fluid subjected to all the rou- tine examinations after the blood becomes negative. The patient should have a careful physical examination be- fore the administration of intravenous medication and the urine examined before and after each injection. Mercury in one of its various forms is used by many, in conjunction with the arsphenamin treatment, but we rarely employ it in the primary stage. In the later stages it is most useful, but in the primary stage the patient has all he can handle with the full size injection once a week. After the course of arsphenamin injections, mercury should be pushed to the physiological limit and the patient kept on it steadily with rest periods for a year. After that it is advised in a six weeks course every fall and spring. There is no advantage in giving the iodides in the primary stage. Owing to the fact that the organisms have already spread beyond the initial lesion as soon as it makes its appearance, there is no advantage in excising the chancre as has been ad- vocated. Local treatment should consist in the application of a dusting powder of calomel, with due precautions against the disease spreading further. 358 DISEASES OF THE MALE GENITOURINARY TRACT. Except in the early stages of syphilis, there is no assurance that treatment effects an absolute cure; it may simply render the disease latent. Clinical and serological cures may not be cures at all, as shown by Warthin and others in demonstrating the treponemata at autopsy in the heart and vascular walls of supposedly cured syphilitics. The fate of the syphilitic is di- rectly dependent upon the earliness of the diagnosis and the in- tensity of treatment during the first few weeks or months of the infection. If after two years the Wassermann is negative and there have been no symptoms, the patient is regarded as clinically cured, but this is by no means an absolute proof that the disease is eradicated. The growing list of reinfections fol- lowing intensive treatment is the best indication that some of the cases must be cured. We recently observed a reinfection within four months. A syphilitic is not permitted to marry until the Wassermann reaction has been continuously negative for two years with no symptoms. In spite of all the propaganda for an early diagnosis, we see but a small percentage of patients in the primary stage, and this is because the patient often attempts to treat himself, assisted by the corner drug store or quack remedy, and too often because the physician either does not have the means at his disposal to make an early diagnosis or rests content until the Wassermann becomes positive or secondaries appear. It is difficult to impress upon the patient the seriousness of the disease and get full cooperation for a longer period than he has actual subjective symptoms. In an analysis of over five hundred cases, we found that only five per cent, re- turned until they were declared cured. The social service department forms a valuable adjunct in treating these cases in the hospital and while private patients are supposed to have enough intelligence to heed advice, too often it is not the case. CHANCROID. Chancroid has been variously named soft chancre, simple chancre, and non-infecting sore, and is a contagious venereal ulcer. In certain localities and in hospital practice especially, chancroids are more frequently encountered than chancres, but CHANCROID. 359 among private patients, whose personal hygiene is better, chancres are more common. Infection may occur at any age but is most common in the decades when promiscuous sexual intercourse is practiced. There is no distinct period of incubation, being between three and five days or longer. The infecting organism is known as the bacillus of Ducrey. The lesions are inflamma- tory and destructive in type and frequently accompanied by a unilateral suppurating bubo. It is a local and not a con- stitutional disease. The chancroid may be located upon any mucous or cutaneous surface about the genitalia. Extragenital chancroid is much less common than extragenital chancre. The shape of the lesion depends to a large extent upon the shape of the eroded surface through which the inoculation takes place. The treatment is cleanliness and antiseptic washes. Cry- stals of argyrol have proven of value in the mild cases. In the rapidly destructive or phagedenic type, the ulcer is painted with a solution of cocaine 10 per cent., followed by 25 per cent, solution of cupric sulphate freely applied and the Oudin current applied through the vacuum electrode till the whole surface is turned a dark gray green. It is of the utmost impor- tance that the current be carried to the deepest crypts of the ulcer and beneath the overhanging edges, otherwise the treat- ment fails. Usually within two days chancroids so treated are converted into clear granulating ulcers. The prognosis is therefore good and unless the destructive area has been considerable, the patient suffers no aftermath. The great danger is that the lesion may be a mixed infec- tion—both chancroid and chancre and the chancre may be overlooked until secondary lesions appear. The dictum that all genital sores should be regarded as chancres until proved otherwise should be strictly observed. Weekly blood examina- tions should be made until the period of incubation for syphi- lis has passed beyond the secondary stage. Gynaecology BY F. A. L. LOCKHART, M.B., C.M. (Edin.), M.D. Clinical Professor of Gynaecology, McGill University; Formerly Professor of Surgical Gynaecology, University of Vermont; Gynaecologist to the Montreal General Hospital and to the Protestant Hospital for the Insane, Verdun. Gynaecology. What is “middle age” in the female? From the standpoint of the gynaecologist, the female ceases to be a woman at the age of forty-five, or thereabouts. A man of that age is in the prime of life and does not begin to be really old for another ten years. With woman, it is different. The male may, and often does, procreate until he reaches sixty-five or seventy but his consort may be said to cease to be fertile by her forty-fifth year, and so must then be classed, physio- logically, as an old woman. In this article, however, she will be given the full benefit and the diseases of the female generative organs most frequently met with between the ages of thirty-five and forty-five will be dealt with. MENOPAUSE. The period of transition from active sexual life to physio- logical old age in woman is variously termed the “Meno- pause,” “Climacteric” or “Change of Life” and includes the time between the beginning of menstrual irregularity to her complete restoration to health. The age at which this occurs depends upon various factors, such as the physiological ac- tivity of the sexual organs, climate, the woman’s general health, neuropathic influences and heredity, daughters fre- quently following in the footsteps of their mothers. The writer knows of one case where four sisters married and had families, yet in each case the menopause was fully es- tablished at the age of thirty. In temperate climates, the woman begins to have symptoms of the change in her forty- second or forty-third year and the process is completed in between two and three years, but when menstruation begins early, thus giving evidence of hyper-activity of the sexual organs, it may not terminate until the fiftieth year of age, or even later. Menstrual life is also prolonged in married women who have borne a moderate number of children, and 364 GYNAECOLOGY. in certain diseased conditions of the uterus or appendages. The duration of the symptoms varies from one to four or five years and their intensity is by no means uniform, a menopause induced by operation, i.e., removal of the appen- dages, being shorter and more violent than one which comes on naturally. Causes. The normal menopause is produced by the re- moval of the influence of the internal secretion of the ovaries. That this period is not always accompanied or preceded by cessation of ovulation is proved by the fact that very occa- sionally pregnancy occurs months after the apparent con- clusion of the climacteric changes. Pathologically, the menopause may be caused by the re- moval of the appendages, although this is not always followed by the immediate cessation of menstruation, by shock, ner- vous strain, neuropathic changes in the central nervous system or acute or exhausting diseases, such as typhoid fever or tuberculosis. Symptoms. These vary in intensity and variety with the cause and with the individuality of the woman. Normally, the amount of the flow becomes less and less and the inter- vals between the periods increase in length until finally nothing more is seen. Even a pre-existing leucorrhoeal dis- charge tends to lessen or even disappear. In some instances, the menopause is ushered in by more or less profuse haemor- rhages from the uterus, either during or between the periods. These must be thoroughly investigated, owing to the lia- bility of women of this age to cancer. This is most im- portant to remember as many women are condemned to an early and painful death through failure to distinguish the existence of this dread malady. Every menstrual irregu- larity, during the menopause, must be carefully considered and cancer excluded before deciding upon any line of treat- ment. At the same time, the woman suffers from vaso- motor disturbances, evidenced by sudden rushes of blood to the head, causing temporary redness of the face, the so- called “hot flushes,” followed by a chilly sensation, as the blood recedes to the internal organs. These gradually be- come less and less until they finally cease. Few escape as easily as this, however, especially when caused by abnormal MENOPAUSE. 365 circumstances or conditions, as after double oophorectomy during active sexual life. In addition to these flushes, the woman may have vicarious menstrual discharge from the nose, lungs, bowels or kidneys, which fact should be bourne in mind when called upon to treat hsematuria in women who have reached the menopausal age. The lungs are apt to be congested, causing a form of bronchitis. Catarrh of the bowels or stomach may be seen. Many women at this time are especially prone to headache, and in some cases the mind is actually affected, either permanently or temporarily. Most women become more melancholic or morose than normally. An excessive deposit of adipose tissue in the omentum and abdominal walls is usually observed, frequently causing the patient to complain of pain in the back, due to excessive weight of the abdominal wall, and an increase in the amount of hair on the face may be seen. Occasionally, the voice assumes a more or less masculine type. An abnormal sexual desire is sometimes experienced by women just previous to or during the menopause, as if the ovaries realised that their time was short and were making a last effort to produce another pregnancy. Treatment. This may be preventive or palliative, but is chiefly the latter. In performing hysterectomy for fibroid tumours of the uterus, one or both ovaries should be left if possible. When this is not advisable and they have to be removed with the growth, one may be implanted in the broad ligament, splitting this and embedding the ovary between the layers, or it may be placed in the substance of one of the recti muscles. The latter situation is preferable, as the organ is better nourished and therefore retains its activity longer. Ovaries so treated may live for some years and favour the occurrence of a normal menopause. A. G. Hulett (Medical Record, Aug., 1921), after a double oophorectomy, gives five grains of ovarian substance four times daily for one month, beginning the treatment five days after operation. During the second and third months, he gives a similar dose three times a day. In the next three months, three grains three times a day are administered and in the seventh and eighth months, the woman receives three grains twice daily. During the ninth month, the dose is 366 GYNAECOLOGY. lessened to two grains twice a day. In the tenth month, the dose is two grains each night, in the eleventh it is two grains every alternate night and for the final, twelfth, month the patient is given two grains every fourth night. By this means, he hopes to lessen the woman’s liability to disagree- able symptoms by the gradual reduction of the amount of the ovarian hormone in the blood. Others are satisfied to allow the flushes and other symptoms to appear and to keep them in check by the administration of five grains of ovarian extract, or substance, alone or combined with the extract of the pituitary or thyroid glands. It is seldom that the exhibi- tion of five grains of “Varium” thrice daily for a few days will not cause the cessation of the symptoms each time that they occur, until they finally disappear. A similar course of treatment will be found to be beneficial during a normal menopause. In addition to the above, the general health of the patient will require attention. Nerve tonics will be found useful. The woman ought to have as much fresh air as possible and it is well to advise change of scene and surroundings. Her diet ought to be of a plain but nourishing description and alcohol should be used sparingly. Every efifort should be made to render the patient’s life as smooth and free from worry as possible during this critical period as her happiness and utility during the remainder of her life are largely de- pendent upon the successful weathering of the storms of the menopause. HAEMORRHAGE. Haemorrhage is only a symptom but is one of such im- portance as to deserve a chapter to itself. Ordinarily, a woman during the period of sexual activity, has a discharge of blood from the uterus every twenty-eight days. This is physiological and its absence, except during pregnancy, is abnormal. There are, however, various pathological con- ditions giving rise to genital haemorrhage which call for special and careful study, as the time of the appearance of the flow, its manner of appearance and the character of the blood lost will be of material value in coming to a decision as to the malady from which the patient is suffering. HEMORRHAGE. 367 A woman who has given birth to many children will fre- quently have a varicose condition of the veins of the vagina or vulva. These may rupture spontaneously or be lacerated by trauma, causing more or less loss of blood.* Inspection of the genitalia will reveal the source of the bleeding, which may be checked by pressure of a pad and bandage or it may be necessary to ligate the vessel. Laceration of the cervix or perineum during labour not infrequently occurs and is characterised by a sudden flow of bright red blood but the vessels soon contract sufficiently to allow of clotting and thrombosis of the blood with a con- sequent cessation of the bleeding. Inspection of the cervix and perineum will expose the bleeding points which may require to be closed by ligature or stitch. When the patient is pregnant, a low implantation of the placenta will produce a flow of blood by separation from the uterine wall. This haemorrhage is slight and intermittent until the later stages when it may be so profuse as to en- danger the woman’s life. In case of slight bleeding every effort should be made to check it and to carry the woman along until, at least, there is a chance of her giving birth to a living child. This may be done by absolute rest in bed on a comparatively low diet together with the use of some sedative to steady the circulation. One of the best drugs for this purpose is heroin, giving it in doses of %0 grain hypodermically as required. Some use morphine but heroin is better as it has no deleterious effect upon the foetus. When the bleeding occurs at full term, and is very profuse, the woman should be delivered at once by perforating the mem- branes, or even the placenta, turning the child and bringing down one leg to plug the cervical canal and produce pressure on the bleeding vessels. Accouchement forcee, with com- plete and rapid emptying of the uterus will be required at times, owing to the severity of the haemorrhage. Carcinoma of the uterus, either of cervix or fundus, causes uterine haemorrhage. In this case, the bleeding is caused by erosion of the vessel wall, consequently the blood appears suddenly and is bright red in colour. It continues until the whole calibre of the vessel wall has been destroyed, at which time the coats of the vessel contract and close the opening 368 GYN/ECOLOGY. so that the haemorrhage is arrested. Sooner or later this haemorrhagic discharge assumes an extremely offensive odour. The sudden onset and cessation and the bright colour of the blood help to distinguish this form of haemorrhage from some of the others. An altogether different picture is seen in bleeding caused by a sub-mucous fibroid. In this case, the bleeding is caused by the increased congestion of the endometrium, therefore it first appears as an augmentation of the ordinary menstrual flow, coming on and ceasing gradually, and the blood is dark red in colour. Only in very exceptional circumstances does this discharge become foul, although it not infrequently has a heavy odour but not in the least comparable to that of car- cinoma. Chronic metritis or endometritis is often the cause of uterine bleeding, usually in the form of menorrhagcea. The blood is dark and tends to clot. Local examination reveals a hard cervix with an enlarged, hard fundus. Certain diseases of the appendages, such as ovarian tu- mours or inflammation, especially if acute, may be accom- panied by haemorrhage, in which case, the history of the patient and the result of the local examination will at once show the cause. Extra-uterine gestation before rupture of the sac, fre- quently gives rise to a form of uterine haemorrhage which is almost typical. The bleeding appears, either with or without previous amenorrhoea, as a slight stain or small flow and this continues each day in such small amount that the woman often complains of it as a “dribbling.” Where this condition is present, there will be a steady pain in the affected side, this pain gradually but steadily increasing in severity. Disease of the heart, kidneys or liver must be excluded, as any obstruction to the circulation tends to engorgement of the endometrium with a consequent discharge of blood from the uterus. Most of the above conditions will be con- sidered under the various headings but one cannot be too insistent upon the absolute necessity of making a diagnosis by careful local examination in all cases of uterine bleeding. PRURITUS VULV7E, 369 PRURITUS VULV^E Irritation or itching of the external genitalia is likewise but a local manifestation that some pathological condition is present and its etiology is at times difficult to discover. An abnormal condition of the blood may produce intense irritation of the vulva, as where it contains an excess of bile, sugar or uric acid or some drug, as for example alcohol, iodin, cantharides or any opium preparation. Anything causing congestion of the vulva will cause it, pruritus oc- curring not infrequently in pregnancy, displacements of the uterus or tumours of that organ. Just as elsewhere in the body, skin diseases may set up itching, or abnormal dis- charges from the vagina or uterus, as in carcinoma. An extremely common cause is the presence of parasites, as pediculi, or want of ordinary cleanliness. Pruritus is more troublesome during the night or while menstruating, due to stagnation of the circulation and in- creased warmth of the parts. Examination of the genitals locally will reveal the cause in those cases due to want of cleanliness, irritating uterine discharges or pediculi. The skin will usually be red and hypersemic, due partly to the disease and increased by scratching. It may even be actually broken down in places. In other women, nothing at all is to be observed, in which case it will be found to be purely a nervous manifestation and examination of particles of skin under the microscope will show the sensory nerve terminals to be increased in number and size. The treatment will depend upon the cause which should be carefully sought, but even where due to some systemic disturbance local attention is necessary for the patient’s com- fort. The latter object is sought by directing the woman to practise scrupulous cleanliness, washing the parts with warm water and pure castile soap or with pure olive oil, omitting the water entirely. Various sedative lotions or ointments may be tried. There is no specific, but one drug after another must be tried until some combination is found which will relieve a given case. At times, simply bathing the parts with a solution of boracic acid, one drachm to the 370 GYN /ECOLOGY. quart of warm water, drying the area gently with absorbent cotton or soft linen and then covering it with dry boracic powder will give great relief, keeping the labia separated by a thin pad of absorbent cotton. This treatment ought to be repeated every time the woman passes water, so as to remove every trace of urine, even when this is not the causative factor in the case. At other times, replacing the boric solution with one of carbolic acid, one in forty or even one in twenty, will be better, the carbolic having an anaesthetic action on the skin. When the parts are moist, they must be kept dry and either some dry powder or ole- agineous preparation be applied. A numbing of the tissues may be produced by either intense heat or cold, by means of hot cloths or an ice-bag or an evaporating lead lotion, the effect of the latter being enhanced by the addition of tinct: opii to the solution or on the cloths. Painting the surface with silver nitrate, 20 or 30 grains to each ounce, sometimes gives relief, or tinct: iodi may be used instead. In very severe cases, it may be necessary to employ an ointment of cocaine of a strength of twenty per cent. Again, a mixture of black wash and bismuth will be useful as a local appli- cation. However, almost the whole pharmacopoeia has been tried with varying success and the cause simply must be found and treated. Where there is an irritating uterine discharge, vaginal douches either of plain sterile water or some mild antiseptic will be beneficial. If formaline is used, however, it must not be stronger than 1 : 5000, as it is very irritating to many mucous membranes. When of nervous origin, Faradism, X-rays, etc., may be tried or, in very obstinate cases, com- plete excision of the affected skin or mucous membrane will be required, cutting wide of the diseased tissues. ESTHIOMENE. Esthiomene is a condition of the vulva of undoubted syphi- litic origin, the Wassermann test giving a positive reaction in almost every case. It is occasionally spoken of as a “rodent ulcer” but it cannot be said to be a true malignant form of disease, nor has the tubercle bacillus ever been TUBERCULOSIS VULWE. 371 demonstrated in any of the cases examined for that organism. The disease is rare and is usually seen in prostitutes, or, at all events, in people of low vitality. In the early stages, nodules form in the vulvar tissues. These enlarge and the tissues between them break down, forming ulcerated patches, which, in turn, give rise to fistul- ous tracts burrowing and running through the tissues, which may be actually honey-combed with them. The disease may be present for a considerable time before giving rise to symp- toms sufficiently marked to induce the woman to seek advice. When they do occur, the patient complains of an itching or burning and, sometimes, of actual pain. The inguinal glands frequently become enlarged and painful due to an extension of the disease. For treatment, the first essential is to keep the parts as clean as possible and they should be dusted with a mercurial powder or anointed with an ointment containing the same drug. In addition, the ordinary anti-luetic treatment should be followed. It may be necessary to remove the diseased vulva by operative measures but usually the above will suf- fice to effect a cure. The prognosis is, as a rule, favorable, but death does now and then occur from exhaustion brought about by the dis- charges. TUBERCULOSIS VULWE. Tuberculosis may affect the vulva, just as other parts of the body, but is very rare and almost never primary, there usually being lesions elsewhere, as in the lungs. Any part of the external genitals may be attacked, it first appearing as small, hard, multiple nodules, which ultimately break down and form ulcers with hard serpiginous margins and which spread very slowly. The surface is of a yellowish- red colour and emits a thin, pustular discharge. The growth bleeds on slight irritation. (Fig. 1.) While the tuberculous process may affect the very young, it is more apt to attack those of more mature years, the women being usually between twenty-five and forty years of age. 372 GYNAECOLOGY. In treating this condition, one should attempt to improve the victim’s general health, just as is done in tuberculosis of any other part. In mild cases, the local application of iodoform powder or ointment will improve the condition. X-rays and radium have been used with benefit but complete excision of the affected areas will usually be required. Fig. 1.—Tuberculosis of urethra. (Private collection.) TUMOURS OF THE VULVA. With the exception of cysts, tumour formation of the vulva is extremely rare, but one does find Elephantiasis, Fibroids, Sarcomata, Cysts, and Carcinomata. In addition, prominence of the labia may be caused by a descent of bowel or omentum, or even an ovary, through the inguinal canal. Elephantiasis. This is a swelling of the labium caused either by syphilis or infection by the filaria sanguinis, and is much more common in the tropics than in colder countries. It consists of an oedema and hypertrophy of the tissues. TUMOURS OF THE VULVA. 373 Uncleanliness favours the occurrence of the disease and it may follow, or be accompanied by, an attack of erysipelas. Any symptoms to which it gives rise are due chiefly to mechanical irritation and walking and sexual intercourse are interfered with by the presence of the mass of hardened tissue suspended between the legs. On inspection, the diseased parts will be seen to be en- Fig. 2.—Melanotic sarcoma of clitoris. (Private collection.) larged, and pigmented with, at times, actual excoriations. An offensive discharge of a serous nature may be present. The treatment is extremely unsatisfactory unless the dis- ease is confined to the actual labia, majora or minora, in which case wide excision is indicated. Fibroma. This growth is rare and chiefly affects the labia majora, its structure being similar to fibroids in other parts of the body. The only symptoms are those caused by the discomfort produced by the presence of a mass in the vulva, the treatment being removal. Sarcoma. This is the rarest form of tumour of the vulva and usually attacks the labia majora but may occur in any 374 GYNAECOLOGY. of the parts around the vaginal orifice. The only case seen by the author was one of the melanotic variety affecting the clitoris. It first appears as a hard nodule but increases in size very rapidly. The prognosis is extremely bad, death usually resulting in a short time from the occurrence of metastases in other parts of the body. If seen in time, com- plete and wide excision is to be carried out. An absolute diagnosis can only be made by the microscope but where at all suspicious as to the nature of a vulvar growth it is better to remove it at once. (Fig. 2.) Cysts. Cystic formation in the vulva is due either to blocking of the duct of a sebaceous gland or of the gland of Bartholini or else to a congenital condition. A labial cyst may be mistaken for a soft myomatous tu- mour, a lipoma or an hernia. A diagnosis between the cyst and the two former conditions is usually readily made by the tense condition of the cyst with its clearly defined walls, while the hernia has the usual signs of that condition, viz., an impulse on coughing and the extension of the neck up into the inguinal canal. If an ovary forms the body of the hernia, pressure will give rise to the sickening pain one produces by pressure upon that structure per vaginam. The only treatment is excision, and in the removal every care should be made not to rupture the cyst during the operation as none of the wall ought to be left. These cysts, especially of the Bartholinian gland, are very prone to become infected, in which case they present all the signs and symptoms of an abscess, which should be treated by incision and drainage just as elsewhere. Carcinoma. Cancer of the vulva is really a disease more of old than middle age, most cases being seen in women between sixty and seventy years of age, but it does occa- sionally occur in those who are younger. When primary, it is of the squamous variety, but it may spread downwards from the cervix, in which case it may be of the glandular type. It affects the sulcus between the two labia or else around the orifice of the urethra, appearing first as a small hard nodule, which ultimately breaks down and ulcerates, the surface of these ulcerations being granular and bleeding TUMOURS OF THE VULVA. 375 easily on irritation. On account of the close apposition of the two labia, it not infrequently happens that a secondary growth is set up by contact. The patient will first complain of itching of the affected region but this becomes infected when the surface breaks down and then there is constant pain. At first there is a serous discharge which soon becomes tinged with blood and before very long is very malodorous. When the disease has become definitely established, it will not be long before the usual cachexia and anaemia are observed. When seen early, complete removal of the growth, to- gether with a wide collar of healthy tissue, may effect a cure and the prognosis is rendered more favourable by the sub- sequent use of radium. If there is any enlargement of the inguinal glands they ought to be removed at the same time as the actual external disease. In the later stages, radium or the X-rays will sometimes improve the condition temporarily but will not cure it. When no operation is indicated, on account of extension of the disease, the application of a strong solution of iodine every second day for three or four treatments will clean up the parts and tend to check both the discharge and haemorrhage. INJURIES FROM CHILD-BIRTH. The passage of the full term foetus down from the uterus through the cervix and vagina to the exterior is very liable to occasion certain injuries to the walls of the canals through which it descends. Even the uterus itself is not exempt from injury where there is a disproportion between the size of child and of the bony pelvis, so that one may have a ruptured uterus or a laceration of the vagina, cervix or perineum. Rupture of the uterus during delivery belongs more to obstetrics than to gynaecology. It is caused most often by meddlesome midwifery, as by efforts at too speedy delivery before the external os is fully dilated or to rough and care- less manipulation with the hand in utero in trying to turn the foetus. It may, however, be caused by the efforts of a thin walled uterus to drive the foetus through a canal which is too small. 376 GYNAECOLOGY. When this condition occurs, the patient will complain of a sudden, sharp pain, followed by a cessation of uterine con- tractions and recession of the head from the pelvis. Palpa- tion of the abdomen will reveal the foetal parts lying im- mediately beneath the abdominal wall, and the woman will exhibit the usual signs and symptoms of shock. The only treatment is to open the abdomen immediately, stop the haemorrhage and deliver the foetus, tying and cut- ting the cord. If the laceration in the uterine wall is not extensive, it may be closed by interrupted sutures of catgut running through the whole thickness of the uterine wall, great care being taken to invert the edges of the peritoneal covering of the uterus. It is seldom that it is necessary to remove the uterus but the operator must be prepared to perform the major operation if required. Whatever is done must be done quickly and the patient placed in bed, with hot bottles or electric pads around her, as soon as possible. Laceration of the Cervix. The cervix is more or less torn in almost every delivery of a full term child. It may give way on one side only or right through from side to side. Now and then, there are several lacerations which radiate out from the canal, forming the “stellate laceration.” The symptoms of a torn cervix are pelvic pain and leucor- rhoea, although—where it is extensive—miscarriage or pre- mature labour may be caused by lack of support for the foetal membranes. The pain is caused by the inclusion in the cicatrix of some nerve filament, and is of the character of a dull ache in one or other iliac region. Absorption through the uterus, on account of the unhealthy condition produced by the irritation of the scar tissue, has been known to cause neuralgic pains in distant parts of the body. The leucorrhoea results from the chronic inflammation of the lin- ing of the cervix or uterus, also as a result of irritation. On making a local examination, the finger will feel the lacerations and the cervix will be felt to be enlarged and hard, while the mucosa covering it may be soft and velvety. When the cervix is exposed by means of a speculum, the actual tears will be seen and the cervical lips will probably be everted. The cervical mucosa is often seen to be red and inflamed and a glary discharge pours from the external os. INJURIES FROM CHILD-BIRTH. 377 Owing to the chronic inflammation of the whole tissues of the cervix, the openings of the Nabothian glands will have become obstructed, giving rise to small cysts which appear as pearly white nodules beneath the mucosa. With regard to treatment, if the laceration is small and there is but little evidence of inflammation, no treatment will be required unless it is a few applications of tincture iodi with the use of boro-glyceride tampons and hot douches. To be efficacious, this treatment must be administered three times a week, except during the menstrual periods, and the douches must be taken in the recumbent position. When at all extensive, however, especially if the woman is approach- ing the menopause, operation is indicated after a course of the above mentioned local treatment to reduce the conges- tion. The methods of repairing a laceration of the cervix are too well known to require any description here, but one cannot be too careful to avoid any diminution in the calibre of the cervical canal. For this reason, the sutures should pierce the cervical tissues at the junction of the mucosa lin- ing the cervix with the raw area formed by the removal of the scar tissue. In addition, it is well to wait until the com- pletion of the operation to give an intra-uterine douche and also to leave a narrow strip of gauze in the cervical canal for at least two days. Finally one must be careful to remove the whole of the scar tissue at the angle of the tear in order to cure the pelvic pain which is so often present in these cases. Lacerated Perineum. Perineal tears are practically always caused during the delivery of a full term child but, in very rare instances, have been known to result from a fall or a brutal assault. They are classified as Complete, where the whole perineum into the rectum is torn, or Incomplete when the laceration stops short of the bowel. The symptoms accompanying an incomplete tear are due more to the loss of support of neighboring structures than to the tear itself. As the chief support of the bladder and rectum have been removed, bulging of the wall of either the bladder or rectum, or both, down into the vagina is met with, the former being spoken of as “cystocele” and the latter as “rectocele.” In both conditions, the patient complains of 378 GYNAECOLOGY. the discomfort caused by the mechanical irritation produced by the prolapse of the vaginal walls. In addition, in cysto- cele, the patient’s inability to completely empty the bladder produces a constant desire to micturate and favours the occurrence of infection with a consequent cystitis. At times, the dragging on the orifice of the urethra prevents control, thus allowing the urine to constantly dribble away, keeping the woman wet and uncomfortable. Rectocele produces a similar effect, in that the patient is often unable to com- pletely empty the rectum without supporting its walls by pressure through the vagina. If the descent of the vaginal walls is extensive, they become irritated and inflamed, actual ulceration taking place at times. Even where the laceration extends through into the rec- tum, the uterus may not descend, thus proving that it is not entirely supported by the perineum, but the patient will, nevertheless, complain of a “down-bearing pain,” due to the dragging of the prolapsed wall. In the complete variety, the patient loses control of the bowel, in addition to the symptoms described above, but when only a few fibres of the anal sphincter have given way, the bowel action may be regulated unless the contents are thin and watery. The treatment consists of operation, but any co-existing inflammation of the vaginal mucosa must first be treated by rest and the use of iodine, douching and tamponade. For the cystocele, the indication is to lessen the lateral area of the anterior vaginal wall. This is best secured by the removal of an elliptical shaped flap of mucous membrane, beginning just above the urethral orifice and continuing the incisions well down on the anterior face of the cervix. This denuded area is closed over by a continuous catgut suture introduced through the vaginal mucosa well to the outer side of the cut margin. The suture is carried as deeply into the tissues as possible without entering the bladder and then up through the tissues of the opposite side in a similar manner. For the posterior wall, a similar principle, viz., removal of scar tissue with union of the underlying muscles and fascia, is to be carried out. In some cases, exposure of the parts INJURIES FROM CHILD-BIRTH. 379 will reveal one sulcus spreading from one side of the vagina to the other. In such conditions, a triangular area is to be denuded, grasping with a tenaculum forceps the centre of the vaginal wall as high up as may be thought desirable and the vulva can be held apart by a pair of similar forceps placed at the level of the last caruncle myrtiformes, as these will mark the spot to which the tissues retracted when torn through. In some cases, however, it will be well to ignore the latter and to make the base of the triangle longer or shorter as may be required. It is well to begin the dis- section at the apex of the triangle in the centre of the vagina and to roll the mucosa down on the tip of the finger as one proceeds, as by so doing one is less likely to perforate the rectum or leave islets of mucosa. Of course the lateral sides of the triangle ought to be marked out by fairly deep in- cisions before the denudation is begun. The field of opera- tion is then to be closed by a continuous catgut suture from the apex down, inserting the needle well to the outer side of the divided mucosa as deeply into the tissues as possible in order to bring together the muscular fibres. When the wider part of the triangle is reached, the needle is to be passed through the tissues at the centre of the wound in order that as little potential space may be left as possible. Where, on the other hand, there is a central rectocele or a bulging forwards of the central part of the vaginal wall, with a consequent sulcus or depression on each side, the denuded area is of a different shape. Here, each sulcus is to be denuded separately and its edges brought together with a continuous catgut suture but the outer side of each triangle must be carried right down to the perineum, the false mucosa between them removed and the wound closed by suture. Briefly, it may be said that an M-shaped area had been denuded and the edges brought together so as to form a cicatrix in the shape of a Y. When the laceration has extended into the rectum, the divided ends of the sphincter are indicated by a slight de- pression on each side of the bowel, being connected by a stretch of puckered up tissue posteriorly, due to the con- traction of the sphincter, and a perfectly smooth area, usu- ally reddened, in front. The first step in the operation, is 380 GYNECOLOGY. to expose the ends of the sphincter by making- a vertical incision over them, the centre of the incision running through the centre of the depression. Next split the margin of the diaphragm separating the vagina from the rectum, beginning in the centre of one of the primary vertical incisions and carrying this incision across to the centre of the other end of the sphincter. Dissect the vaginal mucosa from the rectal wall as high up as may be necessary. Where the actual rectal wall has been torn, the edges must be united by fine interrupted catgut sutures placed close together, and passed in such a manner that the rectal mucosa is not perforated. In a few hours, these mucosal edges are glued together by serum and the sutures are thus buried and safe from infec- tion, whereas if they go through the rectal wall and the knots lie in the bowel, they act as guides along which in- fection is liable to travel with a consequent breaking down of the wound. After the rectal tear has been closed up, a silkworm-gut suture is passed through the skin just outside the centre of the end of one sphincter in such a manner that it will perforate the muscle. It is brought out between the vaginal and rectal flaps and across the wound. On the other side it is inserted in such a manner as to perforate the sphincter and emerge through the skin opposite to its en- trance on the first side. A second, or stay suture, is passed external to the first and then both are tied. If the first stitch has been passed correctly, a finger passed into the rectum will be felt to be grasped equally tightly all around. The laceration has now been converted into one of the incom- plete variety and is to be treated accordingly. After the above various operations, the vagina is to be lightly packed with gauze, which may be left in place for two days. A post-operative complication which is extremely likely to be met with in these cases, is inability to empty the blad- der, catheterisation being usually necessary, but the patient may be consoled by the fact that this frequently occurs but disappears in a few days. In the case of the complete laceration, the bowels ought to be locked up for five days, at the end of which time a dose of castor oil may be given and the effect aided by an UTERINE DISPLACEMENTS. 381 oil enema, but where the rectum has not been interfered with they may be opened as soon as the patient feels the desire. UTERINE DISPLACEMENTS. The uterus lies in the median line vertically in the pelvis in such a position that the tip of the cervix is on the level of a line drawn from the third sacral vertebra to just below the upper margin of the pubic bone. It normally has a con- siderable degree of mobility physiologically, depending upon respiration and the condition of the bladder and rectum. The natural position of the uterus is one of slight ante- flexion, i.e., the cervix and fundus approach each other to some extent in front, the cervix looking downwards and back- wards while the fundus points in the opposite direction. The organ is retained in this position by intra-abdominal pressure, by ligaments, muscles and fascia of the blood vessels. The cervix is drawn backwards by the utero-sacral ligaments, while the fundus is held to the front by the intra-abdominal pressure of the intestines, aided to some extent by the round ligaments, while the broad and round ligaments prevent the organ falling to one side or the other. Any weakness in or destruction of one or other of these ligaments or muscles favours displacement of the organ, as does also the presence of any tumour or inflammatory mass within the pelvis. Posterior Displacements. When the fundus lies posteri- orly to the long axis of the patient’s body with the cervix in front, the condition is spoken of as “retroversion,” while where the fundus is at the back with the cervix maintaining its position, pointing downwards and backwards, it is said to be “retroflexed.” Both having similar causes and symptoms will be considered together. The posterior position of the fundus may be of congenital origin or it may occur secondarily, as the result of blows, falls or some pathological condition in the pelvis. It is fre- quently seen where the patient goes about too soon after delivery, the fundus then being heavy with a tendency to fall back on the slightest provocation, as is seen where the habitually distended bladder pushes the fundus backwards or a chronically full rectum presses the cervix forwards, thus tilting the fundus in the opposite direction. Tumours lying 382 GYNAECOLOGY. between the bladder and fundus push the latter backwards, and it may be drawn in the same direction by adhesions between it and the posterior pelvic wall. A similar effect is produced by the presence of tumours in the posterior wall of the uterus weighing it downwards and backwards. Pure, uncomplicated retroposition of the fundus gives rise to but slight symptoms if any, those which are observed in this condition being due more to a falling of the uterus than to the fundus being displaced backwards. A posteriorly dis- placed fundus frequently has, however, a marked effect on pregnancy in that it tends to prevent conception and, when that does occur, to cause a premature emptying of the uterus. This liability to abortion is due partly to increased conges- tion of the uterus and partly to the danger of the fundus being locked down below the promontory of the sacrum. The interference with the circulation of the uterus produces two symptoms, via.: menorrhagoea and leucorrhcea. In an extreme degree of retrodisplacement where the uterus is hard and large, pressure of the fundus upon the rectum may have the effect of a ball-valve and so prevent the emptying of that viscus. In other cases, it has been known to induce a loose- ness of the bowels on account of the irritating pressure on its wall. Again, a hard, large cervix may press on the blad- der or urethra in front inducing frequency of micturition, this being more marked during the day, i.e., when the woman is in the erect position, than at night when she is reclining. The only treatment is to replace the fundus and retain it in the normal position. In some cases, this may be effected by postural methods, having the woman assume the knee- chest position for some minutes once or twice a day, to- gether with careful attention to the condition of the bladder and rectum. If the knee-chest position is attempted, the patient must be warned to have the thighs at right angles to the structure upon which she is kneeling, as, if the ab- dominal wall is allowed to rest upon them, the abdominal contents are supported and so do not allow the fundus to fall forward. As an assistance, the cervix may be caught by a tenaculum forceps and drawn towards the sacrum. When this fails, manual reposition should be tried. Placing the woman in either the Sim’s or dorsal position, pass one UTERINE DISPLACEMENTS. 383 or two fingers into the vagina and press the fundus to the right of the sacrum and upwards at the same time. Then pass the index finger of the vaginal hand in front of the cervix and press it backwards. At the same time, the fingers of the other hand should be flexed on the lower abdomen to try and reach down behind the rising fundus which ought then to be lifted forwards by those fingers. When the uterus is not held in its abnormal position by adhesions, this is the best method of reposition, the use of instruments being dangerous. Once the fundus is in place, it may be retained there by either a pessary or some operative procedure. If a pessary is used, care must be exercised that the uterus really has resumed its normal position and that the instru- ment fits properly. If too large, it causes injurious pressure on the vaginal walls, while if not large enough it fails in its object. By wearing a pessary for one or two years, a cure will be produced in a small percentage of cases and it will always relieve the symptoms while in position. At all events, when a retroverted uterus is the seat of gestation and an abortion is threatened, the careful replacement of that organ and insertion of a well fitting pessary in the vagina will fre- quently allow the woman to go on to full term without further trouble. Surgical interference is rarely necessary and will be con- sidered when dealing with prolapse. Prolapsus Uteri. This is the most important displacement of the uterus, as it always produces symptoms if at all ex- tensive. In fact, one now and then runs across women who are made miserable by even a slight degree of prolapse. Downward displacement of the uterus is classified as either Complete or Incomplete, the former receiving a special name, vis.: Procidentia. In complete prolapse, or procidentia, the whole uterus lies outside of the vulva, the vagina being more or less inverted. It usually results from a laceration of the perineum, especially if the woman has done hard work or undergone much strain in the upright position, and so is most frequently met with in middle-aged multiparse. It does occur, however, in nulliparae, where they have performed hard labour or when the uterus is heavy and its supports weak. The downward pressure of intra-abdominal tumours 384 GYNAECOLOGY. will cause it, retroversion with prolapse being a common complication of such conditions. With the uterus in its usual position, its long axis points almost directly backwards towards the sacrum and the organ is supported by all of the pelvic contents beneath it, vis.: the bladder, the vaginal walls, the perineum and the rectum. Pressure from above causes the uterus to slide downwards and backwards towards the sacrum. Where, however, the uterus is retroverted the long axis is the same as that of the vagina and pressure forces the uterus down along the vaginal canal. The symptoms of prolapse, especially when complicated by retrodisplacement are very marked at times. The woman com- plains of pain in the lower part of the back over the sacrum, this pain being either a dull ache or acute and sharp. The latter is chiefly seen when the displacement is of an acute origin, as following a blow or fall. She also often describes the sensation as if everything was coming away, or as a “bearing-down” feeling. The pain may radiate out to one or other side or down the sciatic nerve, so-called sciatica being the only symptom. This is more likely to occur when the uterus is retroverted and the fundus contains a small fibroid tumour. The menstrual periods are profuse and may be extremely painful, the pain preceding the flow by several days and last- ing until menstruation ceases. As a rule there is a leucor- rhceal discharge on account of the disturbance of the circu- lation causing congestion of the endometrium, the discharge being rather thick and of a dirty white colour. Mechanical irritation by pressure of the bladder or rectum may produce frequency of urination or defsecation. Local examination in procidentia will show the whole uterus to be protruding from the vulva and palpation will reveal the presence of the uterine body in the sac, while the bladder will be felt in front. As the uterus has usually been in its abnormal situation for a considerable period of time, friction against the patient’s clothes will probably have caused ex- coriation of the most dependant parts which will look red and inflamed. UTERINE DISPLACEMENTS. 385 In lesser degrees, the cervix will be low in the vagina and the fundus will be below its usual level. Unless held down by adhesions, both may be readily pushed up into their nor- mal situation. In the case of an elongated cervix, with which a moderate amount of prolapse is often confused, the fundus is felt to be in its usual position, while the cervix cannot be elevated sufficiently to restore the fornices to their normal depth. The treatment is directed towards replacement of the uterus and maintaining it in the correct position. Where the whole uterus has been outside of the vulva for a considerable period of time, the irritation set up by the woman’s clothes will have caused excoriation or ulceration of the exposed parts. In such a case, place the patient in bed and keep her there and try to reduce the inflammation by douches, the application of tincture iodi and the use of tampons. When the ulceration is healed, you may attack the displacement. As there will be but little support for a pes- sary, some form of plastic operation on the vaginal walls will be indicated but must be supplemented by one of the various methods of supporting the uterus from above, such as by extra or intra-abdominal shortening of the round liga- ments, or suspension from, or fixation to, the anterior ab- dominal wall. When operation is contraindicated for any reason, as by serious cardiac, kidney or lung disease, a ring pessary may possibly suffice, especially if the woman has remained in the recumbent position long enough to allow the vaginal walls to regain their tone but this is exceptional. If a ring cannot be retained, you may try a cup and stem pessary, supported by elastic bands attached to an abdominal belt. This cup and stem is the only pessary which a patient may be allowed to remove and replace herself. The others, Hodge or Albert Smith, may be taken out by the woman but if she attempts to put them back again, she is almost certain to fail to place them in the proper position, so that she will do herself actual harm. The cup pessary ought to be removed each night and placed in some mild antiseptic solution and reinserted in the morning before the patient leaves her bed. When the other instruments are used, they ought to be removed, 386 GYNAECOLOGY. cleansed and replaced by either a doctor or nurse at least once every six weeks. If not, they will set up an irritation of the vaginal mucosa and may be actually embedded in the walls of the passage. INFLAMMATORY AFFECTIONS. Vaginitis. While inflammation of the vagina in the adult is usually either sub-acute or chronic, it may be acute. This latter is caused by infection, especially by the gonococcus, or by intensely irritating discharges, as in cancer of the cervix or, more rarely, of the fundus. The more chronic variety may result from any local hyperaemia, as that ac- companying pregnancy, persistent irritation by uterine dis- charge, want of care when the patient is wearing a pessary, or by the entrance of worms over the perineum. The flow of the urine from the bladder in cases of vesico-vaginal fistula will set up an inflammation of the vaginal walls, and it frequently occurs as a result of acute infectious fevers, diphtheritic and other membranes forming on the vaginal mucosa at times. In the acute form, the mucosa is red and inflamed in appearance. It is swollen, hot and tender and is covered with a thickish muco-purulent discharge. When the sub-acute or chronic form is met with, examina- tion of the vagina will show that its surface is covered with minute red spots from the papillae being affected. The treatment of acute vaginitis consists of rest in bed, low diet and the administration of saline aperients. If the parts are not too sensitive, vaginal douches will be useful. If the latter are used they should contain some mild anti- septic, such as boracic acid, or milk of magnesia may be added to the sterile water. The temperature of the solution ought not to be too high and they are to be given very gently, the solution can not being elevated more than three feet above the level of the patient. In addition to the above, one may insert daily into the vagina suppositories containing antiseptic and astringent drugs, as alum and ichthyol with cocoa butter as a base. Later on when the condition be- comes less acute, or in chronic cases, the treatment may be INFLAMMATORY AFFECTIONS. 387 more energetic. The vaginal walls are now to be exposed and painted with a solution of silver nitrate, 60 grains to each ounce, or tincture iodi may be applied instead. A tam- pon saturated with a ten per cent solution of ichthyol in glycerine is to be inserted and its removal at the end of twenty-four or thirty-six hours followed by an astringent and antiseptic douche. In septic cases, the use of yeast is highly recommended, introducing into the vagina tampons containing powdered yeast and saturated with a solution of cane sugar or glucose. The yeast fungus multiplies and kills off all other germs which may be present. These tam- pons are left in situ for one day (twenty-four hours), when they are removed and a douche of warm sterile water given, this treatment being repeated at the end of another twenty- four hours. Metritis and Endometritis. As inflammation of the mucous lining of the uterus practically never occurs without also affecting its muscular wall, and because their causes and symptoms are similar, the two conditions will be considered together. Inflammation of the uterus may be acute or chronic, the latter usually following the acute, but at times occurring quite independent of it. The acute is caused by infection, in connection with preg- nancy as a rule, but it may result from the extension of the gonococcus up into its cavity from the lower passages. Un- clean instrumentation is liable to cause this condition. It is characterised by acute pain in the pelvis, usually in the median line, and tenderness over the fundus uteri. This will be accompanied by a profuse purulent discharge. Irri- tation of the bladder is usually present, manifesting itself by frequent and painful micturition. This is due, either to direct infection of the bladder by the germs entering along the urethra or to extension of the inflammatory process from the uterus. The patient suffers from chills, the temperature going to 102 or 103 degrees Fahrenheit, or even as high as 107 or 108 degrees. The pulse is rapid, 120 or more beats per minute. The skin may be bathed in perspiration or may be dry and hot. In the more severe cases, the bowels will 388 GYNAECOLOGY. be distended, the tone of their muscular walls being lowered by the infection. On making a. bi-manual examination, the cervix will be found to be soft and the body of the uterus enlarged, tender and rather soft and its movement causes pain. In the treatment of this condition, the first thing to do is to place the woman in the Fowler’s position in order to favour drainage of the genital canal. Simple elevation of the head of the bed will not do; the patient must be almost sitting bolt upright and the thighs must be supported in some manner so as to make her comfortable and keep her from slipping. Where no real peritonitis bed is available, the Fowler’s position may be obtained by placing a kitchen chair, resting on the edge of the seat and the back of the chair, underneath the upper end of the mattress which has been raised sufficiently for the purpose. Pillows beneath the knees will tend to prevent the woman from slipping down in the bed, or a sling composed of a bed-sheet passed under the thighs with its ends fastened to the top of the bed will serve one’s purpose admirably. An ice-bag placed on the lower abdomen will give great relief and tend to prevent spreading of the inflammation. The use of hot antiseptic douches will prove a useful adjuvant in checking the exten- sion of the trouble. The poison may be diluted by making the woman drink as much fluid as possible and by the use of normal saline per rectum or beneath the breasts. When resorting to the use of saline solution, its administration per rectum by the Murphy method, allowing it to enter the bowel drop by drop, will be found to be the most efficacious, as there is no irritation of the bowel. In addition to diluting the poison, this saline undoubtedly acts as a direct stimulant and its beneficial effect is early manifested in most cases. The patient’s strength must be kept up by the use of heart tonics, such as strychnine, %0 grain every four or six hours. The administration of alcohol, either as brandy or whiskey diluted with hot water, will sometimes act as no other drug will, by stimulating the circulation and producing a profuse diaphoresis. At times, the wall of the uterus will be actually riddled with abscesses, suggesting the possibility of hysterectomy, INFLAMM ATOR Y AFFECT IONS. 389 but this operation is not to be recommended in such cases, as the presence of these abscesses is extremely difficult to detect and when they are found the condition of the patient will be such as to make the prognosis of the operation almost hopeless. The chronic form sometimes follows the acute, but not invariably, it coming on more gradually and insidiously, as the result of chronic congestion rather than infection. When a cervix is torn during labour and not repaired at once, or the attempt at repair is not successful, irritation of the uterine tissue is kept up, so that the organ does not involute properly, thus giving rise to chronic metritis. Excessive sexual inter- course or chronic constipation will act in a similar manner. The uterus becomes harder and larger than normal, due rather to the excessive formation of fibrous tissue than to an increase in its muscular elements. The symptoms are a pain in the back, of a dull aching char- acter, together with a feeling of weight in the pelvis, espe- cially when the woman is on her feet. A more or less pro- fuse leucorrhoeal discharge is usually present. The flow at the menstrual periods is increased and there may be metror- rhagoea in addition. Sterility is frequently present as a result of the unhealthy condition of the endometrium. On making a local examination of the pelvic organs, the cervix will be felt to be very hard and to contain small hard nodules which are seen as whitish elevations when exposed by a speculum. These are Nabothian follicles, formed as a result of obstruction of the cervical glands. The cervix is usually lacerated with a more or less gaping os and its surface is covered by a velvety mucosa. The fundus is en- larged, hard and usually displaced in some direction. The uterine body is not tender. Treatment should be directed to the reduction of the con- gestion of the uterus. This may best be obtained by the use of copious warm douches, scarification of the cervix, the application of iodine and the use of boroglyceride tampons. The douche should consist of at least one gallon of warm solution, either sterile water, saline or mild antiseptic and, as it is the prolonged action of moist heat which is sought, ought to be given gently and slowly. After a course of this 390 GYNAECOLOGY. preparatory treatment, any laceration present ought to be repaired and it will often be advisable to amputate a small portion of the cervix. It must be remembered, however that the uterus usually undergoes involution after an amputation of the cervix in such a case, so that one must be careful not to remove too much. INFLAMMATION OF THE APPENDAGES. Inflammation of the Fallopian tubes and ovaries is also due to either infection or chronic congestion and irritation. Fallopian Tubes. The commonest cause of inflammation of the Fallopian tubes is infection by the gonococcus or some pathogenic organism, as the streptococcus or staphylococcus. It also results from tuberculosis or by infection by the colon bacillus extending from some of the neighbouring organs, it not infrequently being met with as a complication of appendicitis, where the appendix becomes attached to the tube and the bacilli travel through from the appendix. In- fection may also spread to the tube from a diseased uterus. In tuberculosis, the infection is a descending one, the bacilli coming from either the lungs or intestine, it being rarely primary in the tube. When the ofifending organism is the gonococcus, it ascends through the uterine canal, so that both tubes are usually afifected. The pathogenic organisms, on the other hand, obtain entrance to either the blood-stream or lymphatics through a localized abrasion or breach of continuity of the tissues. Therefore they are prone to travel through the side on which the lesion has occurred and so that side is more liable to be afifected than both, one tube being perhaps badly diseased while that of the opposite side is entirely unaffected. The relative frequency with which gonorrhoeal salpingitis is bi-lateral while that due to pathogenic bacteria is uni-lateral forms a strong point in the differential diagnosis of the etiology of the case under consideration. In addition to infection, salpingitis may be set up by chronic congestion of the pelvic organs as from too frequent sexual excitement, especially when ungratified, chronic con- stipation, sedentary occupation, etc. INFLAMMATORY AFFECTIONS. 391 This disease may be either acute or chronic, the former being always due to infection. Symptoms of acute salpingitis are a sharp pain in the pelvis with elevation of temperature and increase in pulse-rate. The patient feels nauseated and may vomit. She frequently has a chill. The act of emptying the bowels or bladder may be painful on account of the proximity of the diseased organs. There may be a profuse vaginal discharge, examination of which reveals the presence of the gonococcus, in which case it will be thick, viscid and greenish in colour. Acute tender- ness will be found over the diseased side or even all across the lower abdomen, the point of maximum tenderness being lower than McBurney’s point, seen in appendicitis. The vagina will probably feel hot and a tender mass occupies one or other fornix, this mass being elongated or sausage shaped and probably fixed to the wall of the pelvis. An ex- amination of the blood will show a marked leucocytosis, the white cells running up to twenty-five or thirty thousand. The treatment of this condition is similar to that called for in acute metritis, via.: absolute rest in bed in Fowler’s posi- tion, ice applied to the lower abdomen, hot douches, stimu- lants and, possibly, a sedative for the pain, although this is usually relieved by the ice. The bowels should be emptied by a smart saline laxative and then kept at rest for a few days. The diet must be of the lightest variety consistent with the maintenance of the strength of the patient. In the vast majority of cases, the above line of treatment will be successful in obtaining a complete cure, especially in those of venereal origin, so that operation should be de- layed as long as possible. However, when the woman’s condition does not show any signs of improvement but, on the contrary, is getting worse, the temperature rising and the pulse becoming more rapid and thinner, the only thing to do is to open the abdomen and act according to the conditions found there. After sterilisation of the anterior abdominal wall, an in- cision is made in the middle line between the pubes and umbilicus, cutting through the various layers with the utmost caution in case a knuckle of bowel is adherent to the abdom- inal wall. As soon as the cavity is entered, the bowels are 392 GYNECOLOGY. pushed as high up in the abdomen as possible and the pelvis is walled off by means of large tape-towels wrung out of hot saline or sterile water. The diseased organs are now sought and separated from any of the surrounding parts to which they may have become adherent, care being taken not to rupture any pus sac which may be present. The broad liga- ment of the affected side is tied off with two or more inter- locking ligatures and the diseased organ removed. If pus has escaped into the pelvic cavity it is wiped up as it exudes from the sac and the whole field of operation thoroughly bathed with a hot aqueous solution of formaline, 1 in 500. If the disease was of gonorrhoeal origin, it will be quite safe to close the abdomen but when it has been caused by any of the pathogenic organisms a cigarette drain is placed in the most dependent part and the incision closed all around it. When one tube is but slightly affected, it may be opened up, wiped clean and, with its corresponding ovary, left in situ with the expectation that it will ultimately become healthy. When the condition is chronic, the symptoms are, naturally, less striking. The patient suffers from a dull ache in the affected side. Again there is a leucorrhoeal discharge, which is thick and pustular, but without odour. The menstrual periods are painful, the pain coming on some days before the flow and lasting during the whole period. The flow is ex- cessive and the blood clots. The woman is sterile from the blocking of the tubes, or, when one tube is patent, on ac- count of the accompanying endometritis. Defaecation may be painful, especially when the left appendages are the ones at fault. On making a vaginal examination, a mass is felt on one or both sides. This mass will be sausage-shaped, the outer end being often the larger part. It may be nodular, either from inclusion of an ovary in the mass or from kinking of the tube itself. There may be no tenderness but usually manipulation of some part of the mass will cause pain. If pus is present, there will be an increased leucocytosis but not so marked as in the acute variety. Dyspareunia is fre- quently complained of and may be so severe as to prohibit all sexual intercourse. INFLAMMATORY AFFECTIONS. 393 In treating this condition, much may be gained by local applications and douching, using large quantities of warm solution. Instead of boroglyceride, however, it is better to saturate the tampons with a ten per cent, solution of ichthyol in glycerine, as this drug is an antiseptic and also has a mild analgsesic effect. The use of the hot-air bath at times has a wonderful effect in causing the disappearance of these inflammatory masses. The patient receives one treatment Fig. 3.—Left ovary cystic from chronic ovaritis. Right ovary contains corpus luteum. (Pathological Museum, McGill University.) daily, each one lasting half an hour, but she must be watched during the first one or two so as to avoid any exhaustion. When this fails after a thorough trial, the diseased appen- dages will require removal, either through an incision in the anterior abdominal wall or per vaginam. If both sets of appendages are irreparably diseased, the uterus is almost cer- tain to be badly afifected also, in which case many operators advocate making a clean sweep of the pelvis, removing the uterus as well as the appendages, but this is a matter of opinion. Ovaritis. Inflammation of the ovary without implication of the tube as well is rather rare. Its etiology is somewhat 394 GYNAECOLOGY. similar, as are also the symptoms. When one considers the changes which are taking place in this organ, the ripening of the Graafian follicle, its rupture and final reparation, we are surprised that it does not become inflamed more often than it does. It may be acute or chronic. The acute form of this disease is usually caused by exten- sion of germs along the lymphatics from the uterus or vagina or directly from the tube, as where the latter itself is the seat of inflammatory changes. It may also be the result of haemogenic infection, as where the original focus is in the gums or teeth, and it frequently is a complication of acute parotitis, especially when this occurs in the adult. It is marked by oedema and swelling of the interstitial portion of the organ, followed, later on, by the formation of small cysts, thus giving rise to the small cystic ovary, which the gynaecologist so vigorously removed in the early days of gynaecology (Fig. 3). It may resolve before the formation of these cysts or may proceed to the developement of an abscess, which varies in size from that of a hazel nut to a large orange. There will be an increased leucocytosis. The symptoms are those of any acute pelvic inflammation, except that the pain from which the patient suffers is more sickening as a rule. Where an acute pelvic infectious process starts up several days post-partum, examination of the pelvis will most often reveal the presence of a rounded, fluctuating mass to one side of the uterus, this mass being an abscess of the ovary. The treatment of acute ovarian inflammation, at all events before abscess formation, will consist in absolute rest in bed and the application of ice over the affected region. A hypo- dermic of morphine is often required on account of the in- tense pain and also to quiet the circulation. Even when an abscess is present, it may be overcome by this treatment but it frequently requires evacuation. This may be accomplished by puncture per vaginam when it bulges down into one or other fornix, but this is not unaccompanied by danger, as some of the contents of the abscess may escape into the peri- toneal cavity. A better method is to attack the disease through an incision in the anterior abdominal wall, as in the case of the acute salpingitis, and remove the ovary. EXTRA-UTERINE GESTATION. 395 Chronic ovaritis usually results from the acute but may be seen in women who have never given any symptoms of the latter, resulting from any cause of chronic or rapidly repeated congestion of the organ, as chronic constipation, sedentary habits, too frequent sexual intercourse, etc. The subject of this trouble will have a dull, aching pain in the affected side, aggravated on walking. She will also most likely complain of dyspareunia, the pain starting after full insertion of the male organ. If the left side is affected, there will be painful defsecation. Local examination will reveal the presence of an enlarged, tender ovary which is usually below the normal level. It may or may not be mobile, depending largely upon as to whether or not it has followed an acute attack, in which case adhesions would probably be set up between it and the side of the pelvis or uterus, towards which it tends to sag. In treating this condition, the local use of iodine, tampons and hot douches will often be remarkably beneficial, and their effect will be enhanced by the employment of the hot air bath. This treatment ought to be persevered in for sev- eral weeks before giving up hopes of a cure. In the event of failure, removal of the offending ovary will be necessary. EXTRA-UTERINE GESTATION. When the Graafian follicle becomes ripe, it bursts, allowing the ovum to escape into the peritoneal cavity, there to wan- der around and become absorbed or to enter the Fallopian tube by its fimbriated extremity. It may proceed onwards into the uterine cavity or even into the vagina, there becom- ing lost. If, however, it encounters the male element in any part of its course, it becomes fertilised and proceeds to de- velope. Normally it becomes attached to the mucous lining of the uterus, where it attaches itself and proceeds to de- velope. When, on the other hand, fertilisation and implanta- tion take place before the uterine cavity is reached, the condition is known as “extra-uterine” or “ectopic gestation.” Anatomically, extra-uterine gestation is classified as ova- rian, abdominal or tubal, the latter being again subdivided into ampullary, isthmian or interstitial, according as to 396 GYNAECOLOGY. whether the ovum develops at the fimbriated extremity (“ampullary”), or isthmian part of the tube or in that part of the tube which is embedded in the actual wall of the uterus. All varieties are due to some congenital abnormality or previ- ous diseased condition of the tube. The Fallopian tube is normally lined with epithelium, the cilia of which have a wavy motion towards the uterus which speeds the ovum onwards and prevents the migrating spermatozoa from ascending to the cavity of the tube or peritoneum. When the cilia are destroyed by inflammation or the pressure of a tumour, this inhibitory action ceases and the spermatozoa are free to enter and travel along the tube. In certain conditions, the spermatozoa encounter and fer- tilise the ovum just as it is about to escape from the ovary, in which case the “ovarian” form is developed, or the ovum may have entered the tube before it meets and joins forces with its partner, in this instance becoming attached to and finally embedded in the mucosa lining the tube. The “ab- dominal” variety is usually secondary to one of the others, as where the ovum develops in either the tube or ovary and then escapes into the abdominal cavity, where it attaches itself to the peritoneum and there proceeds to grow. Classified according to the symptoms present, this condi- tion is spoken of as “a leaker,” characterised by repeated attacks of faintness without loss of consciousness, or of the “fulminating” type, where the sac has actually ruptured, pro- ducing all of the symptoms of serious intra-peritoneal haemor- rhage with collapse. The etiological factors are either congenital or secondary. Occasionally the tube has one or more secondary openings at the fimbriated extremity or its wall contains sacs, either of congenital origin or due to folds caused by inflammatory action of the peritoneum covering the tube. Age has but little influence on this condition but, naturally, it is most frequently met with during the period of the woman’s greatest sexual activity, vis.: between the ages of twenty-five and thirty-five. Symptoms. The belief formerly held that this condition was always preceded by a long period of sterility has been EXTRA-UTERINE GESTATION. 397 disproved, as case after case of tubal gestation immediately following a full term delivery is noted. 1. In one variety of case, the woman will have missed one or two periods, and will complain of a dull aching pain in one side. Then there will be slight staining of the under- clothes daily for several days. 2. In another case, the last period may have been normal in every respect. The next period begins but, instead of Fig. 4.—Tubal gestation with rupture near uterine end. (Private collection.) becoming fully established and lasting the usual number of days, a slight discharge of blood takes place daily, this blood- loss often being described as a “dribbling” by the patient. In either of these cases, the woman may have recurrent attacks of sharp pelvic pain, followed by faintness, and slight increase in pulse-rate but there will be little change in the temperature. A pelvic examination will reveal an ovoid mass to one side of the uterus, but separated from it. This mass is firm, but not tense, and slightly sensitive. Repeated ex- aminations show a steady increase in its size. The pain steadily becomes more severe (Fig. 4). 398 GYNECOLOGY. 3. Finally, one or possibly two periods have been missed and the patient considers herself to be pregnant, when, usu- ally between the eighth and tenth weeks, she is suddenly seized by a sharp, agonising pain in the affected side and the woman falls in a faint. While usually felt over the seat of rupture, the pain may be referred to some distant part of the body, as the region of the liver or gall-bladder. The mucous membranes are blanched, the skin becomes waxy in appearance and the respirations are of a sighing character, significant of “air-hunger.” The pulse is extremely rapid, running up to 120 or 180 beats per minute, and the tempera- ture is sub-normal, falling possibly to 95 or 96 degrees Fahrenheit. Examination of the abdomen may, or may not, reveal the presence of fluid in the flanks, or it may be that the tympany in that region is simply impaired. There will be tenderness and, at times, a sense of resistance over the affected side. In many cases of ectopic gestation, a more or less complete cast of the uterus is thrown off, thus giving the impression that the woman is having an ordinary mis- carriage. On vaginal examination, the uterus is found to be pushed to one side with a fullness in one or both lateral fornices. If examined several hours after rupture, a boggy mass is felt in the pelvis, due to clotted and semi-organised blood. Occasionally but little can be made out per vaginam more than a sense of resistance, this being due to the out- poured blood masking the distended tube or ovary. If seen several hours later, or in case of repeated attacks of pain and faintness, the patient may complain of irritation of the blad- der or bowel, feeling a constant desire to micturate or go to stool, or possibly either organ may be obstructed, this symp- tom being due to pressure of the escaped blood upon the viscus. The cases in which there are repeated attacks of pain and faintness are those in which the ovum has been implanted near the fimbriated extremity of the tube. Its growth causes stretching of the tubal walls, which results in the tearing of the small blood-vessels. A small amount of blood escapes into the peritoneal cavity where it sets up a localised peri- tonitis. The clots become organised and form part of the wall of the sac. This is the “leaker” variety of ectopic gesta- EXTRA-UTERINE GESTATION. 399 tion, while the “fulminating” type is simply that in which actual rupture of the tube has occurred (Fig. 5). Differential Diagnosis. At times it is very difficult to dis- tinguish between ectopic gestation and other conditions, such as appendicitis, pelvic tumour with a twisted pedicle, and ordinary threatened uterine abortion, but when the patient is seen immediately after rupture of the sac, there should be little difficulty in arriving at a correct conclusion. 1. In appendicitis, there is no history of amenorrhcea, nor Fig. 5.—Tubal abortion. Secondary rupture at fifth month. (Private collection.) is the shock of a ruptured viscus present. There is no drib- bling of blood from the uterus. Microscopic examination of the blood will present a higher leucocyte count than in ec- topic gestation. There is more vomiting and you will usually obtain a history of rather marked constipation. Palpation of the abdomen will elicit the fact that the point of maximum tenderness is over McBurney’s region. There will be splint- ing of the abdominal muscles over the appendix and re-bound pain will be present. The temperature will be elevated, not depressed. Per vaginam, no mass may be felt or, if one is present, it will be found to be high up in the pelvis. 400 GYNECOLOGY. 2. If the cause of the illness is salpingitis, you will usually obtain a history of gonorrhoea or of sepsis following preg- nancy, or there will be tuberculous disease in some other part of the body. The leucocyte count is high, especially in the acute form of salpingitis. The temperature is elevated and the pulse-rate increased but not to such an extent as in extra- uterine gestation, nor are the mucous membranes so blanched in salpingitis. There is no history of amenorrhoea, nor is there any dribbling of blood from the genitals. The illness is probably one of long standing, unless in the acute form. 3. Where the patient has a pelvic tumour with a twisted pedicle, the onset is usually sudden and is accompanied by shock but not so marked as in tubal rupture. At times, the twisting will take place gradually but in such a case there ought to be doubt as to the condition. The presence of a definite mass in the pelvis may be made out and the lower abdomen will be distended. Often one will obtain a state- ment that there has been a pre-existing enlargement of the abdomen, or the patient will say that she has always had a “high stomach,” especially if she is young. 4. A patient the subject of a threatened abortion gives a history of amenorrhoea and she will have intermittent, cramp- like pains in the pelvis. There will be a discharge of blood from the uterus. The cervix is soft and the external os patulous with possibly portions of the ovum protruding from it. The uterus is enlarged proportionately to the period of gestation. There will be no tenderness, either abdominal or pelvic, or if any is present it will be slight. It must be re- membered that any two of these conditions may co-exist and one must not exclude a ruptured tubal pregnancy simply because the woman has a high temperature and gonorrhoeal discharge. Treatment. Once ectopic gestation is diagnosed, the only thing to do, when the circumstances permit, is to remove the offending organ and the route of choice should be through the anterior abdominal wall, as one wants to act quickly and to be able to see the exact condition of affairs as the opera- tion proceeds. If the woman is in bad condition, the opera- tion should be preceded, or accompanied, by the administra- tion of normal saline solution either per rectum or by the EXTRA-UTERINE GESTATION. 401 sub-mammary method, in order to help take the place of the blood lost. As soon as the abdomen is opened, search for the affected organ and cut off all blood supply from it by passing one pair of long forceps over the tube and round ligament and under the ruptured point and a second pair from the outer side in such a manner that it may meet the first pair. Then cut across the broad ligament between the forceps and tubal sac and close over the ligament by a con- tinuous catgut suture from side to side. Release the forceps and see that there are no bleeding points exposed, after which all blood should be removed from the abdomen, if the con- dition of the patient warrants a prolongation of the operation, as the presence of blood-clot in the abdomen favours the formation of adhesions. Finally, fill the abdominal cavity with saline solution and close the incision. Where the patient is in a serious condition, one has to work quickly so as to get control of the bleeding and to get her back to the ward as soon as possible, so that the ovary may be included in the parts removed, but when time permits and the ovary is healthy, it ought to be isolated from the tube and not re- moved. Some operators split the affected tube, turn out its contents and suture its mucosa to the peritoneal covering in hopes that it may be restored to use, but the chances of its doing so are so doubtful that it is better to remove it at once. Other gynaecologists remove the appendages on the opposite side as well, so as to prevent the possibility of there being any recurrence of this accident but this is not good practice. Not more than five per cent, of women have a second ectopic gestation and many subsequently bear healthy children, one of the writer’s patients giving birth to three full term children normally within three years after the ap- pendages of one side had been removed for this condition. If, for any reason, it is not possible to operate at once, place the patient in bed, the lower end of which should be raised. Apply ice to the abdomen and keep her lightly cov- ered. Administer saline solution per rectum, under the breasts or intravenously. Of these methods, the rectal will usually suffice, introducing from four to six ounces gently into the bowel, as more would probably be rejected. If the condition is not urgent, the use of the Murphy drip is to be 402 GYNECOLOGY. recommended as it ensures a steady supply of solution to the system and may be kept up for several hours. If the pulse is extremely rapid and feeble, the solution is better intro- duced beneath the breasts but its introduction directly into a vein is rarely called for. Where the absorption of the fluid from under the breasts is slow, it may be hastened by the application of heat over the distended mamma and by mas- sage of that organ. It is well to give a dose of morphine hypodermically to quiet the action of the heart so as to lessen the blood-pressure at the point of rupture. It may be nec- essary to administer a stimulant to the heart, so as to tide the woman over the critical period until the saline is ab- sorbed, but it should be given sparingly. The saline itself serves as a stimulant and also takes the place of the blood lost, whereas other stimulants simply increase the cardiac activity and so favour the continuance of the bleeding. The heart requires as much fluid as possible to work on, so the blood may be forced into the upper part of the body by firmly bandaging the legs from the toes up, and it may be well, occasionally, to bandage the arms in addition. If the woman is very thin, a pad may be placed over the abdominal aorta and pressure be applied by a tight bandage but this is of doubtful value. The treatment of a case of ectopic pregnancy where the ovum has gone on to full term deserves special consideration. It is a debated question as to whether the fcetus should be allowed to die before its removal or this should be attempted during the life of the ovum. In the case of ordinary uterine pregnancy, there is no doubt as to the course to be pursued as here one has a contractile muscular organ with which to deal after removal of its contents. In ectopic pregnancy, it is entirely different as the wall of the sac contains no mus- cular elements, so that the removal of the placenta is fol- lowed by a severe haemorrhage which nature can do little to check. For that reason, the older operators would allow the foetus to perish before opening the sac. as then the pla- cental circulation would have ceased to exist and the vessels would be thrombosed, allowing the placenta and membranes to be stripped off without fear of uncontrollable bleeding. In these days of aseptic surgery, however, it is deemed best EXTRA-UTERINE GESTATION. 403 to open the sac during the life of the foetus, and remove the child after tying off the cord. The edges of the sac are sutured to the edges of the abdominal incision and the cavity packed with sterile gauze. This is changed daily and the foetal structures will eventually come away without causing any trouble. The sac will then close rapidly. Prognosis. A large proportion of unoperated cases die as a result of rupture of the sac, but if seen early and bleeding is stopped by operative interference before the loss of too much blood, the prognosis is excellent. In fact there is no class of case which gives more satisfaction to the operator than an ectopic when seen in time as the operation is almost devoid of risk whereas the condition is usually fatal if there is not prompt interference. To secure the highest rate of recovery, operation must be resorted to at once, no matter how serious is the condition of the patient. He who waits until the woman has recovered from the shock of the rupture before opening the abdomen will lose many more cases than the man who goes in at once, irrespective of how serious condition the patient may be in at the time. It is the blood- loss which kills and it must be controlled at the earliest possible moment. Terminations. When the ovum is situated in the tube, the latter usually ruptures between the eighth and twelfth weeks of gestation. This rupture may occur into the peritoneal cavity or between the layers of the broad ligament. The latter situation is the least common but gives the best prog- nosis, as the space is limited so that the escaped blood exerts so much pressure upon the ovum that it perishes, in which case there is every chance of its being absorbed. If the ovum has been arrested in the interstitial portion of the tube, it frequently becomes extruded into the uterine cavity and there develops to full term and no one is the wiser that it has started as a pathological pregnancy. When the preg- nancy is of the ampullary variety, the ovum is often expelled, in whole or in part, into the peritoneal cavity and there develops, obtaining its nourishment from the peritoneum or else from a partial attachment to the tube. Upon the death of the ovum, the foetus may become mummified and remain perfectly quiescent in the pelvic cavity. In some cases, the 404 GYNAECOLOGY. sac becomes infected, with the result that an abscess forms and ruptures into the peritoneal cavity or one of the adjacent viscera, such as the bladder, vagina or rectum, or even through the anterior abdominal wall, the remains of the ovum being discharged through this opening. Occasionally, the ovum becomes impregnated with lime salts, forming a “litho- paedion” which may lie in the pelvis for many years without giving trouble. The writer once removed such a specimen, the ovum having been killed eighteen years previously by the application of electric currents to the pelvis. MALIGNANT DISEASE. CANCER OF THE VAGINA. Primary cancer of the vagina is supposed to be very rare but it is probably more common than imagined because the early symptoms are so slight that the disease is far advanced before discovery, when it may have spread to the cervix (Labusquiere). In many cases, it is only by examining the whole uterus and vagina after removal that the primary site can be determined. From 1500 to 2000 females are admitted yearly to the public wards of the Montreal General Hospital and yet only three cases of primary cancer of the vagina have been recorded among the admissions, viz.: one by Dr. H. M. Little and two by the writer. According to the statistics of Himmelfarb the vagina is the primary seat in between two and three per cent, of cases of cancer of the female genitalia, while Williams only gives it credit for 0.43 per cent. When present, it usually affects the upper third of the poste- rior wall. The histological type is the epithelial and it may be diffuse and infiltrating or circumscribed. In the latter case, it appears as a cauliflower growth projecting into the vaginal canal and being attached to the wall by a broad pedicle. It tends to spread superficially at first but later on it burrows deeply into the tissues (Fig. 6). It bleeds readily on contact. Just as elsewhere in the body, vaginal cancer is caused by irritation, which, in this case may be set up by wearing a pessary or irritating uterine discharges. MALIGNANT DISEASE. 405 Symptoms. First there is an increase in any leucorrhoeal discharge which may have been present or the appearance of such a discharge when there was none previously. This soon becomes stained with blood and, a little later, comes to Fig. 6.—Primary cancer of the vagina. (Montreal General Hospital Museum.) possess a foul odour. The patient may complain of pain which radiates into the groins and down the thighs. When the disease has been present for some time, the patient pre- sents the usual cachectic appearance which accompanies 406 GYNECOLOGY. malignant trouble. There will also be loss of weight and general ill-health. Treatment. As early extension occurs, on account of the very free vascular and lymphatic supply of the parts, complete removal of the uterus and greater part of the vagina is indi- cated, taking great care to cut well free of the disease. If the patient comes under observation at a very early stage, it will be sufficient to excise that part of the vaginal wall bearing the growth, removing a wide collar of healthy tissue as well. After operation, the patient should be submitted to the X-rays or else radium may be substituted, and is probably the best. The prognosis is bad on account of the tendency for the cancer to spread beneath the surface. CANCER OF UTERUS. Cervix. Cancer may start either on the vaginal covering of the cervix or actually inside of the canal. In seventy-five per cent, of cases of uterine cancer, the cervix is the part prim- arily affected, the remaining twenty-five per cent, being met with in the body. Etiology. Heredity plays an unimportant part in cancer of the uterus, merely furnishing a tendency towards its oc- currence. While no case of transference to the physician or nurse has yet been reported, instances are frequently seen where transplantation by actual contact has taken place in the same person. Irritation undoubtedly plays a most im- portant part in the development of cervical cancer. Frankl claims that only three per cent, of cases arise in women who have never born children, and a certain proportion of these probably occur where the cervix has been forcibly dilated with a consequent development of scar tissue. When the fundus is affected, pregnancy has little effect in its develop- ment, a very small percentage occurring in parous women. It is most difficult to account for this form, unless it is due to irritation set up by the presence of a fibroid in the uterine wall, but many cases are seen where no such condition exists. Cancer of the cervix is most apt to start between the ages of thirty and forty but may be seen much earlier or later. MALIGNANT DISEASE. 407 Its rate of growth is much more rapid in the younger women and those who become pregnant, this being accounted for of course by the pelvic blood-supply being richer in these two conditions. Pathology. The portio vaginalis cervicis is covered with squamous epithelium, consequently, when it is affected by cancer, it is the epithelial or squamous type which is seen. The canal, however, is lined by cuboidal cells, so that here you may have either the epithelial or glandular type, the latter being called “adenocarcinoma.” Fortunately the dif- ferential diagnosis between the two types is unimportant, as it rarely can be made without the aid of the microscope. When arising from the epithelium covering the cervix, it usually spreads to the wall of the vagina by direct extension, while when it begins in the actual cervical canal it penetrates the wall and so extends into the paracervical tissue. Either variety, however, may spread upwards or downwards as the case may be. Diffusion takes place either by direct extension or by the cells penetrating the blood or lymph vessels. When the latter are invaded the cells are carried to the hypogastric or iliac glands or even to those of the groin. As advance takes place, the adjacent structures become infiltrated, the bladder and rectum being attacked, causing recto-vaginal or vesico- vaginal fistulse. In long standing cases, openings between the bladder, vagina and rectum form, a regular cloaca re- sulting. Now and then the ureters are surrounded by the growth, obstructing the outflow from the kidneys, with a consequent hydro-nephrosis. On account of extension taking place through the lymphatics, metastases in distant parts of the body are liable to form. The nerves are only affected late as a rule in cancer of the cervix, and this fact cannot be too well bourne in mind, as there will be little or no pain until they are implicated. There are three clinical types of this disease: (1) Vegeta- tive type, where the disease begins in the vaginal mucosa, producing the cauliflower form; (2) Infiltrating, which starts inside of the cervix and extending outwards to the para- metrium, causing hardening and fixation of the tissues, and 408 GYNAECOLOGY. (3) Ulcerating form, characterised by the breaking down of the tissues involved (Fig. 7). Symptoms. The symptomatology of all three varieties is similar. The earliest manifestation of something being wrong is vaginal haemorrhage. It shows itself as a slight bleeding, following any cause of pelvic congestion, such as coitus or defecation. Following either, the woman notices a small amount of blood at the orifice of the vagina. This loss in- creases as time goes on until finally it is very serious. The blood appears suddenly, is bright red in colour and ceases as suddenly as it began. Or the woman will first be con- scious of the presence of a leucorrhceal discharge, which sooner or later assumes a blood-stained appearance. The haemorrhage is due to the erosion into a vessel and con- tinues until the artery or vein is eaten across, when the inner coats contract and so plug the vessel. At first, the discharge has no odour, but soon becomes tainted and, later on, is extremely foul smelling. By the time the odour be- comes marked, the skin will be seen to be of a dirty yellow tinge due to absorption of the toxic products of the dis- integrated tissues. Pain will now occur and is usually felt in the lower part of the back and running down the legs and is worse during the night. At first this is a dull ache but in the later stages freqqently becomes extremely acute. It must be remembered that pain is a late symptom in cancer of the uterus as a rule, so that one should not fail to suspect the presence of cancer simply because the woman has no pain. Ignorance of this fact is the needless cause of the death of many a woman who might certainly have been saved, if she had been carefully examined before the disease had become too extensive. When the bladder wall is infiltrated, the patient complains of frequent, and at times painful, micturition, and of course when so eroded as to produce an opening into the bladder the urine constantly escapes. A similar result is seen when the rectum has been opened up by the disease, the bowel contents then being discharged through the vagina. As a rule, the woman becomes extremely emaciated, al- though occasionally she may retain her usual size, but this is rare. MALIGNANT DISEASE. 409 Local Examination. If there is the least suspicion of can- cerous disease, a local examination of the pelvic contents must be insisted on. It is better to lose the patient than run the risk of overlooking the possibility of the presence of this most dread malady. Fig. 7.—Cancer of cervix. Note erosion of inner surface only. (Private collection.) In the early stage of affection of the vaginal portion of the cervix, the examining finger will detect either a small, hard nodule on the cervix or a heaping up of the vaginal epithelium at some one spot, and the finger will be blood- stained, especially in the latter variety. On exposure of the 410 GYN/ECOLOGY. cervix by means of a speculum, the diseased areas will be seen to be red and inflamed in appearance. Nothing more may be seen or felt but the physician should be suspicious and should take a section right through the suspected area from vaginal mucosa to the actual cervical canal. This sec- tion ought to be submitted to an expert pathologist for his opinion. Where the interior of the cervix is the original site, little or nothing may be seen but the cervix is felt to be harder, and probably a little larger, than normal. Later, a warty outgrowth will be seen or felt or an apparent ulcer will be observed, this ulcer bleeding freely on irritation by the examining finger. When further advanced, there will be either a large cauliflower growth springing from the cervix or the latter will have become so broken down and destroyed that it will present a distinct cavity, as if a cone of cervical tissue had been removed. On palpation, the margins of this cavity will be felt to be very hard and the surface rough. Inspection will show the surface to be covered with patches of greyish membrane and some of the previously mentioned foul discharge. Even the lightest scraping of this surface will cause pieces of tissue to come away. The inguinal glands may now be felt to be enlarged and hard. The fundus is little affected but the whole uterus may be fixed in the pelvis. This fixity is usually due to extension of the disease through the cervix and paracervical tissue to the lateral wall of the pelvis but may possibly be caused by a previous attack of pelvic inflammation setting up adhesions. A history of such an attack should be sought, as fixation from extension of the cancer will absolutely preclude any radical treatment, while if it is due to inflammation it may be possible to remove the whole diseased uterus. If a section be examined microscopically, numerous patches of necrotic tissue and hemorrhagic areas are seen. The blood-vessels are numerous and their walls may be normal or composed either of numerous layers of epithelial cells or a single layer of endothelium. In places they are filled with epithelial cells. These cells are also seen to have invaded the deeper tissues and to have replaced them to a large ex- tent, while fine fibrous trabecula run in various directions through the section. Numerous cell-nests are scattered MALIGNANT DISEASE. 411 through the field of vision, making the diagnosis of squamous celled carcinoma both easy and certain. Treatment. In deciding upon the method of treatment to be adopted, the first question is, can the patient be cured by treatment or only relieved? Not over thirty per cent, of all the cases seen yield a good prospect of cure, no matter what line of treatment is adopted, and many of these prove to be disappointing when removal is attempted. “European operators give an average operability.of sixty-five per cent.; American figures show only thirty-five per cent, of carci- nomas in an operable condition” . (Anspach). Even the American percentage is generous. In cases of cancer of the cervix which are not submitted to operation, death results in from one to two years from the onset of the disease and the end comes more rapidly in young women and where the cancer is of loose structure and very vascular. It is also especially rapid in cases where pregnancy supervenes, due to the increased vascularity. Where the disease has spread beyond the cervix, the prog- nosis is almost hopeless, as, even where the uterus is re- moved, recurrence is almost sure to take place within a few months, although radium may lessen or retard the reappear- ance of the disease. When the uterus is freely moveable and the cancer is con- fined to the cervix, removal of the whole uterus, together with a broad collar of vagina and as much of the surrounding cellular tissue as possible, is the only method to employ. On account of the necessity of making as clean a sweep of the pelvic contents as possible, the abdominal route is preferable to the vaginal, even although convalescence is more rapid and uneventful when the uterus is removed per vaginam. Where there has been much destruction of the cervical tissue, as much as possible should be removed by the cautery before attempting the more radical treatment. Then, with the patient in the Trendelenberg position, a good free in- cision is made in the middle line, between the umbilicus and pubes. The intestines are pushed up into the abdomen and retained there by tape gauzes. The uterus is drawn up as far as possible into view. Two ligatures are passed around the upper part of the broad ligament and the tissues divided 412 GYNAECOLOGY. between them, the appendages being left when healthy and there is no chance of disease having encroached upon the uterine cavity. If it is invaded, the ovary and tube are to be removed also, one ligature, in that case, being passed around the outer border of the broad ligament, which is divided between the ovary and the outer ligature. The broad ligament of the opposite side is treated in a similar manner. The fundus is then held away from the pubes and the at- tachment of the bladder to the uterus defined. This is indi- cated by a fine white line, running across the uterus. An incision is made through the peritoneum along this line and the bladder separated from the fundus, working with the finger or handle of the scalpel as much as possible. Each uterine artery is sought for and a ligature passed around it, as near the lateral wall of the pelvis as possible, and tied. There is little danger of harming the ureter, if, in dissecting the bladder off the uterus, care be taken to separate the tis- sues well downwards and outwards from the middle line. After both arteries are tied, they are divided in turn between the ligature and cervix. The uterus is now brought forwards so that the posterior vaginal wall is put on the stretch and a flap of peritoneum is dissected down from it. It is well to commence the flap just below the cervix in case the dis- ease has penetrated deeper than it appeared to have gone. The uterus is then drawn well up and the upper part of the vagina is dissected from the surrounding tissues to a lower level than it is intended to be divided. A pair of right-angled forceps is passed across the vagina from each side, so as to completely close it, after which the walls are cut across be- low the clamps, thus enabling the operator to remove the uterus with its cervix enclosed in a collar of vagina. One should now feel most carefully for any enlarged glands, which ought to be removed, if found. The anterior and posterior vaginal flaps are to be united by a continuous suture, drawing the stump of each broad ligament down and uniting it to the vagina, after which the vaginal and vesical flaps of peritoneum are attached to each other over the whole field of operation by a continuous suture. After making sure that there are no leaking vessels, wipe the pelvic cavity dry, remove the gauzes and close the abdominal incision, using MALIGNANT DISEASE. 413 one continuous suture for the peritoneum, a similar one for the fascia and a third for the subcutaneous tissue. The skin edges are now to be approximated by a subcuticular suture of silkworm-gut. This is inserted by perforating the skin just below the lower end of the incision, and taking up a small amount of tissue on each side of the wound alternately, going fairly deeply into the tissues but taking care not to enter the actual cuticle, as this is apt not to be quite sterile. Fig. 8.—Subcuticular stitch It is brought out through the skin at the opposite end of the wound. (Fig. 8.) This gives a neat scar and the suture is readily removed if properly inserted and left in situ for at least twelve days before attempting its removal. With the exception of this subcuticular stitch, all of the ligature and suture material used is catgut. If one litre of warm saline is left in the abdomen after the operation, the patient will suffer less from post-operative thirst and shock. Just before the patient leaves the operating table, care should be taken to remove all blood-clot from the vagina, either by a douche or with gauzes. 414 GYNAECOLOGY. Treatment of Inoperable Cases. When is a case of cer- vical cancer said to be inoperable? It may be called such when there is little or no chance of a cure following opera- tion. This is where the disease has spread beyond the actual cervix, especially when the bladder or rectum are involved and where the broad ligaments are infiltrated to such an extent as to fix the organ in the pelvis. Practically, however, one is able to perform palliative operations in many such cases. Of these, more is to be hoped for from the use of the cold heat, a la Percy, than from any of the others. Percy opens the abdomen and ties off the internal illiac arteries, or, if this is not possible, the uterine vessels. An assistant grasps the fundus and steadies it. The cervix is exposed through a water cooled speculum and the diseased area is thoroughly cooked by the cautery at a black heat, until the fundus becomes too warm for the comfort of the assistant. The abdominal cavity is then closed and the cervical cavity packed with gauze which is saturated by a twenty per cent, solution of iodine with dry gauze protecting the rest of the vagina. This causes the death of all cancerous elements within reach of the heat, which penetrates to a considerable depth. The necrosed tissues separate as a slough and the remaining elements of the cervix contract to such an extent that a subsequent radical operation may be rendered possible. The essential object aimed at by this treatment is a thorough baking with the cautery, not cutting, and if too great heat is employed this aim is defeated, the red hot cautery acting as a knife. Repetition of this cauterisation may be called for at varying intervals, but care must be exerted to avoid injury to the bladder or rectum. Where it is impossible to use the Percy instrument, a similar, but not nearly so effective, result may be obtained by the use of acetone, applied directly to the diseased sur- face. Expose the cervix through a cylindrical speculum held firmly in place. Pour pure acetone into the speculum so that the cervix lies in a pool of the drug. After ten minutes la- vage. remove the fluid by lowering the outer end of the instrument and allowing it to run out into some receptacle. Wipe the vagina dry and pack it lightly with sterile gauze. These two methods of treatment check the disease and ren- MALIGNANT DISEASE. 415 der the parts moderately free from malodorous discharge and blood, and so tend to lessen the patient’s discomfort. While employing the above, daily vaginal douches are ad- visable and the best deodorant is undoubtedly potassium permanganate in a cherry red coloured solution, but tincture of iodine or any other antiseptic may be substituted. Pain will be alleviated by either heroin or morphin, given ad lib., as the woman’s condition is hopeless and it is our duty to render life as comfortable and happy as possible. The great danger at this stage of the disease is haemor- rhage, which may be so severe as to end the woman’s life and which is usually the ultimate cause of her death by draining away her strength. This may be checked by the cautery or else by packing the vagina, which, if done at all, must be done firmly and thoroughly. The packing may be assisted by the administration of calcium lactate, horse serum, or some other coagulant, giving some cardiac sedative at the same time. Life may occasionally be prolonged and made more endur- able by cutting ofT the uterine blood supply, the patient being enabled to go about her ordinary vocations and remaining free from symptoms for months after tying ofif the ovarian and uterine arteries. The uterus will obtain sufficient nour- ishment through the vaginal arteries and their branches. The writer exhibited one such case before the American College of Surgeons in Montreal in 1920. The woman’s ovarian and uterine arteries had been ligated twelve months previously. Her uterine discharge and bleeding had ceased six weeks later and when seen by the Fellows she appeared to be in perfect health and had been doing all of her own housework for several months. Curettage, as a preliminary to any of the above, is not to be advocated, as the vessels and lymphatics are opened up, allowing cancer cells to enter and to migrate to distant parts, thus favouring the occurrence of metastases. Since the discovery of the X-rays and radium, these have been vaunted as cancer cures but have been very disappoint- ing, for the simple reason that they were hailed as sure deliverers from that scourge. We are now getting down to facts and it is generally accepted that they are not infallible 416 G YN /ECOLOGY. but that they are most useful adjuvants to the knife. There are still some extremists, however, who make most extrava- gant claims for radium. Two writers, in a recent article, say that “the results of radiation in cancer of the cervix practi- cally removes this class of cases from the surgical field.” The general consensus of opinion is well summed up by R. C. Coffee, who says that there “is not yet sufficient evidence to justify the abandonment of surgery for radiation in very early cases.” In operable cases, exposure of the diseased part to either radium or the X-rays either before or after complete hysterectomy will be beneficial in warding off any recurrence. A similar course in inoperable cases usually relieves pain and clears up and checks any discharge and undoubtedly tends to improve the general condition of the patient. If it is intended to remove the uterus, it should be done within four weeks of the radiation. Where the radium is applied after removal of the parts, one must be careful on account of the cicatricial tissue which will be present or fistulae will be apt to follow. Fundus. Cancer of the fundus is practically always of the glandular type, but occasional instances of the squamous form are met with, being due to the endometrium having undergone a metaplastic change before the onset of cancerous disease. It occurs later in life than when the cervix is the primary seat, is uninfluenced by previous pregnancies and grows much more slowly. On cutting open a uterus which is the seat of fundal car- cinoma, a fungating mass is seen projecting somewhat down into the cavity, and possibly penetrating into the actual uterine wall. On careful examination, it is seen to be made up of numerous finger-like processes (Fig. 9). If a micro- scopic examination of these is made, one will observe that there has been a great increase in the size and structure of the glands. The normal cylindrical epithelium may be present but usually there will be a layer of cuboidal cells beneath and the nuclei of both are hypertrophied and usually take on a very deep stain. Each process has a delicate fib- rous supporting structure with minute vessels running into it. In some cases, the epithelium will have proliferated to MALIGNANT DISEASE. 417 such an extent as to resemble a squamous cancer. The growth may extend all over the lining of the uterus, or it may perforate the wall into the parametrium of the peri- toneal cavity. Metastases usually affect the illiac and lumbar glands but may be seen in any part of the body and, when the disease is of long duration and extensive, the inguinal glands will become affected through the lymphatics of the Fig. 9.—Cancer of fundus. Note secondary nodule (S. N.) to one side of primary. (Private collection.) round ligament. The symptoms are similar to those in cancer of the cervix. There is at first a slight haemorrhage or leucor- rhceal discharge which soon becomes more profuse and mal- odorous. Eventually the patient exhibits the usual emacia- tion and cachexia of malignant disease. On making a local examination, the cervix will often be found to be healthy. The fundus is enlarged and may be either softer than usual or quite hard; you do not get the 418 G YN /ECOLOGY. “firm” sensation of the healthy uterine wall. In those cases where the cervical canal has become occluded, with the col- lection of discharges in the cavity, the body will be markedly enlarged and fluctuation will be elicited. The treatment again consists of early and complete removal of the whole uterus, together with both sets of appendages, followed by the use of radium or X-rays, or both. The prognosis, when the case is operable, is good, a large percentage of the patients operated upon making a complete and permanent recovery. Chorioepithelioma is a malignant disease arising from the epithelium of the chorion. In all pregnancies this epithe- lium proliferates but as soon as the placenta is formed, the activity of these cells ceases. In some cases, however, they continue to multiply and penetrate the uterine tissue. This may be due to their being abnormally strong or to the pres- ence of some substance in the blood which favours their increase. Their growth then becomes irregular and un- limited, forming the malignant growth to which the above name has been applied. It was first described in 1888 by Sanger, who thought that it was of decidual origin and so called it “Deciduoma Malignum,” but, later on, Marchand discovered that it arose from the foetal ectoderm and his view has not been disputed. Etiology. Pregnancy is the great predisposing factor in the causation of this disease, but it is not essential, cases having been observed in young girls before the onset of menstruation, in elderly women and even in men. Those cases in which it does not follow pregnancy are probably due to one of two causes. Either it arises from a teratoma or there has been some inclusion by the developing ovum of trophoblastic cells which have lain quiescent until some mysterious, undetermined agency has caused their active proliferation. Hydatid degeneration of the chorion has an undoubted influence in predisposing patients to this malady. In 262 cases collected some years ago by the writer, 36.78 per cent, were seen to follow molar pregnancies; 31.80 per cent, fol- Chorioepithelioma. MALIGNANT DISEASE. 419 lowed abortions, and 26.43 per cent, occurred after full term labours. Disease of the ovaries is an important complication and occurs with such frequency as to suggest its having some influence in its production. There is usually an excessive luteal formation, especially in the generation of cysts but it%is doubtful if lutealism has any bearing on the question. Pathology. It may be seen as an irregular, diffuse, fungoid mass deeply implanted in the uterine wall and sending pro- longations between the muscular bundles. At other times, it takes the form of a ragged, ulcerating growth with villous prolongations, the uterine wall being entirely eaten through. Occasionally, it may assume a pedunculated form or it may be sessile with numerous nodules lying beneath the mucous surface, the epithelial membrane being practically intact. The tumour varies in size from that of a marble to that of a foetal head. It is usually greyish in colour with dark haemorrhagic spots, but it may be either dark green or bright red. It is soft and friable, here differing from either epi- thelioma or fibroids. Secondary deposits occur both frequently and early, ex- tension taking place by means of the blood-vessels, so that they may be seen in any part of the body but the lungs are the organs which are the first to be attacked, after which come the vagina, liver and nervous system in the above order. Histology. The typical elements of this tumour are: (1) Small well-defined polyhedral cells with large vesicular nuclei packed together in masses with no connective tissue between them, i.e., cells of Langhans layer. (2) Large multi- nucleated masses of protoplasm (plasmodia or syncitia) in which no definite cell boundaries are visible. (3) Large cells, sometimes mono- sometimes multi-nucleated, some of which resemble decidual cells, others being identical in character with the multi-nucleated giant cells which occur in decidua serotina. These, in some places, are seen to be invading and destroying adjacent tissues as in sarcomata. After en- tering the vessel, these plasmodia actively proliferate and form a thrombus which may break off and be carried to a distant part, or may remain in situ, sending cells into the 420 GYNAECOLOGY. circulation to spread the disease. In other cases, these masses become canaliculised and take the place of the original wall of the vessel. Symptoms. In the typical case, a haemorrhage which re- sists all treatment follows the expulsion of an hydatid mole, either soon after or at the expiration of months or years. The administration of drugs fails to effect a cure and even a curettage is of but temporary benefit. Examination of the scrapings may reveal nothing special, as the disease may be very circumscribed and may be missed by the curette. Where, however, there is an early recurrence of the bleeding, especially with a history of an abnormal pregnancy, be sus- picious of chorioepithelioma. Local examination will result in the discovery of an enlarged uterus which is rather soft and boggy and which will probably be of equal consistence throughout. It will be freely mobile and the appendages will be healthy. The cervix is soft and the os slightly patu- lous, but it will rarely admit the examining finger. No enlarged glands may be felt. When the disease has advanced to any degree, the patient will exhibit the usual signs and symptoms of uterine malignancy, the discharge will have become foul and she will be cachectic and emaciated. Prognosis. As a rule the patient dies within a very few months, either from exhaustion from the hemorrhages or the implication of distal and vital organs. In rare instances, spontaneous cure takes place and there are no means available as yet to determine why or in what cases it will occur. Even microscopic examination does not help one. Haultian puts forward the theory that the hjemorrhages which take place into the tissues may, at times, exert such pressure as to cut off the blood supply of the tumour and so cause its death. The only treatment is that of all malignant uterine disease, vis.: early and complete removal of the parts implicated with a subsequent exposure to radium or X-rays. CANCER OF THE TUBES. This may be either primary or secondary and is a very rare condition. The secondary is much the more common and usually results from spread of the disease from the MALIGNANT DISEASE. 421 uterus. Primary tubal carcinoma may arise from either a papilloma of the tube or degeneration of a cystic or other tubal growth. Pre-existing inflammation favours the forma- tion of cancer in the tube. It may occur in youth but is decidedly more a disease of middle life or old age. The symptoms are those of chronic tubal inflammation with wasting and cachexia. The disease being usually unilateral, the patient complains of a dull pain in one side of the pelvis. When the disease is well established, a thin, blood stained discharge is seen to exude from the uterine cavity. Local examination reveals in one side of the pelvis an elongated, usually nodular, mass which may be adherent to the pelvic wall, and which is not tender. A definite diagnosis before removal is extremely difficult, but when a patient, especially of a cancerous age, complains of pelvic pain and a blood-stained serous discharge, and ex- hibits cachexia and wasting, the presence of a nodular mass to one side of the uterus should lead to the suspicion of cancer and a clean sweep of the whole contents of the pelvis should be attempted. CANCER OF THE OVARY. Cancer of the ovary is extremely rare. It may be primary, developing from a Graafian follicle or the germinal epithe- lium, or it may occur secondarily as a degeneration of an ovarian tumour, either cystic or solid, five per cent, of these exhibiting malignant changes, or by spreading from some of the surrounding structures. There are two varieties, vis.; adenocarcinoma and medullary. Medullary carcinomata of the ovary form ovoid swellings with a nodular or smooth surface. They vary in size, but are not usually larger than the head of a foetus at full term. They may be intra-ligamentary or have a short pedicle. While the affection may be on one side only, usually both ovaries are diseased. They have a dense, well marked capsule, and, on section, show a more or less homogeneous picture with a greyish- yellow surface. Occasionally, extravasations of blood into the substance of the tumour give a mottled appearance to the cut surface. Caseous or fatty degeneration commonly 422 GYNAECOLOGY. produces cystic cavities with yellowish walls and turbid or yellow contents. Microscopic examination reveals carcino- matous cells with a fine connective tissue stroma, which may form alveoli filled with cancer cells. Ovarian adenocarcinomata strongly resemble simple serous cysts, being oval or rounded and rarely larger than an'adult head. They may have a short pedicle or lie between the layers of the broad ligament, and both ovaries are usually affected. The wall is composed of fibrous tissue which is friable and it is thickened in spots by the development of cancerous tissue. The epithelium lining the cysts may de- velope papillary outgrowths projecting into, and nearly fill- ing, the cavity. The cyst contents vary in character; they may be clear, turbid or blood-stained from haemorrhage into the cyst. It is almost impossible to differentiate between the benign and the malignant adenomatous ovarian growths, as the gradation of one to the other is so gradual. Ziegler finds no clear line of demarcation between the two, while Pfan- nensteil claims fifty per cent, of ovarian papillomata to be malignant. Metastases are commonly met with in the peri- toneum, omentum, liver, stomach, intestine, the opposite ovary and, but rarely, the pleura, in the above order of frequency. The earliest symptom may be the presence of an enlarge- ment on one side of the lower abdomen, but this is usually preceded by pain in the side, dysmenorrhoea, menorrhagcea and vesical disturbance. If the patient is untreated, cachexia and wasting follow and adhesions to surrounding parts form. Ascitic fluid is found free in the peritoneal cavity. The enlargement of these malignant tumours is very rapid. On making a local examination, an oval or rounded, usu- ally nodular mass is felt to one side of the ut.erus. It is mobile and may be either cystic or solid. The only treatment is removal of the whole uterus and both sets of appendages. SARCOMA OF THE VULVA. When sarcomatous growths attack the vulva, it is usually the labia majora which are affected, but it may develope on MALIGNANT DISEASE. 423 the clitoris (Fig. 10) or any other part of the external geni- tals. As a rule, it occurs in young women but may be seen in old age. The melanotic is the most common variety but any other form may be observed. All of the species tend to grow rapidly and also to send out metastases, which spread by the lymphatics. It most commonly appears as multiple nodules, but there may be only one. These nodules coalesce and ulcerate. They are hard, dark and rounded and originate Fig. 10.—Melanotic sarcoma of clitoris. in either warts or nsevi. The round or spindle celled variety is usually single and grows quickly, at times reaching the size of a man’s head. The only treatment is early and complete removal but they are extremely liable to recur, and therefore to be fatal. SARCOMA OF THE VAGINA. Sarcomata of the vagina are rare but are most often seen in childhood. When present in adult life, they most often appear at forty years of age or later. They may appear as a polyp or a diffuse infiltration of the vaginal wall, being either confined to one side or extending as a ring all around the 424 GYNAECOLOGY. passage which it constricts. While the growth tends to ulcerate, it rarely perforates either the bladder or rectum. Metastases take place relatively early. The tumour mass is made up of small round, spindle and giant cells but contains no muscular tissue. The patient complains of a thin, saneous watery discharge, but no pain. Inspection shows either a polyp with a broad base attached to the vaginal wall or else an area of infiltra- tion, the latter probably forming a ring around the vagina which is thus constricted. As in the case of sarcomata affecting other regions, the proper treatment is complete removal and even this is of doubtful benefit on account of the early implication of the deeper parts. This is not common at any age but when seen in early youth it is usually located in the cervix as a grape-like mass, which rapidly produces a fatal result. In women of more mature years, the fundus is frequently affected, the disease appearing as a solid growth in one wall or affecting the whole uterine body. The disease may originate in the fibrous tissue of the uterine wall or in a fibroid tumour which undergoes a de- generation into malignancy. The variety most often observed is the myosarcoma but it may be of the round or spindle celled type. Metastases occur, spreading by the blood stream to the lungs, liver, ovaries and intestinal tract. The symptoms in the adult are similar to those of carci- noma, viz.: haemorrhage, foul discharge, cachexia and wast- ing. The discharge, however, is more watery and is liable to contain small, hard, white, rice-like bodies. A diagnosis is almost impossible previous to removal and examination under the microscope, but when a woman has a rapidly growing uterine tumour with watery discharge and emaciation, the probability is that she is the subject of uterine sarcoma. The only treatment is removal of the whole uterus with the appendages as soon as the condition is diagnosed. SARCOMA OF THE UTERUS. MALIGNANT DISEASE. 425 SARCOMA OF THE OVARIES AND TUBES. Sarcoma of the tubes is so rare as not to require further mention and even ovarian sarcomata are not common, but when it is present both ovaries are affected usually, the varieties being either the round or spindle celled, the former affecting chiefly the younger females. Cohn finds that their relation to ordinary ovarian cystomata is 1 to 100 and out of 400 ovarian tumours of various kinds, 5.38 per cent, were sarcomatous. Sarcoma of the ovary may grow either very rapidly or slowly and may attain a weight of from twenty-five to thirty pounds. These tumours vary in consistence, those of the spindle-celled variety being hard, while the round-celled are soft and brain-like. They are surrounded by a capsule which may be very soft and friable. The pedicle is usually short and adhesions rarely form; but free ascitic fluid in the ab- dominal cavity is commonly observed. On section, the surface is yellowish-white or pinkish-grey, the colour depending upon the number of blood-vessels present, as well as on the structure of the tumour. Small cysts are often seen, due to haemorrhages into the substance of the tumour with subsequent softening or fatty degenera- tion of the tumour cells. The small round-celled growth is the most malignant, the danger of recurrence being much less where there is a large amount of fibrous tissue than where this is scanty. When metastases do occur, they appear in the peritoneum, stomach, omentum, pleura, lungs, uterus, liver, diaphragm and kidneys in the above order. The tumour may undergo degenerations, of which fatty and myxomatous are the most common. The symptoms are few at first, but ascites developes early and will help to differentiate sarcomata from the more benign growths. Pain and menstrual disturbances are also more common than in myomata. The physical examination yields similar results in sarcoma as in benign ovarian growths. The treatment is early removal, and the post-operative prognosis as regards recurrence is good in the hard, spindle- celled variety but not so favourable when the growth is soft and round celled. A unilateral growth gives a more favour- able prognosis than when both ovaries are diseased. 426 GYNECOLOGY. UTERINE FIBROIDS. There is a form of non-malignant tumours of the uterus which are termed “fibroids,” “fibro-myomata” or “leiomyomata.” They may be classified as “fundal” where they are situated in the fundus or body of the uterus, or “cervical” where the cervix is the seat of the disease (Fig. 11). Another division is into “intra-mural,” “sub-mucous” and “sub-serous.” Most Fig. 11.—Large cervical fibroid polyp. of these start in the centre of the wall of the uterus. If they grow equally in all directions so as to have a similar amount of muscular uterine wall all around them, they are said to be “intra-mural” or “inter-stitial.” When separated from the cavity of the uterus by the mucous lining only, or pos- sibly by a thin layer of muscular tissue in addition, they are called “sub-mucous.” If they project from the uterine wall towards the peritoneal cavity and are only covered by peritoneum, the term “sub-serous” or “sub-peritoneal” is applied to them. When they project from the uterine wall towards the peritoneal cavity, or that of the uterus, having a broad attachment to the uterine wall, they are said to be UTERINE FIBROIDS. 427 “sessile,” while if they are connected to the uterus by a dis- tinct stalk they are known as “pedunculated fibroids.” A uterine polyp is nothing more nor less than a pedunculated mass, consisting of mucous membrane or fibroid tissue, pro- jecting down into the cavity of the uterus. Fibroid tumours of the uterus are extremely common, at Fig. 12.—Multiple fibroids of fundus (sub-peritoneal). (Private collection.) least sixty per cent, of women possessing- them, although comparatively few give rise to any symptoms. They are most commonly met with in women between thirty and forty years of age. The uterus may contain but a single nodule or there may be a very large number, which vary in size from that of a hemp seed to a mass weighing thirty or forty pounds (Fig. 12). As a rule the growth is slow but at times they take on more rapid increase in size, in which case malig- 428 GYNECOLOGY. nancy must be suspected, soft, myomatous tumours found in young subjects being especially prone to a rapidity of growth. These tumours have a distinct capsule enclosing masses of fibrous tissue, arranged in whorls, with bundles of muscu- lar tissue intervening. As a rule a few very small blood- vessels are seen, the tumour being nourished chiefly through lymphatics which run between the fibrous bundles, and there are no nerves in the actual tumour. Occasionally, the cap- sule is not well defined in some one portion and when that is the case the tumour ought to be carefully examined for some form of malignancy. The true fibroid is extremely hard but when it contains much muscular tissue it may be quite soft in consistency, the density of the growth varying with the relative amount of fibrous and muscular elements present. Symptoms. The symptoms depend largely upon the posi- tion of the tumour in relation to the cavity of the uterus. However, irrespective of the location of the tumour, any fibroid which is large enough may produce symptoms of pressure or weight upon some of the neighboring structures, this depending chiefly upon the size of the tumour. The increased size, and therefore weight, of the uterus will pro- duce pain in the back or dragging pain in the sides of the pelvis. Pressure on the bladder causes irritation of that viscus, usually relieved by the patient assuming the horizon- tal position, or the pressure may be upon the urethra, causing complete obstruction to the outflow of the urine from the bladder. At times a temporary albuminuria is caused by the pressure of the tumour upon the ureter. Encroachment of the tumour upon the rectum is liable to cause irritation of the bowel or complete obstruction, the tumour acting as a ball-valve. The pelvic nerves may be subject to pressure, causing pain radiating out to the sides of the pelvis or down one or both legs, this at times simulating typical sciatica. When the growth is sufficiently large, the intestines and stomach are so interfered with as to affect the woman’s nourishment, in which case there may be great emaciation, or it may even encroach upon the diaphragm so as to impede the action of the heart and lungs. UTERINE FIBROIDS. 429 Apart from the effects of pressure, interference with men- struation is the chief symptom and this depends entirely upon the relation of the tumour to the endometrium. A tumour which is situated subperitoneally has absolutely no effect upon the menstrual function. When it is located in the substance of the uterine wall, i.e., when it is an inter- stitial growth, the menstrual flow is slightly increased in Fig. 13.—Multiple fibroids with pregnancy. (Shows fibrous structure of growth.) (Private collection.) quantity, but if a sub-mucous tumour is present there is always an abnormally profuse flow and there may even be an inter-menstrual discharge of blood from the uterus. In other words, there is always menorrhagcea and there may be metrorrhagcea. This menorrhagoea may be simply an exaggeration of the normal amount of menstruation or actual flooding may take place, the blood tending to clot, in either case. In most cases, the patient complains of intense pain, which begins some days before the expected period and lasts 430 GYNECOLOGY. until the flow has terminated. She also has a leucorrhoeal discharge. While the sub-peritoneal variety has no effect upon the fecundity of the patient, conception is unfavourably affected in the other forms of fibroid disease, probably by the un- healthy condition of the endometrium, and, where concep- tion does occur, the pregnancy is liable to be terminated prematurely (Fig. 13). In those cases where the woman goes to full term, post-partum haemorrhage is to be expected and guarded against. In some cases, Caesarean section will be required, especially where the tumour is low down in the uterus or in the actual cervix, but, unless the growth is locked in the pelvis, it is usually possible to push it up out of the way of the descending foetus. While pregnancy favours rapid enlargement of the tumour, the subsequent involution equally favours a rapid diminution in the size of the growth and numerous cases are on record where this has not stopped at the original size of the tumour but has gone on until no mass could be discovered on examination, but this happy result is, unfortunately, very rare. Various circulatory disturbances are very frequently met with in cases of fibroids of the uterus. The commonest is anaemia. This may be due to actual loss of blood, to inter- ference with alimentation or to toxic absorption from the tumour itself, although the importance of this has only re- cently been brought out. There may even be heart murmurs with irregularity and rapidity of pulse. These, however, usually disappear after the removal of the tumour and are not to be taken too seriously when considering the question of operation. Signs. The local findings will depend upon the location and number of nodules. Where the symptoms are caused by a cervical polyp, this is usually felt and seen to protrude through the external os as a cherry-red mass surrounded by cervical substance. This is usually soft and moveable. Where the polyp is small but higher up inside the uterine body, no abnormality in the fundus may be felt and the tumour may only be detected on dilating the cervical canal and exploring the cavity with the curette, or, better, with the finger. When the tumour is of considerable size, single UTERINE FIBROIDS. 431 and composed chiefly of fibrous tissue, it is felt as a very dense, hard body in connection with the uterus. It is rounded, moves with the uterus and no rhythmic contrac- tion and relaxation of the mass felt. It is non-sensitive but if the examiner happens to catch an ovary between his hand and the tumour, pain on pressure is elicited. Usually the fundus can be felt with this mass attached, but frequently the fundus is so incorporated in the mass that this differen- tiation is not always easy. Where several tumours are pres- ent, each nodule will present the above characteristics and a number will render the diagnosis more easy. If the tu- mour is composed chiefly of muscular elements, the mass will be softer and is frequently mistaken for pregnancy, and it must be remembered that degeneration of the tumour may cause the formation of cysts, in which case fluctuation is detected rendering the diagnosis much more difficult. If the growth is large enough to have risen well up into the abdo- men, palpation will teach you that it is very hard, the surface may be smooth and evenly rounded or it may be nodular, and it may dip down into the pelvis and is usually mobile. Per- cussion gives a dull note over its entire surface. The eleva- tion of the abdominal wall from the pubes takes place abruptly while its descent towards the sternum is gradual. Diagnosis. Uterine fibroids must be diagnosed from free ascitic fluid in the abdomen, tumour of some abdominal organ, ovarian growths and pregnancy, the latter being a common cause of difficulty, but in the sub-mucous variety the symptoms will usually enable one to make a definite diagnosis of fibroid. In ascitic fluid, disease elsewhere is usually found, as in the kidneys, liver, heart or malignancy or tuberculosis of the peritoneum. The abdomen is swollen but flat, with bulging in the flanks. Palpation produces the fluid wave of impact. Percussion reveals dullness in both flanks, the upper one becoming clear when the woman is turned on her side. On assuming the sitting or erect posture, a dull note will be found in the lower abdomen while the upper part gives a clear one. When the tumour springs from some abdominal organ, a history of disease of the organ may be obtained. The 432 GYNECOLOGY. fingers of the palpating hand may be passed all around it and its attachment to the liver, spleen or kidney often be detected, while in the case of a uterine growth the mass is in the lower abdomen and may be traced to the uterus. Ovarian growths are usually cystic and lie towards one side of the lower abdomen. Even where they almost fill the abdominal cavity, they tend towards one side. Usually the tumour can be separated from the uterus bi-manually. Frequently, it is very difficult to diagnose a fibroid tumour from pregnancy when one has not seen the patient previ- ously, and cases at times require the utmost care to distin- guish between the two conditions. It may be necessary to keep the patient under observation for some weeks before arriving at any conclusion. When the woman is pregnant one can usually obtain a history of such a condition, but sometimes the patient will deliberately deceive the medical man, when desirous of concealing the true condition. On examination, the usual signs are observed. The breasts are enlarged, the areolae darkened and colostrum can be ex- pressed. The abdominal swelling is ovoid, lies in the mid- line, has a smooth surface and is mobile. Prolonged appli- cation of the hands enables one to feel the rythmic contrac- tion and relaxation of the uterine wall and the movements of the child itself, but these movements may be so weak as to necessitate stimulation by cooling the hands before placing them on the abdomen. The uterine souffle and foetal heart sounds are to be heard when the uterus contains a living foetus, whereas they are absent, of course, in the case of fibroid. Careful palpation of the abdomen, enables the in- fant’s parts to be felt through the abdominal and uterine walls. On making a vaginal examination, the vaginal mu- cosa is seen to be congested and of a dark colour, the cervix is soft in its entire circumference and ballottment can frequently be elicited. Changes, Complications and Degenerations. Fibroids, like all other abnormalities of the body are apt to undergo changes and degenerations of various kinds. Of these, hy- aline is the most common. It may be so extensive as to form distinct spaces, imparting a cystic character to certain areas of the tumour, spoken of by some as “cystic degenera- UTERINE FIBROIDS. 433 tion.” Obstruction to the circulation, often causes a trans- udation of serum into the tumour substance, producing an oedematous condition. In some cases, calcareous particles are deposited in the capsule or throughout the actual sub- stance of the tumour, forming calcareous plaques or nodules, but the whole growth rarely becomes ossified. In other cases, the tumour elements undergo a change into fatty tis- sue, causing the growth to become rather softer and its cut surface to present a yellowish colour. Necrosis often follows interference with the blood supply of the mass. Where no infection takes place, the tumour simply disintegrates, caus- ing but little, if any, general disturbance, in which case the condition is spoken of as “necrobiosis.” At times, however, the woman who is the subject of this condition feels below par and the tumour becomes painful and, at times, of softer consistence. If germs do manage to reach the necrosing growth, an abscess formation is set up with the usual symp- toms of pain, fever and local tenderness. A comparatively common change is for the fibrous tissue to become sarcomatous, Winter stating that no less than four per cent, of myomatous tumours become sarcomatous. While carcinoma cannot start from the tumour substance itself, it containing no histological elements favourable to such formation, it not infrequently becomes implanted on a previously existing fibroid from some neighbouring tissues. In nearly 5000 cases collected by Kelly and Noble, cancer of the cervix was found in one and one-quarter per cent, and in the fundus in one and one-half per cent. Any pedunculated fibroid, whether sub-mucous or sub- serous, may have its pedicle become twisted so as to become necrosed from interference with its blood supply, or the torsion may be so acute as to cause complete separation of the growth. In such a case, if it is sub-mucous, it simply comes away, but in the sub-peritoneal variety the twisting may be very gradual and the tumour become attached to some other structure from which it will receive its nourish- ment, so that its original location is only discovered with considerable difficulty. After the establishment of the menopause, fibroids tend to become smaller and in a few cases they entirely disappear. 434 GYNAECOLOGY. This also takes place, and more’ actively and often, after the termination of pregnancy. Treatment. Should every fibroid tumour which one finds receive treatment? This is a mooted question. Some au- thors hold that, just as all ovarian tumours are removed as soon as discovered, so all fibroids ought to receive the same treatment. It must be remembered that they are fre- quently discovered when looking for some other pelvic con- dition, the tumour having given rise to no symptoms. When that is the case, it is best to ignore the presence of the growth and to say nothing about it to the patient, but it is well to inform the woman’s husband or nearest relative for one’s own protection. However, where a uterine fibroid is giving rise to any symptoms, either mental or physical, as where the patient is worried over its presence, it ought to receive some kind of treatment directed to its cure. There are two methods of treating uterine fibroids, vis.: operative and non-operative. Where the woman’s condition does not warrant any extensive operation, palliative methods are to be employed. Her debilitated condition is probably due to loss of blood, so that the first indication is to combat that. The patient must be put to bed at complete rest and be given treatment which will check the loss of blood. It will be well to give her a sedative of some kind to quiet the circulation, and one of the best of these is heroin, giving Yio grain hypodermically every five or six hours as indi- cated. Some preparation of ergot, or its active principle, ergotine, may be used, but these often aggravate the con- dition. Pituitrin, in doses of 0.5 cubic centimeters, is often beneficial. This is best administered by injection deep into a muscle as it is then much less irritating than when injected more superficially, and may be repeated thrice daily for three days if necessary. Quinine or cotarnine hydrochlorate (“Stypticin”) in % grain doses every four hours, either alone or combined with some other previously mentioned drug will often be found to be efficacious. The coagulation of the blood is favoured by the administration of horse-serum subcutaneously or by giving calcium lactate by mouth. A good form of treatment, is to order a capsule containing: calcium lactate, ten grains, ergotini, one grain; two capsules UTERINE FIBROIDS. 435 to be taken as a first dose and then one every four hours for six doses. If the calcium is used for too long a time, it loses its effect. Local applications to the interior of the uterus are some- times employed. Of these, the favourites are tincture of perchloride of iron, carbolic acid, adrenalin and alum, either in a saturated solution or as the dry powder. Where the above methods fail, recourse must be had to some more active measures. As the blood comes from the abnormal endometrium, this may be removed by curettage, which may be repeated every two or three months, according to indications, until the woman has recovered sufficient strength to undergo some form of curative operation. Of late years, radium and the X-rays have been added to the armamentarium of the gynecologist and each has its place, but only as an adjunct to surgery. Neither should be employed where the tumour is the size of a three months pregnant uterus or when malignant disease cannot be ex- cluded with absolute certainty. Nor ought they to be used in young women, on account of the danger of the production of sterility. In the older females they are useful in checking haemorrhage and some enthusiasts claim that cures may be obtained by these means but it must be remembered that fibroids of the uterus tend to shrink spontaneously after the menopause. A combination of the two is recommended by Weibel, who leaves 50 milligrammes of radium in the poste- rior fornix for forty hours and in conjunction with this uses sixteen fields of X-ray for ten minutes each. He claims that failures to check haemorrhage are almost nil, although a repetition of the treatment is sometimes required to secure a perfect result. Other radiologists prefer the intra-uterine application of the radium. Where the tumour is extremely large, advantage may be taken of the knowledge that many fibroids diminish in size after the menopause. Therefore, if a woman cannot stand a prolonged operation and something rather radical has to be attempted, the removal of both ovaries will often produce the desired result. This operation is especially valuable when there is dangerous pressure, for example upon the urethra- causing obstruction to the outflow of the urine, the tumour 436 GYNECOLOGY. at times rapidly and markedly shrinking after operation, but on account of the improved technique of modern surgery this is rarely resorted to at the present time. The radical treatment of fibroids consists in either remov- ing the tumour without the uterus or taking away both the uterus and growth at the same time. When the latter opera- tion is chosen, two things are to be considered, first the treatment of the appendages and secondly the condition of the cervix. Where the ovaries are healthy and the patient has not passed the menopause, one or both should be left. If, for technical reasons, it is found necessary to remove them both, one may be implanted either in the body of one of the recti muscles, where it will receive the best nourish- ment, or one broad ligament may be split and the ovary buried in the substance of the ligament. This will preserve the secretion of the ovary and so postpone the menopause and also lessen its effects when it does appear. Now and then, a woman presenting the usual symptoms of a sub-mucous fibroid, will call on the physician. On ex- amination, a small fibroid polypus will be found to be pro- truding from the external os, while the uterus gives no further evidence of fibroid disease. In such a case, sterilise the vagina and grasp the polyp with a strong tenaculum forceps and gently but persistently twist it off. This may be done in the office without fear of any untoward result. It is not painful and never gives rise to bleeding of any consequence. If there is any haemorrhage at all. it can readily be controlled by the local application of any styptic. This simple treatment will save many a woman much ill-health and unnecessary mental perturbation. Where the polyp has a broader base or is inside the cavity of the uterus, a more extensive operation is required for its removal. With the patient anaesthetised and in the lithotomy position, carefully sterilise the vagina and the external parts well out from the field of operation. Empty the bladder by a catheter and expose the cervix by a perineal retractor. Grasp the posterior lip of the cervix by a strong pair of curved tenaculum forceps and draw it down as far as pos- sible. Now determine the lower limit of the bladder by a sound introduced into that organ. Make an incision through UTERINE FIBROIDS. 437 the vaginal mucosa across the anterior lip of the cervix just below the vesicle attachment and dissect the bladder well up from the anterior surface of the uterus. The cervix and anterior wall of the uterus are then split in the middle line as far up as is necessary to allow of access to the pedicle of the tumour. This is then dissected away from the uterine wall and the remaining cavity closed by a continuous catgut suture, after which the edges of the divided uterine tissue are brought together by interrupted sutures of the same material and the incision in the vaginal mucosa closed in a similar manner. The uterine cavity is now douched with normal saline solution to remove any blood or detritus and the vagina is lightly packed with gauze. If the tumour is sub-mucous and sessile and situated in the lower part of the uterus, it may be removed by a similar procedure to that described for the intra-uterine polyp, but if it is larger than a two months pregnant uterus, it is better to attack it through the anterior abdominal wall, the opera- tion being termed “myomectomy.” In this case, place the woman in the Trendelenberg position with the table so placed that the best possible light will be thrown into the pelvis when the abdomen is opened. The abdominal wall is care- fully sterilised from the pubes to well above the umbilicus and from one side to the other, and the bladder emptied by a catheter. The incision through the skin and subcutaneous tissue is made in the median line between the pubes and umbilicus, making it as long as necessary for the comfort of the operator, which will depend upon his skill and the size of the growth. Control all haemorrhage in the sub- cutaneous tissue by means of forceps, it being rarely nec- essary to place ligatures on any vessels. The rectal fascia is then incised so that the sheath of one muscle is opened up. Separate this muscle from its fellow of the opposite side, using the fingers or the handle of the scalpel for this. The sub-peritoneal tissue is dissected through until the shining peritoneum is exposed. This is caught by two pairs of for- ceps, one on each side, and an opening in it is made between the two. The greatest care must be exercised not to include the bowel in the forceps or it will be wounded. Once the abdominal cavity is opened, the bowel and omentum will fall 438 G YN /ECOLOGY. away from the anterior wall and the incision may then be enlarged by a small pair of bandage scissors. The intestines and omentum are then pushed well up into the abdomen and retained there by large tape gauzes, each tape being caught by forceps to prevent it from entering the peritoneal cavity. The uterus and tumour are then brought up as well as pos- sible into or through the incision and held there by strong tenaculum forceps. Some operators drive a broad bladed corkscrew into the substance of the tumour and steady it by that means but the forceps are at least as good and may be used in other steps of the operation, thus diminishing the number of instruments required. An incision is made over the most prominent part of the tumour where there are the fewest blood-vessels. It is carried through the uterine wall, down to and through the capsule of the tumour, which may then be readily shelled out by the fingers or some blunt instrument, as the handle of the scalpel. If the bleeding is excessive during this procedure, an assistant can control it by compressing the uterine arteries through the broad ligaments. At times the tumour is covered by a com- paratively thick layer of uterine muscle, from which free haemorrhage is seen. This is best checked by grasping the whole thickness of the uterine wall surrounding the bleeding points by strong double toothed tenaculum forceps, which may remain in situ until ready to insert the sutures. Now palpate the whole uterus carefully to make sure that no other fibroids are present, and if there are any they can usually be treated in a similar manner. After all have been excised, close each cavity with care so that there will be left no dead spaces in which blood or serum can gather, as any such collection favours sepsis. This object is attained by using one or more layers of continuous catgut sutures. When each cavity is closed, the divided peritoneal edges are inverted by interrupted sutures of the same material. The pelvic cavity is wiped clean, the field of operation carefully scrutinised for any bleeding points which are to be secured if present, and the tape-towels are removed from the abdo- men. The incision in the abdominal wall is now closed by three separate continuous sutures of catgut, using one each for the peritoneum, the rectal fascia and the subcutaneous UTERINE FIBROIDS. 439 tissue. The edges of the skin are now united by a sub- cuticular stitch of silkworm-gut. By means of a straight needle, this is inserted through the skin at the lower end of the incision and brought out in the incision. It is then carried across from one side to the other until it finally emerges through the skin at the opposite end of the cut. In going up the wound, care must be taken to pass it just beneath the actual skin, in a sweeping manner outwards, so as to secure a substantial amount of tissue in the stitch, and finally not to cross to the opposite side too acutely, as this would kink the suture and render its withdrawal more dif- ficult. The incision is dusted with dry boracic acid and the ends of the silkworm-gut tied loosely over several layers of gauze so as not to produce tension on the skin, which would favour sloughing. A good layer of absorbent cotton is placed over this and the whole dressing kept in place by strips of adhesive plaster applied firmly. The wound will not require to be disturbed until the stitch is removed on the twelfth day, unless there is some special indication. This may be considered a long time for a stitch to be left in place but by that time the gut will be found to have become com- paratively free and so can be more readily withdrawn than if it is attempted earlier. It is always best to leave the*uterus in situ if the woman is in the child-bearing age, as a myomectomy has absolutely no ill-effect upon a subsequent labour or pregnancy. Large tumours have been removed and yet the patient has subse- quently given birth to children without any special trouble during the whole pregnancy or delivery. Where for any reason the removal of the uterus has been decided on, the question of what to do with the cervix comes up. Should it be left in the pelvis, or ought it to be removed? Where it is in any way abnormal, as inflamed or lacerated, it ought to be taken out, but when it is quite healthy most operators are satisfied with amputation of the uterus at the level of the internal os. It must always be remembered, however, that the cervix is the seat of seventy-five per cent, of all uterine cancers, so the patient’s family history regard- ing malignant disease may influence one’s decision. In fact, Richelot and Tuffier both maintain that total, or pan-hyster- 440 GYNECOLOGY. ectomy, is preferable to myomectomy, unless the fundus can be left in condition fit for pregnancy, on account of danger of the subsequent development of cancer. The old argument that the cervix was the key-stone of the arch, and therefore should be left, is untenable, as the roof of a soft arch cannot be secured by any key-stone. The cervical stump rather tends to weigh down the roof of the vagina, if left to itself, but shortening of this passage will be prevented by suturing the stump of each broad ligament to the cervical flaps or, if the cervix has been removed, to the vaginal walls. Where the tumour is very large, involving the greater part of the uterus, or there are very many nodules present, hyster- ectomy, removing the uterus with the tumours, is indicated. After preparing the patient and opening the abdomen and packing off the pelvic cavity with tape-gauzes as before, lift the uterus through the incision if possible. Pass a double ligature (all ligatures used will be catgut except the sub- cuticular suture, which will be silkworm-gut) through one broad ligament just below the tube. The ligatures are drawn well apart so as to leave as much tissue between them as possible. One is tied around the Fallopian tube and round ligament close to the uterus, while the other embraces these structures nearer the pelvic wall. The tissue is then divided between the two, leaving a good button on the uterine side of the outer ligature to guard against its slipping. Continue the division of the broad ligament as far down as may be possible without endangering the uterine artery. A similar procedure is carried out on the opposite side of the pelvis, both ovaries being left if healthy. If either ovary is to be taken away, the outer ligature is passed around the broad ligament to the distal side of the ovary and the ligament is divided between the ovary and the ligature. The fundus is then drawn well back, so as to expose the utero-vesical pouch. The situation of the reflexion of the peritoneum from the fundus to the bladder is indicated by a whitish line. An incision is made joining the lower extremity of the division of each broad ligament and passing across the front of the uterus just above the vesical attachment. The flap of peri- toneum forming the utero-vesical pouch, together with the bladder, is dissected off the anterior surface of the uterus UTERINE FIBROIDS. 441 and upper part of the vagina. Each uterine artery is sought for where it approaches the uterus and ligated and, after they are both secured, each is divided in turn. Before doing so it is well to have a strong clamp in readiness to grasp any vessel which has been missed by the forceps. The lower part of the broad ligament is now pushed well out from the cervix and vagina, thus avoiding any danger to the ureter. The fundus is now drawn toward the pubes and a flap of peritoneum dissected off the posterior surface of the cervix and upper part of the vagina. When the cervix is to be left, one side of it is caught in a tenaculum forceps to steady it and it is cut across in such a manner as to leave a V-shaped cavity and the uterus is removed. The cervical flaps are brought together with a continuous suture and the stump of each broad ligament is attached to the remains of the cervix, after which the anterior and posterior peritoneal flaps are united so as to leave no raw surfaces to which adhesions could form. If the cervix is to be removed, instead of cut- ting it across, thrust the knife through the anterior vaginal wall and divide it all around the cervix, thus entirely freeing the uterus which may then be lifted out of the abdominal cavity. The vaginal flaps are united by a continuous suture, the stumps of the lateral ligaments attached to them and the whole field of operation covered by uniting the anterior and posterior flaps of peritoneum. The pelvis is now wiped dry and any bleeding points which are found are secured. The tape-gauzes are removed and the abdominal incision closed in layers. Some operators, in addition to suturing each division of the abdominal wall, insert two or more stay sutures through the whole thickness of the wall in order to prevent the possibility of rupture of the wound before com- plete union has taken place, but in an experience of nearly thirty years the writer has never found this to be necessary. The greatest care, however, is taken to secure exact appo- sition of the edges of each layer and also of the different layers to each other and that there are no bleeding points in the walls of the incision. After all major operations upon the pelvic viscera which are performed through the anterior abdominal wall, it will be found that the patients make a much better recovery, 442 GYNAECOLOGY. both immediate and permanent, if they are kept in the re- cumbent position for from nineteen to twenty-one days after operation. In most cases, there has been considerable de- struction of tissue and dislocation of parts and it takes time for these to heal properly and to become accustomed to their new relations. Many also produce considerable shock to the nervous system, for recovery from which a considerable period of rest and quiet is necessary. TUMOURS OF THE OVARY. The ovary is divided into the oophoron, or part containing the ova, and the par-oophoron, of which, as one would imagine from its superior activity, the former is the most important from a pathological point of view. From it are derived the fibromata, myomata, sarcomata, carcinomata, cysts, adenomata and dermoids. The papillomatous cysts spring from the par-oophoron and from the parovarium are developed thin walled unilocular cysts. Of the above tu- mours, cystomata form about ninety-five per cent, and most of these are of the multi-locular type. For the benefit of the general practitioner, these tumours may be classified as benign or malignant, any variety oc- curring during middle life. The benign tumours comprise the fibroids, myomata, ordinary cystadenomata, and der- moids, while the malignant ones are the carcinomata, sarco- mata and malignant papillomata. Of these, the two first have been considered, leaving cystomata and malignant papillomata to be described. Ovarian Papillomata. Papillomatous cysts of the ovary are simply cysts of that structure containing papillary masses, although in one variety the papillae project into the peritoneal cavity and not into that of the tumour. The papillae may be few in number or completely fill the cavity of the tumour, multiplying so rapidly at times as to cause rupture of the cyst. They are pedunculated and vary from simple papillae to complicated branching processes, which may be either white or of a pink colour, the latter depending on the number of blood-vessels present. The tumour is usually soft but may contain sand-like bodies which cause the growths to TUMOURS OF THE OVARY. 443 feel gritty. When they have perforated the cyst wall, they are liable to affect neighboring structures. The cyst usually contains a clear, thin, watery fluid of a yellow colour and alkaline reaction with a specific gravity of 1005 to 1040 and which does not coagulate on standing. It responds to tests for albumin. The microscope reveals the presence of epi- thelial elements, compound granular bodies and, sometimes, cholesterin and haematoidin crystals. In some cases, the fluid may be dark and turbid or even grumous and the mother cyst may contain daughter cysts, in one of which the contents are dark and turbid, while in another they will be clear and thin. The wall of the cyst consists of three layers, an outer one which is thin and is composed of lam- inated tissue, a few cells and sometimes non-striped muscle. The next layer is thicker in texture and contains more cells than the former. There are blood-vessels in both of these layers. Internally is a stratum of epithelial cells which may be of any shape and may or may not bear cilia. It usually rests upon a thin basement membrane. The stroma of the cyst wall is continued up into the papillse, into which it carries blood-vessels, which are thus able to pour out serum into the cavity of the cyst. The previously mentioned sand- like bodies are called “psammomata” and consist of con- centric rings of carbonate and phosphate of calcium. Papillomata may extend from their primary site by any one of three methods, vie.: by direct extension to contiguous structures, by fragments broken off from the papillae attach- ing themselves to other objects or, lastly, by true metastatic formation. The diagnosis of the pathological nature of papillomatous cysts before operation is impossible, but Freund considers that the simultaneous appearance of ascites and hydro-thorax is presumptive evidence of ovarian papillomata. The symptoms may not be manifest until the disease has been present for some time. The patient will usually com- plain of a dragging pain in the lower abdomen, probably more to one side than the other, together with enlargement of the abdomen, the latter increasing rapidly in size. On examination of the abdomen, a cystic tumour is felt to one side in the lower quadrant. Percussion will give a dull note 444 GYNECOLOGY. in the flanks, which dullness moves with the position of the patient. When the growth is malignant, the patient will be thin and emaciated. The only treatment is removal, intact if possible, through an incision in the anterior abdominal wall. Fibromata and Myomata. Both of these tumours are ex- tremely rare and are seldom pure fibrous tissue, usually being mixed with muscular in the same tumour. They have a similar structure to those occurring in the uterus. The whole ovarian stroma may be replaced by the growth or it may be spread out over the surface, but in some cases it is in the form of a pedunculated mass attached to the surface of the ovary. This disease attacks but one ovary as a rule. The symptoms are often absent until the tumour has been present for a considerable time. When they do manifest themselves, the woman complains of a dragging pain in the pelvis, painful menstruation and enlargement of one of the lower quadrants of the abdomen. Ascites is frequently pres- ent but this is not a constant symptom. The growth being freely mobile is liable to have the pedicle become twisted with the usual symptoms accompanying that condition, viz.: pain, tenderness, rapid increase in size of tumour, elevation of temperature and rapidity of pulse. The torsion may be so acute as to cause complete separation of the tumour. A local examination of the pelvis reveals the presence of a hard, rounded mass to one side of the uterus, the tumour being very mobile but not sensitive. The only treatment is removal as it is apt to take on sud- den and rapid growth and is very difficult to diagnose from ovarian sarcoma. Ovarian Cysts. Cystomata of the ovaries may arise from the infolding and downward prolongation of the germinal epithelium covering the ovary or from enlargement of fol- licles which have failed to rupture, this failure being due to the thickness of the outer coat of the ovary. Herman said that the latter theory is “such a simple and natural way of explaining the development of ovarian tumours that one would think any other must apply to exceptional cases,” and there is much wisdom in this statement. It is not known why some follicles remain small while others grow to an TUMOURS OF THE OVARY. 445 immense size. These cysts may be seen at any age or in any condition of life, blit women who have had small fami- lies are supposed to be especially liable to them. The size varies from that of a hen’s egg to the cyst reported by Knight, the tumour weighing 111 pounds while the patient herself turned the scale at 87 pounds after the removal of the growth. Hydrops Folliculi. This is where one or more ovarian follicles becomes distended with fluid, forming a tumour the size of a cherry and globular in character. Several of these may project from the surface of the ovary, producing a grape-like mass attached to the ovary by a pedicle. This mass receives the name of Rokitansky’s tumour, is quite rare and, when present, affects both ovaries. Neoplastic Cysts. Most ovarian cysts are of the prolifer- ating variety and are of two kinds, according to the nature of their contents. One contains a thin, clear, serous fluid and so is called a “serous cyst,” while the contents of the other are dark and turbid and contain a substance called “pseudo-mucin,” which gives rise to the term “pseudo- mucinous cyst.” These pseudo-mucinous cysts form the greater number of cystic growths of the ovary. They are unilateral and vary in size from that of a hen’s egg to a mass weighing between 240 and 250 pounds, but now it is most uncommon to meet with one which is more than thirty pounds in weight, as they are usually removed as they are discovered. No age beyond puberty is free from liability to the occurrence of these tumours but they are more often seen in sterile or unmarried women between the ages of thirty and forty-five than in younger females or those who are the mothers of large families. In shape, they are usually ovoid with a sur- face which is either even or else lobulated, the latter being most common in small tumours containing subsidiary cysts, called “daughter cysts.” The colour is bluish or purplish white and they have a glistening surface with blood-vessels coursing over it. At times, bands of unstriped muscle run over the surface with patches of ovarian tissue flattened out on them. 446 GYNAECOLOGY. When the tumour is opened up and the inside examined, the cyst may be found to consist of a single sac, but careful inspection usually reveals bands running through it or over the walls, these bands being the remains of daughter cysts which have ruptured. When several loculi are present in a tumour, their contents may vary from ordinary thin, serous fluid to a substance of a gelatinous nature, which is viscid and requires to be scooped out by the hand. If the tumour is large, the inner surface of the sac is generally smooth, the internal pressure causing atrophy of the epithelium, but in the smaller cysts small papillae and other excrescences may be observed. This lining is composed of cylindrical epithelial cells, implanted on a basement membrane which is composed of fibrous, ovarian and, sometimes, unstriped muscle tissue, the whole being covered by germinal epithelium. Serous cysts are much less common and not so large. Ex- ternally, they resemble the pseudo-mucinous variety but have a greater tendency to become adherent to the bowel or other neighboring structures. They are usually multilocular but contain fewer subdivisions than the first variety. They con- tain a clear, thin, yellowish fluid, with a large proportion of albuminous material in it, this being produced partly from the blood-vessels and partly by the epithelial lining of the cyst. The wall is composed of similar elements to that of the pseudo-mucinous variety, the epithelium being columnar and ciliated. The Symptoms of Ovarian Cysts. The patient may simply have a feeling of weight or fullness in the lower abdomen, or her first knowledge that there is anything wrong may be the appearance of a swelling in the abdomen below the um- bilicus. This may produce no interference with menstrua- tion, so that when this suddenly ceases one should be on guard in case that the condition is one of pregnancy. At times, however, the flow is increased, in which case endome- tritis will usually be found to be present. The physical signs will vary with the size of the tumour and the nature of the contents. Where it is sufficiently small to be confined to the pelvis, bi-manual examination, will reveal the presence of an ovoid, tense, cystic swelling to one side of the uterus, but it may lie in the middle line, in TUMOURS OF THE OVARY. 447 either case a downward bulging of the vaginal fornix being produced. When the tumour has risen out of the pelvis, it rests upon the brim, in which case the uterus will be de- pressed in the pelvis and readily reached by the examining finger. Inspection of the abdomen, shows an enlargement in its lower half, usually to one side of the middle line, this enlargement being either evenly ovoid or nodular. Upon palpation, the mass is felt to be tense but fluctuating, al- though when the contents are of a gelatinous nature a soft doughy sensation, similar to that found in uterine myomata, will be imparted to the hand. If the cyst is unilocular, or has one loculus which is much larger than the others, with a very thin wall, a thrill may be obtained by flicking one side with the finger while the other hand is pressed firmly against the opposite side of the abdomen. This impact may be intensified by causing an assistant to produce firm pres- sure with the side of one hand over the centre of the swelling. Percussion will show that the intestines are pushed well up in the abdomen and also outwards to each side, the flanks usually giving a clear note, except in the case of a very large growth filling up the whole of the abdominal cavity. Aus- cultation gives a negative result. The diagnosis is not difficult as a rule when the tumour is small and is confined to the pelvis, the peculiar tense, semi- fluctuating sensation which is imparted to the examining finger by an ovarian cyst being felt in practically no other condition except hydro- and hsemato-salpinx or encysted peri- toneal fluid. In the two first named conditions, the mass is elongated or sausage-shaped instead of being ovoid, while encysted peritonitis does not present the well defined out- lines of a cyst. Of course, a par-ovarian growth may be mistaken for an ovarian cyst but a differential diagnosis is not essential as the treatment is similar in both cases. After it has risen out of the pelvis, it may be mistaken for ascites, distended bladder, some form of uterine growth, cyst of the mesentery, some renal condition, a phantom tumour or pregnancy with hydramnios. In ascites, unless it is encysted, you will obtain a history of some disease of the heart, liver or lungs which might produce the intra-peritoneal fluid. The flanks will be seen 448 GYNAECOLOGY. to bulge outwards and the swelling does not stand up promi- nently, as in the case of an actual tumour. Percussion gives a clear note over the centre of the abdomen with dullness in the flanks which will disappear from the uppermost loin when the woman lies on one side. A distended bladder occupies the middle line of the lower abdomen, appearing as a pyramidal mass above the pubes. There is generally dribbling of urine and careful catheterisa- tion of the bladder will clear up all doubt as to the condition present. Uterine tumours are hard and palpation fails to elicit fluc- tuation. It moves with the uterus and the cavity of the latter is enlarged. If the tumour is one of the interstitial or sub-mucous varieties, the menstrual flow will be increased. In the case of a fibro-cystic tumour of the uterus, fluctua- tion may be obtained if the degenerated portion is large, but the growth can usually be found to be connected with the uterus and the condition is extremely rare. Mesenteric cysts lie in the centre of the abdomen and per- cussion gives a clear note all around them. Careful deep palpation does not reveal any pelvic connection. Any enlargement of the abdomen caused by renal tumours will have proceeded from above and downwards to one side. Here again deep palpation will prove of value in excluding any pelvic connection and in tracing the tumour down into one or other flank. True phantom tumours are very rare and will disappear completely when the woman is deeply anaesthetised. In pregnancy with hydramnios, the history will usually be found to be sufficient, but where in doubt the action of the uterine wall will furnish valuable information, as, in the case of gestation, rhythmical contraction and relaxation will be felt, this being absent where the mass is an ovarian cyst. You also will feel the foetal movements and hear the child’s heart. The cervix will be soft and the vaginal mucosa dis- coloured, although there may be some congestion of the vagina in the case of any tumour pressing upon them. Complications of Ovarian Cysts. Any organ in the body may become affected synchronously with the occurrence of an ovarian cyst, but the complications most frequently en- TUMOURS OF THE OVARY. 449 countered are albuminuria, ascites, adhesions, pregnancy, rupture of tumour and torsion of the pedicle. The co-existence of pregnancy and ovarian cyst produces a most grave condition and requires great care before, dur- ing and after labour. If the tumour is large, abortion is very apt to result. The tumour may rotate, causing torsion of the pedicle, owing to some change in the intra-abdominal pressure. This is sometimes followed by infection and sup- puration of the cyst. When the pregnancy goes on to full term, the foetal and maternal mortality is high. In 271 cases of ovarian tumour complicating labour, the maternal mor- tality was found to be twenty-five per cent, and that of the foetus seventy-five. Torsion of the pedicle is not uncommon, especially in cases of dermoids, probably on account of the difference in the density and weight of the various parts of the tumour. The symptoms of this complication are the sudden onset of an acute pain in the lower abdomen, followed by rapid increase in the size of the tumour due to obstruction to the return circulation causing an exudation of blood into the cavity of the cyst. The abdomen becomes tender and the woman may show evidence of profound shock, the respirations becoming rapid and the pulse small, thready and rapid with a subse- quent rise of temperature. When the onset is more gradual, there may be few or no special symptoms, but the pain will be increased. The only treatment is to remove the tumour by an abdominal section. Rupture of the cyst may occur and be followed by its complete disappearance or it may refill. When the contents are either of an irritating nature, as in the case of a dermoid, or malignant, general peritonitis or secondary infection of the peritoneal cavity may take place. Nervous and Mental Diseases BY NATHANIEL S. YAWGER, M. D. Consulting Neurologist to the Norristown State Hospital and to the Penn- sylvania Eastern State Penitentiary; Member of the American Neuro- logical Association; Formerly, Neuropathologist to the Pennsylvania Ep- ileptic Hospital and Colony Farm, and Assistant Neurologist to the Philadelphia General Hospital. Nervous and Mental Diseases. INTRODUCTION. Lombroso, who was sometimes right, claimed for men of genius, longevity. He believed their diminished affection and their apathy toward many things in life, served as a shield from the worries that harass the minds of less gifted men. Obviously, the state of undue solicitude makes for unhappiness, promotes disease and shortens life, and the be- lated regret of an aged man should be an admonition to others. He said: “I am an old man and have had many troubles, but most of them have never happened.” That even middle life does not take sufficient care of itself is abundantly shown by the many lives which through ner- vous disorders and diseases have burned out before their time. If one may believe their biographers, Dickens died at fifty-eight, of apoplexy; Shakespeare at fifty-two, of some nervous disorder, while the average life of his brothers and sisters—there were eight in all—was less than thirty-two years; Pascal, who had headaches, hallucinations, phobias and convulsions, died at thirty-nine; Burns, who lived in an extremely convivial age, did not learn to control his appe- tite and so brought himself to the grave at thirty-eight; and Poe, a similar delinquent, died at the same age; Mozart, who was drunken, at times delirious and delusional, died at thirty-six of inflammation of the brain; Byron, against whom the indictment is long, was licentious, a glutton, a sot and perhaps epileptic, and he also passed away at thirty- six; it is said that Chatterton was the most precocious of all literary geniuses—he committed suicide in his eighteenth year. However, this premature destruction and decay does not prove Lombroso in error, since the list of men who attained advanced life is much longer, and beside those to whom reference has been made lived at a time when hygiene was 454 NERVOUS AND MENTAL DISEASES. little known and less practiced, nor could they avail them- selves of present-day scientific prevention of disease and of our many measures for combating sickness when acquired. Since those days statisticians tell us that life has been ap- preciably lengthened and this despite the fact that we are keeping alive many weaklings who formerly could not have survived. In nervous and mental diseases, more than in any other department of medicine, is one confronted by the serious problem of heredity; but as yet the prevention of many dis- orders is not possible by means of the control of parentage, and, therefore, our work in part must at times be the care of individuals who are somewhat handicapped. Often the cause of much mischief dates from childhood at which period neurotic children should receive scrupulous attention in matters of general hygiene; they should not be pampered but should be judiciously disciplined and taught self-control; they should not be subjected to undue strain in the school- room. Exceptional children also should be given special consideration lest their possibilities be thwarted, since the gift of acquiring knowledge so readily leaves them with much idle time, which may be the means of their falling into vicious habits. A few diseases are directly inheritable, but more frequently in the offspring of bad nervous stock a variety of disorders are found asserting themselves, such as neurasthenia, psych- asthenia, hysteria, hypochondria, insanity, epilepsy, mental deficiency, alcoholism and other addictions, eccentricities of character, gross immorality, and even the greatest of moral obliquities, crime. The nervous and mental diseases of middle life are also concerned with such factors as excessive mental and physical strain, since it is at this time that the maximum effort is made; with traumatism, infections, general diseases, poisons, refrigeration, neoplasms, excess or deviation of sexual relations, dysfunction of the endocrine glands; also disturbances incidental to the involutional period of both sexes and in the malconditions sometimes consequent upon an artificially induced menopause. These numerous affections call for the employment of therapeutic measures that vary widely. Cerebrospinal syph- NEURASTHENIA. 455 ilis must receive prompt, vigorous and persistent medication; sometimes neurasthenia may be overcome without the use of drugs but through the application of rest and other physio- logic procedures;.in psychasthenia, unless complicated, work need not be discontinued, though often a change is desirable and in addition a hobby should be cultivated; hypochon- driacs should not be permitted more than the normal amount of rest but they should be strenuously urged to occupation, including, if possible, a fad; the insane may at times be treated extramurally, as in some of the melancholias, though where expense is an important item and self-destruction is imminent, institutional care is advisable; with paranoiacs who sometimes are so dangerous to others, institutional de- tention is often imperative; a few alcoholics and drug addicts and many degenerates belong in penal institutions where they are not infrequently found. There is left a group of individuals who always have been, and always shall be “nervous,” but in whom a breakdown may be obviated by the constant observance of common- sense rules of general hygiene, such as bodily cleanliness, suitable exercise, proper work, amusements, fresh air, nu- tritious food, general sobriety, the avoidance of intimate contact with invalids, and the cultivation of self-control. Want of space has prohibited more than a brief discussion of the diseases of this period, and but the mere mention of such measures as psychoanalysis, occupation therapy, hydro- therapy, massage, electricity and technical laboratory pro- cedures. FUNCTIONAL AND GENERAL DISEASES. NEURASTHENIA. Neurasthenia, the fatigue neurosis, or as it is familiarly known, “nervous exhaustion,” is usually a disease of adults and is perhaps more frequent in men. Occurring in middle life the disorder is somewhat prolonged, since at this time the metabolic and nutritive processes are noticeably lessen- ing in their activity and, besides, the nervous system does not show the resiliency of an earlier period. 456 NERVOUS AND MENTAL DISEASES. Those predisposed to neurasthenia have come of unhealthy ancestors who often, though not necessarily, were subject to disorders of the nervous system. Perhaps the parents were of somewhat advanced age at the time of conception, or the mother during pregnancy may have been subjected to undue stress. Among the many exciting causes of neur- asthenia are worry, overwork, lack of sleep, excesses of various kinds, intoxications; and following infections, after accidents, often after surgical operations which may have been entirely successful, and sometimes following heat pros- tration ; organic diseases such as syphilis during the secon- dary and tertiary stages, fear and worry from knowledge of the disease, dread of infecting others, and occasionally as the result of prolonged and debilitating mercurial treatment; tuberculosis, gout, rheumatism, diabetes and cardiorenal dis- eases; abdominal ptoses, intestinal putrefaction, affections of the lower bowel such as strictures, fissures and hemor- rhoids. In the male, prostatorrhea. Pelvic conditions and maternal responsibilities in the female; artificially induced menopause and sometimes after menopause proper, which, however, only acts as an exciting cause. The disease usually appears in one of two forms: Prim- ary neurasthenia, much the less frequent, as the result of an inherent weakness of the nervous system, which develops slowly and which probably has shown evidence of the dis- order previous to middle life. Symptomatic neurasthenia, as when it is consequent upon some organic disease, toxic state or trauma. Primary neurasthenia is characterized by the features of weakness and irritability, which may appear in the motor, sensory, psychic or visceral sphere. The denial of the ex- istence of this form is without justification, since it de- velops in individuals who have always shifted their re- sponsibilities and who finally break down without adequate strain. The symptoms commonly met with in neurasthenia are fatigue, backache, headache, irritability, insomnia, muscular tremor, twitchings and exaggerated reflexes; the tongue is coated, there is indigestion, flatulency and constipation, and, occasionally under the strain of worry, mucous colitis; loss NEURASTHENIA. 457 of appetite is by no means a constant finding; palpitation and vasomotor manifestations, with at times a lessening of the secretions, though the opposite condition may be met with. The special senses yield such evidence as exhaustion in the eyelids, blurring of sight, hyperesthesia of the retina, fatigue contractions or fatigue spiral visual fields; also a hypersensitiveness to sounds, tinnitus and throbbing in the ears. Sometimes the disorder conforms rather distinctly to a type which is described either as a sexual, anxiety, occupa- tion or traumatic neurosis. Sexual neurasthenia is most common in young men in whom there may be sexual repression, overindulgence or even unnatural gratification; such persons are concerned over pollutions, masturbation, priapism, premature ejacu- lation, unsatisfying sensation and even the absence of or- gasm ; neuralgia of the testicles and pain in the inguinal region; a cloudiness of the urine is taken for spermatorrhea. Women complain of sexual dreams, nocturnal orgasms, diminished, delayed or absent orgasm. Anxiety neurosis was first described by Freud, who sepa- rated it from the general group of neurasthenic manifesta- tions, though it could be appropriately described as a psycho- neurosis and not infrequently it is a part of hypochondria. Freud maintains that where the etiology cannot be readily ascertained—and then it is usually due to marked hereditary taint—the disorder has its origin in a series of injuries and influences upon the sex life. General irritability and anxious expectation or even fear are present and accompanying these are various bodily manifestations, such as profuse perspira- tion, dizziness and trembling, diarrhea, vasomotor disturb- ances, pseudoangina and paresthesias. Occupation neuroses are confined for the most part to middle life, the subjects are often neurotic, and they have been much more common in men, though the advent of woman is affecting the proportion. These neuroses are as various as are the occupations calling for the repeated action of definite muscle groups, which through overuse assume the symptoms of fatigue, tremor, weakness and cramps, and at times they may even undergo atrophy. Faulty position 458 NERVOUS AND MENTAL DISEASES. at work, previous injuries, general debility, worry and anxi- ety may be factors. The more highly refined the occupational movement, the more likely is this condition to result. Work requiring a sustained effort of the hand is most conducive to this disorder, so that we have it arising among penmen, seamstresses, violinists, engravers, knitters, and many others; clergymen may have their vocal cords affected, and those whose efforts concern special movements of the feet or back are liable to the disorder in the muscles used. Selecting writers’ cramp as illustrative of the type, one finds that when the strain exceeds the individual’s capacity, a sense of fatigue is experienced, soon to be followed by tremor, spasms and even cramps; these irregular movements may so involve the arm as to completely incapacitate the individual for his work. The course of the disease varies, but is, as a rule, more or less chronic. In the more pronounced cases the outlook is not so good, since prolonged rest may not lead to complete restoration. Traumatic neurasthenia is denied existence by a few who believe the resulting condition is invariably hysteria. Cer- tainly the disorder is at times confounded with hysteria, but the more commonly accepted view is that either or both con- ditions may be encountered in one who has sustained an injury. The continuity of the nervous system as a whole persuades one that when a particular part is subjected to trauma, the effect may be widespread—to the brain, muscles, vessels, glands of internal secretion and to the viscera. The claim is often made that traumatic patients lose their ner- vous symptoms when they are compensated. But this is not always true, since some of the mild cases remain unduly apprehensive or become hypochondriacal, and the fact that sometimes an individual does recover after he is paid money does not prove that he was never ill. If such individuals have the symptoms of neurasthenia, how can one escape the conviction that they have that disease? In diagnosis, among the outstanding features are weakness and irritability. Since the disorder is usually secondary, that is, the early manifestation of some bodily disease, this must be sought and if possible eradicated, else the symptomatic neurasthenia cannot be cured. Among the common diseases NEURASTHENIA. 459 to be borne in mind are the cardiorenal affections, syphilis during the secondary and tertiary stages, tuberculosis, hyper- thyroidism, hysteria, abdominal and pelvic conditions, melan- cholia, hypochondria and early paresis. For the successful treatment of neurasthenia, the physician must have psychologic hold of his patient. Profound nervous exhaustion requires the full rest regime, while in the less serious cases modified rest will suffice. Others should have suitable work tempered with recreation, while some may re- quire a change of scene or even of climate. The habits and diet should be regulated and proper exercise taken. Con- stipation must be overcome and good general elimination established. Sometimes cold douches to the spine and salt rubs act as a tonic. Local massage and some of the various forms of electricity may be indicated. The diet of neurasthenics is most important and in those requiring full rest much de- pendence should be placed upon milk. In addition to be- ing highly nutritious, this food has the great additional ad- vantage of exacting but little work from the tired stomach, kidneys and liver. In the few who cannot endure pure milk, the addition of just a little kefir will bring about fer- mentation, thus rendering the milk much more tolerable. Eggs also are useful in the diet and the judicious addition of chicken, oysters, fish and perhaps a chop or small steak, together with one or more of the well borne vegetables, will enable the physician to carry on the much desired full feeding. Medicinally, preparations of iron, arsenic and phosphorus are useful and also strychnin in selected cases. Some special care must be given patients with occupational neuroses. If penmen, the other hand should be used and sometimes a change of work is required. In writing the movement should never be in the fingers, but should always be made with the muscles of the forearm resting upon the desk while the whole arm partakes of the movement. Local treatment should consist of massage, electricity, disciplinary exercises, hydrotherapy and diathermia. The psychoanalytic method finds favor with some when the mental element is pronounced. 460 NERVOUS AND MENTAL DISEASES. PSYCHASTHENIA. Psychasthenia as described by Janet is a chronic psycho- sis, fluctuating in intensity, characterized by obsessions, fears, doubts, compulsions, sometimes by dream-states and dissociated personality, with such motor manifestations as tics, and even epileptiform attacks, but without tending to- ward mental deterioration. Like its counterpart, neurasthenia, psychasthenia may con- form either to a primary or to an acquired type, the latter being the more frequent; it has the same psychopathic or neuropathic antecedents; it may be secondary to many dis- orders and it may result from trauma, not alone of the head, but also of the body. The symptoms are preeminently in the mental sphere, in which the mental effect is that of a general disturbance and results only in general inefficiency. The impulses are usually controlled and the hallucinations, phobias and doubts, are recognized as such. Janet has tabulated over forty distinct phobias, which in- clude: Claustrophobia—fear of closed spaces; agoraphobia— fear of open spaces; mysophobia—fear of dirt; monophobia— fear of being alone; these have been called mental tics and frequently have their origin in emotional shock; here, Freu- dians claim preeminence for the sexual element. Correspond- ing to the foregoing are the motor tics, which are spasmodic, more or less purposeful movements, subconsciously induced, and which cease during sleep; different types are facial tics, mental torticollis, winking of the eyelids, shrugging of the shoulders, movements of the abdomen and various other bodily movements, often bilateral, but never symmetrical; the extreme of the motor tics is carpolalia, in which the movement is accompanied by an indecent explosive utterance. They often make their appearance in youth; some individu- als feel compelled to repeat certain words or phrases, to touch various things or to step on certain objects which they pass over. Being aware of their absurdities, they may en- deavor to conceal them, but this frequently only emphasizes their condition. Psychasthenia, while sometimes combined with neuras- thenia, reveals when alone a less obvious or even a lack of HYSTERIA. 461 fatigue, paresthesias, circulatory and alimentary disturbances, insomnia, headache and backache; it is less serious than neurasthenia by reason of its being more dependent upon outside effects. The disorder lacks the anesthesias, paraly- ses, contractures, amnesias and subconscious states of the true hysteric, but the two diseases are sometimes associated. A psychasthenic state may precede some of the psychoses, but these mental diseases are usually not long in frankly declaring themselves. The course of psychasthenia is chronic and relapses are frequent. Usually, it does not amount to invalidism. Men of intellectual endowments and in active work are sometimes so afflicted, but they are not often thereby obliged to lay aside their duties. Treatment. The primary type is found to be the more resistant. If the disorder is secondary to some bodily dis- ease, this, if possible, should be eradicated. Generally speak- ing, the treatment is mental. The psychasthenic should be taught self-control, he should be occupied, and sometimes the disorder will respond to a change of occupation. In men who have had to perform prolonged and difficult work, the cultivation of a fad has at times prevented mental break- down, and in less serious cases has been the means of re- storing individuals to their normal equilibrium. The most obstinate cases may be afforded temporary relief through hypnosis. Placebos, hydrotherapy and electricity are all useful. * Only when there are exhaustive neurasthenic symp- toms present is absolute rest needed. Special types must be given special consideration; for instance, in the motor tics, there may be some local irritation, which, in that event, must be removed; strong faradism will hold the muscles in tempo- rary tonic contraction, and local, systematic exercises are sometimes useful. Selected cases will be remarkably re- lieved through the medium of psychoanalysis. HYSTERIA. Hysteria is a functional neurosis which develops upon a temperamental background when unusual or even ordinary stress in any of its various forms is brought to bear upon the individual, and is characterized by manifestations—often 462 NERVOUS AND MENTAL DISEASES. amounting to attacks—which may appear in the physical, mental or emotional sphere. The etiological factor of first importance is heredity and when this influence is pronounced, almost invariably there have been manifestations of the disorder in childhood. And let it here be emphasized that even slight mismanagement of a hysterical child may be fraught with dire consequences in later life. An individual of this type should be taught self-control and how to bear more patiently the many petty and unavoidable annoyances in this life. But if such train- ing has been omitted, then the adult must be shown the way of greater submission to things inevitable. After middle life, hysteria is uncommon. In this disease it is the young adult females who pre- dominate largely, but later trauma yields an increasing num- ber of male hysterics, through their greater exposure, as was forcibly demonstrated during the recent war. Indemnity hysteria also illustrates how trauma may at times act as a factor. School children, congregates and soldiers show the effect of contagion in hysteria. Freudians see sex influence— not essentially sensuous—as the predominating cause of the manifestations—dissociations—back of which is the process called “repression” and this leads to the splitting off of parts of the personality. “It is the- fundamental hysterical (con- version) mechanism which throws upon the body, makes it the scape-goat of, the responsibility of our moral failures” (Jelliffe). The views of Babinski have been widely pro- claimed. He believes the symptoms are the result of sug- gestion and that they can be removed by persuasion. Hysterical persons are emotional, unstable, their mental outlook is not large so they often turn to themselves and become introspective; by reason of their weakness they are always inefficient; in some, suggestibility is so pronounced that unless they are adroitly examined by the physician, symptoms may be induced. The findings in hysteria are largely those of disturbed sensation and motion, amnesias and subconscious manifestations. Sensory disturbances ap- pear as an increase, decrease, loss or perversion of sensation and are characterized by their non-conformance to any nerve distribution—psychic not anatomic. A common form is hemi- HYSTERIA. 463 anesthesia which ends abruptly in the midline and which throughout is of uniform intensity though it may vary from day to day; an area may be glovelike or there may be patches with all forms of sensation involved. Hyperesthesia is most familiar as hysterogenic zones, slight irritation of which may provoke convulsions; common sites of such areas are above the ovaries, below the breasts and in the inguinal regions; Fig. 1.—Hysterical hemiplegia showing flaccidity of the paraly- sis. (From “Diseases of the Nervous System,” by Charles L. Dana, M.D., ninth edition. William Wood and Company, New York.) any of these zones may be the seat of spontaneous pains; the joints, spine and even the vagina may be hypersensitive. Motor disturbances are of the nature of paralyses, contrac- tures, convulsions and tremors. Hysterical paralyses may be monoplegic, hemiplegic or paraplegic, and often they are accompanied by anesthesia; the affected member hangs limp, the muscle tone and reflexes are not increased nor are there 464 NERVOUS AND MENTAL DISEASES. altered electrical responses (Fig. 1). Peculiar, rigid positions may be assumed by the parts and these are termed contrac- tures. When tremors are present, they develop suddenly, are coarse and always intermittent. Sometimes there is inability to stand and walk normally and this is termed astasia- abasia, which will be further considered under diagnosis. Convulsions are concerned in the classic paroxysms which are the maximum of hysteric manifestations but which are now seldom seen in their entirety. Charcot and others have divided them into four stages: (1) Epileptoid: The onset varies, but soon the patient falls without sustaining injury and then there follows a series of moans, groans or inco- herent utterances. (2) Grand Movements: A fixed posture is assumed, usually that of opisthotonos or possibly pleuro- thotonos, with consciousness disturbed and perhaps pro- foundly so; then disorderly movements occur, soon to be followed by relaxation and brief rest. (3) Passionate Atti- tudes : Any of the more violent emotions may be expressed. (4) Delirium: Here, illusions and hallucinations may be experienced, often with mental excitement which is most likely to be of the character of depression. The whole scene may be enacted in from five to twenty minutes but some- times the last stage persists for many hours. Subconscious manifestations are usually present indepen- dently of major hysteria. Sleeping attacks, also called narco- lepsy, sometimes appear quite unexpectedly and these may last for a few minutes or for many hours, which state may deepen into lethargy or even trance. Cataleptic attacks usually in- clude the whole body, though rarely they are localized; here, the parts remain suspended for a long time in any position in which they may be passively placed; cutaneous reflexes are decreased, tendon reflexes unaltered, and the patient though unable to move or to speak, is sometimes conscious of his surroundings; he may awaken spontaneously and oc- casionally is responsive to the action of a powerful stimulus. The term somnambulism should perhaps be restricted to the manifestation occasionally observed in natural sleep. As the disorder appears in hysteria, it is much more amenable to suggestive treatment. Hysterical psychoses sometimes de- velop and in adults they are met with almost exclusively HYSTERIA. 465 among women. Here, after paroxysms of laughing or weep- ing, clownism and motor unrest may ensue, together with hallucinations, usually of vision, and these are sometimes attended by raving. Sporadic theft may be committed under hysteric influence. The psychoses which appear are of short duration and are likely to have associated with them some of the more common manifestations of hysteria. Among the special senses, disturbances of sight are the most frequent; the pupils are usually dilated, they always react—though possibly delayed—to light; amaurosis may be present; when so, it is often bilateral and for the most part incomplete; concentric narrowing of the field of vision is the most common eye symptom; of this there are several types, such as “tubular,” “spiral” and “shifting,” though the last two are also common in neurasthenia; changes in the color field may be noted, and in severe grades an ocular palsy may rarely be simulated by reason of a contracture in its antagonist muscle. Disturbances of hearing, either uni- lateral or bilateral, may be present, and the senses of taste and smell may also be affected. A hysterical aphonia is not uncommon. Some of the sexual disturbances are ex- ceedingly troublesome in a marital sense, as in anesthesia or hyperesthesia of the vulva or vagina. Vasomotor mani- festations may occur in the form of edema, a tendency to unusual hemorrhage or sometimes the oppo-site state. Then there may be tachycardia, bradycardia, polyuria, and dis- turbances of the alimentary tract in the form of diarrhea, constipation, vomiting, borborygmi, and meteorism, possibly simulating tumor. As to diagnosis, hysteria has been taken for almost every disease and most diseases have been taken for it, the former being the more serious error. It should also be borne in mind that hysteria confers no immunity—it is often associ- ated with other disorders. The common diseases of neu- rasthenia and psychasthenia usually present little difficulty. The differentiation from epilepsy may be necessary. Usu- ally, by recalling that both diseases are sometimes co- existent, little difficulty will be experienced but a few cases are so obscure as to be classed as hystero-epilepsy. While, of course, both family histories reveal faulty heredity, hysteria 466 NERVOUS AND MENTAL DISEASES. in the process of years, seldom shows a degenerative ten- dency. The individual may with profit be studied during the inter-paroxysmal period, during the paroxysm and in the post-paroxysmal state. Between paroxysms the patient may show hysterical stigmata—anesthesias, paralyses, con- tractures, amnesias or dream-states—but lack the epileptic personality—egocentricity, emotional poverty, social inadap- tability and mental dullness. The hysterical paroxysm is apt to -be precipitated by emotional stress and but rarely is preceded by a short and definite aura. If there is a cry, it is long drawn out and not sharp and shrill. The fall is more of a safe let-down and is unattended by injury of con- sequence. Unconsciousness is frequently prolonged, seldom profound and often of varying intensity. The color of the face changes but slightly. The inflicting of sharp pain will usually restore consciousness while epilepsy must terminate spontaneously. The pupil is not immobile. Tonic spasms often cause a curving of the body in different positions— opisthotonos, pleurothotonos—and the clonic convulsions partake more of the nature of violent swingings in the ex- tremities and body. It is very doubtful if hysterical con- vulsions may occur during profound sleep. There is no genuine biting of the tongue or cheeks but occasionally the lips are chewed. The sphincters remain continent. It must be remembered that in the event of malingering, some of the more characteristic manifestations of epilepsy may be assumed. In the post-paroxysmal stage there is no stupor, nor are automatism, somnolence, headache or exhaustion likely to be met with. Multiple sclerosis shows exaggerated reflexes, later a true ankle and patellar clonus, often a Babinski sign, optic neu- ritis and distinct nystagmus; the tremor, if considered sepa- rately, may at times be confusing. Brain tumor, particularly in the frontal region, may in the early stage lead to error. I have seen patients, when the previous history was un- available, in whom the first examination failed to distinguish clearly between hysteria, dementia precox and feeble minded- ness. The condition of astasia-abasia which sometimes fol- lows physical or mental shock can also be determined by exhaustion, so that in addition to hysteria the disorder may EPILEPSY. 467 occur in neurasthenia, psychasthenia, hypochondria, epilepsy and chorea. When it develops upon a hysterical basis there may be present some of the sensory disturbances common to this disease. Accompanying neurasthenia, there is usu- ally marked fatigue, exaggerated reflexes and paresthesias. The absence of a persistent ankle clonus and the Babinski sign, together with a continent bladder and rectum, would rule out organic disease of the cord. Pronounced incoordi- nation from cerebral and cerebellar diseases is attended by the other common signs of affections of those organs. Treatment. In individuals of a hysterical temperament abstract states of mind and brooding should be discouraged, and employment such as will hold their attention should be given. If exhaustion is present, the rest-cure may be in- stituted and at times, even in the absence of exhaustion, isolation is necessary. The personality of the physician and the tactfulness of the nurse are of the utmost importance. Special examinations and operations should be discouraged unless absolutely necessary. Those of a hysterical tempera- ment should not come in too intimate contact with invalids. The psychoanalytic processes, whereby submerged complexes are brought into the field of full consciousness, are useful in the hands of the skilled operator. Sometimes paroxysms may be aborted by bringing about emesis or by causing sharp pain through pressure upon a particular point. All manner of drugs have been used, valerian and bromides being the most common. The suggestibility of the patient affords an opportunity for the successful administration of a placebo and this may be given in the form of a large capsule con- taining starch. Hypnosis may be used but it is not without very disagreeable possibilities. Electricity and hydrotherapy are often useful as a means of impressing the patient. True epilepsy is a chronic disease or disorder of the brain, characterized by recurrent and paroxysmal disturbances of consciousness, which are usually attended by more or less pronounced motor manifestations. As encountered in mid- dle life the disease is often a heritage from childhood, but when appearing spontaneously one should always suspect it EPILEPSY. 468 NERVOUS AND MENTAL DISEASES. of having developed upon a syphilitic, traumatic or toxic basis, or as being symptomatic of some focal condition such as brain tumor. In type the seizures are usually grouped as: Grand mal: Consciousness is lost, general convulsions ensue and, if stand- ing, the patient always falls; this is known as a major attack or a fit. Petit mal: A minor attack in which consciousness is disturbed and in which the motor manifestations, usually local, are mild. Psychic: A blank in the sphere of conscious- ness varying from a second to perhaps many days and usu- ally unaccompanied by motor manifestations. Jacksonian: A motor seizure confined, at least at first, to a part of the body, and frequently symptomatic of focal brain disorder; ultimately, the spasm may be masked by a general convulsion, when the disorder presents the picture of the idiopathic disease. Epilepsy is so common an affection as to occur about once among every four hundred and fifty persons and is more frequent in men as their occupations and habits favor its development. It is probable that seizures develop as a re- sult of cerebral anemia and most confirmed epileptics show many abortive attacks. While faulty heredity is in many instances a prominent factor the disease is seldom directly inherited, but one finds it cropping out in neuropathic stock along with many other nervous and mental disorders. Additional causes are, birth injuries, infectious disorders which sometimes set up an en- cephalitis, and occasionally psychic trauma is sufficient to precipitate the disease in a potential epileptic. Among the endocrine disorders the pituitary in particular has been held responsible, and occasionally the thyroid. A personal ob- servation was that of a patient in whom the disorder appeared promptly and was persistent, after the removal of both ovaries. The blood pressure of epileptics usually shows hypotension. At times no disease declares itself with more certainty than does epilepsy, but occasionally no clinical entity pre- sents a more baffling picture. The scarring at prominent points on the head and face, the slow and monotonous voice, the mental make-up that reveals “egocentricity, emotional EPILEPSY. 469 poverty and social inadaptability,” together with the expres- sion that betokens mental dullness are all suggestive, and when, with these, there are associated degenerative physical stigmata, one need not observe the cardinal symptom—the disturbance of consciousness—or any other form of psychic, motor, vasomotor or sensory seizure, but may boldly declare for epilepsy. Occasionally, however, the real nature of the disease is much less obvious and then one may be called on to consider the problem in the light of hysteria, alcoholism and other degenerative conditions, major convulsions from toxic states, cerebral syphilis, beginning paresis, brain tumor, aural vertigo, cardiac syncope, reflex epilepsy, spasmophilia, narcolepsy, tetany, anomalous migraine, myoclonus, disordered sleep, or malingering. Others have stated their ability to forecast epilepsy—an- ticipate seizures years in advance—by the mental and physi- cal make-up of the individual, but I confess to a lack of such prophetic acumen. The classic complete seizure begins with a warning which is followed by a cry, the fall and unconsciousness; then come the tonic spasm, clonic convulsions, frothing, biting of the tongue and extravasation of urine; soon consciousness re- turns, shortly to be followed by sleep from which the patient wakens with a headache, all of which—after some hours—is succeeded by muscular soreness. With an absence of the more important data such as recurring attacks of disturbed consciousness, convulsions, biting of the tongue, wetting the clothes, attacks during sleep or periods of automatism, one should have blood and spinal fluid tests made, an ophthal- mological examination and x-ray studies. Complications sometimes arise, such as status epilepticus which is the maximum and the gravest of epileptic mani- festations. Ten per cent, of epileptics are prone to insane periods which are characterized by suddenness of onset and clanger through violence, but usually the attack does not last long. Accidents such as fractures, dislocations and severe burns, are sometimes encountered. There is a som- nolent form of epilepsy in which attacks occur only during sleep; it has happened to such a patient that he has rolled over on his face in a seizure and smothered in the depths 470 NERVOUS AND MENTAL DISEASES. of the pillow. For fear of drowning, epileptics should never be permitted to bathe when alone. Occasionally, important medico-legal questions arise in connection with this disease. An epilepsy developing in middle life gives more hope of recovery than that arising at an earlier period. The average life of the epileptic is about thirty years. Treatment. In the attack, the patient should be placed on the floor, a pillow slid under his head, a towel placed between his teeth and the clothing loosened about the neck. Medicinally, luminal is the drug of choice; other useful remedies are chlorotone, the bromides but in much smaller doses than was formerly used, belladonna, and if especially indicated, antispecific remedies; in selected cases, some of the endocrine preparations will prove of service. Constipa- tion should not be permitted, and attention to general hy- giene and dieting are important. Status epilepticus should be met by applying cold to the head, purgation, warm packs, chloral enemata and stimulation. When there are signs of a distinctly localizing character, surgical intervention is often justified. Where complete restoration is not effected, among the well-to-do the patient may still remain at home, but usually the best place for an epileptic is on a colony farm, while those who show frequent insane periods are safest in insane hospitals. FIBROSITIS. In the middle period of life one often meets with chronic muscular rheumatism, a term frequently spoken of with de- rision, and little wonder when it is recalled that many errors in diagnosis are committed under this name. Yet the con- dition is one so commonly met with as to have been termed “an every-day affection.” For some years past the rheu- matic pains so frequently experienced by many have been known to arise from definite “sore spots” in the body and these have as their underlying pathology a condition de- scribed by Gowers as fibrositis. In nature this disorder is a low-grade inflammation resident in the fibrous connective tissue, which tissue, it will be remembered, extends through- out the entire body, hence the widespread distribution of the affection. FIBROSITIS. 471 Etiological factors are gout, intoxication from intestinal putrefaction, infections, pus in any part of the body, and, most frequently of all, refrigeration. Wherever people con- gregate there are always present some who are particularly susceptible to the mischievous influence of drafts, exposure to which promptly brings about stiffness and soreness in different parts of their bodies. Such individual susceptibility occasions much annoyance and even distress, since doors and windows must remain either open or shut. It cannot be successfully denied that drafts at times are provocative of serious trouble, since all physicians have seen attacks of Bell’s palsy so caused, which condition may leave the patient with a life-long paralyzed and deformed face. In those sub- ject to fibrositis, a slight strain in any part of the body may cause pronounced soreness. The disorder has widespread neurologic significance and already one large volume has appeared, devoted exclusively to this condition. While fibrositis may be met with in any part of the body, the most frequent sites of the disorder are the neck muscles, especially posteriorly; in the back of the scalp and in the temporal region; along the cervical vertebrae, particularly at the points where the muscles are attached; about the lumbar and sacral spine; at the inner sides of the elbows and knees; in the muscles of the abdomen; and in the gluteal region particularly near the sciatic notch, from whence it sometimes extends to the fibrous sheath surround- ing the sciatic nerve, and even into the fibrous septa. Here, then, the explanation for quite a large group of painful dis- orders may be sought with profit, since fibrositis is at times the cause of headache, neuritis, neuralgia, myalgia, lumbago, sciatica, torticollis, intercostal neuralgia, brachialgia, painful feet, etc. The successful palpation of these thickenings is an art possessed by but few, hence the lack of knowledge—and even incredulity—concerning the disorder. One inexperienced will, in seeking these areas, be aided by the use of a lubri- cant, since this renders the skin less resistant and then the parts beneath may be palpated with the greatest facility. These thickenings are found present in three stages: 1. A swelling. This is of a soft, yielding consistency and is fre- 472 NERVOUS AND MENTAL DISEASES. quently observed in the bodies of the muscles where a puf- finess may be noticed. 2. When a slightly elastic resistance is offered to the touch, as though some organization had taken place. 3. Induration. Here there is an absence of elasticity, and organization has advanced to the stage at which a substance of cartilaginous consistency presents itself to the examiner. These indurations may appear again and again for some time before becoming chronic, but the older they are, the firmer they become and the more resistance they offer to successful treatment. Undoubtedly the most satisfactory method of removing these areas is through massage, and the successful treatment of fibrositis is proof of the greatest skill in the manual method. Other measures are hydrotherapy, electrotherapy, hyperemia and special exercises, while a few selected cases will be found to respond to vaccinotherapy. All foci of in- fection, such as offending tonsils and abscesses upon the roots of the teeth, must be eradicated. Where the disorder has developed upon a gouty basis, the diet should be care- fully regulated. Active elimination is often necessary and this may be accomplished through free use of some of the well known laxative waters, hydrotherapy and diuretics. The drugs most helpful are aspirin, atophan, and sodium salicyl- ate, with the employment of small doses of iodides in the more protracted cases. Headache or cephalalgia is the most common symptom met with in the practice of neurology, since many men and most women have the affection occasionally, if .not more frequently. The intellectual, the wealthy, and particularly the metropolitan population, are inclined to the disorder, and it varies somewhat with seasons, being rather more common in spring and fall. Exclusive of migraine, which is considered separately, the affection is overwhelmingly symptomatic. Upon an anatomical basis, headache is due to irritation of the trifacial nerve branches, or of the sympathetic fibers which are distributed to the dural membrane and to the intra- cranial blood-vessels. However, as Gowers remarks, the cerebral substance itself under abnormal conditions may per- HEADACHE. HEADACHE. 473 haps manifest pain. Its causes are many but occurring in middle life the disorder is very often of toxic or of reflex origin. Headache is a frequent symptom in fevers and in circula- tory disturbances, as anemia and hyperemia; in the toxic states of uremia, diabetes, gout and rheumatism; in the in- toxications of alcohol, tobacco, coffee, and lead; in the organic diseases of meningitis, encephalitis, hydrocephalus, tumors, abscess, syphilis, and diseases of the bones; as one of the symptoms of neurasthenia, psychasthenia, hysteria, epilepsy, and hypochondria; it results reflexly from disturbances of the eye, ear, nose, sinuses, teeth, throat, stomach, liver, bowel and pelvic organs; after excessive mental or physical effort, insomnia, and from hot and poorly ventilated rooms; after trauma, and sometimes arteriosclerosis beginning in the lat- ter part of middle life gives rise to headache. One must bear in mind that more than one of these causes may be operative. Headache varies as to character so that it may be dull, sharp, boring, burning, throbbing, or there may be a sense of con- striction or of pressure; also, it may be localized or diffuse. Two varieties of headache are worthy of special mention, the first being due to a mild disorder and the other to a grave affection. Induration Headache. Under the caption of fibrositis reference is made to this type of headache, and Edinger, who has most accurately described the disorder, says it is prob- ably the most frequent form of headache. Meningitis has been mistaken for this condition but a more common error is to consider the attacks as those of migraine. With prac- tice one becomes able to explore the scalp and neck where the nodules and indurations of fibrositis are readily palpable. Slight pressure over these sites elicits marked hypersensi- tiveness and even between the attacks slight tenderness per- sists, though to a lesser degree. Bad weather, a draft (in those unfortunate individuals who are susceptible to this influence), or washing the head without thoroughly drying afterward, may be the means of precipitating an attack. The headache occurs in various parts of the head, depending upon the sites of the indurations, and there may be radiation of the pain. Fever and redness are absent. 474 NERVOUS AND MENTAL DISEASES. Syphilitic Headache. If soon after a luetic infection slight headache is experienced, one should be suspicious of a begin- ning meningeal involvement. Later, the disorder becomes somewhat characteristic by reason of exacerbations, often of a boring or a hammering nature, which may perhaps reach their maximum intensity at night or in the early morn- ing. Syphilitic headache, while rare, is at times most intense and may be accompanied by nausea or even vomiting, in which event it should be differentiated from migraine but more especially from brain tumor. The patient is at all times prone to a dull pressure sensation. The disorder is of course attended by other of the many signs of neurosyphilis. The treatment of headache is removal of the cause. Among the remedies employed in the attack are antipyrin, phenace- tin, acetanalid, caffein, cannabis indica, and the bromides. Syphilitics must receive antisyphilitic medication. Indura- tion or rheumatic headache should be overcome through good general hygiene, active elimination and the administration of aspirin and the salicylates; however, the successful removal of these indurations is only accomplished through scientific massage. MIGRAINE. Migraine is a paroxysmal neurosis with headache, often of a peculiar character, as the prominent symptom, and is at- tended by nausea, usually increasing to retching and fre- quently with vomiting which, however, is independent of the taking of food. Because of its tendency to occur on one side, the disorder is frequently referred to as hemicrania. The attacks usually last a few hours, possibly much longer, and then they leave the patient feeling well. Sometimes the disorder begins in childhood, but almost invariably before thirty years, and tends to terminate in middle life. One doubts if such diseases as malaria, hysteria, nasal and ocular disorders may cause migraine but unquestionably they pre- cipitate attacks. The headache tends to appear upon arising or shortly after, it is felt within the cranium and is accom- panied by a sense of pressure and a burning behind the eyes. The special senses become hypersensitive and prostration gradually develops. MIGRAINE. 475 In pathogenesis, migraine appears to be a vasoconstrictor neurosis, and several types are recognized of which the best known is the ophthalmic. The experiences of a patient that I have recorded elsewhere are illustrative of this type. The subject, who was an epileptic, had her attacks of migraine about once a week. The headache was always preceded by the appearance of a bright light before one or the other eye, but never before both in the same attack; this light was shaped like the flame of a gas-jet, with a serrated upper edge and an attenuated extremity which always pointed to the outer side and which the patient referred to as the “tail.” The light lasted about twenty minutes and before it disap- peared the headache began and this was always preceded by double vision—ophthalmoplegia. Usually, the headache per- sisted for a half hour and frequently there was intense nausea and vomiting; when the attack subsided the patient felt per- fectly well except for weakness. An angiospastic form— where the face is white—and an angioparalytic form—where the face is red—are encountered. Transient aphasia and transient paralysis, either motor or sensory, may be mani- fested and abortive forms occur. For the prevention of attacks, all possible rules of hygiene must be observed. Fresh air, especially at night, must be provided for. Attacks are prone to develop upon an empty stomach, and other causes, which patients have learned through experience precipitate attacks, must be overcome. Constipation, eye, nose and throat conditions should all, if possible, be eradicated. In a severe attack, absolute rest is imperative. Perhaps the most useful drug is potassium bromide, while chloral, antipyrin and cafifein afford relief to some patients. In the more distressing cases, especially with extreme retch- ing, morphin may be used, since habituation probably never occurs where the drug is employed exclusively for the relief of migraine. The head may be tightly bandaged and local heat together with hot foot baths may give comfort. Gal- vanization by applying a weak current to the neck is spoken of with favor. 476 NERVOUS AND MENTAL DISEASES. VERTIGO. The accurate sense of space and the maintenance of equi- librium is manifested through the activity of the labyrinth of the internal ear, of the eye and by the sense of pressure. With the loss of one of these the individual can only main- tain his balance with difficulty, and any perversion of this space sense leads to vertigo. The disturbance, which is also known as dizziness or giddiness, is almost always symp- tomatic, but a few cases are of unknown origin and so are classed as idiopathic vertigo. In this disorder of unsteadi- ness of position, the objects surrounding one appear to re- volve, or the reverse may be true, but neither is distinctive of any particular lesion. Vertigo may result from disease of the vestibular apparatus of the internal ear, from irritation along the vestibular tracts or from a lesion elsewhere within the cranial cavity. Sometimes there are associated such symptoms as nystagmus, deafness, nausea, vomiting, rapid and irregular heart action, general relaxation and weakness, and perhaps profuse sweating. Usually, the attacks are sud- den and of short duration. Rising quickly or placing the head in certain positions may precipitate an attack, and if standing, occasionally the individual may fall. Consciousness may be somewhat disturbed, but seldom is it lost. Depend- ing upon its origin, several varieties of vertigo are recognized. Aural Vertigo. This may arise from a disturbance of the external, the middle or the internal ear. It may be due to the presence of foreign bodies, the accumulation of wax, the presence of boils or to otitis media. When the disease arises within the internal ear it is spoken of as Meniere’s disease, the chronic form of which may be due to gout, rheumatism, diabetes or to exposure to cold. The acute or apoplectiform variety is due to hemorrhage into the labyrinth and yields deafness, tinnitus, disordered equilibration, and perhaps vomiting and syncope. There may be several attacks with more or less permanent deafness resulting. Cerebral hemor- rhage, cerebellar hemorrhage, or tumor of the cerebello- pontile angle may require some differentiation. Vertigo of Visual Origin. This may result from refractive errors, muscle imbalance or ocular palsies. DISORDERS OF SLEEP. 477 The following are some of the more common causes of vertigo: Organic diseases of the cerebellum, its peduncles, and the cerebrum, such as tumors, abscess, syphilis or sclero- sis. Sudden changes in intracranial pressure, as in straining at stool, heavy lifting, and running. Seasickness through agitation of the fluid in the semicircular canals. The toxic substances of alcohol, tea, coffee, and tobacco. Drugs like quinin, salicylates, and the coaltar products. Autointoxica- tions and infections. Cardiovascular conditions, neurasthenia, hysteria, hpyochondria, and epilepsy. Reflexly from the nose, larynx, and stomach. Psychical states, as in the fear of high places, and in some other phobias. In disturbances of muscle sense vertigo sometimes occurs but not so frequently as does staggering. The diagnosis of vertigo requires an extensive general sur- vey with special investigations including the Barany tests with heat and cold, and of pointing and of falling. Treatment consists in removal of the cause, possibly through surgical intervention. During the attack, rest in bed may be required and perhaps sedation. The amount of sleep required varies with many conditions, but a fair average for middle life is about eight hours, with perhaps a trifle more for women. Brain workers need less sleep than do those who only perform physical labor. Some individuals have allowed themselves but little sleep and seemingly without injury—Napoleon and Edison about four hours—but if such statements are trustworthy, the sleep they had must have been more profound than is that of others. An absence from sleep for two weeks or even more, is said in some persons not to be incompatible with life, but cer- tainly it is more quickly fatal than is starvation. One must not always believe the surprising statements made by some patients regarding the extent of their wakefulness. Insomnia. By insomnia one means a period of absence from sleep, or sleep that through frequent interruptions is insufficient. The condition occurs most commonly in middle life and may result from one’s inability to lay aside the mental activity of the day, from excessive fatigue, from dis- DISORDERS OF SLEEP. 478 NERVOUS AND MENTAL DISEASES. eases—organic or functional—and from such intoxications as result from the overuse of tea. coffee, tobacco, or alcohol. Unless relieved it leads to a loss in weight, irritability, de- pression, and a general lowering of the physical and mental force. Prolonged lack of sleep is sometimes a forerunner of insanity or it may be a troublesome feature during the course of a psychosis and then it is apt to be attended by marked motor restlessness. Treatment should be directed toward the cause and for this purpose a careful survey should be made of the patient’s physical and mental condition, together with consideration of his temperament and habits. Matters of general hygiene are important, such as the amount and the kind of work done, exercise and amusement; the quantity and quality of food taken, particularly at night; the condition of the sleep- ing apartment—as to its quietness, the amount of bed-cloth- ing, the securing of good ventilation—and a regular hour for retiring should be insisted upon. In the matter of drugs, care must be exercised and mor- phin is interdicted unless the wakefulness is attended by unbearable pain. The remedies most in favor are bromides, adalin, medinal, veronal, sulfonal and trional. Then there are special indications, such as the use of paraldehyde in alcoholism, and of luminal, scopolamin and hyoscin in mental cases. When the patient is susceptible to suggestion, a plac- ebo in the form of a capsule containing starch, may yield the desired result. Hydrotherapeutic measures are useful, such as the warm bath or in aggravated cases as the cold pack. Gentle massage is sometimes conducive to sleep. A very small quantity of food and in some persons beverages, which must not be taken in stimulating quantities, are helpful. Excessive Drowsiness. This manifestation is occasionally observed, and the neurasthenic whose disorder has developed upon a basis of intestinal intoxication sometimes speaks of feeling “dopy”; it is also a very common accompaniment of “biliousness,” and one must also be alert to the possibility of the individual being a drug addict. Drowsiness may fol- low a number of conditions, such as concussion of the brain, prolonged exposure to cold, after an epileptic seizure, or in DISORDERS OF SLEEP. 479 cerebral syphilis, and a number of general diseases are at- tended by this state. Sometimes it precedes a psychosis, and pituitary disturbances are often provocative of som- nolent attacks. It may be purely a habit, as shown by some healthy individuals who fall asleep during church service. I have seen the condition simulated by pathologic lapses of consciousness due to momentary psychic attacks of epilepsy. Treatment should be directed to the underlying cause. A few cases are benefited by small repeated doses of thyroid extract. Dreams. Apparently dreaming is a normal phenomenon, since it probably always attends sleep, but during the first few hours sleep is so profound that such a manifestation cannot afterwards be recalled. Civilized man is more given to dreams than is his less gifted brother and the latter is prone to regard such experiences with superstitious awe. Recently, the Freudian school has given much attention to the analysis of dreams and its devotees have attached great significance thereto. According to such teaching, dreams show what they have been pleased to term the manifest content and the latent content. By the manifest content is understood the acceptance of the dream as associated with actual occurrences experienced by the individual during the few hours previous. The latent content, however, has a more serious significance and is composed of the material which the individual has crowded out of the field of full conscious- ness—repressed—and which he has endeavored to disbelieve. The interpretation of dreams belongs entirely to the domain of psychoanalysis, where those who are further interested should seek information. Functional disorders such as neurasthenia, psychasthenia, hysteria and melancholia are sometimes attended by trouble- some dreams; also, individuals who are temperamentally nervous and some of those suffering from chronic diseases, notably cardiac disorders, are subject to vivid and distress- ing dreams. When the dream-state becomes an aggravated one, the term nightmare is applied. Sleeping on one’s back is conducive to the condition and in women it may be ex- perienced during the menstrual period. 480 NERVOUS AND MENTAL DISEASES. Somnolentia. Sleep drunkenness, as the condition is also called, develops in a few persons when they are suddenly wakened from deep slumber. The state has grave medico- legal significance, since while in this condition the individual may be fearful, incoherent, even maniacal-and resort to acts of violence, and for which his responsibility may be ques- tioned. Somnambulism. The sleep-walker enacts his dream by moving automatically under the domination of a single idea. The senses are not in operation, though occasionally the eyes are open but apparently the sleeper is not guided by them. Many dangerous feats may be accomplished in this state which would not—perhaps could not—be performed if the individual were fully awake. This strange circum- stance is due to the fact that the senses are not alert, there- fore, the sleeper is oblivious to the actual dangers surround- ing him, and this fact further shows how harm may result from suddenly awakening him if in a position of peril. Narcolepsy. Paroxysms of sleep may rarely be encoun- tered in hysterics, in epileptics, or in other individuals. It is characterized by attacks of complete sleep which the individual is powerless to overcome. Narcolepsy may last for a few minutes or the individual may lie in this state for hours. Trance. This period of prolonged sleep is occasionally observed in hysteria and it may continue for a day or even for months. A similar, though a more stuporous state, is at times seen in dementia precox and in stuporous melan- cholia. When the disorder is attended by a waxy rigidity of the extremities—maintenance of position in which placed— the phenomenon is spoken of as catalepsy. MULTIPLE CEREBROSPINAL SCLEROSIS. This disease, which is characterized by intention tremor, an ataxic-spastic gait, nystagmus, and defective speech, usu- ally begins early in middle life and it is but seldom that the first manifestations appear after this period. Heredity has but little bearing upon the disease, while infections, mineral poisons, trauma and exposure all have been held responsible MULTIPLE CEREBROSPINAL SCLEROSIS. 481 in a number of recorded cases. Multiple sclerosis is rela- tively infrequent in this country, though of recent years more cases have come to light, which perhaps is due to a number of irregular forms having been previously unrecognized. The irregular patches in the brain and cord—possibly limited to one or the other—are more commonly found to have de- veloped on or near the surface. Despite the wide variation as to number, size, shape and location of these areas, the symptoms when compared in different cases are found to be fairly uniform. There are, however, often variations on the two sides of the body. Early manifestations appear first in the motor sphere and it is here that the symptoms continue to dominate. The legs become weak and the gait which at first is spastic, later acquires a cerebellar tendency. The reflexes are exaggerated, clonus appears and the Babinski sign can often be elicited. It is rather characteristic of the disease that abdominal re- flexes show some deviation, also the cremasterics. The tre- mor is distinctive—intention—is not manifested when the hands are at rest, nor is it confined to these parts, since the head, trunk and lower extremities may show some partici- pation. Sensation is not to any considerable degree involved, although patches of anesthesia or hemianesthesia have been observed. Among the special senses only those associated with disturbances of vision are worthy of detail considera- tion. Nystagmus, which is common, may even be spontane- ous ; optic nerve atrophy develops and a paleness of the temporal discs is rather distinctive; then there may be inter- mittent amblyopia, central scotoma, retrobulbar neuritis and transient oculomotor palsies. Sometimes the V, VII, and XII nerves are implicated, the last being concerned in disturb- ance of speech. The speech is slow, monotonous, syllabic and soon shows fatigue, while later it may be explosive or even lost. There is sphincteral involvement which eventu- ally progresses to incontinence. Vasomotor and trophic dis- turbances are occasionally present. Participation of the brain in the pathological process shows itself in vertigo, mental enfeeblement, apoplectiform and epileptiform attacks, spasmodic laughing and crying; the patient may become de- lirious, expansive, hallucinatory and finally demented. 482 NERVOUS AND MENTAL DISEASES. Some differentiation may be necessary from cerebrospinal syphilis, progressive lenticular disease, and in the early stages possibly from hysteria. The disease is progressive in its course, though remissions may occur. An acute and rapidly fatal type has been reported but usually the patient lasts from five to ten years, and then frequently dying of some intercurrent affection such as pneumonia. Occupational therapy in the open air is advisable in the early stage and later the treatment must be symptomatic. PARALYSIS AGITANS. This affection, also known as Parkinson’s disease, is sel- dom met with until late in middle life. Direct heredity is not recognized as a cause, though the ancestry may have shown a tendency to early degenerative changes in the ner- vous system. Possibly mental shock and probably physical shock are at times active in its production. Exposure, hard work and worry may be factors. Hypothetically, overaction of the parathyroids has been cited (Lundborg). It may per- haps be due to an arteriosclerosis of the lenticular and thal- amic portions of the brain and of parts of the cerebellum, whereby a presenile degeneration is brought about. In most instances the symptoms appear insidiously, be- ginning with slight muscular rigidity in the arms, head, trunk and legs; but sometimes even preceding this there have been paresthesias and fugitive and lancinating pains in the extremities. As the disease progresses an attitude is assumed which is characteristic. The patient moves slowly about with short shuffling steps, with the head and body bent forward; the arms and knees are slightly flexed, the fingers and thumbs tremulous and they have the appearance of constantly rolling some small object between them; the face is mask-like, the eyes widely open and winking but in- frequently ; all movements are performed slowly and stiffly. At first the muscular rigidity may not be symmetrical but gradually it extends throughout the body, is attended by but little increase of reflex activity and is without clonus or the Babitiski sign. The tremor, while not invariably present, usually begins with the rigidity, but occasionally it appears subsequently. It is slow and rhythmical and occurs from PARALYSIS AGITANS. 483 three to five times per second. Commonly beginning in one or both arms, the tremor gradually extends to the rest of the body and head. This agitation decreases when the part is in motion and ceases during sleep. It is intensified by emotional excitement and by cold. The patient’s strength is fairly well preserved and his paralysis never reaches an extreme degree. The speech is hesitating and monotonous. Often the gait is singular, tending toward propulsion, latero- pulsion or retropulsion. Sensory manifestations are infre- quent except for some fugitive pains and feelings of heat and cold. Sometimes there are active secretory disturbances, and vasomotor manifestations may appear in the form of. flushing of the face, cyanosis, tachycardia and dermographia. The mentality is usually well preserved except for some anxiety and depression, though I have had two patients who developed a psychosis of sufficient intensity to require in- stitutional detention. Diagnosis of paralysis agitans is usually unattended by difficulty but certain disorders such as hysteria and multiple sclerosis may occasionally require some differentiation. The course of the disease is very slowly progressive, though abor- tive types may be encountered. The patient is later obliged to remain in his chair and ultimately becomes bed-fast, where he may lie for years until carried off by some intercurrent affection. Treatment is discouraging. Hyoscin hydrobromate was formerly the drug of choice to relieve the tremor, but since a toxic action is sometimes observed, belladonna is probably preferable. Favorable results have recently been reported from the use of parathyroids, but their continued administra- tion has resulted in muscular and cardiovascular weakness, which, however, may be prevented by reducing the dose and by the addition of a small quantity of digitalein. Sedatives in the form of bromides and the alcohol group of hypnotics are useful. Tonics should be employed, and the measures conducive to the best general hygiene must be adopted. Oc- cupational therapy is of the utmost importance and exercise through the various forms of Zander apparatus are helpful. Hydrotherapy and diathermy are useful. 484 NERVOUS AND MENTAL DISEASES. TETANUS. This is an acute or subacute infectious disease, character- ized by paroxysmal tonic spasms of the voluntary muscles, notably those of the jaw, hence the familiar term of “lock- jaw”; it is not attended by unconsciousness. The affection is most common in hot countries and the colored race show some susceptibility. Tetanus is caused by the tetanus bacil- lus, which may normally be found in the feces of the horse, cow and also of man, from which it finds its way into the soil. The organism is highly resistant and does not suc- cumb to the ordinary destructive agencies. Entrance into the body is usually through wounds of the hands or feet, since it is these parts that are most exposed to injury; here the organism remains, though the reaction at the point of entry is but slight. Two toxins are recognized: tetano- spasmin, which produces the convulsions, and tetanolysin, which is destructive to the red corpuscles of the blood. The activity of the former poison is for the most part manifested upon the spinal cord, which it has reached by traveling along the course of the axis cylinders, probably of the motor nerves. The period of incubation varies from a few days to perhaps three weeks. Usually, the first symptom is a slight stiffness or spasm of the muscles in the neck or face; if the latter, the characteristic risus sardonicus is produced; soon the muscles of mastication become tonic, and trismus or lock- jaw results. The body muscles become involved and with a paroxysm the positions of opisthotonos, pleurothotonos, orthotonos or emprosthotonos may be assumed. Profound exhaustion ensues. The spasms extend to the muscles of respiration and of the larynx, interfering with breathing and endangering life. The slightest peripheral stimulation is sufficient to precipitate a paroxysm. Seldom is there a rise of temperature until death approaches. Where the point of entrance has been about the head or face, cephalic tetanus may result. Some differentiation is at times required from strychnin poisoning, hysteria, epilepsy, and hydrophobia. If the dis- ease becomes fully developed, death usually results in three or four days, though the modern treatment with antitoxin has lessened the number of fatalities. RABIES. 485 Treatment consists of immediate surgical attention to the wound; prophylactic doses of antitoxin should then be ad- ministered, and these must be followed by larger doses if the disease progresses; intravenous and hypodermic injections of magnesium sulphate solution find favor with some, and chloroform and sedatives are indicated. On account of the high tension of the cerebrospinal fluid, frequent lumbar punc- tures are often necessary. Rectal feeding must be resorted to in the more grave cases. RABIES. This disease, while not confined to middle life, is con- sidered here, because hysteria, which is commonly met with at this period, has frequently been mistaken for rabies in those who believed themselves exposed to this infection. Furthermore, the “mad-dog” scare causes an almost annual alarm in many communities. Rabies, formerly known as hydrophobia, is an acute infectious disease caused by the neurorrhyctes hydrophobia, which are also called the bodies of Negri, since it was he who first described them. At necropsy lesions have been found in the cerebrum and its associated ganglia and in the ganglia of the sympathetic system. To man the disease is usually transmitted by dogs, though not necessarily so, since cats, cattle and wolves may also convey the infection. The bite of a rabid animal may not be followed by rabies, particularly if the individual has been bitten through the clothing, and less than half of those actually wounded develop rabies. The period of incubation varies widely from a few days to several months, and it is said may be for more than a year. The first symptoms are usually pain and redness at the site of the wound, and these are followed by the mental mani- festations of' depression, irritability, restlessness, sleepless- ness and headache, which symptoms constitute the prodromal stage. Soon the period of excitement develops, beginning with great hyperesthesia, so that the slightest peripheral irritation may bring on pronounced spasms; the muscles of the pharynx, larynx and those of respiration become involved; attempts at swallowing, even of water, cause intense spasms of the larynx and this has led to the unsatisfactory name 486 NERVOUS AND MENTAL DISEASES. of hydrophobia. Maniacal excitement often develops to the extent that restraint is necessary. The spasms are not con- tinuous and the patient may be rational at intervals; the temperature is usually elevated. After two or three days the excitement subsides and the paralytic stage ensues; here the patient becomes unconscious, which condition progresses into deep coma, with death usually resulting in a few hours. Sometimes the symptoms partake of those of Landry’s paralysis. The only disease requiring differentiation is hysteria and formerly it sometimes happened that one who had been bit- ten by a dog, not rabid, would get into an emotional state and simulate the manifestations of rabies. After the disease has developed, it is usually rapidly fatal. Animals suspected of having had rabies should be allowed to live for the pur- pose of observation; and even after death the hypocampal and cerebellar cells should be examined, where, in the event of rabies, the organism can usually be demonstrated; with negative findings, this effort should help to relieve the ap- prehension of any one who may have been bitten. Treatment consists of at once applying nitric acid or actual cautery to the wound, then if possible place the patient in a Pasteur institute where an attenuated virus is used for the purpose of immunization, or, if the disease has developed, as a means of cure. Occasionally, the peculiar condition known as “treatment paralysis” results from use of the attenuated virus. SUNSTROKE. Heat stroke, heat exhaustion, thermic fever, insolation, and siriasis, are all terms used in this connection. The common forms of disturbance are thermic fever or sunstroke, heat exhaustion and heat cramps. Thermic fever occurs most frequently in men who are exposed to the sun in a hot, humid atmosphere. Roofers, hod-carriers, brick-layers, masons, farmers and soldiers are those most frequently affected. It also occurs among the workers in a closely confined atmosphere, as in boiler rooms, laundries, glass factories and kitchens. Such workers who are heavily clad and who use alcohol are particularly liable SUNSTROKE. 487 to the disorder. As one would expect, the colored race shows considerable immunity. Exposure out of doors between the hours from 2 to 5 p.m. shows the most victims. The intense heat leads to extensive engorgement of the brain, cord and meninges; also, the lungs and spleen; the liver and kidneys show parenchymatous changes. One form, the asphyxial, while not common, may prove rapidly fatal and sometimes, as if by a blow upon the head, with just a few convulsive movements, death will occur al- most instantaneously. In such cases the symptoms are coma with cardiac and respiratory failure. More frequently, how- ever, there are observed vertigo, headache, nausea and vomit- ing, colored vision, dryness of the skin, dyspnea, diarrhea, and frequent micturition. Often the patient becomes deliri- ous and this frequently deepens into coma. The pulse is full and rapid, and the pupils are contracted. Petechise some- times appear. The temperature may be subnormal, but usually it ranges from 102° to 106° F. In fatal cases there may be convulsions, the coma deepens, there is muscular relaxation, the heart action weakens, and the breathing be- comes shallow. Death may occur in from twenty-four to forty-eight hours. Many recover, though not always com- pletely, since a few may ever afterward find any considerable degree of heat insufferable, and others sometimes show such after-effects as failure of memory and inability to properly concentrate. In the hyperpyrexial form the early symptoms are pro- gressive weakness, nervousness, irritability, dizziness, head- ache and cramps. The state of automatism is occasionally seen. The skin becomes dry, red and hot, though rarely it is clammy. The temperature mounts to above 106°, with a corresponding rise in pulse rate. The patient becomes delirious, confused, and finally comatose. The sphincters may be incontinent. When the symptoms are less severe, there may be a gradual abatement, but in others the tem- perature may rise to from 110° to 115° F. with death soon resulting. Heat Prostration. With this there may be associated some of the symptoms of heat stroke. The symptoms of prostra- tion are weakness, vertigo, headache, nausea, numbness, and 488 NERVOUS AND MENTAL DISEASES. tingling-. Later, cardiac and respiratory weakness appear, together with the other symptoms of collapse. The tem- perature is usually subnormal though occasionally a slight elevation may be observed. Heat Cramps. This condition was described by Edsall, who observed that laborers working hard in high tempera- tures, such as stokers, workers in boiler rooms and about furnaces, were occasionally seized with painful spasms. He believed the condition to be due to an acute degenerative process in the muscles involved. The musculature of the forearms, legs and abdomen was chiefly implicated, and the spasms developed spontaneously, though they could be elicited by physical or electrical stimulation. Fibrillary con- tractions were sometimes seen. The pain (which was in- tense) was followed by soreness and exhaustion. The at- tacks lasted from ten to thirty hours. Treatment. When the temperature is high, it must be reduced by rubbing with ice or it may be employed in the form of a bath, a pack or an enema. A subnormal tempera- ture must be combated with warm baths or with hot-water bottles. In exhaustion, cardiac and respiratory, support must be given. For the convulsions, morphin or chloroform may be necessary. Careful feeding must be instituted. Subse- quent exposure to any considerable degree of heat should be avoided and possibly a change of climate may be necessary. DISEASES OF THE PERIPHERAL NERVES. THE NEURALGIAS. Neuralgia is a symptomatic, paroxysmal pain, limited to the anatomical distribution of a sensory nerve. The dis- order is most pronounced in middle life, women are the more frequently affected and often an hereditary influence is shown. Many conditions underlie these intermittent or re- mittent pains, such as diseases causing general debility, func- tional neuroses, strong emotion, excessive hemorrhage, re- frigeration and trauma; malaria, tabes and other common affections, the intoxications and early arteriosclerosis. In character the pain is variously described as tearing, burning, darting, piercing, and stabbing. Often the affected nerve THE NEURALGIAS. 489 is sensitive to moderate pressure, frequently it will be found much more so than the corresponding nerve upon the op- posite side. At certain sites particularly painful sensations may be elicited and these are known as the painful points of Valleix. The blood pressure usually shows hypertension. Sometimes there are associated the vasomotor manifestations of pallor, flushing and increased pulsation; secretory dis- turbances of increased sweating, salivation, edema, and large quantities of urine may be passed; trophic disturbances of blanching of the hair, of its increase or loss, pigmentation, cutaneous eruptions of various kinds and of hypertrophy or atrophy of a part, also, trophic changes in muscles, bones, and joints. Some differentiation may be necessary from in- flammatory conditions in the joints, periosteum, and bones. Ultimately, some of these patients with the severer grades of neuralgia, through inability to bear their suffering, in a minor sense become antisocial. They grow irritable, moody and morose; they may not be able to work among others and so lead more or less solitary lives. The more common types of neuralgia are those of the tri- facial nerve, the cervico-occipital region, brachial neuralgia, intercostal neuralgia, mammary neuralgia, coccygodynia, crural neuralgia, testicular, ovarian, and traumatic neuralgia. Trifacial Neuralgia. When neuralgia of the fifth nerve reaches its maximum intensity it is known as “tic douloureux.” This nerve is most frequently the seat of neuralgia and the affection is largely one of middle life, with the female sex predominating. An hereditary influence is sometimes ob- served and winter, by reason of its effects consequent upon refrigeration, is the season most to be dreaded. The milder type of the disorder is generally symptomatic and the in- volvement is usually of the supraorbital branch, but either of the other two, or all of the branches may be implicated; the affection is mostly unilateral. Rheumatic disturbances may cause attacks, and nose, throat and dental affections are frequent causes; other factors are debilitating diseases, syph- ilis, malaria, epilepsy, hysteria, and trauma. Often there is extreme tenderness to pressure in the branches of the nerves as they emerge from their foramina upon the face. The pains come and go but they may last for several days; if 490 NERVOUS AND MENTAL DISEASES. very intense there is dilatation of the pupil and possibly reflex facial spasm. The more severe form—tic douloureux—usually appears later in life than the preceding variety and is characterized by the most agonizing pain; almost invariably it is uni- lateral. One or more branches of the nerve may be affected but the ophthalmic division is most frequently the seat of this pain. The affection may result from debilitating dis- orders, local conditions, arteriosclerosis of the Gasserian ganglion, or it may be symptomatic of such grave disturb- ances as growths at the cerebello-pontile angle. Attacks sometimes appear spontaneously, by the taking of cold water or even from an attempt to talk. Most commonly the pain starts in the upper lip, and then with agonizing intensity it darts up to the brow or into the lower jaw, and sometimes into the tongue, roof of the mouth or into the ear. The agony may last but momentarily or the patient may be held in its throes for hours. The suffering produced has been compared to the feeling which would be caused by drawing a red-hot wire through the face, and occasionally—in des- peration—the patient will attempt suicide. When the parox- ysm is at its height, vasomotor and secretory manifestations are common ; tears pour down the face and nasal and lachry- mal secretions are poured out. During a series of attacks herpes may develop and ultimately such trophic changes as blanching of the hair and even hemiatrophy of the face may occur. The special senses sometimes show manifestations and mental confusion may result. Convulsive movements of the facial muscles are common and even the upper extremi- ties may become spasmodic. Attacks are likely to appear in series and may extend over years, while, on the other hand, some patients have only a few attacks during a whole life- time. A few cases terminate spontaneously. The disorder, though severe, does not appear to be in conflict with longevity. Cushing speaks of five types of facial neuralgia which may be mistaken for trigeminal neuralgia: those ascribed to the sphenopalatine ganglion, to the geniculate ganglion, those secondary to zoster, those accompanying cases of convulsive tic, and those due to trigeminus involvement by tumors; all THE NEURALGIAS. 491 of which, if possible, should be excluded before neurectomy is performed. Treatment should be directed to the cause and with this in view one should make a critical survey of all parts of the head and its associated cavities and sinuses; general diseases must be considered. Such drugs as the coal-tar products, allonal, bromids, nitroglycerin, aconite, gelsemium, strychnin, quinin, iodids, and preparations of iron, may be useful. Local applications should be tried and local heat often affords relief. Injection of alcohol into the branches of the nerve sometimes stops the pain for long periods, and injection of alcohol beneath the sheath of the Gasserian ganglion has been done, though the procedure is a dangerous one; x-ray treatments are reported to have been of benefit. Formerly, neurotomy of the nerve branches was employed aiid some- times even the radical procedure of removal of the ganglion was resorted to. Recently, the less objectionable operation of cutting the sensory root posterior to the ganglion has gained in favor, since in skillful hands the operation is safe and the relief afforded is permanent. Narcotic drugs should be withheld as long as possible, for the intense suffering makes easy the establishment of drug addiction. Cervico-occipital Neuralgia. This occurs in the distribu- tion of the first four cervical nerves, especially in the great occipital nerves. The disorder results from trauma, strain, diseases of the cervical vertebrae such as tuberculosis, syph- ilis or rheumatoid arthritis; from tumors or pachymeningitis; from an aneurism or enlarged lymphatics; and emotional disturbances or excessive mental strain may also cause such pain. Often the neuralgia is bilateral, the head is stiffly held, the scalp and skin are hypersensitive, and deep pressure will cause the patient to wince. In extreme cases, trophic dis- turbances in the form of thinning and graying of the hair are sometimes encountered. The disorder is sometimes associated with the following variety. Brachial Neuralgia. The lower four cervical nerves are here implicated and the affection is rather more common in women, with an occupation neurosis frequently as the precise condition. It may result from trauma, diseases of the verte- brae, tumors or aneurisms; from diseases of the cord and its 492 NERVOUS AND MENTAL DISEASES. membranes; it occurs in angina pectoris; or the cause might be a cervical rib, the presence of which would be re- vealed by an x-ray study. The pain is likely to be shooting, the skin is tender, and the reflexes of the extremity are in- creased; there may be painful points upon pressure at the axilla, elbow or wrist; sometimes there are secretory and vasomotor phenomena, and trophic changes may ensue; zoster may be present and a burning pain—causalgia—fol- lowing puncture wounds of the arm or forearm, is occasion- ally observed. Some differentiation is desirable. When the pain has its origin in diseases of the spine, cord or membrane, the disorder may be bilateral and local signs in the extremities would for the most part be wanting. A possible poisoning from al- cohol, lead and diabetes, should be borne in mind, and special consideration must be given to the pains of neurasthenia and hysteria. Treatment consists in removal of the cause, if possible, otherwise, rest for the part, massage, electricity, hydro- therapy, psychotherapy, eliminants and analgesics, with pos- sible cutting of the posterior nerve roots in extremely intractable cases. Intercostal Neuralgia. This disorder results from involve- ment of some of the twelve thoracic nerves, usually from the fifth to the ninth. A stabbing or tearing pain is felt along one or more of the ribs, and tender points may be elicited at the intervertebral spaces, around the chest, or at the sterno-costal junctions. The suffering is intensified by movements of the chest and even pressure from the clothing may be unbearable. Trophic changes are sometimes ob- served and herpes zoster, which is separately considered, is a not uncommon manifestation. The neuralgia may result from grave spine and cord conditions, and some differentia- tion is necessary from local fibrositis and intrathoracic dis- orders. The affection is rather stubborn. A sub-type is mammary neuralgia or mastodynia. This is uncommon and almost invariably occurs among women. When seen it is usually late in pregnancy, late in lactation, or at the menstrual period. The neuralgia experienced is deep seated and there is sometimes an increase of secretion. THE NEURALGIAS. 493 If in addition to extreme tenderness, a local induration is present, one might be suspicious of a growth. Local appli- cations and support are indicated. Much relief has been afforded by firmly but slowly elevating the entire breast for a period of about twenty seconds, which slowly stretches the nerve; this should be repeated several times a day. For the treatment of intercostal neuralgia support is often necessary. Blistering and cautery have been used, and spray- ing with ethyl chloride often gives great relief. Local reme- dies and anodynes are usually necessary and reconstructive tonics may be indicated. Coccygodynia. This is a term applied to neuralgia occur- ring at the tip of the spine and is more common in women, especially primiparse. Obstinate constipation, trauma, and local diseases are factors in different patients, and sometimes it develops in the functional neuroses. Defecation is likely to be especially painful and the patient may not be able to sit. The disorder is a not uncommon feature of litigation cases. Management of such a patient is difficult and an operative procedure should not be resorted to unless abso- lutely necessary. Crural Neuralgia. Pain in the course of the anterior crural nerve is more common in men, since exposure, in- juries and excessive physical effort—such as long marching— may bring it about. The disorder is sometimes secondary to diabetes, vertebral caries, and it may be associated with sciatica. The condition may also result from pressure at the bottom of a corset. Painful points are sometimes found in the groin, down the front of the thigh, and at the inner side of the knee and ankle. Sometimes there results slight trophic changes. Intrapelvic conditions as a cause should be eliminated. Testicular Neuralgia. This condition is at times a very painful one, so much so, that the patient may ask for the removal of his testicle. The disorder is usually unilateral and the organ may be slightly swollen, tender and drawn tightly upward, with excruciating pain extending into the leg or back, and sometimes sufficiently intense to induce vomiting. Refrigeration may provoke an attack or it may be secondary to a local disease. Men who are hyperactive 494 NERVOUS AND MENTAL DISEASES. sexually sometimes suffer from such pain, and then it is likely to be associated with pain in the groins. Traumatic Neuralgia. Trauma to the nerves occurs in many different forms, as from contusions, falls, or blows, incised or punctured wounds, in fractures and dislocations, in diseases of the bones and periosteum, and in the develop- ment of neoplasms. Following such injuries, neuralgic pains may appear. Sometimes after amputations, neuromata are found to have developed at the cut ends of nerves, and these give rise to intense paroxysms of pain. Mitchell observed a condition which he designated “causalgia” but for which the term “thermalgia” has been suggested, since an intense burn- ing pain is its characteristic symptom. This condition most commonly follows gunshot wounds which give partial di- vision of the nerves, resulting in an excessive scar tissue formation—a secondary intraneural fibrosis. Injuries to the median and sciatic nerves are particularly liable to be fol- lowed by this disorder. The condition is believed to be of vasomotor origin. Treatment is surgical, but in the meantime some relief may be obtained by elevation and the application of an evaporat- ing lotion. THE PARALYSES Paralysis of the Facial Nerve. This is the most frequent form of peripheral nerve paralysis, and when due to disease of the nerve trunk is commonly known as Bell’s palsy. The disorder is most usually encountered in early middle life and is more common in the male sex. It may result from trauma, syphilis, and middle ear disease, but the prepon- derant cause is refrigeration. The onset is usually abrupt and is often preceded for a day or two by pain about the ear or in the neck. Minor variations are observed, depending upon the portion of the nerve trunk involved, but changes in the sense of taste speak for a lesion posterior to the stylo- mastoid foramen. Mild attacks may not amount to more than a paresis of the muscles, and even then the branches may not be evenly affected, but in a complete paralysis the lines of the face are obliterated, the cheek has dropped and in some instances has become edematous; the forehead THE PARALYSES. 495 Fig. 2.—Author’s device for support in facial paralysis. (Archives of Neurology and Psychiatry, Dec., 1920.) 496 NERVOUS AND MENTAL DISEASES. cannot be wrinkled, the lips closed, nor the mouth puckered; the angle of the mouth not only cannot be retracted but is actually drawn to the opposite side, especially when the unopposed muscles of the sound side are in action; tears often overrun the paralyzed cheek, and food in mastication collects on the disabled side. In looking upward, the eye on the paralyzed side rotates to a higher plane than does its fellow. The disease lasts a variable time, usually terminating in from three weeks to eighteen months. The longer it per- sists, the less is the hope of complete recovery. The elec- trical reactions are not a safe guide as to the extent of recovery that one may expect, since reactions of degeneration have been reported as having persisted for three years and yet a complete recovery was made. The curious phenomenon termed “contracture” is not infrequent in a mild form, but the disability is much less than when a complete, permanent paralysis remains; such a contracture by reason of the con- tracted and wrinkled appearance which it induces, would at first lead one to believe that the sound side is the seat of a paralysis. Some differentiation may be necessary. A cen- tral paralysis almost invariably leaves the patient with the power of closing the eye, of wrinkling the forehead, and the electrical reactions are normal. In looking upward, the eye on the paralyzed side does not rotate to a higher plane as it does in the periphereal type of facial paralysis. A cortical lesion of the left side may yield aphasia in a right-handed individual. There may be weakness of the arm and the leg on the same side as the face, but on the side opposite to the lesion. A pontine lesion above the nucleus would give the same symptoms, perhaps with some sensory loss, con- jugate deviation of the eyes and ocular paresis. In the part of the pons affecting the nucleus, the face will be paralyzed on the same side as the lesion, since the fibers have crossed, with arm and leg paralysis on the opposite side. There will be muscular atrophy and reactions of degeneration in the facial distribution. Moreover, nuclear paralysis is usually bilateral and is accompanied by other symptoms. Treatment. I am convinced from experience with an ad- hesive device that I am using, that in all cases of complete THE PARALYSES. 497 paralysis, immediate support should be given to the face, since in this way the course of the disease may be shortened and some of the permanent deformities and disabilities may be prevented. This device should be worn until the muscles regain most of their tone. Men, from shaving, sometimes find that adhesive plaster strips loosen, and in hot weather also, the device may slip a trifle. To overcome this objec- tion, I have recently been making the support of a new material, distributed under the trade name of “Tirro.” This substance possesses the property of adhering tenaciously and its rubber content renders it impervious to water. In those who are fastidious, the device may be tinted flesh-color. My experience with this new adhesive material is now quite large, and, so far, no dermatitis has been observed to result from its use. I am opposed to blistering about the ear, which neces- sarily leads to some congestion, and which, when applied for other causes, has been known to produce a Bell’s palsy. Gentle massage and weak galvanism may be used early but they must be judiciously employed. Either, if used too vigorously, may lead to contracture. Diathermia is useful and ideomotor stimulation must be persisted in. The drugs to be given are salicylates, strychnin and the iodides. In the unfortunate event of a complete permanent paralysis, the surgical procedure of anastomosis, either with the spinal accessory or with the hypoglossal nerves, has been done with some measure of success. With the development of a contracture, judicious massage and stretching may cause the muscles to lose some of their rigidity. Musculospiral Paralysis. Paralysis of this nerve is more frequent than that of any other arising from the brachial plexus, and by reason of its exposure as it courses around the humerus, injury may result in a variety of ways. In the act of throwing, the forcible contraction of the triceps may lead to paralysis. Bone fragments from fracture in the middle third of the humerus and sometimes callous forma- tion have pinched the nerve. Pressure in the axilla from a crutch and constricting bands about the middle of the arms as in forcible restraint; and prolonged pressure in sleep, in drunkenness and during anesthesia, occasionally cause par- 498 NERVOUS AND MENTAL DISEASES. alysis of this nerve. The higher up the paralysis, the more extensive the symptoms. The muscles usually affected are the supinators, the extensors of the hand, the extensor com- munis digitorum, extensor indicis, the extensor minimi digiti and extensors of the thumb. Inability to extend the hand at the wrist—wrist-drop—is the characteristic symptom. Pain is not complained of but there may be some numbness and tingling on the back of the hand and at the base of the thumb and index finger. For the most part, recovery is made in from three to five months. In treatment, the wrist-drop should always receive mechanical support. Median Nerve Paralysis. It is unusual for the median nerve to be paralyzed alone except as a result of trauma. More often it is a part of a brachial plexus palsy. Paralysis of this nerve in the axilla is more frequent than is that of the musculospiral nerve. Sprains, dislocations and fractures about the wrist may injure the nerve. Penetrating wounds in any part of the arm may cause paralysis and pressure at the elbow is sometimes responsible for the condition. Paraly- sis of the upper portion yields inability to pronate the fore- arm or to flex the wrist properly. The fingers cannot be firmly flexed nor the hand satisfactorily used. The thumb cannot be abducted nor used properly to pick up small ob- jects. An injury at the wrist will limit the paralysis to the fingers. There is some pain in the hand and anesthesia of the radial palm, thumb, index, middle and part of the ring fingers. Atrophy appears in the thenar eminence and trophic changes in the skin and the nails. Volkman’s ischemic con- tracture paralysis, which sometimes results from faulty application of a splint to the forearm, may be differentiated through implication of the flexor muscles, absence of sensory changes and the presence of feeble but otherwise normal electrical reactions. Ulnar Nerve Paralysis. This form of palsy yields sensory changes in the forearm and hand, and atrophy in the hand. The nerve may be injured at the elbow by direct trauma, fracture or dislocation, by penetrating wounds at the wrist, and in war injury may be inflicted upon it throughout its course. When the ulnar nerve is injured above the elbow, THE PARALYSES. 499 it is usually found to be part of a brachial plexus palsy. Refrigeration is sometimes a cause of ulnar neuritis. Symp- toms vary according to the site of injury. When above the elbow, flexion at the wrist is almost wanting; abduction and adduction of the fingers, and movement of the little finger is impossible; the proximal phalanges of the fingers cannot be flexed and the last joint of the middle and ring fingers cannot be moved. Paralysis lower down yields atrophy of the interossi and thumb muscles, with the final production of the “clawed” hand. The best test for ulnar paralysis is to have the patient grasp between the thumb and forefinger a sheet of paper, when it will be observed that the paper is but loosely held and that only the end of the thumb is in contact with the paper. There is complete sensory paraly- sis in the little finger, and partial loss in the ring finger and ulnar portion of the hand. Trophic changes are at times observed. Some differentiation may be necessary from involvement of the eighth cervical and first thoracic nerves, in which instance there will be attending eye symptoms. Pressure from a cervical rib may cause similar symptoms but this anomaly is easily demonstrated through an x-ray study. External Popliteal Nerve Paralysis. Here is found paraly- sis of the peronei, of the extensors of the foot and long extensors of the toes, with a resulting foot-drop and toe- drop which gives the characteristic steppage gait. When sitting the patient is unable to elevate his toes or foot, nor can the foot be rotated at the ankle. Some disturbance of sensation may be met with on the outer side of the leg and upon the dorsum of the foot. Internal Popliteal Nerve Paralysis. The foot and toes cannot be flexed, the toes cannot be abducted nor adducted, and rotation can only be but feebly performed. It is im- possible for the individual to rise upon his toes. There is sensory involvement of the heel, plantar surface, outer side of dorsum and ends of toes. Slight trophic changes some- times occur, and the plantar and Achilles reflexes are lost. Sciatic Trunk Paralysis. Here will be found more or less of a combination of the two preceding symptom complexes. 500 NERVOUS AND MENTAL DISEASES. NEURITIS AND MULTIPLE NEURITIS. Lesions of the peripheral nerves vary greatly in their manifestations as to whether the nerves implicated are motor, sensory, mixed or those of the special senses. When several nerves are simultaneously involved the disease is spoken of as multiple neuritis. An important group showing exten- sive paralyses will be considered separately under paralyses of the peripheral nerves. The implication of a single nerve may result from such causes as trauma, refrigeration, com- pression from growths, extension of local inflammation, and from poisons or infections. Sciatica. The term sciatica is employed in a very broad sense and so is sometimes misapplied, since too many diffuse pains in the lower extremities are thus labeled. Such a desig- nation should at least be restricted to those disorders caused by neuritis, perineuritis or by a neuralgia of the nerve. The affection is distinctly more common in middle life, particu- larly in the latter period, with males contributing the larger number of cases. Those prone to gouty and rheumatic dis- turbances, especially when in addition they are subjected to exposure and physical strain, are among its most common victims. Frequently there is extension of the disorder from lumbago. Pressure from occupation and constipation are sometimes exciting causes, and lesions of the hip-joint, pelvis and spine may give rise to sciatic pains. In elderly primi- parae, where labor is apt to be prolonged and the use of forceps resorted to, the sciatic nerve may be injured. Cer- tain chronic diseases such as diabetes, syphilis and phthisis, may be attended by sciatic neuralgia. More attacks of sciatica develop in fall and winter. In onset the disorder is usually abrupt, with pain and ten- derness, which may be either localized or which may extend down the back of the extremity. In severe cases there are usually paroxysms of pain which sometimes become aggra- vated at night; there may be a dull ache and in other instances pain which is burning, stabbing or tearing in character; that appearing at the proximal portion of the extremity is likely to feel deep seated while distal pain is felt more superficially, and below the knee is usually in the NEURITIS AND MULTIPLE NEURITIS. 501 external popliteal distribution; the discomfort is much in- fluenced by posture; pressure may elicit pain in the gluteal region, near the sciatic notch and down the back of the extremity, but the impossibility must be borne in mind of pressing directly upon the sciatic nerve in the thigh, since muscular tissue intervenes and soreness here may be mis- interpreted as sciatic tenderness. Cutaneous sensibility of- ten shows hyperesthesia of the sciatic area and possibly some anesthesia in very protracted cases; numbness, tingling, and a feeling of cold is often experienced. Pain-spasms some- times occur; the knee-jerk may be exaggerated early but later is likely to be diminished, while the Achilles-jerk in severe cases is usually lost. If the disease is long-continued the muscles of the buttock and even of the thigh sometimes show atrophy; contracture may ensue, and a scoliosis be induced. The phenomenon of Lasegue is quite distinctive— inability to properly flex upon the pelvis, the extended leg, because of the pain produced in the back of the thigh. Trophic disturbances, such as herpes and edema, may appear. Some differentiation of the various types is necessary and x-ray studies of the hip-joint, pelvis and spine may be desir- able. Of recent years, sacro-iliac strains have received much consideration, perhaps more than is justified. In double sciatica, growths or diseases within the pelvis or spine must be considered, and diabetes and syphilis should be eliminated. Sciatica dependent upon a well developed sciatic neuritis should not be difficult of recognition. The course of this disease is variable, with mild cases recovering in a few weeks, while severe ones may last many months and relapses are not infrequent. The affection at times is exceedingly painful. Of recent years less has been heard of sciatica, which, however, is not due to a greater infrequency of pain in the extremities but rather to greater accuracy in diagnosis. In treatment the cause must be sought. Rest in bed, and perhaps fixation, is imperative in all severe cases. The measures employed are many—hydrotherapy, electricity, massage, diathermia, stretching (very judiciously applied), blistering, and injections of normal saline solution; the em- ployment of such drugs as salicylates, aspirin, bromides, 502 NERVOUS AND MENTAL DISEASES. iodides, atropin, and nitroglycerin, but the more powerful anodynes only if absolutely necessary. Multiple Neuritis. Occasionally, multiple neuritis occurs before middle life but seldom after. Rarely, it has appeared as an epidemic and a recurrent type has been reported. The inflammation is parenchymatous and may be due to many causes which can be grouped as: (1) exogenous poisons, such as alcohol, lead, arsenic, mercury, carbonmonoxide, copper, silver, phosphorus, potassium cyanide, and aniline products; (2) toxins from the infections of diphtheria, influenza, ty- phoid, pneumonia, gonorrhea, small-pox, scarlet fever, sep- ticemia, malaria, cholera, tuberculosis, syphilis, beriberi, leprosy, and the puerperium; (3) intoxications from certain diseases, as gout, rheumatism, cancer, and blood diseases. The neuritis is symmetrical, with the extremities more com- monly affected, and with the involvement more pronounced at the distal ends, from whence it extends toward the trunk. Occasionally, the disorder develops acutely with a chill, fever and headache, but more frequently the onset is gradual with symptoms appearing first in the sensory sphere. First there is numbness, tingling and pain in the hands and feet, with the gradual appearance of weakness which is soon followed by a loss of power; the pain may be intense and burning or tearing in character; often there is hyperesthesia with areas of hypesthesia and such manifestations are frequently glove-like in their distribution; sensory symptoms are some- times attended by ataxia. The motor manifestations begin with weakness and tremor which may advance to a complete paralysis; the paralyzed muscles become flabby, undergo atrophy and the tendon reflexes are diminished or lost; the electrical reactions may become those of degeneration. Cer- tain nerves are particularly prone to involvement—the ex- ternal popliteal leading to foot-drop with its characteristic “steppage” gait, and the musculospiral causing wrist-drop; to the latter may be added a median nerve palsy which gives rise to the deformity of claw-hand. Depending upon their etiology certain varieties are worthy of special mention: Alcoholic neuritis usually appears in steady drinkers and women are the more likely to develop the disorder. The lower extremities usually bear the brunt NEURITIS AND MULTIPLE NEURITIS. 503 of the attack; cutaneous hyperesthesia is present and in addition spontaneous pains appear together with hypersensi- tiveness upon pressure over the nerve trunks and in the muscles themselves; the tendon reflexes are diminished, atrophy—perhaps with contractures—results, and trophic changes may appear. The motor cranial nerves are some- times implicated, and optic neuritis is now and then a mani- festation. Mental symptoms, which are not infrequently associated, may be of the Korsakow type, but all of these forms are considered elsewhere. Recovery from the neuritis is rather rapid after withdrawal of alcohol, but return to drink soon leads to a relapse. Since the prohibition law has been effective, wood alcohol poisoning is more frequent, when in addition to multiple neuritis, blindness and death may result, even if but a small quantity of the poison has been ingested. Lead poisoning results from continued exposure, and in the production of a neuritis is particularly selective in its action, as shown by the frequent involvement of the posterior interosseous branch of the musculospiral nerve; the patient develops wrist-drop, muscular atrophy, and shows lost re- flexes ; pain and tenderness are usually not a feature of this form of neuritis; rarely, the legs are affected and a shoulder- arm type of paralysis has been recorded; ocular palsies and an optic neuritis sometimes result, while a lead encephalo- pathy is a possibility. Arsenical neuritis in its manifestations approaches that of alcoholic neuritis; there is pain, tenderness and paralysis, and sometimes skin lesions develop. One must bear in mind that arsenical poisoning has resulted from the injudicious use of arsphenamin, and also that it has developed in those syphilitics who were unduly sensitive to the drug. Diphtheritic neuritis usually appears some weeks after subsidence of the active symptoms and is largely confined to the cranial nerves; the soft palate and the pharyngeal muscles are first implicated and the voice has a decided nasal twang; later, possibly oculomotor paralysis and even facial paralysis may ensue; sometimes paralyses in the extremi- ties, with their consequent manifestations, are seen, and a 504 NERVOUS AND MENTAL DISEASES. rare but most serious involvement is that of the pneutno- gastric nerves. Pregnancy, especially if attended by excessive vomiting, may show a polyneuritis which in some instances is due to cachexia. In grave cases the neuritis may be of the ascend- ing type of Landry. The course of multiple neuritis varies with its cause but often it runs for weeks and months, and with the best of care, contractures and paralyses may be unavoidable. Fatal cases are usually those with cardiac and respiratory involve- ment. Treatment varies somewhat, depending upon the etiological factor. In the withdrawal of alcohol the patient must be actively supported, and in lead palsy elimination is of the greatest importance. Rest in bed should usually be enforced and support with mechanical appliances must be given to the paralyzed parts. Pain can be relieved by the use of coal- tar products, bromides, salicylates, and possibly with chloral, but morphin and cocain should only be resorted to in extreme cases. Strychnin, iron and the iodides are often indicated. Later, massage, exercise, hydrotherapy and electricity are helpful. HERPES ZOSTER. This disorder is also called acute posterior poliomyelitis and is familiarly known as “shingles.” It is due to a neuritis and ganglionitis of the sensory system, and is characterized by neuralgic pains and a herpetic eruption. The affection is not limited to the thoracic distribution, since there is sometimes cervical, lumbar and sacral implication, and oc- casionally involvement of the Gasserian and geniculate gan- glia attached to sensory cranial nerves. The disorder may result from diseases of the vertebrae and meninges, tabes, and from acute infections or intoxications. The first mani- festation is shooting neuralgic pains in the fibers implicated, and this is soon followed by the development of tenderness and redness over the course of the nerves where the herpes shortly appear. The affection is at times preceded by such general symptoms as fever, headache and gastro- intestinal disturbance. Rarely, the disorder is so severe as to lead to extensive ulceration and even gangrene, but in PROGRESSIVE MUSCULAR ATROPHY. 505 mild cases, it usually subsides in a few days. However, neuralgic pains are sometimes experienced for a few weeks after the skin lesions have disappeared. A severe type is ophthalmic zoster; this is not apt to occur except late in middle life and then usually in individuals with an alcoholic history. Here, in association with the intense pain an ery- sipelatous condition may develop, together with the grave ocular manifestations. Treatment consists in the application of local remedies and internally in the administration of salicylates and bromides. If gangrene develops, or if grave ocular complications appear, special treatment must be adopted. CERVICAL RIB. The symptoms caused by this anomaly do not usually appear before adult life, and though manifestations from such a condition are rare, they have been recorded as occur- ring bilaterally, and likewise have been known to be due to pressure from the first rib. Pressure, which is most likely to be exerted upon the lower trunk of the brachial plexes, is not necessarily confined to this portion. There is usually experienced pain and an aching sensation along the ulnar side of the hand and forearm, together with the insidious development of atrophy in the muscles of the hand. Slight sensory changes may be present. Church has observed that weights borne upon the shoulder or carried in the hand may produce these symptoms, and adds that sometimes there is an interruption of the pulse in downward or upward extension of the member. Palpation may not reveal the presence of the rib so that in all cases of brachial neuralgia and atrophy of doubtful origin, x-ray studies should be made. The of- fending rib together with its periosteum should be removed with care, since the operation is not devoid of danger DISEASES WITH PRONOUNCED MUSCULAR MANIFESTATIONS. PROGRESSIVE MUSCULAR ATROPHY Various types of this disorder are met with and sometimes they occur in mixed form. The affection results from vascu- 506 NERVOUS AND MENTAL DISEASES. lar changes and a slow disappearance of the anterior horn cells with consequent atrophy of the corresponding muscles and sometimes with involvement of the pyramidal and anterolateral tracts of the cord. Upon an inherently weak nervous system, trauma, exposure, over-exertion, infections, and intoxicants, may act so as to bring about the various forms of this disease. A type known as that of Aran- Duchenne is distinctly of spinal origin and appears insidi- ously through inability to perfectly adduct the thumb of one hand, which is soon followed by imperfect separation of the forefinger from the middle finger; later, the patient notices that skilled movements of the fingers and hand can no longer be properly executed and atrophy sets in, noticeably that of the thenar and hypothenar eminences; soon the other hand becomes involved and both assume a claw-like appearance; the shoulder girdle, forearm and back are implicated, fibril- lary tremors are seen, the tendon reflexes diminish, and electrical changes appear which ultimately amount to re- actions of degeneration. Bulbar symptoms sometimes de- velop later. Rarely the disease shows an abortive tendency but usually it terminates fatally within a few years. Treatment consists of rest, nutritious feeding, strychnin and reconstructive tonics, together with the mild application of electricity. PROGRESSIVE NEURITIC MUSCULAR ATROPHY. This type, spoken of as that of Charcot-Marie-Tooth, rarely declares itself in middle life. Here, the muscles involved early are the peronei, extensor longus digitorum, and the tibialis anticus, thus at times giving rise to some form of talipes. Later, other muscles in the leg and thigh become implicated and finally those of the hand and forearm. Fibril- lary tremors are seen, the reflexes weaken and perhaps dis- appear, and the electrical changes pass gradually into those of degeneration. Frequently the disease is a familial one. ARTHRITIC MUSCULAR ATROPHY. This disorder is sometimes present in an active arthritis or it may result from a previous joint disease. It is charac- terized by a much greater involvement at the proximal side MYASTHENIA GRAVIS. 507 of the articulation, by the extensors being chiefly implicated, by slight quantitative electrical changes, but without the reactions of degeneration, and by an increase in myotic irritability but with an absence of fibrillary tremors. The tendon reflexes about the joint are often increased and rarely clonus is observed. Treatment must be directed to the joint, with the judicious application of massage, electricity, exercises and hydro- therapy to the muscles affected. MYASTHENIA GRAVIS. This disorder may be encountered in middle life, with its first manifestations appearing not later than thirty years. It is characterized by exhaustion upon slight effort, and by a special electrical response known as the myasthenic re- action; this latter is brought about through faradic stimula- tion with the result that the muscles soon show exhaustion, and the more rapidly the current is interrupted, the sooner does the exhaustion appear. Etiology is uncertain, but pos- sibly it will later be classed as an endocrine disturbance. The early symptoms are weakness and fatigue toward night which, however, is soon recovered from. Later, when walk- ing, the patient may become so exhausted in his legs as to fall. Not infrequently the facial muscles are the first to reveal the disorder, and weakness of the upper lids or even ptosis with paresis of the ocular muscles and diplopia— asthenia ophthalmoplegia—is not uncommon. Other cranial nerves may be implicated thereby giving rise to difficulty in talking, mastication, and deglutition. Slight exertion may cause dyspnea and tachycardia. The tendon reflexes are present though easily exhausted, but sensory changes are wanting. An interesting leucocytosis is sometimes observed. Pain may be complained of and atrophy and fibrillary twitch- ing have been noted. The most important diagnostic point in myasthenia gravis is the early exhaustion of the muscles through faradic stimu- lation, which, however, is soon recovered from. Some dif- ferentiation may be necessary from bulbar paralysis, brain lesions and hysteria. Rarely, there has been observed ces- sation of the disorder, but generally it proves fatal, occa- 508 NERVOUS AND MENTAL DISEASES. sionally in five or six months; however, more commonly it endures for many years. The treatment is rest, full doses of strychnin, the mineral tonics, careful feeding and possibly artificial feeding late in the disease. If an endocrine imbalance can be demonstrated, an effort should be made to overcome it. PROGRESSIVE BULBAR PARALYSIS. This is a glosso-labio-laryngeal paralysis of the degenera- tive type with the seat of the disorder in certain of the motor cranial nerve nuclei—VII, IX, X, and XII—but without sensory involvement. It is only occasionally that the disease is met with and then usually late in middle life. As to cause, there must be some weakness of the nervous elements to permit of such a premature decay. Exciting causes may be overuse of the muscles involved, trauma, emotion, and per- haps some toxic substance, either exogenous or endogenous. The muscles of the lips, jaws, tongue, palate, pharynx, and larynx, first show fatigue, then exhaustion, and finally paralysis with accompanying loss of function which results in the defective action of speech, mastication and deglutition. The muscles affected become the seat of minute fibrillary tremblings and show partial reactions of degeneration. The speech assumes a nasal twang, food enters the nose, and drooling occurs. Emotionalism is the only mental mani- festation. Ultimately, the jaw drops, the tongue atrophies and lies motionless in the mouth, and the soft palate be- comes paralyzed. Finally, the patient cannot speak or swallow and his helplessness becomes truly pitiable. Rarely, the oculomotor nuclei are affected, and sometimes the dis- order is associated with amyotrophic lateral sclerosis or progressive muscular atrophy. While the disease may show temporary abatement, it is found to terminate fatally in from one to four years, with death resulting from inanition, pneumonia, or some intercurrent affection. The earliest possible recognition of progressive bulbar palsy is of especial importance in relation to life insurance and industrial accidents, and with this thought in mind fibrillary contractions should be carefully sought for, any beginning change in mechanical and electrical muscle con- MYELITIS. 509 tractility should be noted, together with difficulty in the pronunciation of linguals and labials. Diagnosis is attended by but little difficulty since only one disorder, pseudo-bulbar palsy, shows much similarity and this disease is produced through bilateral lesions in the cere- brum. Here, there is an obvious mental defect with an absence of rapidly progressive paralysis and atrophy, fibril- lary tremors and the electrical reactions of degeneration. Myasthenia gravis may possibly need some differentiation. Rarely, there is an acute bulbar paralysis and this results from hemorrhage, thrombosis, softening or infection, but with these the onset is sudden and there is likely to be spme sensory involvement. The management of such a patient is difficult and often artificial feeding must be resorted to early. Medicinally, strychnin, arsenic and phosphorus are indicated, and the tonic effect obtained through the physio- logical methods of massage, hydrotherapy and the galvanic current, is helpful. DISEASES OF THE SPINAL CORD. Inflammation of the spinal cord, though not common, may occur as an acute, subacute or chronic disease. It may de- velop at any level—cervical, thoracic, lumbar, or sacral— and transversely, it may involve a part or the entire cord. It may be localized or diffused, with the process extending either upward or downward. Myelitis more commonly af- fects men and is most frequently met with in middle life. The causes are many but usually it is a secondary affection. The condition has followed infectious diseases and pus producing conditions on the surface or anywhere within the body. Fracture-dislocations and even traumata unat- tended by bone lesions have preceded it. It may be an extension from the various forms of meningitis, such as tuberculous, syphilitic, pyogenic, and epidemic; it is said that pus may extend from the periphery through the course of the nerve trunks. Myelitis has accompanied rabies and even exposure to cold is said to have precipitated it. A condition spoken of as myelomalacia is a softening of the cord result- MYELITIS. 510 NERVOUS AND MENTAL DISEASES. ing from embolism and thrombosis, and in this the symptoms closely resemble those of myelitis. Manifestations vary widely depending upon the cause, site and extent of the disease process, but most frequently it is the thoracic or the lumbar cord that is involved. Some- times the disorder begins with malaise but soon numbness and weakness are experienced, following which there de- velops paralysis of sensation and motion, together with bladder and rectal disturbances and possibly with vasomotor manifestations. An encircling band of anesthesia often cor- responds to the level of the lesion and above this is some- times found a zone of hyperesthesia. The muscles controlled from the area of the lesion show atrophy, reactions of de- generation and loss of reflexes, while those controlled from below the disease are usually spastic, with increased reflexes and finally with contractures. Sometimes the symptoms partake of the Brown-Sequard syndrome. A transverse lesion of the cervical region may be distin- guished by pain, hyperesthesia and anesthesia in various parts of the upper extremities with anesthesia in the body and lower extremities; paralysis of motion in the arms, neck, trunk, diaphragm, and legs; atrophy confined largely to the arms and for the most part attended by reactions of de- generation ; the reflexes usually are lost but later show an increase; disturbances of the bladder and rectum; priapism is often present, and sometimes there are pupillary changes. A transverse lesion of the thoracic region yields pain and hyperesthesia around the abdomen and back; paralysis of some of the thoracic, abdominal and intercostal muscles; atrophy of some of the thoracic and abdominal muscles, and possibly slight atrophy in the legs with corresponding elec- trical changes; reflexes are lost at first but later they may be increased; there are bladder and rectal disturbances, and priapism is frequently present. A transverse lesion in the lumbar region gives pain in the legs, hyperesthesia around the loins, with anesthesia in the legs wholly or in part; paralysis of motion usually amounts to a paraplegia with clonus and the Babinski sign, some atrophy, loss of reflexes, and with changes in the elec- MYELITIS. 511 trical reactions; also, there are disturbances of the bladder and rectum. Some differentiation may be required from meningitis, multiple neuritis, Landry’s paralysis, poliomyelitis, and pos- sibly from hysteria. In course the disease is variable, with lesions of the cervical region showing the greatest mortality. The higher the temperature rises and the more extensive the paralysis, the greater is the danger. After a few weeks the patient may show some improvement, which is first to be observed in the sphere of sensation and later in that of motion. If the individual progresses favorably, he may later be able to be about though usually with some disability. Others may become bed-fast, develop sores and cystitis, and ultimately die. Treatment consists in rest upon a water-bed with cupping of the spine, purgation, diaphoresis, urotropin, and with most careful attention to the bladder; if bed-sores and contractures threaten, they must be vigorously combated; later, strychnin, iodids, and physiological therapy may prove helpful. Compression Myelitis. One of a number of causes may be operative in bringing about a slow and continuous pres- sure upon the cord, such as bony growths, tuberculosis or syphilis of the vertebrae, membranes or cord, from tumors and cysts, and from an aortic aneurism. Pain and rigidity of the back are often present, together with shooting pains and muscular twitchings in the extremities. Sometimes de- formities of the spine develop. Generally, there is spasticity in the parts supplied below the lesion and sensory changes may be present. The spinal fluid should be examined and x-ray studies made. In some instances the pressure may be relieved as in tuberculosis of the vertebrae and in certain operable tumors. When an acute myelitis develops, it must receive prompt and careful attention. Chronic Myelitis. This may result from the acute form or it may be primary. The symptoms, which are very gradual in their development, consist of vague pains, numb- ness, weakness, later sensory disturbances and atrophy fol- lowed by some changes in the electrical reactions. Ulti- mately, the sphincters may be involved and the patient may become bed-fast. Certain other chronic nervous diseases 512 NERVOUS AND MENTAL DISEASES. may require differentiation, such as meningitis, the muscular atrophies, lateral sclerosis, and symptomatic disturbances produced by some form of compression. The disease is often long drawn-out and treatment is that of other chronic paralytic and bed-fast patients. HEMATOMYELIA. Hemorrhage into the structure of the cord sometimes re- sults from trauma, which is not necessarily attended by fracture-dislocation, and it may follow upon unusual physical exertion or excessive sexual intercourse; it may be secondary to diseases of the blood-vessels, diseases of the cord itself, or to neoplasms; it has followed exposure to high atmos- pheric pressure, and has resulted from convulsive disorders. Hematomyelia may occur as a single hemorrhage, at times extending for considerable distance, or there may be several foci. Hemorrhage into the cervical cord is the most dan- gerous. The onset is sudden with weakness and numbness in the extremities, which is soon followed by motor paralysis, sen- sory disturbance and sphincteral implication. The reflexes are at first lost, but later return, and then become exag- gerated. Symptoms vary somewhat depending upon the extent and site of the lesion. Sometimes acute myelitis develops, with death following rapidly. The treatment is that of acute myelitis. LANDRY’S PARALYSIS. This disease is an acute and probably an infectious process, characterized by rapid progression, generally ascending but occasionally descending, sometimes attended by an advanc- ing anesthesia and usually, rapidly fatal. Recent investiga- tions incline one to the belief that many, and perhaps most, cases develop upon an acute poliomyelitic basis; rabies also, has been known to show these symptoms. The picture pre- sented is somewhat like that of multiple neuritis, either with or without myelitis, and often with febrile symptoms. The affection begins abruptly with flaccid paralysis, which usu- ally appears first in the lower extremities. Numbness and CAISSON DISEASE. 513 paresthesia are present, and often anesthesia, but seldom is there pain. The reflexes are abolished but the electrical re- actions are unchanged. The disease extends rapidly to the thigh muscles and then to those of the trunk and abdomen. Soon the thorax and arms are involved, the latter being implicated in the same direction as were the legs. In all of these parts the muscles are perfectly flaccid. Only very rarely do the bladder and rectum become paralyzed. The power of deglutition is often lost. It is but seldom that the cerebrum becomes implicated, so that the patient remains conscious almost to the last. Some differentiation may be necessary from acute polio- myelitis, acute myelitis, and multiple neuritis. Usually, the course of the disease is rapidly fatal in from a few days to perhaps two weeks, though abortive types are occasionally encountered. Death generally comes suddenly either from failure of respiration or heart action. Treatment is not successful, but the patient should be placed on a water-bed, carefully fed and nursed, and in- ternally urotropin should be administered. CAISSON DISEASE. Among the numerous affections induced through occupa- tion is that of air pressure paralysis. Occasionally, one finds this disorder arising in miners, divers or tunnel workers, who after having been under heavy atmospheric pressure, come too suddenly into the normal atmosphere. The de- compression is sometimes so rapid as to lead to points of softening, particularly in the posterior and posterolateral columns of the cord. The nitrogen gas which cannot be eliminated with sufficient rapidity through the lungs, ac- cumulates as gas emboli, which have been demonstrated not only in the arterioles of the cord, but also in the heart and mesentery. There may be free hemorrhage into the cord. The symptoms appear rapidly, beginning with pains in the legs and abdomen, and sometimes elsewhere in the body. Soon the patient begins to stagger, paralysis sets in, and anesthesia appears in the body though the pain continues. The sphincters may relax. Less conspicuous are the cere- bral symptoms, which consist of vertigo, headache, prostra- 514 NERVOUS AND MENTAL DISEASES. tion, vomiting, double vision, and difficult breathing. The patient may develop an acute myelitis, become comatose and die in a few days. Others recover with a slight residual chronic myelitis, and mild cases are often completely restored. Among workmen who are habitually exposed to high air pressure, the return to normal atmosphere should be gradual, and some far-seeing employers have had a cabinet especially constructed to meet this condition. After the accident has occurred, ergot in large doses should be administered, the extremities bandaged, and if a myelitis develops, appropriate care and treatment must be given. SYRINGOMYELIA. Syringomyelia, an uncommon nervous disease, is due to cavity formation in the spinal cord, which extends longi- tudinally for considerable distance, and is characterized by a loss in pain and temperature sensations—dissociation anes- thesia—in any part of the body, trophic disturbances and a progressive muscular atrophy which is attended by paralysis. The more usual location for the cavity is in the lower cer- vical or thoracic regions, and in the less severe cases with an involvement of not more than five or six segments of the cord. Sometimes there is an upward extension into the medulla and even into the pons, and two or three separate cavities may exist. Transversely, the opening is usually situated near the central canal, with asymmetrical exten- sions into the anterior and posterior gray matter, and perhaps into the white columns. Usually, syringomyelia develops early in middle life and it may extend through this entire period. The disease is more common among men who have subjected themselves to great physical effort or who have sustained an injury. Such causes together with intoxications and infections, may act upon an inherently weak nervous system and bring about the disorder. The symptomatology is extensive and irregu- lar. In development it is insidious, with aches, pains and paresthesias in the upper extremities and neck as its first manifestations, following which, atrophy slowly appears with a corresponding weakness. The most striking feature is the presence of irregular areas where pain, heat and cold sensa- SYRINGOMYELIA. 515 tions are only slightly if at all recognized, but where touch is preserved, so that occasionally burns or other injuries are brought about unawares. Sometimes burning pains are ex- perienced in the affected members, and the development of atrophy, which is more common in the arms, may also appear in the back and give rise to a scoliosis. Reflexes that are first diminished, later disappear. Fibrillary tremors may be observed and finally there are reactions of degeneration, so that the picture in part may be that of amyotrophic lateral sclerosis. Trophic disorders in the form of glossy skin, and herpetic and bullous eruptions, may appear. There has been observed a Charcot joint in the spine and elsewhere. When the trophic disturbances are pronounced, leading to atro- phies, hypertrophies, felons, affections of the nails, necroses and deformities, the type is that of Morvan, and here care must be exercised lest the disease be confounded with the anesthetic type of leprosy. Ultimately, cystitis, bed-sores and incontinent sphincters warn of the approaching end. Involvement of the first thoracic segment may cause sympa- thetic paralysis with its narrowing of the palpebral fissure retraction of the eye-ball, tardy action of the pupil and de- fective dilatation, disturbance of sweat secretion and flat- tening of the face. Syringobulbia results from extension of the process into the medulla, with the development of tremors in the tongue and facial muscles, with atrophy, nystagmus, ocular paralyses, and dissociation of sensation in the head and face. Occa- sionally, the vocal cords are implicated, difficult swallowing and disturbances of respiration and heart action usually develop. This type is the most rapidly fatal. In the early stage some differentiation may be necessary from other diseases showing marked sensory changes, later from other progressive spinal atrophies, from cervical pachy- meningitis, and in the bulbar type from bulbar paralysis. Without bulbar involvement, the disease is often of long duration. A very few cases may abort and temporary arrest in its progress is not infrequent. Through care, some of the trophic lesions may be prevented, but since there are no special remedies, treatment must be symptomatic. 516 NERVOUS AND MENTAL DISEASES. LATERAL SCLEROSIS. Lateral sclerosis is characterized by a bilateral spasticity, affecting first and chiefly the legs, and attended by weakness, increased reflexes, clonus and the Babinski sign, but without sensory disturbance, except for a little pain, or visceral im- plication except in the late stage. The disorder is most common early in middle life but is rare as a pure type, it being more frequently associated with other cerebral and spinal diseases. The early symptoms are weakness and stiff- ness in the legs and this may be attended by slight pain. The gait is rather distinctive—the feet are shoved forward as though glued to the ground, and since the toes cannot leave the ground, the shoes are worn off in front. The adductor muscles are contracted so that the knees are ap- proximated and the legs may even be crossed, thus giving rise to the so-called scissors gait. Muscular atrophy is ab- sent and the electrical reactions are normal. The disease often lasts for years, with the patient finally becoming bed- fast. The upper extremities may be involved late. Treat- ment consists in the use of such measures as rest, hydro- therapy and massage, together with the special exercises known as motor training. Any evidence of syphilis should be met promptly with specific medication. AMYOTROPHIC LATERAL SCLEROSIS, This progressive degenerative disease is almost invariably one of middle life, with the male sex predominating. The disorder is due to chronic vascular changes which involve the lateral columns of the cord and anterior horn cells, the latter implication giving rise to a progressive muscular atrophy. Sometimes there is associated a degeneration of the cranial motor nerve nuclei, in which event the disorder includes a progressive bulbar palsy. With an inherently weak motor system, such causes as exposure, trauma, infections and intoxications may excite the disorder. The progress of amyotrophic lateral sclerosis is by no means uniform, but often the first evidence is stiff- ness of the hands and later it is observed that the small muscles are undergoing atrophy, which gives a claw-like COMBINED SCLEROSIS. 517 appearance to. these extremities. Soon the forearm is in- vaded and perhaps the shoulder girdle, with fibrillary tre- mors appearing. Occasionally the legs are first affected with a gradually developing gait that is spastic-paretic in charac- ter, increased knee-jerks, ankle clonus and the Babinski sign. It is only late that atrophy and fibrillary tremors appear in the lower extremities. Reactions of degeneration in the muscles are only present in advanced cases but there is an earlier quantitative decrease to both the galvanic and faradic currents. Talipes and lordosis may develop. There is no distinct sensory involvement though paresthesias, aches, pains and cramps are sometimes complained of. The sphinc- ters remain intact. Some differentiation may be necessary from a primary spastic paralysis and a chronic muscular atrophy. The dis- ease usually lasts for years with its progress occasionally abating, but when there is bulbar implication, death may be only a matter of months. Treatment consists in nutritious food, tonics, and the ju- dicious employment of massage, hydrotherapy and electricity. In this disease a diffuse sclerosis implicates chiefly the posterior and lateral columns of the spinal cord, with a re- sulting ataxic paraplegia. In a few cases the basic cause appears to be an endarteritis of the spinal vessels. It may, however, develop upon a luetic basis and then the condition approaches the Erb type of spastic paraplegia. Combined sclerosis has been known to follow intense physical effort and finally to develop in the course of a prolonged and ex- hausting disease. For the most part it is a disorder of middle life, with the male sex predominating. The symptoms vary as to whether they more closely simulate locomotor ataxia or lateral sclerosis. The disorder begins with weakness in the legs, early fatigue, and soon an unsteady gait. Rom- berg’s sign is present, the knee-jerks are plus, and an ankle clonus and a Babinski sign can be elicited. While the dis- ease is not a painful one, some aching and paresthesias are experienced. There is some disturbance of sensation, espe- cially in the feet and legs, where the senses of vibration and COMBINED SCLEROSIS. 518 NERVOUS AND MENTAL DISEASES. touch are impaired and perhaps wanting. Nystagmus and optic atrophy have been recorded. Finally, the sphincters become implicated and cystitis may develop. The patient becomes bed-fast, the legs—which are now paralyzed and drawn up—are the seat of painful spasms, and even with the best of nursing, bed-sores may develop. Usually, the disease lasts for some years with death resulting from exhaustion, complications or some intercurrent affection. Rarely, a mild case may recover. Early in the disease a differentiation from tabes, other scleroses and multiple neuritis may be necessary. If the disorder has developed upon a luetic basis, some bene- fit may result from specific medication, otherwise the treat- ment is symptomatic and supportive. A subacute, combined degeneration of the spinal cord, associated with pernicious anemia, is important. The dis- ease is characterized by a rather rapid loss of the vibration sense and the sense of position, together with disturbances of the sense of touch and of superficial pain. The posterior and sometimes the lateral columns of the spinal cord bear the brunt of the disease process, though the nerve roots, posterior and even anterior, may be implicated, and not in- frequently the peripheral nerves show degeneration. It is estimated that three-fourths of the cases of pernicious ane- mia present changes in the nervous system, but the severity of these symptoms need not keep pace with the blood picture. The disease is distinctly one of middle life, occurring most frequently between forty and fifty years, with women the more commonly affected. The early symptoms are pares- thesias, often appearing as numbness and cold, most com- monly beginning in the feet and sometimes spoken of as stocking- or glove-like. A girdle sensation is experienced and associated with this are weakness, shortness of breath, sometimes gastrointestinal disturbance, perhaps a lemon- colored skin, and beginning bladder and rectal incontinence. The disease progresses and the patient develops ataxia. It is rather the rule that the reflexes are increased early, and later diminished or even lost. Neuralgic pains are common. Occasionally, epileptiform seizures occur and more rarely an optic neuritis develops. A loss of the senses of vibration and of position is quite distinctive, and when to this is added SPINAL MENINGITIS. 519 the characteristic blood picture, no doubt may remain as to the diagnosis. Generally, the disease is progressive although remissions may occur, which, for the most part, apply to the general condition, since degenerated nerve fibers cannot be restored. The disease usually terminates fatally in from one to three years, and death may result from cerebral hemor- rhage, but more usually it is the outcome of a slow asthenia with the occasional development of bed-sores and cystitis. Treatment for the most part is that of the underlying con- dition and for this purpose cacodylate of sodium and neo- salvarsan may be used. Normal salt solution, in the form of hypodermoclysis, is useful, and for the disability, massage and exercises are to be employed. SPINAL MENINGITIS. This disease, which may be acute or chronic in its course, may result from syphilis, tuberculosis or malignancy of the spine, or of the membranes; it may extend from the cranial cavity or from septic foci in the body by traversing the course of the nerves or of the blood-vessels; through the medium of the blood it may be carried from a pneumonia or from other infections, and it may follow trauma. The pathology differs, pus being found in some cases, but this is not encountered in the tuberculous form, when, however, miliary tubercles are met with. Myelitis may result and may be attended by softening of the cord and destruction of the tracts and gray matter. Sometimes the disorder is ushered in abruptly, at others it begins with malaise. Soon there appears tenderness along the spine while pain, shooting sharply into the extremities, may be experienced. The neck and back become rigid and the position of opisthotonos is often assumed. The muscles of the limbs and abdomen show spasms, and implication of the bladder and rectum may lead to retention of urine and feces. Pulse and temperature are variable. At first the re- flexes are increased but ultimately they may be abolished. Kernig’s sign can be elicited. Scratching the skin with the finger nail leaves behind a streak of hyperemia. Paresis, and later paralysis in the form of paraplegia, may appear. 520 NERVOUS AND MENTAL DISEASES. Following a lumbar puncture, the spinal fluid often yields evidence of diagnostic importance. In the adult, meningo- cocci but seldom give rise to meningitis; however, when this condition arises, the spinal fluid is observed to flow rather faster than normal, it is usually milky or creamy, the spe- cific gravity is generally increased (sometimes to 1.008), there is commonly a polynucleosis and perhaps pus, albumin varies greatly in amount, and the meningococci are easy of recognition. In tuberculous meningitis the fluid—which gen- erally is clear—is under great pressure, the specific gravity is high (at times up to 1.012), a lymphocytosis is usually present, but the tubercle bacilli, though present, are difficult of demonstration. It is important to distinguish meningismus, a condition which sometimes attends infections; such manifestations are not serious and a lumbar puncture reveals normal spinal fluid. Spinal meningitis may prove fatal in a few days and this is especially likely to occur when there is implication of the bulb; a myelitis gives grave complications. Treatment should consist of absolute rest on a water- or an air-bed, with the patient in such position as may afford most relief from his suffering. Ice-bags, leeching and mer- curial inunctions can be applied to the spine. Internally, urotropin and bromides, with the possible addition of mor- phin for the pain. Lumbar puncture sometimes affords relief. Special conditions, such as cystitis and bed-sores, must be dealt with as they arise. Circumscribed Serous Meningitis. Locally, occasionally there is found a collection of fluid beneath the dura, in dis- eases of the vertebrae and of the meninges, in syringomyelia and in tabes, and a similar condition has been observed in the pia-arachnoid. Edematous fluid may likewise collect during infections, after trauma, and it may arise spontane- ously. Such collections of fluid may be more or less diffuse. The attending symptoms being much like those resulting from tumor, errors in diagnosis have arisen. Sometimes the symptoms show a tendency to fluctuate and this should cause one to suspect the condition of circumscribed serous menin- gitis. Treatment is evacuation through operation. HYPERTROPHIC CERVICAL PACHYMENINGITIS. 521 Chronic Spinal Meningitis. In a few instances this dis- order results from acute meningitis and from trauma, but more commonly it is caused directly by syphilis or tubercu- losis, or extension of these diseases from the vertebrae, and rarely it may result from pressure of a tumor or aneurism; it may also accompany tabes and diseases of the cord. The symptoms consist of sensory changes (either an increase or a decrease), motor disability, and perhaps bladder and rectal disturbances. Pain is conspicuous and this may extend from the cervical and thoracic regions into the extremities. Para- plegia sometimes develops and the patient may be unable to be about. Treatment in an advanced case is that of other bed-fast paralytic conditions, together with counterirritation to the spine and such special measures as its primary cause may require. While this is a rare disease, it concerns us for the reason that the middle decades of life are particularly liable to the effects of its etiological factors, which are syphilis, trauma, alcoholism, and exposure, and consequently with such causes the male sex must predominate. The dura becomes thick- ened and the pia adherent, which mass later involves the nerve roots and the cord. The early symptoms are those of irritation while the later manifestations are those of com- pression. First, there is hyperesthesia and pain in the neck, shoulder or arm, which may be accompanied by muscular twitchings and later by atrophy. The cervical spine is stiff, tender, and sometimes it is laterally deviated. There may be involvement of the cervical sympathetic and finally a spastic paraplegia with its attendant phenomena may de- velop. The sensory changes are variable, sometimes sensa- tion is delayed, and in other instances there is dissociation. While the cervical meninges are the site of predilection, one must bear in mind the possibility of the lesion developing lower, with the symptoms corresponding to that of the level implicated. Prognosis is unfavorable except in the few in- stances where the condition may be an operable one. Luetics should receive active specific medication, and in the event HYPERTROPHIC CERVICAL PACHYMENINGITIS. 522 NERVOUS AND MENTAL DISEASES. of appearance of the much dreaded symptoms of cystitis, paralysis of the bladder and bed-sores, these must be ener- getically met. TUMORS. Tumors of the cord occur much less frequently than do those of the brain, but they are more operable and for this reason their early recognition is important. They are met with most frequently between thirty and fifty years, and are distributed about equally between the sexes. These growths are of various kinds, such as glioma, sarcoma, psam- moma, angiosarcoma, carcinoma, gumma, tubercle, parasitic, cystic, osteoma, and chondroma. The growths proper are commonly divided into hard and soft tumors. Malignant growths may be either primary or secondary, and cystic growths occasionally result from traumatism. These offend- ing bodies develop within the cord and within the dura, or they may appear extradurally. The symptoms produced are pain, hyperesthesia, hypes- thesia, motor phenomena such as paresis, paralysis, spasms, twitchings and spasticity; changes in the reflexes of the ex- tremities and sometimes of the abdomen and scrotum; atro- phy, trophic disorders and visceral disturbances. The symp- toms vary with the level of the lesion and to some extent with their transverse site. Pain is an early, persistent and troublesome feature, often agonizing in its intensity; it is due to irritation of the sensory roots or to involvement of the sensory tracts of the cord; the pain is usually shooting in character and at first is likely to be unilateral; in the beginning its origin is obscure and often passes for rheuma- tism or sciatica. Where implication is largely in the anterior part of the cord, pain is sometimes absent. Other sensory manifestations are hyperesthesia at about the corresponding surface level, with hypesthesia or anesthesia below and these are apt to be segmental in their distribution. A unilateral lesion will often yield the symptoms of a Brown-Sequard paralysis. With involvement of the anterior part of the cord the motor symptoms predominate, such as paresis, spasticity, and possibly compression to the extent of a paraplegia; often the reflexes are increased and the Babinski sign and clonus FRACTURE-DISLOCATION SYNDROMES. 523 may be obtained. Implication of the bladder and rectum are not infrequent, with bed-sores developing late. Except for a gumma and tubercle which appear rather rapidly, tu- mors are usually slow in their growth and progressively worse in their course. An early diagnosis, though surgically most desirable, is seldom made. There should be x-ray studies, which, how- ever, are most helpful in the matter of excluding bone dis- ease. Xanthocromia in the spinal fluid often speaks of an extramedullary growth and a lumbar puncture may yield other important information, particularly in cases of sus- pected gumma. A history of previous syphilis should be considered and a primary growth in another part of the body may be the origin of the trouble. If the tumor is of rapid development and is multiple, it may be sarcomatous in nature. Some differentiation may be necessary from tabes and neu- ralgic disorders; from meningomyelitis and pachymenin- gitis; multiple sclerosis and syringomyelia should be readily ruled out; a compression myelitis and particularly a circum- scribed serous meningitis must be considered. Treatment. If the lesion is gummatous, antiluetic meas- ures should be adopted. After the site has been determined, at least an exploratory laminectomy may be done. In in- operable cases, cutting of the implicated posterior roots, and even an incision into the anterolateral column of the cord, have been employed for the control of intractable pain. A few tumors are operable early, notably the fibroma, psam- moma, osteoma, lipoma, and cyst, and fortunately for sur- gical approach the greater number of them lie laterally or posteriorally, and by far the larger number are extramed- ullary. An intramedullary growth cannot be satisfactorily removed. FRACTURE-DISLOCATION SYNDROMES. Injuries to the spine resulting in cord symptoms may be due to falls or blows, to forcible movements, and to cutting instruments, or bullets. Sometimes the cord sustains only a bruise but there may result a laceration or hemorrhage, and occasionally the cord substance is more or less com- pletely divided. Even complete severance of the cord is not 524 NERVOUS AND MENTAL DISEASES. incompatible with life, since patients have lived for many years after, though, of course, with great disability. An injury may occur at any region along the spine, but the thoracic region, owing to its greater exposure, is a quite common site. The higher the seat of injury the greater the danger, and if above the fourth cervical vertebra, death usu- ally follows rapidly from failure of respiration. Symptoms vary greatly, depending upon the level of the lesion and upon the extent of transverse involvement of the cord.. An injury high in the cervical region may involve the phrenic nerve directly, with death following promptly, or from an injury somewhat lower there may be upward extension of inflammation and so implicate the phrenic nerve. Priapism most commonly results from involvement of the cervical segments of the cord. Lower in the cervical region and high in the thoracic, arise the fibers of the cervical sympathetic nerves, disturbance of which yields the well- known ocular phenomena. In the “dorsolumbar” region the anesthesia usually reaches as high as the superior spines of the iliac bones and possibly upward to the umbilicus. In- jury at the level of the lower three lumbar vertebrae may yield the saddle-like patch of anesthesia around the anus and the gluteal and perineal regions. It is generally recog- nized that a complete anesthesia—pain, touch and tempera- ture—of a skirt zone can only result from the implication of three successive nerve roots. Rapid disappearance of symp- toms is indicative of hemorrhage and is regarded as a favorable omen. At first there is likely to be flaccid paralysis, loss of re- flexes, and incontinence of the bladder and bowel, with sensory loss below the lesion and an area of hyperesthesia at the level of the lesion. Later, a spastic paralysis often ensues. An injury approximating a hemisection of the cord will cause the Brown-Sequard syndrome; this consists of sensory changes on the side of the lesion, showing at that level a band of hyperesthesia, and beneath this one of anes- thesia, paralysis on the same side without atrophy, reflexes are lost at first, but later return and finally become increased; on the opposite side of the body, below the lesion, there is loss of pain and temperature sense and perhaps of the sense RAYNAUD’S DISEASE. 525 of touch. Careful x-ray studies should be made. If the patient survives a severe injury, more or less permanent disability usually results. The treatment consists in rest upon a water-bed and such other attention as is accorded an acute myelitis, otherwise, the treatment is surgical. VASOMOTOR AND TROPHIC DISEASES. RAYNAUD’S DISEASE. This disorder, also known as symmetrical gangrene and local asphyxia, is rare but may be met with early in middle life, and women are the more frequently affected. It usually appears in individuals of a psychopathic makeup, and psychic trauma may cause the disorder to develop; it has been ob- served in hysteria, epilepsy and acute mania; also in the organic diseases of tabes, myelitis, multiple sclerosis, in dis- eases of the blood and in infections; an arteriosclerotic con- dition may aid in its development. The fingers and toes are most commonly affected, but other extreme points of the body—as the ears, nose, tongue, and genitalia—may be the seat of the disorder; rarely it may occur elsewhere on the body surface and possibly in the interior. Although there may be abortive attacks, in the complete process, three stages are observed: local syncope, local asphyxia, and local death. First the affected part becomes death-pale, then in a few minutes or perhaps hours cyanosis develops, following which vesicles appear and break down and some days after this gangrene may ensue; later, the area heals with cicatrization. Blood may appear in the urine and there have been observed attacks of transient hemiplegia or migraine. The lesions vary greatly in frequency and in intensity. Treatment must if possible be directed to the underlying cause. When the pain is intense, morphin may be necessary; where the psychic element is pronounced, psychoanalysis has proved useful. Such measures as diathermia, hydro- therapy, electricity, and the intermittent bandage of Cushing should be employed. 526 NERVOUS AND MENTAL DISEASES. INTERMITTENT CLAUDICATION. The disorder of intermittent limping is for the most part limited to middle life, and is due to insufficient circulation in the calves of the legs and sometimes in the feet. It arises from spasm of the arteries of the nerves supplying the im- plicated muscles, from an arteriosclerotic process in these arteries, or from arteriosclerosis of the cord. The manifesta- tion is prone to appear after physical exertion and is often preceded by paresthetic sensations; the muscles may cramp and in the milder cases the attack passes away with rest. In the more severe form there is an absence of pulsation in the dorsalis pedis artery and sometimes also in the posterior tibial, both of which may be rigid. Intermittent claudica- tion has also been met with in the upper extremities. The use of alcohol and tobacco, and the presence of flat feet, are said to be factors in its causation. From Raynaud’s disease and from erythromelalgia it may require some differentiation. The affection must be combatted with hydrotherapy, dia- thermia, massage, electricity and good hygiene. ANGIO-NEUROTIC EDEMA. These attacks of local edema, fugacious in character, are largely confined to the middle period of life, with the female sex predominating. They develop in neurotic individuals and sometimes there is shown an hereditary influence. The affection is characterized by suddenly appearing edematous swellings in the skin, attended by changes in coloi* and tem- perature, and by an interference with the function of the part. The indurations which develop do not pit on pressure. Sud- den exposure will precipitate an attack, and while any part of the body may be affected, it is most common in the hands and feet. The color varies from pale yellow to bluish-red, the local temperature is lowered, a sense of discomfort is felt and burning pain may possibly be experienced, but an actual anesthesia is rare. While attacks do not usually last more than a few hours—possibly days—their inopportune appearance sometimes leads to much apprehension upon the part of the patient. Urticarial manifestations may be experi- enced. The disease is not without danger, as, for instance, ERYTHROMELALGIA. 527 when the larynx is attacked; then the pharynx, gastro- intestinal tract and even the brain,'it is said, have been the seat of these swellings. Treatment, with involvement of the larynx, might be operative. If the pain is intense, morphin may be required; otherwise the management must be that adapted to other neurotic individuals. > ERYTHROMELALGIA. This disorder is rare but may be encountered late in mid- dle life, with males the more commonly affected. It is a chronic disturbance, characterized by attacks in which a part becomes red and hot, and is attended by an agonizing pain; the latter is much aggravated by a dependent position. The feet are the more commonly affected, and owing to the active hyperemia present there may be some local rise in tempera- ture. Local sweating is sometimes present, as is also slight swelling. The affection occurs in neurotic individuals and can result from chronic cord diseases, infections, physical and mental strain, and exposure. Treatment. There must be rest of the part, and cold af- fords some relief. Hydrotherapy, massage and electricity, and the application of the intermittent bandage of Cushing may be tried. SCLERODERMA. Scleroderma, though rare, is by preference a disease of middle life, with women its most frequent sufferers. While the manifestations of this affection fall for the most part within the domain of dermatology, its origin is usually to be found in the sphere of neurology, since its progenitors have been diseases and injuries of the spinal cord and periph- eral nerves, physical and mental strain, and endocrine dis- turbances. Exposure and the infections have likewise been held responsible for its development. The first symptom is usually pain in the implicated part, or sometimes the patient’s attention is attracted to an indurated area in the skin which later becomes thickened and shows a pronounced luster; the skin is rigid, cannot be picked up, and does not pit on pres- sure. Sometimes irregular areas of pigmentation are seen, 528 NERVOUS AND MENTAL DISEASES. and disturbances of sweat, growth of hair, and vasomotor changes, may appear. Lesions are not absolutely confined to the skin, since the mucous membrane, muscles and joints have been observed to be implicated. When the disorder affects chiefly the hands or possibly the feet, sclerodactyle is spoken of, and here thickening and deformity results. A local type, occurring somewhat earlier in life and known as progressive facial hemiatrophy, has been described; in addition to atrophy (even of the bones), there are secretory and trophic changes. A few mild cases may recover but where the skin is dis- tinctly hidebound the affection becomes very chronic, though perhaps with slight remissions. Treatment should be supportive and includes tonics, hydro- therapy, massage, electricity, and diathermia, with attention to any endocrine imbalance that may be detected. This rare affection is probably a form of rheumatoid arthri- tis, but one which shows pronounced nervous symptoms. Middle aged males are most frequently affected. The dis- order is progressive and while it may at first be confined to a particular part of the spine—often the cervical region— ultimately the entire column becomes ankylosed, perfectly rigid, bent forward, and moves as a whole; it has been termed the “poker spine.” Often there is associated ankylosis of the large joints, such as the shoulder and hip, and in ad- vanced cases the jaw may become immovably closed, and the ribs fast at their spinal attachments leaving respiration to be carried on largely through the abdominal muscles. It is generally insidious in onset and the first symptoms result from irritation of the nerve roots, with the patient experienc- ing sharp shooting pains along the course of the nerve dis- tribution ; there may be some additional sensory symptoms such as anesthesia, and even atrophy of muscles has been observed but without reactions of degeneration. Later, when the ankylosis is extreme, the pain usually decreases. Osteo- phytes have been developed within the spinal canal and have impinged upon the cord substance, thereby giving rise to such symptoms as occasionally result from intraspinal tumors. SPONDYLOSE RHIZOMELIQUE. SYPHILIS OF THE NERVOUS SYSTEM. 529 Minor infections are sometimes at the root of this dis- order so that pus should be searched for around the teeth, in the various sinuses, the tonsils, intestinal tract, ovarian tubes, prostate and seminal vesicles. The discovery and de- struction of such sites of infection may in the early stage arrest the disorder; later the treatment must be tonic, sup- portive, and possibly with inoculations, and with recourse to hydrotherapy, diathermia, massage, and electricity. SYPHILIS OF THE NERVOUS SYSTEM. Luetic infection is a prolific source of disease and it is variously estimated that from eight per cent, to twenty per cent, of the cases show involvement of the nervous system. The organism, which is a very motile one, is known as the Spirochcta pallida, and the escape of many luetics from neurosyphilis is due to the local action of the antibodies in destroying the organisms. There are reasons for believing that different strains of this organism, or possibly variations of the same strain, may be the cause of different clinical types of neurosyphilis. The manifestations of congenital syphilis almost invariably declare themselves before middle life. Few if any persons who have had neurosyphilis should ever marry. Following infection, evidence of neurosyphilis has been observed as early as ten weeks by Mott, and within three months by Nonne, while, on the other hand, symptoms may not be encountered until many years after infection. A case recently studied by me was that of a convict who had been continuously in prison for twenty-seven years and during which time he had enjoyed good health. Then he had an apoplectiform attack which led to a Wassermann study and he was found to be suffering from neurosyphilis. It was believed extremely improbable that he had acquired syphilis during his incarceration. In most instances the clinical symptoms will enable one to make the diagnosis, but there are exceptions where the laboratory data aid in arriving at definite conclusions, and certain findings in the blood and spinal fluid occasionally direct attention to a previously unsuspected neurosyphilis. Furthermore, repeated laboratory studies give some indica- 530 NERVOUS AND MENTAL DISEASES. tion as to the progress of the disease and the success of anti- syphilitic treatment. A positive blood Wassermann by no means denotes the presence of neurosyphilis nor does its absence eliminate neurosyphilis. Either a blood Wasser- mann or a spinal fluid Wassermann may be present without the other and a positive reaction is of much greater value than a negative one. The blood is almost always positive in paresis and in taboparesis; the spinal fluid also is almost always positive in paresis and in taboparesis but not so fre- quently is it positive in uncomplicated tabes and in cerebro- spinal syphilis. The pressure of the spinal fluid is increased in paresis and in taboparesis, and usually in tabes, but less frequently so in cerebrospinal syphilis. Nonna regards the number of lymphocytes normally found in the spinal fluid as varying from none to five; from six to ten as borderland; and from ten upward as pathological. In neurosyphilis the increase is sometimes enormous, and this in a measure bears some relation to the activity of the luetic process. A lympho- cytosis is with few exceptions indicative of neurosyphilis, and in those syphilitic disorders especially marked by chron- icity—as tabes and paresis—it may precede by a considerable period the clinical symptoms of the disease. Therefore, if the spinal fluid speaks of syphilis, one should not wait for the clinical symptoms but should institute treatment at once. Chemical analysis may show the presence of globulin in normal spinal fluid, but any decided increase is indicative of disease though not necessarily of syphilis. It parallels to some extent the lymphocytosis. In the presence of syphilis the luetin test of the epidermis appears constant, there- fore, this is of special value in the few cases showing a negative Wassermann. The colloidal gold test is one of great delicacy and is of most value in making a careful search for the so-called parasyphilitic affections. By the provoca- tive Wassermann reaction one understands the rendering of a negative spinal fluid positive through the injection of arsphenamin or some allied preparation. A more compre- hensive term is neurorecidive or neurorecurrence, which signifies the appearance in the course of arsphenamin treat- ment, of the symptoms of neurosyphilis, usually resulting TABES DORSALIS. 531 from meningeal implication and sometimes with cranial nerve involvement. Syphilis of the nervous system is often a diffuse process, so that it is generally regarded as difficult to limit the process to definite diseases. For instance, such widely separated manifestations as pupillary changes and disturbances of mic- turition, nerve root lesions and hemiplegia, frequently occur in a number of the syphilitic diseases. Head and Fernsides mention as early signs and symptoms of cerebrospinal syph- ilis : Changes in personality and aptitude.—Patients may become entirely untrustworthy, are neurasthenic, attention and concentration are affected and they lose their efficiency. Disturbance of sleep.—A few show a pathologic tendency to sleep, but more commonly there is insomnia; disturbing dreams often occur, and hallucinations amounting to minor psychoses may be encountered. Headache.—The nocturnal feature of this symptom has been given undue prominence; it is paroxysmal, often severe, and is sometimes accompanied by extreme tenderness of the scalp; when in addition there are optic atrophy, nausea and vomiting, the Wassermann test may be needed to eliminate brain tumor. Shivering attacks with or without fever have been observed. Root lesions.—In posterior root involvement neuralgic pains are common and sensory diminution or loss is frequent; attacks of herpes zoster are sometimes observed; involvement of the anterior roots yields motor disturbances and muscular atro- phy. Abnormal reactions of the pupil.—Variations as to size, inequality, irregularity and irresponsiveness to light are common. Disturbances of micturition are often early manifestations. The pathologic types of syphilis of the nervous system are of the more or less benign meningo-vascular type and the malignant parenchymatous type, both of which are some- times combined, and beside these many atypical forms are frequently encountered. Tabes dorsalis or locomotor ataxia, which perhaps is the most common disease of the spinal cord, is mostly confined to middle life. It is a syphilitic affection, though less than TABES DORSALIS. 532 NERVOUS AND MENTAL DISEASES. one per cent, of those infected develop tabes. The disorder is for the most part located in the posterior nerve roots and posterior columns of the spinal cord, but there is also im- plication of the peripheral nerves and nerves of the special senses. It is more frequent among the metropolitan popu- lation and occurs oftener in men. The disease has been known to begin as early as four years after infection, but the average is about fifteen, while in a few patients the first signs have not appeared until many years later. It is notable that in tabes dorsalis the constitutional manifestations of syphilis have been few and sometimes have entirely escaped observation. The symptoms are conveniently divided into three stages: preataxic, ataxic, and paralytic. Preataxic Stage. One of the earliest symptoms is pain in the lower extremities. By the laity this is sometimes spoken of as “rheumatic,” but the shooting and lancinating charac- ter of the pain should cause one to be suspicious of its luetic origin. Usually the disease begins in the lumbar region but rarely it is the cervical roots that are first implicated, in which event the pain will shoot into the upper extremities. A still more rare form is that with bulbar involvement and here a trifacial neuralgia may be the first manifestation. Paresthesias, anesthesias, and hypesthesias are common. Numbness and tingling are frequently experienced. Bands and irregular areas of diminished and even lost sensation are frequent in the legs, soles of the feet, about the chest and below the nipples. Important sensory changes result- ing from impaired integrity of the posterior columns of the spinal cord are, diminished appreciation of tuning fork vibra- tions when this instrument is applied to the surface of a superficially placed bone (as the tibia), inability to properly recognize the exact position into which a segment of the extremity may be placed, and failure to recognize, as two points, the widely separated arms of a compass. Biernacki’s sign, an insensitiveness to pressure over the ulnar nerves at the elbow, is an advanced symptom. The tendon reflexes at the knees and ankles are soon lost. Pupillary abnormali- ties tending toward the Argyl-Robertson type are usually seen. Then there are the various crises, often leading to TABES DORSALIS. 533 errors in diagnosis—paroxysmal attacks of intense pain in the stomach attended by nausea, persistent vomiting and prostration; the bladder, rectum, clitoris and larynx may also be the seat of attacks. Romberg’s sign (unnatural sway- ing of the body when the patient stands with his eyes closed and his feet squarely together), hypotonia and ocular palsies are early symptoms, together with the Wassermann findings and the lymphocytosis in the spinal fluid. Ataxic Stage. This period, which sometimes lasts for many years, is characterized by incoordinate muscle action. The patient’s gait becomes unsteady, he cannot walk well in the dark, he stumbles and soon comes to the use of a cane; the feet are lifted high in the air and the heels are first to touch the ground. While the shooting pains become less pro- nounced, the paresthesias increase. Disturbance of muscle sense renders it impossible to properly appreciate the posi- tion of the extremities. Crises continue, optic atrophy be- gins and bladder and rectal disturbances become pronounced; vesical incontinence is sometimes so troublesome a feature as to necessitate the patient’s wearing of a special rubber device to catch the dribbling urine. Trophic disorders ap- pear in the form of arthropathies with their attending de- formities, and the knees in particular are prone to show the Charcot joint. Perforating ulcers of the feet may develop, and various types of muscular atrophy are occasionally en- countered. Herpes and other skin lesions appear. Paralytic Stage. Finally, the patient is no longer able to walk, he takes to a chair and ultimately to bed. Bed-sores appear and while he usually lives for a long time, death, from some intercurrent affection, may occur at any moment. The course of the disease is variable and if recovery is possible, it is only in the earliest stage. However, much may be done to ameliorate the condition and to prolong life. In those individuals who early develop an optic atrophy, the disease is of longest duration. Diagnosis. Lost knee-jerks, ataxia, and Argyl-Robertson pupils are almost diagnostic. A possible exception in the early stage is an alcoholic multiple neuritis. Another possi- bility is a submyxedematous condition, which may yield neuralgic pains, coming and going, absent knee-jerks and 534 NERVOUS AND MENTAL DISEASES. Achilles-jerks, sluggish pupils, some incoordination, and physical and mental fatigue; but here the blood and spinal fluid findings are negative and the disorder responds to thy- roid treatment. Tabes dorsalis is at first sometimes regarded as neurasthenia. Because of the various crises surgeons have frequently been led into operations for supposedly local con- ditions. Sometimes diabetes gives rise to similar symptoms, and the gait in cerebellar disease is occasionally misleading. The type of disease known as taboparesis may develop, in fact paresis may precede, may appear simultaneously with or may follow tabes dorsalis. Treatment. Because of the chronicity of the disorder and its many complications, much is required in addition to anti- syphilitic measures. Occupational therapy is important, and in the well-to-do a change of climate often affords comfort to these sensitive invalids. By means of special exercises, marked improvement in the ataxia may be secured through reeducation of the muscles. A period of rest in bed with full feeding and massage will give temporary relief. These patients frequent all manner of electrical institutes,, with but little relief, except in a psychic sense. Medicinally, salvarsan and its derivatives are used intravenously and intraspinously, while other preparations of arsenic are employed by injection into the muscles. Mercury is used internally and in the form of inunctions. Potassium iodide should be given at intervals. Systematic spinal drainage is employed by Gilpin and this it is claimed is not only beneficial per se, but that it also causes more drugs to pass through the spinal fluid. What is known as the Aachen method includes the systematic in- unction of a per cent, ointment of mercury which, under careful medical supervision, is applied by a trained rubber; this is augmented by the internal and external use of sulphur water, which it is believed tends to the formation of a more soluble compound of mercury than is the albuminate. In addition scrupulous attention is directed toward the condi- tion of the mouth, kidneys, heart, lungs, and liver. Such a course may take from one hundred to two hundred days. For the paroxysmal pains, allonal may give relief. As a bed- fast patient, the various procedures that are employed in other paralytic conditions must be resorted to. PARESIS. 535 This disease is also known as dementia paralytica, pro- gressive general paralysis, general paralysis of the insane, and by the laity it is frequently spoken of as “softening of the brain.” The affection is a chronic, diffuse meningo- encephalitis, characterized by progressive mental enfeeble- ment, together with progressive paralysis of the entire body. On the whole, the psychic manifestations tend to dementia, but there may appear various phases, such as neurasthenic, hysterical, depressive, or maniacal, and sometimes there is an expansive period showing the classic delusions of gran- deur. It has been definitely determined that paresis results from syphilis and it is said to actually develop in about two per cent, of those infected. The disease is most commonly met with between thirty and fifty years and usually appears from four to ten years after infection, with the male sex looming much the larger in statistical studies. Causes which may be somewhat predisposing are, alcoholism, prolonged physical and mental strain, trauma to the head in a syphilitic may favor its development, and such a disease as influenza may precipitate paresis. While paresis is classed as of the parenchymatous type of syphilis, there are extensive findings in the meninges and in the blood-vessels. The meninges are thickened, opaque and adherent. The brain has lost in weight, the cortex is thinned and the convolutions are atrophied. The pons and medulla are frequently involved, and often implication of the poste- rior columns of the cord give rise to so-called taboparesis. The ganglion cells are degenerated, as are to some extent their connecting fibers. Also marked evidence of the disease is shown in the blood-vessels. Paresis conforms more or less closely to various types, such as dementive, expansive, agitated, and irregular. The stages of the disease may be conveniently divided into the prodromal period, period of the established psychosis, and the terminal period or that of dementia. Prodromal Period. Rarely, paresis develops suddenly with an epileptiform or apoplectiform seizure, and it may also be precipitated by trauma to the head, but the more usual course PARESIS. 536 NERVOUS AND MENTAL DISEASES. is with an insidious onset, so that the disorder is sometimes mistaken for neurasthenia or psychasthenia. Often there is insomnia, headache, loss of appetite and digestive disturb- ances, but soon minor mental defects develop, such as failure of memory, indifference, character changes, intemperance, licentiousness, errors in money matters, and carelessness in dress. Defects in speech and hand-writing occur, and pupil- lary abnormalities together with ocular palsies often occur. Commonly there is increased reflex tendon activity, dimin- ished cutaneous sensibility, and even lost sensitiveness to pressure, as may be demonstrated by squeezing the testicles. Such a state may last for many months before the more characteristic manifestations obtrude themselves. Period of the Established Psychosis. This stage of the dis- order is characterized by definite mental and physical symp- toms. The speech and hand-writing become distinctly “paretic.” The patient experiences difficulty in using words containing the letters known as labials and linguals and this may be demonstrated by having him repeat “truly rural,” “Methodist Episcopal,” “royal artillery brigade,” etc. In writing, besides the conspicuous tremor, it is often noticed that letters, syllables and even words are omitted. Tremor of the hands and lips is noticed. The pupillary changes and those of the tendon reflexes become more pronounced than in the preceding stage and trophic disturbances may occur. The mental symptoms previously observed become empha- sized and more obvious changes, such as actual delusions, appear. Although a very much changed individual, the patient will speak of himself as exceptionally well. His ideas become exaggerated and he may plunge into gigantic busi- ness schemes, even taking with him associates who still have faith in his ability. Soon, however, his conversation and actions excite suspicion and as the disease gradually unfolds itself, it is realized that a mentally deranged man is being dealt with. Hallucinations are not common except in the depressed types. The delusional content of the mind is con- stantly changing. The patient may believe himself possessed of great physical strength, of commanding personal beauty and great intellectual endowment; that he is some mighty person with countless millions at his command, which he PARESIS. 537 proceeds to lavish upon those about him; wives and con- cubines by the hundreds are his. A frequent and a conspicu- ous feature is emotivity, so that the paretic often changes suddenly from laughter to anger. Grievous offenses are sometimes committed and maniacal outbreaks are common. Optic atrophy may develop and not infrequently tabetic symptoms are associated. Remissions. This strange circumstance is sometimes ex- perienced after the patient has been placed in a detention hospital and possibly even after he has become bed-fast. Here, mental and physical improvement gradually shows itself until finally the patient regains mental control so that his friends believe him to be perfectly well, but such con- fidence is usually unwarranted since the individual will almost surely, in the course of a few months or possibly years, have another mental break-down. Rarely, remissions occur more than once, but to the skilled observer there al- ways remains some reminder of the condition, such as pupil- lary and tendon reflex changes with possibly ataxia and some slight speech defect. If paresis is ever permanently curable, and a few of our best observers believe that it is, it must be early in the disease. Either following a remission or following the progress of the uninterrupted disease, the patient almost invariably arrives at the final stage of paresis. Period of Dementia. Through his generally progressive disease, the paretic becomes less active physically, his de- lusions less pronounced and his words scarcely intelligible. Finally, he is a bed-fast dement with complete loss of vesical and rectal control and often with the development of bed- sores. Diagnosis. In the beginning the disorder may be regarded as neurasthenia or psychasthenia, but the mental and some- times the moral weakening, together with a study of the blood and the spinal fluid should eliminate these diseases. Chronic poisoning from alcohol or lead may have to be con- sidered, since these also show tremor, disturbances of speech and mental manifestations. Brain tumor and sleeping sick- ness sometimes counterfeit paresis. An important differentia- tion is that of cerebral syphilis; here, the manifestations usually appear much earlier and are commonly attended by 538 NERVOUS AND MENTAL DISEASES. headache; it is more likely to involve other cranial nerves than the third, often shows distinct localizing signs, and is much more responsive to treatment. Paresis yields more pronounced mental symptoms and more definite spinal fluid findings. Types of syphilitic psychoses, other than paresis, are sometimes encountered such as simple mental enfeeble- ment, and paranoid, manic-depressive, epileptic, hallucinatory and confused states. In course the disease is progressive except in the few in- stances where remissions occur, and these may last for a few months or possibly for a few years. Paretics usually die in from three to five years, although one of my patients lived for seven years after his admission to an asylum. Treatment has not proved very successful but the common method has been that of injecting intravenously antispecific remedies, together with mercurial inunctions. Recently, heroic measures have been adopted by means of injecting antispecific remedies every few days, first intradurally, both cerebral and spinal, next into the lateral ventricles through the site of a former decompression, and finally into the cisterna magna. Such substances have also been introduced into the carotids. Ultimately, paretics, except those who are well-to-do, require institutional detention and care, and even- tually they must be accorded the same careful attention that is given to patients in other paralytic disorders. SYPHILITIC CEREBRAL MENINGITIS. Syphilis of the cranial bones is usually, though not nec- essarily, accompanied by meningeal involvement, and when a gumma develops in these structures, it commonly gives rise to the symptoms of brain tumor. At the base of the brain is where the meninges are most frequently implicated and the region of the interpeduncular space is the most com- mon site. The usual symptoms are headache, optic nerve involvement either directly or through pressure, with con- sequent disturbances of vision. The third nerve is frequently affected, thereby showing ptosis and oculomotor palsies. Other cranial nerve implication ranges all the way from the fourth to the twelfth. The mental symptoms are usually minor, though they may vary from apathy to mania. When SYPHILITIC SPINAL MENINGITIS. 539 the involvement of the meninges is on the convexity, certain symptoms are likely to be encountered, such as convulsions from implication of the motor area, speech defects from the affecting of Broca’s convolutions, hemiplegias and mono- plegias ; then there may be sensory disturbances—anesthe- sias, astereognosis and optic hallucinations. CEREBRAL SYPHILIS. This form is usually also attended by some involvement of the membranes, but the meningitis by no means dominates the picture. Cerebral syphilis is largely a vascular disease whereas paresis is of the parenchymatous type. The symp- toms are innumerable and, like those of brain tumor, are divided into general and focal. The general symptoms are headache which is chronic but intermittent, is often intense and is sometimes worse at night. Vertigo, which may occur with headache or independently, is always aggravated by physical or mental strain. Dis- turbances of sleep consist of insomnia, which is the rule, but a morbid drowsiness is not infrequent. The mental symp- toms are those of slight memory defects, irritability, poor attention and lack of concentration; delirium, stupor and confusion may occur, and an actual psychosis sometimes develops. Focal symptoms, of which many are possible, embrace all forms of convulsions, hemiplegias, monoplegias, and sensory disturbances including involvement of the special senses. The paralyses are often transient. Apoplectiform and epi- leptiform seizures may occur and there may be implication of any of the cranial nerves. For a differential diagnosis, a study of the spinal fluid in all of its variations is of the utmost importance. SYPHILITIC SPINAL MENINGITIS. This disease is often a part of a meningomyelitis, and frequently it is accompanied by a meningoencephalitis, but there are patients in whom the meningeal syndrome pre- dominates. Percussion over the spine sometimes yields ten- derness and this may be intensified at certain points, which 540 NERVOUS AND MENTAL DISEASES. is indicative of a more extensive process involvement. Par- esthesias occur in the form of numbness, tingling and cold- ness, and these are followed by pain which often shoots into the extremities, neck, and body. A gummatous forma- tion may cause the symptoms of tumor, and a diffuse thicken- ing tends towards the spastic-paretic type of gait with an increase of reflex activity and the Babinski sign. If the in- volvement is far down, often there are vesical and rectal disturbances. Radicular Type. Sometimes there is special nerve root im- plication. When it is a posterior root involvement, there are disturbances of sensation in the areas supplied; pain is often a prominent symptom and this is often erroneously interpreted as of rheumatic origin. Implication of the an- terior roots leads to a more or less isolated muscular atrophy and reactions of degeneration in parts of the extremities or body. SYPHILITIC MYELITIS. In this type the cord involvement predominates over that of the meninges. When the implication is chiefly of the lateral columns, the disorder has been spoken of as Erb’s spastic spinal paralysis. Here there is weakness of the lower extremities and stiffness in walking. Paresthesias appear in the legs and dorsum but without anesthesia and pain. The gait becomes progressively more stiff and difficult until finally the rigidity is extreme. Romberg’s sign is present, the re- flexes at the knees and ankles are exaggerated, there is ankle clonus and the Babinski sign. The sexual power is dimin- ished and the bladder and rectum become involved. Muscular atrophy and the reactions of degeneration are wanting. The transverse myelitic type yields complete flaccid paraly- sis below the lesion, also complete sensory loss with associ- ated vesical and rectal disturbances. Sometimes there is encountered the Brown-Sequard syn- drome, due to a unilateral cord lesion, which gives complete loss of power below that level on the same side, with com- plete anesthesia below the level on the opposite side. Other possible types are the tabetic, poliomyelitic, and that of amyotrophic lateral sclerosis. EPIDEMIC ENCEPHALITIS. 541 The cranial nerves most frequently affected by syphilis are the optic, leading to optic atrophy; the oculomotor, patheticus and abducens, giving rise to ocular palsies; and the auditory, yielding deafness. The other cranial nerves may also be involved, though their implication is infrequent. Treatment. Cerebrospinal syphilis should be treated ju- diciously, and one should remember that sometimes remis- sions occur without treatment. The disease is chronic and, generally speaking, there is not the urgency for intensive treatment that obtains in the so-called early syphilis; how- ever, if a gummatous formation threatens important struc- tures, the urgency for forceful measures becomes at once apparent. The drugs of first choice are arsphenamin (sal- varsan) and neo-arsphenamin, both of which are given intra- venously. An arsphenaminized serum is also employed and this may be given intravenously or intraspinously. Of late, a preparation of silver has come into prominence. Since harm may result, it is well for one to be a bit conservative about these injections, beginning with one injection every two weeks and during the interval using mercury either in the form of inunctions or injections. Since the susceptibility to mercury is increased by the use of arsphenamin, and also because the prolonged mercurialization is of itself at times debilitating, it is well to employ not more than a half dram of the ointment daily. A course of potassium or sodium iodide is often useful, though here the greatest benefit per- haps is in its resorptive power. Systematic spinal drainage is sometimes employed but it should be born in mind that lumbar puncture may be contraindicated in brain tumor and in brain abscess. DISEASES AND DISORDERS OF THE BRAIN. In the light of further inquiry, the term of “lethargic en- cephalitis” has yielded to that of “epidemic encephalitis” since it has been abundantly shown that lethargy is a symptom in only one of several types of the present extensive epidemic of this disorder. Neither should the popular name of “sleep- ing sickness” be employed, even though pathologic sleep is EPIDEMIC ENCEPHALITIS. 542 NERVOUS AND MENTAL DISEASES. a frequent symptom, because this is the common name of a well known and usually fatal disease met with in. Africa and which follows the bite of the tsetse fly. Many of the clinical symptoms of epidemic encephalitis have been recorded for hundreds of years, so that the disease is by no means new, but by reason of the long periods be- tween its recurrence, the affection appears new. The present epidemic was first brought to our attention by v. Economo, of Vienna, in 1917. Its bacteriological factor is uncertain and a number of organisms may be implicated, but in many instances the disease is found to be post-influenzal. Perhaps influenza or some other disease, or poison, may so reduce the resistance of the individual, that some unrecognized germ can then produce the encephalitis. It is thought that the germs may gain entrance to the body through the nose and throat, and sometimes the salivary glands are implicated, but certain it is that the virus has an especial affinity for the gray substance of the nervous system. Claim is made by Strauss and Loewe that they have isolated from the naso- pharynx of patients, an organism yielding a filtrable virus, having some of the characteristics of the organism de- scribed by Flexner and Noguchi in poliomyelitis. One must bear in mind that occasionally in the past there have been encountered the symptoms of epidemic encephalitis which have resulted from poliomyelitis, syphilis, tuberculosis, al- coholism, food poisoning, pneumococcic infection, measles and other infectious diseases. The disorder must be regarded and dealt with as a probably communicable, infectious disease. The many necropsies performed have tended to show that meningitis is a not very extensive finding, except as it in- volves the region of the interpeduncular space; often the peduncles, pons, medulla, cranial nerve nuclei and thalamus have been found the seat of punctate hemorrhages and edema; sometimes the pituitary is involved; further vascular changes in these areas and in the floor of the fourth ventricle are hyperemia, with perivascular infiltration and thrombosis of the small vessels. It appears that epidemic encephalitis is most prevalent in March and April, and while no age is exempt, most cases EPIDEMIC ENCEPHALITIS. 543 have developed between twenty and fifty years, with the male sex rather more commonly affected. Where a history of influenza has been obtainable, the disease has antedated the encephalitis sometimes by one month but more frequently by many months. Usually, the disorder is of abrupt onset, but occasionally it develops more slowly and it appears probable that many mild cases escape recognition. The symptoms fall conveniently into two groups, those of the prodromal period and those of the established disease. Prodromal Stage. Not infrequently, following an influ- enzal attack, the patient for several weeks may have felt perfectly well and may have resumed his duties, when slight blurring of vision is experienced and this perhaps is accom- panied by ptosis or diplopia; to these may be added vertigo, gastrointestinal manifestations and frequently slight muscu- lar unrest. After such symptoms have persisted for a time, the more definite illness declares itself. Stage of the Established Disease. During this period the disorder will be found to conform more or less closely to one of several types, which usually run a course of from six weeks to several months, unless the disease is of the ful- minating form, in which event it may prove rapidly fatal. Many patients tend to sleep more than is normal, but which, as regards depth, is not abnormal. Lethargy. This is a frequent symptom but by no means a necessary one, as may be observed in patients who become maniacal when sleep may even be almost wanting. From this lethargy the patient can be aroused and his mind is usually found to be clear, but soon he relapses into a state of profound somnolency. Facies. Often the patient lies expressionless and some- times the face assumes a mask-like appearance similar to that of paralysis agitans. This facial change is probably due to some loss of expressional tone or to a bilateral weakness of the seventh nerve. Temperature. Cases are reported without temperature, which, however, is not the rule and the range is usually from 99° to 103° F., while occasionally higher elevations are noted. Psychotic states are prone to a more or less continued tern- 544 NERVOUS AND MENTAL DISEASES. perature and fatal cases run high. In a few instances a subnormal temperature has been noted. Asthenia. Pronounced weakness is not always present but in grave forms of the disease it may be so marked as to prevent the patient from moving in bed. One must not regard the lethargic patient as necessarily asthenic. Cranial Nerve Disturbance. Implication of the third nerve is most common. There may be ophthalmoplegia externa and interna, ptosis, interference of accommodation, nystag- mus, and even optic neuritis. Other nerves that may be involved are the sixth, seventh, ninth, tenth, and twelfth. Tremors. These are quite frequently encountered and they may be coarse or fine, and sometimes fibrillary twitchings are seen. In character they may resemble those observed in paralysis agitans, in multiple sclerosis or in paresis. Some- times there are motor manifestations in the form of clonus, which may be unilateral or it may be localized, and in one case reported the clonus was confined to the rectus ab- dominalis muscle. Sensation. Disturbances of this kind are not common ex- cept headache, though occasionally neuralgia is experienced or a burning sensation may be complained of. Paralyses. Ocular palsies are frequent, while those of the extremities are only occasionally encountered. Hemiparesis may be seen and rarely there are Jacksonian seizures. Local atrophies have been observed. Reflexes. The tendon reflex changes are varied and they may be increased, diminished or absent. Sometimes, in addi- tion, the Babinski sign and ankle clonus are observed. Menial Symptoms. Depression is the commonest mental manifestation but still, not infrequently, the mind is entirely clear. From the lethargic state the patient can easily be aroused but he soon lapses into his former drowsy condition. Emotional expression is often lacking. Occasionally there is encountered one of the more or less pronounced classic, psychotic types of disease. Blood. Nothing worthy of mention is here seen except that rarely a moderate leucocytosis is met with. Spinal Fluid. Often this is normal but not infrequently the pressure is increased. Occasionally there is a moderate EPIDEMIC ENCEPHALITIS. 545 lymphocytosis and an increase in the globulin content. The sugar content is said to be usually increased. Other symptoms observed have been disturbances of vision and audition. Then there may be a slow, nasal and often hesitant speech; vertigo, delirium, cerebellar ataxia, cata- lepsy, catatonia, peripheral neuritis, athetosis, sweating, hic- cough, and sometimes endocrine implication. Usually the patient is persistently constipated and quite frequently respiratory disturbances are associated. While the complexion of the case may vary from time to time, and while the varieties may occasionally overlap, still, depending upon the part of the nervous system attacked by the inflammation, the disorder will usually be recognized as belonging to one of the following sub-groups: Lethargic, polioencephalitic, paralysis agitans, cataleptic, meningitic, myelitic, polyneuritic, or acute psychotic. Lethargic Type. This is a common variety and results when the brunt of the inflammatory process falls upon the mid-brain, which forms the connection between the spinal cord and the higher cerebral regions, thus preventing im- pressions and stimuli from passing in from the outside world. Some attribute the lethargy to pituitary involvement, while others hold that it is due to a thalamic implication, and the latter is the more probable cause in most instances. The cause of the frequent cranial nerve implication in this type of the disorder is due to the presence of the various nerve tracts and nerve centers in this important region. Occa- sionally the lethargic state is preceded by a period of in- somnia. The lack of facial expression is quite characteristic but is unlike the mask-like appearance of the paralysis agitans type. Polioencephalitic Type. This group results from a rather low grade encephalitis in which there is involvement of one or more cranial nerves, the most frequent of these being the third, sixth, seventh, and twelfth, but the fourth, fifth, eighth, ninth, tenth, and eleventh, are occasionally implicated. Pu- pillary changes are common and retinal involvement may be seen. Other symptoms are asthenia, somnolence, vomiting, and dysphagia. In this group the disease process is largely confined to the mid-brain, pons, and medulla. 546 NERVOUS AND MENTAL DISEASES. Paralysis Agitans Type. Several of the more prominent symptoms of Parkinson’s disease may be present. There is the mask-like face, the fixed and bent attitude, the slow and monotonous speech, spasticity, and usually there is tremor at least during some period of the disorder. In this instance the disease is found resident in the lenticular nucleus. Cataleptic Type. Before the patient becomes mentally unresponsive, vertigo may be complained of, and there may be ataxia and nystagmus. Soon an increased muscle tone develops so that the parts may be involuntarily sustained, for considerable time, in any position placed. Later, the patient lies motionless and in an inflexible rigidity. Sensa- tion cannot be investigated but the reflexes, so far as they may be studied, are usually found to be normal. Here, the cerebellum shows the brunt of the disease. Meningitic Type. This form is by no means common though some of its symptoms may be met with in other types. The manifestations to be looked for are irritability, headache, photophobia, delirium, rigidity of the neck, Kernig’s sign, and tache cerebrale. Myelitic Type. Reflex changes are common and response may be entirely wanting. Sometimes there are twitchings in the extremities, and there may be the Babinski sign, ankle and knee clonus and even clonus of the arm. The sensory manifestations are pain and numbness in the extremities and about the chest. Bladder and rectal implication is frequent. Occasionally there may be seen a sub-group of the polio- myelitic type. In the myelitic form the disease is of course, for the most part, in the spinal cord. Polyneuritic Type. While this is not so common, an ir- regular form may yield pain, paresthesia and other sensory disturbance in the extremities. General symptoms are anor- exia, insomnia, tachycardia, epistaxis, loss in weight, eleva- tion of temperature, hiccough, and perspiratory and lachry- mal activity. Acute Psychotic Type. It is a well known, though curious fact, that acute affections may lessen the manifestations of a chronic insanity, or for a time even hold them in abeyance, but an actual restoration is so rare that when it occurs, the question naturally arises as to whether the restoration has APOPLEXIES. 547 not resulted from some other cause. On the other hand, preexisting psychoses may be aggravated by epidemic en- cephalitis and paresis and dementia precox may be precipi- tated by the disease. Hallucinations, illusions, delirium, con- fusion and depression may be encountered without there being a frank psychosis. Depression is the condition most frequently met with. A fairly clean-cut manic-depressive case usually makes a good recovery, but when the depression is a part of a developing dementia precox, the prognosis is not nearly so good. Important differentiations to be made are those of acute poliomyelitis and tuberculous meningitis. In the latter, signs of distinct meningeal involvement are very suggestive. Mild and abortive cases are rather common though usually not serious, but the mixed forms may at times be rather con- fusing. In duration, the disease lasts from six weeks upwards, and following this an asthenia may persist for many months. The mortality is from twenty per cent, to twenty-five per cent. Treatment. No measures of a specific nature have yet been found. Absolute rest of mind and body are essential, and careful feeding and nursing are required. An occasional lumbar puncture sometimes affords relief and this may facili- tate the action of urotropin, which is so often administered internally. A diminished heart and respiratory action re- quire support. Pronounced insomnia should be met by the administration of adalin and medinal; restlessness, with bromides, perhaps morphin and scopolamin; and delirium, with sponging. Marked agitation may be benefited by hyoscin, and special features of the different cases must be disposed of as they arise. There is an erroneous belief regarding apoplexy, since it is not necessarily due to rupture of a blood-vessel but it may also result, and usually does, from thrombosis, embolism, or arterial spasm. Bearing this in mind one may meet with the disorder at any age, but most frequently it occurs in middle life, particularly between forty and fifty, with the APOPLEXIES. 548 NERVOUS AND MENTAL DISEASES. male sex predominating. Strictly speaking, an apoplectic attack implies the sudden loss of consciousness with a fall; but the term is employed in a larger sense so that it includes less severe and more varied manifestations. Thrombosis. This condition results most frequently from a syphilitic arteritis, though it may also be due to such causes as lead poisoning, gout, and diseases of the blood. If the lumen of a vessel becomes completely blocked, de- generation and softening may occur and finally result in a small scar or a cyst. The offending thrombus usually de- velops slowly so that the symptoms are less precipitate than in other conditions. Such prodromes as headache, vertigo, and drowsiness, may be experienced, together with transient paralyses, muscular twitchings, and even convulsions. The drowsiness sometimes deepens into coma. If a hemiplegia develops, it differs in no wise from that of other origin ex- cept in its more frequent recovery. Depending upon the site of the lesion, such special symptoms as aphasia, hemianopsia and astereognosis may appear. Embolism. The sudden blocking of a vessel by an em- bolus is likely to occur somewhat earlier in life than is a thrombus formation. The condition usually results from endocarditis, infections, pregnancy, malaria, or grave anemia. The pathologic picture is much the same as in thrombosis, and the symptoms also are similar, with the exception that they usually develop much more abruptly. Cerebral Hemorrhage. The conditions operative in middle life are not so conducive to cerebral hemorrhage except in the matter of trauma. However, late in middle life an arterio- sclerotic process may be well advanced, so that a sudden increase in blood-pressure as produced by heavy lifting, straining, or cpitus, may result in the rupture of a blood-vessel. Usually, it is the branches of the middle cerebral artery that are implicated and the site of hemorrhage is for the most part in the internal capsule, lenticular nucleus, optic thalamus, or caudate nucleus, though cortical hemorrhage, while not so severe, is not so infrequent. Often there are prodromal symptoms but the coma appears suddenly; there is flushing of the face, the pupils are sometimes unequal, the breathing is stertorous, the extremities are cold and at first completely APOPLEXIES. 549 relaxed; often there is conjugate deviation of the eyes; the reflexes are absent, and sometimes the sphincters are in- continent. If the hemorrhage is extensive and happens to break into the ventricles, death usually is only a matter of hours; the common types of paralysis are, arm and leg; arm, leg, face, and perhaps tongue, and sometimes with aphasia or sensory manifestations. When the hemorrhage is from a meningeal vessel, there is often present the irritative Jack- sonian symptom and this is a much less serious condition than is hemorrhage into the brain. Hemorrhage may also occur in the crus cerebri, the pons, or the cerebellum. Im- plication of the posterior cerebral artery yields the syndrome of Benedict with its resulting oculomotor paralysis on the same side, and with tremor, choreiform movements and paralysis of the extremities on the opposite side. Involve- ment of the posterior inferior cerebellar artery sometimes occurs; here, consciousness may be disturbed but it is seldom lost; often there is paralysis of the muscles of deglutition, the soft palate, and of the vocal cords; disturbance of sen- sation in the fifth nerve distribution, cervical sympathetic involvement and ataxia of the extremities on the same side; on the opposite side there may be ataxia, paresis, and loss of sensation. In severe cases with implication of the middle cerebral artery which are not fatal, the patient is usually left with a residual condition, and this may be considered to be present about a month after the onset. The improvement made is most apparent in the tongue and face, next in the leg, and least of all in the arm. There is less return of power in the distal ends of the extremities than in their proximal parts. The affected side is spastic, the tendon reflexes are exag- gerated, and clonus and the Babinski sign may be present. Changes in mentality may be noted; the patient may be ir- ritable, emotional, sometimes shows failure of memory, and a right hemiplegia may be attended by an aphasia. A late traumatic apoplexy is recognized and is recorded in medicolegal annals. It is said the period of a month may intervene between the head trauma and the apoplexy, and in one instance it was claimed that it did not occur until a 550 NERVOUS AND MENTAL DISEASES. year after. Probably through concussion the vessels are in- jured and subsequently thrombosis or rupture results. Sometimes differentiation is necessary from the uncon- sciousness of hysteria, epilepsy, alcoholism, opium poisoning, diabetes, and uremia. As regards life, prognosis is usually good except when there is hemorrhage into the ventricles, the pons, or the cerebellum. Treatment. If seen immediately after an attack, elevate the patient’s head and apply an ice-cap. Venesection may be dangerous but at times it is useful where the hemorrhage has occurred in an individual who was previously known to have hypertension. Manual pressure over the carotids should be judiciously employed, the blood directed toward the ex- tremities and active purgation brought about. However, if it is believed that the condition has resulted from thrombus formation, such active measures should not be applied as they would prove harmful. Drugs must be used cautiously unless syphilis is an active factor. If trauma is suspected surgical intervention may be required. Cushing has operated for the removal of a blood-clot where the blood-pressure was high. Such intervention has even afforded relief as a decompressive measure. Later, massage, exercises and mechanical support should be employed. THE APHASIAS. Aphasia is a disturbance or a loss (1) of the ability to express one’s self in speech, writing, or otherwise; or (2) of the understanding of language written, spoken, or of in- formation otherwise conveyed. A combination of both may be present and in fact a definite and separate motor or sen- sory aphasia is clinically, scarcely possible. This disorder is resident in the cortical areas or their connecting tracts and is not in the special organs or in the peripheral nerves. Aphasia, in right-handed persons, is due to disturbance of the left cerebral cortex or its associated paths, and is usually (1) organic, when it may be due to tumor, hemorrhage, en- cephalitis, thrombosis, embolism, and acute edema; (2) func- tional and usually transient, as in hysteria, epilepsy, arterial spasm, anger or fright, and in such toxic states as uremia, diabetes, alcoholism, or that due to other poisons. THE APHASIAS. 551 Certain clinical types are recognized though they are not clearly cut. Motor Aphasia. This results from involvement of Broca’s zone and some of the surrounding areas and their associated pathways. The patient is more or less incapacitated in his speech or in his writing. Cortical motor aphasia yields a defect in silent reading or in writing. Subcortical motor aphasia, which is the more common, shows an incapacity to speak, to read aloud, or to repeat what has been said; spoken words or written signs are usually understood but writing is not often possible. Sensory Aphasia. This is an inability to properly recog- nize spoken words or written symbols, and is divided into auditory aphasia and visual aphasia. Auditory aphasia, which is also spoken of as word-deaf- ness, is produced by a lesion in the upper surface of the temporal lobe. It is an inability to properly appreciate sounds though they are distinctly heard. Cortical auditory aphasia shows implication of spontaneous speech, either in talking or in reading aloud. The patient cannot repeat or write from dictation and he may be more or less unconscious of his defect. Subcortical auditory aphasia is due to a block in the tracts below the auditory area and here the individual is unable to understand spoken words, or to repeat or to write from dictation. Visual aphasia, which is also called alexia or word-blind- ness, is due to involvement of theTangular gyrus. It shows an inability to comprehend what is seen. Cortical visual aphasia shows a preservation of volitional speech but it ren- ders the patient unable to read aloud or to himself. He cannot copy, write spontaneously nor from dictation. Sub- cortical visual aphasia is due to a block in the paths below the visual area and is frequently accompanied by hemi- anopsia. The patient cannot understand written words, even his own; he cannot read aloud, but he may write from dic- tation. The prognosis in sensory aphasia is somewhat better than in motor aphasia. The patient may be more or less re- educated by special methods. Some forms of aphasia are spontaneously restored. 552 NERVOUS AND MENTAL DISEASES. Growths in the brain and its appendages are more frequent, though less operable, than are those of the spinal cord. After late middle life they are not common. The more usual tumors are the glioma, endothelioma, neurofibroma, tuber- culoma, syphiloma, sarcoma and carcinoma. The rarer forms are fibroma, osteoma, angioma, lipoma, psammoma, choles- teatoma, circumscribed serous meningitis, actinomycotic and echinococcic. The causes of primary tumors of the brain are for the most part uncertain except the syphilitic, the tuberculous, the aneurismal and the paralytic. A few are developmental anomalies and trauma is a doubtful etiological factor. The symptoms are divided into general and focal, either of which may appear first. The general symptoms are in the main caused by an increase of intracranial pressure be- cause of the confinement of the fluid within the rigid adult skull. These symptoms vary with the growth of the tumor; they are more pronounced when the neoplasm is in the posterior fossa and they are not of much localizing, diag- nostic value. While the general symptoms vary from time to time and may even disappear, on the whole, they are progressive. Headache. This is the most common symptom and is due to a stretching of the fibers of the fifth nerve or to their actual implication in the, growth. The site of the headache is by no means necessarily indicative of a tumor in the cor- responding region. The intensity varies but it is usually quite severe, especially if the growth is in the posterior fossa. Physical strain and emotional excitement aggravate the symptom, while, on the other hand, the distress may cease for a time. Occasionally, the sensation is one of pressure or tightness. Mental Changes. These are especially pronounced in tu- mors of the frontal lobes. There is dullness, irritability, somnolence, lapses of memory, and the individual may lose his way, show foolish attempts at humor, there may be a lack of moral sense, and he may even become delirious. Maniacal outbreaks may occur, later a pseudo-dementia, and TUMORS. TUMORS. 553 eventually a comatose state. The foolish acts of the patient may at first lead one to believe that the disorder is hysteria. Papilledema and Optic Atrophy. Papilledema or choked disc is an exceedingly frequent sign and results from the intra- cranial pressure forcing the cerebrospinal fluid along the optic nerve sheath. It is usually bilateral, though often of unequal intensity. Reversal and interlacing of the visual field has been insisted upon by Cushing as an important finding, but the sign is seldom available early. Other occasional eye symptoms are nystagmus and diplopia. Convulsions. These seizures are common, are general in character, and may persist irregularly during the progress of the growth, with death frequently occurring in a convulsion. Nausea, Vomiting, and Dizziness. These manifestations ap- pear rather late. The vomiting, which may be forcible, often occurs spontaneously, though it may be absent even in growths of large size. Other varied symptoms are a pulse which is at times slow and which sometimes shows arrhythmia. Respiratory dis- turbances, in the form of hiccough and yawning, may occur and Cheyne-Stokes breathing may be present. Metabolic disorders have been known to arise. A carcinoma yields a cachexia and marasmus. Tumors of the pituitary sometimes show ovarian and testicular aplasia, adiposity, perhaps acro- megalic tendencies, and in the female, amenorrhea. Focal symptoms depend largely upon the site of the growth, and, if it is the “silent areas” of the brain that are invaded, they may even be absent. Tumors of the Frontal Lobes. Involvement of this region of the brain often yields changes in the higher psychic sphere so that there may be shown impairment of memory, irrita- bility, poor concentration, and foolish tendencies. Vertigo, a staggering gait, and a disturbance of the sense of smell, may be present. If the tumor is in the left hemisphere, perhaps aphasic manifestations will appear. Sometimes the motor signs of stiffness of the neck muscles, tremor of the hands, and Jacksonian spasms, are encountered. Tumors of the Motor Area. Irritative manifestations are numerous in this region. Lesions of the cortex usually cause spasms and convulsions, while those of the deeper parts 554 NERVOUS AND MENTAL DISEASES. generally lead to paresis, or paralysis. Psychic manifesta- tions are not common but sensory symptoms may be present. In right-handed persons, involvement of the left motor area often leads to disturbances of speech. Growths here show marked localizing signs and so lend themselves rather readily to operation. Tumors of the Parietal Lobes. Disturbances of sensation and muscle sense are often present together with stereog- nostic changes. Word-blindness and homonymous hemi- anopsia may be encountered, and sometimes there are con- jugate movements of the eyes to the opposite side. Tumors of the Temporal Lobes. These are often difficult of recognition. If in the left hemisphere there may be word- deafness. Occasional uncinate fits are present—aura of taste, chewing movements, and a peculiar dreamy state. When the optic thalamus is pressed upon, emotional expression may be interfered with and hemianopsia likewise may be produced. Tumors of the Occipital Region. Complete homonymous hemianopsia and visual hallucinations are quite common. Mind-blindness may be present and there may be additional symptoms through implication of adjacent parts brought about by pressure. Tumors of the Optic Thalamus. Hemianesthesia, spon- taneous pain, and choreic movements, may be observed. Hemianopsia, mental dullness, and causeless laughing, occur but are less common. Tumors of the Crus. These show third nerve paralysis on the same side and hemiplegia on the opposite side. Tumors of the Pons. Early recognition is here often pos- sible by reason of the many focal points present. If the growth is in the upper part, the symptoms are the same as in the preceding site. If lower down, there may be caused hemiplegia and sensory paralysis of the opposite side, to- gether with involvement of the sensory fifth, sixth, seventh, or eighth nerves; also, there may be forced movements and conjugate deviation of the eyes. Tumors at the Base of the Brain. Implication of the Gas- serian ganglion causes excruciating pain with disturbance of sensation in the part supplied and sometimes with involve- ment of other cranial nerves. Tumors of the pituitary may DELIRIUM, CONFUSION, AND STUPOR. 555 lead to acromegalic symptoms, adiposity, mental dullness, somnolence, amenorrhea, and asexualism; there may also be hemianopsia, optic atrophy, and convulsions. Tumors of the Cerebellum. Symptoms vary with the site of the growth. The general manifestations are headache, vomiting, vertigo, papilledema, and optic atrophy. Hydro- cephalus is common. The gait is quite characteristic. Then there may be asynergia, ataxia, adiadokokinesis, hypotonia, and nystagmus. Tumors of the Medulla Oblongata. Here, a large growth would cause marked paralysis of motion and sensation, most probably, bilateral. The symptoms of progressive bulbar palsy might be produced and there would be cardiac and respiratory arrhythmia. Diagnosis. The diseases most likely to require differen- tiation from brain tumor are paresis, brain abscess, tuber- culous meningitis, chronic hydrocephalus, multiple sclerosis, and hysteria. X-ray studies should be made and a small cylinder of tissue from the brain site has been successfully removed for microscopic sections. Lumbar puncture, it must be borne in mind, is at times dangerous and this is especially true of growths in the posterior fossa. Prognosis. A syphiloma may yield to vigorous medication, although usually the outcome is not so favorable, and a few tumors can be successfully removed. Death, which often occurs suddenly, frequently supervenes by the third year. Treatment. When the growth is due to syphilis, per- sistent antisyphilitic medication must be carried out. For the inoperable tumors, a decompression relieves the headache and often improves the vision. DELIRIUM, CONFUSION, AND STUPOR. Delirium is a condition which occasionally attends the ad- ministration of certain drugs, it also accompanies various diseases and sometimes it follows trauma. One group of drugs, such as cannabis indica, hyoscyamus, and belladonna, is known as delirifacients. The bromides, cocain, opium, to- gether with the true hypnotics, may also cause this state to develop. Infections, exhaustion states, alcoholic and lead 556 NERVOUS AND MENTAL DISEASES. poisoning, one stage of major epilepsy, certain operations (notably upon the external genitalia and the bladder), and trauma (especially of the head), all may lead to the disorder. Finally, there is a fulminating psychosis known as acute delirium. A delirium is caused by cerebral excitation, the essential features of which are illusions, hallucinations, fleeting de- lusions, incoherence, confusion, with motor restlessness, though sometimes the patient lies quietly, and the state is commonly but not necessarily attended by fever as, for instance, in delirium tremens. In duration it is short, lasting from a few hours to possibly two weeks. Delirium occurs more frequently in private practice and in general hospitals than in hospitals for mental diseases. This condition may precede the active manifestations of an infection, it may occur during the course of the disease, or it may follow the disease. In the last instance the delirium is a part of an exhaustion state. It is a frequent accompaniment of certain diseases. In typhoid fever delirium is usually of the low muttering type, but occasionally, owing to a greater cerebral irritation, it is more active. However, much of this dis- turbance has been obviated through the cold water treatment. Delirium often develops early in pneumonia, and usually shows visual and auditory hallucinations, with confusion as a rather frequent manifestation. Erysipelas with face and scalp involvement is most likely to develop the condition. Sometimes a traumatic delirium appears independently of an alcoholic intoxication. Burns and scalds of the head and face, and intracranial injuries frequently show this state. Some persons have such an idiosyncrasy that any severe pain is likely to be attended by delirium. Acute Delirium. This disease, which is also called Bell’s delirium and typhomania, is characterized by delirium, fever, great motor restlessness, rapid and extreme exhaustion, and frequently terminates in death. Some writers deny its ex- istence as a separate entity, but the symptom complex at least is seen, since it may accompany typhus fever, tubercu- losis, cancer, influenza, and dysentery. Cases of unknown origin are believed to be due to some specific infection, and a recent explanation of the psychosis is rapid adrenal break- DELIRIUM, CONFUSION, AND STUPOR. 557 down. Most attacks develop in middle life, with females perhaps the more frequently affected. It is one of the rarest of the psychoses. The average duration is from ten days to three weeks, and it is estimated that from one-half to three-fourths of those afflicted die. A fatal issue may come as soon as the third day. Prodromal symptoms are insomnia, depression, hallucinations, a clouding of consciousness, and disorientation. The patient passes into the stage of violent delirium and becomes rapidly exhausted. He is wildly fren- zied, tears about the room and throws himself against the walls or attacks those who come near him. If restrained, he tugs frantically at his fastenings. Annoying paresthesias are experienced and delusions of persecution present them- selves. He refuses food and wastes rapidly. Often the re- flexes are increased, the expression is anxious, and the body becomes pale and shrunken. The lips are parched and cracked, the tongue dry and covered with a heavy brownish coat. The patient is constipated, the fever ranges from 102° to 106° F., and now, being too weak to sustain the struggle, he passes rapidly into stupor, followed by profound uncon- sciousness and death, frequently from hypostatic congestion of the lungs. The diagnosis rests upon the fever, delirium, the rapid course, the early exhaustion and high mortality. Treatment of mild forms of delirium consists in the free use of liquids, packs, and baths. The patient should have nutritious food, stimulants and sedatives such as medinal, sulphonal or luminal. In Bell’s delirium, restraint in a warm immersion bath is most useful and artificial feeding is often necessary. Stimulation must be actively employed. Confusion. In this condition various synonymous terms are used, such as acute hallucinatory confusion, confusional insanity and amentia. The symptoms are more mild and usually of longer duration than are those of delirium. The characteristics of confusion are, a clouding of consciousness, incoherence, fleeting hallucinations, perhaps with delusions and emotional changes, and with only a mild degree of motor unrest. Essentially, the disorder consists in the dissociation of ideas and a failure to properly recognize external objects. Like delirium, it may result from infections, intoxications, 558 NERVOUS AND MENTAL DISEASES. prolonged use of hypnotics, trauma, and exhaustion. Con- fusion may occur in connection with hysteria, before or after epileptic seizures, in a number of the psychoses, possibly even in paresis and paranoia, and sometimes in focal brain diseases. Prodromal symptoms are, insomnia, restlessness, nervousness, and with some failure of memory. Gradually the patient becomes more and more disoriented as to time and place. It is only by great effort that the attention can be held. There are hallucinations and apprehensiveness. The patient often wanders about the room, or if in bed tries to get out, though occasionally he will lie quietly. The ap- petite weakens and nutrition is impaired. Finally after some time, a change is gradually brought about, the patient gains a little in strength, the nutrition improves, consciousness returns at first for brief periods until fully regained. Con- fusion may last for a few weeks or for some months, and it is but seldom fatal unless accompanied by some serious organic disease. Treatment. The nursing and sick-room care is important. If exhaustion is at all pronounced, the patient should be kept in bed and be given massage. Restlessness does not require the active combating that does the struggling of delirium. Sometimes the patient will not eat, so that feeding will have to be forced. Medicinal treatment should be supportive and tonic. In a protracted case, the expense may necessitate the installation of the patient in a detention hospital. Stupor. In addition to stupor, the terms stuporous in- sanity, and acute curable dementia, are sometimes used. Delirium and confusion may, and often do, precede stupor, and stupor in turn may deepen into coma. There is an im- portant distinction—in stupor the patient can be partly aroused, but this is not true in coma, so that the latter is much the more serious state. The condition of stupor may be encountered under various circumstances. It may follow alcoholism and is seen in status epilepticus. A stuporous form of melancholia is recognized in which, however, the obtundity is not so pronounced as in some other diseases; here, the patient who has sunk into the depths of despair seems entirely oblivious to his surroundings and he cannot make the necessary effort to arouse himself. HYPOCHONDRIA 559 Stupor may result from infections and intoxications. It may also be due to brain exhaustion, mental shock, or it may result from trauma to the head. The condition, except when due to shock, develops slowly and often is preceded by confusion. Gradually, the patient becomes less and less aware of his surroundings until finally he is almost oblivious. He lies expressionless and when addressed is but slightly responsive. The tendon reflexes are often increased, the pupils are usually dilated and react sluggishly to light. Pain and tactile sensations appear lost, which however is not due to an actual anesthesia, blit rather to the mental obtundity. The muscle tone is lessened and there is lowered vasomotor tone so that the extremities may be cold, cyan- otic, and even edematous. If the patient does not take sufficient food to sustain life, one becomes obliged to employ forced feeding. At times the loss in weight is most remark- able. The disorder may last for some months, with perhaps occasional brief lucid periods. Then the patient gradually gains in strength, he becomes more observant, and begins to talk a little, but complete restoration is always a matter of considerable time. When trauma is suspected, the head should be carefully examined for external injuries, for blood or other fluid in the external cavities, for hemorrhage under the scalp; the eyes and the extremities studied for localizing signs, and an x-ray examination should be made. Treatment. Medicinal remedies should be supportive and tonic. Forced feeding may be required. Massage and packs are very useful. Depending upon the etiology, some special forms of treatment may be required, and surgical interven- tion is occasionally necessary. A perplexing problem is sometimes presented by patients who believe they suffer from a definite disorder, and for which the physician can discern little or no foundation. As a syndrome the condition may be encountered in such dis- eases as melancholia, neurasthenia, psychasthenia, hysteria, dementia precox, paranoia, and early paresis. But occasion- ally there exists sufficient evidence to convince one that the HYPOCHONDRIA. 560 NERVOUS AND MENTAL DISEASES. disorder develops independently of other diseases and for this affection the term hypochondria is employed. Somatic impressions, which are being continuously re- ceived by the brain centers, constitute the cenesthetic sense but in health we are not aware of such sensations. Either hyperesthetic brain centers or indiscernable somatic condi- tions give rise to the abnormal sensations of the hypochon- driac. More commonly the disease appears in men who are unmarried and whose work is sedentary, but no occupation or station in life is exempt. Successful business men who retire from active work in middle life are sometimes its victims. Hypochondria is temperamental • and such an individual may become introspective, finally settling upon some part of his body as the seat of an imaginary disease and over which condition he proceeds to brood. He may worry over having masturbated, he may believe that his bowel is blocked, and again it may be syphilophobia or phthisophobia that is slowly undermining him. He talks constantly of his ailment, likes to be examined and so visits many physicians and cults. He is prone to become an enthusiast in matters of exercise, diet, the amount or kind of clothing required, and as to bathing, seems at times to forget that man is a land animal. The disorder often lasts for years, subject to fluctuation, during which period the hypochondriac may appear in fair health. Mental deterioration does not occur and the patient is not so apt to commit suicide as is one suffering from melancholia, though sometimes an attempt is made, to elicit sympathy. The disease may recur in certain families, and where chil- dren are inclined to be morbid and introspective they should be trained out of such tendencies by having their home surroundings and associations as wholesome as possible. The hypochondriac should not be permitted among invalids, since such contact often leads him to believe he has the same disease. Since hypochondria is temperamental, alcoholic stimulants should not be prescribed. Medicines are of little value ex- cept in the matter of suggestion and for this purpose a large capsule containing starch may be administered. The physical MANIC-DEPRESSIVE PSYCHOSIS. 561 measures of massage, hydrotherapy, and electricity, may be helpful. Occasionally, it happens that a hypochondriac through worry becomes debilitated and even exhausted, when, either a rest cure or modified rest should be instituted. But usually the individual is not badly off and needs mental occupation, so that often his best interest is served by direct- ing him to an active out-of-door life with the cultivation of some fad. MANIC-DEPRESSIVE PSYCHOSIS. The various types of mental disorders included under this heading seldom occur before adult life.' Formerly, mania and melancholia were considered separately and for the most part were regarded as curable. It had long been known that another group of patients who showed both conditions were not nearly so hopeful as to the ultimate outcome and these were often described as cases of circular insanity. Finally, Kraepelin, from an exhaustive study of the life histories of many cases of mania and melancholia, was able to show that an excited and a depressed phase was likely to be encoun- tered in each of these individuals, that these phases were prone to recur, and so he included the entire group under the comprehensive title of manic-depressive insanity, which term has been almost universally adopted. However, Kraepelin’s studies were largely those of asylum cases, which are necessarily more severe than the group of psycho- ses commonly accorded extramural care. Therefore, in private practice, patients are sometimes encountered with hypomania or mild melancholia which do not conform to this alternating type of insanity, since these psychoses may remain as solitary attacks. A faulty heredity is back of nearly all cases of manic-depressive insanity, though it has not necessarily manifested itself as the same type of disorder. The manic phase of this disease when well developed, is characterized by emotional exaltation, a rapid flow of ideas, and by psychomotor agitation. In the beginning there are prodromal symptoms which may precede the actual outbreak from a few days to several weeks. The individual may show insomnia, anorexia, constipation, restlessness, ineptitude for work, apprehensiveness, headache, cephalic paresthesias, 562 NERVOUS AND MENTAL DISEASES. brooding or hypochondriasis, and loss in weight. But later a change comes over the personality of the individual and he passes into the state of hypomania. Now he becomes energetic and lively, has a general feeling of well being, emotional activity appears and every undertaking is over- done. His movements are hurried, he talks rapidly and some- times incessantly. He is conceited, self-assertive, he unfolds his many plans and unbosoms himself to utter strangers. He is jocular, is angered without cause, and immoderatior is shown in every action. A not uncommon feature of this state is excessive alcoholic indulgence, which debauchery may last for weeks, and this condition constitutes the so- called periodic drinking. Another and even more unfortunate occurrence is erotocism, so that sexual indulgence may be practiced to a shameful extent, which, when appearing in a woman seems especially disgraceful and may be fraught with disastrous consequences. The whole state may end only in hypomania or it may advance to a graver form of the psychosis. Acute Mania. Here, the disorder has progressed to a state characterized by incoherence, clouding of consciousness, per- haps some disorientation, later with delusions which are often expansive, and occasionally with illusions and halluci- nations. Physical and mental agitation increases. There is a rapid flight of ideas but the patient is easily distracted. He mistakes those about him and a moment later identifies them as still other persons. Long recitations, sometimes of poems, are rendered. He shouts, yells, runs and jumps, and tears to pieces clothing and furniture. God and the heavenly angels may be seen, though they only appear momentarily. In this state of frenzy, which may last for days or possibly for months, the patient sometimes eats but little, conse- quently, emaciation is not infrequent. In other instances the body weight is maintained or possibly the patient may fatten. For the most part this mental excitement subsides gradually but sometimes a grave state of delirium develops and this is termed hypermania. Hypermania. Here, one sees the extreme of the condition and injuries from violence in this exhausted state occasionally lead to suppuration and possibly general infection, so that MANIC-DEPRESSIVE PSYCHOSIS. 563 to the symptoms of acute mania may be added those of delirium. In this violent state it may not be possible to give patients the best of attention, nor can they always be properly examined physically, so that for a time their exact condition may be overlooked, and an unfortunate, fatal kidney or lung disease develop. Depressive Period. Temporary depression is the natural expression consequent upon misfortune or other distressing circumstance, but where depression becomes chronic, or where it appears without adequate cause, the state assumes pathologic significance. Such a mood may develop into a melancholia or it may precede other psychoses, and the most common factors that make for this disorder are tainted heredity, * poor health, and mental strain. The course of melancholia may be acute, subacute, or chronic, and in point of age it is most frequently encountered between twenty and thirty, and at the climacteric. Recognized types are, simple melancholia, delusional melancholia either with or without agitation, sometimes showing a pronounced religious trend, and another form which displays more or less stupor. The most important type of depression is that which oc- curs as a phase of the manic-depressive psychosis, and as such is characterized by emotional depression, retarded cere- bration, and psychomotor inhibition. In addition to de- spondency there is a slowing of the process of thought, usually the patient talks but little, often in a low voice, and sometimes in monosyllables. There is a disinclination to associate with others, and a feeling of inadequacy together with a general neglect of duty in every respect. A few patients develop illusions and hallucinations and when these are extensive they constitute a sub-group known as halluci- natory melancholia. Others show a marked religious color- ing with the delusion of unpardonable sin, leading to eternal damnation, as a frequent symptom. Some patients are in- cessant in the outpouring of their mental distress, while others may remain mute for a long time. The mental State is always reflected in the face and this sometimes speaks of utter despondency. Where agitation is a marked feature, the skin may become raw from constant rubbing, tufts of hair may be pulled out, and even the body may be mutilated. The 564 NERVOUS AND MENTAL DISEASES. secretions are usually decreased, the tongue coated, anorexia and constipation are usually present, and the blood-pressure may show hypertension. Suicide is always a possibility and, in the delusional form, must be especially guarded against. The stuporous group show the extreme of the depressive period. Here the patient may sit or lie almost without mov- ing and may remain mute for many months at a time. Forcible feeding may be necessary, the bowels moved by means of an enema, and catheterization regularly performed. Occasionally the condition of catalepsy supervenes. The temperature is subnormal, the circulation is feeble, and the loss of weight may be extreme. Periodicity is sometimes so pronounced as to render it possible for the patient, and even those about him, to fore- tell the oncoming attack by reason of some slight change in manner or action. Some periodic attacks have been spoken of as recurrent and intermittent mania or melancholia, cir- cular insanity, and alternating insanity. Insanity of the circular type may vary somewhat as, for instance, the un- interrupted and repeated cycle of melancholia and mania, or there may be an interval of normal mentality between these phases. Such cycles vary vastly in point of time—they may be completed in from two days to many months. The melan- cholic phase is frequently the longer of the two. Involutional melancholia is a term used to designate those types of depression occurring in women at about the meno- pause—between forty and fifty years—and also the depressed states occurring in men, but here manifesting themselves at a rather later period. The condition is not unlike that of the melancholic phase of manic-depressive insanity. The manic phase may require some differentiation from those cases of paresis beginning with excitement. The phase of depression should not be mistaken for neurasthenia, psych- asthenia, or paresis. The prognosis of an existing attack of manic-depressive psychosis is favorable, but recurrence is frequently encoun- tered. Insanity of the circular type is somewhat less promis- ing, and involutional melancholia likewise shows a less frequent complete restoration. PARANOIA. 565 Treatment in the excited stage must vary with the extent of the disorder. Hypomania may be treated at home or given care elsewhere, outside of an institution. In the more noisy and violent forms the patient may be so objectionable as to render institutional detention imperative. The out-of- door treatment is highly endorsed by some. Hydrotherapy is most quieting and the patient may be sponged between blankets or be given wet packs. Those showing extreme excitement are often most successfully treated by means of the continuous baths or such baths may be given intermit- tently. Such a procedure often does away with the necessity for powerful hypnotics. The nutrition must be maintained by careful feeding, possibly by forcible feeding. Drugs used for their sedative and hypnotic effects are, adalin, medinal, sulphonal, luminal, and perhaps hyoscin and morphin. Ow- ing to the violence of some patients, the protective measure of mechanical restraint may be desirable. In the treatment of the depressed stage, and where there is a profound suicidal tendency, a hospital of detention may be preferable; however, among the well-to-do, where every possible safeguard may be thrown about the patient, this is not so imperative. Severe cases do well under the full rest regime, while milder ones may be cared for with modified rest treatment. Laxatives, stomachics, reconstructive tonics, and sedatives, are sometimes required. Occasionally, thy- roid preparations in moderate doses are helpful. A nutritive and easily assimilable diet should be given, and where the patient persistently refuses to eat, forced nasal feeding must be resorted to. Later, light exercise and a change of scene can be advised. Alcoholic stimulants should be avoided. In the stuporous state the position of the body should be changed from time to time, and enemata and catheterization are sometimes necessary. PARANOIA. The term paranoia has been used since ancient times, though its application has undergone much change and at present is employed in different ways by various writers, but always in a much more restricted sense than formerly. In a general way the disease may be said to be a slowly 566 NERVOUS AND MENTAL DISEASES. developing and chronic psychosis, with the gradual unfolding of delusions, often of persecution, unyielding in character, but in which the intellectual processes are otherwise well preserved, though mental deterioration sometimes results in the late stage. The deranged thoughts sometimes tend more or less in one direction, so that a former synonym was mono- mania, but often this does not hold true and the term has fallen into disuse. Paranoia is not a common form of insanity, since it seldom occurs oftener than once among two hundred admissions into our large asylums. But the nature of the disorder, frequently with delusions of persecution, with threatened and some- times actual litigation, and occasionally with murderous as- saults upon the believed persecutors, has kept the disease prominently before the public, so that it appears a rather common one. For the most part paranoia develops in middle life, and those individuals who have shown somewhat similar symp- toms at an earlier period, probably have had an aberrant form of dementia precox or have been alcoholic, syphilitic, or epileptic subjects. The disease is more common among men. Hereditary influence is difficult to trace, but so much history as has been obtained points to the rather frequent occurrence of mental diseases in the ancestry. In times of great stress, such as wars, there always come to public notice a few of these insane persons. As to the individual, he appears often to have been regarded as a bit different from other children, which variations may have shown some accentuation at puberty. Later, there may have appeared some unusual am- bition ; suspiciousness, stubbornness, untrustworthiness, or general weakness of personality, may have been observed, so that psychopathic tendencies earlier in life have probably been present. Environment appears to have little if any bearing upon the disease. Paranoia is an endogenous and primary affection of the intellect which in its development is almost imperceptible. The course of a typical case of paranoia has been con- veniently divided by Ziehen into four stages: Prodromal, persecutory, expansive, and pseudo-demented. In the pro- dromal stage the individual may be employed at his business, PARANOIA. 567 but he becomes preoccupied and introspective. Sometimes peculiar paresthesias are experienced in the extremities, body, and viscera, and other neurasthenic symptoms manifest themselves. He may be, and often is, hypochondriacal. Per- haps he is conscious of the difference between himself and others, which he seeks to explain by special inquiry into his condition. Failing in this way to find an adequate explana- tion for his discomfort, he begins to wonder if some outside influence may not be at the bottom of his various annoy- ances. Soon his duties are neglected and he becomes more or less distrustful of those about him, believing himself to be the object of their special attention. Finally, it becomes clear to his associates that there have actually developed in him some peculiar traits of character. Unusual noises and sounds are heard, to which he at first gives strange interpre- tations, but which later become well marked hallucinations. Now there gradually appears the persecutory period, in which the individual has arrived at the definite conclusion that scheming and plotting is being carried on against him— he is the victim of a conspiracy—though as yet he does not identify his persecutors. Often he believes scandal is being spread about him. People at a distance are engaged in con- versation concerning him, though he may be so far away as to render it impossible to hear their voices. The paranoiac is thoroughly modern in his hallucinatory experiences. For- merly, the machinations of his enemies were directed at him through telegraph wires, then the telephone was employed as a means of torturing him, and now it is the wireless system that flashes the damnatory messages. Electricity is shot into his body and x-ray machines are used to read his thoughts. Often his food is poisoned and poisonous gases are being directed toward him. Since he has now worked out elaborate details, the plot against him is complete. At times the persecution comes from a single individual, but more frequently it is some religious body, some political or fraternal organization that is attempting to ensnare him in its toils, so that it may be the Jesuits, Protestants, Masons, or Socialists, that are conducting this nefarious propaganda against him. By this time he begins to enter complaints, though they may not be made directly or openly to those 568 NERVOUS AND MENTAL DISEASES. engaged in the conspiracy. Anybody may be complained to or the local authorities may be apprised of the crime, and sometimes an astonishing amount of credence is at first given to his charges. Failing to get the necessary local protection, the Governor may be communicated with and finally an ap- peal may be made to the President, either through the mail or in some instances by attempting a personal interview. In the meantime the paranoiac may appear in good health and may be moving about his community without attracting attention. Sometimes he attempts to defeat his persecutors by a change of residence but they invariably find him out and renew their diabolical work. After having identified some individual as the author of his trouble, or as the head of a group conducting these persecutions, he may attempt to avenge himself upon his enemy and a homicide result. So dangerous may a paranoiac become, that the subject seems worthy of special consideration. The most forcible case that has come under my observation was that of an Austrian who was a waiter in a restaurant and who killed a fellow waiter. He was suspected of having mental trouble so that a commission was appointed to determine his mental status, with the result that he was found to be a lunatic. The man was then committed to the Philadelphia Hospital for the Insane, and while there, together with another inmate, he murdered one of the patients. A few years later this paranoiac escaped and was traced to a town in New Jersey. The authorities of the town were notified that he was an escaped lunatic and also of the dangerousness of his charac- ter. In the meantime he had been working quietly in a restaurant and had gained the confidence of those about him, so that it was not deemed necessary by them that he be returned to the hospital from which he had escaped. In 1913 letters which were threatening the life of the President were definitely traced to this man, who was still faithfully performing his duties as a waiter. Upon its being estab- lished that he was the author of the letters, the local authori- ties recalled what had been previously said concerning his dangerousness, when he was at once returned and committed to a state hospital for the criminal insane. This is a most striking instance of a paranoiac who had already murdered PARANOIA. 569 one man, had helped to murder another, and was planning to take the life of the President, but yet who conducted himself with so much propriety that his homicidal insanity was not for one moment suspected by those about him. The expansive stage is characterized by a change of per- sonality, wherein the individual comes to believe that he is some exalted personage, perhaps of royal lineage, a prophet, or the son of God. Some paranoiacs have become great leaders or reformers and in such ways have illuminated history. It is claimed that Mohamet and Swedenborg were paranoiacs, but they also have been charged with being epi- leptics. The career of Jeanne d’Arc conforms closely to that of a paranoiac. The enthusiasm and persistence with which they attempt to carry out their “mission” may render them so obnoxious as to necessitate placement in a detention hos- pital. Others are more or less inoffensive, particularly if they are not too actively opposed. The final stage of secondary dementia does not always develop, but frequently there is a weakening of their insane manifestations, such as hallucinations, persecutory delusions, and those of exalted personality, so that the individual may become less troublesome and less dangerous than at an earlier period. Often in this state they are found to be quiet institution inmates without their insane persistence and litigious tendency. Certain types are described, such as acute paranoia and periodic paranoia; then there are the important groups of reformers, and religious and erotic paranoiacs. Acute paranoia is an unfortunate term. What one really observes is the occasional development of a temporary para- noid state, such as is seen in toxic conditions and in which hallucinations may or may not be present. Most present- day writers maintain that paranoia is essentially a chronic disorder, but with mild and abortive types sometimes pre- senting themselves. Periodic paranoia is likewise an unsatisfactory designation, even when applied to those cases which from time to time show marked amelioration of symptoms. The reformers constitute a group of egotistical, fantastic, and mentally in- ferior individuals, who go about attempting to achieve some 570 NERVOUS AND MENTAL DISEASES. great social reform, or who may have some “invention* through whose instrumentality they expect to confer lasting benefits upon mankind. They sometimes journey to distant parts and suffer great privations in order that their plans may succeed. Their creative faculty is always lopsided, therefore, their schemes are always impracticable. Often they are harmless “cranks” most of whom eventually drift to institutional care. The religious paranoiac of mild degree may be seen in our large cities where he succeeds in holding the attention of a crowd on Sabbath afternoons, which while perhaps regard- ing him as a bit eccentric, still consider him very devout. A more pronounced type become disturbers and possibly dangerous, so that they may find residence in asylums. The religious paranoiac is found quite as'frequently among women and not uncommonly there is an erotic trend to these pious but deranged individuals. True erotic paranoia probably does not occur separately, but many patients show more or less of a tendency in this direction. Masturbation is common and often the sex desire is somewhat fantastic so that offenses of sexual perversion are sometimes committed. These patients are quite prone to charge infidelity against those whom they marry. The course of paranoia runs over a period of many years and some, under good institutional care, die of old age. The disease progresses very slowly and a secondary dementia may develop. There may be remissions but the complete restoration of a well marked case probably never occurs. The diagnosis of paranoia is not difficult, but in the milder forms one should bear in mind that the condition may be simulated by individuals whose education has been faulty, who have been pampered, and who, when not allowed to have their own way, may stoutly maintain that they are persecuted. Hysterical persons sometimes show this tend- ency and frequently a sex coloring is observed in their tem- peramental disorder. Certain intoxications and diseases at times yield paranoid states. Treatment. Medicinally, nothing can retard the progress of the disease, though during those periods when the delu- sions are most compelling and dangerous assaults threaten, PARANOIA. 571 recourse may be had to powerful sedation—even morphin— in the effort to avert a calamity. The individual should have mental occupation and should take enough exercise to promote physical well being. Those physicians who employ psychoanalysis extensively, speak of gratifying results in some cases. Where the manifestations are mild, the patient is often inoffensive and he may lead an extramural life, but once becoming dominated by delusions of persecution, he is frequently highly dangerous and should then be committed promptly to a detention hospital. Paranoid States. These are occasionally encountered, oc- curring for the most part among syphilitics, alcoholics, and epileptics.. Others are commonly found to have a lowered mentality as the result of an earlier dementia precox. A few cases of syphilitic insanity show a paranoid trend with de- lusions of persecution or those of exalted personality. Here should be some of the signs of neurosyphilis and the blood and spinal fluid may be looked to for evidence of this disease. Occasionally, in chronic alcoholism, the condition known as pseudoalcoholic paranoia develops. The individual may be expansive, frequently there are delusions of persecution and those of marital infidelity are quite distinctive. The his- tory of alcoholism may be obtained and often there is a brutish appearance to the face as the result of drink. Then there may be tremors, paresthesias, and forgetfulness. The epileptic is antisocial in his nature, he feels the world is against him and this is pretty much the fact. Sometimes he believes himself a person of unusual consequence, per- haps with a “mission.” When actually insane he occasionally becomes homicidal. In the epileptic there may previously have been attacks, either motor, vasomotor, sensory, or psychic, and one sometimes finds such physical evidence as scars. In other paranoid states, the condition has resulted from a previous dementia precox, as. seen in some “hobos,” cranks, and degenerates. Possibly the history of a previous mental disease may be obtained. The individual’s having been in some asylum may be a matter of record or he may be known previously to have been picked up for vagrancy or for larceny. 572 NERVOUS AND MENTAL DISEASES TRAUMATIC PSYCHOSES. Under this heading are included those mental disturbances resulting from, or consequent upon, trauma to the head or brain, whereby distinct psychotic symptoms are produced. These conditions, however, are exclusive of heredity, alco- holism, or brain syphilis, and it must also be borne in mind that some of the typical forms of mental disease may be precipitated by trauma. Such an injury may vary from con- cussion of the brain without fracture, to brain injury of wide extent with fracture. The impact may be at any point on the skull, and the manifestations, which are either mild or severe, may appear soon after the injury or may develop at a more remote period. In a general way, the more ex- tensive the area of cortex involved, the greater is the mental derangement. A convenient classification for these disorders is: Dis- turbances which follow almost immediately and which sub- sequently subside completely; those in which recovery is almost complete, but which leave the individual with the so-called traumatic constitution; finally, a terminal condition known as traumatic dementia may supervene. Following concussion, the symptoms may be those of con- fusion or there may be unconsciousness. If the latter, the symptoms of shock or of collapse are usually seen, such as pallor, weak and rapid pulse, cold and moist extremities, headache, and often dilatation of the pupils. Delirium may be manifested. Sometimes there is impaired memory or an actual retrograde amnesia; irritability, childishness, or apa- thy; melancholic, or hypochondriacal periods; emotionalism, rage, convulsions, and even violence. Such symptoms con- stitute more or less the state known as traumatic delirium. When there has been an organic injury to particular parts of the brain, such localizing symptoms as Jacksonian con- vulsions, hemianopsia, aphasia, and other motor and sensory manifestations may appear. • Occasionally there develops temperature with insomnia, convulsions, paralysis, and finally coma, which speaks of abscess or meningoencephalitis. The traumatic constitution that sometimes follows trauma to the head, develops slowly, and has been described by PSYCHOSES INCIDENTAL TO CHILD-BEARING. 573 Friedmann as having its origin in vasomotor instability. Here vertigo, periodic headache, insomnia, bodily fatigue, brain fag, irritability, and explosive emotionalism, may ap- pear. Dream states and hysteroid, epileptoid and paranoid manifestations are sometimes experienced. Of some im- portance in this state is the post-traumatic intolerance to alcohol, and there is also lessened resistance to heat and to the use of tobacco. In traumatic dementia there is a slowly developing mental enfeeblement, which follows in the wake of trauma, and this is shown by a very gradual change in the personality of the individual; that may or may not be associated with aphasia, epileptiform seizures, and arteriosclerosis. The defect is one of general intelligence, with a gradual falling off in efficiency, failure of memory, and sometimes with moral deterioration. Usually, the dementia does noj: become marked, and after reaching a certain point remains stationary for years, while the patient continues fairly normal otherwise. The condi- tion may at times be mistaken for paresis, toward which it bears some outward resemblance, but present laboratory methods of studying neurosyphilis should, together with the history of trauma, clear up the diagnosis. However, it must be born in mind that trauma to the head can precipitate paresis in one who has not yet shown the frank* manifesta- tions of this psychosis. The treatment of shock must be carried out in a supportive way with external heat and cardiac and respiratory stimu- lants. Later, the patient must be kept quiet and free from annoyance. A fracture may require surgical intervention. When the state of traumatic constitution appears, much for- bearance on the part of those intimately associated with the individual will have to be exercised. With the residual con- dition of dementia developing, some individuals may remain at home, while others must be placed in detention hospitals, there to end their days as public charges. The periods of pregnancy, parturition, puerperium, and lactation may be attended by mental disturbances which, however, are not distinctive, since they conform more or less PSYCHOSES INCIDENTAL TO CHILD-BEARING. 574 NERVOUS AND MENTAL DISEASES. closely to those occurring at other times. Such factors as uremia and other intoxications, infections, emotional stress, and sometimes inanition, help to bring about psychoses dur- ing these periods. The strain incident to child-bearing may be sufficient to precipitate one of the classic types of dis- turbance in a potentially psychotic individual. Insanity during pregnancy is not common and even when occurring, it is but seldom that a pregnant woman is ad- mitted to an insane hospital. On the one hand this is due to the family’s aversion to the procedure, and, on the other, to the reluctance of institutions to admit such cases. Those in charge of insane institutions have occasionally been hor- rified to learn that one of their patients has become pregnant during her detention, which, to be sure, is most embarrassing to the institution; but so far as the individual’s insanity is concerned, she usually has gone forward to labor without any pronounced change in her mental state. Primiparoe are not more frequently afflicted with insanity than are others. The state of pregnancy is usually attended by some nutri- tional disturbance, so that morbid cravings for food, longings, pronounced emotionalism, capriciousness, and even moral perversions, are not so uncommon during this period. Preg- nant women have been known to become mildly kleptomanic. However, the mental condition most frequently encountered is that of depression, and this is a natural consequence in cases of illegitimacy except among the lower classes. The pregnant woman often wearies of people and things. She may imagine herself diseased in various ways, so that hypo- chondriacal manifestations are not uncommon. Her depres- sion may deepen into a melancholia, with a delusional con- tent showing self-accusation and with the charge of having committed the unpardonable sin. She may be seized with the desire for self-destruction, so that the utmost vigilance is required to prevent physical injury. These mental states are most likely to develop late in pregnancy, and usually they terminate with delivery. However, a few are affected during the entire period, with a continuation into the puerperium. Rarely, the condition becomes so aggravated as to render the interruption of pregnancy desirable. Occasionally, the state is one of pathological excitement, which may be more PSYCHOSES INCIDENTAL TO CHILD-BEARING. 575 or less continuous during pregnancy. Sometimes the symp- toms are only general nervousness, restlessness, insomnia, and loquaciousness. On the other hand there may be great motor restlessness, hallucinations, delusions (particularly of persecution), with the whole condition totalling a mania. If the physical state is fair and the ancestry not badly tainted, the outlook is favorable. During labor, psychoses may develop. This is most un- usual and when occurring is most commonly found to be dependent upon bad kidneys, a hysterical temperament, or under great mental stress as in illegitimacy. A post-partum psychosis, while not so rare, is less frequent than formerly, since strict asepsis is now more common in obstetric practice. The period of greatest danger is in the first few days, when the uterine vessels are still open and there are perhaps tears in the vagina and perineum. Later, a fissured nipple may be the source of infection. An anes- thetic may be responsible for a psychosis, and extensive hemorrhage may lead to an hallucinatory and confused con- dition. Uremia, alcoholism and morphin sometimes cause psychotic complication, while emboli occasionally set up meningitis and encephalitis. An individual with hysteria or epilepsy may show frank mental manifestations. Most patients are hallucinatory and confused but a considerable number develop melancholia. The tragedy of a suicide, or even a homicide, is a possibility. Most puerperal psychoses are recoverable in from four to six months. A few recur with other pregnancies, and a patient of mine who has borne nine children, has had four such attacks, but the adult life history of this individual showed a manic-depressive trend to her mental make-up. The possibility of the patient drift- ing into a dementia must not be lost sight of. When death occurs, it is either from sepsis or exhaustion from motor unrest. Lactational psychoses are those developing two months or more after childbirth and for the most part are dependent upon exhaustion, though possibly upon hemorrhage. Occa- sionally, there is delirium, often there are hallucinations and confusion, while rarely a stuporous state develops. Most cases appear among the lower classes who are underfed, not 576 NERVOUS AND MENTAL DISEASES. properly nursed, and whose surroundings are unhygienic. When such mothers have particularly troublesome children to care for, mental breakdown is not surprising, and if in addition there is ancestral taint, a psychosis is almost to be expected. The first symptoms are those of general debility, emaciation, weakness, anemia, then there develop irritability, loss of the power to concentrate, lack of attention, failure of memory, confusion with hallucinations of vision and hearing. From being suspicious the patient may become terrified and attempt to injure herself, her child, or others. A rise in temperature may or may not be present. The condition lasts from eight months to a year, and while generally recoverable, is not so hopeful as when the psychosis has appeared in the post-partum period. Recovery is usually very slow and a few drift into a dementia. The treatment of these period psychoses varies somewhat. If occurring in pregnancy, it may be desirable to interrupt the condition. When developing in the post-partum stage and upon a septic basis, surgical intervention may be nec- essary. Sometimes transfusion is required. Otherwise the treatment is tonic, supportive, perhaps with sedation and hydrotherapy. The patient must be skillfully nursed and the child provided for in some other way. THE TOXIC PSYCHOSES. Pellagra. Pellagra is endemic to some of our southern states and occasionally the disorder is encountered elsewhere. By no means do all cases show mental symptoms, though neurasthenic manifestations are rather common early in the disease, and rarely, a toxic psychosis does develop. Mental cases are for the most part among our poorer classes and so are apt to drift to institutions of detention. Spinal cord involvement is rather frequent, with variable symptoms, de- pending upon whether the brunt of the disorder is borne by the posterior columns or by the lateral columns. The mental manifestations may be those of depression, retardation, con- fusion, acute delirium, and sometimes with a rapidly progres- sive and fatal dementia, simulating a paretic dementia. Other mental types may be simulated, such as the manic-depressive group and an anxiety psychosis. Identity of the disorder is THE TOXIC PSYCHOSES. 577 dependent upon the associated intestinal disturbance and the skin lesions. Since the patients are usually poor, they can be best cared for in an asylum. Carbonmonoxide Poisoning. This form of intoxication is not infrequent, sometimes resulting from attempts at sui- cide, though it may also occur accidentally. Patients with a depression psychosis of course may attempt suicide with il- luminating gas, but the gas itself may also induce a psycho- sis which sometimes develops as late as ten or more days after the poisoning, while during the interim the individual has appeared normal. This late development of the psycho- sis is supported by the recent finding of the poison in blood intermingled with the spinal fluid, long after its disappear- ance from the blood stream. In fatal cases there have been observed congestion of the brain and its membranes, de- generation, especially in the lenticular nuclei, but also in areas of the cord and rarely in the peripheral nerves. The fact that the carbonmonoxide of illuminating gas has a two hundred times greater affinity for the blood than has oxygen, renders it a highly dangerous gas. The temperature is at first subnormal, but later it rises rapidly. There is salivation and the face and extremities assume a cherry-red color. Leukocytosis is marked. Head- ache, restlessness, excitement, and drowsiness develop. Tre- mors and muscular twitchings appear, together with anes- thesia and vasomotor paralysis. Finally, the patient becomes unconscious, the breathing is stertorous, and unless relief is speedily obtained, the patient perishes. If he recovers from the immediate toxic symptoms, there may appear later mental excitement, fabrications, amnesia, and emotional manifestations. Diagnosis of the acute toxic state rests upon the history, the coma,' the cherry-red color of the face and hands, and upon a spectrum analysis of the blood. Treatment consists in the transfusion of blood or of normal saline solution, electrical stimulation, cardiac and respiratory stimulation and the persistent use of the pulmotor. Carbonbisulphide Poisoning. This occasionally occurs among vulcanizers who are not properly safeguarded, in cleaning establishments, and in preparation of cellulose for 578 NERVOUS AND MENTAL DISEASES. the manufacture of artificial silk, where the chemical is some- times used. Poisoning results from inhalation, and the chemical appears to have a special affinity for the nervous system. While acute intoxication may occur, the chronic form is of most consequence. Various types are recognized, such as hysterical, pseudotabetic, and that of peripheral neu- ritis, while the psychic form is the most serious. Disturb- ances of vision are common and sexual manifestations occur— early there is apt to be sexual excitement, but later weakness and even loss of power. In the psychic sphere the disturb- ances are usually those of excitement or depression, but sometimes stuporous manifestations are present. Some differentiation may be necessary from hysteria, mul- tiple neuritis, tabes and the other forms of toxic psychoses. Severe intoxication may not be recovered from and the milder forms have been known to leave the individual with permanent disability. Treatment is symptomatic. Other toxic psychoses, such as those due to alcohol, opium, and cocain intoxications, are considered under Diseases of Inebriety. HEREDITARY CHOREA. This disease, which was first described by Dr. Huntingdon and whose name it usually bears, is distinctly a development of middle life, often appearing at about forty years. Males are the more commonly affected, but in conformity to the rule so frequently observed in hereditary nervous disorders, females are the more concerned in its transmission. The disorder may, perhaps, develop along Mendellian lines. The first sign observed is excessive movements in the hands and feet, these increase and soon the body and head are similarly affected. The movements are not of muscle fibers, but are massive involuntary movements of groups of muscles. For a time the patient exercises some volitional control over the excessive jerkings; ultimately, however, these incoordinate movements become actually violent. They are aggravated by mental and physical effort and are present when the body is at rest, but they are not manifested during sleep. Eccen- tricities of character appear and the patient becomes irritable, depressed, or emotional. Finally, he must remain in his ALCOHOLISM. 579 chair and later in bed, while the muscle unrest becomes so incapacitating that at last he cannot feed himself. Delusions of persecution appear and sometimes there are suicidal or homicidal tendencies. If the patient survives sufficiently long, a grave dementia overtakes him. The course of the disease is irregular and by no means do the motor and the mental symptoms keep pace. The affection lasts for many years. Treatment is unavailing except in a supportive sense and unless the family is well-to-do, institutional care best meets the requirements. DISEASES OF INEBRIETY. In a general way, the period of alcoholism is middle life, for it is then that both the mental and the physical activities are at their height. Among civilized people the desire for success may tempt them to increase their power of endur- ance through artificial stimulation, and if failure threatens, either there is an unwillingness or an inability to bear the strain without recourse to false support. The immediate ef- fect of this is to the advantage of the drinker, but ultimately alcoholic excesses lead to permanent mental and physical impairment. Nor is this all of the harmful effects—the off- spring too may be blighted in mind and in body. On the other hand, it must be borne in mind that a drunken parent may have healthy and even brilliant descendants. The re- cent Prohibition Act has changed somewhat the aspect of the alcoholic question. At first there was noticed an enormous decrease in all forms of alcoholic excesses, which was largely due to the inaccessibility to alcoholic beverages, to a fear of poisoning from those that were available, and in a limited degree to submission on the part of dealers and con- sumers to the newly established order. Later, dealers eager for gain and imbibers eager for drink caused a minor degree of drunkenness to again assert itself, so that to some extent through illicit distribution of alcoholic beverages, the dis- orders resulting from their disuse are still encountered. No one defends drunkenness, but the view held by some ex- ALCO HOLISM. 580 NERVOUS AND MENTAL DISEASES. tremists, that alcohol is not a medicine and never should be employed as such, is not shared by most of us. What is said against its use may with even greater emphasis be ar- gued against morphin, although of course alcoholism is relatively more common. But no one will say because mor- phin is a most dangerous habit-producing drug, that it never should be prescribed as a medicine. Unquestionably alcohol has destroyed useful people, but it also has helped eliminate many more who were not useful. Beer and light wines, which have always been used by civilized nations, are now scarcely obtainable, but wretched concoctions sold illicitly as whiskey appear to be quite abundant. History shows that the successful nations have all been alcohol users, while those which practiced abstinence have amounted to but little, such as Egypt, India, and Turkey. We were told that with prohi- bition there would be a great decrease in crime, but unfor- tunately all kinds of offenses have increased appallingly. To be sure, some of these are due to the lowered state of morals that inevitably follows war, but usually crime is in the mental make-up of the individual before he becomes addicted to drink. In this country the effect of beer and of light wine drinking as provocative of nervous and mental diseases was rather inconsequential, but great harm did result from the excessive use of strong liquors, which beverages contained approximately from forty per cent, to fifty per cent, of ethyl alcohol. An actual craving for drink does not usually begin before adult life and often it terminates, either through loss of desire or perhaps death, by forty-five years. One harmful effect of alcohol is that indirectly it contributes to the spread of social diseases, not through the stimulation of sexual desire, but through its lessening of self-control, chances are taken that otherwise would not be risked. In addition to the kind and quantity of the alcoholic beverage consumed, individual susceptibility is of great importance, with heredity as a strong etiological factor. A single dose of alcohol will lower blood pressure, but its continued use leads to arteriosclerosis and hypertension. One individual may consume a quart of whis- key a day for a long time without the appearance of intoxi- cation, while another becomes delirious under the influence of a very small amount. The steady drinker is almost cer- ALCOHOLISM. 581 tain to show deterioration after years of use, though occa- sionally men have reached an advanced age who are known to have used strong drink excessively most of their life. The periodic drinker is often harmed less by alcohol than is the steady user, but periodic alcoholic debauchery is sometimes due to a manic-depressive trend in the mental make-up of the individual. Drunkenness becomes pathologic when it causes the drinker to commit unusual acts—sometimes of violence—or when it gives rise to other deleterious effects. Following the intemperate use of alcohol one may meet with various types of mental manifestations, such as delirium tre- mens, Korsakow’s psychosis, alcoholic hallucinosis, pseudo- paresis, pseudoparanoia, and alcoholic epilepsy. Delirium Tremens. This is an acute disorder which de- velops upon a basis of acute alcoholism and is characterized by delirium, hallucinations, tremor, and toxic symptoms. It may develop gradually or abruptly, and sometimes it is pre- cipitated by the too sudden withdrawal of liquor; trauma, physical or mental, are also said to be exciting causes. In a well developed attack visual hallucinations of a horrid and a terrifying nature are conspicuous; there is mental depres- sion, apprehension and confusion; tremor, insomnia, anor- exia and weakness are manifested; the heart action is often weakened, but there is seldom fever; sometimes the pupils react sluggishly, albuminuria is often present and there may be epileptiform convulsions. The disorder usually lasts three or four days, with a mortality of ten per cent, or fifteen per cent., in which death is due to acute cardiac dilatation, pneu- monia, or “wet brain.” Treatment should be supportive, with free elimination through the bowel, kidneys, and skin. Sedation may be ob- tained through the use of bromides, paraldehyde, and pos- sibly chloral; strychnin and digitalis are often indicated, and hypodermoclysis may be necessary. Careful feeding, pos- sibly through a tube or even by the rectum must be employed. In the event of extreme violence, restraint may be necessary. Korsakow’s Psychosis. This disorder, while usually due to alcoholism, has been known to develop from infections like typhoid, from the intoxications of diabetes and uremia, and in metallic poisoning from lead and arsenic. While a 582 NERVOUS AND MENTAL DISEASES. polyneuritis has been considered a necessary accompaniment, this does not always hold true; delirium may or may not be present, while disorientation is a pronounced feature. Memory for recent events is unfaithful, which defect the patient often attempts to overcome by various rather charac- teristic forms of grotesque fabrications, implicating himself in many impossible and ridiculous incidents. The disease is a serious one, though in mild cases recovery does occur; others who do not die may be left as physical or mental cripples. Treatment is that employed in other intoxications, with the application of devices to overcome deformities which might otherwise result from the neuritis. Acute Alcoholic Hallucinosis. Sometimes there develops an acute auditory hallucinatory disorder lasting for an in- definite period and accompanied by delusions of persecution and of jealousy, but without disorientation or fabrication. The “voices” heard often accuse the patient of sexual irregu- larities and deviations. While these mental symptoms have a paranoid trend, the disorder is not chronic, which differen- tiates it from true paranoia; from delirium tremens it may be distinguished by the great preponderance of auditory hallucinations. The disease usually subsides after a few weeks or months but occasionally a patient will drift into a chronic state of mental derangement. Alcoholic Pseudoparesis. In a case of chronic alcoholism there may appear the symptoms of expansive delirium, ataxia of the gait and speech, rigid pupils, and tremor, which mani- festations approximate paresis; however, the patient may have a history of dissipation, the brutish face that is some- times shown by the drinking man, but without the positive blood and spinal fluid findings of the paretic, together with a lack of other evidence of neurosyphilis. Withdrawal of alcohol will cause a subsidence of the symptoms. Alcoholic Pseudoparanoia. Sometimes a chronic alcoholic will make the charge of marital infidelity and will have de- lusions of persecution, all of which clear up under enforced abstinence; such patients may, from believing themselves grievously wronged, become dangerous. MORPHINISM. 583 Other conditions resulting from chronic alcoholism are recognized, such as alcoholic epilepsy; here, fits occur only during, or just after, a spree; such an individual shows the alcoholic make-up, but lacks that which is characteristic of the epileptic. Dipsomania is a term signifying a sudden, irresistible desire to drink which is then followed by an in- terval of freedom from such a desire. One may also meet with an alcoholic amnesia and a dissociation of personality, which conditions sometimes present perplexing medico-legal aspects. The mildest form of disorder that may result is a slow deterioration, shown by irritability or undue humor, suspicions and jealousies, carelessness, untrustworthiness, fabrications, and a general lessening of the physical, mental, and moral forces. MORPHINISM Among narcotic drugs, opium and its derivatives are the substances most frequently employed by addicts. Crude opium is sometimes chewed, prepared opium is smoked, and laudanum is drunk, but most frequently it is morphin, heroin, or codein, that are used, either hypodermatically or otherwise. Some years ago the number of habitues was increasing enormously, but at present two factors render statistical inquiries on this subject difficult. Undoubtedly enforcement of rigid laws controlling the distribution of nar- cotic drugs has restricted their use, but as a result of the recent prohibition act, some alcoholics have turned to drugs to satisfy their cravings. People of the present-day are as unwilling to bear pain as were those of an earlier period; the injudicious administration of narcotic preparations to relieve suffering, in such disorders as sciatica, colic, tabes and dysmenorrhea, has fastened the habit upon many persons; the nerve racking diseases of neurasthenia, hysteria, hypochondria, melancholia and alco- holism are afforded great temporary relief through the use of morphin; some psychopaths and degenerates take naturally to vice, becoming at once its votaries, and these individuals are particularly prone to adhere to the use of drugs. One is amazed at the matter of tolerance in morphinists— forty and sixty grains daily, or even more, are at times used; 584 NERVOUS AND MENTAL DISEASES. and laudanum is sometimes drunk in enormous quantities. Another surprising fact is the lack of degenerative effect upon the body as compared with alcohol, since from the long continued use of morphin, the arteries, kidneys and liver show but little involvement; neither are the offspring tainted to the same extent. While the moderate use of morphin may be carried on for years without any pronounced effect upon the mind and body, in this country many users of the drug become rapidly excessive in their indulgence. The appearance of a confirmed morphinist is quite charac- teristic. The skin becomes yellow, anemia is present—opium cachexia—and the activity of the secretions is markedly lessened, leading to sluggish peristalsis and obstinate con- stipation. A whole host of minor affections of the gastro- intestinal tract, and the urinary and respiratory systems, is common. The pupils are contracted—perhaps pin-point— and inactive to light. The skin and tendon reflexes are diminished. Impotence is the rule. In certain concealed parts of the body the integument may show scars and pig- mentation from long continued use of the hypodermic needle, and this is an important diagnostic point. The mental symp- toms are insomnia, with a gradual lessening of all the intel- lectual processes, and with such moral deviations as will render the individual’s personality an exceedingly unpleasant one. The morphinist is irritable, untruthful, sometimes dis- honest, and may show a criminalistic tendency. The con- dition approximates insanity, but seldom may the individual be detained in an institution upon that ground; and un- fortunately he may live for many years in this state. Such symptoms as are produced by sudden deprivation are worthy of note. In a few hours the morphinist becomes restless, anxious and weak; tremors, sweating, cramps and diarrhea are experienced, and collapse is imminent; the crav- ing for the drug may become pitiful, but occasionally the victim’s suffering is relieved through the development of delirium. In the matter of treatment, the untrustworthiness of the drug addict renders institutional care desirable. Three methods of procedure are open to the physician: The drug may be stopped abruptly, it may be withdrawn rapidly, or COCAINISM. 585 it may be reduced slowly. Without giving these methods in detail, it appears worthwhile to remark that some mor- phinists run counter to the established order of things, and as a result are ordered to penal institutions; there, the treat- ment of choice is the sudden and absolute withdrawal of the drug; recovery is usually so prompt that the procedure is desirable, except where a pronounced physical debility renders it inadvisable; obviously, this method of treatment cannot be carried out so completely elsewhere. During the first few days the patient should be kept under control through the use of trional, medinal, or luminal, and with the administration of such other remedies as the symptoms in- dicate. Unfortunately, if morphin becomes again available, most of those who have become confirmed users return to the vice, and the combination with other narcotic drugs or alcohol, makes the outlook particularly gloomy. Cocain came into general use after 1884, when its value as a local anesthetic in ophthalmic surgery was discovered. The injudicious administration of the drug in diseases of the nasopharynx, has occasionally led to the habit, and because of its producing physical and mental stimulation the drug was formerly used in the treatment of morphinism and al- coholism, which, unfortunately, frequently resulted in the individual’s becoming a combined addict. From periodic use at first, cocain takers drift rapidly into its continued use, and since its effect soon wears off, the drug is resorted to at frequent intervals. The debilitated and the neurotic take to it readily, and the poorer classes fall an easy victim to its charms. The habit is common in some parts of the south, and criminals are sometimes users of the drug. It comes as a great temporary solace to those already exhausted from other drug excesses. Cocain is the worst of drugs to enthral its devotees, luring them to an almost hopeless captivity. Soon, it induces physical, mental, and moral deterioration, often leading to rapid death, but not commonly to a per- manent insanity. The symptoms presented by a cocain addict are rapid emaciation; the individual is distressed of countenance, is COCAINISM. 586 NERVOUS AND MENTAL DISEASES. restless, talkative, and secretive; the skin has a pale, yellow and withered appearance; the eyes are sunken and the pupils dilated; there is muscular weakness and tremors; the ex- tremities are cold and cardiac irregularity is not uncommon. The cocainist is constantly changing his plans, so that work of various kinds is started only to be abandoned later. Some- times from the poisonous effects of the drug, and perhaps also from a marasmic condition, there develops an hallucin- atory phase, beginning with great restlessness and distrust, from which the individual passes rapidly into a condition of irresponsibility. The special senses may be involved, vile language is often heard, and they hear persecutory threats shouted at them. They imagine seeing small black spots wandering over a light surface, see vermin of various sorts about the room or upon the clothing. A most common sen- sation experienced is that of insects crawling under the skin, which is known as Magnan’s sign and has been termed the “cocain bug”; this sensation of bodies under the skin is characteristic of cocainism. Needle pricks are felt, and many other painful sensations are experienced. The patient may believe these sensations are due to the machinations of his fancied persecutors, a homicidal insanity may develop at once, and he may proceed to arm himself for the destruction of his supposed enemies. Accusations of marital infidelity are quite common, and he has now become an exceedingly dangerous person. Rarely, in this condition of physical and mental torture, he commits suicide. When a combination of drugs is used, the diagnosis may be quite difficult. The cocainist is erratic, secretive, dis- trustful, and inclined to be solitary. This is not usually true of the morphin user. It differs from an alcoholic psychosis in the peculiar form of skin sensations, the more severe character of the maniacal manifestations, and in the absence of albuminuria; the administration of a single dose of cocain will aggravate the condition, while little or no effect will result if the patient is an alcoholic. From paranoia it may usually be observed that the delusions are less systematized, less constant, and more numerous. If the patient is treated early, the prognosis is perhaps more favorable than in either morphin or whiskey addicts. However, except in the early CAFFEIN ISM. 587 stage, a permanent cure is exceedingly rare. Those indi- viduals who use a combination of drugs are the least hopeful. The chronic patient may be treated by stopping the drug at once, by rapidly reducing it, or it may be slowly with- drawn. In many cases its immediate withdrawal will be the most satisfactory, for the reason that during the gradual re- duction it sometimes happens that the patient will not re- main under treatment when the discomfort incident to the partial deprivation manifests itself strongly. In those states where institutional detention is lawful, patients are more easily managed by confinement. If maniacal symptoms are present, they usually subside when the patient can no longer obtain the poison. The suffering attendant upon deprivation is not so great as in the morphinist, but there is danger of the symptoms of collapse for some time after the drug has been withdrawn. Strychnin is a sustaining remedy; the mental distress may be relieved by hyoscyamus, valerian, or large doses of the bromides; the appearance of collapse should be met by the administration of cardiac stimulants; insomnia is best overcome by prolonged baths; nourishing food should be given at frequent intervals. CAFFEINISM. Humanity has always craved something to soften its sor- rows or to add to its pleasures, and when deprived of one substance that has afforded this gratification, has immedi- ately sought another. Almost half of the coffee output of the world comes to the United States, and probably no country, except Holland, consumes more per capita. Formerly, we used more than eleven pounds annually per individual, but for the year ending June 30, 1920, owing to the effects re- sulting from the Prohibition Act, we consumed almost four pounds more per capita. With us, there is no longer much adulteration, but injury frequently results from insufficient roasting, which leaves the coffee-bean weighty and which prevents the vaporization of certain harmful products. Cof- fee contains three important ingredients: the alkaloid caf- fein, the volatile oil caffeol, and caffetannic acid; to each of these has been attributed its harmful effects but it is probable that caffein is the greatest offender. Coffee should be thor- 588 NERVOUS AND MENTAL DISEASES. oughly roasted, finely ground, and then strained through cotton cloth; it should never be boiled. Many alcoholists and morphinists have used coffee to excess before arriving at their baser inebriety. A patient of mine who drank a pint of black coffee at frequent intervals, was a dipsomaniac and also was afflicted with kleptomania. Some users have been known, to chew the coffee-bean. Indoor workers and those who are temperamentally nervous, do not bear coffee so well, and the habit is more common among women. Cof- fee shows a slightly laxative action, due to an irritating oil which it contains and which also gives rise to indigestion. Following the drinking of a moderate amount of coffee there comes an increased capacity for physical exertion, or if the individual be fatigued, there will be a loss of this feeling. The same may be said of the psychic sphere, for coffee is a true brain stimulant; under its influence ideas become clearer and flow more rapidly, fatigue and drowsiness dis- appear, and the special senses are rendered more acute. A secondary fatigue, such as is seen after the taking of alcohol, is almost wanting. After the prolonged use of excessive quantities there results emaciation, weakness, trembling of the hands which is sometimes noticeable even when they are at rest. Anorexia and indigestion are common. The pulse is rapid, sometimes irregular, there is palpitation with pre- cordial distress, and ultimately a hypertonicity in blood pressure. The mental symptoms of depression, headache and insomnia occur, and in extreme cases convulsions have been noted. Most of the symptoms subside after the dis- continuance of the beverage, and the general debility will usually be found to respond to reconstructive treatment. Tea, next to water, is the most widely used beverage and as a drink antedates coffee by many hundred years, since in China, where the water was infested with typhoid, dysen- tery and other germs, tea drinking was regarded as a medi- cinal measure; obviously, any benefit derived lay in the boiling of the water. In this country tea inebriety is most frequently encountered among the Irish and the Russian populations. Rarely, one meets with an individual who chews tea-leaves. The active and the most harmful principle is thein, and when taken to excess is attended by as much NICOTINISM. 589 injury as is caffein. Tannin also in any considerable quan- tity is harmful and frequently leads to indigestion through an active precipitation of proteids. Tea should not be boiled, but an infusion should be made quickly, since by this method only a little of the thein and tannin are extracted. NICOTINISM. Tobacco is smoked and chewed, and also is used in a powdered form known as snuff. Great difference of opinion exists as to whether, when taken in moderation, it is harm- ful. Those most temperate in their views hold that tobacco of good quality, not too strong and not used to excess, is without injury, provided there is no idiosyncrasy. It is sig- nificant that insurance companies, always watchful of their interests, have attached no great importance to the use of tobacco. There are contradictions to its use as in certain affections of the heart, dyspepsia, respiratory disorders, eye affections, and nervous conditions. Tobacco is least offen- sive in the form of cigarettes, except when the smoke is inhaled; then follow cigars, the pipe, and most harmful of all is chewing. In heavy smokers there is a tendency toward an increase in blood-pressure, thus promoting arteriosclerosis. It is doubtful if excessive smoking causes carcinoma about the mouth, though trauma, from smoking a pipe, may be conducive to the development of malignancy. Certain bene- ficial effects are claimed for moderate smoking, and no less authority than Clouson says, “it tends to calm and continu- ous thinking, and in many men promotes the digestion of food.” Perhaps there is a psychic element in the hold smoking has on one, since it is less satisfying to smoke in the dark and few blind men enjoy smoking. Excessive use of tobacco leads to irritation of the pharynx and the larynx. The functional disorder of “smoker’s heart” may develop, a condition which includes palpitation, tachycardia, arrhythmia, and possibly syncope. Sometimes dimness of vision, im- paired accommodation, and myosis may result; if destructive changes occur, alcoholism is usually associated. Anorexia, dyspepsia and gastric catarrh are present, and eventually emaciation and anemia occur. There is lack of energy, re- tarded mental action, insomnia, vertigo, headache, and neu- 590 NERVOUS AND MENTAL DISEASES. ralgic pains. The tendon reflexes are increased, and muscular weakness and tremors are present. Snuff, which is tobacco specially prepared by the process of fermentation and then finely powdered, was formerly in almost universal use. It is now consumed but little ex- cept by the negroes in the south and by some of the in- habitants in the northwest. In the latter region, however, the powder is often chewed and, if one may believe reports, the habit is assuming serious proportions. Its victims are said to develop ulcers inside the mouth and show marked evidence of physical and mental intoxication, and in some instances even develop a psychosis. In excessive use of tobacco, withdrawal of the substance usually leads to prompt subsidence of the symptoms, but limitation and avoidance of inhalation are often sufficient to overcome the harmful effects. PSYCHOPATHIC PERSONALITIES. Many eccentric characters exist who may not be classed as insane, but who in some instances may have had earlier in life a mild psychosis, such as dementia precox, and from which only partial recovery was made, thereby leaving them somewhat mentally dwarfed. A few of these individuals ulti- mately become permanently insane, while others always remain queer and are classed as “cranks.” History shows that a touch of genius may be observed in a few of these persons, so that their efforts if concentrated in a definite direc- tion sometimes prove rather remunerative. But many lead lives of inefficiency and the poorer class often become vaga- bonds or not infrequently are found in penitentiaries, jails, or alms-houses. These individuals are always more liable to develop a psychosis than is the general population. Their malady is a mental one and often they are found to have average physical health. Sometimes there is an obvious hys- terical strain in their mental make-up and, as we all know, hysterical persons as a class lead lives of inefficiency. Of recent years, my personal observation has revealed more major hysteria among penal inmates than has been seen else- where. Frank epilepsy is encountered in a few and the epileptic character with its egocentricity and social inadapta- PSYCHOPATHIC PERSONALITIES. 591 bility is frequently met with. They are prone to alcoholic excesses, often in the form of periodic debauches, and some even becoming dipsomaniacs. All manner of offenses may be committed during a state of intoxication and, since drunken- ness usually affords no protection to the offender, they are frequently the subject of medico-legal inquiry. Sexual ex- cesses are likewise common and far beyond that usually seen, so that libertines, bigamists, and others who indulge in sexual vagaries, are sometimes found among this group. Several types are well known. Pathological lying and swindling are degenerate acts which are almost invariably associated with other character deviations. In a case re- ported by me, beside the abnormal fabrication there were two attempts at homicide (one successful), three attempts at suicide, probably rape, and possibly simulation of insanity. As Kraepelin says: “Here we have, in general, to deal not only with hyperexcitability of the imagination and defective faithfulness of the memory, but also with a certain unsteadi- ness in the sphere of the emotions and of the will.” Pseudoquerulants, while presenting something of the out- ward appearance of paranoiacs, differ from them in not being actually delusional nor dangerous; also, their condi- tion remains practically stationary, not being progressive as is paranoia. However, they give rise to much trouble through quarreling, the threatening of litigation and not in- frequently actually resorting thereto. These individuals are not well balanced intellectually, though often they possess considerable cunning and exhibit colossal conceit. Their quarrels are not prolonged and after one is settled they seem to forget the matter, but soon they discover other grievances which cause them again to institute Jegal proceedings. Formerly, the distinctly criminal class were rather loosely grouped as moral imbeciles or as individuals possessed of a moral insanity. These terms are unsatisfactory, since they imply irresponsibility, which might carry with it immunity from proper punishment. The moral sphere and the intel- lectual sphere, while to some extent dependent upon each other, may still vary in their development, and in the “born criminal,” as Lombroso termed one group, the individual is sadly wanting in his moral sense. 592 NERVOUS AND MENTAL DISEASES. The treatment and care of individuals with a psychopathic personality is a difficult problem. Some are inoffensive and may be of small concern. Those given to alcoholic excesses can in some states be detained in hospitals for varying peri- ods of time. The psychotic, also, if mentally incapacitated, can be placed in detention hospitals. Those guilty of mis- demeanors will from time to time be subjected to prison sentences while others will drift to alms-houses. But there still remains a group whose individuals escape the various hospitals and institutions, and who by reason of their activities continue to be more or less of a nuisance in their respective neighborhoods. SEXUAL ANOMALIES. Nature has placed within beings a powerful sexual appe- tite in order that the various species will propagate and thereby perpetuate themselves. Through some means dif- ficult for us to understand, sexuality among human beings is often less decent than among the lower animals, since it has been prostituted to the extent that sexual indulgence is frequent, with procreation proportionately a very diminu- tive quantity. Nor is this the worst of sex vices, for occa- sionally sexual gratification is procured through the basest and most perverted means, which acts constitute one of the blackest pages of human history. The perpetrators of these monstrous vices do not usually consult physicians concerning their weaknesses, since they seldom desire to overcome them, so that these individuals are most frequently encountered in penal institutions, where they are undergoing sentence for some sex crime; or, by reason of the usual channel of sexual indulgence having been shut ofif, they may have ac- quired the vice in jail. The navy and to a lesser extent the army yield a few devotees to these vices. As a class such individuals are usually psychopaths and a few in time actu- ally become insane. The drive of the passions shows a noticeable weakening by forty-five years, though occasionally degenerate acts are committed by the old of the male sex. Homosexuality. Sexual desire for those of the same sex is sometimes so pronounced as to render contact with the opposite sex repugnant. In some males this desire is so SEXUAL ANOMALIES. 593 compelling as to cause them to don female attire, and they are particularly attracted not by those of their own cult, but by men, normal and strong in appearance. Some such men are astonishingly feminine in their outward physical appear- ance as well as in their actions. However, these individuals are not always obviously effeminate, since some of the world’s great men have been charged with the vice of love for their own sex. It is a fortunate feature of the practice that pro- creation cannot result, so that it tends to die out. When the vice appears in the female, it is spoken of as Lesbian love. Such women are prone to feel, dress and act like a man toward other women, and they have even been known to live together, outwardly, as man and wife. Fetichism. This trait reveals itself normally in some re- ligions, where the sight of certain objects is sufficient to produce religious ecstasy. Erotic fetichism, while common to a very limited extent and perhaps harmless, may become so pronounced as to be distinctly a part of the mental make-up of the psychopath. In some, extreme sexual excitement and gratification may be had through the sight of, or through contact with, certain articles of wearing apparel or certain parts of the body. The objects necessary to exert such a charm may be of various kinds; a slipper, a handkerchief, or a lock of hair. A case with which I was thoroughly conversant was that of a man who came of distinctly psychopathic stock. He had married and was the father of three children when his wife refused him further sexual intercourse. Previously, he had observed that coming into the presence of women who were veiled—particularly when they wore a harem veil— sexual excitement followed, even to the extent of producing an orgasm. This plan he then adopted as his means of sexual gratification, and in order that he might gratify himself fully, selected from among others one woman whom he maintained in ease and comfort. She was sexually unattractive to him when without a veil and he never had natural sexual rela- tions with her. This life satisfied him but the maintenance of two establishments led to his embezzling twenty-four thousand dollars, for which crime he served a two-year sen- tence in q. penitentiary. This prisoner’s wife, who was 594 NERVOUS AND MENTAL DISEASES. conversant with his weakness, since she herself had worn a veil for his sexual gratification, confirmed most of the details related to me by the prisoner. Sadism. This is perverted sexual gratification, usually encountered in males, practiced toward the opposite sex, in which violence and cruelty are associated with the sexual excitement. To a minor degree unnecessary violence is sometimes practiced among ordinary individuals during the sexual act, and this is an expression of sadism in its mildest form. Some perverts cannot satisfactorily perform coitus until they have inflicted pain. The extreme of the condition is found in those fiends who after having committed an atrocious murder, proceed to sexual indulgence or other sexual revery with the body of their victim. Where the sexual relation is with a dead body which has been the victim of a murderous assault, or where the body is accidentally encountered as in an undertaking establishment, the act is termed necrophilia. Masochism. This is the opposite of sadism and sexual gratification is found through subjection to force and the enduring of pain. Such sufifering is usually born by the man. Exhibitionism. This act consists in exposure of the geni- talia to the opposite sex, and is confined almost exclusively to males, although, rarely, it has been observed among in- sane women. Some such individuals show a frank mental disease, as paresis, epilepsy and alcoholism, but another and an important group, are just morally weak and find sexual gratification through such exposure. Occasionally, these individuals are picked up in parks or other public places which are frequented by girls and women. The offense con- sists in the indecency of the act, as such men are otherwise harmless, never attempting an assault upon females. Bestiality. Sexual gratification through intercourse with animals is occasionally encountered among the feeble minded and the degenerate. Women have been known to copulate with dogs. Such acts, while most revolting in their nature, are unattended by venereal infection, or by the possibility of conception, so that they are not the worst of sexual anomalies. THE ENDOCRINOPATHIES. 595 THE ENDOCRINOPATHIES. The vegetative system is now attracting much attention, though some of its affections are not yet well understood. This important system is composed of nerve ganglia, nerve fibers, and nerve plexuses, which supply the involuntary muscles, the pupils of the eyes, the glands and viscera, and the cardiovascular system and genital organs. It is com- posed of two separate systems each of which tends to control over-activity of the other; these are the autonomic system and the sympathetic system. Individuals vary greatly, depending upon which of these systems has the dominating influence. The Autonomic or Vago-tonic Type. In such individuals there is believed to be prompt action to the substance called cholin. The symptoms of this type are shown as brady- cardia, myosis, tendency to sweat, gastric hyperacidity, asth- matic tendencies, and a torpid bowel. Eosinophilia may be present and the sugar tolerance is high. This system is very responsive to the action of pilocarpin and its activity is re- tarded by the administration of atropin. The symptoms of the disorder may be general or they may be more or less confined to one of the anatomical divisions of the system— the cranial, the cervical, or the sacral. The Sympathetico-tonic Type. Such individuals are char- acterized by their greater activity and excitability. There is a rapid heart action, dilated pupils, and the skin is dry and warm. Great susceptibility is here shown to the action of adrenalin, thyroid substance, and pituitrin. Many of the symptoms of Graves’s disease are of sympathetico-tonic ori- gin, as are those of the angio-neuroses such as angioneurotic edema, Raynaud’s disease, and erythromelalgia. One encounters much in the literature of endocrinology that is speculative, which in a measure may be due to a frequent pluriglandular implication, wherein the relative component gland values cannot yet be definitely determined. However, the fact remains that certain important diseases are recognized as originating through endocrine disturbances, hence the subject compels our attention. Furthermore, when it is realized that in the lower animals, removal of either 596 NERVOUS AND MENTAL DISEASES. the adrenals, the parathyroids, or the pituitary body, is fol- lowed by death, one feels that at least some of these organs must be of vast consequence during life. The list of structures contributing important internal secre- tions has from time to time been enlarged, and in the matured adult the principal organs that so far have been shown to be active are the thyroid, parathyroids, adrenals, pituitary, ovaries, testes, and pineal body. But as for the inclusion of such structures as the appendix vermiformis, which it is said contributes an important “energizing” substance to the economy—when all know patients who have not enjoyed good health until after their appendix was removed—one then cannot help viewing some of the writings upon this question with skepticism. The secretions of the endocrine glands deliver to the blood certain chemic substances known as hormones, which, when carried to associated organs, excite functional activity, and such an influence is observed normally at puberty. This hormonic power may lead to excessive, diminished, or per- verted secretion, and thus disease is sometimes established. Thyroid Disturbances. The most important and the best understood of the endo- crine glands is the thyroid. The secretion from this organ contains much iodin, which substance, it is believed, is largely responsible for its activity. The chief influences attributed to its secretion are stimulation of the adrenals and mammary glands; regulation of the activity of the ovaries and testes; a protective action against toxins entering the blood, and perhaps the maintenance of a vicarious relation with the pituitary body. Hypothyroidism. This condition results from the lessened activity of the thyroid gland, and the definite clinical entities ensuing are cretinism, which belongs to early life, and myx- edema, which may result from disease of the gland, or a too extensive surgical removal may cause a myxedematous con- dition—cachexia strumipriva—to develop. Among the minor manifestations of hypothyroidism are dryness of the skin and of the mucous membranes, scleroderma, and' perhaps THE ENDOCRINOPATH1ES. 597 with pruritis, psoriasis, or ichthiosis. The hair becomes dry and scanty, and the extremities are cold. There is retarded cerebration and a lack of emotional response. Defective oxidation is present so that there may be rheumatic and arthritic manifestations. Gastric disturbances are common and marked constipation is the rule. In the female, often there is dysmenorrhea or amenorrhea. Acquired myxedema is commonly a disease of middle life, with women the more frequently affected. This disorder may develop slowly after a goiter has led to extensive de- struction of the thyroid, or to some disease of the gland (possibly syphilis), or it may appear rapidly after severe hemorrhage. The disease is characterized by a myxedema- tous accumulation beneath the skin and mucous membranes, together with progressive mental and physical enfeeblement. The skin is of a palish yellow color, dry, thickened, scaly, firm, and elastic, but it does not pit on pressure. The con- dition is most obvious in the face and the extremities. The nails and hair are irregular, dry, and brittle. Perspiration and sebaceous secretions are diminished, and the tendon re- flex activity is diminished. The facial expression is quite characteristic: There is apathy, the lips and the nostrils are enlarged, the mouth is big and it may reveal a thickened tongue. In mental make-up the individual shows cerebral torpor, irritability, somnolence, and occasionally there are frank symptoms of disturbed mentality. Then there may be such general manifestations as cardiac irregularity, a small and weak pulse, subnormal temperature, headache, dizziness, hemorrhages, albuminuria, and sometimes with an accumula- tion of fat at unusual sites. An operative myxedema occasionally develops after a too extensive removal of thyroid substance. The condition may appear in from three to six months, when it partakes of some of the symptoms just described. If the parathyroids also have been unwittingly removed, tetany follows. The progress here is not so rapid as in the preceding form, since other glands may act vicariously. Jelliffe, in a preliminary statement concerning “Hypothy- roidism and Tabes,” relates the circumstance of a woman who had been pronounced a tabetic by a number of phy- 598 NERVOUS AND MENTAL DISEASES. sicians, in whom there was found shooting pains, coming and going, loss of knee and ankle jerks, slight incoordina- tion, slight sluggishness of the pupils, difficulty in thinking, and marked asthenia. At first Jelliffe confirmed the diag- nosis, but a careful examination of the blood and the spinal fluid gave negative findings, and he then revised his diagnosis to that of a sub-myxedematous state. Institution of thyroid treatment caused a disappearance of the neuralgic pains, sluggish pupils, physical and mental fatigue, and a return of knee-jerks. The treatment of hypothyroidism consists in the giving of thyroid substance together with the administration of a small quantity of iodin. Gland implantation has not yet, in the human subject, proven successful, though there is the possi- bility that it may be helpful in the future. Hyperthyroidism. This condition arises from various causes and is a frequent accompaniment of menstruation. Toxic matter absorbed from the mouth or sinuses, or infec- tive substance from any part of the body, may provoke hyperthyroidism. Following severe emotional excitement, which acts directly upon the adrenals, there is often a hyper- function of the thyroid. One occasionally meets with a persistent thymus whose presence may be revealed by fluoro- scopic study, and this is sometimes a source of irritation to the thyroid. A minor degree of hyperthyroidism is common and usu- ally precedes for some time the pronounced symptoms of exophthalmic goiter, which, therefore, offers the opportunity of instituting treatment before the disease has advanced to a stage where an absolute recovery is not to be expected. For the early recognition of hyperthyroidism one should look carefully for a tremor, which symptom is fairly con- stant; the heart may show beginning dilatation, the pulse is slowed but little by assuming the recumbent posture, and there may be a noticeable pulsation of the thyroid; eye symptoms may be apparent, flushing is common, and the appetite is usually increased. There is a decreased sugar tolerance, feeding on thyroid substance promptly aggravates the symptoms, and there is a positive Goetsch test, which is based upon the fact that the thyroid secretion sensitizes THE ENDOCR1 NOPATH 1ES. 599 the sympathetic nerve endings to the action of adrenalin. The Goetsch test is an important diagnostic point in dis- tinguishing hyperthyroidism from incipient tuberculosis. As the disease advances it is recognized under the various names of Basedow’s disease, Graves’s disease or exophthalmic goi- ter, though occasionally the exophthalmos is wanting, as may be any other of the prominent symptoms. Heredity has some bearing and the disease is occasionally seen in stock Fig. 3.—Exophthalmic goiter. (From “Diseases of the Nervous System,” by Jelliffe and White. Third Edition. Lea and Febiger, Philadelphia.) where epilepsy develops. Abortive types are frequent. Ex- ophthalmic goiter is more common among females, but is infrequent after the third decade. The most striking feature is the prominent eyeballs, which give the patient the “tragic look.” The most characteristic symptoms are the exoph- thalmos, tachycardia, and tremor; then there occur cardio- vascular implication, skin and muscle symptoms, metabolic, gastrointestinal, genital and respiratory changes, together with manifestations in the psychic sphere. 600 NERVOUS AND MENTAL DISEASES. Goiter. This is usually present and it varies in size, usually bearing a definite relation to the intensity of the disorder. Rarely, it develops suddenly and sometimes the growth re- cedes. The enlarged and often symmetrical mass is soft, elastic, and from its increased vascularity pulsates freely, which upon auscultation yields a systolic bruit. In the late stage the goiter may become cystic, possibly atrophic, when myxedematous manifestations may appear. Cardio-vascular Symptoms. These are prominent. Dilata- tion of the heart may occur early and its tumultuous action is characteristic; often this leads to dizziness, redness of the surface, particularly of the extremities, and to precordial distress and psychic apprehension. Ocular Manifestations. The protrusion of the eyeballs may be unequal or one only may be involved. An infrequency in winking is observed, incomplete closure of the eyelids, and failure of the upper lid to move synchronously with the eyeball; often convergence is difficult, and even ophthalmo- plegia has been noted. Lowi has called attention to the frequent dilatation of the pupil upon the application of ad- renalin. The lack of protection of the eyeball leads to lacry- mation, conjunctivitis, and possibly keratitis with perforation. Photophobia and hallucinatory manifestations may be ex- perienced, and rarely an optic atrophy may be met with. Motor Manifestations. Tremor, which may be general, is an early and an important sign; usually it is fine but occa- sionally the more pronounced choreic or epileptiform move- ments are seen; muscular asthenia is present. Vasomotor and Secretory Manifestations. Irregular blushing and a sensation of heat is common; dermographia, epistaxis, urticaria, and circumscribed edema may occur. Often there is profuse and widespread perspiration, and this will give rise to an increased electrical resistance in the skin; then there may be albuminuria, and even glycosuria. Gastrointestinal and respiratory manifestations are sometimes encountered and menstrual irregularities may be experienced. Metabolic changes are observed, the patients becoming weak and emaciated. Mental Manifestations. These are important. The patient is emotional, depressed, and sometimes suicidal. An acute THE ENDOCRINOPATHIES. 601 and grave delirium may develop. Hallucinations and even delusions, usually of persecution, occasionally appear and a frank psychosis of the manic-depressive type has been described. The course of exophthalmic goiter is chronic, though a case is reported with death resulting in three days. The usual range is from a few months to many years. Treatment. All possible infective foci must be investi- gated. Rest in bed is in some cases imperative. On account of the iodin content, iodides must be avoided. In selected cases, x-ray treatments are of possible value. Bromides, belladonna and arsenic may afford relief. In aggravated cases the operative procedure of vessel ligation, or a partial ex- tirpation of the gland substance, sometimes proves beneficial. Parathyroid Disturbance. Two pairs of parathyroid glands are in intimate contact with the thyroid, hence the danger of injury or even of removal in operations upon the latter. In the event of such an accident to the parathyroids, the symptoms of tetany will follow. These glands concern themselves with calcium metabolism and perhaps their secretion exerts an inhibitory influence upon toxins within the body. Hypoparathyroidism gives rise to tetany, and some of the varieties described by Falta are traumatic, idiopathic (occu- pational), that due to disease of the thyroid gland, infectious diseases and intoxications, and the type that sometimes oc- curs during the period of maternity. In tetany there occur continuous or paroxysmal bilateral spasms, chiefly of the extremities, though most parts of the body and the face may be implicated. But seldom is there an attendant disturbance of consciousness. The disorder may be acute or chronic and it may be of a recurring type. The idiopathic form occurs epidemically in some European cities, where it appears among certain workmen—shoemakers and tailors—who are otherwise healthy. Occasionally there is hyperesthesia and sometimes the spasms are painful. The hands assume the obstetric position and the feet that of equinovarus. The face, tongue, neck, diaphragm, bladder and even the eyeballs 602 NERVOUS AND MENTAL DISEASES. may be implicated. In the more chronic types, vasomotor, secretory and sometimes trophic disturbances are seen. Cer- tain signs are quite characteristic of the disorder. Tapping over the facial nerve causes spasm in the muscles supplied (Chvostek). Pressure over large nerves and vessels causes spasm (Trousseau). There is a hyperexcitability to elec- trical currents (Erd). Also sensory hyperexcitability (Hoff- mann). Usually, the jaw muscles are not implicated and this offers an important differentiation from tetanus. The chronic cases may last for a few months and possibly recur for a few years. Prognosis is not unfavorable unless due to extensive parathyroid removal or to acute gastric dilata- tion, either of which may prove rapidly fatal. Treatment. Removal of the cause if this is possible. Medi- cinal salts of calcium should be prescribed, and foods con- taining such substances should be eaten. Parathyroid sub- stance may be administered and the antispasmodics employed in severe attacks. Suprarenal Disturbances. The two suprarenal bodies rest directly upon the kidneys. The medullary portion of these structures contains the chromaffin cells which secrete the important substance known as adrenalin; this substance is now being- made synthetically. The routine function of such tissue is said to concern itself with the regulation of emotional overactivity. Additional chromaffin cells are found along the carotids, the left coro- nary and superior mesenteric arteries, and also in parts of the sympathetic nervous system. The cells in these sites, and the occasional presence of accessory adrenals, probably account for the development of Addison’s disease without an involvement of the medullary substance of the adrenal glands; also, of extensive disease of the same structures with- out the appearance of the symptoms of Addison’s disease. The medullary and the cortical parts of the glands are some- what interdependent, but the activity of the latter tissue is not yet well understood. Loss of these glands leads to great emaciation, prostration, apathy, and a lowering of blood pressure and of temperature. An acute hypoadrenalism can be caused by hemorrhage into the medullary substance and THE ENDOCR1NOPATH1ES. 603 this may be followed by rapid death. The milder forms are recoverable. Chronic diypofunction of the adrenals for the most part re- veals itself as Addison’s disease which, generally speaking, is a disease of the third and fourth decades, and which usually develops upon a tuberculous basis. The disease often has a tumultuous course. At first there is a gradually developing asthenia—the patient is tired mentally, physically, and physiologically—and this state later leads to exhaustion. The blood-pressure is lowered and the output of urinary solids is diminished. There is a gastrointestinal atony lead- ing to stasis, nausea and vomiting. The pigmentation in the skin and in the mucous membranes is quite characteristic. This is brownish in color and is encountered chiefly on the unexposed surface or at points where pressure or irritation is most apt to occur. The hair is sometimes affected and while the whole body may be tinted, the most pronounced pigmentation is in the areas surrounding the nipples, about the genitalia, in the anal folds, and in the edges of the eye- lids. The disorder may be precipitate, with death ensuing so rapidly—as in the case of hemorrhage into the gland— as not to leave time for the discoloration to appear. Motor symptoms are common in the form of temporary paralyses, or myoclonic, epileptiform, and tetanoid spasms. Mental symptoms begin with apathy and inertia, later with delirium and confusion, possibly with a delusional phase, finally ending in coma and death. Treatment must be supportive and perhaps adrenal sub- stance should be administered. Adrenal hyperfunction of marked degree is usually due to the development of tumors especially in the cortex, which part of the gland appears to influence the growth of the body, causing the development of hair and inducing pre- cocity in the genital sphere. The most striking results of hyperfunction occur in children who prematurely and rapidly take on physical sex characteristics, but without a corre- sponding sex desire and certainly without precocious mental development. Sometimes, however, such activity is mani- fested in the adult, especially in the female, who then may show such a secondary masculine appearance, as the growth 604 NERVOUS AND MENTAL DISEASES. of a beard. The changes may have been such as to leave the real sex of the individual in doubt, so that some have been classed as instances of pseudohermaphroditism. It is believed that such individuals may indulge in the perversion of homosexuality. In the matter of treatment, organotherapy may be tried and a neoplasm might possibly require operation. Pituitary Disturbances. Terms used in respect to the anatomical division of this structure are somewhat confusing. The anterior lobe is now generally spoken of as the pituitary, and the posterior lobe as the infundibulum, while together they constitute the hypo- physis. The pituitary portion is much the more important and disturbances here give rise to more or less definite mani- festations, while its removal causes death. The activity of the pituitary is intimately concerned with growth of the body, particularly that of the bones and connective tissue, and the entire hypophysis seems able to come to the assist- ance of the thyroid, the testes and the ovaries when these organs lag in their activity. Hyperpituitarism leads to acro- megaly and gigantism, the latter beginning in early life and causing lengthening of the long bones. Acromegaly. The development of this disease is usually limited to middle life and it is commonly due to an adenoma or an adenosarcoma of the pituitary gland. The activity induced frequently causes changes in the thyroid, the gonads and the suprarenal cortex, so that a complication of symp- toms often results. Gradually a change comes over the face of the individual, so as later to render him unrecognizable. The superciliary and malar regions protrude, the nose is enormously enlarged, and the upper and lower jaws increase in size, thereby causing a spacing of the teeth. The tongue is enlarged and the mucous membrane thickened. The cla- vicles increase in size and a kyphotic spine is often seen early. The individual hairs of the head are thickened and there may be an enormous increase of hair on the body and the extremities. The hands and the feet broaden, and the fingers and the toes thicken. While in the beginning the THE ENDOCRINOPATHIES. 605 disorder may lead to hypersexual activity, later, the reverse is true. Impotence occurs in the male, with amenorrhea and dysmenorrhea in the female. A thyroid implication may show marked symptoms of hyperthyrosis, and the manifesta- tions of adrenal activity are sometimes observed. Carbo- hydrate tolerance is reduced and glycosuria is not infrequent. Later, the symptoms of intracranial pressure are sometimes present. There may be headache, vomiting, hemianopsia, disturbances in the visual field, papilloidema, and possibly blindness. There may be other cranial nerves besides the optic implicated. Pressure upon the crura cerebri would yield the familiar symptoms of pyramidal tract involvement, while pressure upon the uncinate gyri would cause the “uncinate fits” spoken of in epilepsy. Mental symptoms sometimes occur. An x-ray study usually discloses an enlarged sella turcica. In course, the disease is usually progressive, often ending fatally in from five to twenty years, though abortive types are sometimes encountered. Hypopituitarism is most common in children, but occasion- ally adults are affected, in the latter the disorder usually resulting from syphilis, a neoplasm, or following traumatism. The symptoms are commonly those of localized fat accumu- lation, together with a lessening of function in the genital sphere. Asthenia and somnolence are often present. There is a tendency to subnormal temperature, dry skin, loss of hair, slow pulse, lowered blood-pressure, and possibly epileptic seizures or a psychosis. The treatment of acromegaly is perhaps surgical. Hypo- pituitarism may possibly be benefited by an operation, also by the administration of pituitary substance, and perhaps by thyroid medication. Pineal Disorders. These are very infrequent. A tumor arising from this structure will cause some such symptoms as hydrocephalus, ocular palsies, a deposition of fat, and perhaps with changes in the genital sphere. Surgical relief is possible, but in this region an operation is very difficult as well as very dangerous. 606 NERVOUS AND MENTAL DISEASES. Testicular Disturbances. The structural activity of the male gonads is in the gam- etic cells, which give rise to the spermatazoa, and in the cells of Ledig—interstitial cells—which appear to be the active internal secretion producers. Today, much is written about the remarkable rejuvenating power of the interstitial tissue. The experimental French surgeon, Voronof, has supplied us with reports upon the lower animals that show a measure of success. Here, the sex glands from the same species were used. Sometimes the whole testicle was em- ployed, but generally it was a large fragment that was trans- planted, though in some instances only a small portion of the gland was used. Of the sites chosen for grafting, the subcutaneous tissues, the peritoneum, and the scrotum, the last yielded much the best results. Following such experi- mental work, the reports of this surgeon state that old, timid and decrepit rams have later become full of spirit, aggressive and belligerent, with a return of procreative power. Though highly desirable, testicles from the young of the human species are practically unavailable, so that Voronof is using for old men transplants from the higher simian apes. The condition of hypergonadism, with its heightening of sexual desire, leads to immoderate cohabitation and is some- times seen in the beginning of the manic phase of the manic- depressive psychosis and occasionally it is present in a developing paresis. Another phase of sexual hyperesthesia which may be observed in some men, is where they are so persistent in the sexual demands upon their wives as to compel submission to sexual intercourse during the period of menstruation, and the state not uncommonly leads to infidelity. Where the male becomes insatiate the condition is spoken of as satyriasis, which may be a degenerate trait, when it is more properly considered under sexual anomalies. In the human subject, the psychic element is a powerful factor in the sex life of the individual. A case recently re- ported by me was that of a colored man, who at eighteen years had sustained a severe injury to his testicles which necessitated their complete removal. Twenty-four years later he was charged with and was convicted of the offense of THE ENDOCRINOPATHIES. 607 rape. Presumably, he had been fairly active sexually for the intervening years. Such could not have been the cir- cumstance had he been castrated before puberty and had he been without the personal experience of sexual intercourse. Eunuchoidism (Acquired). The site of this disorder is probably in the interstitial cells of Ledig, with consequences comparable to those observed in the castrate, but in such individuals the testicles are pre- served. This condition may result from accident, or through the diseases of syphilis, gonorrhea, or tuberculosis. A study of case reports shows that a variety of symptoms may be present. Sometimes the external genitalia undergo atrophy, and the bodily contour may become similar to that of the female. Sexual desire is usually lessened, and the individual may show some weakening of his physical and his mental powers. The treatment of these disorders is very unsatisfactory. Ovarian Disturbances. It is stated that the ovaries contribute two definite internal secretions, one of which arises from the corpora lutea, and the other from the interstitial cells. The ovaries maintain an intimate association with the thyroid and a less intimate relation with the pituitary. Hypoovarianism. This condition is at times concerned with irregular, scanty, or suppressed menstruation, perhaps sterility, with varying degrees of sexual obtundity, and in the extreme may amount to frigidity, which is an embarrassing state beset with grave marital dangers. Hyperovarianism. Here, menstruation may be too fre- quent or too profuse. When sex hunger passes beyond nor- mal bounds, masturbation may be resorted to, the individual may be insatiate—a nymphomaniac—or she may stoop to the lowest depths of degradation and become a pervert. Nymphomania at times proves a very troublesome patho- logical condition, since by reason of the sexual act being less exhausting to the woman, her desire and activity may 608 NERVOUS AND MENTAL DISEASES. know but little abatement. Such individuals are always psychopaths and their insatiability is sometimes a feature of a psychosis, as in those who show more or less of a manic-depressive trend to their mental make-up. Women, the victims of this trait, may be given to exhibitionism. Occasionally, the disorder declares itself at the climacteric period, when it may become so pronounced as to necessitate placement in a detention hospital. Climacteric Disturbances. The phenomena incident to the “change of life’’ are practically those of slight hyperthyroid- ism and are probably due to the cessation of the restraining activity of the ovaries upon the thyroid, but usually such manifestations are not incapacitating and subside without untoward effects. However, in those individuals who earlier in life have been subject to hysterical or neurasthenic dis- turbances, pronounced symptoms may appear and an actual psychosis occasionally develops, which for the most part conforms to a melancholia or to the manic-depressive type of disorder. The common symptoms are exaggerated flushes, spots before the eyes, ringing in the ears, headache, fatigue, in- ordinate sweating, a tendency to faint, and an inclination toward obesity. Not infrequently, owing to a pelvic con- gestion, there is a lighting up of sex desire, which, however, usually subsides without special consideration but which, on the other hand, may be of such a violent nature as to require some hospital supervision. Sometimes the condition known as “surgical menopause” results from the removal of diseased ovaries. Here the symptoms are precipitate and are said to be somewhat more severe, when, in addition to removal of the ovaries, sacrifice of the uterus has also been found necessary. The Inflammatory Arthropathies BY JOHN A. LICHTY, M. Ph., M.D. Associate Professor of Medicine, School of Medicine, University of Pittsburgh. The Inflammatory Arthropathies. (The Arthritides.) INTRODUCTION. The inflammatory conditions of the joints have engaged the attention of the physician ever since the practice of medi- cine began. The earlier writers discussed practically all forms of joint diseases under the broad term of “Rheumatism.” It is an interesting chapter in the history of medicine which describes the evolution of ideas in relation to joint diseases. The term rheumatism came into use on account of the early notion that disease was due to a disturbance of the flow of the fluids or elements of the body. This idea was included in the humoral theory of disease. It was supposed that there existed a catarrhal fluid or “rheum” in the brain which flowed into the various parts of the body and caused pain. Wherever, therefore, any pain was experienced which could not be ex- plained readily by ordinary causes such as traumatism or sprain, especially if the pain was supposed to be localized in the bones and joints, it was called rheumatism. Unfortunately up to very recent times there has been this same tendency to refer to all obscure pains as of “rheumatic origin.” It was early in the seventeenth century that the renowned Sydenham first differentiated between the condition of the joints caused by rheumatism and those caused by gout. From this time on the development of our knowledge of the diseases of the joints was largely in two directions. The one pointed to- wards infection as the chief etiological factor, the other pointed towards metabolic change as the cause of the arth- ritides. The greatest impetus to, and the most convincing evi- dence of, the theory of the infectiousness of joint diseases was given by Cheadle in the latter part of the 19th century (1888) in his Harveian lectures upon the manifestations of the rheumatic state in children. This paper served to bring out 612 THE INFLAMMATORY ARTHROPATHIES. in great clearness the symptom complex of a disease—acute rheumatic fever—which heretofore had been confounded with the great group of the common arthritides. It was about this time that the greatest activity was evidenced by those who contended that joint affections were largely of metabolic origin. Among these were Haig and his predecessors and followers who taught that uric acid was the chief etiological factor. There can be no doubt that Cheadle and those who accepted his theories were influenced in their views largely by the new science of bacteriology which at that time was being applied to certain forms of disease. The possibility of stain- ing and culturing microorganisms as shown by Carl Weigert and others in the latter half of the 19th century opened up avenues of research which lead direct to the problem of the arthritides. It was this vantage ground which enabled Cheadle to speak with such prophetic certainty when he said, “The occasional epidemic prevalence, the variability of type, the incidence upon the young, the occurrence of tonsillitis, of en- docarditis, of pneumonia, of erythematous eruptions; the rapid anemia, the tendency to capillary hemorrhages, the implica- tion of joints, the relapses, the occasional supervention of hy- perpyrexia, the nervous disturbances, the specific power of salicylic acid, are all suggestive of an. infectious disease.” This marked the beginning of an entirely different concept of the diseases of the joints. Acute rheumatic fever was looked upon as a disease due to a bacterial infection in which the joint involvement was only a part of the manifestation. The new science of bacteriology was'thus called upon to aid in discovering the specific infection responsible for the disease. The inflammatory conditions of the joints other than those associated with acute rheumatic fever were supposed to be local conditions, due either to localized infection or to certain metabolic disturbances or both. However, with all the effort put forth since the advent of bacteriology a specific germ for acute rheumatic fever has thus far not been found. The work in this direction of Poyn- ton and Paine in England and of Rosenow and others in this country has been stimulating but not convincing. At present the attention of investigators is directed more particularly towards the joint affections which are not so definitely as- DISEASES OE THE JOINTS. 613 sociated with a systemic infection and yet are often loosely called “rheumatism.” The result of all these investigations is that our ideas of joint diseases are changing. The late Dr. John B. Murphy, who was a close student of the diseases of the joints, as he was of many other diseases, was of the opin- ion in his time, “that the day is not far distant when the terms rheumatism and gout will no longer be employed in our nomenclature.” The orthopedic surgeon, as well as the bac- teriologist, is in a measure responsible for the more limited use of the term “rheumatism.” Faulty posture, certain ab- normalities of weight, and certain definite principles of strain have been brought to the attention of the physician by the orthopedist with the result that there are fewer cases of rheumatism diagnosed and the salicylates are less frequently prescribed, all of which again shows the transition in view- point up to the present in the consideration of the arthritides. CLASSIFICATION OF DISEASES OF THE JOINTS. In the present transitional stage of our knowledge of joint diseases it is difficult to speak definitely or authoritatively of any classification. In certain affections the lesion may begin as an acute process, pass gradually through a subacute stage, and terminate as a chronic process. In others the lesion may begin as a chronic or subacute affair and never show any acute manifestations. Again in certain joint diseases the specific microorganism is apparently the essential and determining factor, as in tu- berculosis of the joints, while in others, as in the arthritis of scarlet fever, the microorganism is only an incidental fac- tor and seems to have very little determining quality as to the character of the lesion. In joint diseases there must also be taken into consideration such factors as trauma, sudden and acute, or prolonged and chronic; also the effect upon the joint of disturbances of blood and nerve supply, of nutrition and the effect of faulty posture. With the present progress of our knowledge it appears that it may not be long until all inflammatory conditions of the joints in whatever stage will be attributed to a more or less 614 THE INFLAMMATORY ARTHROPATHIES. specific microorganism, and other factors which have already- been suggested will be only considered as incidental or con- tributory. Until that time, however, a comprehensive classi- fication may be given somewhat as follows: 1. Infectious arthropathies (the arthritides). (/)) Incidental. (a) Occurring in connection with pyemia, septicemia, small-pox, measles, scarlet fever, typhus fever, typhoid fever, cerebrospinal meningitis, pneu- monia, dysentery, diphtheria, erysipelas, puer- peral fever, and influenza. (b) Rheumatic class; acute rheumatic fever, arthritic purpura, erythema nodosum. (c) Polyarthritis associated with focal infection, mul- tiple arthritis (rheumatoid arthritis, going on to arthritis deformans). (B) Essential. (a) Tuberculosis. (b) Syphilis. (c) Gonorrhea. 2. Traumatic arthropathies. (a) Chronic villous arthritis. 3. Static arthropathies. (a) Flat foot, sacro-iliac strain, etc. 4. Hemorrhagic arthropathies. (a) Hemophilia. (b) Scurvy. 5. Neuropathic* arthropathies. (a) Occurring in connection with locomotor ataxia, syringomyelia, etc. (b) Occurring in connection with Raynaud’s disease. 6. Congenital luxation of joints. ARTHRITIS IN THE ACUTE INFECTIOUS DISEASES. An acute inflammation of a former healthy joint may oc- cur during the course of certain of the well-known infectious fevers. In some, such as typhoid fever, due to a specific microorganism there may be an acute inflammation of the ARTHRITIS IN INFECTIOUS DISEASES. 615 joints, and yet the Eberth bacillus is rarely recovered from the joint; while in others, such as scarlet'fever and measles, in which the specific microorganism is not yet known there may be a similar complication of the joints with probably even a greater obscurity as to its cause. In other words, what definite information there is at hand as to the specific microorganisms responsible for certain in- fectious diseases does not in the least warrant the conclusion that the accompanying lesion in the joint is due to the same microorganism. There may be an' exception to this state- ment in the case of an acute arthritis associated with pneu- monia. In such cases the pneumococcus may be recovered from the joint tissue and not infrequently in pure culture. The acute infectious diseases complicated with occasional lesions of the joints are in their order of frequency about as follows: scarlet fever, pneumonia, typhoid fever, influenza, and erysipelas. In some of these the joint symptoms and the appearance of the joints are much like those found in an ordinary toxemia, or septicemia, or septicopyemia. The joint lesion may resemble even that of acute rheumatic fever, but the distinguishing feature is that in all of these infec- tions suppuration may occur and the joint may be perma- nently damaged, a condition which never occurs in rheumatic fever. Scarlet Fever. The joint complication occurs usually in the latter part of the course of the infection, or during con- valescence. The small as well as the large joints may be involved. Insofar as swelling, redness, and fixation, of the joint are concerned the appearance is almost the exact coun- terpart of rheumatic fever. However, the temperature is not so high, the pain is not so great, and there is not the characteristic sweating. Suppuration of the joints may occur, but usually the condition subsides without leaving any damage to the joint. Pneumonia. Soon after the pneumococcus was isolated as the cause of pneumonia, Weichselbaum reported (1888) a case of pneumococcic arthritis and referred to four cases which had been cited by Leroux from Grissollis Traite de la Pneumonie, 1864. This was the first case that had been worked up in detail. In 1902 Herrick1 reported four cases, 616 THE INFLAMMATORY ARTHROPATHIES. bringing the number then reported to fifty-two cases. Her- rick, in his comprehensive paper, concluded that the lesion occurs infrequently, but oftener in men than in women, and is usually monarticular, the larger joints being most fre- quently affected. The lesion may be only in the synovia or it may be more extensive and may be highly destructive to the joint. It may occur at any time during the course of a siege of pneumonia and may also occur late in the con- valescence. A pneumococcus arthritis may occur as an in- dependent process without there being a primary lesion in the lungs. This has been demonstrated by cultures taken from the affected joints. The writer has seen two cases of pneumococcic arthritis complicating lobar pneumonia. Both were of the knee and presented symptoms and signs of such an arthritis as may occur in the septicemia of an acute ulcerative endocarditis. The prognosis in these cases is always grave. When sup- puration is detected immediate incision and drainage should be done. The serous type, according to Herrick, may re- cover by aspiration, rest, and compression. Typhoid Fever, The joint affections in typhoid fever may be of an acute form occurring in the height of the fever or at any time during convalescence, or of a chronic form occurring late after convalescence. The chronic form occurs more frequently than the acute, though both occur rather infrequently. McCrae2 reports only eight cases in fifteen hundred patients with typhoid. The joints rarely suppurate. It usually occurs in the large joints and especially in the spinal column where it may produce rather unusual symp- toms, especially in the chronic form. The writer has seen only one case in the acute form. This patient had been discharged from the hospital after a mild course of typhoid with no complications. In two weeks he was readmitted on account of a pain in the lumbar region, and with a tem- perature of 102° F. After ten days of rest in bed the tem- perature subsided, and the pain and tenderness became localized about the second and third lumbar vertebrae. A fixation cast was applied before the patient was well. In 1893 and 1894, while on duty as resident physician at the Philadelphia Hospital, it was the writer’s privilege to ob- ARTHRITIS IN INFECTIOUS DISEASES. 617 serve two cases of chronic “typhoid spine” in the service of Dr. James Hendrie Lloyd, chief physician to the neurological wards. At that time this complication was looked upon as of nervous origin. Both patients seemed to have a definite deformity of the spine, which was bent like the half of a barrel hoop and compelled them to assume a characteristic- ally fixed decubitus. They sufifered severe girdle pains, which were interpreted as being due to certain changes in the ganglia of the posterior roots. McCrae3 reported four cases in which he demonstrated by x-ray that there was a bony change in the vertebrae. One of his cases had a paratyphoid infection. A curious manifestation of the joints in typhoid fever is that of the hips in older people. There is occasionally a spontaneous luxation of the hip joint. This was brought to our attention by Keen. Suppuration of the joints in typhoid fever is rare. Typhus fever is rarely associated with an acute arthritis. When it does occur it is no doubt due to an associated septicemia. Small-pox. In this disease there may occur a polyarthritis which is likely to become purulent as in a pyemia. The elbow joints are particularly prone to be involved. Influenza. Polyarthritis is mentioned by most writers as a common complication of influenza. There is no doubt that the incidence of joint pains and of stififness of the joints during the attack of influenza, and for some time after the attack, is high. It is one of the cardinal symptoms. How- ever, few patients show any evidence of acute or chronic arthritis. Among 547 acute cases of influenza which formed the basis of a report from the University of Pittsburgh School of Medicine,4 none had any complication of the joints. Several who had previously had chronic joint affections experienced a relighting of these processes. Erysipelas. Acute arthritis may occur as a complication. In an analysis of 1673 cases of erysipelas by Anders,5 only twenty cases of acute arthritis were noted. It is evidently a rare condition. Pyemia and Septicemia. The synovial membranes of the joints are as prone, or even more so, to become involved 618 THE INFLAMMATORY ARTHROPATHIES. as are the other serous membranes when there is a blood- stream infection from the microorganisms which are respon- sible for a pyemia or a septicemia. Sometimes the joint involvement is the first localized evidence of the general infection. It may have the appearance of the joint in acute rheumatic fever, but it is frequently of one joint only and the process has a tendency to go on to suppuration. The condition is usually fatal. The more chronic, or the mildly acute forms, under proper surgical treatment, frequently recover. Puerperal Sepsis. This is not infrequently associated with an arthritis. Many joints may be involved and the condition may easily be confused with acute rheumatic fever. The literature of some years ago gives evidence of this, as more cases of “rheumatism” complicating fever were reported then than now. The arthritis is usually of a large joint as of the knee, is not so often multiple, and not so fugacious as in acute rheumatic fever. It is usually of long duration and may lead to an ankylosis. In a woman who has had a gonorrhea the process may be nothing more than a gonor- rheal arthritis. Measles. Arthritis is a rare complication of measles. Other diseases, such as bacillary dysentery and cerebrospinal meningitis are also characterized by the infrequency of such a complication. ACUTE RHEUMATIC FEVER. This is an acute infectious disease of unknown origin, characterized by a more or less rapidly migrating poly- arthritis, accompanied by a characteristic fever and associ- ated frequently with an acute endocardial or myocardial change, or both. It is largely a disease of childhood and early adult life. In fact it was first definitely differentiated from the group of the ordinary arthritides by the distinctness of its symptom complex as manifested in children (Cheadle). It is a disease which is always present, but seems to be more frequent in certain years, and especially in certain months of the year. These are the late winter and the early spring months. It is also supposed to flourish in damp places ACUTE RHEUMATIC FEVER. 619 and in climates where sudden changes of temperature are likely to occur. It is therefore largely a disease of the temperate zone. On account of the difference of opinion with reference to the nature and cause of the disease, statistics vary greatly. Also because the disease occurs more frequently in some years than in other, and because it seems to be less frequent in those years when great epidemics (such as influenza) oc- cur, it is difficult to obtain dependable statistics. According to Lambert,6 who reviewed the Bellevue Hospital statistics from 1906 to 1919, the highest percentage of cases of acute rheumatic fever was in 1907, when 2.45 per cent, of 28,789 of the admissions to the hospital, or 706 patients, were thus afflicted. The lowest percentage was in 1919, when 0.521 per cent, of 37,632 of the admissions, or 190 patients, were thus afflicted. In the Mercy Hospital, Pittsburgh, among 9230 admissions, from June, 1920, to June, 1921, there were only thirty-three cases of rheumatic fever. These constitute about 0.36 per cent, of the admissions. In the Columbia Hospital, for the same year, among 3184 admissions (of which 693 were medical cases) there were only three cases. In both hospitals the incidence was even less during the years of the epidemic of influenza, 1917 and 1918. It is thus seen that acute rheumatic fever cannot be said to occur fre- quently, especially in hospital practice. In a family and consulting practice outside of the hospital the writer has seen only fifteen cases among about 23,000 patients suffering from all forms of disease. In all the statistics consulted, three rather interesting points were noticed: First, the dis- ease does not occur frequently; second, it varies in incidence in the different years; and third, it seems to occur even less frequently during years in which there is an epidemic, as for example during the influenza years. INCIDENCE. The specific cause of acute rheumatic fever' is not known. It is as much of an enigma from the standpoint of its bac- teriological origin as typhoid fever was almost one hundred ETIOLOGY. 620 THE INFLAMMATORY ARTHROPATHIES. years ago, or when it was first differentiated by Louis and his pupils from typhus fever. No definite microorganism has yet been isolated which will meet the postulates laid down by Koch as being absolutely necessary before any germ can be designated as specific for a certain disease. The work begun some twenty years ago by Poynton and Paine at first seemed convincing but according to most bacteriologists it has not stood the test. The “Streptococcus rheumaticus,” so called, does not receive the same consideration from the clinicians now that it did fifteen years ago. During the past ten years fresh impetus has been brought to the study of acute rheumatic fever as well as to diseases of the joints in general by the epoch-making work of Billings and Rose- now, from the standpoint of the so-called focal infections. And while the clinic and the laboratory have been greatly impressed with the apparently definite relation of infection, especially focal infection, to the inflammatory joints and other conditions, no specific microorganism has been found for acute rheumatic fever or for the arthritides in general. The conclusions of Swift and Kinsella,7 of five years ago, still seem to obtain, though an enormous amount of work has been done since their publication. They are as follows: 1. Cultures from the exudate aspirated from the joints in acute rheumatic arthritis have been uniformly sterile. 2. Non-hemolytic streptococci have been recovered in blood culture from less than ten per cent, of patients suffering from acute rheumatic fever. 3. Similar streptococci have been recovered from the active endocardial lesions in only half of the fatal cases of acute rheumatic fever. 4. From the above results it seems evident that no type of streptococci has been constantly associated with acute rheumatic fever. 5. We do not feel that the etiologic relationship between the streptococcus and acute rheumatic fever has been def- initely proved, but if the streptococcus is the etiologic agent in acute rheumatic fever, it is shown by means of cultural and immunologic studies that it is through various members of the viridans group, and hence no one member can be called the Streptococcus rheumaticus. ACUTE RHEUMATIC FEVER. 621 The search for the specific microorganism, though it has not resulted in positive findings thus far, has stimulated the clinician to a more careful study of suspected cases of acute rheumatic fever and the outcome is that diagnoses are made more carefully and the incidence, probably for this reason alone, is not so great. On the one hand, the cases of acute endocarditis which may be associated with mild joint pains, and pains from thrombi anywhere, are definitely classed as acute ulcerative endocarditis, and not as acute rheumatic fever as was previously the tendency; and on the other hand, cases of polyarthritis, subacute or chronic with acute ex- acerbations, are not so frequently diagnosed as acute rheu- matic fever as in the past. Until recently statistics have been unreliable. It has been suggested by Lambert6 that the apparent decrease in the incidence of this disease is due to the greater care which is now given to the teeth and tonsils and other possible foci of infection. This may be so, but the writer is inclined to believe that the more careful study of diseases of the joints on account of influences brought to bear by the pathologist and the bacteriologist as well as by the orthopedist, has developed a greater diagnostic skill and care, and that acute rheumatic fever is really not as frequent as it was formerly thought to be. Notwithstanding the negative results in the study of the causes of acute rheumatic fever, there is a general belief that a definite microorganism exists which is responsible for the disease. The writer is fully convinced of this, even though his many careful blood cultures made in undoubted cases of acute rheumatic fever have all been negative. This has been the experience of many other clinicians, of which the literature bears abundant evidence. It has always been a question upon which there has been a diversity of opinions, as to how the microorganism, whatever it may be, gains ac- cess to the body. The general belief is that it enters the blood-stream through an acute local infection somewhere in the upper respiratory tract. This infection may be so mild as to escape attention or it may be so severe as to obscure the early evidences of an acute rheumatic infection. The tonsils and sinuses are frequently involved in such a local in- 622 THE INFLAMMATORY ARTHROPATHIES. fection and form apparently the starting- point of the general infection. The organisms isolated from such foci have produced joint diseases—polyarthritis, and also endocarditis in the lower animals—but this is not definite proof that they cause acute rheumatic fever. No doubt the reason for the almost universal belief that acute rheumatic fever is due to a specific microorganism is that it is in accord with the course of acute infectious dis- eases in general. But there is a wide difference between declaring a disease as being of specific origin from a clinical standpoint and designating a specific microorganism accept- able to the bacteriologist as the only cause of that disease. Acute rheumatic fever occurs more frequently in the male than in the female. It is no longer considered so strictly an hereditary disease. This again is no doubt due to the fact that the clinical conception of acute rheumatic fever is becoming more definite, being definitely differentiated from gout and other joint affections which seem to prevail in families. The character of the diet has very little affect upon rheu- matism from an etiological standpoint. It is largely a dis- ease of the temperate zone and where sudden changes of temperature are likely to occur. It seems to occur more frequently when there is a state of subnutrition or of mental strain. If to these are added exposure to cold and wet, practically all the conditions necessary for the onset of an acute infection are present. A previous attack is always conducive to recurring attacks. There is apparently no immunity established. Subsequent attacks are, however, often not so severe as the initial attack. MORBID ANATOMY. The most characteristic lesion of acute rheumatic fever is in connection with the serous membranes of the joints. The synovial membranes and the sheaths of the ligaments are generally also involved. The synovial fluid becomes turbid but never is purulent. Another striking characteristic is that during the convalescence, the reddened and swollen joints resume their normal color and contour, leaving ap- ACUTE RHEUMATIC FEVER. 623 parently no trace of the profound infection. After repeated invasions, however, the joints may become somewhat im- paired. The endocardium, especially of the mitral valves, is frequently involved. The pericardium, the myocardium, and the coronary arteries, also may show changes due to the profound infection, or to repeated mild infections. When the endocardium is affected the lesion is usually of a vegetative nature located at the extreme edge of the valve leaflets. In its location it differs from that of syphilis and other infections which commonly produce a sclerosis at the base of the valve leaflets. In a case followed by the writer to autopsy this difference was strikingly demonstrated. There was a positive Wassermann and the lesion was ap- parently at the aortic orifice, and was supposed to be due to lues. At autopsy luetic plaques were found in the arch of the aorta and there was a definite sclerosis at the bases of the aortic leaflets, evidently of a luetic origin, but the edges of the valves contained fresh vegetations from which a pure culture of the viridans group was obtained. There may also be changes in the wall of the aorta, of an inflammatory nature, as was observed by Klotz.8 He calls attention to the pathological lesions in the case of a six-year-old boy with acute rheumatic endocarditis, in which he found at autopsy a saccular aneurism of the ascending arch of the aorta. According to his observations the lesion is usually in the outer portion of the media and adventitia. Death due to rheumatic fever is most frequently a cardiac death, but it occurs many years after the acute infection has spent itself. The mechanical difficulty under which the heart must perform its function after valvular lesion has been es- tablished leads to well known myocardial changes. But these myocardial changes may also occur in later years, long after the acute infection is spent, independent of endocardial and pericardial lesions. This may be explained by a latent subinfection of the myocardium direct. This is of extreme importance and should always be reckoned with when con- sidering the prognosis of a case which presents no evidence of valvular lesions but in which there is a history of previous attacks of acute rheumatic fever. Hence, while the interest and concern of this disease in childhood lies largely in the 624 THE INFLAMMATORY ARTHROPATHIES. direction of diagnosis, in adult life or in old age it lies decidedly in the direction of prognosis. The lungs are rarely involved in acute rheumatic fever, except as they are affected secondarily by the changes due to cardiac insufficiency. The pleura may be involved occa- sionally, as serous membranes elsewhere are affected. An effusion into the pleural cavities is occasionally found. The kidneys do not give evidence of any specific changes except such as may be found in cases of pyrexia ordinarily. Later changes resulting from a chronic endocarditis due to acute rheumatic fever are not a part of the acute rheumatic infection. It is rather interesting to note that the so-called “rheu- matic iritis” occurs very seldom during an acute attack, and often the history of a definite attack of acute rheumatic fever cannot be obtained. Certain subcutaneous nodules found especially in children suffering with acute rheumatism are supposed to be definitely characteristic of this disease. In older individuals this lesion may not appear at all. Histological examination of these nodules reveals a mass of spindle shaped and round cells. Nodules similar to these may be found in migraine, in chronic polyarthritis, and in gout. They are therefore not pathog- nomonic signs of acute rheumatic fever. Similarly there may also be found certain cutaneous manifestations. These are the various forms of erythema—marginatum, papulatum, and nodosum. Rheumatic purpura is a striking skin mani- festation which is always looked for and when it appears is usually considered as evidence of the gravity of the dis- ease. These also may be found in various other infections, especially in acute ulcerative endocarditis, or in blood-stream infections. The writer recalls a striking case of posterior urethritis of Neisserian origin which developed into a so- called gonorrheal arthritis of acute form. Before the patient died there appeared an intense purpuric rash, beginning in the region of the right shoulder and finally, just before death, covering almost the entire body. These skin mani- festations are also found when there is no evidence what- soever of a systemic infection. Erythema nodosum usually occurs along the spine of the tibia and on the forearm and ACUTE RHEUMATIC FEVER. 625 dorsal surface of the hands. It usually is accompanied with severe localized pain which may have no relation with the joints. The onset may be abrupt and sudden, accompanied by a decided chill. This is followed by a fever, and finally by pain in one or more joints. Redness and swelling with immobility of the joint soon appear, and this sequence passes from joint to joint until every joint in the body may become involved. The distribution is not symmetrical. The pain is severe to the extent of producing a helplessness amounting almost to a paralysis. The process may subside in a joint and later during the same attack there may be a recurrence in the same joint. When the disease has run its course the joints are left intact without any ankylosis. The temperature does not run a definite course. It may be of a hectic type. The height of the temperature furnishes no evidence of the severity of the attack. With the elevation of the temperature there is usually a profuse sweat. This at first is sour smelling and produces a characteristic “rheu- matic odor.” The pulse rate rises and falls with the tem- perature. It varies also with the extent and severity of the complications of the heart. As the disease progresses the patient becomes pale. This pallor is not always, especially in the early stage, accounted for by an actual anemia, for the hemoglobin and the erythrocytes may not be particularly lowered. The leucocytes are increased to 12,000 and 14,000 or more per cubic millimeter, the increase being largely in the polymorphonuclears. The pallor early is due to the intense pain, the consequent loss of sleep, and the profuse perspiration. Later in the disease there may be a marked secondary anemia. Blood cultures, as stated before, are al- most invariably sterile. The urine is concentrated, as one would expect it to be in a febrile disease with profuse perspiration. The evidence of a nephritis is rarely present. The course of the disease is usually over a term of weeks or months rather than days. One attack does not establish an immunity; on the other hand, the patient seems to be rather predisposed to subsequent attacks. After an attack SYMPTOMATOLOGY. 626 THE INFLAMMATORY ARTHROPATHIES. there may occur, in a short period of time, another attack, mild or severe. COMPLICATIONS. Next to the serous membranes of the joints the heart is most commonly affected. Endocarditis, especially at the mitral orifice, is the most frequent lesion. The aortic orifice may occasionally be infected, and this should always be kept in mind when dealing with an aortic lesion. The usual in- terpretation of aortic valve lesion is that it is of luetic nature. Considering the frequency of rheumatic endocarditis as com- pared with syphilitic involvement of the heart, it can be said that a rheumatic lesion at the aortic valves is not in- frequent. While the lesion is acute, it is, after all, different from the condition found in acute ulcerative endocarditis— “malignant endocarditis.” From acute rheumatic fever the patient usually recovers, though with a damaged heart; from ulcerative endocarditis there are few, if any, recoveries. Rheumatic endocarditis occurs most frequently in children, but it is surprising how often it produces only a slight change of the heart in the course of the fever, is apparently recov- ered from, and is not considered to have been of any conse- quence until in adult life when there appears a cardiac decompensation. Often also in the course of a general examination, as for insurance or for military service, a car- diac lesion may be unexpectedly found—the evidence of an endocarditis which occurred years before. The pericardium is frequently involved, particularly in children and in early adult life. The myocardium is probably also involved at the same time but the evidence of its presence and extent is not so marked until in later adult life. Chorea is occasionally present, especially in children, and it seems to occur more frequently when the rheumatic attack is mild, or sometimes long after the acute attack. It is not uncommon for chorea to appear in a child as the first recog- nized evidence of a rheumatic infection. The history of such a case may bring out the first intimation that a previous sore throat or that previous vague pains have been experi- enced. ACUTE RHEUMATIC FEVER. 627 Severe headache is sometimes experienced and may be- come a serious complication. It is more likely to occur when there is a hyperpyrexia. Occasionally this is the forerunner of cerebral disturbance such as coma and convulsions. PROGNOSIS. The disease is rarely fatal, and yet in its complications it may bring about certain conditions which definitely shorten life and determine the cause of death. This is espe- cially true in those cases in which endocarditis has been a complication. Because it is the most frequent cause of simple endocarditis, the prognosis, while good for the im- mediate attack, may after all be relatively bad. There has been no death in the past five years from acute rheumatic fever at either the Mercy or the Columbia Hospitals, with an average annual admission of over 12,000 patients suffering from all conditions and diseases. DIAGNOSIS. This is usually not difficult, especially if it is an acute case and if there is the history of a preceding slight sore throat, of exposure to cold and wet, and of previous attacks. The symptom complex which is almost pathognomonic is as follows: Sudden, rather severe pain in a joint with red- ness and swelling, the same process in the course of a day or so in other joints, rarely symmetrical, high fever, rigor, rapid pulse, acid sweats, subsidence of the symptoms with the administration of the salicylates, followed by great pros- tration and a return of the joints to the normal. To this combination of symptoms there may be added, in nearly half the cases, those of an acute simple endocarditis. It is necessary to differentiate from an acute polyarthritis, also from arthritis due to infectious fevers, and from gonor- rheal rheumatism and simple pyemia, or septicopyemia. These joint conditions are discussed more definitely under their separate heads, but it may be said in a general way that in none is the general systemic infection so evident as in acute rheumatic fever. The pulse and temperature are not so high, there is not the same tendency to sweating, and 628 THE INFLAMMATORY ARTHROPATHIES. the joints (which are affected symmetrically) tend to show permanent deformities. Acute rheumatic fever has been considered by some as a form of pyemia. The two conditions have, however, very little in common. In pyemia there is a septic focus in an active state with apparently no wall of defence about it to protect the healthy organism. The absorption is direct into the blood-stream or from the lymphatics into the blood- stream, and multiple secondary foci originate. These are not distributed particularly in relation to the joints, but may occur anywhere, especially in the liver, the lungs, and the pericardium. The secondary foci are purulent, and the condition is rapidly fatal. It may at first be difficult to differentiate from an acute ulcerative endocarditis with septic emboli, especially if these occur in or near the joints. These emboli may occur in any part of the body but are not as likely to occur in the large joints. They frequently occur in the spleen, leading to en- largement which is uncommon in acute rheumatic fever. The courses of the two diseases are entirely different, in one there is recovery, in the other death. It should not be difficult to differentiate from arthritis deformans, and yet in the early stages, the polyarthritis, with the occasional flare-up of a joint, may be for a time confusing. Acute rheumatic fever leaves no deformities and does not lead to ankyloses. There should also be no difficulty in differentiating from gout because of the peculiar constancy of the location of the lesion in the great toe, and because of the age and the absence of the characteristic fever and sweats. TREATMENT. This resolves itself into prophylactic and curative measures. Prophylaxis. The prophylactic treatment of acute rheu- matic fever is of the utmost importance. When the disease has once begun, comparatively little can be done to change its course or to prevent the grave complications. The im- mediate comfort of the patient is then the chief concern. Complications may arise regardless of how great the care exercised, so also may recurrences occur regardless of every precaution. ACUTE RHEUMATIC FEVER. 629 The prophylactic measures to be instituted are as follows: The individual should be warmly clad, and should avoid be- ing chilled when there is changeable weather. The feet and ankles should be kept warm and dry. There are certain damp localities in which people live and work which should be avoided if possible. Overeating should be avoided, and the bowels should be kept regular. The patient should drink plenty of water. If the patient has a tendency to take cold, he should have the upper respiratory tract carefully exam- ined by a competent nose and throat specialist. If the tonsils are diseased, or only “suspicious” of disease, they should be enucleated. Also infected sinuses should be looked for and cleaned up. Other foci of infection should receive the same consideration, but the tonsils should receive par- ticular attention. By following the above directions, in many cases the attacks may be avoided. There is as yet no specific vaccine against the disease, but should one eventually be discovered the same prophylactic care will, no doubt, still be necessary. Active Treatment. After the disease has once begun, the patient should be put to bed immediately and kept there until the temperature has been normal and the swellings have subsided for at least two weeks. There should be no exception to this. Patients might be allowed to get up sooner providing there has been no evidence of heart com- plication, but sometimes the heart sounds seem normal for a considerable time after the temperature has subsided and later the evidence of an acute endocarditis may appear. The patient should be kept warm and the joints handled or moved as little as possible. Sometimes fixation of the joint with a light, easily removed splint, gives great comfort. The de- sired warmth may be obtained by putting the patient between blankets, and applying hot-water bags or electric pads. Woolen bandages or raw wool should be applied to the joints. The nightgown should be changed frequently when there is profuse sweating. Application of medication to the joints is of little value. The liniments which have been used are valuable largely for the amount of alcohol they contain and for their soothing and convincing odor. Fre- quent general warm alcohol rubs are agreeable during the 630 THE INFLAMMATORY ARTHROPATHIES. height of the fever. The local application of a hot pack of a saturated solution of sulphate of magnesium, or of normal salt solution, or boracic acid solution, is agreeable, especially if the pack is firmly applied and covered with oiled silk or waxed paper. It is doubtful, however, whether more is gained from such applications than the warmth and fixation which they afford to the joints and tissues. The joints should be protected from the weight of the heavy bedding by suitable supports. Massage is harmful in the early stage of the disease; later it may afford considerable comfort to the patient if it is properly administered. The rubbing and kneading should not be so vigorous as to pro- duce pain, and it should not be accompanied by Swedish movements. In fact there is such a danger of delaying recovery by too vigorous massage that it is safer not to use massage at all. Medication. When the diagnosis is once made there is nothing gained by allowing the patient to suffer pain for want of proper and sufficient medication. The salicylates are almost a specific for this condition. They should be given at once and in large doses. Sodium salicylate is the preparation most frequently given. Other preparations, such as salicylic acid or strontium salicylate, may be given, but they possess no advantages over the old reliable sodium salicylate. It can be given in from ten to twenty grain doses by the mouth, dissolved in a glass of water, every two hours, until the pain is relieved and the temperature is normal. The contraindications to this medication are, tinnitus aurium, gastric intolerance, and kidney irritability. The first two are fortunately not frequently met in severe cases. It seems that the patient who does not have the severe pains, for which the salicylates are often used in a rather desultory way, is most likely to experience tinnitus or gastric irritability. The writer has seen many patients who have attributed certain gastric symptoms to the use of salicylates for “rheumatism.” Almost invariably it was found that the patient had not been confined to bed, had had no temperature, or redness and swelling of the joints, and had not taken large doses. Whereas the patient with a real severe attack after the ACUTE RHEUMATIC FEVER. 631 prolonged use of large doses rarely complains of gastric dis- turbances. As stated before, the evidence of kidney irritation is not so great in this disease as in other febrile infections, such as typhoid, for example. Even with the large doses of sali- cylates the writer has not seen any greater incidence of albumin, casts, or blood, than is found in typhoid fever, nor has the subsequent history of his cases shown the evidence of kidney injury. Some of the cases in which large doses of salicylates had been prescribed have been followed for nearly twenty years with no evidence of nephritis. It is necessary for the patient to take large amounts of water when the salicylates are taken. Sodium bicarbonate is usually given in conjunction with the salicylates. No satisfactory reason has yet been given for this combination. It may be that it helps to prevent or to overcome an acid- osis. It has been said of the renowned clinician and author, Dr. Robert Bartholow of Philadelphia, that he declared he cured his patients by giving them lemons and oranges freely. It is possible that these had the same effect as bicarbonate of soda, or even a better effect, in overcoming the acidosis which accompanied the high fever so often associated with acute rheumatism. It seems that the patient is able to take larger doses of the salicylates and with greater comfort when bicarbonate of soda is added. The salicylates may be given per rectum, if the stomach is in- tolerant, but this is very seldom necessary. The action of the salicylates in acute rheumatic fever is not known. It is generally accepted that the salicylates are our best— probably our only—intestinal antiseptic, but whether this action is on the bowel content or indirect through stimu- lating biliary secretion, is not definitely known. It may be that the intestinal tract plays a greater role in the causa- tion of acute rheumatic fever than is at present known, and it is possible that this effect of the salicylates upon intestinal content may be the reason for its well known value in acute rheumatic fever. In very severe cases the action of the salicylates may not be sufficiently prompt to secure the desired results. 632 THE INFLAMMATORY ARTHROPATHIES. Under those circumstances a hypodermic of morphin may be given from time to time in addition to the salicylates. If only to induce sleep, morphin should be given. Occasionally a case is found which will not be affected by the salicylates, even in large doses. In these the writer has used successfully cinchophen, a preparation which has been on the market for a long time under the trade name of “atophan.” Atophan, when first introduced, was strongly recommended as a uric acid eliminant. It has been used largely in gout and in the gouty diathesis. According to some authors it has an irritating effect upon the kidneys. In the writer's experience with cinchophen he has not been able to determine that it has any deleterious effect upon the kidneys, or an effect different from that of the salicylates. Hanzlick and his colleagues,9 in a clinical study in which cinchophen and other remedies were compared with the salicylates as to the therapeutic efficiency, concluded that their therapeutic effect is about the same, the toxicity of one is no greater than of the other, and that the renal injury is somewhat less after cinchophen administration than after the salicylates. Other medication than that which has been mentioned is of very little value. The iodides are given at times, but unless there is that condition present in which the iodides are indicated, namely, lues, they will be of no value. On account of the anemia which usually accompanies or fol- lows the attack, iron and arsenic in various forms may be given. The preparation of arsenic in the form of cacod- ylate of sodium is satisfactory in the convalescence of these cases. It can be given in three-fourths of a grain or three or five grain doses, intramuscularly, every second day for twelve to sixteen doses. It is particularly necessary to watch carefully for the evidence of arsenical poisoning when administering the remedy in this way. Other measures, such as vaccines, and foreign proteins, may be mentioned only to remind the reader that they are of no value in acute attacks and their indiscriminate use may do harm. In considering joint affections, such as poly- arthritis, especially chronic, these preparations will be discussed. ACUTE RHEUMATIC FEVER. 633 It has already been suggested in the consideration of prophylactic measures that foci of infection, such as dis- eased tonsils, should be removed. The question arises, should these be disturbed during the height of the infection? Two dangers are confronted when considering operative treatment: First, the danger from the operation itself, the anesthetic, and the nervous shock. These are factors which are of greater or less importance, depending upon the indi- vidual case. It is a question of judgment after all the avail- able facts are in hand. Second, the effect upon the course of the general infection when a focus is disturbed. This can scarcely be determined beforehand. It is the opinion of the writer, from a large experience in dealing with foci of infection in the chronic arthritides, that to disturb such a focus in an acute stage is hazardous. After the acute infection has subsided the course to pursue is a very plain one, that is, all questionable foci should be cleared up so as to prevent, if possible, a recurrence. This is as necessary in the adult as it is in children. The question often arises as to what can be done spe- cifically to prevent the grave complication of acute endocar- ditis. One can truthfully say, insofar as our knowledge of the disease goes, nothing more can be done than what has already been mentioned in a general way. However, one point cannot be overestimated and that is the importance of absolute rest during the attack and of prolonged modified rest during convalescence. The rest should be begun as soon as the slightest temperature is detected, or the slightest joint disturbance is noticed. Diet. The dietetic measures which should be established in the treatment of acute rheumatic fever are practically those which obtain in the treatment of other infectious dis- eases accompanied with fever. The diet should be liquid at first, and later—with improvement—semisolid, light, and later, full diet. The caloric value of the diet should be kept as high as possible. In this way complications and prolonged convalescence may be avoided. On account of the confusion which exists in the use of the term “rheumatism” especially in its relation to gout, there is a great tendency to deprive patients of such ordinary 634 THE INFLAMMATORY ARTHROPATHIES. food as goes to make up the bulk of the calories of a daily ration. Some will proscribe one class of foods, such as the citrous fruits; others another class, as the carbohy- drates, and still others the highly nitrogenous foods. If the physician is not aware of this, the patient soon will realize that he really has nothing upon which to subsist. The in- dication for high caloric feeding is as definite in the acute stage of rheumatic fever as it is in typhoid fever, and the results are as satisfactory. After the fever has subsided the patient should be on a light diet such as is indicated in convalescence, but the caloric value of the diet should be maintained at a high level. When the patient becomes am- bulatory, a full, well balanced diet should be prescribed, and a good state of nutrition established so as to raise the re- sistance against any future infection. It goes without saying that the patient should be induced to drink water freely at all times, a matter which is of great importance but is frequently neglected. ARTHRITIS DUE TO CHRONIC INFECTION- POLYARTHRITIS. Multiple Secondary, Including Rheumatoid Arthritis and Arthritis Deformans. This is an affection of the joints characterized by rather sudden and repeated acute or subacute inflammatory re- actions occurring symmetrically which may result in a more or less permanent disturbance of function of the joints on account of the associated pain and swelling and the resulting deformity. The disease process may involve all of the tis- sues which constitute the joint. The soft tissues are affected first, beginning in the synovial membrane. It is entirely distinct from acute rheumatic fever, which is rarely, if ever, followed by permanent swelling and deformity. It may, however, be a sequel of repeated attacks of acute rheumatic fever and in this way produce a confusing picture. The distinction between arthritis due to a chronic focal infec- tion—multiple arthritis or rheumatoid arthritis—and arthri- tis deformans, so-called, is not so definite as is the distinction between it and acute rheumatic fever. In fact it is some- ARTHRITIS DUE TO CHRONIC INFECTION. 635 times quite difficult to differentiate between the two chronic conditions, and it seems to be the present trend of opinion that the difference lies only in the extent and chronicity of the lesion. Arthritis deformans will therefore be considered only as an advanced or unusual stage of polyarthritis, and the term “rheumatoid arthritis” will be dropped as obsolete. The arthritides due to chronic infection, of course, do not constitute a disease in themselves; they are only the evi- dence of an infection which has gained access to the body somewhere and has localized at one or more definite points. While not a disease as such, the condition has so many points in common with systemic disease, that one may refer with considerable reason to its etiology, incidence, pathology, symptomatology, diagnosis, and such other elements which go to make up a disease picture. ETIOLOGY. The cause of this condition, as its name indicates, is a chronic infection due to certain microorganisms or types of microorganisms which have in some way gained access to the body tissues. There are no specific microorganisms, but a streptococcus or a staphylococcus, with its various strains, is most frequently suggested. Predisposing Causes. Certain predisposing conditions usu- ally combine to determine the incidence, locality and the extent of the joints involved. Among these are: Age. It is largely a disease of middle life and of old age. In this respect it is in marked contrast to acute rheumatic fever, which is a disease of childhood, or youth, or early manhood. While the foundation of the condition may be laid in early life, the manifestation in the joints comes in later life. It is the “rheumatism” of the old man, and un- fortunately is too often looked upon and treated as rheu- matism. It is probably the most frequent and deciding factor which marks the advance of age, for it is often re- sponsible for the beginning of the unsteady gait, the stooped shoulders, the lack of agility, the awkwardness of movement in general, and the disappearance of the freshness of vigor and health which otherwise might continue through middle life. 636 THE INFLAMMATORY ARTHROPATHIES. Sex. The incidence in males and females is about the same. In one hundred and ninety-two private cases of which the writer has records, however, there were eighty-one males and one hundred and ten females. It is possible that the greater frequency of infection of the pelvic organs in women will account for at least some of this difference. Hospital statistics as a rule are not reliable in establishing the inci- dence of disease from the standpoint of sex, because from the nature of things there are usually more men than women in a general hospital. Women will be more likely to take care of themselves when they are taken with any sickness, while men promptly seek the hospital. Heredity. There is apparently considerable ground for con- cluding that arthritis is hereditary. If it can be considered as such, it is very likely because certain conditions which seem to be large factors in the causation of a polyarthritis are more frequently found in certain families than in others. Among these conditions is particularly that of hyperplasia of the lymphatic tissues, such as the tonsils and certain glands in the genitourinary and the gastrointestinal systems. This tendency seems peculiar to certain families and is car- ried from generation to generation. Certain habits of eating and drinking, as well as of body hygiene, conducive to local or systemic infection, are no doubt carried from generation to generation and in this way the condition may appear to be hereditary. It is not the disease but the tendency towards the disease that is transmitted. Climate. Like acute rheumatic fever it is a disease ap- parently more common in the temperate zone, though there are no statistics which directly bear this out. Sudden changes in temperature which characterize the climate of the temperate zone and are conducive to colds no doubt are also responsible for fresh infections of the joints and for acute exacerbations of previous infections. Occupation. Individuals who are exposed to dampness and cold are particularly susceptible to joint affections. The writer has seen a number of patients who entered the hos- pital suffering from polyarthritis, who gave their occupation as mining engineers, “pit bosses,” or “coal diggers.” In- dividuals thus employed experience sudden changes of tern- ARTHRITIS DUE TO CHRONIC INFECTION. 637 perature when they pass from the warm atmosphere of the coal pit to the outside atmosphere; especially is this true in winter time. The coal miners in particular who do heavy labor in the pit, causing considerable perspiration, are in- clined to wear thin clothing while working, and later when they emerge from the mines thus scantily clad they are susceptible to infection. The joints affected in these cases are more frequently the large ones, such as the knees, the hips, the shoulders, and the lumbar spine. This is due very likely to the fact that the coal miner usually works in a stooping or crouched position, because of “shearing” and undermining, and because many times the drift is low, neces- sitating constant stooping while working. Men who work in places of excessive heat, such as before blast furnaces or in steel mills, where frequent “shifts” are made, are likely to suffer from joint diseases. Nutrition and Hygiene. It might be concluded from the above description that heavy physical work is the larger factor in determining the incidence of the arthritides. Such is, however, not the case. The writer has seen a large group of individuals not engaged in physical labor who seemed to have brought on the lesions apparently as the result of under- nutrition, mental strain, and bad hygiene. This is particu- larly true of a certain class, such as college students, clerks, secretaries, telephone operators, and others. A college stu- dent who is “working his way through” will often deny himself both sufficient food of a wholesome quality and variety and the proper amount of exercise, thus diminishing his body resistance until an infection, which otherwise might be of little significance, occurs and an arthritis is the result. Not the least factor in such an instance is that of worry on account of the uncertainty of success in class work, stu- dent life, and life as a whole. These individuals rarely allow themselves vacations or that diversion which is necessary for healthful existence. The lack of proper nutrition and of sensible hygiene is not always the result of the want of sufficient means to provide them. The patient afflicted with arthritis not in- frequently makes a diagnosis of his own—it is usually “rheu- matism”—and places himself upon an unnecessarily rigid 638 THE INFLAMMATORY ARTHROPATHIES. diet, and a taxing regime, leading to subnutrition and loss of general health. It would be of inestimable value to any community if sufficient propaganda could be put forth to teach people that neither acute rheumatic fever, nor poly- arthritis of any type are nutritional diseases. This will be discussed more fully in the treatment of the disease under consideration. Traumatism. The relation of traumatism to diseases of the joints is of considerable importance. Whether traumatism without a secondary infection can of itself produce a lesion of the joint which can be rightfully called an arthritis, is an open question. It is of more than academic interest. An injury of a joint may be of such a nature as to carry with it into the deepest structures the elements of infection which, under favorable conditions, may go on to a stage of complete ankylosis, entirely disabling it. This is, however, not the kind or degree of traumatism in mind when discussing the relation of traumatism to diseases of the joints due to chronic infection. The traumatism considered as etiologic may be looked upon as of two dififerent forms. The first is that which may be sustained from without, or externally, without such a break of the integument as might lead to a local infection. The second is such traumatism as may come from within, as by faulty posture or by other improper use of the joints. In both of these conditions the infecting organisms must necessarily already have been present in the joint tissues. Its relation to the disease process is the same as though no traumatism had occurred. The infecting micro- organism lies dormant, as it were, in the tissues, ready, how- ever, for the conditions to arise which favor its propagation. It is the “latent infection” described by Adami.10 “For months, and it may be for years, pathogenic bacteria may persist in the tissues or cavities of the body, setting up no disturbances, but capable at any moment of doing so.” Or the traumatism may light up a “subinfection,” also described by Adami and McCrae as indicating “a slight degree of in- fection, such as is expressed by the presence of bacteria in the blood, which are not potent enough to cause gross symp- toms of infection, yet which do actually wear out the cells whose duty it is to combat with and kill them.” ARTHRITIS DUE TO CHRONIC INFECTION. 639 A good example of the effect upon the lesion of trauma- tism from without may be seen in the early stages of a poly- arthritis beginning in the hands and wrists. Almost always the joint lesions of the right hand are more advanced than those of the left. This is without doubt because the right hand is used more than the left and sustains the brunt of the traumatisms which go with the ordinary use of the hands. In a left-handed individual the opposite condition maintains. The writer has under his care a patient suffering with a chronic arthritis who, in his work as a wood carver, uses a chisel which he pushes into the wood by applying violently the palm of his right hand to the handle of the chisel. The metacarpal joints of the right hand are con- siderably enlarged while those of the left are only slightly enlarged. His teeth and tonsils are infected. A good example of the effect of traumatism from within may be noted most any time in the obese individual whose weight is out of proportion to the bony frame, and who has a chronic infectious arthritis especially of the knees. The lesion in the knees is almost always advanced out of proportion to that in the other joints. The more the patient is on his feet the more marked is the difference. This comes from the constant traumatism to the tissues of the joints consequent upon walking. It is not an unusual occurrence for a patient to have received a blow on a joint which has resulted in giving no immediate inconvenience other than that from the local con- tusion. Some years later, however, when a focus of infection occurs, this same joint which had been apparently normal will be the first to give evidence of inflammation. Exciting Cause. In the discussion of the etiology thus far it is plainly seen that the predisposing causes are of themselves not sufficient to account for the lesions associated with a multiple arthritis. There is abundant evidence to lead one to conclude that a common exciting cause must he present. The general opinion is that this is of bacterial origin. But attempts made thus far to isolate a specific microorganism which is common to these infections have been singularly unsuccessful. 640 THE INFLAMMATORY ARTHROPATHIES. The work of Poynton and Paine—about 1900 and there- after—in attempting to isolate the specific microorganism of acute rheumatic fever, has formed the basis of investiga- tion for the arthritides in general. They described a micro- organism in the form of a small micrococcus, one-half micron in diameter, which usually grows in pairs or in short chains. It does not show any capsule, as a rule; it stains readily with analine dyes, and it retains Gram’s stain but not with great tenacity. They gave it the name of “Streptococcus Rheumaticus.” It was isolated from undoubted cases of acute rheumatism and was found in the most important human lesions. These investigations of Poynton and Paine have had a far-reaching effect, even though now—after twenty years—their conclu- sions are not generally accepted. The early attempt at recovering and identifying the microorganism was to isolate it direct from the lesion in the joint. Later it was attempted to recover the microorganism from the blood—“Net it out of the blood-stream” (Mayo, Wm. J.). More recently the attempt has been made to identify the microorganisms ob- tained from certain foci of infection with the microorganisms obtained from the joints of the same case. The work of Billings and Rosenow has been developed largely in the latter direction, and has compelled renewed effort from both the laboratory investigator and the clinician. In this work Rosenow has come to the rescue of the microorganism pro- posed by Poynton and Paine with the theory of “mutation” or “selective affinity.” He developed a technique with which he was able, it seems, to obtain cultures from blood and from tissues where before he was unsuccessful. In addition he modified the aerobic and anaerobic conditions of his cultures with varying grades of oxygen tension, so as to offer the microorganism every facility for growth which it enjoys in the suspected focus. In his article on “The Etiology of Acute Rheumatism,” Rosenow11 concludes with the following words: “The name Streptococcus rheumaticus may be retained at present, not with the idea that the organisms so-called always produce rheumatism, but rather to call attention to the fact that when streptococci produce the symptoms and lesions of 'ARTHRITIS DUE TO CHRONIC INFECTION. 641 rheumatism they have certain special features which strepto- cocci from other sources do not usually have. “The affinity for joints, endocardium, pericardium, and often also myocardium and muscles, which characterized these organisms when first isolated, tends to disappear on cultivation. It may be restored by animal passage, and other strains of streptococci under certain conditions may be made to acquire the features of the strains from rheumatism. When the rheumatic strains have acquired the cultural fea- tures of hemolytic streptococci they lose the affinity for the endocardium and pericardium, and acquire even a greater affinity for the joints. When they have been converted into pneumococci of a certain grade of virulence, pulmonary hemorrhages and pneumonia are commonly formed after intravenous injections, whereas when the virulence is still greater, death from pneumococcemia results. These and other facts suggest strongly the possibility that previous to an attack of rheumatism various types of the streptococcus group, especially hemolytic streptococci, acquire in the tis- sues of the infected individual the features which give the simultaneous affinity for joints, endocardium, pericardium, and myocardium. “The experiments on mutation show that when these and other streptococci are grown in symbiosis with other bac- teria, and under a low oxygen pressure, they may acquire new features and that sometimes they undergo marked changes on passage through animals. The places in the human body where such conditions prevail and where special features are likely to be acquired are parts of infection, such as in the tonsils, various sinuses, the appendix, and about the gums and teeth. That this actually occurs in the tonsils in rheumatism seems quite clear; the mild character of the tonsillitis at the time of the attack and the late appearance of rheumatism in some cases of acute follicular (strepto- coccal) tonsillitis, accord with this idea. The importance of focal infections as a point of entrance of bacteria in general is quite well recognized, but the idea that the focus serves in addition as a place zirhere bacteria can acquire new properties (italics my own), is not generally recognized and needs to be emphasized.” 642 THE INFLAMMATORY ARTHROPATHIES. While these conclusions have not been generally accepted, after all, they have suggested a fascinating way of approach in the study of focal infections in general and of the arthri- tides in particular. McMeans12 experimented upon ten rab- bits under control with a single strain of streptococcus— Streptococcus pyogenes (Holman)—of submaxillary gland of the human. His aim was to preserve a possible elective affinity for the submaxillary gland, and his technique fol- lowed closely that of Rosenow. The lesions produced in the rabbits were almost entirely limited to the joints instead of the submaxillary glands. The quality of this organism of attacking the joints was not lost after a period of three months of artificial cultivation. McMeans13 concludes that, “it would be difficult to ascribe to an organism a particular affinity for a given tissue unless the reaction is read in terms of intensity over and above that noted in other tissues.” He further came to the same conclusions with respect to mutation and elective affinity of certain microorganisms in his experiments on artificial acute inflammations of the appendix. Henrici,14 in an article on the “Specificity of Streptococci,” in which he reported his results from inoculating fifty-three strains of streptococci from various sources into two hun- dred and twenty-five rabbits, with the purpose of comparing the virulence and elective affinities with the powers of hemo- lysis and carbohydrate fermentation, concludes: “We are not justified from evidence obtained by rabbit inoculation experiments in recognizing any particular class of strepto- cocci as specific for rheumatic fever, since the various rheu- matic lesions, arthritis, myocarditis, endocarditis, pericardi- tis, and myositis, may be produced by some strains in each of the varieties and are produced in equal proportion by both hemolytic and non-hemolytic streptococci.” In this whole controversy one must not lose sight of several facts. First, while many attempts have been made and reported, it seems no one has yet found a microorganism with which he can at will reproduce the clinical picture of acute rheumatic fever. Second, while there seems to be a definite relation between foci of infection and the acute, sub- acute, and chronic varieties of joint lesions, no one has yet ARTHRITIS DUE TO CHRONIC INFECTION. 643 been able to explain why the same microorganism in one individual will apparently produce an acute rheumatic fever with temporary changes in joint and muscle, but destructive changes in endocardium; in another, extensive permanent change of the soft tissues of the joint only, and in still an- other profound destruction of the cartilages and of the bony structures of the joint, while the endocardium escapes. It is to be hoped that the fascination which this field of investigation affords will continue to lure able investigators on until the problem of the infectious origin of the arthritides is permanently solved. Even though the specific microorganism of chronic infec- tious arthritis is at present not knowm, there are certain reasons why one is inclined to conclude that there is a definite causal relation between a focus of infection and an existing inflammatory process in joint structure. What are some of the evidences which permit of such conclusions? They are largely based upon clinical observations which have been noted in acute rheumatic fever, and in subacute and chronic multiple arthritis for many years, or since these conditions were first differentiated. First, there is the coexistence of the lesions. An acute infection of the throat occurs, and coincidentally or following there is joint affection. This occurs so frequently that their relation is acknowledged generally. Second, an acute ex- acerbation of the focal infection is followed at once by an increase in severity of the joint symptoms. This has been noted also when anything is done to aggravate the focal process, such as expression of secretion from the tonsils, especially if roughly done, or local application to diseased tonsils. The extraction of an infected tooth, or the im- mediate effect of the drainage of infected sinuses, will fre- quently result in a sudden flare-up of the heretofore sub- siding joint symptoms. And third, the removal or over- coming of a focus of infection in a reasonable time may be followed by recovery from the joint affection. From these facts there is abundant evidence to conclude that the common and exciting cause of the subacute and chronic arthritides is a focal infection. 644 THE INFLAMMATORY ARTHROPATHIES. The location and modes of entrance of the infection is an important factor in the etiology of joint diseases, since upon an understanding of these factors a rational treatment may be established. In certain conditions the focus of in- fection, such as of the teeth and tonsils, can be easily de- termined, but in others, such as certain of the sinuses in the upper respiratory tract or certain lesions in the gastro- intestinal tract and in the genitourinary tract, it may be difficult to determine. In searching for foci of infection one should always be able to demonstrate that a lesion actually exists, and next that there is reasonable evidence that it is the primary cause of the lesion of the joints in question. The first of these requirements should not be difficult to one who is accus- tomed to make careful clinical studies of his cases and who can surround himself with a group of reliable clinicians, laboratory workers and specialists. The second is largely a matter of exclusion, in which sound logic controlled by good common sense should prevail. The prevailing tendency to attribute indefinite symptoms and obscure diseases to “focal infection” is liable to work hardship and harm to the unsuspecting patient. If the fact is once lost sight of that a so-called focus of infection must be a veritable pathological lesion before it can be considered a part of the chain of conditions leading to an infected joint, the treatment of the condition will be disastrous. The possible relation of “sub- infection,” as defined by Adami,10 to the arthritides may lead one to incriminate most any organ when he is on the search for foci of infection. The supposed relation of dis- turbance of the gastrointestinal tract to joint diseases is a good example. On account of a ptosis of the stomach and colon, and on account of fecal stasis, it is assumed that micro- organisms (existing in unusual number) gain entrance to the blood-stream through a practically intact mucous mem- brane. These microorganisms, though usually avirulent, break down the defenses of the tissues and become virulent. Disease processes accordingly result and among these are certain well defined joint lesions. Such a chain of reasoning is fascinating, but should not be accepted until an actual lesion is found in the gastrointestinal tract, or an invading ARTHRITIS DUE TO CHRONIC INFECTION. 645 organism is found, red-handed, as it were, breaking through the natural defenses. In discussing the essential causes of polyarthritis one may well consider the relation of disturbances of body metabolism to the disease process. The border line between an infec- tious arthritis and an arthritis due to metabolic change is not always definite. Both etiological factors may be at play in the same joint at the same time. Ralph Pemberton, in a number of comprehensive papers since his first report in 1914, has shown from many standpoints the relation of metabolic disturbances to the different forms of joint dis- eases.15 In a second contribution,16 Pemberton concludes that from a clinical standpoint, at least, rheumatoid arthritis seems to belong to the category with diabetes and gout. This had long been accepted by clinicians, but it remained to be demonstrated. He claims that the fault is both with carbohydrate and proteid metabolism, and possibly also with the fats. He speaks of an associated infection as being inter- current, or possibly causative, and says in the large group of cases in which a causal source of infection cannot be found or removed, the dietetic treatment is particularly in- dicated. This will be discussed more fully under treatment. In a subsequent paper Pemberton17 calls attention to the prevailing lowered sugar tolerance found in chronic infec- tions, especially in cases with diseased tonsils and infected joints. The lowered tolerance is found in a large proportion of the cases and is “roughly proportional” to the activity of the arthritis, and also that in some cases this disturbance of carbohydrate metabolism may be due to the focal infec- tion rather than to the disease under consideration. These observations have been confirmed to a degree by the writer in a number of cases and have served to emphasize again the close relationship between nutrition and infection. But the writer is of the opinion that the relation of disturbed metabolism to joint affection is the same as that of trauma- tism, which has already been discussed. It prepares the field for the invading and determining microorganism, but of itself is not sufficient, except as in gout, which is generally considered a non-infectious lesion. 646 THE INFLAMMATORY ARTHROPATHIES. PATHOLOGY. Before discussing the morbid process which takes place in inflammation of a joint, it might be well to consider in a sort of a review the structures which go to make up a joint. Usually the character of joint disease is determined by the particular tissue affected and the degree or extent to which the lesion has progressed. Not all tissues are affected alike. A joint consists primarily of the coaptation of two or more bones, which move to a greater or less degree one upon the other. Between the bones lies a sac called the synovial sac, which is lined with a layer of endothelial cells. The sac frequently extends beyond the coaptating bone surfaces, forming a fringe. It contains fluid which is much like a simple serous fluid except that it contains mucin and al- bumin, giving it a slimy consistency. The bones forming the joint are in turn held together by ligaments which pass from the lateral surface of one to the lateral surface of the other, or may pass from the end of one bone to the end of an adjacent bone, as in the crucial ligaments of the knee joint. The synovial sac may extend between the interstices of the ligaments, especially when under tension of excessive fluid. Between the synovial sac and the bone proper lies the articular cartilage. External to the ligaments are the muscles and tendons with their sheaths, and external to these are commonly muscles, such as the deltoid muscle over the shoulder joint. Occasionally between the overlying mus- cle and the tendon sheaths is a bursal sac which has the same structure as a synovial sac and contains a like fluid. There is an adequate blood and nerve supply, as well as a lymphatic system. Over all this is the skin, with the sub- cutaneous fat and the areolar tissue. When an inflammation of the joint (an arthritis) occurs, whether precipitated by traumatism or due primarily to an infecting microorganism from within or without, the begin- ning is usually in the synovial sac of the joint, or in a bursa, or in the tendon sheaths, or wherever endothelial cells lie. A hyperemia occurs and there is an increase of the serous contents, producing tension and swelling. The character and ARTHRITIS DUE TO CHRONIC INFECTION. 647 extent of this depends largely upon the form and type of the invading microorganism, and possibly upon the age of the individual and the degree of body resistance and the kind of joint affected. With reference to age, Silver18 has suggested that the age of the joint influences the character of the pathological change; the hypertrophic type occurring in joints physio- logically old; in favor of this is its preference for the second half of life, its frequent association with general arterio- sclerosis, and the occurrence of the sclerotic changes in the joint vessels. With reference to body resistance, McCrae19 suggests that in cases of arthritis of the more acute type of onset the system is showing a more marked response and a more active resistence to the infective agent and its toxins than in those with a more gradual onset in which we may assume the body defenses are unable to rise to the emerg- ency. This may explain, to a degree at least, why the same organism from apparently the same focus of infection may in one (the child, or young adult) produce acute rheumatic fever, in another (the young adult or mature individual) produce a subacute or chronic multiple arthritis, and in still another (the one in the second half of life, and the aged) a permanent hypertrophic or atrophic change, as in arthritis deformans. As soon as the synovial sac undergoes inflammatory change the surrounding soft tissues begin to undergo the same change. There results, with the rapid increase of the serous contents of the synovial sacs and bursal and tendon sheaths, an infiltration of the surrounding soft tissues, a definite swelling and change of contour of the joint. This consti- tutes a serous arthritis, is of an acute or subacute nature usually, and may resolve without leaving any trace of change in structure or function (acute rheumatic fever). The process may be more severe and the synovial fluid become turbid with added deposits of fibrinous material. This constitutes a serofibrinous arthritis, and may result in organization and permanent joint changes such as are found in subacute and chronic multiple or polyarthritis. The in- flammatory process, as it extends to the surrounding soft 648 THE INFLAMMATORY ARTHROPATHIES. tissues of the joint, may produce a more or less permanent deformity (infectious arthritis). If pyogenic microorganisms prevail a suppurative arthritis occurs, and with this there may be a destruction of synovial sacs and cartilages, resulting in a true osteoarthritis (arthri- tis deformans). The pathological change in a chronic arthri- tis is almost entirely a local process. Other organs and tissues are not involved primarily but may be secondarily on account of functional disturbances resulting from the ex- treme general physical debility which may accompany a chronic arthritis. These may be called terminal changes. However desirable it may be to make a distinct clinical differentiation between an infectious arthritis, and the arthri- tis due to metabolic disturbances (gout), one must recognize that under certain circumstances the infectious and metabolic processes go hand in hand. Thus in a chronic infectious arthritis there may be deposits due to the long continued local inflammatory process interfering with the nutrition of the joint, and in a gouty joint there may be occasional in- flammatory reactions due to the ever-present microorganisms of a subinfection as suggested by Adami. SYMPTOMATOLOGY. The symptoms of acute, subacute, or chronic arthritis are characterized by localized pain, redness, swelling, and dis- turbance of function of the joint. There may be a slight systemic reaction, as chilliness and a moderate increase of temperature, but frequently this is so mild as to go unrecog- nized ; occasionally it is high and of a hectic type. There is a distinct sense of local heat to the touch. There may be only one joint affected but there are usually a group of joints, as of the wrist and the fingers of the same hand. Both hands may be affected, and the condition thus localized throughout the entire course. The lesion is usually sym- metrical. In some cases there seems to be a predilection for the large joints, while in others it is the small joints. The periarticular tissues are involved, and the signs of a mild effusion may appear. Whatever constitutional dis- turbances there are, usually subside in a few days, or at least they do not run a long course. The local conditions ARTHRITIS DUE TO CHRONIC INFECTION. 649 remain for a much longer time. The redness of the joint disappears but some degree of swelling and stiffness remains. At a subsequent attack the joints formerly involved are more likely to relight first. The subsequent attacks may not be so severe, but they leave the joints more disabled. These recurrences occur from time to time until the joint is more or less fixed or ankylosed. There may be a slight leucocytosis during the first attack but at subsequent attacks the blood is usually normal. If a focus of infection is responsible for the disease, any disturbance of the focus may precipitate an exacerbation in the joint. This is strikingly noticeable in case of chronically infected tonsils when vigorous local treatment of the tonsils is persisted in. During the height of an attack, especially if it is the first attack, fluid may be aspirated from the joint. This is usually sterile, insofar as ordinary cultural methods are concerned. At each subsequent attack the evidence of fluid is less marked. The movement of the joint becomes gradually more restricted and finally complete ankylosis may occur. The shape and size of the joints are markedly changed. This is particularly emphasized, when, on account of loss of joint function, the muscles and tendons become atrophied. The pain is at first quite severe, almost as severe as in acute rheumatic fever. It is not particularly increased at night. Later as the joint becomes more fixed, the pain is less, and finally, in complete ankylosis, there can occur an acute relighting of the joint with redness and swelling but with little, if any, associated pain. The joints, especially those of the fingers, take a fusiform shape. The temporo- maxillary and the joints of the spine are frequently involved, in fact, there is no joint, or set of joints, which are immune to the infection. Depending upon the direction and charac- ter of the extension of the inflammation, and also upon the distribution, the process has been distinguished by certain terms, such as atrophic arthritis, hypertrophic and osteo arthritis, and spondylitis. There are also certain forms which have been named after the clinicians who first called atten- tion to the peculiar lesion, such as Heberdon’s nodes, the Von Bechterew type of spondylitis, the Strumpell-Marie 650 THE INFLAMMATORY ARTHROPATHIES. type, and Still’s disease. These are nothing more nor less than rather advanced types of infectious arthritis, and prob- ably do not deserve any special classification. However, they will be discussed later, when considering so-called arthritis deformans. There is seldom hyperpyrexia, and a complicating endo- carditis is very rare. Very few, if any, complications arise. If the patient is beyond middle life and becomes greatly restricted in the usual physical activities, and does not fol- low an imposed diet, there is a general tendency to obesity. The accumulation of weight is, in a way, very unfortunate, especially if the knees are largely involved. The additional weight thrown upon the knees is likely to tend toward greater injury to the joint when attempting to walk, with more pain, which, in turn, limits the physical activities, and thus a vicious circle is established. Usually a slight secondary anemia is present. There are no characteristic blood findings. The urine is normal. Studies made by Pemberton and others fail to show any characteristic kidney disturbance or digestive disturbance. Arthritis Deformans. It was stated at the outset of this article that arthritis deformans will be considered as having the same etiology as that of multiple secondary, or so-called polyarthritis of an infectious nature, and hence will be dis- cussed under the same heading. Heretofore it has been the custom to consider arthritis deformans as a distinct entity, and it has usually been classified with such nutritional dis- eases or diseases of metabolism, as diabetes mellitus and insipidus, gout, and rachitis. It is the opinion of the writer, based upon extensive clinical observations and upon the pub- lished reports of laboratory investigators, that this condition is due to an infection, and represents only the advanced or highly chronic stages of an ordinary polyarthritis, the eti- ology and pathology of which have already been discussed. It will only be necessary, therefore, to call attention to the peculiar symptomatology which characterizes some of the stages of a chronic polyarthritis. Chronicity in this condition is not always measured or estimated by the length of time the joint has been involved, for a polyarthritis may, early in its course, give the evidence ARTHRITIS DUE TO CHRONIC INFECTION. 651 of a deformity of the part affected which is likely to charac- terize the course of the disease. This is due to the dis- tribution of the infection, as to whether it is confined to the synovial sac or whether it spreads to the cartilages, or to the tendon sheaths and surrounding tissues, or to the bony structure of the joint. The deformity of the hands, therefore, on account of anatomical conditions, is peculiarly striking. There is an early ulnar deflection, which may become quite marked. The distal phalanges are deviated to one or the other side, or may be flexed at an obtuse angle, and the metacarpal bones become concave on the dorsal side, the carpal bones become prominent on the dorsal surface. This produces the peculiar “silver fork deformity.” The joints gradually become fixed. Some of the fingers become fusiform in shape. This process is usually more marked in the right hand. The elbows and shoulders are next involved. The same peculiar deformity has a tendency to occur in the feet and ankles, but on account of the natural splint which the shoe affords, it is not so great as in the hands. This is a fact which is often strangely overlooked in these cases. The orthopedist has called our attention to the fact that early support, in the nature of a splint, to the phalanges or the entire hand, may prevent the deformity, as it is prevented in the foot. In the lower extremity the process is most marked in the ankles and the knees, in fact, more marked correspondingly than in the wrist and elbows. This is no doubt due to the fact that the patient insists upon bearing the weight of his body on these joints for a longer time than he should. This again points to rest, especially in bed, as a necessary factor in treatment. As the joints become involved and the tendons fixed in their sheaths, atrophy of the muscles in relation to the shafts of the bones occur. The joints become thus rela- tively large, but they also enlarge on account of the inflam- matory proliferative process taking place. Hence the atro- phic and hypertrophic forms. The patient sooner or later becomes helpless, bed fast, with uncomfortable deformities. In some this whole process may develop in the course of two or three months and the patient become an absolute, permanent cripple. This rapid process is more likely to 652 THE INFLAMMATORY ARTHROPATHIES. occur in the young. In the older individual the progress of the disease is relatively slow. Frequently there is a peculiar and distressing crepitation in the joints, especially in the knees and wrists. Depending upon numerous circum- stances, but probably most frequently upon the renewed invasion of a focus of infection, there may be an acute ex- acerbation in the joints, when they become red, inflamed and painful as at the outset of the disease. As the disease de- velops and joint after joint becomes fixed, the patient may become helpless to the extent of being unable to separate the jaws. The vertebrae become fixed and the patient’s condition is truly pathetic. Villous Arthritis. This process, which Goldthwaite has described, can scarcely be confused with a chronic infectious arthritis of the type of arthritis deformans. From the stand- point of etiology they differ greatly. However, the static and infectious elements may be contributory causes in both conditions. If the infectious element predominates it may be difficult to determine, in a single joint involvement, to which group the condition rightly belongs. But it should not be confusing when one remembers that villous arthritis is most frequently confined to the knees and that the other joints may be singularly free from disease. The distribution and the striking physical condition characterize quite def- initely this form of arthritis. DIAGNOSIS. It is necessary to note at once that infectious arthritis, even though it may have acute manifestations early in the course, is a chronic disease. If a careful history is taken and a thorough physical examination is made, usually the evidence of previous joint disease will be found. In the very early acute stage, however, it is often difficult, in fact at times impossible, to differentiate from acute rheumatic fever. Fortunately time usually comes to one’s assistance and this, as the differences in symptoms become manifest, decides the diagnosis. The following table may be helpful in differen- tiating : ARTHRITIS DUE TO CHRONIC INFECTION. 653 Chronic Arthritis from Acute Rheumatic Fever. Chronic Polyarthritis. Acute Rheumatic Fever. Age Middle life or later. Childhood to middle life. Onset Gradual. Rapid from joint to joint. Distribution Symmetrical. Scattered, irregular. Deformity Always more or less per- manent and character- istic. Rarely if ever permanent. Pain Mild to severe. Severe to excruciating. Swelling and red- ness Moderate. Marked. Temperature None or slight, only oc- casionally high. High, frequently hectic. Pulse Slight increase. Rapid. Sweats None. Marked. Endocarditis Rare. Frequent. Skin Purpura-rare. Purpura-frequent. Erythema absent. Erythema present. Blood Slight leucocytosis. Marked leucocytosis. Effects of Salicy- Unsatisfactory. Usually prompt and sat- lates isfactory. It will be seen from this table that nearly all the symptoms of one condition are found in the other, the difference being only in the degree of severity. If acute rheumatic fever can be excluded with a reasonable certainty, it still remains to differentiate the condition from certain other diseases of the joints. Among these are certain septic joint conditions, also gonorrheal arthritis, syphilitic arthritis, tuberculous arthritis, and acute and chronic gout. An acute bursitis, or a tenosynovitis, may be mistaken for a mono- or a polyarthritis, and finally such conditions as flat feet, sacroiliac strain, and the congenital deformities of joints must be excluded. These conditions are discussed under their separate headings, and while theoretically chronic infectious arthritis should be readily differentiated from them, the report of a concrete case will serve to demonstrate how difficult the diagnosis may be. Miss McM., aet. 18, was admitted to the hospital complaining of pain in the joints which had begun three months ago. It followed an attack of tonsillitis. She said she had just recovered from an “attack of pneumonia” which came on while she was in bed suffering from her swollen and painful joints. The hands and feet had been swollen and at present the right knee was extremely painful and swollen. 654 THE INFLAMMATORY ARTHROPATHIES. In the course of the physical examination it was found; that the patient was about four months pregnant. The right knee was red, acutely swollen, and was very tender. No other joints were involved. A purulent vaginal discharge was present. The temperature was hectic, going from 98° to 102° F. There were profuse sweats at times. The heart was normal. The leucocytes were 18,000, the Wassermann was negative, and a blood culture was sterile. A smear from the vaginal discharge was negative for gonococci. How- ever, neither syphilis nor gonorrhea were entirely excluded as there was an offensive ozena, and a perforation of the nasal septum and it was found there had been a previous pregnancy. Salicylates were given in large doses as only in this way could the pain be controlled. After a month the pa- tient had a miscarriage and in six weeks more with continued salicylate medication the fever and pain had disappeared. The leucocytes were 11,000. In a month more the patient was ready to be discharged, but there remained a considerable enlargement of the right knee joint. At no time was there pain in any other joint. Summary. A patient with apparently a monoarticular af- fection, high temperature, no cardiac complication, question- able vaginal discharge, but no gonococci after repeated ex- aminations, a perforated nasal septum, with a negative Was- sermann, and an apparent cure with salicylates, leaving an enlarged and stiffened knee joint. While the preponderance of evidence seems to be in favor of this being of gonorrheal origin, a definite diagnosis could not be made. This discussion cannot be properly closed without calling attention to the remarkable frequency of so-called sacro- iliac strain, “sacralization” of certain lumbar vertebrae, ham- string tension, and “faulty posture,” which exists among a large group of patients seeking relief from joint disease. These conditions are often mistaken for rheumatism, or for an infective polyarthritis. It is the experience of the writer that many of these patients do have definite foci of infection, but they are not necessarily the cause of the pain. They should be taken care of from this standpoint, of course, but no results can be expected unless the orthopedic side of the case, which is practically the only side, receives careful attention. A disease which is of such uncertain origin and which has such a tendency to run a protracted course, sometimes leading to chronic invalidism permanently crippling the TREATMENT. ARTHRITIS DUE TO CHRONIC INFECTION. 655 patient, is one that should be prevented if possible. Though our knowledge of the condition is far from complete, the relation of certain factors to the disease have been well established and form the foundation for rather definite pre- ventive treatment. Prophylaxis. The lowering of the powers of resistance and the exposure to certain general infections are the two factors which seem to contribute largely to the incidence of joint diseases. Individuals should avoid the dangers which frequently arise from an unbalanced diet. They should not lend themselves to dietetic experiments, such as are usually recommended when an indefinite pain in the joints is ex- perienced. The obscure pains in joints will frequently be interpreted as of rheumatic origin, and lead to the establish- ment of a diet which will tend to make the patient all the more susceptible. Excessive physical fatigue and exposure to cold and wet should be avoided. Mental and nervous strains are equally injurious. Next to a well balanced diet of sufficiently nourishing food is the necessity for systematic rest and sleep. The habit of being in the open air as much as possible and of having the living and sleeping rooms well ventilated is of great importance. The ventilation of school rooms and of business offices should receive scientific atten- tion. Adequate clothing should be worn. Many attacks of joint infections are precipitated by having cold and wet feet. It is advisable also to have at stated times a physical ex- amination made by some physician who is in sympathy with prophylactic medicine, and who appreciates the value of pre- serving health as much as of curing disease. Such an ex- amination may lead to the discovery of errors in diet and errors in the ordinary methods and habits of life. It may also lead to the early discovery of foci of infection which can be properly dealt with. These physical examinations are particularly helpful in persons beyond middle life. There is no doubt that life could be prolonged and much suffering avoided if physicians would attempt to impress upon their patients and the families with whom they come in contact the value of thorough physical examinations at stated inter- vals. Everyone must acknowledge the definite advantage which occasionally comes to an individual because he has 656 THE INFLAMMATORY ARTHROPATHIES. undergone the routine examination required by a life insur- ance company or by a “lodge.” General Management. Whether the initial attack is acute and extensive, or early, mild, and localized, rest of the part affected is of greatest importance. It is of great importance also that the early manifestations of the disease are care- fully observed so that a diagnosis can be definitely estab- lished, and the proper treatment instituted. The unintelli- gent, aimless treatment of joint disease is a sad reproach upon our profession, and no doubt is responsible for the origin of the many healing cults with peculiar names which are being foisted upon an unsuspecting public. Orthopedists are particularly impressed with the shortcoming of the aver- age practitioner when he comes in contact with joint diseases. He is likely to overlook the very early manifestations and to consider all joint pain and disturbance as of a rheumatic nature until confusing complications arise. It is needless to say that the general management of a subacute or chronic case of polyarthritis should include the elimination of the supposed etiological factors which may be responsible for the infection. Besides the elimination of foci of infection it should also include the reestablishment of the normal body resistance, and the restoration of joint function. These three aims may be pursued at one and the same time, but there is a natural order in which they should be undertaken. It may be of very little avail to try to build up a patient if a slow infection is continually feeding into the system. Also it may do little good—in fact it may do more harm than good— if a joint is manipulated and exer- cised before the foci are completely eliminated and the general health is on the mend. Whatever cause is operating, should therefore, if it is pos- sible, first be removed. Much has been said and written in defense of the relation of focal infection to diseases of the joints as well as to many other diseases. Attention has already been called to the fact that this is still, insofar as the arthritides are concerned, largely a matter of theory, and has little more in its favor than post hoc propter hoc. How- ever, this should not deter one from making a definite and ARTHRITIS DUE TO CHRONIC INFECTION. 657 systematic search for such foci and from attempting to over- come them. Pyorrhea should be treated as such because it is present and may impair the general health to the extent of making a joint more vulnerable to disease process. It may or it may not have a direct causative relation to the joint or joints immediately affected, but it should be corrected, if for the purpose of saving the teeth alone. The same may be said of dental caries, and of apical abscesses. This is a safe attitude to take in the disposition of all foci of infection where the treatment of joint diseases is under consideration. Of these foci, apparently, from the writer’s experience and from the experience of others who have reported cases, the most frequent are the tonsils, the teeth, the sinuses leading into the nasal channel, the middle ear, the genitourinary tract, the gastrointestinal tract, and the respiratory system in general. In the genitourinary tract in the male the prostate gland and the seminal vesicles are frequently the seat of infection, and in the female the endometrium and the tubes are most likely to carry infection. In both sexes any part of the entire urinary tract may be chronically infected and serve as a focus. In the gastrointestinal tract the colon and par- ticularly the appendix has been held under suspicion by many clinicians and investigators. Also the biliary tract and the stomach and duodenum are supposed to harbor germs which may feed into the blood stream. The upper respiratory tract has already been mentioned. The bronchial tree and the parenchyma of the lungs may, under certain conditions, be the seat of focal infection. In the treatment of the arthrit- ides, therefore, where it is attempted to eliminate the sup- posed foci of infection the undertaking must be thorough and complete. Halfway measures will not suffice, either from the standpoint of curing the disease or of establishing the fact that the disease was due to any one particular focus. The writer has in a number of cases seen good results, apparently, from removing foci of infection, but he has also seen undoubted failures. In some of these cases it was found that the investigation had not been thorough, and one or another point had been overlooked. In other cases it was 658 THE INFLAMMATORY ARTHROPATHIES. found that the eradication of the focus, for some reason or other, was not complete. For example, a pair of tonsils was removed, or thought to have been removed, when later a tonsillar “stump” was found to have been left. When this was removed, the results were satisfactory. In fact, it seems that the lesion in the joints is frequently decidedly aggra- vated after an incomplete tonsillectomy. Until this was fully appreciated, many patients were compelled to have a subse- quent complete enucleation of the tonsils. The same may be said of the sinuses and in fact of any forms of infection, unless the removal is complete, harm may come from the procedure. The failures which occur even after the work has been done thoroughly may be due to various causes. Among these may be the fact that the state of nutrition is so low, as the result of the disease, or from other causes, that there can be no repair; or again, that the lesion is so far advanced that under the most favorable circumstances there can be no approach towards the normal. It may also be possible that the lesion in one or other joint may in itself remain active and supply sufficient infective material to light up the process from time to time in other joints which had not heretofore been involved. If this opinion has any foundation, it can readily be seen that the problem of focal infection in relation to the arthritides is complex and difficult from every stand- point. The question occasionally arises as to whether a focus of infection should be operated upon when the disease is in the active stage, or where there is an acute exacerbation. Unless there is some other condition which would contraindicate operative procedure, there should be no reason for delay, and operation should be done as soon as possible. The question of safety on account of the acuteness of the joint condition, however, is not nearly so important as is that of the acuteness of the focus of infection itself. To operate on chronically diseased and hypertrophied tonsils for ex- ample, when they are in a state of acute exacerbation, for the purpose of curing an acutely inflamed joint, may make a very dangerous operation when, by a little waiting, a comparatively safe operation will do as much or even more ARTHRITIS DUE TO CHRONIC INFECTION. 659 to bring about the desired results. The whole matter of focal infection in relation to the arthritides resolves itself into the plain fact that it must be based upon sound clinical and surgical judgment, with additional good sense. The care of the general health of the patient suffering from an infectious arthritis is of considerable importance. This has already been discussed with reference to the eti- ology of the disease and the preventive care. It has been pointed out that these patients are usually in a state of sub- nutrition, though occasionally the disease seems to be the result of overeating and under exercise. Of the latter the obese patient is a good example. The patient should have a well balanced, nutritious diet. The normal or standard weight should be maintained. Pem- berton has called attention to the advantage of under feeding and especially to the benefits arising from keeping the carbo- hydrates approximately lower than the other elements of the diet. The tendency in these patients is, however, already towards subnutrition. This may be accounted for in several ways. The patient usually has a preconceived idea that he needs “an anti-rheumatic” diet, or he is told by his friends that such a diet is necessary; he accordingly deprives himself of one article of food after the other until he is in a state of subnutrition. Again, there is not always the studied care taken by the physician to differentiate between acute rheu- matic fever, chronic polyarthritis, and gout. All are included under the general term “rheumatism,” and a so-called “anti- rheumatic” diet is prescribed. This usually consists of a diet with very little meat and the exclusion of sour foods, and the avoidance of alcoholic stimulants. The carbohydrates and fats are allowed, apparently without reservation. From our present knowledge of the arthritides such a diet must be considered largely empirical. There is no doubt that the obese, over-fed patient will do well with a diet of low caloric value. This is often the case in patients who consult the physician in the early stages of the disease. On the other hand, those who consult the physician later in the disease, when their nutrition is already greatly impaired, should have a well balanced diet of high caloric value. In short, there is as yet no rational basis for a specific diet for patients 660 THE INFLAMMATORY ARTHROPATHIES. suffering from either an acute or a chronic arthritis. The arthritis patient is usually more or less limited in his ability to live in the open air and to have the proper amount of physical exercise. The diet from this standpoint again should vary in proportion to the extent of the disability. The aim of all dietetic measures should be to obtain the highest state of nutrition and health possible under the existing disability. Restoration of the function of the joints is to be considered as well as the elimination of foci of infection and the restora- tion or maintenance of bodily health. The treatment for the acute stage of the infection has already been established in the manner described, that is, rest has been instituted, local applications, such as cloths soaked in a saturated solution of sulphate of magnesium, or lead water and laudanum, or an ice-bag, or a hot-water bag, or alternate heat and cold, have been applied. Probably fixation of the joint has been found necessary, either by an ordinary felt, wooden, or wire splint, or in a more thorough way by the application of a plaster bandage. With these procedures the pain, redness, and most if not all of the swell- ing may disappear, but the function of the joint may remain impaired as the result of more or less permanent swelling and stiffness, or by adhesion and deposits. This loss of func- tion may be restored by using the joint in doing the ordinary duties of life, taking them up gradually, or certain specific movements can be prescribed. If these are persistently car- ried out, in most cases the results will be satisfactory. This is especially so if the foci of infection have been completely eradicated. If they have not been eradicated, the joints will usually become more inflamed and their use must be tem- porarily discontinued. If there is no inflammatory reaction with a definite attempt of function, mechanical means may be safely instituted. These include massage and Swedish movements, and the use of certain appliances such as weights and pulleys as ordinarily found in a gymnasium equipment. These treat- ments should be begun very gently and increased as the special condition of the joint will permit. In the acute joint the mechanical treatment may not be applicable; in the subacute it should be very mild at first, ARTHRITIS DUE TO CHRONIC INFECTION. 661 and in the chronic it may be heavy, even to producing mild inflammatory reactions. No hard and fast rules can be set, but it must always be kept in mind that any treatment which is so severe as to produce a local reaction lasting for over twenty-four hours is likely to do more harm than good. The patients should be instructed to treat themselves whenever it is possible. Such treatments must necessarily be carried on for a long time—for months and years sometimes—and make it impractical from the standpoint of compelling the patient always to have some one at hand to exercise the joints, or impossible for some on account of the expense which such a prolonged course entails. Sometimes the joint is partly or completely ankylosed and one would think that no such mechanical treatments would be of any avail. It is remarkable, however, what can be accomplished if a patient will cooperate and persist in the treatment. If the ankylosis is such that no results can be expected from passive movements, or if passive movements have failed, the advisability of giving the patient an anes- thetic and breaking the adhesions should be considered. It is a question which taxes one’s judgment to determine whether a joint should be thus severely dealt with or whether passive movements, massage, and exercise, should be con- tinued longer. It must always be remembered that after the forcible breaking up of the adhesions of a joint, it must for the time receive the same care as an acute joint, and must be eventually restored by employing first gentle and later more or less severe passive movements. It requires a great deal of judgment to decide in a particular case whether further passive movement should be continued or whether more active treatment should be undertaken. These patients constitute the class of cases which are fre- quently benefited by a sojourn to certain mineral springs or resorts which are supposed to have a specific effect. There is no question that some are greatly benefited by hydro- therapy, massage, and the regime which is usually instituted. Prolonged hot baths may, however, be debilitating and may do more harm than good. The change in diet which is usu- ally insisted upon, whether rational or otherwise, is often quite different from the patient’s accustomed diet, and may 662 THE INFLAMMATORY ARTHROPATHIES. therefore have a good effect in those cases where gastro- intestinal disturbances are an etiological factor. Drinking an abundance of water, which is usually required at these resorts, is also helpful. Extremes in diet should, however, be avoided. Certain other special treatments in these cases are of con- siderable value. Among these are superheated air. Some twenty or more years ago it was advocated to place the ankylosed joint in an apparatus made of layers of sheet tin, asbestos, and felt. Heat from an ordinary gas jet or an alcohol lamp was applied beneath the apparatus and the temperature of the compartment was raised at times to 200° or 250° F., with no danger to the part treated and with considerable relief from pain. After the treatment by super- heated air the part is massaged, and attempts are made to overcome whatever ankylosis might be present. This is a form of treatment which has been supplanted, largely be- cause of the ease of the application by heat from electric light. This heat, besides being more readily applied, is supposed to penetrate the tissues more easily than that from super- heated air An electric light bath including the whole body may be given where many joints are involved. What is con- cluded to be the best form of heat, however, is that which comes from exposing the joint or lesion to the direct rays of the sun. This has been recognized for some time in the treatment of tuberculous lesions of the bones and joints. It is systematically employed in certain health resorts, espe- cially in the Alps, where the benefit of high altitude and reflected light from the snow may be secured. The results of direct or reflected sunlight in polyarthritis are equally as good as in tuberculous arthritis. The treatment can be car- ried out whenever the sun shines. The local effect is quite definite, and unless care is exercised to avoid exposing too much of the body surface at a single seance, harm may come from the treatment. The part or parts should be exposed for certain hours regularly each day. The effect of the direct sun rays in this condition, as well as in other diseased con- ditions, is not sufficiently appreciated. The Roentgen rays, as well as radium emanations, have been used in chronically inflamed and ankylosed joints, but the skill required for such ARTHRITIS HUE TO CHRONIC INFECTION. 663 application, the tediousness and expense of the course, make them a more or less impractical procedure. The plan of producing a local and temporary hyperemia of the joint according to the method of Bier,20 of Bonn, has been followed with excellent results, according to the re- ports of some clinicians; in the hands of others, among whom is the writer, the method was difficult of application and the results not always satisfactory. In fact, in all of these ap- plications a large factor, which is most likely to be the deciding one, is the patient and intelligent cooperation pos- sessed and displayed by the patient and the physician. The treatment of polyarthritis of the subacute and chronic types by means of vaccines, specific or polyvalent, and mixed, has from time to time been attempted. From the very fact that no specific microorganism has yet been found in the joints affected, and that the etiological relation of foci of infection to affected joints is still far from being proven, there can be no other conclusion than that such treatment lacks a scientific basis. This is the reason, no doubt, why the reports of such treatment as carried out by different in- vestigators and clinicians do not altogether harmonize. Some report favorable results, while others report unsatisfactory and even harmful results. The writer has attempted in a number of cases, autogenous vaccines obtained from sup- posed foci of infection, such as the tonsils, teeth, and ali- mentary tract in general, but thus far has not been able to report a single conclusive satisfactory result. More than this in some cases the results apparently were disastrous. The use of polyvalent vaccines in these cases should be condemned. Since the publication by Miller and Lusk,21 the effect of protein shock reactions on the arthritides has been observed by many investigators and clinicians. The protein shock therapy is instituted by injecting a foreign protein into the vein. The protein usually employed is the typhoid vaccine. Miller and Lusk at first used a four per cent, proteose solu- tion but later found the ordinary typhoid vaccine as satis- factory. This has also been used in cases of acute rheumatic fever. The reaction is often quite profound, resulting in a severe chill, followed by a high fever and profuse sweat. 664 THE INFLAMMATORY ARTHROPATHIES. The patient experiences relief from the pains almost at once. This at first, however, is only temporary. In a few days or in a week another injection may be given, and after a time the relief becomes more permanent. This therapy has also been tried by the writer and in certain less advanced cases the results have been fairly satisfactory, but in the advanced, markedly ankylosed cases, the results were, to say the least, discouraging. The reactions are sometimes so severe and unpleasant as to lead to considerable objection on the part of the patient. The danger of such therapy as compared with vaccine therapy seems to be very small. The success of the treatment seems to depend largely upon the stage (early) at which it is instituted and the persistence with which it is followed. Medical Treatment. The indications for medication in chronic arthritis are for the relief of pain and for the im- provement of the general health. There is no specific medi- cation. For the relief of pain the salicylates in their various forms may be given, though with varied results. Aspirin, guaiacol carbonate, the iodides, antipyrin, and pyramidin, may be found useful. Opium and its alkaloids, especially codein, may be necessary if the coal tar preparations are not satis- factory. However, one should always be careful in prescrib- ing opiates in chronic conditions. It has been the experience of a number of observers that the administration of ether will overcome the pain to a large extent for a limited period. The writer has frequently no- ticed this following a tonsillectomy in the course of the treatment of a polyarthritis. The patient usually experiences remarkable relief lasting for several days, when the pain returns and sometimes with greater severity for a time. As in acute rheumatic fever, cinchophen or neocinchophen has been recommended where the salicylates have been unsuc- cessful. The medication given for the improvement of the general health are usually directed towards a coexisting anemia, or to a general “loss of tone.” Iron in its many forms has been recommended, also arsenic in the form of Fowler’s solution, or what is better still, in the form of cacodylate of soda, given intramuscularly. This is apparently very helpful. GONORRHEAL ARTHRITIS. 665 Three to five grains can be given intramuscularly every sec- ond day until ten to fifteen doses are administered. Ars- phenamin, given intravenously, as in the treatment of syphilis, has also been advocated, but there can be very little reason given for such specific arsenical treatment. The iodides are frequently given, as are many other remedies, with less reason for their administration. When the iodides are efficacious it might be well to accompany them with some preparation of mercury, as the case is very likely of luetic origin, or is associated with lues. The treatment of polyarthritis in the acute form should be taken up promptly and followed through persistently; in the subacute and chronic form it will require in addition a great deal of patience on the part of both physician and patient. When one contemplates the distressing deformities and the permanent disabilities which may arise in difficult and neglected cases, on the one hand, and on the other hand, the satisfactory results which may follow when the case is favorable, and actually yields to treatment, he will not lack for an incentive. GONORRHEAL ARTHRITIS. The gonococcus as an infecting microorganism has cer- tain well-marked peculiarities. It is known how limited its area of infection seems to be, as is shown in its invasion of the pelvic organs and the pelvic peritoneum, and how un- usual it is for a general peritonitis to follow such an infec- tion. It is also known how infrequently the gonococcus is recovered from the blood-stream, and how rarely it can be found in foci which occur after an acute gonococcal urethri- tis. That the disease does extend to other organs, as by continuity to the prostate, seminal vesicles, and other organs, has long been known, but its extension through the blood- stream was not definitely known until it was demonstrated by Thayer and Blumer,22 in Dr. Osier’s wards at the Johns Hopkins Hospital, in 1896. The microorganism had been recovered from an infected joint some ten or twelve years before the work of Thayer and Blumer. It was found that such joint involvement may also follow gonorrheal ophthal- mitis and vulvovaginitis. 666 THE INFLAMMATORY ARTHROPATHIES. The joint complication of this infection may occur soon, that is, within six weeks of the acute urethritis. Its fre- quency is reported by different observers as being anywhere from two to eleven per cent, of cases of gonorrhea. This percentage is much higher (twenty-five per cent.) in recur- ring attacks of acute gonorrhea. It occurs more frequently in the male than in the female. It may occur in children from a vulvovaginitis or from an ophthalmitis. While it may occur soon after the primary infection, many joint conditions, presumably of gonorrheal origin, occur in later life or long after the acute infection has subsided or may have entirely disappeared. It is on account of this that such an arthritis after middle life assumes such importance in a diagnostic and therapeutic way. BACTERIOLOGY AND PATHOLOGY. As has already been stated, the lesion is due to the presence of the gonococcus in the joint. This is carried to the affected joint through the blood-stream and invades first the synovial membranes. It may also affect the tendon sheaths, and in some cases all the structures which enter into the making up of a joint, including the articular ends of the bones. The gonococcus does not enter the joint until the more violent local infection has subsided. Often the local lesion shows a marked and unexpected amelioration just before the joint complication occurs. It apparently remains in the lesion of the joint for only a short time, as it cannot be recovered after the acute stage has subsided. It does not remain in pure culture but for a few days, as it is soon accompanied with a mixed infection, which later largely determines the character of the process. Search for the gonococcus in the blood-stream or in the local lesion is therefore frequently futile. This is on account of one or both of two conditions: the culture may not be taken at the proper time, or the culture medium is not suitable or may not be properly pre- pared. It is a difficult microorganism to culture. After the gonococcus disappears from the lesion, other microorganisms, such as the staphylococcus, streptococcus, and other com- monly associated organisms, remain to carry on the disease process. GONORRHEAL ARTHRITIS. 667 The pathology of the joint infected with the gonococcus or with the associated microorganisms, does not differ greatly from that of arthritis already described as due to other micro- organisms. The synovial sac is first affected and the con- tents become turbid. Depending upon the severity of the attack and the degree of mixed infection, the process may be of a mild type or it may go on to the surrounding tissues, producing suppuration, necrosis, and hemorrhage. Perios- titis is by no means rare. The joint may recover, leaving very little evidence of the invasion, or it may become ankylosed partially or completely. SYMPTOMATOLOGY, Depending upon the character, extent, and distribution of the lesion, it seems desirable to classify clinically the various forms of gonorrheal arthritis. Within four or six weeks after the acute local (nearly always urethral) infection takes place, there may be slight pains in the joints without any apparent local change. This may be characterized as merely a “joint pain,” an arthralgia, or there may occur a redness and swelling of the joints and the surrounding tissues. This is associated with great pains and has all the evidence of an acute arthritis. It may be a single joint (monarticular), or it may occur in many joints (polyarticular). The opinion generally prevails that gonor- rheal rheumatism is usually monarticular, in contradistinc- tion to the many-joint involvement of acute rheumatic fever. It is true that in the case of a monarticular involvement the cause is more likely than not a gonorrheal infection; how- ever, Cole and McCrae have found the number of joints involved in a gonococcus arthritis as compared with those of rheumatic fever as two to one. In the acute form there may be only a serofibrinous condition, the more common, or it may go on to a phlegmonous condition. In this there is usually a mixed infection. The process is quite rapid and destructive. The periarticular structures are involved. Sur- gical interference is nearly always necessary. In the large venereal wards of the Philadelphia Hospital, where the writer was resident physician some years ago, this form of gonorrheal arthritis was frequently observed. The joint 668 THE INFLAMMATORY ARTHROPATHIES. most frequently affected was the knee. The joints of the lower extremities are usually more frequently affected, but any joint is liable to the infection. The temperature and systemic effect in general is not so marked as in acute rheu- matic fever. The tendency to sweating is not so in evidence. Endocarditis, while it may occur, is very rare. The con- valescence is protracted, much beyond the time of acute rheumatism. A permanent deformity or destruction of the joint may follow. When the condition passes from an acute form to a subacute form, there is a tendency to a hydrops of the joint which may come and go on the least provocation. The true nature of this condition may be frequently over- looked, especially when it is impossible to obtain the history of a gonorrhea or to prove its presence. The chronic form of gonorrheal arthritis must be consid- ered in two different aspects. In the first there may be simply a continuation of the original infection to a chronic state, or as the result of recurring attacks of an acute ure- thritis due to repeated exposures. The joints may after a number of attacks become chronically inflamed. It is contended by most observers that the patient having frequent attacks of gonorrhea is more susceptible to an arthritis and is likely to have it in the most severe form. These repeated acute attacks will lead finally to a chronic arthritis. In the second aspect we deal with an entirely different condition of the joints. It probably should not be called a gonorrheal arthritis, but it is usually classed as such because there is a history of gonorrhea having occurred years ago, and on careful examination of the genitourinary tract the evidence of an old stricture, a chronic posterior urethritis, or a chronic prostatitis or vesiculitis may be found. There is usually no history of an arthritis, either acute or chronic, having immediately followed the former acute (but now long forgotten) gonorrhea. The condition comes after middle life and is more frequent in the male than in the female. It bears a close resemblance to the chronic polyarthritis due to a focal infection. Its symptoms and physical deformities are almost identical to those of a so-called rheumatoid ar- thritis or arthritis deformans. The distribution, however, is GONORRHEAL ARTHRITIS. 669 dififerent, in that it usually affects the joints of the lower extremities first. It is more likely to be monarticular, and it frequently affects the articulations of the pelvic bones as well as the vertebrae, especially the sacral and lumbar. It may have no other relation to gonorrhea except that the focus of infection was originally due to the gonococcus which had “closed its onslaught and abandoned the trenches in the form of a seminal vesiculitis, in favor of a mixed infection” (Thomas) consisting of various strains of streptococci, pneu- mococci, staphylococci, and perhaps colon bacilli. As has been stated above, therefore, this form of arthritis should probably not be included in gonorrheal arthritis, but it is of such importance that it demands discussion here. An inflammatory condition of the joints, acute or chronic, should not be interpreted before a careful examination of the genitourinary tract has been made. DIAGNOSIS. By reason of the uncertainty of our knowledge of the cause of the arthritides in general, it should be refreshing from a diagnostic standpoint when a suspected case of gon- orrheal rheumatism is about to be considered. The diag- nosis will be based largely on the history of a gonorrheal infection, whenever that may have occurred. The history of the onset of the attack, the distribution and the peculiar behavior of the joints, are of a certain value. In men this may be a very simple matter, but in women the primary infection may be so mild as to be easily overlooked. It is not always possible to get a satisfactory smear for micro- scopic examination. It must not be forgotten that in chil- dren a gonorrheal ophthalmia or a vulvovaginitis may be the focus of infection. On account of the usual unreliability of the history and of the occasional obscureness of the symptoms and physical signs, the diagnosis must frequently be concluded or at least confirmed in the laboratory. The laboratory should be of assistance in several ways. The easiest and most reliable is the confirmation which comes from a study of the mor- phology of the Gram-negative intracellular diplococcus in the secretion from the focus of infection, the urethra. This ex- 670 THE INFLAMMATORY ARTHROPATHIES. animation should be made in all suspected cases of gonorrhea and in all cases of arthritis where there is a suspicion of a gonorrheal origin. Another method which should be used more frequently is the complement-fixation test. According to Schwartz,23 a positive complement-fixation test is an absolute indication of gonococcic infection somewhere in the body. This reaction should come about the fourth week after the onset of the infection. Other writers ascribe one hundred per cent, reliability to this test. The fact, of course, must not be lost sight of that a patient may be suffering from a double infection, that is, a patient with gonorrhea may also be suffering from acute rheumatic fever. A very simple laboratory test in suspected gonorrheal arthritis can be made by the injection of gonococcus vaccine. The re- action is not unlike the tuberculin reaction and can be done in very much the same way. With the aid of one or other of these laboratory tests it should not be difficult to differentiate from certain other conditions which sometimes are confusing, such as acute rheumatic fever, polyarthritis due to focal infection, gout, sacroiliac strain, and tuberculosis and syphilis of the joints. TREATMENT. It goes without saying that prevention of a disease which is so destructive and disabling is highly desirable. The first plan of prevention is to prevent the original infection. This is a social as well as a medical problem which is too large to discuss here. The second plan is to treat the patient for the local lesion as early as possible and along the most approved lines. This also is in part a social problem, for the physician cannot treat the patient until he presents him- self for treatment. On account of the nature of the disease and the manner in which it is usually contracted and the stigma attached thereto, the patient naturally keeps away from the doctor as long as he can. It should, therefore, be the duty of the physician or the profession in general, to educate the public so that the individual will apply early for relief when the infection occurs. This is a large and almost uncultivated field for the real public health physician. One might conclude that by this prompt treatment gonorrheal GONORRHEAL ARTHRITIS. 671 rheumatism might be stamped out, but unfortunately this is not the case. Many cases have been reported where the treatment for gonorrhea was early and apparently efficient, and yet later gonorrheal rheumatism developed. Also it has been noted that the severity of gonorrheal rheumatism is apparently not at all dependent upon the degree of the sever- ity of the primary infection. However, it seems reasonable to expect that early, careful, and persistent local treatment should lead to a reduction of the incidence of gonorrheal rheumatism. Aside from prophylactic measures, the treatment of gonor- rheal arthritis depends upon the acuteness of the infection in the joints, and also upon the stage of development of the local or original infection. In all cases the original focus must receive consideration, but the character of this treat- ment will depend upon the acuteness or the chronicity of the local lesion. If arthritis develops early, or when there is still a rather acute urethritis, for example, the treatment of the urethritis should be carried out very carefully. Any traumatism may result in more joints being involved, because of the possible septicemia. The treatment of the local parts should, there- fore, be mild so as not to irritate the mucous membranes. There should be no unnecessary instrumentation, and no irritating application made. If, on the other hand, the attack of arthritis should occur late after the original infection or when it has already become chronic, stimulating treatment may be very beneficial. It will result not .only in healing the original focus, but it may result in delivering to the blood-stream sufficient autogenous vaccine to have a bene- ficial effect on the lesion in the joints. In the chronic cases, as well as in the acute, the local treatment of the original focus of infection should be persistent until every vestige of the infection is overcome or removed. The necessity for radical treatment of gonorrheal salpingitis at the proper time has long been recognized and practiced, but a gonorrheal vesiculitis which does not yield to medical treatment is usu- ally allowed to continue until some serious complication has arisen. Fortunately the modern genitourinary surgeon is well aware of his responsibility in this matter, and it is 672 THE INFLAMMATORY ARTHROPATHIES encouraging to note the results. A competent genitourinary surgeon should be consulted in all cases of gonorrheal arthritis. Next to the importance of treating the seat of the initial infection is that of caring for the affected joints and of administering such internal medication as may be indicated. The local care of the joints will depend upon the character of the lesion. An irritative arthritis or “arthralgia,” may be satisfactorily cared for by applying compresses soaked in a saturated solution of sulphate of magnesium, or of boracic acid, or of lead water and laudanum, and by having the patient rest the part. A fibrinous arthritis may require very little in addition to this, except a fixation splint as in an ordinary arthritis. However, inasmuch as the tendency to ankylosis is quite definite, it is well not to fix the joint for a long time, or as long as one would in an ordinary joint infection. In a phlegmonous or purulent arthritis it may be necessary to aspirate the joint, or to open the joint freely and establish drainage. When the indication for drainage is evi- dent it should be done promptly and thoroughly so as to avoid destruction of the joint. There is no specific remedy. The internal medication or constitutional treatment, is rather unsatisfactory, as will be perceived by the many medicines which have been suggested. The treatment is therefore largely symptomatic. The one symptom which requires the greatest consideration is pain. This may be met by a liberal administration of the salicyl- ates, very much as in acute rheumatic fever. Benzoate of soda has been advocated by some authors as being effica- cious. In fact, it has been suggested as a point in differential diagnosis between acute rheumatic fever and gonorrheal rheumatism—in the first the salicylates are most likely to relieve the pain and in the second, the benzoates. This has not been the experience of the writer. When the pain is severe, opiates are necessary. The iodides and mercury have been used in small doses with reported success. One must be inclined to feel that in those cases in which the iodides and mercury have been found helpful or curative, there must have been also an infection with the Spirocheta pallida. GONORRHEAL ARTHRITIS. 673 As stated above, no so-called, specific remedy has yet been found; many have, however, been suggested and tried, with usually unsatisfactory results. Among these the remedy which seemed most likely to be satisfactory is the specific vaccine treatment. The use of the specific vaccine in the treatment of gonorrhea seems to be amply justified—many successful cases have been reported. Its use in gonorrheal arthritis has not, however, proven satisfactory. The reasons for this seem quite obvious. It has already been stated that the gonococcus does not remain in the affected joint during the whole time of the disease, that it soon dies out and a mixed infection remains. It would seem, therefore, that a polyvalent vaccine should be more satisfactory, but this is not as efficient as it is in a general polyarthritis. Evidently the damage already done to joints’ structure by any micro- organism cannot be removed by vaccine treatment. The wofk of Victor Vaughan, on the behavior of the pro- tein split products, has brought new interest to treatment with non-specific vaccines, and many contradictory reports are resulting. The writer has used typhoid vaccines in some of the cases of gonorrheal arthritis and has had most pro- found reactions. The results in these cases were not satis- factory, and did not warrant a continuance of the treatment. Whatever treatment is undertaken, to be successful, must be continued for a sufficient time to permit results, as the process of recovery is naturally slow. The patient should be warned against fresh infection. To conclude: Acute gonorrheal rheumatism should be treated by a careful, thorough and prompt treatment of the focal lesion; by complete rest of the joint or joints involved, and by the administration of salicylates, and, if necessary, opiates in sufficient dose to control the pain. Chronic gonorrheal rheumatism should be treated as a polyarthritis and in the same manner as those due to the ordinary infections are usually treated. This is described in the chapter relating to such a condition. In both acute and chronic gonorrheal rheumatism the specific vaccine may be tried with benefit, and in the chronic condition the protein split products, such as typhoid vaccine, or horse serum, may be used to advantage. 674 THE INFLAMMATORY ARTHROPATHIES. SYPHILITIC ARTHRITIS. INTRODUCTION. Syphilis of the joints has not, until very recently, received from the internist the consideration which it demands. When the diagnosis of general syphilis is established, any special manifestation such as a lesion of the joints is generally ac- cepted as an expected complication and very little special reference or attention follows. Most information in the present literature upon this sub- ject comes, therefore, from the syphilographer, or from the orthopedist and the general surgeon. There are two notable exceptions to this treatment. They are: First, the early writers (those in the times of John Hunter and immediately following) have given most accurate descriptions of the syphilitic joint, even though the direct relation between syphilis and diseases of the joints was not generally accepted; and second, more recently or since the discovery of the germ of syphilis and the introduction of the more accurate methods of diagnosis, the literature of syphilis gives evidence of more careful consideration of the syphilitic lesion of the joints. The orthopedist, with the aid of the roentgenologist, has also been a great aid to the internist in this, as in other of the arthritides, in the study of syphilis of the joints. There is now no longer any doubt that syphilis has a direct in- fluence in causing disease of the joints, and the early con- tentions of Lancreau and Virchow are definitely confirmed in the more recent knowledge of syphilis. Syphilis of the joints is not a frequent lesion, but in the consideration of disease of the joint it should always be kept in mind. Especially is this true in the obscure joint affec- tions of children. O’Reilly24 says between nine and ten per cent, of all cases seen at the orthopedic clinic of Washington University Hospital, St. Louis, have been joint syphilis, also that in children with joint disease the incidence of the syph- ilitic joint may be as high as twenty-five per cent. According to Hutchinson, in the inherited form of syphilis it may occur SYPHILITIC ARTHRITIS. 675 soon after birth,, though it is probably more frequent between the ages of seven and twenty years. It may present an epiphysitis in the young infant, or later in life it may occur as a chronic effusion associated with very little pain, in one or more joints. In this form it is usually preceded by an interstitial keratitis, and by gradually oncoming pains, not severe, but worse at night—“growing pains,’’ as designated by the unsuspicious mother. It may be spoken of first, be- fore the lesion is definite, as an arthralgia, which is no doubt akin to the condition frequently occurring early in the sec- ondary stage when there are general muscle and joint pains without any apparent localizing manifestations. Syphilis of the joints, producing extensive pathology, is more frequent in individuals of adult or middle life, though it may also occur in the aged. There is a manifestation of the joints in early syphilis, contracted at any age, which is scarcely worthy the name arthritis, but which will be con- sidered in the classification of this affection. And there is also that lesion called Charcot’s joint, which is undoubtedly of trophic origin, associated with a syphilitic lesion of the spinal cord. It usually comes late in the course of syphilis and may precede the first symptoms of tabes dorsalis. While it affects the joints, such as the knee, elbow, or shoulder, it is not in the strict sense the result of a direct infection of the joints, and will, therefore, not be considered except insofar as the differential diagnosis may be con- cerned. Aside from the conditions to which brief reference has already been made, namely, joint changes due to inherited syphilis, the arthralgia of early syphilis, and the Charcot’s joint, there are definite manifestations in the joints of adults and in those of middle life and old age which may be classified as follows: 1. Acute synovitis. 2. Chronic synovitis. 3. Subacute and chronic synovitis associated with intra- or peri-articular gummata or with an osteoarthritis. CLASSIFICATION. 676 THE INFLAMMATORY ARTHROPATHIES. This classification is suggested by the writer as it seems to represent more clearly what can be differentiated clinically.* PATHOLOGY. In the congenital form there may be an acute epiphysitis, which occasionally goes on to suppuration. It may occur in more than one joint. This is usually in infants. In older individuals there is more likely to be a chronic effusion, which may affect several joints, and is generally symmetrical. In the acquired form there may be an acute synovitis, which cannot readily be distinguished from an ordinary acute ar- thritis. This may pass on to a serofibrinous stage. A chronic hydrops may result. The characteristic pathological lesion of the syphilitic joint, however, is the gummatous formation which may oc- cur in the synovial sac or in any of the joint structures. There may also be an osteitis, or a periosteitis, in direct relation to the joint. The gummatous formation may break down into the joint, but more frequently it affects the cutane- ous surface. These advanced lesions are most frequent in the knees or the elbows, though they may occur in some of the smaller joints. The sternoclavicular joints are occa- sionally affected, producing a localized swelling which is quite characteristic. An inflammatory condition of the ar- ticulation formed by the manubrium and the gladiolus has long been considered as highly suggestive of syphilis. During the secondary stage of syphilis general pains throughout the body are a common symptom. This may be the first evidence of an arthritis, but not infrequently it is only a symptom of a general infection with no localizing SYMPTOMATOLOGY. * Hutchison (A Lecture on Syphilitic Joint Diseases, British Medical Journal, Vol. I, 1892, page 797) gives the following clinical-pathological classification: 1. Synovitis during the secondary stage. 2. Perisynovial gummata. 3. Arthritis due to osseous nodes or gummata in the neighborhood of the joints. 4. True chronic synovitis. 5. Syphilitic chondro-arthritis (Virchow). SYPHILITIC ARTHRITIS. 677 symptoms. This may occur with or before the appearance of the secondary skin eruption. When there is a definite acute arthritis the pain localizes at one or more joints. These are usually the knees or elbows, or occasionally the shoulders, ankles, and wrists. These are in the main the joints which also are most likely to be involved with the tertiary lesion. No joints are immune. The sternoclavicular joints have been mentioned. With the pain comes swelling and the evidence of effusion. It con- stitutes an acute synovitis. The pain may not be severe, and is characterized by being worse at night. The effusion is not marked, and there is seldom any discoloration of the skin. There is no great soreness or tenderness, and the joint may be moved with considerable and surprising ease. Fever and sweating are usually not present. The effusion may also be met with in certain bursae or tendon sheaths. The symp- toms disappear much more readily than in the ordinary poly- arthritis or in gonorrheal arthritis. Certain cutaneous nodules, especially on the extensor aspect of the joint, may appear. In the case of a chronic synovitis, the swelling and stiff- ness may occur with little, if any, pain. The effusion is greater and usually varies from time to time without any apparent cause. It may follow the acute form, however, but it usually occurs later and is not preceded by an acute stage. With this hydroarthrosis, or without it, a rather painless, irregular swelling of the joints may occur. This is the char- acteristic syphilitic joint. It is usually the knee, and is likely to be unilateral. The swelling is out of all proportion to the discomfort or lose of function. Parts of the swelling may be movable, but manipulation does not cause any great degree of discomfort. The gummatous process which is re- sponsible for this particular condition may break down and involve the synovial sac or may involve the skin, producing an irregular external lesion. If the gummatous process has involved the bone, or if there is an osteoarthritis, the joint is usually large and irregular, and probably more painful and tender. Regardless of the extent of the lesion, the subjective symptoms are remarkably mild. Unless treatment is insti- tuted the lesion will continue for an almost indefinite time. 678 THE INFLAMMATORY ARTHROPATHIES. DIAGNOSIS. The lesion is so characteristic that a diagnosis should not be difficult. However, because of the irregularity and ap- parent lawlessness of the syphilitic lesion in general, the manifestations of syphilis of the joint may be quite mislead- ing. In all obscure joint lesions an attempt should be made to get the history of syphilis, and a Wassermann test should be done. If the Wassermann reaction is negative and there is yet a suspicion of syphilis, specific treatment should be instituted as a therapeutic test. When this is undertaken, it should be with great thoroughness, for it is quite common for a chronic syphilitic arthritis to be present and the Was- sermann test to be negative. This is illustrated by the occasional experience one has with a chronic syphilitic who has gone the rounds of physicians and has had just enough mercury and iodides to prevent a positive Wassermann, but not enough to prevent a definite lesion of the joints or elsewhere. An x-ray examination may be of assistance, but this is often disappointing, unless there is a syphilitic process of the bones in relation to the joint. Under such circumstances the roentgenological examination will reveal the character- istic osteochondritis or osteoperiostitis. In advanced cases the x-ray may show destruction of bone and cartilaginous tissue. The condition should be diagnosed from acute rheumatic fever. The acuteness of the course, the local distribution, the fever and sweats, the severe pain, and the beneficial effect of the salicylates, in acute rheumatic fever should be sufficient to make the differentiation. It should be diagnosed from so-called arthritis deformans. The symmetrical distri- bution in the small joints, the acute exacerbations, the local redness and stiffness, with severe pain, also the peculiar deformities, such as “silver fork” and ulnar deflection of the hands, should mark the difference. There is scarcely, if ever, “lipping” of the margin of the bones in syphilitic arthritis. It should be differentiated from sarcoma of the joint, by the rapid growth of the tumor and the negative Wassermann. X-ray examination should be of some assistance in differen- TUBERCULOUS ARTHRITIS. 679 tiating from the above mentioned diseases, but a careful physical examination, following a comprehensive history and an intelligent interpretation of the Wassermann, are more to be depended upon. The treatment of syphilitic joints demands persistent use of the remedies ordinarily employed in the treatment of syphilis in general. The arthralgia of the secondary stage is best overcome by giving mercury, or arsphenamin, or both. The extensive joint involvement will be favorably affected by using in addition to these remedies, the iodides in large doses. This treatment should be continued until the joint is restored. Unless there is definite destruction of certain of the joint tissues, a cure can be reasonably expected. A systematic checking up with a Wassermann test will prove satisfactory, during the course of the treatment. Rest and fixation splints, together with such local applications as are usually employed in an ordinary arthritis, are, of course, helpful. When there is considerable effusion into the joint and antisyphilitic treatment with rest and pressure are not successful, drainage may be necessary. TREATMENT. TUBERCULOUS ARTHRITIS. INTRODUCTION. This is largely a disease of children and also is generally agreed upon as being a surgical disease. The exceptions to this statement are that it not infrequently is found in adults, and that while it is conceded to be a surgical disease, it is a fact that the employment of operative procedure in these cases is not so frequent as it was some years ago. There is some justification, therefore, for a discussion of tubercu- losis of the joints from the standpoint of the internist who deals largely with adult patients or with those who have passed middle life. It is a chronic disease with occasional acute manifesta- tions. It affects in the order of frequency, the spine, the hips, the knees, the ankles, shoulders and wrists. By far the most frequent location is in the spine (Pott’s disease), 680 THE INFLAMMATORY ARTHROPATHIES. in the hips (hip joint disease), and in the knees (white swelling). These manifestations of the disease have been recognized almost from the earliest records of man. The cause, however, and its relation to tuberculosis in general is only of recent date. The tubercle bacillus is brought to the joint by the blood- stream or by extension from a lesion in the vicinity of the joint. It is now generally agreed upon that the micro- organism gains entrance to the body largely with the food, by way of the digestive system. If not in all cases, at least in the great majority of cases, the lungs and the lymphatic system are first infected and the joint infection is secondary to this. In children there is probably more reason for think- ing that the infection may be primary, whereas in adults it is most likely to be secondary to a pulmonary involve- ment. While the interpretation of pain in the joint should always be a matter of importance, in an adult who has a known tuberculous lesion of the lungs, either healed or active, the possibility of a tuberculous process should receive careful consideration. Not infrequently an injury to the bone or joint, of the slightest nature, may appear to be the im- mediate cause of the disease. The process usually begins in the cancellous portion of the bone which enters into the formation of the joint. There is a rapid caseation following the formation of tubercles, and a breaking down of bone tissue which soon extends into the cartilages and finally results in miliary tubercles being scattered over the synovial membranes of the joint. This is followed by an effusion which in itself is not very extensive. Later, on account of the bone destruction, there is an apparent atrophy of the joint. Fistulae occur, from which there is either a purulent or a sanguineous, watery discharge, with occasional spicules of bone. In some cases the disease may begin more acutely with primary tubercles on the surface of the synovial membranes of the joint. Depending upon the location there is a characteristic de- formity. In the lower dorsal vertebrae, and also in the lum- bar, on account of destruction of the bodies and the super- PATHOLOGY, TUBERCULOUS ARTHRITIS. 681 imposed weight of the body, there is angulation and the protrusion of a “knuckle.” In the upper dorsal region, on account of fixation by the ribs, there may be little deformity, and in the cervical vertebrae the first effect may be a torti- collis. Always there is the possibility of a “cold abscess,” which may burrow along the sheaths of tendons and muscles in the immediate vicinity. Thus arises the psoas abscess. The hip may become dislocated and the leg finally shortened. The knee is drawn up so as to relax the tendons and liga- ments, when this joint is involved. The pathological process is practically the same in all joints. SYMPTOMATOLOGY. Usually the localization of the lesion is preceded by a decline in general health, with loss of weight. With this, localized pain is experienced, which is associated with mus- cle spasm, depending in character upon the seat of the lesion. The pain is usually referred in such a way as to be par- ticularly misleading. If the lesion is in the vertebne the pain may be referred to the abdomen, and if in the hips it may be referred to the knees. The pain is usually worse at night, but not so markedly as in syphilis or secondary cancer. In children the pains at night result in the so-called “night cries.” The pains are wearing on account of their regularity and constancy, and the patient loses sleep, loses his appetite, and takes on the appearance of serious illness. There may be an elevation of temperature, but this does not occur until for some reason or another the infection be- comes a mixed one. The pulse becomes rapid. Blood ex- amination will show only a secondary anemia, not necessarily a leucocytosis. The local symptoms are pain and tenderness over the joint. There is redness, providing the lesion is not too deeply buried in the joint structures. If the lesion is superficial, as in the ankle or wrist, there is a slight blush, but no great amount of swelling. There is a tendency to local necrosis and fistula formation. On account of the deep location of the lesion and the tendency to burrow, the swelling and redness may occur at some distance from the original lesion, as in a psoas ab- scess, pointing below Poupart’s ligament, when the lumbar 682 THE INFLAMMATORY ARTHROPATHIES. vertebrae are diseased. Limitation of use of joint, especially in a child, is highly suggestive. The more common and easily recognized symptoms of pulmonary tuberculosis are usually not in evidence in a case of tuberculous arthritis. DIAGNOSIS. The symptoms of pain in a single joint in a child, espe- cially if it be in the knee or hip, should make one suspicious of tuberculous arthritis. With such a lesion in mind every effort should be made to confirm or disprove the diagnosis. The symptomatology given above will lead one to an un- doubted diagnosis, but except for the pain, most of the symp- toms occur late, or after the disease has done almost irre- parable harm. It is very necessary to make the diagnosis early in these cases. To do this, x-ray examination by a skillful roentgenologist is of the utmost importance. This should be done as a matter of routine. It is surprising how valuable this procedure is in the diagnosis of an early lesion. This is particularly true in spinal and in hip joint disease. The primary focus in the bone can be made out long before the other symptoms besides pain appear. The importance of this from the standpoint of treatment cannot be over- estimated. Very helpful in the diagnosis is, of course, the discovery of a tuberculous focus in other parts of the body, such as in the lungs. If this verification cannot be made, and if the x-ray examination does not give positive findings, a hypo- dermic injection of Koch’s old tuberculin, 0.001 to 0.002 cubic centimeters, should be employed as a test. Very little harm can come from such a test if the case is carefully selected. Disturbance of temperature must be carefully interpreted. The condition must be diagnosed from syphilis, congenital or acquired. In this the Wassermann test, with proper in- terpretation, is exceedingly helpful. In the adult, particu- larly, the possibility of a gonorrheal arthritis is to be con- sidered, and in all cases sarcoma of the bone as well as an osteomyelitis must be kept in mind. It has been the experience of the writer that in adults tuberculous arthritis is more likely to be overlooked than in TUBERCULOUS ARTHRITIS. 683 children. Especially is this true if the lesion happens to be in the upper portion of the spine. A routine and intelligent use of the x-ray should be of great assistance in these obscure cases. TREATMENT. It is not the purpose to enter into a discussion of the surgical treatment of tuberculous arthritis, except to empha- size again in particular the necessity for rest of the joint. This is done with various splints, or with extension, pro- cedures which are well known and established. Before beginning a treatment there should be a definite understanding with the patient or the parents of the patient, relative to the probable length of time for the treatment and the necessity for cooperation on the part of all. It means a course of one to two, or even five years, and it means, if the case is met early and there is perfect compliance, that the patient will undoubtedly get well. All encouragement should be given after the patient once expresses his willing- ness to follow the course. With this, every attempt should be made to improve the patient’s general health by following such hygienic and dietetic treatment which occur to the intelligent physician. Fresh air and sunshine are absolutely necessary. If the sick room is not open to sunshine the patient should be moved out daily if possible. The local effect of the direct rays of the sun upon a tuberculous lesion, especially of the joint, is well recognized. There are places where this can be carried out in more satisfactory detail, such as in some of the cures established in the Swiss and Italian Alps, but it should not be forgotten that heliotherapy can be instituted wherever the sun shines, and this both in winter and summer time. This treatment, to be successful, must be systematized. An occasional exposure to the sun for varying time is of no particular benefit, but when given daily for definite periods it is of great value. The food should be nutritious and appetizing. Cod-liver oil should be a part of the diet. If it cannot be taken as food it should be given as medicine. Iron and arsenic with malt may be given from time to time. Because the patient leads such an inactive life the regularity of the bowels should 684 THE INFLAMMATORY ARTHROPATHIES. be made a matter of great care. Tuberculin treatment may be instituted, but in comparison with the measures already mentioned it is not of great value. By following such a course it is remarkable what can be accomplished in even a late case. The experience of the patient and the occasional checking up with x-ray examina- tion will give abundant evidence of the satisfactory progress towards the cure of the disease. WORKS OF REFERENCE. 1. Herrick: Pneumococeic Arthritis, Amer. Jour. Med. Sc., cxxiv, p. 12, 1902. 2. McCrae, Thos.: Osier’s Modern Medicine, ii, 1907, Lea Bros, and Co., Publishers. 3. McCrae, Thos.: Amer. Jour. Med. Sc., 1906, cxxxii, p. 878; Johns Hopkins Hosp. Bull., March, 1911, p. 75. 4. Studies on Epidemic Influenza, School of Medicine, Univ. of Pittsburg, 1919. 5. Anders, James M.: Osier’s Modern Medicine, ii, Lea Bros, and Co., Publishers, 1907. 6. Lambert, Alexander: The Incidence of Acute Rheumatic Fever at the Bellevue Hospital, Jour. Amer. Med. Assoc., April 10, 1920. 7. Swift, Homer F., and Kinsella, Ralph A.: Bacteriologic Studies in Acute Rheumatic Fever, Arch. Intern. Med., March, 1917, xix, pp. 381-396. 8. Klotz: Arterial Lesions Associated with Rheumatic Fever, Jour. Path, and Bact., xviii, p. 259, 1913. 9. Hanzlick, P. J., Scott, R. W., Weidenthal, C. M., and Fetterman, Jos.: Cinchophen, Neocinchophen and Novaspirin in Rheumatic Fever, Jour. Amer. Med. Assoc., June 18, 1921, p. 1728. 10. Adami: Text Book of Pathology, Adami and McCrae, Lea and Febiger, Phila. and N. Y., 2d Edit., 1914, p. 144. 11. Rosenow: The Etiology of Acute Rheumatism, Jour. Infect. Dis., xiv, 1914, p. 61. 12. McMeans: Chronic Suppurative Arthritis, Amer. Jour. Med. Sc., Sept., 1920, No. 3, cix, p. 417. 13. McMeans: Arch. Intern. Med., May, 1917, xix, p. 709, 749. 14. Henrici: Specificity of Streptococci, Jour. Infect. Dis., 1916, xix, pp. 572-605. 15. Pemberton, Ralph: The Metabolism and Successful Treatment of Chronic Joint Diseases; A Preliminary Report, Amer. Jour. Med. Sc., cxliv, p. 474, 1914. 16. Pemberton, Ralph: The Metabolism, Prevention and Successful Treatment of Rheumatoid Arthritis, Amer. Jour. Med. Sc., cxlvii, p. 423, 1914. 17. Pemberton, Ralph, and Buckman, Thos. E.: Studies on Arthritis in the Army Based on 400 Cases, Arch. Intern. Med., xxv, p. 335, 1920. WORKS OF REFERENCE. 685 18. Silver, David: Our Present Conception of Arthritis Deformans, Penna. Med. Jour., May, 1914. 19. McCrae, Thos.: Osier’s Modern Medicine, 1909, vi, p. 501. 20. Bier, Augustus: Hyperamie als Heilmittel, Verlog. von F. O. W. Vogel., Leipzig, 1906. 21. Miller, Joseph L. and Lusk, Frank B.: Foreign Protein in the Treatment of Arthritis, Jour. Amer. Med. Assoc., 1916, lxvi, p. 1756. 22. Thayer and Blumer: Johns Hopkins Hospital Bull., Balto., 1896, vii, p. 57. 23. Schwartz: The Complement Fixation Test in the Differential Diagnosis of Acute and Chronic Gonococcic Arthritis, Amer. Jour. Med. Sc. cxliv, p. 369, 1912. 24. O’Reilly: Joint Syphilis in Children, Amer. Jour. Orthop. Surg., xii, No. 4, p. 683. Gout BY EDWARD J. G. BEARDSLEY, M.D., L.R.C.P. (London). Assistant Professor of Medicine, Jefferson Medical College; Assistant Physician to the Jefferson Medical College Hospital. Gout. (Podagra; Arthritis Urtica; Goutte; Gicht.) Gout is a constitutional disorder, frequently inherited, due to faulty metabolism and functional inferiority of the kid- neys ; in which the amount of uric acid and other purin bodies in the blood and tissue fluids is increased and specific in- flammation of the joints with deposition of uratic salts in certain affected structures takes place. If one is to acquire the proper perspective for an intimate study of gout one cannot do> better than search out the earli- est recorded statements upon the subject and learn of the ad- ditions to this knowledge as the general advancement of learning and scientific progress have made such enlighten- ment possible. Gout can be truly said to be a very ancient as well as a modern enemy to mankind. Clifford Allbutt writes that, “of all maladies gout has perhaps the longest and most worship- ful pedigree,” while Ewart, in discussing the antiquity of the disease, states that “it is certainly as ancient as civilization.” It is interesting to note that in the accounts of the disease handed down from the remote past, the theories concerning the etiology, the accounts of the leading symptoms and the general ideas concerning the essentials in treatment were practically the same as exist in the modern treatises upon medicine. All authorities agree that gout has been from the beginning and still is practically unknown in those countries where the inhabitants obtain a livelihood by means of their own exer- tions, and especially if they subsist upon simple fare undi- luted by alcoholic beverages. Medical history teaches us that gout is not only a disease of great antiquity but it is acknowledged to be one of the earliest forms of bodily disorder that mankind acquired when HISTORICAL. 690 GOUT indolence, intemperance and luxurious living replaced the laborious days and simple foods and pleasures of our early ancestors. Hippocrates (460 to 370 b.c.) refers to the “unwalkable dis- ease,” and his clinical description of the disorder is accepted by authorities as proving that the entity described was true gout. Cicero (106 to 43 b.c.), himself a sufferer from the disease, mentions gout as a common disorder throughout the Roman Empire, while Celsus, Pliny and Seneca (first century a.d.) give excellent descriptions of the malady and state that its prevalence was due to luxurious living, all kinds of debauchery and to the lack of suitable exercise. We know from Lucian (120 to 200 a.d.), the brilliant Grecian poet, that the physicians of his period gave various names to the entity that we now term gout according to the part of the body affected. The term “podagra” simply in- dicated that the foot was the seat of the painful affection while if the hand, knee, shoulder or elbow was involved the terms “chiragra,” “gonagra,” “omagra,” or “pechyagra” were used. Thus the term “foot seizure” or “foot ail” similarly indicated the most characteristic symptom. Sir Dyce Duckworth states that it is probable that the earliest English (Saxon) name for gout was “fotadle” or “foot addle” the term “adle” being a synonym for ailment. The term gout was first used by Radulfe near the close of the thirteenth century. It has been thought that the name was derived from the Latin “gutta,” a “drop.” The ancient theory concerning the etiology of the disease was that it was due to the presence in the blood of some peculiar humor which, under certain conditions, “dropped” into the joints. Trousseau wrote of the word gout: “It is an ad- mirable name, because in whatever sense it may have been originally employed by those by whom it was invented, it is not now given to anything else than that to which it is applied.” The earliest theories concerning the etiology of gout are interesting and reveal all too truly the extreme slowness of medical progress. HISTORICAL. 691 Galen (131 to 201 a.d.) believed that the disorder was due to ‘'thick and morbid humors” in the blood and realized perfectly that the disease was frequently hereditary. He felt that the gouty deposits (tophi) were the result of desiccation of “mucus, gall and blood” (Neuburger) and he was familiar with the diathetic relationship between calculus and gout (Garrison). Soranus (second century a.d.), who is the authority on the gynecology, obstetrics and pediatrics of antiquity, writes with no uncertainty regarding the clinical manifestations of gout and ascribes the cause of the disease to over feeding and under exercising. Aretaeus (second century a.d.), who, to again quote Gar- rison, “ranks next to Hippocrates in the graphic accuracy and fidelity of his word pictures of disease,” gives an excellent account of the mode of invasion of gout and makes a special point of the tendency to involve the larger joints in later attacks of the disorder. This author mentions too the re- luctance which the victims of gout display in assigning the malady to its true cause—their own excesses—naturally pre- ferring to attribute the illness to an injury or other cause. Caelius Aurelianus, the fifth century neurologist, writes of Erasistratus, the famous Alexandrian anatomist, treating King Ptolemy for gout by restricting his diet. J. Mason Good states that gout was one of the maladies which was common in England in its earliest ages of barbar- ism. It was frequently referred to by the Anglo Saxon his- torian under the term “fot adl.” We learn from the references quoted, therefore, that gout was a common disorder in ancient days but it is not to be expected that the diagnosis was any more accurately made formerly than in our own time. It is scarcely necessary to point out that many other forms of arthritis such as the infective forms, or Neisserean and luetic manifestations were probably mistaken for gout as is true in modern medicine. It is interesting to note that the majority of the ancient writers agree that gout was produced by over eating and by drinking alcohol to excess. They felt that under the influence of a life of ease, particularly when suitable exercise was lack- ing, the “morbid humors” were generated in the blood and at 692 GOUT stated intervals there was a precipitation of these humors into or about the joints. Alexander of Tralles (525 to 605 a.d.) was of the opinion that there were many varieties of gout. Some were due to the effusion of blood into the joints and others to the ex- travasation of bile or other fluids between tendons and liga- ments. He recommended, in addition to careful dieting and suitable exercise for the patient, that the affected joints be rubbed with an ointment containing ammonia and turpentine in order that the tophi should be dissolved. Paul of TEgina (625 to 690) had what might be teriped very modern views regarding gout for he was sure that the dis- ease was frequently mistaken for other common joint affec- tions. One of the medical pioneers in the field of chemistry was Paracelsus (1493 to 1541) who was one of the first to look upon certain disorders as diathetic in nature. Garrison states that Paracelsus regarded both gout and the formation of stone as “tartaric processes” caused by the precipitation of sub- stances that were normally voided from the body. This is the first recorded attempt of ascribing a chemical etiology to a disease process. In 1643 the word “rheumatism” was intro- duced into medical science by Baillou who differentiated it from gout and from other forms of arthritis. In 1683 the English Hippocrates, Sydenham, wrote a treatise upon gout that still remains one of the best descriptions of the disease. As Sydenham was a victim of the disorder for many years it is not strange that his account of the malady should be graphic, accurate and forceful. Boerhaave (1668 to 1738) was of the opinion that gout was contagious and the same idea was maintained by Van Swieten. Among the first to dispute the long held view of the humoral pathology of the disease was William Cullen (1712 to 1790) who, in 1784, promulgated the theory that gout was a dis- order of the nervous system. Cullen admitted that the tis- sue fluids of the patient’s body became changed in gout, but he felt that this was a result of the malady rather than its cause. Cullen’s high place in English medicine caused the “nervous theory” to become popular despite the fact that Scheele had discovered uric acid in the urine in 1776 and that HISTORICAL. 693 Wollaston had proved in 1797 that gouty and urinary con- cretions contained uric acid. Following these discoveries many physicians began to re- gard gout as a disease intimately connected with the presence of uric acid although it was not until Sir Alfred Garrod dem- onstrated in a series of studies, during the period from 1848 to 1854, the relationship between uric acid retention and gout that the, so-called, chemical theory of the etiology of gout became popular. The demonstration of the presence of uric acid in the blood by the use of the very simple “thread test,” by Garrod greatly interested the medical profession and further influenced the adoption of the chemical hypothesis regarding the etiology of the disease. As early as 1854 Gairdner held that the disappearance of urea and uric acid from the urine and their accumulation in the blood was but a symptom of gout and in no way explained its cause. It was Gairdner’s thought that there was some obscure nerve influence at work. Barclay, in 1866, advanced the view that the primary change in gout lay in the blood corpuscles that were deleteriously affected by the action of the “gout pro- ducing elements” circulating in the blood stream. A novel theory was introduced by Ord in 1872, i.e., that there was an inborn tendency for the fibroid tissues of gouty subjects to undergo a special type of degeneration and Eb- stein’s experimental study substantiated the view that there was a disturbance of tissue nutrition apparently brought about by the irritant action of sodium urate in the tissue fluids. Murchison, Latham and others were of the opinion that gout was the result of a functional disturbance of the liver which caused a condition of lithemia. That the condition was “nervous” in origin was advocated, in 1873, by Liveling. Sir Dyce Duckworth, in 1880, gave as his opinion that gout was a “primary neurosis,” a functional disorder of a definite tract of the nervous system due to a central neurotic taint, and originating as the result of prolonged toxemia. Garrison indicates in his admirable History of Medicine that the aid of the physiological chemist was invaluable in further studies concerning gout. He points out the important items 694 GOUT. of progress in such works as Marcet’s discovery of xanthine (1819); Stecker’s demonstration of the same substance in the urine (1857); the discovery of the “family tree” of gout by Emil Fischer during the period from 1879-1895 when this great chemist demonstrated the purin nucleus as a sort of germ plasm common to all the metabolic products of the disease and made extensive studies upon the synthesis of proteins from their amino-acid constituents; Kossel’s proof that xanthine bases are derivatives of the urine (1879) ; the deter- mination of the true formula of nucleic acid by Schmiedeberg (1896) ; Kossel’s classification of the nucleins; Horbaczewski’s synthesis of uric acid in vitro (1882) and his proof that it is derivable from nuclein (1889) ; Minkowski’s discovery that a diet of xanthine bases will increase uric acid excretion (1868), that, in birds, the uric acid is synthesized in the liver through the influence of lactic acid (1886) ; and the relation of the liver to metabolism was studied to advantage by the Russian physiologist, Eck, in 1877 and much new light thrown upon this very complex subject. In the latter years of the nineteenth century, Chalmers Watson, Gore, Minkowski and others propounded the theory that gout was the result of a chronic infection. Their idea was that a toxin was formed within the intestine as a result of an infection by bacteria and that this toxin acted upon the blood in such a way as to cause gout. In 1905 Trautner came to the conclusion that the Bacillus coli communis was respon- sible for the production of gout. During the past forty years there has been a growing feel- ing that in a study of the metabolic relations of proteins will come the solution of the mystery of the cause of gout. Although the majority of authorities feel that uric acid, its formation and excretion, or lack of excretion, explains many factors of the disease; many other observers feel that there is a definite relation between local foci of infection and gout. Infected teeth, pyorrhea alveolaris, infected tonsils and sin- uses, chronic infections of the gall bladder, appendix and other regions of the body are often thought by certain clinicians to be the primary focus in bringing about the disease. GEOGRAPHICAL DISTRIBUTION. 695 Llewellyn, in a recent comprehensive work about gout, gives as his conclusions concerning the etiology of the dis- order the following factors; (1) The majority of the cases of gout reveal the presence of local foci of infection. (2) The local foci of infection should be regarded not as symptomatic of, but etiologically related to, gouty arthritis. (3) There is inherent abnormality or instability of nuclein metabolism, conjoined with an enhanced tissue affinity or in- creased retention capacity for uric acid. (4) These latent tissue peculiarities, through the agencies of infections or sub-infections (the presence of microbes that do not set up a focus of infection) become manifest as gout. (5) The organism or organisms excite inflammatory re- action with sequential uratic deposition, either of articular or ab-articular site. (6) The predilection of such uratic deposition for certain peculiar tissues is determined by their greater content of sodium ions as compared with the blood. (7) The local and general phenomenon of gout, its paroxys- mal nature and tendency to periodicity, are most readily ex- plainable on the basis of the presence of a chronic infection supervening in a subject the victim of those innate peculiari- ties of tissue with their correlated obliquities of function which we term the “gouty diathesis.” GEOGRAPHICAL DISTRIBUTION As a rule, gout is found indigenous only in the Temperate Zone. Stanley found that the natives of Africa never suffered from its effects but the more prosperous negroes of the United States are by no means immune. In China and Japan the disease is rarely met with except among the wealthy classes in the large cities. Where there are leisure classes with luxurious habits the disease is to be found. These conditions are usually found in the larger centers of population where the well-to-do citizens fail to earn their bread by the sweat of their brows. It is a common statement that there are more cases of gout in England than in the rest of the world. It is not to be 696 GOUT forgotten, however, that English physicians are perfectly fam- iliar with all varieties of the disease and, therefore, seldom fail to recognize it while physicians in other parts of the world being less familiar with its characteristics often fail to recognize even the tophaceous variety. The disease is also common in Holland, Belgium and France and was beginning to be frequently observed in Germany during the twenty years that preceded the great war. In Canada, Australia and South Africa it is found that gout is increasing, while in the United States it is certainly increas- ing in certain sections. It is to be remembered that the Eng- lish colonies as well as the United States will receive many emigrants from England—the home of gout—during the next few years and that many of these individuals will bring with them a gouty heritage. We can expect to see more gout in the future than we have been accustomed to find in the past. INCIDENCE. The statement is often made that gout is a rare disease in North America, but a truer statement is that the disease is fre- quently overlooked and its symptoms and signs misinterpreted. Futcher well says that: “If physicians will recognize the fact that there is, probably, no such affection as chronic rheu- matism, and that the vast majority of cases of chronic arthri- tis are either gout, arthritis deformans, or some other form of infectious arthritis, it will be found that, with due regard to the points in differential diagnosis, a great many more cases will be justly attributed to gout than in the past.” There were ninety-two cases of gout diagnosed among a total of thirty thousand eight hundred and seventy-one med- ical admissions in the Johns Hopkins Hospital in twenty- four years, or 0.29 per cent. A comparison of the number of cases in the above hospital and in St. Bartholomew’s Hospital, London, shows that the ratio was just two to three. When we consider that gout is more prevalent in Southern Eng- land than anywhere in the world, it indicates that North America has its share of patients suffering from gout. Williamson studied a series of one hundred and sixteen cases in the Cook County Hospital of Chicago, during six ETIOLOGY. 697 years, which is the largest series of cases ever reported from an American Hospital. The ratio of admissions from gout to total medical admissions in the hospital was four to ten, which is a higher percentage than that reported by other hospitals in America. Pratt states that only forty-one cases diagnosed gout were treated in the medical wards of the Massachusetts General Hospital between the years 1821 and 1916, and McClure found only thirteen cases of tophaceous gout among the first eleven thousand medical admissions to the Peter Bent Brigham Hospital, Boston. The writer has been much impressed in talking with various physicians at the number of cases of acute gout that are under treatment. The large number being treated at home is in marked contrast to the very small number encountered in hospital wards. Another impressive difference is the number of cases of “chronic rheumatism” met with in dispensary work who ex- hibit typical tophi, and frequently give a history of typical arthritic gout, who have never been admitted to the ward but who have been content to remain at home during the acute seizure. In questioning patients concerning former deposits of tophi, they frequently mention former salty deposits in the ear or over the knuckles or toes that have “dropped out” or have been removed. One cannot but be impressed with the fact that gout is not uncommon, but that it is diagnosed as such less often than it should be. ETIOLOGY. PREDISPOSING CAUSES. Heredity. From the earliest days of written medical history gout has been looked upon as a typical example of a disease transmitted by consanguinity. A family history of gout can be elicited in a very large percentage of gouty patients among the ed- ucated classes. Some authorities state that, in their opinion, the disease is always inherited. Although this statement may be entirely true, proof of its accuracy is difficult to ob- tain. Authorities agree that in from 40 to 75 per cent, of gouty patients met with in private practice a family history 698 GOUT of maladies that may easily be interpreted as gout can be ob- tained. In hospital statistics the hereditary factor is more difficult to accurately trace, as correct medical histories are not commonly fully appreciated by the average ward patient. In Williamson’s series of cases from the Cook County Hos- pital, Chicago, only thirteen per cent, of one hundred and six- teen cases gave a history of parental gout. It has long been noted that, although the women of gouty ancestry may escape typical gouty manifestations, they are more likely to transmit the disease than are the men. The disease is frequently transmitted from grandparents to grand- children without the fathers or mothers ever having suffered from classical gout. A study of the influence of heredity in this disease would tend to the belief that if the inherited ten- dency is sufficiently marked an individual may develop gout no matter how self-denying a life he may lead. On the other hand, a less marked inheritance may lie dormant until such time as the combination of other influences act as determining factors. Alcohol. Next to hereditary influences alcohol would head the list in importance among the predisposing causes. Beer, ale and porter with port and sherry wine have the deserved reputation of being much more “gout producing’’ than are the distilled liquors such as whisky, brandy, rum and gin. It has been many times pointed out that in Scotland, where whisky is the favorite drink, gout is much less often met with than in Southern England and certain sections of Ger- many where beer is the chief beverage. Futcher considers that beer is the chief etiological factor in the production of gout in the United States and lists “heredity” as secondary in importance to it. It will be interesting to note whether the attempted elimination by law of alcohol as a beverage will decrease the amount of gout in years to come. Excessive Amount of Food and Deficient Amount of Exercise. All authorities agree that gout is frequently the penalty of high living in the individual with a tendency to metabolic deficiency. Too much rich highly nitrogenous food has always been accused of rendering an individual liable to gout. ETIOLOGY. 699 Too much food and too little systematic exercise are cer- tainly two most important factors in the development of gout, especially when those factors are reinforced by the influence of heredity and the action of alcohol. Pratt states that the increase of gout in Germany during the twenty years that pre- ceded the world war was due to the fact that increasing prosperity had allowed the people to indulge in a much greater consumption of meat than they had formerly been accustomed to. Age. Gout is truly a “disease of middle life,” that is, its onset usually dates from the thirtieth to the fortieth year. Exceptions to this general rule, however, are met with in both youthful and aged patients. In Scudamore’s study of 515 cases he mentions four cases as having occurred before the age of 17, while in James Lind- say’s series of four hundred and eighty-two cases, one in- stance was in a boy of 9; four between the ages of 10 and 14, and thirteen between 15 and 19 years of age. Three cases were observed in Futcher’s series of ninety-two cases whose ages were from seventy-one to eighty years, and Garrod re- ports several instances where gout made its appearance after the patient had lived in health for seventy-five years, he men- tions one who had her first attack in her ninety-first year. The statement has been frequently made that most of the cases of gout reported as having occurred in childhood and in extreme old age are errors in diagnosis. This general statement may be true and still the writer has seen gouty tophi (proved by microscopical examination of the contents) in a boy of 12 and another of 14 years of age and treated a man of 91 in his first and only attack of gout, which was fol- lowed two months later by the appearance of a typical gouty tophus in the ear. Sex. There is a marked contrast in the susceptibility of the sexes. Males are much more liable to the disease than fe- males. Of the eighty cases submitted to the French Academy, seventy-eight were men and only two women. In James Lindsay’s series of five hundred and sixty-nine cases, 84.7 per cent, were males and 15.3 per cent, females. If we judge the presence of gout by the only pathogno- monic diagnostic criterion, i.e., tophi, gout in women is ex- 700 GOUT tremely rare but if we are tempted to interpret as gout atypi- cal cases of arthritis in the over-nourished and under-exercised women of the leisure class, then the diagnosis will be much more frequently made than proved. It is to be remembered that a female patient suffering from an arthritis should be as closely scrutinized for the evidences of gout as a male, for women, as a class, are taking less sys- tematic exercise during the middle years of their life than they should while they continue to consume more food and, as a rule, richer food than is good for them. Sedentary occupations and sedentary living especially when associated with lack of systematic exercise and over-indul- gence in food and alcohol is a factor of great importance in the production of gout in either sex. Lead. Futcher quotes MUsgrave, Huxham and Falconer as having drawn attention to the relationship existing between lead poisoning and gout as long ago as 1772 and Parry, in 1807, again directed the attention of the profession to this intimate relationship. Sir Alfred Garrod (1854) awakened new in- terest in the subject by reporting that one-fourth of all his patients that suffered with gout had at some time been af- fected with lead poisoning. He called attention to how many of the gouty patients had been employed as plumbers and painters. Sir Dyce Duckworth noted that twenty-five of one hundred and thirty-six typical cases of gout showed signs of lead poisoning and recently James Lindsay has reported that out of a total of four hundred and eighty-two instances of males afflicted with gout that one hundred and eight or 22.4 per cent, were workers in lead. In Futcher’s series of sixty-three cases of gout only three showed definite signs of lead poisoning. Pratt states, however, that among a large series of cases of chronic lead poisoning studied at the Massachusetts Gen- eral Hospital there was not a single case of gout and Frerichs had the same experience in a study of one hundred and sixty- three cases of plumbism in the Berlin Hospital (Duckworth). A few days since there was admitted to the wards of Dr. H. A. Hare at the Jefferson Medical College Hospital a well nourished man, aged 52, who gave a characteristic history of repeated attacks of articular gout. This man had been exposed to the ETIOLOGY. 701 fumes of lead for eighteen years. He had typical gouty tophi (proved by microscopic examination). The tophi were soft and appeared so pultacious that it had been suggested that they might prove to be sebaceous cysts. We do not know how lead acts to bring about a predisposi- tion to gout, but Garrod made the suggestion that as so many cases of lead poisoning develop an albuminuria and later a nephritis, and as so large a number of these cases also reveal an abnormal amount of uric acid in the blood, that the latter condition was probably due to a renal insufficiency. Sir Dyce Duckworth held the opinion that lead acted injuriously upon the nervous centers and thus caused gout. The former view appears the more tenable. Occupation and Physique. Painters, plumbers, enamelers and those who are exposed to the fumes of lead are likely to be attacked although it must be remembered that it usually takes a long period of exposure to bring about the conditions necessary to cause gout. In very susceptible individuals very mild exposure to lead has been known to precipitate an attack of gout. Sir Lauder Brinton has reported a patient who, following the ingestion of a small amount of lead in the form of lead and opium pills, developed a typical attack of gout although he had never previously been so afflicted. Llewellyn reports a similar but more striking instance in which a woman not known to be gouty used a hair lotion containing lead and who in a few days developed arthritic gout. The drinking of water im- pregnated with lead by being allowed to stand in pipes of this composition has apparently precipitated gout in the susceptible. Bartenders and those who work in breweries, owing to the free use of malt liquors are prone to become gouty. Persons who have a large frame with a tendency to obesity are usually the type likely to manifest gout. Traumatism. Authorities differ regarding the importance of the role of trauma as a predisposing factor in the produc- tion of gout. Certain observers feel that coincidence explains the onset of an attack of gout after an injury to a joint. The majority of authorities upon the subject, however, and all the experienced gouty patients feel sure that injury to a 702 GOUT. joint renders the part very much more susceptible to an attack of gout. The disease has been often observed for the first time following an injury to the joint, and equally often a gouty individual has noted that following an injury to a joint never before affected with gout an attack in this particular joint is apparently precipitated by the trauma. Sprains, fractures, dislocations and even slight injuries often precipitate an attack of gout in the susceptible. Lindsay reports nineteen cases in which tramua appeared to be the active and definite predisposing factor in precipitating an attack of gout. Dr. Thomas Kain of Camden reported to me an instance in a patient who fractured his femur and who developed a few days later a typical attack of acute gout in the big toe of the affected limb. This was followed in ten days by the appearance of gouty tophi in the ear. The patient had never before had an attack of gout and was accustomed to live a very active life. EXCITING CAUSE. The exact cause of gout is unknown. The modern view of the etiology is expressed in the definition of the disease, “a constitutional disorder, frequently inherited, due to faulty metabolism and functional inferiority of the kidneys, in which the amount of uric acid and other purin bodies in the blood and tissue fluids is increased and in which deposition of uratic salts in certain tissues takes place.” To possess a complete understanding of the biochemical problems involved in a study of the metabolism of the purin bodies would necessitate the highly specialized education and training of the modern biochemist. It is sufficient, however, for the purposes of the general practitioner of medicine to enable him to make himself familiar with the essential facts concerning the chemistry of the purin bodies, for in a study of the metabolism of these bodies one approaches the truth concerning the etiology, pathology, symptomatology and treatment of gout. The older physiologists believed that protein in the food was rendered soluble by the digestive enzymes and then absorbed into the blood and at once in- corporated into the tissues. The modern study of protein ETIOLOGY. 703 metabolism indicates that protein cannot be absorbed as such from the alimentary canal, but must first be broken down into the amino-acids, which are then rebuilt into the protein of the organism. The amino-acids not required for the purpose of recon- struction of the broken down protein of the body, along with those that may be liberated in the tissues themselves by dis- integration of tissue proteins, are then split into two portions, one represented by ammonia and the other by the remainder of the amino-acid molecule. The former is excreted as urea and the latter is oxidized to produce energy (Macleod). By an examination of the chemical formulas of the purines we note that the basic substance from which the others are derived is purin. The list is as follows: Purin, C5H4N4. Hypoxanthin, CnH4N40. Adenin, C5H3N4O2. Xanthin, C5H4N4O2. Guanin, C5H3N4ONH2. Uric acid, C5H4N4O3. It will be noted that the highest oxidation product of all is the urinary constituent, uric acid, which may be designated as trioxypurin. These purin bodies result from the action of certain specific ferments or enzymes, upon the nucleo- proteins of the food and of the tissues. Uric acid is thus formed both from the body tissues and from the proteins of the food. When uric acid is once formed in an individual with in- herited tendency to gout, there is difficulty in ridding the body of it. This inability to oxidize or excrete the excess of uric acid formed appears to be the important factor in the production of gout. Biologists inform us that, “all mam- mals, with the important exception of man, are able to destroy uric acid rapidly and in considerable quantities. This destruction is an oxidation brought about by a specific en- zyme called uricase, and the reaction seems to consist of the removal of one of the carbon atoms from the uric acid, thus converting it into the more readily soluble allantoin” (Wells; quoted by Osier and McCrae). 704 GOUT Llewellyn states that the enzymes responsible for the dis- ruption of the nucleic acid complex are not to be found in all the body tissues. The liver, spleen, thymus, and pancreas* more particularly, contain enzymes in abundance. The en- zyme responsible for the oxidation of xanthin into uric acid, viz., xanthin-oxidase, is found in man only in the liver. In man, as in most mammals, uric acid is formed chiefly in the liver from purins. Nucleic acid is a chemical complex, made up of phosphoric acid with purin bases. The nuclein element of the food requires the enzymes of the pancreatic secretion to break it up into nucleic acid and protein. The nucleic acid undergoes partial decomposition after it is acted upon by the intestinal juices through the action of a ferment called nuclease. Under its influence the nucleic acids are further split into groups known as nucleotides. Through the action of another enzyme, nucleotidase, the purin nucleo- tides are further decomposed into nucleosides. The nucleo- sides are again acted upon by the enzymes of the spleen, liver and thymus (nucleosidases), and broken down into the so-called “building stones” of the nucleic acid molecule, phos- phoric acid group, carbohydrate group, pyrimidin and purin bases, especially adenin and guanin. The adenin and guanin thus formed are, by the action of the ferments adenase and guanase, converted and by the removal of their amino group, transformed (adenin into hypoxanthin, and guanin into xan- thin). By the action of oxidases in the tissues hypoxanthin is changed into xanthin, and xanthin into uric acid, this by a specific ferment xanthin oxidase. Summary Concerning Metabolism. We have learned that in man, uric acid is the end product of protein metabolism. It is derived from nucleins and formed chiefly in the liver. Loss of the power of elimination favors the deposition of uric acid products. Those individuals who cannot rid them- selves easily of their purins, endogenous or exogenous, may be said to be gouty. Certain persons inherit this tendency to defective elimination of uric acid products, and certain others acquire it by their mode of life. In typical cases of gout the amount of uric acid in the blood is increased from the normal quantity of one to three millegrams per cent, to several times that amount. This PATHOLOGY. 705 appears to indicate the inability of the kidney to rid itself of this product. The true cause of the deposits of uratic salts must be some change in the chemistry of the blood that alters the form of uric acid there contained and thus brings about a deposit of its salts. It is to be remembered that uric acid is found in excessive amounts in certain other disorders, such as leukemia and chronic nephritis, and it is equally true that in the interval between acute attacks of gout there may be marked increase in the amount of uric acid in the blood without there being symptoms of gout present. The proved fact that uric acid can be injected into the blood-stream in considerable quantities without causing symptoms of gout, does not indicate that there is no danger to susceptible individuals who are unable to rid themselves of the excess of uric acid in their blood. PATHOLOGY. The Blood in Gout. The amount of uric acid is definitely increased. Garrod was the first to point out the quantitative increase, in 1848. By his introduction of the “uric acid thread experiment,” better known as the “thread test,” Garrod stimulated an active interest in the disease by the new light that he had been able to throw upon the pathology of the disorder. Garrod described the “thread test” as follows: “Take one or two fluidrams of the serum of blood, and put it into a flattened glass dish; to this add ordinary strong acetic acid, in the proportion of six minims to each dram of serum. When the fluids are well mixed, introduce one or two linen threads, about an inch in length. The glass should then be set aside in a cool place until the serum is quite set and almost dry. Should uric acid be present in quantities it will crystallize and during its crystallization will be attracted to the thread, and assume forms not unlike that presented by sugar candy upon a string. The glass, with its threads, should be placed under the low power magnification and the crystals of uric acid easily seen.” The thread test has been replaced by more modern tests but it is still useful for demonstration. 706 GOUT, Roethlisberger, Folin, and Denis, and Stanley Benedict, have introduced simple and accurate tests for uric acid in the blood which are available to all. Benedict’s latest test will probably supersede all other tests as it is simple, accurate and easily performed. The fact that extreme accuracy is possible, even when only one or two cubic centimeters of blood serum is used for testing, will recommend it. The importance of the work of Folin and Benedict in per- fecting the tests for uric acid in the blood cannot be ex- aggerated. Previous to Folin’s work no method existed by which the amount of uric acid could, even approximately, be determined. Adler and Ragle tested the blood of one hundred and fifty- six non-gouty patients and found that the average amount of uric acid was 1.7 milligramms per 100 cubic centimeters of blood. In Pratt’s study of twenty-one gouty patients there was an average amount of 3.7 milligramms per 100 cubic centimeters of blood. The same observer noted that in a few cases of undoubted gout the uric acid content was within normal limits, though it never fell, even on a purin- free diet, below 1.4 milligramms. Pratt feels that the low values in certain of his cases may have been due in part to the errors inherent in the original Folin method. In a later study by McClure and Pratt of forty-nine cases of gout in which the uric acid in the blood was estimated by the original method of Folin. thirty-eight (or eighty-six per cent.) showed 3.1 to 7.2 milligramms per 100 cubic centi- meters, and six from 1.7 to 2.8 milligramms. Macleod mentions four cases in which the figures were 9.5. 8.4, 7.2, and 6.8, respectively. Although the high uric acid content is a feature of the majority of the cases of gout and the content is usually higher during an attack than in the intervals, Pratt’s ob- servations indicate that both in gouty and non-gouty sub- jects fluctuations in the uric acid content occur quite inde- pendently of diet. Pratt states that a characteristic of gout is the presence of three or more milligramms of uric acid with the non-protein nitrogen amounting to less than fifty milligramms. PATHOLOGY. 707 Authorities agree that leucocytosis is the rule in an attack of acute gout and it is usually stated that there is a very marked degree present (20,000 to 50,000). Even in a sub- acute gouty polyarthritis high counts are frequently reported and in the chronic forms it is common to find a moderate leucocytosis. Chalmers Watson reported the presence of a large number of myelocyte-like cells during an attack of acute gout, and Bain confirmed his finding in one of his cases but states that the peculiar cells were present in small numbers in his case. DaCosta and Ewing have reported instances of moderate leucocytosis in both the acute and chronic forms of gout. In the chronic forms of the disease a mild anemia is fre- quently observed but whether this is due to the frequent association of a nephritis or to the metabolic disease is not definitely known. It is reasonable to believe, however, that the loss of sleep, the pain and general distress might easily bring about an anemia, and these causes in addition to the marked tendency to arteriosclerosis and kidney pathology, might easily explain the anemia without ascribing it to podagra. Tophi. A gouty tophus is a local deposit of uratic salts. Such deposits are usually found in connection with cartil- ages, especially the cartilages of the ear, tendons, synovial membranes, muscles, and the skin, but are also frequently found in the vicinity of the joints and bursae, especially over that of the olecranon and patella. According to the statistics of Duckworth, in one-third of all well marked cases of gout, tophi are to be found in the helix, antihelix, fossae, and in the lobule of the ear, and, in rare cases, also upon the posterior surface of the pinna. It is to be noted that in many cases where gouty deposits exist in the joints, there may be an entire absence of tophi in the ears and other superficial parts. Tophi were recognized very early in the history of gout, and Aretaeus, writing in the second century, a.d., made the following observations: “Callosities also form near the joints; at first they resemble abscesses, but afterward they get more condensed, and the humor being condensed is dif- ficult to dissolve; at last they are converted into hard white tophi and over the whole there are small white tumors like 708 GOUT vari or larger, but the humor is thick and like hailstones.” The view that tophi were made up of chalk existed for cen- turies and it was not until the researches of Wollaston (1797) that tophi were found to be very largely made up of sodium urate. It is well known that tophi occasionally become calcified, but repeated examinations by modern chemists have shown that the chief constituent of all true tophi is sodium biurate. We know that in the blood and lymph of an individual suffering from gout there is an excess of uric acid, either existing in the free state or in combination. In uratosis we have a precipitation of the uric acid salts and a collection of these salts in certain structures. We do not yet know the exact nature of the chemical change that brings about a precipitation of the salts of uric acid in the blood. Why a patient may carry an excess of uric acid in his blood for months and years without uratosis, and why he suddenly develops the latter, is as yet a medical mystery. The biochemists inform us that uratosis cannot exist without excess of uric acid in the blood. The exact composition of the nucleus about which the urate of soda is deposited is unknown, but as concretions in the body frequently form about masses of mucin, bac- teria and precipitated proteins, it is quite possible that this combination may form the nucleus of a tophus. As the acicular crystals are deposited they become covered with mucin, animal, or earthy matter. The tophus is thus formed of crystalloids and colloids, both evolved from the fluids of the body. Chemists state that the conditions that control the solubilities of crystalloids and colloids are most complex, and although these conditions do not entirely explain the nature of gout, the variations doubtless stand in intimate relation to the formation of tophi. Authorities seem agreed that tophi are always preceded by local inflammatory re- action of varying degrees of severity, and that uratic deposits are a sequel to the inflammatory change. It is this tendency in gout to uratosis, i.e., the deposit of sodium urate, that frequently renders the diagnosis of even an obscure con- dition easy. We know that uratosis is confined to one dis- ease—gout—constituting its pathognomonic stigma. Osier PATHOLOGY. 709 pointed out how helpful the presence of tophi were in a differential diagnosis of any form of polyarthritis. He ad- vised a careful inspection of the ears, the tendons, and the region of the smaller joints, for tophi in all obscure arthritic conditions. Negative findings may be of almost as much value as positive findings in certain complicated joint dis- orders. It is well to bear in mind that when a tophus first makes its appearance it is, not infrequently, immature, soft, and abscess-like. It begins as a small red area on the auricle of the ear or elsewhere, and is all too frequently overlooked or misinterpreted. It has been pointed out that it is well to remember the possibility of the disease being gout when dealing with obscure maladies, especially in those connected with an ar- thritis. The following symptoms and physical signs have been helpful: (1) Pain, pricking sensations, heat or tenderness in the ears, with or without small red swellings of the skin. (2) Similar sensations at site of finger and toe joints, with dorsal swellings over which the skin may be reddened or unchanged in color. (3) The *existence of white pearly concretions, sometimes soft, i.e., mature and immature tophi. In dealing with both the mature and immature tophi it is usually easy to determine the true nature of the swelling. In the immature (soft) swellings a portion of the semiliquid contents can frequently be withdrawn by aid of a hypo- dermic syringe and needle, for examination. If a mature tophus, its contents can be removed by a surgical needle and examined with the microscope. Many observers have noted that when tophi first appear, sensations' of stinging pain and tenderness accompany them. The patient often finds the pain unbearable when his ears (containing begin- ning tophi) rest upon the pillow. Graves, of Dublin, a victim of gout, reports that in his own case this burning pain and tenderness of the ears was most distressing and only disappeared when the gout invaded his finger joints. It is in the chronic form of articular gout that tophi are most likely to occur, but it is also true, as Duckworth and 710 GOUT other observers have shown, that tophi sometimes precede by several years the arthritic form of gout. Trousseau states that small and often immature tophi or “cutaneous gravel’’ may constitute the only manifestation of the gouty diath- esis, and is often accompanied by a sensation of pain or prickling unattended by any disturbance of the general health. Tophi are frequently met with over the tendon sheaths, and especially over the olecranon and patella. These sub- cutaneous tophi in the neighborhood of the joints sometimes become tense and painful, and restrict the movements of the adjacent articulations. Tophi are found invading the integu- ment of the limbs at times. They are not infrequently seen over the ulna and tibia. Pye Smith saw a man with ulcers upon his thigh and legs which ulcers were discharging sodii biurate. Tophi are to be found in severe cases in the palms of the hands, the soles of the feet, pulp of the fingers, over the knuckles and the phalanges. They have been found in the eyelids, in the skin of the nose and cheek, and more rarely in the skin of the penis and scrotum, in the perineum and in the scapular region. Even in the conjunctivse and sclerae tophaceous deposits have been rarely seen and recognized. Uratic deposits may be of a considerable size and are frequently misinterpreted because of this fact. Llewellyn reports having seen deposits that were as large as a small hen’s egg. The largest tophi are usually found near a joint, frequently in the upper extremity. Even when large they are frequently non-adherent, the skin moving freely over the surface. Sometimes the presence of the tophus induces irritation of the overlying skin, which becomes reddened, then purple, and not infrequently the skin becomes ulcerated from pressure. Such ulcers often dis- charge large amounts of sodium urate, which gives the patient great relief. Gouty inflammation never ends in suppuration, yet ab- scess formation very commonly occurs in the tissues about a gouty tophus. Garrod saw a patient that had five gouty abscesses on each hand and others on his feet. He writes that as long as the uratic deposit was discharged the patient PATHOLOGY. 711 enjoyed immunity from gouty symptoms, but when healing occurred it was often the cause of a sharp attack. Uratic deposits within a joint are, of course, invisible, but they can sometimes be recognized by a grating sensation and noise when the joint is used. The Kidneys. Many observers having had much experi- ence with patients suffering from gout feel that an inflam- mation of the kidney is an integral part of the disease. Certainly the presence of nephritis is extremely common and an investigation of the kidney function in the presence of gout is most important. Ebstein describes two types of gout cases: (1) the “primary renal gout,” and (2) the “primary articular gout.” Certainly a condition that might be termed “primary renal gout” is not a rarity. Futcher reports such an instance from the wards of the Johns Hopkins Hospital, in a colored man of twenty-four years of age. For several months he had complained of the usual symptoms of chronic nephritis. There had been no previous arthritic history. A few days before his death, he developed pain and swelling of his right great toe-joint. The joint, at autopsy, revealed the characteristic deposits of sodium biurate in the articular cartilage. The kidneys were much contracted. A very similar case was admitted to the wards of the Jefferson Medical Hospital, under the care of Dr. Thomas McCrae a number of years ago. The patient was a young white man of seventeen years of age, who came to the medical dispensary complaining of dyspnea. He was found to have a greatly enlarged heart and was sent to the ward for observation. A few days after his admission he developed a typical attack of acute gout with the suppression of urine. At this time tophi appeared in the pinna of the ear, with considerable inflammatory swelling. The patient lived a number of weeks and was to all appearance a classical pic- ture of chronic interstitial nephritis. The systolic blood- pressure was extremely high, approximating 300 during the acute seizure of gout. A microscopical examination of the tophus in this case revealed the typical acicular crystals of sodium biurate, and the autopsy revealed deposits of this same salt about the only affected joint. 712 GOUT. The usual form of nephritis met with in gouty patients is that commonly spoken of as “contracted kidney.” The clinical relation, however, between gout and chronic neph- ritis is not definitely known. Sir William Roberts observed: “It is quite common to see articular gout, even of a chronic and inveterate character, run its entire course without any accompanying signs of structural disease of the kidneys.” It is everyday experience to care for patients with chronic contracted kidney who never develop gout, and in those gouty patients that develop nephritis late in life there are many etiological factors that appear more important, in many cases, than does gout. Mosenthal’s two-hour test to discover the true renal function is proving far more important than chemical or microscopical examination of the urine. In a small number of cases of gout coming to autopsy a deposit of urates is found chiefly in the region of the papillae. Norman Moore found this state in twelve out of eighty cases. The most important statement that can be made regarding the relation of gout to nephritis is that the same etiological factors that tend to produce gout also serve to cause renal changes that lead to nephritis. We must leave to the future the solution of the relationship of the two diseases and in the mean time carry on a propaganda of prophylaxis that will aid in lessening the morbidity rate of both disorders. Cardiovascular Lesions. Arteriosclerosis is a common ac- companiment to gout, but whether the patient acquired his vascular pathology independently of the metabolic disorder is a difficult matter to prove. The blood-pressure is usually high and the vessels appear stiff to the palpating finger. Although the symptoms may be entirely connected with the heart and circulation, it is necessary to study the kidney function with great care lest the true cause be overlooked. Disturbed cardiac action is very frequent in “gouty” patients; palpitation, arrhythmia, and even syncopal attacks, are not uncommon, especially among patients who eat too rapidly as well as too heartily. Attacks of true angina do occur, but attacks that simulate angina are far more com- monly met with. Faulty hygiene: in eating often causes flatulence that not uncommonly causes functional heart dif- ficulties. Hypertrophy of the left ventricle is frequently met PATHOLOGY. 713 with and systolic murmurs at the apex are common. It makes little difference whether we look upon the arterio- sclerosis as primary or as secondary to the gout or to the kidney pathology, the symptoms and physical signs are the same and the treatment not unlike. The arch of the aorta is frequently involved in an arterio- sclerotic process, and systolic murmurs over the base of the heart and in the vessels of the neck can frequently be heard. The orifices of the coronary vessels may be narrowed and the vessels themselves sclerosed. Myocarditis is a common complication, as one would expect, and fatty degeneration of the heart muscle occurs. It is difficult to ascribe to gout the terminal pericarditis that is encountered, because the renal pathology might easily account for its appearance. Phlebitis is a relatively common complication. It sometimes occurs as a complication in varicose veins of the legs, or it may occur in various portions of the body. Respiratory System. Acute and chronic attacks of pharyn- gitis are proverbially frequent in the subjects of gout. Ton- sillar inflammation, both acute and chronic in nature, occurs, and in certain rare cases deposits of biurate salts have been recovered from the follicles. Laryngologists have reported similar gouty deposits about the vocal cords, and in the epiglottis and laryngeal cartilages. Gouty tracheitis, bronchitis and pleurisy is met with occa- sionally, and it is quite likely that it occurs more commonly than is suspected. Emphysema is an extremely common complication of gout and is accompanied by the chronic bronchitis that causes so many of the “winter coughs” that torment the victims of the disease. One characteristic that is possessed by the majority of the complications of gout is the intractable course of the dis- order when treated as a local ailment. Unless one has the presence of tophi to aid one, or the equally enlightening repeated attacks of an arthritis limited to the great toe, the failure of a local manifestation (as noted above) to improve under treatment may well direct one’s thoughts to the possibility of gout. 714 GOUT Eye Complications. Ophthalmologists ascribe to gout many conditions of the eye in which the proof of the re- lationship is difficult, if not impossible. That a correct diagnosis of gout is frequently made by an experienced oculist months or years before typical arthritic symptoms occur, or before the deposit of tophi, is well known. It is equally true that the term “gouty” is carelessly used to designate conditions that could with justice be termed “toxic” or even “idiopathic.” It is well known that an excess of uric acid in the blood can cause certain acute hyperemias of the conjunctivse, often recurrent in nature, that may or may not be associated with arthritic difficulties. Certain forms of keratitis occur so commonly in patients whose heredity and general charac- teristics incline to class them as victims of a metabolic dis- order, that the condition is often termed “gouty keratitis.” There is a class of too well nourished patients, particularly women, who suffer with episcleritis and episcleral nodes, that respond so well to the treatment usually instituted for gout, that many careful observers believe that this disease accounts for the local inflammation. That gout can be the sole cause for a severe, recurring, iritis has been known for a long time. This condition usually attacks one eye at a time and affects chiefly the superficial layers of the iris (de Schweinitz). Such an inflammation may appear as the first symptom of gout, the arthritic dif- ficulties appearing months or even years later. It is well known that glaucoma occurs frequently in gouty subjects, but the exact relationship between the two disorders is not fully understood. Gout is so constantly associated, in its later stages, with arteriosclerosis and renal changes that it is impossible to feel that gout alone causes the condition. Cataract, too, is a frequent complication of gout. Opaci- ties of the vitreous occur, hemorrhage into the same structure as well as into the retina, and all these conditions have been ascribed to gout. Orbital optic neuritis, paralysis of the ocular muscles, and imbalance of the same structures, have occurred so frequently during the course of chronic gout that the disease is always mentioned as a possible cause of the condition. PATHOLOGY. 715 Nervous Manifestations. Headache, attacks of migraine, neuralgias, and other nerve pains, are a very common ex- perience of gouty patients. These individuals frequently complain bitterly of itching feet at night, and of itching sen- sations about the joints that later show inflammatory changes. Sciatica and lumbago have frequently been ascribed to gout, perhaps more commonly than careful study would warrant. That uric acid deposits can and do cause both of these disorders has been frequently proved at the autopsy table. Functional nervous symptoms are so frequent in patients known to be gouty that such symptoms are looked upon as part of the usual symptomatology of true gout. A careful history elicited from many so-called neurotic individuals fre- quently reveals a classical hereditary gout. The presence of tophi, or the onset of a typical attack of acute gout, not infrequently causes a change of diagnosis from a functional nervous difficulty without known cause, to the same diag- nosis with a well defined cause, i'.e., gout. Urinary Disorders. Albuminuria is an almost constant finding. Casts, hyaline in type, are found in nearly all cases of chronic gout, while in many cases the urinary sediment is similar to that commonly encountered in a case of chronic nephritis. The urine is, as a rule, abnormally acid, high colored and scanty during the acute attack. There is commonly a marked deposit of uric acid and uratic salts. Sugar is found inter- mittently—gouty glycosuria. This condition sometimes de- velops into a state of true diabetes. When this happens the dietary treatment seems more effectual than it is in many cases of uncomplicated diabetes mellitus. Kidney, ureteral and bladder stones are not uncommon complicating factors. Urethritis, with a profuse, purulent discharge, has been reported a number of times in connection with acute gout. It usually appears at the end of the attack, without any other etiological factor than, possibly, a gouty tonsillitis being discoverable. 716 GOUT. SYMPTOMS. Gout is usually divided into the acute, chronic and irregular forms of the disease. Acute Gout. Premonitory symptoms are the rule, al- though they are not infrequently ignored or misinterpreted. Uncomfortable sensations are commonly experienced for days and sometimes for weeks before an attack. Distaste for food, indigestion, oppression and fullness after eating, with eruc- tations, tympanites, and constipation, are frequent symptoms. Twinges of pain in one or several joints, «. feeling of heat and itchiness in a foot, slight swelling of a joint that causes a sense of stiffness, are frequently complained of. Irritability of temper, restlessness, especially at night, burn- ing sensation in an ear, or in both ears, and general bodily discomfort, are frequent. A pharyngitis, coryza, a tonsillitis, a tracheobronchitis with troublesome, unproductive cough, frequently initiates the attack. The acute seizure usually begins in the early morning hours with a sudden agonizing pain in the great toe, more commonly in the right foot than in the left. At the same time the patient has a frank chill or a sense of chilli- ness. There is fever and the temperature may rise to 103° F. The pain is said by those who have experienced it to be more agonizing than mere words can describe, and Syden- ham, himself a martyr to the disease, says: “The pain in- sinuates itself with the most exquisite cruelty among the numerous small bones of the tarsus and metatarsus, in the ligaments of which it is lurking.” The joint or joints swell rapidly and become hot, tense and shining in appearance. The local sensitiveness is ex- treme and the pain almost intolerable. There is often a local engorgement of veins about the affected joint or joints, and this engorgement becomes more marked as the attack pro- gresses. Edema in the region of the joint is common, and in the sthenic attacks there have been reported ecchymoses. With the subsidence of the attack the redness, edema and venous turgescence gradually disappear, and desquamation with itching occurs. Not infrequently there is more than one joint involved, particularly the tarsal joints. The in- SYMPTOMS. 717 flammation, no matter how intense, never suppurates, and with the decrease of the swelling the joint returns to normal. The tongue is usually coated during the attack, the breath foul, and the patient suffers with anorexia and intense thirst. The dyspeptic symptoms of the premonitory period often persist and are at times exaggerated. On the other hand, the digestive symptoms may disappear with the onset of the attack. The urine is diminished in amount, high colored, extremely acid, and often reveals the presence of albumin. As a rule the temperature abates during the morning hours and often reaches normal, or nearly so, but in the evening it rises to a higher level, with a morning remission as before, and so continues for a varying number of days, usually two to eight. The temperature then subsides and is often sub- normal for a number of days. There is usually a moderate leucocytosis during the acute seizure, and occasionally an unusual high count without known complications. After an attack of acute gout the general health is fre- quently much improved. Recurrences, however, are fre- quent, and a patient may have several attacks in a short period or, on the other hand, may be free of symptoms for months and even for years following a severe attack. It should be remembered that following an attack of acute gout the formation of tophi often occurs. Trousseau pointed out that the tophus was evolved between attacks rather than during the attack. Chronic Gout. It is difficult to sharply differentiate chronic from repeated attacks of acute gout. A long interval may elapse between the early manifestations of the disorder, and in many instances a period of from many months to several years intervene between the first anti second seizures. After two or more attacks later paroxysms occur, usually, at more frequent periods. The dividing line between acute and chronic gout is very indefinite and is regarded as an arbitrary matter. Flint stated that, “if the disease continues beyond three or four weeks, it is to be considered as chronic,” while Trousseau stated that, “should the disorder extend beyond three months, it is chronic gout.” 718 GOUT The predilection of the disease for the great toe-joint con- tinues into the chronic form. In a progressive case, joint after joint is involved, the tarsal joints, wrists, knees, and elbows being most frequently affected. Garrod held the sequence to be as follows: the great toe, heels, ankles, knees, small joints of the hands, shoulders, and hips. Lindsay states that in a total of four hundred and eighty- two cases in males, the great toe was the initial point of attack in two hundred and forty-eight cases, or 51.3 per cent. In females the great toe is not so frequently affected. Thus, in a total of eighty-seven cases the onset began in the great toe in twenty-two cases, or 25.3 per cent. A striking feature is the frequency with which the joints of the lower extremities are first invaded in comparison with those of the upper extremities. Thus, in Lindsay’s series of four hundred and eighty-two males, the joints of the lower limbs were those first affected in four hundred and six, or 84.2 per cent. Norman Moore states that the gouty deposits may affect all the joints of the lower limbs and be entirely absent from those of the upper limbs. Sometimes one attack seems to merge into the next, but the latter seizures are rarely as severe in character as are the earlier experiences. The joints become more or less de- formed, and tophi may develop about the joints as well as in other portions of the body. There is much difference in patients regarding the amount of deformity that results. Certain patients are badly deformed by one attack, while in other patients there may be no noticeable change in the joints after many and apparently severe attacks of the dis- order. In severe forms the hands and feet may be much deformed, and there may be extensive concretions about the elbows and knees, in the bursae and along the tendons. Tophaceous deposits occur almost exclusively in connec- tive tissues, especially those in connection with the joints. As a rule, the deposit is first made in the synovial membranes, articular cartilages and other tissues within the joint cavity. Later on in the history of the disorder deposits may occur in the tendon sheaths, synovial bursae, fasciae, and certain subcutaneous tissues. In the course of years the frequently SYMPTOMS. 719 affected joints become swollen and deformed, and there may be extensive concretions about the elbows and knees and along the tendons and in the bursae. The successive attacks of painful swelling, with the con- sequent loss of sleep and digestive disturbances, often seri- ously affect the patient’s general health. The complicating arteriosclerosis and renal changes produce symptoms com- monly associated with such disorders. Intercurrent attacks of acute arthritis frequently occur, and the temperature may range from 100° to 103° F. On the other hand, there may be redness, pain and swelling in a number of the joints without fever. Irregular Gout. This term is commonly used in describing a group of ill defined symptoms that occur in certain patients suffering from nutritional disorders in which there is, for one reason or another, a suspicion that the symptoms are “gouty.” It is well known that a strong temptation exists to think of “gout” in dealing with the symptoms of members of a family in which there may be a typical example of acute or chronic gout associated with tophi. Such symptoms are often encountered in the class of patients who live sedentary lives and who eat and drink too heartily. Functional liver disturbances, indigestion, headache, neuralgias, eye symp- toms not explained by refractive errors, irritability and vague symptoms of unrest, are the common symptoms ascribed to irregular forms of gout. Certain of the patients who exhibit such symptoms do later in life develop typical gout, while others with equally disturbing family histories and suspicious symptoms fail to do so. There is little doubt but that a diagnosis of “irregular gout” opens a wide field for mistaken diagnosis, but it is equally true that one is forced to such unsatisfactory diag- noses at times and the developments of time apparently justifies the use of the term. Retrocedent Gout. The term “suppressed” or “retro- cedent” gout has been applied for many centuries to serious symptoms that occur coincidentally with a more or less rapid disappearance of the local arthritic inflammation. There can 720 GOUT be little doubt that many of the reputed instances of this nature were incorrect diagnoses. Symptoms of tabes, angina pectoris, coronary thrombosis, biliary colic, appendicitis, renal stone, uremia, pericarditis, cerebral apo- plexy, and many other conditions, could easily be mistaken for the mysterious entity that has been characterized as “metastatic gout.” Very remarkable manifestations have undoubtedly oc- curred following the rapid disappearance of or improvement in the local inflammatory symptoms and signs. What the true explanation of these symptoms—acute pain, vomiting, diarrhea and great depression in one class of dyspnea, pain, and irregular heart action or possibly delirium or coma in another—is, is not easily ascertained. Llewellyn quotes Dr. Parry, of Bath, as having witnessed in one winter two instances of apoplexy following “the re- moval of gout in the extremities by immersing the feet affected in cold water.” Llewellyn states that in certain individuals under his care who attempted the same revul- sive procedures, severe cardiac pain has ensued with syncopal attacks, sometimes fatal, while in others gastrointestinal attacks of great severity have developed. When we remember the state of the circulation and the altered kidney function in many of these patients who suffer with gout, one can see that coincidence may explain many puzzling factors in these medical emergencies. One does well to follow the advice of Sydenham, “to study the patient instead of the gout.” DIAGNOSIS. In the majority of cases of acute gout no great difficulty should arise. An arthritis, limited to the great toe or to the metatarsophalangeal and tarsal joints, is very characteristic. The extreme grade of inflammation, the shiny appearance of the skin and the agonizing pain is very characteristic. If the affected individual has a gouty heredity and lives the kind of life that encourages metabolic disturbances, the diag- nosis of gout is all the more plausible. There are many cases of this malady, however, who will have arthritic disturbances elsewhere than in the feet, and only a carefully elicited his- tory will reveal that years previously there had been an DIAGNOSIS. 721 involvement of the great toe. It is commonly observed that after one or more attacks of the disease limited to the meta- tarsophalangeal joints, other articular surfaces may be af- fected at a much later period when the memory of the original involvement has been dimmed by time. An arthritis of the hip, knee or shoulder due to gout is sometimes misinterpreted as due to a focal infection, to lues or to rheumatoid arthritis. The presence of tophi are most helpful in arriving at a correct diagnosis when such deposits are present. Osier felt that a careful search for tophi should be made in every case of arthritis. Although the tophi are commonest in the cartilaginous portions of the ear, in the vicinity of the helix and antihelix, they are frequently found in other situations as mentioned under the section describing them. Tophi should not be confused with sebaceous cysts nor with the small fibroid nodules sometimes observed on the margin of the ear. An examination of the contents of a tophus with the microscope obviates any possibility of error. Where there are large deposits about the knee, elbow, toe or finger, the diagnosis is manifest. Futcher has pointed out that subcutaneous tophi, clinically indistinguishable from fibroid rheumatic nodules, may occur over the extensor surfaces of the forearms and about the knees. The excision of such a nodule and microscopic examination of its contents will reveal the characteristic crystals. A feature of diagnostic importance is the low range of temperature seen in acute gout when compared with the temperature range of acute rheumatic fever. Numerous reliable observers have reported cases of acute gout that were afebrile. Any polyarthritis with acute manifestations and unaccompanied by fever, should always cause a strong sus- picion that it is gouty in origin (Futcher). The family history, the personal history as to occupation, habits, exposure to lead poisoning, the history of the onset of any arthritic disorder, are all most important in attempting to diagnose an obscure condition. The x-ray may be of some assistance in differential diagnosis but other arthritic disorders simulate the shadows of gouty manifestations to 722 GOUT such an extent that the photograph is, frequently, of less importance in deciding the matter than is the history of the attack. The x-rays frequently fail to reveal the existence of a deposition of urates in the articular cartilages. When an attack of acute rheumatic fever subsides there is no de- formity or limitation of functional activity observed. When we deal with an acute arthritis that does leave as a sequel a deformity or some limitation of motion as a sequel, we may assure ourselves that we are dealing with gout or with rheumatoid arthritis. In arthritis deformans the well known ulnar deflection of the fingers takes place, as well as the almost constant occur- rence of atrophy of the dorsal interossei muscles of the hands. Heberden’s nodes, the exostoses on the terminal phalanges in arthritis deformans, have been known very rarely to occur in true gout but their appearance points, as a rule, to arthritis deformans. It has often been pointed out that when arthritis de- formans affects the larger joints, such as the knee, wrist, or elbow, the deformity is more likely to be fusiform in shape. When arteriosclerosis and renal involvement complicate a chronic arthritis it is well to search for evidences of gout. The fact that we do not think of gout in connection with obscure arthritic disorders often accounts for our failure to correctly diagnose it. The estimation of the amount of uric acid in the blood by the latest Benedict test will, in the future, prove a helpful agent in differential diagnosis when considered in conjunc- tion with other and equally important facts. An estimation of the number of leucocytes is also helpful, as there is so consistently a leucocytosis in the acute manifestations of gout. The Wassermann test, a search for bfeisserean shreds in the urine, a prostatic examination, have all been known to reveal the exact nature of an obscure arthritis. PROGNOSIS. This depends more upon the complications that may occur than upon the treatment instituted. TREATMENT. 723 The complications that may shorten life are those con- cerned with the circulatory organs and the kidneys. The appearance of albumin in the urine is by no means to be taken as an indication that the patient has a serious nephritis. This symptom should be carefully studied, as albuminuria has* been known to exist in a gouty patient for many years without the kidney function becoming seriously impaired. Members of gouty families are frequently long lived and certainly their death is seldom due directly to gout. The prognosis depends, in part, upon (1) the constitution of the patient; (2) upon the early and correct diagnosis; (3) prevention of complications; (4) intelligent direction and treatment of the patient. TREATMENT. The modern treatment of gout cannot be said to be entirely satisfactory. Like the treatment of many other chronic dis- orders, the results are satisfactory neither to the victim of the disease nor to the physician who attempts to relieve the patient and cure the disease. The subject of the treatment can be appropriately divided into three parts: (1) Prophylaxis. (2) Treatment of the acute attack. (3) Treatment of chronic gout. Prophylaxis. From what has been previously stated con- cerning the nature of gout and concerning the various etiological factors involved in the production of the malady, it must be evident that preventive measures are likely to be much more efficient in preventing the onset of the disease than are drugs or other therapeutic measures in curing it. Ideal prophylaxis would naturally and correctly begin with a careful selection of a patient’s ancestors, in order to insure that no tendency to metabolic disorders should be inherited. The selection of proper ancestors for our patients, however, is seldom practicable, even when such selection might be possible. There are prophylactic measures that are both practical and helpful. The prevention of gout, even in sus- 724 GOUT. ceptible families, may be expected when physicians become particularly interested in metabolic disorders and when they take advantage of their opportunities for giving helpful instruction regarding personal hygiene to their patients. Practical advice regarding diet, beverages, exercise, bath- ing, choice of occupation and sports, can be of the greatest value if based upon scientific data and sound reasoning. There can be no doubt that individuals who have been unfortunate enough to have inherited a tendency to gout or who have exhibited evidences of the malady, should abstain from all alcoholic beverages, eat moderately of plain foods, and live active lives, if possible, in the open air. Dietary indiscretions, especially those of overeating and overdrinking of alcoholic beverages, in conjunction with lives of physical inactivity, lead straight toward gout and other metabolic disturbances. This is particularly true if there has been inherited a tendency to gout. Both ancient and modern authorities upon the subject of gout agree that open-air exercise, good hygienic surroundings, moderation in food consumed, complete avoidance of alcoholic beverages, and freedom from worries, are among the best prophylactic meas- ures that can be employed. It is well to remember that gouty individuals are susceptible to other infections and the better hygiene that can be adopted the better chance the patient has of escaping various infections. Particular attention should be directed to the care of the skin. Frequent bathing is particularly necessary in the gouty, and blanket baths, vapor or hot-air cabinet baths are distinctly helpful in selected cases. Care should be observed to prevent undue chilling of the body at • any time and especially following the hot baths. An occasional mercurial purge, followed by mild salines, is frequently helpful and possesses the impressive authority of long usage by the profession. Few prophylactic measures are based upon such scientific facts as the necessity for a decreased amount of food consumption in the average case of gout. The somewhat trite but true statement that the average person, whether child or adult, eats too much, will not be questioned by any observing person. The truth of the state- TREATMENT. 725 ment is proved in part by the evidence of one’s eyes. For men, women and children are to be seen who are and who remain through life, much overweight. The diet of a patient who, through heredity, is susceptible to gouty influences, should be a simple, easily digested, mixed diet. Alcohol, tea and coffee should be avoided. That the average individual drinks too little water is frequently pointed out by those who make a study of metabolism, and it is particularly well for persons predisposed to gout to drink water freely. There is little evidence that aerated and other expensive waters are superior to any pure water as an elim- inant. Water cannot leave the body without carrying with it certain accumulations of waste products. No one will venture to assert that the use of tobacco will prevent gout, while a number of authorities feel that this drug, even in so-called “moderate quantities,” is a distinct source of danger as a predisposing cause in a subject sus- ceptible to gout. Exercise as a prophylactic measure is highly recommended by those who have an extended experience in the study of gout. The patient should be instructed to exercise or walk vigorously, unless there are complications that prevent such a course, daily. Care should be taken to avoid chilling following such ex- ercise, and usually a hot bath and vigorous rubbing add to the benefit of the exercise. Sports in the open air, not too strenuous in nature, add the benefit of the interest elicited to the beneficial exercise in the open air, and should be enthusiastically encouraged in suitable cases. Gout is so invariably the result of over- nutrition and under-elimination that encouragement should be given all measures that tend to decrease the amount of food consumed and aid in the excretion of waste products. Treatment of the Acute Attack. This consists of those measures that will relieve the patient’s pain, reduce the swell- ing in the joint or joints, permit rest and sleep, and, if possible, prevent another attack of similar nature. Acute gout must be treated somewhat differently according to the age, constitution, and present vital powers, of the individual affected. 726 GOUT In this disease it is particularly necessary to bear in mind that it is the patient suffering from an attack of gout that is to be treated, and not the disease alone. It is the man or woman that we must have constantly in our minds, and a careful study of each individual patient must be made in order that one may be successful in treating the malady. For the relief of the intense pain and associated sleepless- ness, it is frequently necessary to administer morphin or other sedative drug by hypodermatic injection. To the writer, all the possible theoretical objections to this plan of procedure give way before the great and practical good ac- complished by the administration of suitable doses of the drug. In this connection it is well to remember that suf- ficient drug should be administered to relieve the symptoms, even if large amounts are required. In mild attacks and when dealing with patients who are willing to endure a certain amount of distress, opiates may not be necessary, but in the presence of great pain and restlessness, morphin should be freely used. The patient should be confined to the bed, or at least should be recumbent for several days. The affected limb (or limbs) is nearly always made more comfortable if it is elevated slightly and kept warm by enveloping it in cotton wool or by frequently applying hot fomentations. In severe attacks it is always wise to protect the affected limb from the pressure of bed clothing and accidental pressure, by the use of a cradle or other protective measure. All varieties of hot applications have been used and pro- nounced efficient by various patients which fact probably indicates that the virtue lies in the heat applied, rather than in the various medicaments incorporated in the various lo- tions. Applications of whisky and water as hot as could be endured was a favorite treatment in preprohibition days; lead water and laudanum, hot menthol solutions and other spirituous applications, are popular throughout the world. The hot-air cabinet, the electric light bath, and other and more homely means of applying heat, such as poultices of various kinds, are very acceptable to many patients. Two medicinal agents have proved most valuable in the treatment of the acute manifestations of the disease. TREATMENT. 727 Tolysin (novatophan) is frequently most useful in reliev- ing both the pain and inflammation of the joint or joints. This drug should be given freely early in the attack, in doses of fifteen grains, well diluted, every two hours until the pain is relieved or until it is evident that the drug is ineffectual in this particular case. The wine of colchicum or the tincture of the same drug is known as a specific for gout and has been used for many generations. Given in doses of from one-half to one fluid dram every second hour until patient is relieved or until free purgation with gastrointestinal irritation ensues, the drug is frequently of great value. Unfortunately, at times, each drug fails and it is necessary to try first one and then the other. Many physicians add a laxative to the use of either drug, although in the case of colchicum the added laxative is frequently unnecessary. When both of the above mentioned drugs fail to improve the condition after a fair trial, the possibility of a mistaken diagnosis as well as the possibility of inert drugs must occur to us. Textbook authority to the contrary, it is perfectly possible to mistake a septic arthritis, a luetic and even a Neisserean arthritis, for an acute attack of gout, and as can be readily surmised it is equally possible to mistake gout for one of the other forms of arthritis. Instead of using the wine of colchicum many therapeutists use colchicina, U. S. P., in doses of %00 to %>o of a grain. Most practitioners adopt the plan of giving a thorough mercurial purge followed by a saline before beginning the administration of any other drug. When opiates are not required to control pain and when insomnia is a troublesome feature of the attack, such drugs as chloral, luminal, barbitol, paral- dehyde, or similar hypnotics, prove useful. Chloral can be used with benefit in doses of from twenty to sixty grains, and is, in the experience of the writer, a harmless and most useful hypnotic. Paraldehyde is useful in a dose of from one to three fluid drams. Barbitol, in ten grain doses administered six hours before its effects are to be realized, has often proved effectual. Administration of one grain of luminal twice a day will sometimes make the patient 728 GOUT. very comfortable and sometimes do away with the necessity for stronger remedies. Inert drugs are, unfortunately, not a rarity and one must be assured of potent preparations before condemning a remedy. It is particularly important that one in whose care a gouty patient places himself should remember that because the patient has gout it does not follow that he may not have other and equally important maladies. When treatment appears to fail, an investigation should be made for com- plications. Diet. The diet of a patient suffering an acute attack of gout depends, in great part, upon the age and general con- dition of the patient. The young, robust and plethoric in- dividuals who have no complicating disorders, do excellently when deprived of all food for several days. During this period, water, carbonated or plain, should be given freely and the patient urged to drink large quantities of this diluent fluid. When the patient complains of hunger he may be given bouillon, consomme, vegetable, or chicken soup that is slightly salted and a moderate amount of toast. The quantity of food administered during an acute seizure of gout should be negligible and should preferably be adminis- tered in liquid form. After a few days, when the seizure is improving, a small quantity of fish and a small amount of thoroughly baked potato, with spinach, lettuce, celery, or other green vegetable, may be allowed. The return to regular diet should be made gradually and with caution as to the amount of food allowed. A gouty patient will, if in otherwise excellent health, never receive too little nourishment, and the temptation of both physician and patient is to allow too much food. In aged, asthenic gouty patients, or in those individuals who have complications, the light diet above described is frequently insufficient. One is surprised, nevertheless, to find how well starvation agrees with certain of the so-called asthenic patients. Each gouty patient is particularly a law unto itself, but as Allen has so well and so profitably pointed out in dealing with another metabolic disorder, starvation can accomplish TREATMENT. 729 so much more than we ever dared to hope for in former plans of treatment. Plain, well-cooked foods should be allowed to asthenic patients who do badly rather than feel badly under the plan of a rigid withholding of food. In advising a very gradual return by very slow stages to the usual diet, after an attack of acute gout, it is well for both physician and patient to remember that Sydenham, himself a great sufferer from gout, said: “Great eaters are liable to gout, and of these the costive more especially.” The patient should be advised to limit his diet as well as to vary the same as to varieties of food. Lettuce, spinach, asparagus, endive, beet and dandelion greens, celery, toma- toes, brussel sprouts, cauliflower, cabbage, and similar vege- tables, whose carbohydrate content is low, can be eaten with impunity. Bran biscuits, with or without the addition of agar-agar, are very useful in correcting the tendency to constipation that is so frequently a feature of gout and goutiness. Dr. F. M. Allen suggests the following recipe for the use of his diabetic patients: Bran 60 grams (2 oz.) Salt U teaspoonful Agar-agar, powd 6 grams l1 teaspoonfuls Cold water 100 c.c. glass) The bran should be purchased at a feed store and should be the coarse bran that is used for feeding cattle. Tie bran in a cheesecloth and wash under cold-water tap until water is clear. Bring agar-agar and water (one hundred cubic centimeters) to the boiling point. Add to washed bran the salt and agar-agar solution (hot). Mould into two cakes. Place in pan, on oiled paper, and allow to stand for half an hour: then, when firm and cool, bake in moderately hot oven thirty to forty minutes. When no glycosuria compli- cates the gout, the bran muffins can be made more palatable by adding butter and eggs. Bran cakes may be made as advocated by Joslin for the use of diabetics as follows: 730 GOUT Bran 2 cupfuls Melted butter 30 grams Eggs (whole) 2 Egg (white) 1 Salt 1 teaspoonful Water. Tie bran in cheesecloth and wash thoroughly by fastening onto the water tap until the water comes away clear. The bran should be frequently kneaded so that all parts come into contact with the water. Wring dry. Mix bran, well beaten with whole eggs, butter and salt. Beat the egg-white very stiff and fold in at the last. Shape with knife and tablespoon into three dozen small cakes. If desired, one-half gram of cinnamon or other flavoring may be added. Another helpful measure in overcoming the tendency to constipation is the administration of heavy liquid petroleum at night. Usually a tablespoonful of this oil is effectual if taken regularly over a period of time. If the oil is kept on ice or in a cold place, there is little or no taste, and it can be administered either plain or in orange or grape juice. A glass of hot water before breakfast sometimes acts as a mild laxative, as is well known. The use of fruits, such as figs, prunes, and grapes (the latter eaten with the skins), is most helpful. Treatment of Chronic Gout. All that has been written concerning the prophylaxis of acute gout is equally true when applied to the subject of chronic gout. The violence of the symptoms of acute gout attract attention, and fewer mistakes in diagnosis are made in this form than in the chronic inflammation due to uratic deposits. The treatment of this or any other condition depends in a great measure upon the correctness of the diagnosis of chronic gout. Mistakes in diagnosis are frequent. The presence of tophi ordinarily determines the diagnosis, but it is well to remem- ber that not all true cases of gout exhibit tophi and that patients revealing typical tophi may be suffering with other maladies in addition to the gout. When we have assured ourselves of the accuracy of our diagnosis, the treatment of chronic gout divides itself into: (1) Dietetic treatment. TREATMENT. 731 (2) Local treatment for the affected joints. (3) Medicinal treatment. Diet. The value of frugal and temperate living in pre- venting attacks of gout has been recognized from the earliest times. It has been long known that an active life with de- creased amount of food tends to prevent the occurrence of gout. Liver, sweetbreads and kidney should be eliminated from the diet, as they contain the greatest amount of purin sub- stances. Roasted or broiled meats are more injurious to the gouty patient than are boiled meats, as the purins are ex- tracted by boiling water. Pratt points out that nearly all soups are made from meat stock, even creamed soups, and hence are rich in purins. All kinds of fresh fruits may be eaten, and sweets are allowable unless the blood sugar content is high. Local Treatment of the Affected Joints. Hot baths, either general or local baths to the affected joints, are usually grate- ful to the patient. Massage, gentle in character, with passive movements and the rubbing into the tissues over the joints of various ointments, is a very ancient as well as a modern mode of treatment. In skilfully applied massage there is much greater virtue than in drugs in the treatment of chronic gout. The beneficial effects are not confined to the affected joints and muscles but, as a result of the improved circula- tion, waste products are more readily excreted and the general health improved. Hot douches have been used for many centuries in the treatment of chronic joint affections and such treatment is decidedly helpful in treating the arthritic form of chronic gout. To relieve the stiffness and swelling of the joints, alternating jets or sprays are most suitable. Massage re- inforces the stimulating and absorbing action of the douches and the patient’s general condition is improved as a result of the local measures. Medicinal Treatment. In chronic gout we deal with a deficiency of elimination, and our treatment may well be directed to- ward correcting the defects of elimination through kidneys, bowels, or skin. 732 GOUT, Alkalies such as bicarbonate of potash in 15-grain doses can be given with benefit twice daily, in combination with a bitter tonic. When constipation exists, the alkali (either sodium or potassium bicarbonate) may be administered with magnesia and rhubarb. Much pure water should be prescribed for its action upon the skin and kidneys. Iodide of soda and potash have excellent reputations as useful alteratives. There can be no doubt in connection with the painful joints of chronic gout but that iodin is a useful remedy. Three to five grains of the sodium iodid is quite as useful as the larger doses sometimes prescribed. Atophan or tolysin (novatophan), is a decidedly useful remedy and often relieves the joint pains in a most efficient manner. Wine of colchicum, in full doses, is equally helpful at times and should be given a thorough trial before being discarded. Garrod thought very highly of the resin of guaiac in the treatment of chronic gout, giving 5 grains three times a day. He held that this drug exerted a specific action on the fibrous tissue, and advocated its use in chronic forms of gout with feeble circulation. Llewellyn also advocates its use as a laxative for constipation in the gouty. He prescribes it combined with equal parts of sul- phur and potassium bitartrate. Treatment of Tophi. Tophi in the neighborhood of joints sometimes become very painful and restrict the movements of the articulations. There are no solvents for these uratic deposits, but massage, hot douches and external application of iodin, is decidedly helpful in relieving the symptoms. Surgical treatment of uratic deposits when they give rise to pain or restrict the movements of the joints is advisable and the results satisfactory. Healing of the wounds without suppuration is the rule, and in suitable cases surgical meas- ures should be adopted to give the patient the relief that is easily obtainable by skilful use of the knife. Obesity BY GUY HINSDALE, M.D. Member of the International Society of Medical Hydrology: Former President of the American Climatological and Clinical Association; Fellow of the College of Physicians of Philadelphia. Obesity. FOREWORD. It is only within recent years that obesity has been classi- fied as a disease. Until thirty years ago it was scarcely accorded any attention in textbooks on the practice of medicine. The popular attitude toward the obese has varied throughout the ages and in different countries; even now it is considered favorably in Turkey. Julius Caesar must have preferred fat men, for he says to Mark Antony: Let me have men about me that are fat, Sleek-headed men and such as sleep o’nights; Yond Cassius has a lean and hungry look, He thinks too much; such men are dangerous. Act I, Sc. 2. A book on the psychology of the obese would be most interesting. Sir John Falstaff alone would fill a large chap- ter, and Dr. Johnson, unkindly called a behemoth by one of his fair contemporaries, would fill another. But obesity has its pathetic side; it should be a subject for medical study and assistance and not a target for the caricaturist. Not all cases are exogenous or due to excesses in food and drink. Probably some inherit such tendencies or are brought up amid surroundings that led their fathers or mothers to take on excessive weight. But a large num- ber are endogenous or due to faulty glandular action—a condition we recognize as endocrine obesity. In these cases the cause is due to aberrations in the pituitary gland, the thyroid gland or the gonads. For each individual there is a normal weight which may be regarded as normal for him at the time and which he tends to maintain under varying circumstances. It requires some effort to change this normal average weight. Any change due to variation in the water content is usually tran- sient and limited to a few pounds. During violent exercise five or more pounds may be lost, mainly from profuse sweat- 736 OBESITY. ing, and most of this is made good by drinking more liquid. But fat is more stable than water; they are partners, to be sure, in the making of an obese individual but their activities and relative resistance to attempts to dislodge them are obviously very different. Nothing makes such a rapid re- duction in the watery content as diseases like Asiatic cholera and yellow fever. The fat does not disappear pari passu with the water but it contributes naturally to the total loss in avoirdupois. Fat is deposited whenever the energy intake of the food exceeds the energy requirements of the body. Immoderate eating, on the one hand, and indolence, on the other, are recognized causes of obesity. Hewlett1 has summarized our knowledge of metabolism in this regard in his excellent chapter on “Pathological Physiology and Its Relation to Internal Medicine,” in Oxford Medicine. Recognizing that some individuals appear to gain weight despite a moderate intake of food and an average amount of exercise, we get the impression that in such individuals the rate of com- bustion in the body is less than normal, and that in this way food material is conserved and is converted into fat. They conserve their energy by sleeping well, maintaining an even disposition, without worry and without unnecessary movement; excepting in the latter respect there is no ac- cepted proof, according to Hewlett, that the rate of metab- olism in the obese individual is different from the normal in any essential particular. The resting metabolism, the liberation of heat after eating and the liberation of heat after exercise, have all been studied and found within normal limits. The real difficulty lies in a failure to adapt the intake of food to the needs of the body; rather than to charge it to a primary reduction in metabolism. There is an insidious constraint, or at least a failure to resist the temptation to eat day after day more than the body requires; this excess need not be great; it may easily escape detection, but the added increment asserts itself in a gradual gain, and once gained is easily maintained. “So long as fat is simply stored up as adipose tissue, and between and not within the cellular elements of the body, THE FORMATION OF FAT. 737 it is comparatively harmless, excepting as it indicates a disproportion between functional activity and the amount of fuel taken to develop force, interfering with personal con- venience, and causing greater muscular fatigue from the increased work thrown upon the muscles in supporting so heavy a body. The special danger in all cases of this class is that the heart muscle may become affected in this manner, which renders it liable to cease beating whenever the slightest additional strain is thrown upon the circulation. Thompson instances a woman weighing one hundred and twenty pounds at 20 years and two hundred and forty pounds at forty years. In doubling the size of her body she has the same size of heart to maintain the circulation that she had at 20 years, but she has more work to do, for every time she walks or climbs a flight of stairs she raises the additional one hundred and twenty pounds of dead weight” (Gilman Thompson). A GENERAL CONSIDERATION OF OBESITY. THE FORMATION OF FAT. Adipose tissue is not as simple in its structure and func- tion as was formerly believed. Seventy years ago and for many years after, it was held, according to the teaching of Virchow in his “Cellular Pathology,” that fatty adipose tis- sue is merely a common connective tissue loaded with fat. This remained unchallenged until 1870, when Toldt first stated that the fatty tissue of mammals is a specific organ entirely distinct from the connective tissue.* He recognized that beside the usual fat deposits, the cells of which, derived from the primitive fat organ of the early fetus, form lobu- lated structures with an independent and characteristically glandular type of blood supply; there also occur irregular deposits of fat in connective tissue not possessing these features and returning to their original connective tissue structure and function when the fat is reabsorbed. It would seem that both types of fatty tissue exist, the glandular type being the more important and abundant. It is supposed that fat soluble vitamines are stored in the glandular adipose * We are indebted to an editorial in the Journal of the American Medical Association, Oct. 23, 1920, for a discussion of this subject. 738 OBESITY. tissue. The conclusion is drawn from studies, which we do not need to rehearse, that there are at least two and probably three types of adipose tissue, namely: ordinary connective tissue, storing surplus simple fats; glandular adipose tissue, storing lipoids with varying amounts of simple nutritive fats; and glandular adipose tissue, with close functional relationship to the endocrine glands. Dr. S. Weir Mitchell,2 in one of his best known books, “Fat and Blood,” published in 1877, discusses gain and loss of weight in a very interesting manner. It was the custom at the Infirmary for Nervous Diseases where Dr. Mitchell held clinics, to weigh patients when they entered and at subsequent intervals, and Dr. Mitchell took pains to also record their height, not doing, as a recent writer complains so many do, that is, weigh them when alive and measure them after they are dead. Dr. Mitchell was chiefly engaged in restoring to health a class of nervous patients generally emaciated and anemic, but not so often in reducing the obese. However, his observations on the fat-making function and his method of accelerating it are famous the world over. He emphasized the fact that it is important to remember that it is almost invariable that loss of flesh occurring rapidly is accompanied soon or late with more or less anemia, and it is uncommon to see a person steadily gaining fat after any pathological reduction of weight without a correspond- ing gain in amount and quality of blood. Patients, therefore, who lose weight from any pathological cause, are liable to have thin blood as the tissues decrease and richer blood as they increase. Fatty matter is the one constituent of the body that goes and comes most easily. The loss of fat which is not due to change of diet and exercise, especially its rapid or steady loss, nearly always goes hand in hand with conditions which impoverish the blood, while a gain of fat up to a certain point seems to go hand in hand with a rise in all other essentials of health and notably with an improvement in the color and amount of the red corpuscles. He noted that men, as a rule, preserve their nutritive status more equably than women, many of whom lose or acquire large amounts of adipose matter without any corresponding loss or gain THE FORMATION OF FAT. 739 in vigor, and Dr. Mitchell attributed this possibly to the enormous outside demands made by their peculiar physio- logical processes. Seasonal Influence. There is a seasonal influence which is apparent in a study of the less fortunate class of men who are hard worked physically and unable to leave town during hot weather. Dr. Mitchell2 many years ago was en- gaged in determining the weight, height and girth of all the members of the Philadelphia police force. The examination was made in April and repeated in October, and it was found that a large majority of the men had lost weight during the summer. The sum total of loss was enormous. Climate. This has a great deal to do with the tendency to take on fat. In this respect the climate of the United States and of Canada, complex and variable as it is, in such diverse localities, nevertheless does not tend to the develop- ment of such numbers of inordinately fat middle-aged people as are met with in England and the continent of Europe. It is probable that certain restrictions in the use of alcohol now common to the United States and to a large part of Canada, will accentuate this difference. Alcohol. If no beer is brewed, nor even malt extract is allowed to be sold, the problem of what to do with the obese may be expected to be easier than in the past, for it was a common observation that alcohol gives rise to an increase of adipose tissue in many cases, especially when malt liquors were taken as a liberal part of the daily ration. It will be interesting to observe the effect of prohibition, when it actually goes into effect in America, on the occur- rence of obesity. Competent observers seem to think that some change has been going on during the last decades, that more fat people, more people even enormously stout, are seen with us than formerly and fewer of the inordinately fat middle-aged people in England than used to be encoun- tered. With us the over-fat are chiefly to be found among the women of the well-to-do classes of the cities and from thirty years old onward. They persecute the medical man to reduce their weight, and the vast number of advertise- ments of quack and proprietary remedies against obesity indicate how widespread the tendency must be. 740 OBESITY. Racial Tendencies. These have long been noted. The Jewish race seems to have a tendency to obesity. As a rule these people as they gain in affluence tend to indulge in rich food; but they are not as a race inclined to over- indulgence in alcoholic drinks. They are, however, keen to recognize the advantages offered by spas and all forms of physical therapy commonly used for the relief of obesity. It is probable also that the desire for a better bodily style will have a strong influence in checking these tendencies, as the modern woman, no matter what her race, is now keener than ever to conform to mode in figure and in dress. RELATION TO THE ENDOCRINE SYSTEM. Obesity occurs in types of pituitary disease, and in women after natural or artificial menopause. In the latter case there is a deficiency in ovarian secretion that tends to in- complete oxidation and elimination of waste products. In these cases the use of ovarian substance internally has been followed by good results. When the anterior pituitary lobe is overactive during the period of growth or before ossi- fication of the epiphyses is complete, gigantism is possible. This has been designated the type Lannois. Hyperpitui- tarism, coming on later in life, gives rise to acromegaly, the type Marie. Hypopituitarism occurring in infancy or early childhood gives a picture of sexual or skeletal infantilism with marked adiposity, which is termed the typus Frohlich. When hypopituitarism occurs in adult life, although the skeleton is developed, there is a reversion of the sex organs 'to infantile conditions and a great deposition of fat. This latter type is at times spoken of as dystrophia adiposo- genitalis.3 Disease of the anterior pituitary lobe leads in many cases to an unusual deposit of subcutaneous fat. Possibly not all cases included under such various terms as adiposis dolorosa (Dercum’s disease), adiposis universalis, dystrophia adiposo- genitalis, and adiposis cerebralis, have pituitary disease, but it should be suspected and demonstrated by x-ray if possible. When actually of hypophysial origin, Cushing attributes the accumulation of fat to a posterior lobe insufficiency and this is generally accepted. He states that all the patients in RELATION TO THE ENDOCRINE SYSTEM. 741 the series discussed in his monograph who, after a period of primary pituitarism, began to show evidences of glandular activity, have acquired some measure of adiposity; and an increase of weight has been an early feature in the larger number of those showing signs of primary hypopituitarism. In both experimental studies and in clinical observation there is a greatly increased power to assimilate excessive amounts of sugar which are then turned into fat owing to an abatement of the sugar metabolizing powers of the body. The symptom complex of adiposity, high sugar tolerance, subnormal temperature, slowed pulse, asthenia, and drowsi- ness, is thus attributed to a deficiency of the posterior lobe. Cushing remarks that the adiposity of hypopituitarism is a generalized one, not limited solely to the panniculus, and that the fat shows, post mortem, certain peculiarities of color and consistency which suggest a different chemical composition from that of “normal panniculus,“ and suggests that it is worthy of a differential analysis. It furthermore invades the organs such as the liver, where there is often an extraordi- nary replacement of the cells by fat globules. Figures 73 and 74 illustrate this in Cushing’s work. He attributes hypo- physial adiposity to the fact that the posterior lobe secretion contains what may be regarded as a hormone essential to carbohydrate metabolism and this is easily obstructed by divers intracranial lesions. In the childhood types, the so-called cerebral adiposity, the combination of genital dystrophy and skeletal under- development, with manifestations of cranial disorder, render its recognition easy. In all cases the deposition of fat is fairly universal with, perhaps, a special predilection for the loins, the inner parts of the thighs, the pubes, and the ab- domen. The types differ chiefly in the character of dys- genitalism which they display, and in the presence or absence of overgrowth. In the adolescent types, especially when occurring in the male, and dating from puberty, there is a juvenile skeletal configuration or an outline of feminine type. In the adult types of adiposity there are some striking examples due to dyspituitarism, for example, gigantism and acromegaly a result, in the later phases at least, of insuf- 742 OBESITY. ficient posterior lobe activity. Cases of adiposis dolorosa, described by Dercum, come under this head. Burr reported in 1900 a typical example of the disease in which a pituitary glioma was found; and in a case of Dercum’s, McCarthy found an adenocarcinoma of the pituitary body. Disease of the pituitary is possibly not the rule in Dercum’s disease, but it certainly occurs. This distressing disease involves the syndrome of adiposity, tenderness and pains, asthenia and psychoses. The local obesity of eunuchs is one of their well known features, and as it is customary to perform this mutilation between the tenth and sixteenth years, such individuals put on fat over the buttocks and thighs so as to resemble the female. That there is a close connection between obesity and dia- betes has long been known. It is also evident that the treatment for both these conditions, at least as regards diet, lies along the same lines. Specialists in diabetes are, there- fore, those most liable to meet in their practice those who are markedly overweight. Recently Joslin4 has again called attention to this subject. His first record of one thousand and sixty-three cases of diabetes in his own practice showed that in more than forty per cent., marked obesity preceded the outbreak of the dis- ease, and the prediction was made that if more exact data were available the percentage would be fully twice as great. A prediabetic stage in fat persons was recognized as possible by Joslin and von Noorden, who emphasized the necessity of examining the urines of such persons for sugar; and further, that examinations of the blood sugar of these sub- jects would disclose their approach to the disease when the urine was still sugar free. A study of one hundred and eighteen diabetics, made in the laboratory of the Carnegie Institution in Washington, in whom the height, weight and age were recorded, showed the interesting fact that persons about the age of fifty rarely acquired diabetes if their weight remained a little below RELATION TO DIABETES MELLITUS. RELATION TO DIABETES MELL1TUS. 743 normal, and the study emphasized the connection between obesity and diabetes. Joslin then undertook the study of one thousand cases, in which age, weight and height were known to have been compiled. Incidentally he criticizes the strange failure to measure the height in making the case records. It is noto- rious that fat people underestimate their weight and this is not confined to either sex. The tables in this study show that among one thousand diabetic persons there was no instance in which diabetes occurred when the maximum weight was thirty-one or more per cent, below the normal zone; whereas there were two hundred and seventy-three persons who developed the disease who were thirty or more per cent, above it. Taking a pair of groups nearer the normal zone for weight, namely, between twenty-one and thirty per cent, below and above normal, there were found five cases below and one hundred and sixty-nine above normal. Consolidating this pair of groups with the pair first mentioned, it is found that in one thousand diabetics there were five who showed a maximum weight twenty-one or more per cent, below nor- mal and three hundred and ninety-four whose maximum weight was twenty-one or more per cent, above normal. Therefore in this series when the persons were twenty-one or more per cent, over weight diabetes occurred seventy-nine times as frequently as when in the corresponding degree of underweight. Joslin emphasizes his belief that diabetes is a penalty of obesity, and the greater the obesity the more likely is Nature to enforce it. He scoffs at the “fat diath- esis” : “granted that there is one person in a thousand who has some inherent peculiarity of metabolism which has led to obesity, there are nine hundred and ninety-nine for whom fat implies too much food, or too little exercise, or both combined.” In the attempt to induce obese persons to correct this preventable and dangerous condition, there are phases of the incidence of diabetes that should be mentioned. Joslin for- mulates the following law: It is rare for diabetes to develop in an individual above the age of twenty years who is habitually underweight and when it does so develop, the 744 OBESITY. case will usually be found to be extremely severe, extremely mild, or associated with a marked hereditary taint or de- generative stigma. Joslin goes so far as to say that obese individuals should be frankly told that they are candidates for diabetes. How many of us will have the courage to do this, granted that the argument is correct? A slight trace of sugar is not very uncommon in obese persons; but this lipogenic glycosuria is not of grave sig- nificance and is only occasionally followed by true diabetes. Diabetogenous obesity in early life is very unfavorable. LIFE EXPECTANCY AND MORTALITY IN THE OBESE. STANDARD WEIGHT. A committee representing the Association of Life Insur- ance Medical Directors and the Actuarial Society of America has published valuable tables showing the influence of build on mortality among men and women. It would appear that for men, taking all ages at entry into insurance, there is a steady increase in the mortality with increasing weight.5 Weight Ratio of deaths to expected. Over 15 to over 20 pounds 104 Over 25 to over 30 pounds 113 Over 35 to over 40 pounds 131 Over 50 to over 60 pounds 144 Over 65 to over 80 pounds 165 Over 85 and more pounds 223 Overweight to a moderate degree is not a serious impair- ment at the young ages of entry but has a material effect at the middle ages. For example, in the age group 20 to 24 the mortality among those fifty to eighty pounds overweight was three per cent, in excess of the standard; while in the age group 40 to 44 it was seventy-five per cent. At the ages of entry 50 to 62, it does not appear that from twenty- five to eighty pounds above the average weight is as serious an impairment as at ages 40 to 49. The mortality of those more than twenty pounds overweight reaches a maximum at entry age 40 to 44. In the report referred to there are interesting tables of mor- tality arranged for attained ages and for height and weight LIFE EXPECTANCY AND MORTALITY. 745 in men whose policies terminated (the experience of the first five policy years was excluded). For example: Height 5 feet, 3 inches to 5 feet, 6 inches. Over 35 to over 45 pounds. Attained ages 27 to 36 Ratio 100 per cent. Attained ages 37 to 46 Ratio 133 per cent. Attained ages 47 to 56 Ratio 155 per cent. Attained ages 57 to 66 Ratio 171 per cent. Attained ages 67 and over Ratio 115 per cent. Over 50 to over 60 pounds. Attained ages 27 to 36 Ratio 85 per cent. Attained ages 37 to 46 Ratio 186 per cent. Attained ages 47 to 56 Ratio 195 per cent. Attained ages 57 to 66 Ratio 193 per cent. Attained ages 67 and over Ratio 192 per cent. Attained ages 27 to 36 Ratio 33 per cent. Attained ages 37 to 46 Ratio 200 per cent. Attained ages 47 to 56 Ratio 257 per cent. Attained ages 57 to 66 Ratio 133 per cent. Attained ages 67 and over Ratio 300 per cent. Over 65 to over 80 pounds. These ratips were somewhat less for the greater height group of 5 feet 7 inches to 5 feet 10 inches. Obesity does not predispose to tuberculosis; on the con- trary it is a safeguard. Taking men at entry at 30 to 44 years of age fifty pounds or more overweight, compared with those twenty-five pounds or more underweight, the ratio of mortality is as 1.8 to 16.5. So the fat man is not very liable to consumption.* His fat is an asset and not a liability. If weight and girth are in excess the expectation of life is considerably impaired. Taking a group of risks thirty per cent, to thirty-nine per cent, overweight, with excess ab- dominal girth when compared with a similar group without such girth, it was found that the mortality was: Excess girth not exceeding 1 inch 107 per cent. Excess girth not exceeding 1.25 to 2 inches 114 per cent. Excess girth not exceeding 2.25 to 3 inches 130 per cent. In a group 40 to 49 per cent, overweight the figures were 103 per cent., 127 per cent, and 144 per cent. * The author is indebted to Dr. Oscar H. Rogers of the New York Life Insurance Co. and to Mr. F. L. Hoffman of the Prudential for the opportunity of examining interesting data. 746 OBESITY, LIFE EXPECTANCY AND MORTALITY. 747 Rogers6 has constructed a sketch to show in perspective the mortality to be expected by reason of build alone, with- out regard to any other factor. The plane represented by the horizontal lines represents the mortality in his company. The age lines, “age 20,” “age 30,” “age 40,” etc., show the age of each group. The lines running at right angles to these age lines represent the degree over- or underweight, seventy per cent, overweight, sixty per cent., fifty per cent., etc., down to thirty per cent, underweight. The curved line which extends at age 20 from twenty per cent, underweight to seventy per cent, overweight shows the mortality either over or under the tabular, due to the build, i.e., to the degree of over- or underweight. It will be seen from his diagram that at the age 20 and twenty per cent, underweight, the mortality is fairly high and that it falls to the normal at ten per cent, underweight; and that the mortality continues below normal, i.e., is better than the tabular, up to about twenty-three per cent, or twenty-four per cent, overweight and that thereafter the mortality rises rapidly until, at seventy per cent, overweight, the degree of mortality is quite high as represented by the vertical line between the plane of tabular mortality and the curve. In the same way, at age 60, the mortality at thirty per cent, underweight is very slightly in excess of the nor- mal ; the curve of mortality meets the normal plane at about twenty-three per cent, underweight, after which the mortality is below the normal up to about eight per cent, overweight and from that point it rises rapidly until we have the exces- sive mortality represented by a vertical line which rises from the age 60 line.* INSTANCES OF EXTREME OBESITY We are familiar with the grotesque pictures of the fat habitues of the English spas of a century or more ago. Rowlandson depicted these in the most ungainly attitudes in the pump room at Bath and in their uncouth dress they make the impression that none such as these are seen today. Excessive obesity is not by any means a thing of the past, * For normal standard weight, according to sex, height and age, see Mohler’s article on Diabetes, Vol. I, pp. 739 and 740. 748 OBESITY. nor is it found only in England or on the continent of Europe. The writer has a photograph of a phenomenally fat man who lives at Waycross, Georgia, and is said to have attained the extraordinary weight of six hundred and ten pounds. He was 55 years old in February, 1921 ; his height is six feet, two inches, and weighs five hundred and fifty-five pounds, but recently lost fifty-five pounds owing to business and domestic worry. His general health is good and he has no The grand pump room, Bath, 18th Century (after Rowlandson). disease such as diabetes. The assigned cause for obesity is heredity. His normal weight is 603 pounds. Only a few months ago, in November, 1920, a wedding is reported to have taken place in Santa Ana, California, the bride tipping the scales at seven hundred and twenty-five pounds. The account of this wedding gives the interesting information that the bride’s sister is living and weighs four hundred and twenty pounds. The photograph of the lady on her wedding day shows that the estimate of her weight may be trusted. In a little over a year her death was re- ported. A third American whom we have to record died in Bristol, England, within a year, weighing six hundred and sixty- INSTANCES OF EXTREME OBESITY: 749 eight pounds, and travelled all over the world as the heaviest woman in the world. She was a native of Kentucky. Mr. Charles H. Jackson, said to have been the largest man in the world, died in Cambridge, Massachusetts, on July 7, 1921. His age was 61; height, six feet; and weight, in 1916, was six hundred and thirty pounds. During the ensuing year he gained eighty-three pounds and steadily increased Case of Mrs. J. H. H. in weight until his health began to fail in 1916. He worked as a foreman in a brass foundry, and left three children: a son weighing about one hundred and sixty pounds, and two daughters, said to weigh about three hundred pounds each. He was in a hospital for four months previous to his death. There was no autopsy. Mrs. Fannie Cumberland, aged 47, died in Minneapolis, Minnesota, on March 1, 1921, weighing six hundred pounds. For twenty-five years she had weighed over five hundred 750 OBESITY. pounds, was married and had no children. Her physician informs me that she had never had diabetes and that she died of chronic interstitial nephritis of three years’ duration, with dropsy. As far as he knows she never took any treat- ment for overweight. Her height was five feet, nine inches. In January, 1919, there died in Bridgeport. Connecticut, Mrs. Matilda Gilbert, who toured with Barnum’s circus and weighed four hundred and twenty pounds just before her last illness, which was from pneumonia following influenza, epidemic throughout the country at that time. These six cases are therefore all indigenous to the United States, and are from widely separated localities. What their habits were we cannot say, nor do we know whether they ever tried seriously to change their mode of life. The English record for men seems to have been held by Mr. Thomas Lambert, who died in 1809, and who weighed seven hundred and thirty-eight pounds. His waistcoat, said to be in the Lynn museum, is reported to measure one hundred and two inches around. There is one tendency of obese persons that is almost unique and that is their gregarious instinct. There are associations or societies that are more or less well known, and their convivial and gastronomic doings are recorded from time to time in the public press. Unlike the United States Hay Fever Association, these clubs do not seem to have contributed to the literature or therapeutics of their disease. The most famous of the fat men’Sj clubs is the “Cent Kilos,” of Paris, which has over three hundred mem- bers, all weighing over two hundred and twenty-five pounds Before the recent war the attendance at their annual gather- ings exceeded five hundred. They have weekly Sunday gatherings at a restaurant in the Rue Folies Mericourt, where with due solemnity they imbibe the two liters of heavy red wine allotted to each member besides the five courses of substantial proportions considered essential to maintain adiposity.15 In the United States these gatherings take the form of clam-bakes and always excite popular interest. TREATMENT—PROPHYLACTIC. 751 TREATMENT. PROPHYLACTIC. Prophylactic treatment is more easy than to remedy the disease when well established; but in practice the majority of patients are those who between forty and fifty years of age have already entered the heavy-weight class. When a family tendency toward obesity manifests itself in earlier life the patient should at once be placed on a regime, the opportunity for carrying out physical measures being much greater at that period. The general plan, therefore, will be to combine several measures. There must be cooperation and a very earnest desire to reduce. It must be sufficient to insure the patient’s making sacrifices. The appetite must be controlled. Sweets of all kinds are to be reduced to a minimum; starches and fats likewise. A disease like obesity is eminently suitable for psycho- therapy. It is highly desirable to arouse the interest of the patient, stimulating his ambition and affording encourage- ment as the treatment progresses. Where the will is weak it must be strengthened, and the physician’s duty is to teach and inspire him to cure himself. This will include much self-denial and the fortification against the prejudices and possible discouragement from friends and relatives; but the modern trend of popular medical teaching and the dictates of fashion are lending a steadily increasing support to various plans of treatment toward this end. What is the best time to adopt prophylactic measures against the occurrence of obesity? Perhaps we can answer that question by recalling what an eminent physician is re- ported to have said apropos of rheumatism. “Madam,” said he, “if you had come to me twenty years ago I could have cured you; now I ean do nothing for you.” “But, Doctor, I didn’t have rheumatism twenty years ago.” “No, Madam, but the causes were there; I could have removed them.” Five years later the woman’s daughter walked into the office of the same physician and said: “I wish to be cured of rheumatism.” He examined her thoroughly. “What do you mean?” he said, “You haven’t rheumatism.” “No, but 752 OBESITY. I am following your advice and coming twenty years ahead of my rheumatism.” Substitute the word “obesity” for “rheumatism” and we have a situation reflecting the same truths and the same prophylactic problems. Certainly the best time to cure obesity is before it begins; before hereditary or acquired tendencies render a cure arduous or even impossible. The only paper on this subject we are familiar with in American literature is by Means.7 The cases studied in- cluded that of a woman of forty-eight years, weighing two hundred and forty-five pounds, who by dieting and fasting was reduced to two hundred and eleven pounds in two and one-half months. The increase of weight dated from the birth of her first child, nineteen years previously, and, aside from a large ventral hernia at the site of a previous opera- tion, her general health was excellent. She took very little exercise. Her systolic blood-pressure was 120; diastolic, 90; hemoglobin, 80 per cent., and a roentgen ray examination of her head showed a normal sella turcica. Three absolute starvation periods of six, five, and four days, were instituted, and complete details of the basal metabolism, materials katabolized, the respiratory quotient, the fluid intake, the urine, the pulse rate, and the daily body weight, are given. Three other cases of obesity, one weighing three hundred and ninety-seven pounds, were likewise studied and re- ported on. Means also details studies of metabolism by foreign observers in seventeen obese cases in which the surface areas were calculated. The full particulars of all of these cases are well worth study as given in this paper. The results show that the basal metabolism of the two cases of simple obesity, using the DuBois formula for body surface, was normal. One case, however (Case iV), which was one of undoubted hypopituitarism showing marked obesity, had an increased basal metabolism. An interesting and important observation on the adminis- tration of thyroid is given by Means. During its adminis- tration to the obese there seems to be an increase of meta- bolic activity. Jaquet and Svenson, in three cases, however, METABOLISM IN THE OBESE. METABOLISM IN THE OBESE. 753 did not find any rise in metabolism while on thyroid, or any striking change in the respiratory quotient. They hold that the loss of weight in the obese during thyroid adminis- tration may be entirely due to loss of water or, in some cases, to actual tissue destruction. Magnus-Levy came to the same conclusion. On the other hand, Thiele and Nehring, in a woman of one hundred and twenty-four kilograms (two hundred and seventy-three pounds), noted a rise in basal metabolism of thirteen per cent. Bergman’s case gave a twenty-five per cent. rise. Means’s case was put on thyroid, with an initial dose of 1.5 grains per day, gradually increased to nine grains per day, on which she remained five days. The result was that there was a definite rise in metabolism and in nitrogen elimination, the nitrogen balance becoming negative after she had been on thyroid for a week. This patient lost weight rapidly, but Means thought this may have been due to loss of fluid, since the amount of urine increased. The pulse rate showed a marked rise. The patient had no subjective symptoms, such as feeling nervous. The respiratory quotient showed a tendency to rise above its usual figure. She burned twice as much or more carbo- hydrate as when on the same diet without thyroid. The increase in protein metabolism was not sufficient to explain the rise in the respiratory quotient. The katabolism of fat during the thyroid period was about the same as without thyroid and that of protein somewhat increased. Thus it appeared that in this patient the effect of giving thyroid is to' increase the basal metabolism. Also the in- crease is met by an increased combustion of carbohydrate and protein and not of fat. Moreover, the increase in the case of the carbohydrate is greater than in that of the protein. The conclusion is that thyroid produces a greater utiliza- tion of carbohydrate, it being burned instead of being stored as fat. The loss of weight may have been entirely due to loss of fluid. The loss of body protein was not great enough to become alarming but might easily have become so if the dosage had been continued. 754 OBESITY. We have detailed the results of this admirable study be- cause the use of thyroid is so largely empirical, the modus operandi is so little appreciated. The conclusion of the matter as based on the cases cited is that any destruction of body fat is lacking; “so it does not seem reasonable to suppose that thyroid will cure obesity by actually causing the burning of the excess of fat. On the other hand, by producing a better utilization of carbohydrate it might act beneficially in preventing further formation of fat from carbo- hydrate and so be an aid to the dietetic treatment of the condition. Whether this action can be secured by smaller doses of thyroid will have to be determined in future ex- periments. The dosage used here owing to its effect upon circulation and body protein could not be used for any con- siderable length of time. The above statements’ must not be interpreted as a recommendation of thyroid in the treat- ment of obesity. It is well recognized that it is not necessary and also that grave dangers may result from the incautious use of it.” When first introduced thyroid was a very popular treat- ment for obesity. Like all new measures it was overdone and bad effects were noted. This was doubtless due to the large doses used. Ebstein formulated an argument against its use, claiming that loss of weight produced by it is quite inconstant and always ceases at once with its discontinuance. H,e warns against the danger in the loss of body albumin. He believes it to be quite unnecessary, inasmuch as we have dietetic rules for the treatment of obesity that are as suc- cessful as they are devoid of danger. However, the later practice seems to allow its use in small dosage, one-half or one grain three times a day. We have used it in this manner, with close supervision, apparently without any bad effect. There is a large commercial demand for thyroid and probably it is prescribed by physicians or given surreptitiously to the obese more frequently than text- books would indicate. (See page 756.) Thyroid extract should be used only in cases showing definite symptoms of hypothyroidism. In obesity of the type of Frohlich thyroid would not be indicated but rather the pituitary extract, whether it is the whole gland or the an- DANGERS OF ANTI FAT CURES. 755 terior lobe which is considered the responsible factor. It is claimed on good authority that a combination of a tablet of the whole gland with a tablet of anterior pituitary gives better results than either one given singly. When obesity is observed in women near the menopause and is due to ovarian dysfunction, ovarian substance in five grain tablets may be employed. The United States Department of Agriculture, through its Bureau of Chemistry, has made tests of various nostrums advertised by the promoters of fat reducing cures and many have been found worthless and even dangerous. The adver- tisements appeal to the vanity of people who wish to regain graceful figures, and also to the business necessities of those who become so fat that they cannot do their accustomed work. Unfortunately the Department will not publish or divulge in any manner the names identifying these so-called remedies unless the Post Office Department should issue a fraud order denying them the use of the mails. This is done in only a small proportion of cases. The Bureau’s work, is, therefore, in most instances of little more than academic interest. Its practical value to the public is to that extent lost. However, in one instance the Bureau tried out “one of the most widely advertised so-called prescriptions for reducing flesh.” Employes of the Department who wished to lose surplus flesh without injuring their health, volun- teered as subjects but the result was that two of the sub- jects under experimentation were obliged to stop after taking the medicine for two or three weeks because of its injurious effects. The third subject gained two and one-half pounds instead of losing flesh. Another of the so-called remedies of a “Great Obesity Specialist” was tried. The subject scrupulously followed the diet list which accompanied the remedy, and faithfully carried out the system of exercises recommended. After six months’ treatment there was reduction of eighteen pounds of flesh, but this the experimenters attribute to the fact that the subject ate no bread, butter, starchy food, pastry, sugar or candy while under observation. The first month after DANGERS OF “ANTIFAT CURES.” 756 OBESITY. discontinuing treatment the subject gained ten pounds and in three months was back at the old weight. The promoters of one preparation assert that it secures most marvelous results by a process of elimination of foods without digestion. These people guarantee a loss of a pound a day. Another scheme provides chemicals to be added to the water in which the patient is to bathe. The chemicals are of such a nature as to form a sort of curd in the water after the patient has bathed. This curd, the advertisement states, is fat and surplus tissue removed from the body. Then there is a kind of bread at the modest price of a dollar a loaf that in connection with a certain diet is claimed to do wonders. It would appear that women are usually the victims of these promoters or “professors” or fakers, or whatever we may choose to call them. The strong feature of most of the literature is that no dieting is necessary; the medicine is all-sufficient. The experience of the Bureau is that these preparations usually contain thyroid extract and a laxative, or phytolacca (poke weed), both of which may be dangerous in the hands of ill-advised persons. The Bureau states that it has the record of a case in which death occurred from overdoses of thyroid extract. We cannot understand why laws should not be enacted by which some precise information can be given out by the Department as to the names or brands of these dangerous or fraudulent preparations. In the case of thyroid extract there is a great practical difficulty, as we do not know of any chemical test whereby the presence of this organic substance can be detected. There are physiological tests, however, by which samples of thy- roid extract can be tested so as to ascertain whether they measure up to a standard. This requires complicated laboratory facilities. In giving thyroid extract to obese patients it has occa- sionally been found that sugar appears in the urine and a diabetes ensues. This observation should make us cautious to examine the urine and blood sugar frequently in cases undergoing thyroid treatment. As we have previously noted, DANGERS OF ANTIFAT CURES. 757 the incidence of diabetes in those over weight is greatly above that noted in persons of normal weight. Purgative treatment has been likewise abused and conse- quently condemned; but as an adjunct to other measures mineral waters have a legitimate place in treatment, espe- cially at the outset. The Hathorn of Saratoga; Pluto, and other fortified waters, are extensively used, as well as foreign waters such as Hunjadi and Apenta. When they seek treatment the obese frequently do so because of a rebellious liver, overloaded colon, or for some kidney or hepatic condition. Gall-stones are more common in the obese than in the thin. Hence it is that mineral water resorts, catering to bilious patients and with some reputation for dissolving gall-stones, will therefore attract corpulent people; dietetic restrictions in vogue at these resorts incidentally help them. Cases of obesity are met with showing a history of some earlier tuberculous trouble, either glandular or pleural, or of the bronchi. In such cases too vigorous treatment of the obes-ity has caused a flaring up of long latent disease; hence there should be a search for signs of tuberculosis before instituting treatment and no debilitating measures should be allowed; at the same time strict supervision is desirable throughout the course. The measures should aim not only to reduce the fat and insure its more perfect oxidation but also to restore nerve and muscle force, modifying the diet completely, without rendering it distasteful, with exercise and plenty of water between meals. Attention has been called to these dangers by De Fleury,8 who allows one small tumblerful of water with the meals, one on rising and retiring, with another at 9, 10 and 11 a.m., and again at 4, 5 and 6 p.m. A half hour of exercise, out of doors, three times a day is advised. He also advocates the Bergonie method of prolonged and frequently repeated faradization of whole groups of muscles at once. (See page 782.) DeFleury has obtained great benefit from very small daily doses of thyroid extract; but claims that even better effect can be obtained from repeated subcutaneous injection of small amounts of a hypertonic artificial serum. The solu- tion used is composed of eight parts of sodium sulphate, four 758 OBESITY. parts sodium phosphate, two parts sodium chloride, and one hundred parts of water. This serotherapy stimulates the internal secretions and this in turn promotes the metabolism, and the appetite increases while the food is utilized better. A distinction has been made between obesity cures and emaciation cures. While the former involves the loss of only superfluous fat, in the latter both fat and muscle are dimin- ished. “Starvation cures” and “hunger cures” are alike and really mean nothing more than emaciation cures or, as the French say, “la cure d’amaigrissement.” In obesity cures we should aim at depletion without bring- ing about inanition or malnutrition. The depletion should not go to the extent of loss of muscular substance. The whole system of reduction might do great harm. Ebstein has insisted that the no-fat cure, for example, is one of these dangerous practices and “may produce severe organic disease of the kidneys.” But he points out that the danger is some- what mitigated inasmuch as even lean meat contains as much as two per cent, of fat. Of course it should not be forgotten that milk also contains fat. Probably a strict no-fat cure is not adopted by anyone at present. Fat is a necessary food. Ebstein maintains that “it is sufficiently proven by experience that even in fat per- sons the ingestion of a measured quantity of fat under certain circumstances fails to produce any accumulation of fat, and that the person in question may even rid himself of his superfluous fat provided that the carbohydrates are properly limited and that the manner of living is otherwise normal and in accordance with the fundamental laws of the modern physiology of nutrition.” He cites the observation of Hippocrates in advising for the obese the ingestion of foods prepared with fat, as in this manner the appetite was more easily satisfied. It has been remarked that in its ultimate analysis the problem of obesity may resolve itself into a question of nutritive bookkeeping, that is, of the relative balance between food intake and energy output.9 Now that caloric values for food and the careful estimate of the weight of every article composing it are considered indispensable in ordering diets, a great many problems arise POPULAR REDUCTION CURES. 759 in particular cases. One of these is that the body weight does not always fall pari passu with a reduction in the food allowance. It was probably a question like this that started Sanctorius on a physiological investigation of the relation of the food intake to the excretion of it. He regulated his food so as to preserve an even balance and weighed himself daily. Sanctorius and his balance. (1561-1636) De Statica Medicina. POPULAR REDUCTION CURES. In England, in 1863, Mr. William Banting published his letter on “Corpulence,” addressed to the public. He stated that in 1862 he was sixty-six years of age, five feet ten inches in height and weighed two hundred and two pounds. He was of active and regular habits and (as he believed) did not indulge in anything to excess. There was no hereditary tendency to corpulence. He took more exercise, especially rowing, but his appetite grew and he felt constrained to satisfy it. He took ninety Turkish baths and “gallons of physic.” He took to “riding on horseback, the waters and climate of Leamington, Cheltenham and Harrogate, and 760 OBESITY. spared no expense in consultations with the best authorities in the land.” But all this did not avail, for he says he could not stoop to tie his shoe and he had to go down stairs slowly backwards. But under a diet, which Mr. Harvey, of Soho Square, had learned from M. Bernard’s lectures in Paris on diabetes, he found the famous cure for corpulence. Mr. Banting lost thirteen inches in bulk and fifty pounds in weight in a year. His health returned; he ate and drank and slept well, had no indigestion and could stoop with ease and freedom. He suffered no longer from faintness and his personal appearance was greatly improved. The forbidden foods were bread, butter, milk, sugar, beer and potatoes. Mr. Banting’s view was that “saccharine matter is the great moving cause of fatty corpulence.” The following dietary is simple but it is obviously unsuited to those having any signs of nephritis as it is highly nitro- genous, and the wine, whisky and brandy are probably super- fluous, and in America, at least, well nigh unobtainable. Brcakfasi (8 to 9 a.m.) : Four or six ounces of beef, mutton kidneys, broiled fish, bacon, or cold meat of any kind except pork; a large cup of tea (without milk or sugar), a little biscuit, or one ounce of dry toast. Dinner (1 to 2 p.m.) : Five or six ounces of any fish except salmon, any meat except pork, any vegetable except potato; one ounce of dry toast; fruit or pudding; any kind poultry or game; and two or three glasses of good claret, sherry or Madeira-champagne; port and beer forbidden. Tea (5 to 6 p.m.) : Two or three ounces of fruit, a rusk or two, and a cup of tea without milk or sugar. Supper (9 p.m.) : Three or four ounces of fish, similar to dinner, with a glass or two of claret. Nightcap (when inclination directs) : A tumbler of grog (gin, whisky, or brandy, without sugar), or a glass or two of claret or sherry. In 1887 Mr. J. H. Salisbury of New York, published a “Brief Statement of the So-called Salisbury Plan for the treatment by Alimentation of Various Diseases Produced by Unhealthy and Indiscrete Feeding.” It was intended to influence various diseases of the digestive system and those “associated with excessive development of either the connec- tive or fatty tissues.” The essentials are the taking of hot water, and a diet consisting of about two-thirds lean meat and one-third vegetables.10 The water should be taken as hot as the patient can bear it; one pint in bed in the morning or on rising, one pint POPULAR REDUCTION CURES. 761 one hour and a half before each meal, and half an hour before bedtime. It should be slowly sipped, so that the time taken be five to fifteen minutes, uncomfortable distention being thus avoided. If there be thirst between meals, the patient may take hot “clear” water, lemon water, or “crust coflfee.” At meals, five to eight ounces of clear tea or clear coffee is allowed. Food should be either the muscle pulp of beef, broiled, broiled beef-steak free from fat, roast beef, broiled or roasted lamb or mutton; boiled fish; chicken, game, and turkey, broiled or roast; salt, pepper, Worcester sauce and chutney in moderation; celery. All meats should be fairly well cooked, and meals should be taken regularly, either alone or in the company of others taking the same diet. It is claimed that under this system adipose tissue will rapidly disappear, the loss of weight being at the rate of ten pounds to thirty pounds per month, according to the degree of fatness, the strictness of the diet, the amount of exercise, and the mental condition of the patient. If the loss of weight be too rapid, so that the skin hangs in folds, such food as bread, toast, rice, cracked wheat, and potatoes may be added. The loss of ten pounds to fifteen pounds a month is advocated as the ideal rate of weight reduction. When the desired weight and bulk have been reached, the fat- forming foods should be taken in such proportion as may suffice to maintain them, usually two parts of meat to one part of vegetable bulk. It is stated that the relish for beef may become so great that from one to two pounds may be taken at each meal. The body should be washed twice daily with soap and water, and afterwards rubbed with equal parts of glycerin and water. Regular exercise, short of fatigue, should be taken; or, where this is impossible, the body should be well rubbed from head to foot for from ten to twenty minutes three times daily. Flannel or silk should be worn next the skin, and the body be kept comfortably warm. All methods calculated to maintain health should be observed. The above diet will cause most people to lose weight quickly. Before advising anyone to rigidly adhere to it, however, it would be well to exclude the existence of chronic 762 OBESITY. granular nephritis. A dietary with so great a proportion of nitrogenous food will tax severely any but the healthiest kidneys. About twenty years ago the late Mr. Horace Fletcher11 published several works relating to diet and the hygiene of food. They made a strong appeal for more moderate and better habits of eating. The chief points in Fletcher’s system included: early rising; no breakfast; one meal daily about 1 p.m.; a moderate selection of foods; thorough and pro- longed mastication. This last was the essential feature of the system which soon became known as Fletcherizing—a term which has maintained itself in our vocabulary for over twenty years. It is the overcorrection of what is undoubtedly a very bad habit; and this habit is common to many besides the obese. Horace Fletcher is therefore included in a trio, with Mr. Banting and Mr. Salisbury, who have had a marked influence in dietetics and an enthusiastic following. Among the dis- tinguished followers of Fletcher was the late Right Hon. W. E. Gladstone, who practiced the method faithfully and insisted on thirty-two chewing movements for each mouth- ful. “Munching parties” became popular in England and made “epicures” of many whom Fletcher denounced as “gluttons.” There is a valuable lesson to be derived from the details of Mr. Fletcher’s own case as published in “The New Glutton or Epicure.” In 1898 Mr. Fletcher was forty-nine years old and five feet, seven inches, in height. His extremes of weight for fifteen years in ordinary clothing were: minimum, one hundred and ninety-eight pounds; maximum, two hundred and seventeen pounds. Chest measure, forty-two inches; waist, forty-three to forty-four inches, and usual weight two hundred and five pounds (June 1, 1898). By October 10th, as the result of experiments, he weighed one hundred and sixty-three pounds; the chest measure was the same, but the waist measure was reduced to thirty-seven inches. One meal a day was taken. He rose at or before day- light and began writing dr other work. He says that by one o’clock he usually was “worked out” but had already disposed of practically a day’s work. Then in the middle POPULAR REDUCTION CURES. 763 of the day, when all the animals rest and some of them chew the cud, he took his meal, for which he had an epicurean appetite. “The article of food on the menu that first attracted me I fixed my desire upon. At the time it was usually a meat or a fish, and there accompanied it only a cup of coffee, nine-tenths milk, bread and butter and potato. Sometimes the meat selected was an entree and was garnished with rice and other vegetables or fruits. “About thirty mouthfuls of these, disposed of in some- thing less than twenty-five hundred acts of mastication or other movement of the mouth, and taking about thirty to thirty-five minutes, satisfied the appetite so perfectly that all the ices and desserts on a sumptuous bill of fare had no attraction. In the meantime water was drunk, in small por- tions only, and ice water at that, without restriction to satisfy thirst but not when any food was in process.” Fletcher notes that water injures digestion by being taken with meals only because it is used to wash down food not yet prepared for the stomach. “It is the unfit food that is carried down by it and not the water that does the harm.” Horace Fletcher’s books unfold the philosophy of rational eating; they may be considered extreme but the tests have a decided scientific interest, as they were conducted for several months on Mr. Fletcher by Dr. William G. Anderson and Prof. Russell H. Chittenden in their laboratory at Yale University. The technical account was published by them in the Popular Science Monthly in June, 1903. It may be mentioned that Mr. Fletcher was given the same set of exercises that were given to the Yale Varsity crew and he took them with an ease that was unlooked for and with fewer noticeable bad results than in any man of his age and condition they had ever worked with. The later test of work was accomplished on two meals a day, having a nitrogen value of less than seven grams daily, as compared with about one hundred in ordinary working men; the food represented less than sixteen hundred large calories, and the heat-economy-showing was verified later in a thirty- two-hour calorimeter measurement in the apparatus of Pro- fessors Atwater and Benedict at Middletown, Conn. The 764 OBESITY. body weight was maintained all through at about one hun- dred and sixty-five pounds. These studies were conducted in January and February, 1903. The details are very inter- esting to anyone studying human nutrition. It is a mistake to suppose that the mere drinking of some mineral water will cure obesity. Mineral waters have no specific action upon adipose tissue, although helpful in so far as a daily action of the bowels is concerned and as far as they may be used externally in hydrotherapy. We will mention hydrotherapeutic measures later on. The role of water metabolism in obesity has been studied by Grafe,12 and it has an important bearing on the results of dietary treatment. His patients were kept in bed during the whole course of treatment and strictly isolated. The response to the respiratory tests refuted the assump- tion that obesity is due to disturbance in the oxidation of fat. Some of the patients, especially those with slight dis- turbance of the circulatory system, lost weight rapidly on reduction of the food to fifty per cent, of the normal re- quirements; the weight of others scarcely declined even when the nourishment was only thirty per cent, of the requirement, and the weight then kept constant for a long time. The tests showed that this was due to an extreme tendency to retention of water, although the cardiovascular system and the kidneys seemed to be normal. The retention of water from the food may keep the weight at a constant level al- though the body is constantly losing more and more of its dry constituents. This tendency to retention is far greater than corresponds to the prolonged underfeeding, even with very small intake of fluids. This is the reverse of what occurs in healthy persons and dogs under forced feeding. The excess of food forms dry tissues, and water is cast off to compensate for this, so that the weight may not increase in spite of the overfeeding. In the obese the dry tissues melt away and water is retained to compensate for this. So the weight keeps on a level in both conditions. All this is altered, however, by removal of the thyroid or ovaries. In the thyroidectomized but otherwise normal ani- USE OF WATER. USE OF WATER. 765 mals, retention of water to an extreme degree follows and the weight increases rapidly and continuously. This and other facts cited demonstrate that the thyroid not only con- trols the intensity of the oxidations but also the intracellular water metabolism. The importance of the thyroid in the pathology and treatment of edema and obesity has been over- looked ; the retention of water in the obese has been errone- ously ascribed to cardiovascular weakness. This may develop secondary to the sluggish and abnormal water metabolism, and it calls for endocrine treatment, especially thyroid treat- ment. Two of the patients took for weeks thyroid extract three times a day, with a diet of only thirty per cent, of the normal requirement, and all with good effect and without appreciable subjective disturbances. Moderate exercise, such as a short walk, has generally a favorable effect, but it renders more difficult the oversight of the case. He begins with reduction to fifty per cent, of the require- ment, with a maximum of fifteen hundred cubic centimeters of fluid. The food should contain at least eight grams of nitrogen and be predominantly of carbohydrates and be salt- poor. A milk diet is often excellent, not allowing over one and one-half liters daily. If these measures fail, the food can be reduced to thirty-three or even twenty-five per cent, of the requirement, with only one thousand cubic centimeters of water, if there is nothing to hinder on the part of the circulation or subjective findings. A day of very little or no calory intake may be interposed. There is not much danger, he says, of appreciable losses of nitrogenous sub- stances from the body with this, as in the overfed organism a large part of the albumin stored up in the obese tissues is quite different from living protoplasm albumin, and is by no means biologically on a par with it. Only when all these measures fail, does he supplement them with endocrine therapy. Men are much less sensitive about their personal appear- ance than women and they do not hesitate to record and publish the history of their struggles to overcome a tendency to obesity. Recent books like Irvin Cobb’s “One Third Off” are frank expositions of an awakening to the fact that the overload of fat is detrimental to comfort and positively dan- 766 OBESITY. gerous to existence. The realization of this danger and the determined and successful efforts to reduce weight are related by Cobb in a very readable book. Women are reticent but, as we have shown, many of them are also quite determined to follow a plan if it appeals to their reason and especially if it is likely to improve their figure and spare them criticism. Women whose occupation brings them before the public go to unending effort to keep within bounds and one of the most famous of these wrote out what she found to be the successful solution of the problem. The late Lillian Russell contributed a valuable summary of her system and it reveals the arduous road which the devotees of her art must follow if they would arrive at her state of physical perfection. DIETETIC TREATMENT. The food requirements will vary naturally with the weight and the energy expended in the daily occupation. Growing children will require thirty to forty calories per pound of body weight; adults (depending on activity), eighteen to twenty calories; and old people, fifteen or less calories per pound. A man at rest and of average size requires eighteen hundred to two thousand calories; while working at a seden- tary occupation, twenty-two hundred calories; and at hard work, thirty-five hundred to four thousand calories per day. The relative figures for women are sixteen hundred to eighteen; two thousand to twenty-two hundred, and in very active occupation, twenty-two hundred to twenty-five hun- dred calories, or possibly three thousand (see Farr, Vol. I, page 12). No system of diet can be properly carried out without recognizing the caloric values of foods, and this has received an extraordinary amount of attention in recent years. We have our nutrition laboratories and experimental feeding tests conducted by governmental and private institutions, from which emanate from time to time valuable data for the education of the public in this vital matter. During the recent war the food problem became acute and public senti- ment was strongly opposed to waste and extravagance in DIETETIC TREATMENT. 767 food. It was not patriotic to indulge in unnecessary food when the soldiers needed it and the slogan went forth that “food will win the war.” It almost needed a war to make some realize the great amount of unnecessary food that most of us were taking. As the cost mounted, economy had to be practiced and the result was that less fat and sugar were used in the household. We cannot present this subject in a more graphic and succinct manner than by repeating what Dr. Eugene L. Fisk,13 now of the Health Extension Institute, wrote some eight years ago. In a colloquy between a Martian and the Cold Blooded Scientist, Martian says: “I have been observing the eating habits of your people and am amazed at the volume of food they consume. Is your food so innutritious that it must be taken i,n such bulk? C.B.S.: No, most of our food, except some of the canned stuff, is nutritious. The quantity consumed is governed by habit, not by necessity. The average man eats enough meat to support a giant. Martian: Is this just a belief on your part, or is there exact scientific evidence to support it? C.B.S.: The beliefs in the matter are mostly held by those who advocate generous feeding. The old orthodox views on this question were based on curiously insufficient and un- scientific data, znz., observation of the habits rather than the needs of large groups of individuals. C. B. S. then goes on to enlighten Martian on the calory and the researches of Atwater and Voit, whose standards were based upon the average man’s consumption of food, claiming that from three thousand and fifty-five to thirty-five hundred calories and from one hundred and eighteen to one hundred and twenty-five grams of protein were required daily. He then shows his celestial visitor that man’s health and endurance can be maintained and even improved on half that allowance. A man requires only sufficient food to repair the waste of tissue and to make good the heat lost by the body each day. Appetite and instinct, when an excess of appetizing food is available, usually lead to excess. 768 OBESITY. The over-nourished are blessed, or rather, cursed, with keen appetite. Mental ease and contentment, politeness, good fellowship, attractive and tempting dishes, mere habit— a multiplicity of influences aside from the body’s needs— arouse appetite and govern our consumption of food. C. B. S. instructs Martian, who is apparently ignorant, like some of the earthly mortals, of the relative value of protein and carbohydrate food. The protein is required for muscle building, organ building and bone building; it is found in lean meats, the white of eggs and in some vegetables and cereals, such as peas, beans, lentils, wheat, oats, and in milk. Very little protein is needed for repair purposes after ma- turity; but the fat building foods, such as butter, fat, oils, and cereals, and starchy vegetables furnish the reserve supply of possible fat. They are not so injurious, perhaps, as excess of protein, but used unstintingly they lead to corpulence. The carbohydrates, like fat, can protect circulating albumin from katabolism and aid its transformation to organic al- bumin, but it is not proved that they themselves make fat as at first supposed, for they are very completely destroyed even when eaten in excess. They merely protect other foods from oxidation under such conditions. Meat and carbo- hydrates alone increase the fat in the body without the aid of fatty food; for fat, which originates from splitting up albumin, is spared further metabolism. Hence fatty metab- olism in the body may be quite independent of fatty ingestion. A gain in muscular efficiency should go hand in hand with loss of weight. Otherwise harm may result, nervousness, general weakness, especially of the heart, are to be feared if reducing measures are blindly persisted in. In order to prevent loss of body proteids suitable exercises should be instituted to strengthen a heart that has become weak from inactivity. It follows that rapid reductions of weight should not be undertaken unless some exercise can be given (Hewlett1). George Cheyne’s thirteenth aphorism should be borne in mind. “Every wise man over fifty ought to begin to lessen at least the quantity of his aliment, and if he would continue free of great and dangerous distempers and preserve his senses and faculties clear to the last, he ought every seven DIETETIC TREATMENT. 769 years to go on abating gradually and sensibly, and at last descend out of life as he ascended into it, even into the child’s diet.” All life insurance experts know that the best risks at middle life are somewhat below the average weight, as we have shown. The following shows the caloric value of articles of food commonly used for breakfast, luncheon and dinner, and with a total of 2729 calories. A departure from this total value can easily be made by omitting some of the articles: Breakfast Protein Calories One shredded wheat biscuit . 3.15 106 One teacup of cream . 3.12 206 One breakfast roll . 5.07 165 Two one-inch' cubes of butter . 0.38 284 Three-fourths cup of coffee . 0.26 One-fourth teacup of cream . 0.78 51 One lump of sugar 38 • 12.76 850 Lunch Protein Calories One teacup homemade chicken soup . 5.25 60 One luncheon roll . 3.38 110 Two one-inch cubes of butter . 0.38 284 One slice lean bacon . 2.14 65 One small baked potato . 1.53 55 One rice croquette . 3.42 150 Two ounces maple syfup 166 One cup of tea with one slice of lemon One lump of sugar 38 16.10 928 Dinner Protein Calories One teacup cream of corn soup . 3.25 72 One luncheon roll . 3.38 110 One-inch cube of butter . 0.19 142 One small lamb chop, broiled . 8.51 92 One teacup of mashed potato . 3.34 175 Apple-celery lettuce salad with mayonnaise dressing . 0.62 75 . 1.32 47 One-half inch cube American cheese . 3.35 50 One-half teacup of bread pudding . 5.25 150 One demi-tasse coffee One lump of sugar 38 29.21 951 Grand Total: Protein. 58.07, Calories 2729. 770 OBESITY. Although it is usual for hospitals and sanatoria to have a service of diet, it has remained for the leading hotel in New York to provide a set of specially arranged menus suit- able for a number of affections for the use of their patrons who may require them under medical advice. In this in- stance the diet scheme has been arranged by a physician who has grouped the particular needs of patients under seven different classes. Under diet No. 2,* which is designated as being of high cellulose, low calory, and low in fat, starch and sugar, is found the following list of items: Breakfast. Fruit (unsweetened). Orange, apple (raw), grapes, baked apple, stewed pears, stewed prunes. Cereals (with cream). Shredded wheat, krumpled bran, cereal meal, cracked wheat. Bread. Bran muffins, bran bread, gluten bread (toasted), wheatsworth biscuit, whole wheat biscuit, casein bread (Lister’s). Eggs. Boiled, poached, scrambled. (or) Meat. Broiled lean ham, broiled lamb chop, broiled mutton chop, broiled chicken, steak (lean). (or) Fish. Bluefish, striped bass, brook trout, codfish. Beverages. Tea (no cream or sugar), coffee, hot skimmed milk, kaffee hag. Luncheon and Dinner. Relishes. Radishes, olives, celery, pickles. Soups Vegetable (strained), bouillon, chicken broth, clam broth. Fish Blue fish, brook trout, lobster, codfish, striped bass, crab meat. * The author is indebted to Mr. Carruthers of the Waldorf-Astoria for this menu. DIETETIC TREATMENT. 771 Cold Fish (as above), Meats (as below), Lean ham, tongue. Meat Broiled, boiled or roasted lean meat or chicken, any variety (plain) on general menu except liver, pork, goose and duck. Vegetables (without butter or cream). Asparagus, spinach, peas, string beans, mushrooms, tomatoes, cabbage, cauliflower, stewed celery, onions, sauerkraut, brussels sprouts, green peppers. Salads Grapefruit, Romaine, hearts of lettuce, celery, chicory, water- cress, French endive, tomato, cold slaw. With lemon juice only or special Waldorf diet dressing. • Desserts Pineapple (fresh), raw pear, raw apple, grapefruit, stewed pears (without sugar), baked apple (without sugar), ices (any flavor). Beverages. Tea, coffee, buttermilk, skimmed milk. In connection with this menu there is this note: “Food quantity, food quality and the will to get thin are important factors in reducing. Obesity fads do tremendous harm. Weight reduction by following the straight and narrow paths of rational dieting and exercise, rather than the devious paths of drugs and ’isms, is the only safe course. A reducing cure should be supervised by your physician.” Reduction Cures for Surgical Purposes. It is occasionally deemed necessary to attempt a reduction cure before operat- ing on the abdomen. The difficulties and dangers of ab- dominal operations in the obese are well known. Large abdominal scars are liable to hernia and their repair can be better accomplished if the superficial fat is removed by a course of dieting. It was such a case that Dr. J. H. Means” had the opportunity of studying in the Massachusetts Gen- eral Hospital, carrying out an experimental study of the metabolism to which we have previously referred. In this case the patient was reduced from two hundred and forty-five pounds to two hundred and eleven pounds in two and one- half months when she was operated on successfully. Three months later the patient weighed one hundred and eighty-five pounds and was in excellent health. 772 OBESITY. CLASS TREATMENT OF OVERWEIGHT. In the spring of 1920 the Health Commissioner of Chicago, impressed with the fact that a great many good men and women are overweight, undertook to organize a physical culture and gardening club. He called for fifty volunteers— twenty-five men and twenty-five women, to embark on a sixty day course of weight reducing and health promotion. The women volunteers ranged in age from twenty to forty- five and all were engaged in sedentary occupations. But no men volunteered, as they evidently were not as much inter- ested in improving their health status. The age, weight, height and occupation of each applicant were taken and records were kept, noting gain and loss of weight as well as general health conditions. This municipal experiment reflects great credit on the Health Department of Chicago. It included exercises and a course of dieting, accompanied by lectures and careful physical examinations. A set of menus was prepared by Miss Ruth Wilbur, dietitian of the Chicago Training School for Home and Public Nursing. These contain the food essential for those desiring to reduce their weight. We have taken the opportunity of reproducing them, as they contain a surprising variety of foods and suc- cessfully avoid a monotony of dishes, a very desirable feature in matters of diet. Dr. Robertson, the Commissioner, recognizing that a course of physical exercises must go hand in hand with diet, made them a feature of the course. The exercise of walking, weeding or hoeing in the garden, was supplemented by a system of setting-up exercises which, it was emphasized, should be taken in the morning on rising, before dressing or eating and with all windows open. The exercises were as follows and it was noted that those who followed the system made the best progress in getting rid of surplus fat: (1) Feet together, stand erect, bend body forward slowly, touch fingers to floor without bending knees, six times. (2) Right foot forward, bend body in same way, touching fingers without bending right knee, six times. (3) Repeat same with left foot forward, six times. CLASS TREATMENT OF OVERWEIGHT. 773 (4) Stand at open window, inhale (take deep breath, hold it, drop chest), raise right arm above head, lower it, exhale (blow air out of lungs), six times. (5) Repeat same with left arm. (6) Repeat same with both arms. (7) Inhale, drop chest, arms clasped straight forward, raise arms above head without bending elbows, bending head for- ward. (Do not put hands back of head, only above head.) (8) Hands on hip, balance on ball of right foot, then left, alternately, changing weight, twelve times. (9) Raise right leg sideways, six times; then left leg, six times. (10) Place both feet firmly on floor, one foot apart, and stoop six times without assistance. (11) Hands and feet on floor, animal fashion, kick out six times. (12) Lie on back, clasp hands underneath knees, roll to sitting posture; repeat twelve times. Menu prepared for the Chicago School of Sanitary Instruc- tion.* First Day. Breakfast: One-half grapefruit. One slice bacon. One slice toast or bran muffin. One cup coffee with 1tablespoons skim milk. Note: If milk is heated for coffee, it will taste as good as cream. Use no sugar. Dinner: Medium serving of any lean meat. Salad—lettuce with sliced tomatoes, French dressing. Green peas without butter or milk. Rye bread with 1 teaspoonful of butter. Sliced pineapple for dessert. Black coffee. Note: Avoid cream sauces or rich meat gravies. Supper: Tomato bouillon. Two crackers. Salad—lettuce with French dressing. Bran bread without butter. Fruit for dessert. Black coffee. * Bulletin Chicago School of Sanitary Instruction, June 26, 1920. 774 OBESITY. Second Day. Breakfast: One medium apple. One egg. One slice toast. One cup coffee with one and one-half tablespoons skim milk. 10.30 a.m.: One-half cup bouillon. One cracker. Luncheon: Lean, cold roast beef, medium serving. Rye bread, two thin slices. Lettuce and cottage cheese salad. Lettuce—any amount. Cheese—two and one-half tablespoons. French dressing—one-half tablespoon. 4.30 p.m. : Tea with lemon. One cracker. Dinner: Boiled cod with lemon (large serving). Cauliflower (plain) one large serving. One scant teaspoonful butter. Lettuce salad or celery (large serving). One-half of a large orange. Black coffee. 10.30 p.m. : One-half cup hot skim milk. Third Day. Breakfast: Stewed prunes (ordinary serving). One egg on one slice toast, without butter. Bran muffins. Coffee with boiled skim milk, no sugar. Luncheon: Asparagus on one slice toast, without butter. Lettuce salad—French dressing. Fruit for dessert. Coffee with boiled skim milk, no sugar. Dinner: One serving of any lean meat. Spinach any amount. Salad—lettuce and cucumber with French dressing. Fruit gelatin, without cream or sugar. Tea or coffee, clear. CLASS TREATMENT OF OVERWEIGHT. 775 Breakfast: FouEIH Day' One apple. Two slices bacon. One slice any coarse bread with one teaspoon butter. Coffee with hot skim milk. Luncheon: Clear soup with two crackers. Salad—lettuce with any cold vegetable, French dressing. Fruit for dessert. Clear coffee. Dinner: One serving of any lean meat.* String beans. Graham bread with one teaspoon butter. Cabbage salad (shredded raw cabbage served with vinegar, salt and pepper). Stewed fruit for dessert. Tea or coffee. Fifth Day. Breakfast: One-half grapefruit without sugar. One egg on slice of unbuttered toast. Bran muffins. Coffee with heated skim milk. Luncheon: Clear tomato soup with little rice, no crackers. Lettuce salad with French dressing—you may add chili sauce to salad if you like. Fruit. Coffee. Dinner: One serving of any lean meat (perhaps corned beef, if lean). Cabbage (boiled) or sauerkraut. Best way to cook cabbage: Shred it and boil for only fifteen minutes in little water. Add vinegar when serving, if you wish. Salad—lettuce with apple sliced, and a few raisins. Bran bread with one teaspoon butter. Fruit for dessert. Tea or coffee. Sixth Day. Breakfast: One orange. Asparagus on unbuttered toast. Bran muffins. Coffee with hot skim milk, no sugar. * Pork not included. 776 OBESITY. Luncheon: Clear soup. Two crackers. Lettuce salad with sliced tomatoes and cucumbers, French dressing. Bran bread. Fruit for dessert. Coffee. Dinner: One serving of broiled fish—halibut, perhaps—no salmon. Stewed tomatoes—any amount. Waldorf salad—lettuce with chopped apple and celery. French dressing. Sliced pineapple. Bran bread with one teaspoon butter. Tea or coffee. Note: If you must have your coffee and fruit sweet, you may use saccharine or sweetena. Get it at any drug store. Use sparingly and follow directions, because it is much sweeter than sugar. It is not fattening. If you are in the habit of eating more than is listed here, you will prob- ably feel hungry between meals, especially if you are exercising. If this is so, you may take any clear soup or bouillon with a cracker between meals. A glass of water will often satisfy this hungry feeling. Meat once a day is enough. No potatoes. First Week. Breakfast: One soft boiled egg. Dish of tomatoes. Cup broth. One cup coffee, (no milk or sugar). Dinner: One soft boiled egg. Two ounces 5 per cent, vegetable. Two ounces 5 per cent, vegetable. One cup broth, (no milk, sugar or salt). Supper: One soft boiled egg. One dish S per cent, vegetable. One dish 5 per cent, vegetable. One cup broth. Second Week. Breakfast: One soft boiled egg. One dish of tomatoes. Dish of vegetables. One cup broth. One graham gem, no butter. CLASS TREATMENT OF OVERWEIGHT. 777 Dinner: Two ounces meat or fish. Three ounces 5 per cent vegetable. Three ounces 5 per cent vegetable. One cup broth. One soft boiled egg. Supper: Two ounces meat, lean. One egg. Three ounces 5 per cent, vegetable. Three ounces 5 per cent, vegetable. One graham gem. Third Week. Breakfast: Two eggs. Six ounces broth. Four ounces 5 per cent, vegetable. One slice bread. Dinner: One-sixth ounce butter. Two ounces meat. Three ounces 5 per cent, vegetable. Six ounces broth. Two ounces 5 per cent, vegetable. One slice bread. Supper: One-sixth ounce butter. One ounce meat. One egg. Three ounces 5 per cent, vegetable. One slice bread. Fourth Week. Breakfast : Three ounces cream. One-third ounce butter. Two eggs. Three ounces 5 per cent, vegetable. One-half cup of oat flake. One slice bread. Dinner: One-third ounce butter. Two ounces meat. Three ounces 10 per cent vegetable. Five ounces broth. One slice bread. Two ounces 5 per cent, vegetable. 778 OBESITY. Supper: One-third ounce butter. One slice of bread. Two ounces meat. One egg. Three ounces 5 per cent, vegetable. Two ounces 10 per cent, vegetable. One slice bread. 5 per cent, vegetables. Lettuce. Asparagus. Celery. Chard. Endive. Cauliflower. Spinach. Cabbage. Sauerkraut. Tomato. String beans. Eggplant. Radishes. 10 per cent, vegetables. Onions. Squash. Turnips. Carrots. Beets. Parsnips. Low Calory Diet. Breakfast: One slice of very dry, coarse, bread toast % inch thick .. .. 50 Butter % cubic inch .. 25 Hot water flavored with coffee .. 00 75 Luncheon: One corn muffin .. 125 One pat of butter . 100 Salad, Roquefort cheese dressing .. 100 One cup of coffee with a tablespoonful of cream .. 50 375 Dinner: Vegetable soup or bouillon, no fat .. 25 Lean meat or lobster, or fish, 5 or 6 ounces .. 300 Large serving of uncooked lettuce or cabbage .. 00 Mayonnaise or oil, teaspoonful .. 50 One large dish of tomatoes or cauliflower, or string beans or carrots or turnips .. 25 One slice of bread, medium, or one medium potato .... .. 100 One pat of butter .. 100 Dessert, two macaroons or ladv fingers .. 100 One cup of cereal-coffee, water .. 00 700 Total ..1150 Another attempt to treat overweight on a large scale was made by Dr. Royal S. Copeland, Health Commissioner of New York City, in October and November, 1921. It has CLASS TREATMENT OF OVERWEIGHT. 779 attracted wide-spread interest and, as in Chicago, women have been most interested and have formed the larger part of tho class taking treatment. As a spectacular undertaking it has been a great success. It was designed primarily to attract attention to the Health Exposition held in New York in November, but quickly demonstrated that there were thousands in New York who are honestly anxious to get rid of superfluous flesh. At the close of the thirty day contest, November thirteenth, prizes were awarded. The winner of the first prize was thirty-two years old, and five feet, seven and three-quarters inches tall. Her bust measurement was 52 inches and fell to 47.5 inches. Her waist was 50 inches and at the end of the test, 39 inches. Her hips were reduced from 60 inches to 53 inches. Her weight at the start was 281 pounds; at the finish, 250 pounds. The second prize went to a lady thirty-three years old; five feet, eight inches tall; who was reduced from 258 pounds to 229.5 pounds. The third, aged twenty-four, and five feet, four and one-half inches tall, dropped from 194 pounds to 168 pounds. Thirty-four persons lost an average of 16.5 pounds. The Health Commissioner states that the demonstration has shown several interesting things. “Hunger, a perfectly natural symptom, is satisfied in a wrong way by very many persons. When the stomach is empty it communicates with the brain and a call for food is sounded. Likely a drink of water would satisfy this yearning but instead of taking water a quantity of chocolate candy, or ice cream, half a pound of sweet grapes, a handful of raisins, dates, figs, or other similar articles, is taken. These but add to the fuel. “The greatest mistake people make is in the selection of their food. The average meal is poorly balanced. This is particularly so of breakfast. Imagine wanting to get thin on a breakfast like this: Cereal and cream, hot muffins with butter and honey, sausage, and possibly some fruit covered with sugar. This entire meal is made up of starches and sugar, which add to the flesh, and very often as an added ofifense it is washed down with tea, cofifee or cocoa saturated with sugar. 780 OBESITY. “There is no secret in a system of fat reducing. No sys- tem can succeed unless the candidate for a sylphlike form has instructed herself in food values and is willing to ‘carry forward’ until the end is accomplished. It is easier to say what foods ought not to be eaten than to set down those that are safe to take. There are certain foods that may be taken abundantly. Some of them are celery, buttermilk, radishes, endive, lettuce, tomatoes, watercress, clams, whites of eggs, chicken without the skin, shad, white meat of lobster, codfish, pears, apples, grapefruit, lemons, oranges, rhubarb, lean meat and skimmed milk. “Don’t forget in reducing flesh exercise is important. One cannot expect to get thin when all the exercise taken in a day consists principally of getting on and off cars. Let me repeat again that all these things may be done with good result, but if a person goes back to the old method of eating it will all have been done in vain.” Susannah Cocroft of Chicago, is a lady who is widely known as an exponent of physical culture and has helped many thousand men as well as women to a better physique by the rational application of the methods enumerated. Miss Cocroft undertook the training of a large number of women em- ployed in Government service in Washington during the war, rendering in this way a patriotic service. CIRCULATORY DISORDERS IN THE OBESE. The order in which these occur is somewhat as follows: Dilatation is liable to occur first in consequence of the fatty deposits; afterward, when compensation for the damaged heart muscle is impossible, the symptoms of muscular in- sufficiency supervene. In case of arterial disturbances suf- ficient to cause effusions of blood to the brain, the outlook is very serious and its occurrence is a common cause of death in the obese. They also readily succumb to any infectious disease that attacks them. Whenever cardiac dilatation, valvular lesions, myocarditis, fatty heart, or other degenerative changes in the heart mus- cle are noted, much care should be used in giving advice and treatment. Removal of an extra burden will naturally favor a weak heart and check a tendency to hypertrophy and CIRCULATORY DISORDERS IN THE OBESE. 781 dilatation. Heart affections of this type may be benefited by the reduction cure. But in advanced arteriosclerosis, or in such cases as are suspected to have any aneurism, naturally much harm might be done. Active muscular ex- ercise would not be warranted, but rather, passive exercises. The so-called resistance exercises, under skillful guidance, will be a suitable measure. Many probably fear that a reduction cure will take away strength along with the fat. Overexercise and underfeeding may readily do this, especially if purgatives and organic drugs are given at the same time. The aim should be to enhance muscular power while fat is lost. The muscles should be rescued from inertia and indolence by affording a fresher circulation and an increased muscular tone. The skin is the greatest organ of the body and it is, of all the organs, the one most intimately associated with the fat; hence it is reasonable to suppose that massage and a course of baths in which the skin is made to yield profuse perspira- tion, especially when we follow these measures with a hot- blanket pack, will give good results. The mechanical effects of increased abdominal and intra- thoracic fat are exerted on the lungs; the breathing space is encroached upon, the respiratory capacity is lessened. Dr. James M. Anders14 has observed that the respiratory expan- sive movement of the lungs, as measured outside the chest, is often less than 2.5 inches and hence muscular exercise usually causes dyspnea when such fatty deposits are present. It is obvious that the coexistence of a very full stomach and much surrounding fat will cause interference with respiration. In the anemic form of obesity there is small capacity for exercise; the fat globules are more loosely grouped, together with greater abundance of intervening material in the form of seromucous fluid, which greatly interferes with muscular action. In the plethoric form of obesity the dyspnea is much less and the general bodily vigor is not lessened, but is often about the standard. In these cases of overfatness Dr. Anders14 has noted a peculiar pain in the subscapular and intrascapular muscles extending across the back from side to side and giving the sensation “as though the flesh had grown fast to the bones.” 782 OBESITY. “Mere obesity or subpericardial fatness does not imply fatty infiltration but it may, in a mechanical manner, pro- duce respiratory and circulatory disturbances, particularly venous stasis, as shown by cyanosis, a frequent, small pulse and dyspnea; or a distinctly asthmatic form of breathing and sometimes cough.” MECHANICAL AND ELECTRIC DEVICES. Mechanical-electrical devices have been used in recent years for weight reduction. In 1909 Bergonie, of Bordeaux, described results of his system of passive ergotherapy by means of a coarse wire Faradic apparatus. This is provided with a metronome with variable time control and quicksilver contacts, a current controller, a series of circuit controllers, and a chair with both stationary and movable electrodes. In one form of apparatus there are four large metallic elec- trodes : two for the abdomen, to be placed on either side of the median line, and two for the anterior portions of the thighs. In another form there are twelve electrodes: six stationary (for the back, buttocks and thighs, and legs) and six movable (two for the arms, two for the abdomen, and two for the thighs). Provision is made for contact in from two to ten different parts of the body, so that different parts may be stimulated simultaneously to powerful but compara- tively painless contractions. The current is rhythmically interrupted and reversed and timed to correspond with the action of the heart. The interrupter, or vibrator, is made to operate at thirty per second, the rate of normal muscle fibrillation; the gross muscular contractions are regulated during treatment by the metronome according to the chang- ing heart beat. In Titus’s method the chair is covered with a moderately thin bibulous material wet with warm water, and the mov- able electrodes are slipped in suitable sized covers like a pillow slip, also wet and of the same thickness of material. It is necessary that the covering material of all electrodes should be of the same thickness, as the tension of the current from the machine to the patient being only twenty-four volts the slightest difference in this detail will make the current irregular and quite unsatisfactory in its effects; not over MECHANICAL AND ELECTRICAL DEVICES. 783 fifty to seventy-five milliamperes are required. The total area of the electrodes may amount to ten thousand square centimeters. Titus holds the arm electrodes in place by crepe bandages because they are elastic; those on the thighs and abdomen are best secured by sand bags. By their weight they secure a good contact and give the muscles a little more work to do. Titus describes the technique quite fully as to the preparation of the patient, who, besides wearing his shoes and stockings, is covered with a sheet; as to the testing of the mechanism; the duration of the seance and the general period of treatment. He advocates a treatment daily for the first three or four weeks; then on alternate days for a similar period. Associated with this is a special diet of small caloric value and liberal doses of a saline laxative water morning and night. The results are apparently satisfactory. Morse wave generators used to produce muscle stimula- tion, may be attached to a type of Bergonie chair for a similar plan of treatment. The suggestion has been made to have the chair fitted with a series of incandescent lamps underneath, as already tried successfully at the Walter Reed General Hospital in Washington. The Morse wave afifords a slow expansion and contraction resulting in a possibly fuller action; but unless it is adjusted with proper rheostats for different degrees of current for the various parts of the body, it is painful, a condition said never to be met with in using the Bergonie method. Titus has criticised these other methods, saying that they have been followed by ex- haustion physical and mental, with changes in the urinary content (which indicated irritation), such as large quantities of urea, sometimes sugar and frequently albumen and casts. Hence, caution in advice as to electromechanical treatment. There are several very useful effects. In the first place, muscular contractions tend to an increase in the size of the muscle and a loss of fat. One may balance the other for a time but ultimately the loss of fat is greater. This shows itself—at first in a better bodily contour, and later by an appreciable loss in body weight with better elimination of the products of tissue waste. It is claimed that deep res- piratory excursions are involuntarily induced and a greater activity of both skin and kidney function is likewise observed. 784 OBESITY. Patients who seldom perspire will develop most active di- aphoresis and diuresis, and it is not uncommon to have them void from twelve to sixteen ounces of urine which is both physically and chemically normal at the end of an hour’s treatment. Franz Nagelschmidt, of Berlin, modified Bergonie’s ap- paratus so as to give greater energy, as claimed by those favoring this type. It has been advertised energetically as a cure for obesity, without pain, without dietetic restrictions, and of course with lasting results. No patients should be subjected at the beginning to a full hour’s treatment with maximum energy; beginning with fifteen-minute sessions, sixty minutes may be attained gradu- ally. Nagelschmidt administered treatment in two series: at first a series of twenty-five sessions covering four weeks; then an intermission of from one to four weeks; and then a series of the same length. He added that if necessary the treatment should be repeated. We can readily see that the exercise with any form of apparatus producing sixty contractions per minute is repre- sented by thirty-six hundred contractions per hour for each electrode used—no small expenditure of physical energy. Voluntary physical exercise, of course, involves likewise a large number of muscular contractions, but few of those who need it most can voluntarily make a corresponding degree of effort. The wrell known system of mechanical exercises invented by the late Prof. Gustaf Zander, of Sweden, is a combination of both active and passive movements by means of apparatus of great ingenuity and adapted for every part of the body. This apparatus is found in “Zander Institutions” in European resorts and in a few places in the United States. Some pas- senger steamers are also equipped with a few of the simpler pieces. The first installation in America was made at the Massachusetts General Hospital in 1905 and it is there that the most systematic and intelligent use of the system has been made in America. The hospital has one hundred pieces of apparatus. They are in part active, or depending on the voluntary effort of the patient; and in part passive, or elec- trically operated. In the larger sets, as those in Boston and EXERCISE. 785 at the Virginia Hot Springs, one can choose special forms and arrange the time allotted to each form or group of apparatus so as to judiciously enhance muscular power and incidentally reduce the undesirable superficial fat. A trained attendant and medical supervision are naturally required to carry out this plan of treatment successfully. There are over fifty pieces and they are quite expensive to install, as they must be imported. EXERCISE. Active exercises in the open air are desirable if the physical condition warrants and the environment permits. A great change, however, has come over us in this regard during the last few years. Walking exercises, in our cities at least, are not carried out so easily or so safely as formerly. The patient who most needs the exercise usually has his car and uses it on all possible occasions. It may be thought quicker, easier or safer than to walk through the streets. Outside of the cities the pedestrian has a sorry time of it if he presumes to walk upon a popular highway these days. Not unfrequently pride will prevent the adoption of such a pre- scription and hence the exercise must be taken in secret. We ought to give to our obese friends the prescription which was handed to his customers by an old English boot- maker nearly one hundred years ago. “The best medicine: Two miles of oxygen three times a day. This is not only the best but cheap and pleasant to take. It suits all ages and constitutions. It cures cold feet, hot heads, pale faces, feeble lungs and bad tempers. If two or three take it together it has a still more striking effect. This medicine never fails. Spurious compounds are found in large towns; but get into the country lanes among green fields, or on the mountain top and you have it in perfection as prepared in the great laboratory of nature.” Horseback exercise belongs for the most part to a bygone age. There are, to be sure, a few resorts where saddle horses may be had and where there are suitable roads; and there are bridle paths in most of our parks; but the horse and the rider are surely vanishing. More than that, a very fat man or woman does not look well on horseback. In Mr. Dooley’s 786 OBESITY. essay on Banting, which might be called in the elder style “A Vindication of Corpulence,” he says that: “Nowadays ’tis the fashion to thry to emaciate ye’ersilf.” Speaking of his friend Carney, he said : “then he thried takin’ long walks. The long walk rayjooced him half a pound and gave him a thirst that made him take on four pounds of Boodweiser. Thin he rinted a horse an’ thried horseback ridin’. The horse liked his weight no more than Carney did an’ Carney gained tin pounds in the hospital.” The skeptical Dooley gives this comfort to the corpulent: “If Nature intinded ye to be a little roly poly, a little roly poly ye’ll be. They aint annything to do that ye ought to do that’ll make ye thin and keep ye thin. Th’ wan thing in the worruld that’ll rayjooce ye surely is lack of sleep an’ who wants to lose his mind with his flesh? I’ll guarantee, with the aid of an alarm clock to make anny man a livin’ skiliton in thirty days. The only ginooine anti-fat threat- ment is sickness, worry, throuble and insomnya.” HYDROTHERAPY. Hydrotherapy is used for the reduction of weight with more or less success in connection with systematic exercise and dieting. In itself it is not sufficient. There is a type of the overfat, high-living man who has eaten and drunk without very serious effects, and who peri- odically takes some form of reduction cure in order to keep his weight down and, incidentally, enjoy life once more in his accustomed way. Patients of this type are likely to have dilated stomachs and sluggish livers. They probably have learned to use laxative mineral waters or salts and in that way obviate any serious illness. Besides a dilated stomach, careful examination will some- times reveal a dilated -or fatty heart, a slightly dusky look, yellowish conjunctiva, a quick pulse and a tendency to dysp- nea. Hydrotherapeutic measures should therefore be care- fully instituted and if possible, the patient should be seen shortly after his first bath. The visitors at spas generally include cases of this kind and they demand suitable treatment. It should be based always on individual requirements and capabilities. Most HYDROTHERAPY. 787 of these subjects are in middle life, are of sedentary habit and consequent muscular weakness. The heart should be observed at the start and all through the course of treatment. If baths are ordered, a daily record should be kept of weight and also of the heart’s action. From time to time the blood- pressure should be recorded. Few go to hospitals for the reduction of weight but many go to spas. The further they WEIGHT CHART CHART I. CHART II. WEIGHT CHART Upper line weight before the bath, and lower line after the bath. go and the more sacrifices they make to undergo the cure, the more conscientious they are in adhering to discipline. Men hear a great deal about the “boiling-out” process in use at certain springs. They are impressed with the advan- tage of extreme measures, and are usually anxious to lose a great deal of flesh in a minimum of time. If they go to a resort, they expect to dispense, more or less, with alcohol, and to limit their dietary. It is remarkable how much weight is lost in a single bath, when careful weighing is made be- fore and afterward. The author has known a patient to lose five pounds in a single bath and a subsequent hot pack. 788 OBESITY. A patient has stated that he lost seven pounds in a single bath and pack. The accompanying charts illustrate the loss of weight while bathing, exercising, and dieting. The weight was taken without clothing before entering the bath, and on being dried after the final cold douche. The regime in Case I allowed two meals a day; walking seven miles; swimming half an hour; a bath consisting in a warm douche for six minutes to the entire body, the water 104° F., and the temperature of the room about 100° ; a tub- bath at 104° for twenty minutes, followed by a hot pack with eight blankets for twenty-five minutes. After this, the patient got into a tubful of water at 54° to 60° F. When he came out, he was dried and was ready to rest for an hour. This rather strenuous regime is suitable only for a man in perfect health and of perfect habits, to whom the term “patient” seems wholly inappropriate. The chart shows that in Case I, as much as three pounds was lost in a single bath, and as much as four and one-half pounds was gained in twenty-four hours as the result of breaking the dietary regime. In another case the conditions were somewhat different. While accustomed to take a good deal of exercise, there was a decided alcohol habit, greater indulgence at the table, a very slight albuminuria, and a sluggish and overloaded liver. The patient was inclined to break through the regime, but, never- theless, lost ten pounds in a month. The bath adopted by this patient consisted of: Hot douche 104° F. (40° C.), for ten minutes. Full bath 104° F. (40° C.), for ten minutes. Hot, dry blanket pack, for twenty minutes. Cold douche 50° F. (10° C.), followed by alcohol rub. In the case of a third patient, weighing two hundred and fifty-one pounds, decidedly alcoholic, twenty pounds were lost in twenty-two days. The bath consisted of a warm douche for ten minutes, tub for fifteen minutes at 104° F., and a hot blanket-pack, using six blankets. The author has not found the hot-air cabinet followed by circular, jet, Scotch and fan douches, so efifective as full baths and packs in the reduction of weight. Even when the cabinet is used for fifteen or twenty minutes at temperatures above 170° F., HYDROTHERAPY. 789 there is not the same tendency to lose flesh. The following formula is sometimes used in this plan of treatment: H. A. B., or electric-light cabinet, up to twenty minutes. C. D., 105° down to 70°, two minutes, twenty to thirty pounds. J. D., 100° down to 70°, one minute, twenty to thirty pounds. S. D., 105° and 70°, twenty seconds, twenty to thirty pounds. Fan D., 65°, ten seconds, twenty to thirty pounds. Alcohol rub. Reduce minima, 1° daily to 60°. Certain European spas have acquired a great reputation for the treatment of obesity. Marienbad, Germany, and Carlsbad, Czechoslovakia, have been specially prominent in this respect and great favorites with American and English travelers. They are better suited to the plethoric cases rather than for the anemic types of obesity, or those presenting serious cardiovascular disease. Vichy and Brides-les-Bains are the spas of choice in France. In America specialization of spas is not so definite as in Europe. A regime adapted to the needs of the obese is available at the Hot Springs, Virginia, and the White Sulphur Springs, West Virginia, and also at French Lick, Indiana, and Glen Springs, New York. The tendency at American spas is to treat all patients presenting themselves and it is likely that the methods adopted by individual phy- sicians practicing at spas will vary greatly, even in reference to the same class of cases. One may emphasize the use of baths and exercises, and passive exercise by massage; another may institute some form of electrical treatment; others use thyroid extract in cases deemed suitable. The results obtained at spas, while strikingly successful in many cases, have been held to be “rarely permanent un- less the patient can be enjoined to continue certain details of treatment afterward.” This criticism can be fairly made in discussing the results of treatment in any of the so-called diseases of metabolism. It is equally applicable in cases of gout and rheumatism, diabetes, diseases of the intestinal tract, or nephritis. When bodily disorders are once corrected, or even par- tially corrected, we fall short of our duty if we neglect to stress the rules of life that must govern the patient who passes from observation. I think that the average visitor 790 OBESITY. to an American spa who once realizes the benefit derived from his visit, makes a decided efifort to profit by his experi- ence, and the repeated visits of these patients bear witness to the success of treatment. I have known a lady to return on ten successive years in a determined efifort to check a strong tendency to acquire too much flesh. The weight and diet records of this case afford a good example of a per- sistent endeavor to reduce weight and are here appended. February 2. Sixteen ounces water, twelve ounces milk. 3. Sixteen ounces water, twelve ounces milk. 4. Thirty-two ounces water, twelve ounces milk. 5. Twenty-four ounces water, twelve ounces milk. 6. Twenty-four ounces water, twelve ounces milk. 7. Thirty-two ounces water, eight ounces milk, one piece Melba toast, two cups clam broth. 8. Forty-eight ounces water, four ounces milk, spinach, one piece pulled bread. 9. Thirty-two ounces water, four oranges, one piece pulled bread, two cups chicken broth. 10. Thirty-two ounces water, four oranges, one and one-half lemons, one piece Melba toast. 11. Forty ounces water, one-half lemon, one piece Melba toast, one baked potato. 12. Forty ounces water, four oranges, spinach. 13. Twenty-four ounces water, sixteen ounces milk. 14. Eight ounces water, eight ounces milk. 15. Sixteen ounces water, sixteen ounces milk. 16. Thirty-two ounces water, four oranges, one piece pulled bread, spinach. 17. Forty ounces water, four oranges, one piece pulled bread, spinach. 18. Forty-eight ounces water, twelve ounces milk. 19. Thirty-eight ounces water, twelve ounces milk. 20. Sixteen ounces water, six ounces milk, one piece pulled bread. 21. Twenty-four ounces water, two oranges. 12.45 p.m., one piece pulled bread; spinach. 6 p.m., Melba toast. ‘ 22. Forty ounces water. 9.15 a.m., one orange. 1 p.m., one piece pulled bread; spinach. 5.30 p.m., tea. 23. 9 a.m., magnesia water and Vichy. 12.30, magnesia and Vichy. 1 p.m., Melba toast; spinach. 4 p.m., Melba toast. 6 p.m., tea with half a lemon. 24. 9 a.m., magnesia and Vichy. 12.30 p.m., two oranges; pulled breads. 4.30 p.m., magnesia water and Vichy. 5.30, tea. 8.30, magnesia water and Vichy; one glass of water. 25. 9 a.m., magnesia water and Vichy. 9.30 a.m., two pieces of Melba toast. 12.15 p.m., magnesia and Vichy water. 1 p.m., beefsteak; one piece pulled bread. 4.30 p.m., one orange. 9 p.m., one orange. HYDROTHERAPY. 791 Weight chart of patient whose diet is detailed on pages 790 and 792. WEIGHT CHART 792 OBESITY. 26. 7.30 tea. 9 a.m., one orange. 12.30, magnesia and Vichy. 1 p.m., chicken, creamed carrots; pulled bread. 5 p.m., tea. 6.30 p.m., magnesia and Vichy water. 7.30, two pieces roast beef. 11 p.m., magnesia water. Two glasses plain water in the day. 27. 9.30, magnesia and Vichy water. 12.30, magnesia and Vichy water. 1.45, ccld chicken; tongue; lettuce; egg; Melba toast. 5, tea. 6.30, cold chicken; tongue; Melba toast. 28. 11.30, magnesia and Vichy water. 1.30, roast beef; turnips, spinach. 5 p.m,, magnesia and Vichy. 7.30 steiwed After Rowlandson. tomatoes. 11 p.m., magnesia and Vichy; one orange. Two glasses of water in the day. March 1. 12.30,, corned beef; Melba toast. 4 p.m., carbonated water. 5.30, magnesia and Vichy water. 7.30, roast chicken; Melba toast. 11 p.m., magnesia and Vichy. Three glasses of water in the day. A similar diet was continued for three additional weeks and the weight remained, with slight variations, at 146.5 pounds. The general health and energy seemed to be unimpaired. Loss of Weight by Baths and Severe Exercise. A man of fifty-two years, accustomed to intense actvities, physical and mental, a repeated visitor at Hot Springs, Virginia. WORKS OF REFERENCE. 793 March 5th, 1921 189 pounds After bath at 5.30 p.m 187.5 pounds March 6th, hard tennis and golf Weight after bath 181. pounds March 7th, hard tennis before bath 183. pounds After bath 180.5 pounds March 8th, after bath 182.5 pounds March 11th, after bath 182. pounds The loss was due to bathing and exercise and not to diet. WORKS OF REFERENCE. “Diet and Health, with Key to the Calories.” Luiu H. Peters, M.D., Reilly and Lee Co., Chicago, 1918. “Food Values.” E. A. Locke, M.D., Appleton, New York, 1913. “Eat and Grow Thin.” A series of menus. 1. Hewlett: Oxford Medicine, i. 2. Mitchell, S. Weir: Fat and Blood, Eighth Edition, 1907, p. 32. 3. Cushing, Harvey: The Pituitary Body and Its Disorders, J. B. Lippincott, 1912; also Jour. Amer. Med. Assoc., June 18, 1921. 4. Joslin, E. P.: Jour. Amer. Med. Assoc., January 8, 1921. 5. Medico-Actuarial Mortality Investigation, ii, New York, 1913. 6. Rogers, Oscar H.: New York Life Insurance Co., New York. 7. Means, J. H.: Jour. Med. Research, xxxii, pp. 121-158, Boston, 1915. 8. DeFleury: Bull, de l’Acad. de Med., Paris, lxx, No. 17. 9. Editorial, Jour. Amer. Med. Assoc., February 19, 1921. 10. Luke, Thomas D.: Manual of Natural Therapy, Bristol, Eng., 1908. 11. Fletcher, Horace: The A-B-Z of Our Own Nutrition, and The New Glutton or Epicure. F. A. Stokes Co., New York. 12. Grafe, E.: Jour. Amer. Med. Assoc., February 12, 1921. 13. Fisk, E. L.: Bulletin No. 10, Postal Life Insurance Co. 14. Anders, J. M.: Amer. Jour. Med. Sciences, April, 1901. 15. Beraud, Henri: Le Martyre de l’Obese. Goncourt prize, Paris, 1922. A work of fiction which portrays vividly the trials of the stout. Incidentally it gives a remarkable description of the Cent Kilos of Paris. Diseases of the Skin BY FRANK C. KNOWLES, M.D. Professor of Dermatology, Jefferson Medical College; Dermatologist to the Dispensary of the Pennsylvania Hospital; Member of the Amer- ican Dermatological Association. Diseases of the Skin. FOREWORD. The Section on Diseases of the Skin, of the present volume, has been written with the thought in view that this is a textbook on general medicine. Under these circumstances, only those dermatological conditions have been mentioned which have some relationship to the general economy. The outbreaks or abnormalities described, occasionally or usually appear between puberty and forty years of age. The large group of cutaneous affections caused by vegetable or- ganisms and animal parasites, external irritants, etc., has been excluded because they are exclusively of external origin and have no relationship to internal conditions. Those out- breaks distinctly of infancy and childhood, and others occur- ring after the age of forty years, have likewise been excluded. Among the former might be mentioned the eruptions caused by a congenital defect, such as nevi, ichthyosis, epidermoly- sis bullosa, and those of inheritance, such as hereditary syphilis. That so frequently occurring disease, epithelioma, has not been described, as it develops beyond the age scope of the present work. TOXIC ERYTHEMA. Toxic erythema is a congestion of the skin, consisting of variously sized patches of a reddish or pinkish color and of a localized or general distribution. The characteristic feature of the disease is the redness, which exhibits no infiltration or elevation. The color can be entirely eliminated by pressure, but recurs immediately upon withdrawing the same. The congestion in most cases is of a limited distribution. The skin of the affected area is unusually hot, and there is generally mild itching and burning. 798 DISEASES OF THE SKIN. An outbreak of a rather localized distribution is usually due to external irritation, while those more or less generalized are of internal causation. The widely distributed erythemas are usually caused by internal toxemic conditions, visceral and nervous disturb- ances. ERYTHEMA MULTIFORME. Erythema multiforme is an acute inflammatory disease characterized by the formation of macules, papules, tubercles, and at times vesicles and bullae, which may be scattered or tend to group. The disease may be ushered in with mild malaise, pains, and slight fever. Osier has recorded cases of this affection with visceral involvement or complications of considerable severity, some with abdominal crises simulating appendicitis. In the great majority of cases the affection starts with an acute outbreak of the eruption and mild, or an absence of, constitutional or subjective symptoms. The eruption is usually observed upon the dorsal surface of the hands and lower portion of the forearms, the tibial aspect of the legs, and the face or neck. The palms and the soles in certain instances show extensive involvement. The outbreak is almost invariably of a symmetrical distribu- tion. The lesions may be generally distributed in extensive cases. Exceptionally the mucous membranes of the mouth, the throat, the lips, the tongue, the eyelids, and the nose, may be attacked. The eruption usually consists of but one moderate or extensive outbreak, or new efflorescences may continue to appear over a period of from five to ten days. There is a great tendency for the condition to recur. The lesions are usually of a bright pink or red color. The most frequently observed type of outbreak consists of papules of a flat character, which are small to large pea in size. A larger and deeper-seated type may be present, some of the latter resembling the lesions found in erythema nodosum. The lesions may take the form of macules, which tend to group in the form of rings. Patches of erythema may be present which exhibit sharply defined borders and only a faint redness of the center. Coalescence of several ERYTHEMA NODOSUM. 799 rings may occur and patches of a gyrated appearance are observed. In addition to the usual type of eruption, an out- break may consist of vesicles or of bullae. There is usually one predominant type of lesion present, although other varieties may be observed. The form known as erythema or herpes iris consists of concentric rings of vesicles or blebs of a variegated color, such as red, violet, and purple. The disease usually runs a course of a few days to a few weeks. The exact cause of the affection is unknown, but it is probably of toxemic origin, either due to some intestinal toxin or of a bacterial nature. The disease has been at- tributed to the eating of stale articles of food, particularly the various sea foods. A considerable number of the milder attacks certainly seem to be of gastrointestinal origin. The severe cases have been attributed to various microorganisms, but none have been proved as causal. The outbreak may be associated with rheumatic pains and swellings of the joints. Antitoxin and various drugs, such as quinin, arsenic, bella- donna, salicylic acid, potassium iodid, copaiba, some of the coal-tar group, and others, have been causative of an out- break of multiform erythema. It is more often observed during the spring and autumn months. Early adult life is more frequently attacked, par- ticularly in females. Newly arrived immigrants are more prone to an attack, or those who change their residence from the country to the city. Other factors which have been mentioned as causal are urethral irritation, uterine disturb- ances, and a neurotic disposition. Erythema multiforme is an acute condition running a course usually of from a few days to four or six weeks. The disease tends to relapse in a considerable proportion of cases, usually recurring each spring, each autumn, or in certain instances both spring and autumn. ERYTHEMA NODOSUM. Erythema nodosum is an acute inflammatory disease of the skin characterized by the development of node-like swellings over the anterior surface of the lower legs. 800 DISEASES OF THE SKIN. The disease may begin with fever, pains, and swelling of the joints, some gastric disturbance, and malaise. The erup- tion usually appears suddenly, and in the majority of cases is limited to the tibial aspect of the legs. The eruption consists of from half a dozen to twenty or thirty nodes, which enlarge and become elevated, from a cherry to a hen’s egg and larger in size. They are not sharply marginated, but fade off more or less into the sound skin. The color varies from a pinkish to a bright red in the be- ginning, and in the course of a few days they undergo all the different hues of a bruise: reddish-blue, bluish, violet, dark brown, greenish, yellowish, and almost black in color. They have a tense and at times somewhat glistening ap- pearance and are very tender to the touch and extremely painful. They are quite hard in the beginning, but soften after two or three days or longer, and fluctuation is present as if suppuration is about to occur, but absorption occurs without a break in the surface. The outbreak is usually symmetrical. The disease runs a course of a few days to a week or more. There may be but one crop of lesions or others may sometimes appear, lasting over the course of a few days. The disease occurs usually in childhood or early adult life, most frequently under the age of thirty. It attacks females three to five times as frequently as males. It is probably caused by some toxin of a nature at present unknown. It has been observed in the course of syphilis, tuberculosis, glandular fever, diphtheria, malaria, and has occurred in in- dividuals with gastrointestinal derangement. Certain drugs, such as antipyrin and the iodides, have apparently produced an outbreak in a few instances. Endocarditis has been a determining factor in a few cases. The disease usually runs an acute course, lasting for a few days, a week, or slightly longer. URTICARIA. Urticaria is an inflammatory disease of the skin charac- terized by the development of whitish, pinkish, or reddish elevations of a transient character, which are accompanied by itching, stinging, and burning. URTICARIA. 801 The eruption in most cases appears suddenly, with or with- out preceding burning or tingling. There may be symptoms of gastrointestinal derangement, nausea, possibly vomiting, a coated tongue, loss of appetite, malaise, and headache, either accompanying the outbreak or preceding it by a few hours, a day, or more. The outbreak may involve the entire cutaneous surface, or certain portions of the integument exhibit a profuse erup- tion. The efflorescence may be observed on one part of the body, lasting from a few minutes to an hour or two, and then may appear on another portion. No part of the surface is immune to an outbreak. The wheals differ greatly in size, varying from a split pea to an egg, occasionally being so grouped that large areas are covered, with no normal skin intervening. The lesions are of a transient character, frequently vanishing within a few minutes after their appearance. The skin is extremely irritable in most cases, and slight irritation such as rubbing or scratching may produce fresh wheals. The subjective symptoms of burning, itching, tickling, crawling, prickling, and stinging, are frequently distressing and the patient, because of scratching and rubbing, aggra- vates the irritability of the skin and causes an increased wheal formation. There may be a considerable amount of swelling and edema of the affected parts, particularly the hands, the feet, and the face. The mucous membranes of the mouth, the throat, the larynx, and the intestinal tract, are at times attacked by wheals. Occasionally alarming symptoms are produced by the edematous swelling of the throat. Urticaria may occur at any age and in both sexes; most cases, however, are observed in early adult life and in child- hood. The female sex shows a greater tendency to an out- break. In certain instances there seems to be a hereditary predisposition to an outbreak. The articles which are prone to cause wheal formation are the various sea foods, such as oysters, clams, crabs, lobsters, shrimps, mussels, fish; pork, sausage, scrapple, veal, nuts, mushrooms, strawberries, cu- cumbers, and the various canned foods. Certain individuals are unable to properly digest oatmeal, butter, potatoes, and 802 DISEASES OF THE SKIN. even eggs. Changes in environment and mode of living and eating not infrequently are causative factors in an outbreak, as particularly evinced by immigrants. Any cause that produces digestive disorders or an incom- plete digestion of the ingested food may become the de- termining factor in an outbreak. Emotional or psychic phenomena, such as fright, anger, shock, have been men- tioned as causative. Outbreaks have been observed in as- sociation with various diseases, such as malaria, jaundice, albuminuria, diabetes mellitus, and also in the rheumatic and gouty individual. Various disorders of the female generative organs are exceedingly apt to cause an outbreak. Certain medicaments may cause an attack of the affection, more particularly copaiba, cubebs, chloral, turpentine, quinin, opium, the iodides, the coal-tar products, antitoxin, etc. LICHEN PLANUS. Lichen planus may be acute or chronic, localized or of a generalized distribution. The areas of predilection are the flexure surface of the wrists, the forearms, the ankles, and the lower legs. In extensive cases there may be numerous lesions on both surfaces of the extremities and scattered over the trunk. The face, the scalp, the palms, and the soles, are rarely attacked. The characteristic lesion is a pinhead to pea-sized, slightly elevated, flat papule, the base of which is irregular or angular in shape, and with an umbilicated, shiny surface, at times covered with a fine glistening scale. The lesions may remain discrete, but tend in extensive cases to form large confluent patches, of a violaceous hue, and covered with glistening silvery scales. The disease may run a chronic course, lasting, untreated, for months or years; the original lesions persist and new papules may appear. Lichen planus not infrequently attacks the mucous mem- brane of the mouth, chiefly the inner surface of the cheeks, and occasionally the tongue. The lesions consist of white, whitish-lilac * and grayish colored dots; practically non- elevated papules, plaques or streaks; resembling markedly LICHEN PLANUS. 803 the appearance immediately after a cauterization with the nitrate of silver. The disease is not frequent. Less than one per cent, of our dermatological cases are of lichen planus. The condition occurs in both sexes; usually in active adult life, and only rarely in childhood. It is chiefly found in private rather than in hospital practice, patients frequently being of a nervous temperament. Overwork, worry, anxiety, nervous shock, and exhaustive conditions, tend to cause an outbreak in those predisposed. It occasionally follows the course of nerves and nerve injury. Traumatism, digestive disturbances, malaria, malnutrition, and diseases of the generative organs, have all been cited as causal. Diabetes occasionally is a precursor of an outbreak. It has been suggested that as lesions develop in the course of scratch marks the disease is caused by traumatism following some disturbance of the nervous system (Jacquet) ; others take the traumatic origin of the lesions as the evidence of the parasitic nature of the affection (Hallopeau and Jomier). PSORIASIS. The affection starts with the appearance of a few pinhead- sized, slightly elevated, sharply marginated, infiltrated red flat papules with thin whitish scales. These papules increase in number, size, thickness, and also in the abundance of the scale. Although the affection may be of generalized distribution, in the majority of cases the disease is prone to attack the extensor surfaces of the extremities, particularly the elbows and the knees, and the scalp. The face is only exceptionally attacked, excepting that the patches may be observed along the hairy line of the forehead, extending downward from the scalp. The palms and the soles are rarely involved, and the dorsal surface of the hands and feet only exceptionally and in extensive cases. The course of the disease is slow and recurrences are com- mon. There seems to be a tendency for the affection to be more marked in winter and for relapses to occur during the cold weather. In mild cases there may be an almost complete 804 DISEASES OF THE SKIN. disappearance of the eruption in warm weather. Relapses may occur months or years after the previous outbreak. There may be numerous patches present or only a few, and the lesions are small or of a large size. The etiology of psoriasis is unknown. The disease com- prises from two to seven per cent, of skin cases, varying somewhat in different countries. Males show a slightly greater predisposition to the affection than do females. Most cases are observed between the ages of fifteen and thirty years, sometimes younger and also at a later period. Various constitutional disorders have been mentioned as causal: a rheumatic and a gouty tendency; defective kidney elimination; and pancreatic disease. The eruption is fre- quently worse or recurs during pregnancy or the nursing period. It has been suggested that an abnormal retention of nitro- gen is either causative of the affection or makes the outbreak more severe. ECZEMA. Eczema is an acute, subacute, or chronic inflammation of the skin, characterized by the development of erythema, papules, vesicles or pustules, slight or marked infiltration of the integument, a secondary scale or crust formation, and is accompanied by itching and burning. Eczema may have its beginning on any portion of the integument; it may remai,n limited to the part first attacked; several parts may be attacked synchronously; it may have a more or less generalized distribution in the beginning, or may extend universally either slowly or rapidly. The out- break is usually more or less localized. The eruption may consist of erythema, papules, vesicles or pustules, and later scales and crusts may be observed. Usually more than one type of outbreak is present. In other words, the eruption is frequently multiform, mixed, and very often one type pre- dominates. The character of the outbreak is also apt to change as the disease progresses. For instance, an erythe- matous outbreak may by local irritation become vesicular; vesicles may likewise be added to the dry forms of the dis- ease. In every type of the disease itching is a marked ECZEMA. 805 symptom, and very often burning or the sensation of heat is also present. There is apt to be redness, possibly slight or marked swelling, frequently moisture, and the patches usually fade away into the sound skin. The disease has been entitled acute, subacute, or chronic, but these terms can scarcely be applied accurately, because an outbreak may be of long duration and yet of a very acute type, or lasting but a short period and less acutely inflam- matory. Certain areas are prone to an outbreak at different ages; the face or scalp, or both, are more apt to be attacked in infants and young children; adults in active employment exhibit the outbreak usually upon the fingers, the hands, and the forearms; the scrotum and the anal regions in the male, and the vulva in the female, are often involved; and the face and the lower legs in the older female are not infre- quently attacked. Adults show the tendency, more or less markedly, to an outbreak on the flexure surface of the elbows, the knees and the axillae. The nails also may be attacked and are dry, and show a tendency to crack. Constitutional symptoms are absent excepting in the generalized type of affection. Eczema comprises a large proportion of all cases of dis- eases of the skin. The writer, from the years of 1902 to 1912, observed 24,459 dermatological cases, and of this mon- ger 4142 were classed as eczema (16.9 per cent.). Eczema is not inherited, it is non-contagious, and excepting in gen- eralized cases and after prolonged and continuous itching, does not affect the general health. There may, however, be an inherited tendency to an irritable skin, which may there- fore be more easily excited to an eczematous outbreak by lesser stimuli than the average integument. The cutaneous covering of those of the blond type is usually more sensitive than those of darker coloring. A certain idiosyncrasy is the unsatisfactory explanation of causation that has to be given in a considerable proportion of cases. Any internal condition which lowers the vitality of the individual naturally decreases the resisting power of the skin and makes the individual more susceptible to an outbreak. Gouty and rheumatic subjects are apparently prone to this 806 DISEASES OF THE SKIN. condition. Defective kidney elimination, uric acid, lithemia, albuminuria, diabetes mellitus, and diabetes insipidus, have all been accompanied by attacks of eczema. Various gastro- intestinal conditions have been mentioned as causative, par- ticularly incomplete metabolism. The term neurotic eczema has been applied to cases of this affection which are ap- parently more or less identified with the nervous system. Nervous shock and hysterical conditions have been men- tioned as precursors of an attack. Functional and organic uterine disorders and nerve injuries have been thought to be etiologicallv significant. Certain outbreaks of the disease have been associated with asthmatic seizures. In a paper read by the writer, in a symposium before the American Dermatological Association in 1912, the external origin of eczema was discussed at length, and it was deter- mined that fully one-quarter of eczema cases are of external origin, and almost one-sixth are caused by the trade of the individual. HERPES SIMPLEX. A disease characterized by groups of vesicles occurring chiefly on the lips and contiguous portions of the face. The outbreak consists of pinhead to pea-sized vesicles, fre- quently on an erythematous base, arranged in groups, which may be bilaterally situated, usually in the vicinity of or involving the mucous membranes of the lips. There may be only one or several groups of vesicles. Practically any portion of the cutaneous surface may be attacked, but the outbreak is usually observed upon the face. There may be a preliminary feeling of heat or burning in the part to be attacked, or the vesicles may appear without previous sen- sation. The lesions tend to break and to form into crusts. The affection lasts from a few days to a week. There is frequently a tendency to recurrence. Lesions may not only be observed on the buccal mucous membranes but also on the gums, in the mouth, the tongue, within the nose, the larynx, the pharynx, the esophagus, the vagina, and the urethra. Groups of vesicles may develop in certain individuals at each menstrual period, either on the vulva, within the vagina, HERPES ZOSTER. 807 or elsewhere on the body. Herpes simplex is frequently ob- served in croupous pneumonia, in cerebrospinal meningitis, in malaria, at times in influenza, in typhoid fever, and rarely in variola, in scarlet fever, and diphtheria. Herpes facialis is frequently associated with cold and also digestive disorders. Long exposure to the sun, particularly when on the water, is provocative of an outbreak. Dental irritation is at times apparently causative. Certain articles of diet, such as cheese, may predispose to an outbreak. The affection runs a course of a few days to a week. There is, however, a tendency in certain instances for the outbreak to recur, particularly in the genital variety. HERPES ZOSTER. An acute inflammatory self-limited disease, characterized by the development of groups of vesicles on an inflamed base, unilaterally distributed, and following the course of one or more cutaneous nerves. The attack may be ushered in with pain of a neuralgic character, which precedes the outbreak by a few days, a few hours, or appears synchronously with the eruption. There also may be chilliness, malaise, slight fever, or nausea, or all symptoms of every kind may be asbent. The pain may continue during the course of the affection or may be en- tirely absent. Groups of pin-point to split-pea sized vesicles develop on an inflamed base, following the course of one or more of the cutaneous nerves or their branches. The vesicles are tense, their walls quite thick, the contents clear, and they do not tend to break, unless accidentally ruptured, but dry up, forming yellowish-brown crusts. The lesions tend to remain discrete, but exceptionally may run together and form small bullae. In a few instances the contents become purulent or hemorrhagic; small scars frequently remain at the sites of former lesions. Rarely ulceration or gangrene occur. The outbreak is almost universally unilateral, and the chest and back are the usual site of attack; the right side is more frequently involved. In certain instances the mucous membranes may show involvement; such as the lips, the inner surface of the cheeks, 808 DISEASES OF THE SKIN. the tonsil, the tongue, the bulbar conjunctiva, and the cornea. The disease runs a course of a few days to two weeks. In a few cases the lesions remain quite small, of an abortive character, and dry up without reaching full development. Exceptionally pain, tenderness, burning, or itching, may re- main at the site of an attack for a considerable length of time after the lesions have disappeared. “Shingles” is a disease of early life. The majority of the writers’ two hundred and eighty-six cases appeared between the tenth and thirteenth years. Numerous predisposing causes have been mentioned, such as exposure to draughts, various depressing agencies, certain poisons, carbon dioxide, belladonna, atropin, pyemia, carcinoma, measles, pulmonary inflammation, septicemia, hemorrhages, traumatism, malaria, puerperal eclampsia, spinal injections, vaccination, the pas- sage of electrical currents, the extraction of teeth and dental caries, pricking with thorns, gun-shot wounds, and tapping of hydatid cysts. Any influence sufficient to induce inflam- mation of a sensory nerve or its ganglion may be followed by an outbreak. Operations upon the Gasserian ganglion may be a prelude to an attack. Some authorities consider that zoster is an infectious disease. The administration of arsenic has been provocative of an outbreak in quite a number of instances. PEMPHIGUS. A rare acute or chronic disease characterized by the de- velopment of bullae, which usually arise from the sound skin, tending to form in successive crops, and accompanied by mild or severe constitutional symptoms. Blebs, frequently the size of a pigeon’s or hen’s egg, may be found in any location but there is a great tendency to involvement of areas of heat and moisture and the mucous membranes. Pemphigus may be divided into acute or chronic, and such extremely rare examples as foliaceus, and pemphigus vegetans. Pemphigus is extremely rare in this country, particularly the acute form, the vegetative and foliaceus varieties. It DIPHTHERIA OF THE SKIN. 809 may occur in both sexes and at any age; the acute type is apt to be observed in early life. It is not hereditary. Acute pemphigus has been observed in young girls with menstrual disorders. It has followed sepsis, vaccination, rheumatic and other fevers, diphtheria, the exanthemata, and from puerperal processes in the mother. Animals and their products have been causal, particularly from wound infec- tions, in butchers and those handling meats. The similarity to the “foot and mouth disease” of cattle has been often mentioned. The other types of the affection have been attributed to nervous influences, such as hysteria, functional nervous dis- orders, peripheral nerve injuries, diseases of the central nervous system, degenerative changes of the peripheral nerves and nerve centers, and autointoxication. Bacteriological influence has been mentioned as causal in the various varieties of the affection, particularly in the acute type. Cocci have been found in a considerable number of instances, particularly diplococci and streptococci. The Bacillus pyocyaneus has also been isolated. DIPHTHERIA OF THE SKIN. The bacillus of Loffler gains entrance to the skin through some opening; in cracks, slight excoriations, erosions result- ing from herpes, and in breaks in the continuity of the skin secondary to an eczema, an intertrigo or an impetigo. The former writers upon this subject considered the affection, in most cases, developed secondarily to other patches of diphtheria in the patient, and*they also affirmed that every case had a diagnostic false membrane. The bacillus attacked the skin through some break in its continuity; this area would almost immediately become painful; it would puff up; there would be a profuse fetid discharge; a false membrane would form and the edge of the patch would become elevated and the bottom ulcerated. Not infrequently an attack of ery- sipelas would develop around the diphtheritic patch. The prognosis was grave because of absorption of the diphtheria toxins from the large surface involved. Paralysis, particularly of the extremities, has followed the clinical form. 810 DISEASES OF THE SKIN. It is not rare, however, to observe an attenuated form that consists of grayish plaques, more dry than moist, discrete and slightly spreading. These plaques are detached in about ten days, some persisting for a longer period, but without presenting a grave appearance. Recently several cases of diphtheria of the skin have been reported in which there was no false membrane formation, but the lesions were of an impetiginous eczema aspect, or of the bullous or vesicular variety. The writer has seen cases of diphtheria of the skin which had the appearance of bullous impetigo, excepting for the virulent appearance of the lesions and a profuse cheese-like purulent contents. It is proved that diphtheria of the skin may begin as a primary condition, remaining localized as such, or may be followed by involvement of the throat or larynx. The diag- nosis has to be proved by means of smears or cultures. The prognosis of the localized disease is not grave; the chief danger is from sequelae. HYPERHIDROSIS. An affection characterized by an increased production of sweat, of local or general distribution, slight or marked, either acute or chronic. Generalized sweating to an exaggerated degree is an idio- syncrasy of otherwise normal individuals, and therefore is present through the life of the individual, or may develop secondary to certain diseases, and is usually most marked in the axillae, the genitocrural regions, the hands and feet. The slightest exertion greatly increases the tendency, and in addition to being profuse during the summer, it is also marked in cold weather. Because of the amount of excretion and the chemical changes which the sweat may undergo, the individual is prone in warm weather to outbreaks of eczema, to boil formation, prickly-heat, and intertrigo (chafing). In rare instances sweating may be limited to localized areas or of a unilateral distribution. Unilateral sweating of the face occasionally occurs. Sweating is frequently limited to the hands or feet alone, or both may show the anomaly. The condition limited to DERMATITIS DYSMENORRHEICA 811 both hands is rather frequent and is most marked on the palms and the palmar surface of the fingers. The sweating may be persistent or be excited by nervousness or excite- ment. It may exist in a mild degree or the excretion may be so copious that the sweat accumulates in drops and drips from the fingers. Gloves will frequently become saturated in a few hours’ wear. Occasionally there will be deep-seated vesicles (pompholyx) associated with the sweating and a horny or wart-like thickening. Severe or a mild degree of sweating is of quite frequent occurrence upon the feet, almost entirely limited to the soles and the plantar surface of the toes. The feet are constantly damp or wet, the socks or stockings moist or drenched a short time after they are put on, and in severe instances the shoe becomes water-soaked. In the cases with marked sweat- ing the skin is macerated, soggy, pinkish-red or violet in color, puffy, and irritated. In addition there may be deep- seated vesicles in the affected areas, and, at the edge, abra- sions and some vesicle formations. The sweat not infre- quently has an offensive, fetid odor. Excessive general sweating is generally associated with debility and is a symptom of some underlying disease, such as an incipient Graves’s disease, tuberculosis, malaria, ner- vous influences, hereditary tendencies, and following con- valescence from prolonged and debilitating conditions such as influenza. Idiosyncrasy is the unsatisfactory explanation of some of the localized cases, although flat-foot, malpositions of the feet, and nerve irritation (central or truncal), have been cited as causal. Certain articles of diet have apparently caused this condition. The sweat does not differ from that normally secreted. DERMATITIS DYSMENORRHEICA. A curious eruption has recently been described, which manifests itself during the menstrual periods and at no other time. The outbreak consists of spontaneous, usually symmet- rical lesions attacking the face, the trunk and the extremities, composed of erythematous patches, urticarial wheals and vesicles. During pregnancy the eruption ceases to appear. 812 DISEASES OF THE SKIN. RAYNAUD’S DISEASE. In this symmetrical form of gangrene a profound disturb- ance of vascular innervation is noted. The phalanges become symmetrically pale, bloodless, and painful. The affection may then proceed to the stage of asphyxia, the attacked areas become of a dark red, livid hue, swollen and tender, and later of a bluish to bluish-black, or black and gangrenous. Gan- grene is usually of the dry form. The condition may remain without the development of gangrene for a considerable period or indefinitely but eventually, in most cases, death of the skin and the underlying tissues results. The condition is occasionally better during the summer months. The ex- tremities, particularly the hands and fingers, are symmetri- cally attacked. The sufferers frequently have cold hands and feet. The ears, the nose, and other portions of the integu- ment, may show the anomaly, but in these areas gangrene usually does not result. If gangrene does not result the affected parts become atrophic and indurated, and ulcers may be observed. There is frequently a considerable amount of burning and pain of the affected areas. The condition apparently is due to trophic disturbances associated with changes in the nervous system. It is prob- ably due to some underlying condition rather than a separate disease. The affection has been ascribed to cold, exposure, nutritional disorders, and neuroses. Raynaud’s disease has been observed in connection with diphtheria, scarlatina, typhoid fever, measles, diabetes, malaria, hemoglobinuria, cardiovascular conditions, Bright’s disease, exophthalmic goiter, hysterical affections, syphilis, tuberculosis, generalized scleroderma, and associated with eczema, hyperhidrosis, pur- pura, and urticaria. Both sexes and all ages have been attacked. DERMATITIS MEDICAMENTOSA. An inflammatory outbreak of generalized or localized dis- tribution and of varying type, caused by the ingestion or absorption of drugs. The external manifestations of drug absorption may be of any type, and general in distribution or with localized lesions, DERMATITIS FACTITIA. 813 depending upon the quantity of the preparation that has been administered, the length of time the remedy has been in- gested, and any idiosyncrasy of the patient or derangement of the eliminative organs or the cardiovascular system. The outbreak may occur after one or only a few small or medium sized doses, in some individuals; in others the preparation may have been given over a considerable period; or the drug may be more or less cumulative, as with the bromids. Any drug may produce an outbreak in a predisposed individual. The drugs which most frequently give rise to an eruption are the bromids, iodids, arsenic, aspirin, copaiba, cubebs, and quinin. Women and children are more susceptible to an outbreak. A weakened condition of the individual, particularly cardio- renal disease, defective elimination, and a nervous tempera- ment, predispose to an eruption. Several theories have been promulgated: that the skin is irritated by the drug being eliminated through the cutaneous tissues and the glands; increased skin elimination due to a defective condition of the gastrointestinal tract and the kidneys; that the presence of the drug generates some toxin or irritant in the blood which causes the cutaneous outbreak; and that the drug acts upon the vasomotor centers or peripheral nerves. Engman and Mook found iodin or bromin in lesions caused by these preparations, and they consider that the drugs circulating in the body tissues may produce an outbreak, probably caused by the formation of a toxin acting at the points of present or former disturbances, such as on comedones, acne, and seborrheic lesions, scars, traumata, scratches, etc. In a large proportion of instances, however, no determinable reason for a drug rash can be ascertained, and the unsatisfactory deduc- tion has to be made that the outbreak is caused by a certain susceptibility or idiosyncrasy. DERMATITIS FACTITIA. An eruption artificially produced, of a mild or severe character, usually observed in a neurotic individual, and for the purpose of exciting sympathy or for malingering. The outbreak does not conform to any type of lesion but is of a peculiar rounded, linear or angular conformation, with 814 DISEASES OF THE SKIN. very sharp borders, and in right-handed individuals within easy reach of the right hand, while the reverse is true of those using mostly the left hand. Artificial dermatitis is usually in the form of ulcers, the individual having applied some form of irritant until ulceration occurs, and the lesions are not infrecjuently covered by black, gangrenous sloughs. There may be one or a great many ulcers, the patient by irritant applications continuing the process, continuously or intermittently, for months or years. Suggestion is a remarkable source of a new outbreak, mentioning to the patient the possibility of a crop of lesions occurring on an unaffected part, not infrequently causes a self-produced outbreak on the area suggested. The affection is fortunately of rather •unusual occurrence. PURPURA. A hemorrhage into the skin, of determinable or unknown origin, accompanied by or without constitutional derange- ment. The affection can conveniently be divided into three groups, depending upon their severity: Purpura simplex, purpura rheumatica, and purpura hemorrhagica. The mild form of purpura is usually unaccompanied by constitutional derangement or rheumatic symptoms. The attack is characterized by a sudden appearance of pin-point to bean-sized bright or dark red spots from which the color cannot be pressed, limited to the lower extremities, or with an associated outbreak upon the forearms. The affection usually reaches its height in a few days and the lesions then become of a bluish-red, violet-blue, and yellowish-brown; the active stage subsides with the leaving of temporary pig- mentation. The affection usually runs a course of one to two weeks; exceptionally, however, crops appear over a few months, a year or longer. Subjective symptoms are absent or extremely slight. The mildest form of purpura rheumatica, or arthritic pur- pura, is practically a simple purpura with the addition of rheumatic pains, occasionally swelling about the joints, and mild or severe constitutional symptoms including fever. PURPURA. 815 The more severe form of rheumatic purpura, known as pelio- sis rheumatica, or Sehonlein’s disease, is characterized by multiple arthritis, a purpuric outbreak, and lesions of an erythema multiforme and urticarial types. In addition there may be nodes indistinguishable from erythema nodosum, exceptionally vesicles or bullae, and extensive areas of angio- neurotic edema (giant urticaria), with or without hemor- rhagic contents. |The term febrile purpuric edema has been applied to these cases. The attacks start with moderate or high temperature, mild or severe articular pains, and sore throat. The throat symp- toms, in certain instances, are severe, and sloughing of the uvula may occur (Osier). Endocarditis, pericarditis, and other symptoms of acute articular rheumatism, may be present. Purpura hemorrhagica (Morbus maculosus Werlhofi; land- scurvy) may begin as a simple purpura without constitutional derangement, with mild systemic disturbances, or with grave symptoms. Those cases with a mild beginning may later develop moderate fever, considerable prostration, and typhoid fever may be simulated. The lesions at the onset may be small and few in number, increasing rapidly or slowly in size and number until the greater portion of the integument is involved, and there may be extensive hemorrhages of the mucous membranes and the various internal organs. In favorable cases the disease terminates in from ten days to two weeks. In other in- stances profound anemia may rapidly develop and death results from loss of blood or cerebral hemorrhage. The disease has been observed in epidemics. In rare in- stances, usually in children, the affection pursues a malignant course, terminating fatally in twenty-four hours (purpura fulminans). The disease is not uncommon in the milder forms and is met with in both sexes and at all ages. A considerable num- ber of cases have to be classed as idiopathic, as no etiological factor can be determined. The symptomatic causes of an outbreak may be classed under the headings.of microorganis- mal, infectious, toxic, cachectic, neurotic, and mechanical. 816 DISEASES OF THE SKIN. The various organisms which have been found in the blood or integument associated with the condition are the pneumo- coccus, streptococcus, colon bacillus, anthrax bacillus, bacil- lus pyocyaneus, staphylococcus aureus and albus, and certain undifferentiated organisms. Outbreaks have been associated with pyemia, septicemia, malignant endocarditis, and with typhus fever, measles, scar- let fever, small-pox, cerebrospinal fever, syphilis, malaria, and rheumatism. Toxic causes consist of venomous snake bites, and various drugs such as copaiba, quinin, belladonna, mercury, ergot, salicylates, chloral, and the iodids. Cachectic conditions have been causal, as exemplified by cancer, tuberculosis, pseudoleukemia, Bright’s disease, vari- ous disturbances of nutrition, cirrhosis of the liver, lung and cardiac conditions, chronic alcoholism, and the debility of old age. The affection has been observed secondary to locomotor ataxia, acute myelitis, transverse myelitis, severe neuralgias, tuberculous meningitis, emotional and hysterical conditions, and the menstrual state. The mechanical causes of an outbreak may be prolonged standing, relaxations of the blood-vessels due to intense heat, as in stokers, following paroxysms of coughing or epileptic attacks, tight bandages, etc. SCLERODERMA. Scleroderma differs considerably in its clinical aspects, in some instances exhibiting more or less diffused, hard, board- like areas, while in others the patches are sharply circum- scribed or consist of bands, having a lardaceous appearance, with a pinkish border, and exceptionally a combination of the two. Although in certain cases these types may more or less approach each other, it has been thought best to describe the two conditions separately, the first being known as diffuse symmetrical scleroderma and the latter as morphea or circumscribed scleroderma. The cause of the affection is unknown. A large proportion of cases occur in women, usually in the young or middle- CHLOASMA. 817 aged. The changes in the skin are apparently due to vas- cular changes, probably due to a lesion or defect of the nervous system. The various causes which have been men- tioned are rheumatism, climatic changes, neurotic conditions, traumatism, injury to the nerves, extreme exposure to the sun, Graves’s disease, Raynaud’s disease, leprosy, Addison’s disease, and various other morbid states. CHLOASMA. An affection characterized by pigmented spots or diffuse pigmentation of the skin. Smooth non-elevated, yellowish, brownish, or blackish patches, of varying size and shape, appear slowly or rapidly. The spots may be sharply mar- ginated or fade off into the sound skin. The patches are observed in most instances on the face, although no portion of the cutaneous surface is exempt, and in certain instances the mucous membranes are attacked. The diffuse variety of the affection may involve the trunk or a considerable portion of the integument. The type associated with uterine and ovarian disorders usually attacks the face, and occasionally the breasts and the genitalia. In Addison’s disease the skin is either bronzed generally or it is most pronounced on the face, the neck, the scrotum, the groins, the axillae, and surrounding the nipple. The mucous membranes of the lips, the gums, and other portions of the mouth, may be attacked. In Graves’s disease there may be diffuse pigmentation or freckle-like spots, with associated telangiectases. Bronze diabetes, which is characterized by general bronz- ing of the skin, is a sequela of diabetes mellitus and hyper- trophic cirrhosis, and was originally described by Hanriet and Chauffard. Osier has shown that diabetes and the bronz- ing of the skin is a late phenomenon, due to a disease termed hemochromatosis, characterized by accumulation of an iron- containing and an iron-free pigment. Etiologically the affection has been divided into idiopathic and symptomatic chloasma. 818 DISEASES OF THE SKIN. Idiopathic chloasma is the term applied to the hyper- pigmentation of external origin, such as from and following exposure to the heat and actinic rays of the sun, the roentgen rays, sinapisms, blisters, and certain drugs, the hyperemia or irritation due to pressure, friction, scratching, parasites, and following certain diseases such as chronic eczema of the legs, lichen planus, generalized exfoliative dermatitis, leprosy, scleroderma, etc. Symptomatic chloasma is the form secondary to internal conditions, such as are observed in association with tubercu- losis, secondary syphilis, sarcoma, organic affections of the uteroovarian system, chronic alcoholism, etc. Jaundice also is productive of a yellowish discoloration of the skin and mucous membranes. ARGYRIA. Argyria is the term applied to the permanent bluish-gray or slate-colored pigmentation of the skin which follows the prolonged administration of the nitrate of silver. The first manifestation is a bluish line at the margin of the gums, and the generalized discoloration of the skin develops gradually. VITILIGO. An acquired affection characterized by the development of patches without pigment. The affected areas are milky- white in color, irregular or rounded in contour, small or large, and frequently surrounded by an areola of increased pig- mentation. The hairs in the depigmented patches usually exhibit the same change, although they may remain normal in color. One or many non-pigmented spots may be present. The usual sites of attack are the backs of the hands, the face, the neck, and the arms, and they may be distributed more or less symmetrically. The patches tend to increase in size and the tendency for new areas to develop may last over months or years; rarely the entire cutaneous surface is involved. The affection is most frequently observed in brunets and negroes rather than in the blond type, and between the ages of ten and forty years. The cause of the disease is unknown, but it is probably a trophoneurosis. LEUKEMIA CUTIS. 819 XANTHOMA DIABETICORUM The eruption is secondary to a glycosuria, and an out- break may appear gradually or rather rapidly. The lesions are usually, in the beginning, of a dull red color, but shortly most of them develop a minute yellowish summit which tends to spread to the elimination of a considerable portion of the inflammatory base. They are firm or hard, rounded or conical, sharply defined pin-head to pea-sized papules, mostly discrete but at times crowded together into a patch. New lesions may continue to appear, while some of those already formed disappear. Some of the lesions may show a predominance of the yellow color, and because of their flatness resemble ordinary xanthoma. Although a consider- able portion of the cutaneous surface may be involved, the disease tends to attack the buttocks, the extensor surface of the forearms, the elbows, the knees, and the back. PRURITUS. An affection of the skin without eruption, except as the result of scratching, characterized by itching, burning, and pricking sensations. The pruritus is not infrequently limited to the genital and anal regions. The affection has been associated with or is excited by hepatic derangement, tumors causing congestion of the pelvic viscera, uterine and ovarian disorders, intestinal catarrh and fermentation, the gouty diathesis, fissures, fistulse, and hemor- rhoids. Frequently no cause can be determined excepting the neurotic character of the patient. LEUKEMIA CUTIS. There are two types of cutaneous outbreak in this con- dition, a superficial and a deep variety, or a combination of the two. The first is characterized by hemorrhages (petechial and diffuse), papular, vesicular, urticarial and pigmented lesions, symptomatic erythema, diffuse scaly erythrodermia, and, rarely, a moist or scaly dermatitis accompanied by intense itching. The deeper lesions consist of ulcers and necrotic areas, usually attacking the mucous membranes and 820 DISEASES OF THE SKIN. secondary to the breaking down of hemorrhagic or lympho- matous deposits. Nodules and tumors of various size, shape, and color, are also observed. Although any portion of the body may be attacked, the usual sites of attack are the extremities and face. The nodules may be from a pea to a coffee-bean in size, few or numerous, of a pale waxy, red- dish, brownish-red, or yellow-red color, firm or soft in con- sistency, movable, smooth or scaly, oval, round, flat and at times with a depressed center. Telangiectases may also be present. The tumors are small hen’s-egg or larger in size, rarely present in large numbers, and grow slowly, with the tendency to break down. FURUNCLE. An acute circumscribed inflammation of the hair follicle with central necrosis and suppuration. The boil starts as a painful, indurated, slightly raised papule, which forms a convex tumor and the induration spreads peripherally. Later the central portion softens and becomes yellow, while the surrounding skin is red and densely infiltrated. The epidermis covering the center of the furuncle finally breaks and pus is discharged through the irregularly shaped opening. The deepest portion of the boil is known as the core, which is spindle-shaped and consists of yellowish- gray necrotic tissue. After the lesion breaks, fragments of the core are discharged and finally the entire mass is exuded. The symptoms subside rapidly with the elimination of the pus. The process is at times checked before the suppuration occurs and resolution occurs without actual necrosis. This is designated a “blind boil” and does not progress beyond the stage of painful inflammatory induration. Furuncles are frequently exceedingly painful and there may be considerable constitutional disturbances. They are apt to occur in those with glycosuria, albuminuria, and in individuals considerably below par. The neighboring lymphatic glands may be enlarged, tender, and at times suppurate. Boils occur singly or in crops, com- ing out in certain instances for several weeks or months. The areas usually attacked are the neck, the face, the forearms, TUBERCULOSIS VERRUCOSA CUTIS. 821 the legs and the buttocks. In most instances they reach full development in from three to six days. ERYSIPELAS. Erysipelas may begin with intense chilliness or a distinct chill, nausea, sometimes vomiting, and fever,‘which precede the cutaneous outbreak by a few hours, a day or more, or the eruption may* in mild cases begin without previous symp- toms. One or more red spots appear at the site of infection. They become confluent and form a swollen, large, red, in- flammatory, irregularly shaped and sharply marginated patch that is tender, smooth, glistening, and elevated. As the in- flammation becomes more intense the patch grows angry red in color, the swelling increases, the surface is more glazed in appearance, and vesicles and bullae filled with clear yellow serum develop on the affected area. The cause of erysipelas is inoculation through an abrasion of the skin or an adjacent mucous membrane, at times so minute as to be undiscoverable, or an invasion of wounds, burns, scalds, and the like, by the Streptococcus pyogenes. The lowered resistance of the tissues is a contributing factor. The disease most often occurs in middle life. Certain indi- viduals are particularly prone to an outbreak. Causes which predispose by lessening the resistance of the individual are, chronic alcoholism, lack of cleanliness, and trauma. The specific streptococcus discovered by Fehleisen is apparently the cause of the affection. KERATODERMIA BLENNORRHAGICA. A rare affection characterized by symmetrical keratoses on the soles of the feet and palms, occurring secondary to gonor- rhea. The condition was first described by Vidal, in 1893. TUBERCULOSIS VERRUCOSA CUTIS. Two types of the affection are recognized: The first is characterized by a single small red swelling, with a pustular head which developed at the point of inoculation. The lesion slowly enlarges and forms a warty nodule, with an infiltrated 822 DISEASES OF THE SKIN. base and a surrounding reddish areola. The pus removed from the small abscesses contains tubercle bacilli. There is usually enlargement of the contiguous lymphatic glands. This is the typical anatomical tubercle or verruca necrogenica. It usually occurs either on the dorsum of the hand or on the fingers. The second type is characterized by the development of an ovoid or lobulated warty swelling which cicatrizes in the center and slowly spreads peripherally. The matured lesion has a depressed, often pigmented, cicatrix, surrounded by reddish-brown warty nodules which at times are covered with a grayish crust, and frequently an areola of a purplish- red color. The disease may last over a period of months or years, and exceptionally spontaneously involutes. Itching may be present. There is apt to be lymphatic involvement and occasionally the visceras are attacked. The back of the hands (sometimes both) and the dorsum of the fingers are the usual sites of attack. The cause of the disease is the inoculation by the human or bovine type of the tubercle bacillus at the site of a small break in the skin. It may occur in patients who rub the sputum-covered lips with the back of the hand. It is very likely to develop in medical students, physicians, labora- tory workers, butchers, and handlers of dead tuberculous bodies. ERYTHEMA INDURATUM. The characteristic lesions consist of multiple red or pur- plish, indurated, ill defined plaques, usually from one-half to one inch in diameter. The swellings develop subcutaneously, run a chronic course, and tend to break down into deep ulcers with an irregular edge and a grayish or reddish infiltrated base. When the ulcers heal, pigmented depressed scars, which eventually turn white, result. The lower portion of the calf of the leg, particularly the outer and posterior aspects, is the area usually attacked. The outbreak is frequently symmetrical. Occasionally the upper extremities are in- volved. The condition is more apt to develop in young girls earlier than twenty-five years of age. LEPROSY. 823 LEPROSY. The tubercular or nodular is more common than the anes- thetic variety of leprosy, it runs a more rapid course, and the skin is chiefly attacked. The typical lesions of tubercular leprosy consist of distinct nodules and more or less ill-defined areas of infiltration, with subsequent ulceration. The skin of the face, the ears, and often other parts, is thickened, with an accentuation of the natural lines and furrows. The earliest infiltration is usually observed in the eyebrows. The nodular or infiltrated masses, when well developed, cause great de- formity of the parts involved, particularly the face, which has a leonine appearance. The areas of greatest involvement in most cases are the face, the ears, and the hands; the palms and scalp are rarely attacked. The tubercles are brownish or brownish-yellow in color, frequently quite large, and de- velop from preceding macular patches or from the sound skin. The nodules may persist indefinitely without change; disappear, leaving at their sites atrophied, thinned, pigmented skin or cicatrices; partial absorption with the formation of indurated raised fibrous masses may occur and many tend to ulcerate. New nodules appear from time to time. Fresh crops are frequently accompanied by fever and chilliness. The nodules on the extremities ulcerate, with the formation of shallow indolent ulcers covered with brownish crusts and a yellowish-brown discharge. Some of these ulcerations ex- tend deep into the tissues, exposing ligaments and bones, while others are superficial and tend to heal. The lymphatic glands and channels leading to those of the neck, the groin and the axillae, become enlarged, particularly in the vicinity of the ulcerating areas. These lymphatic glands and chan- nels not uncommonly break down and ulcerate. The mucous membranes of the nares, the mouth, the pharynx, and the neighboring channels, and also the con- junctivae, have been attacked. The hair of the eyebrows, and at times the scalp, becomes dry, lusterless, and because of impaired nutrition eventually falls. The nails suffer nutritionally and become thickened, brittle and somewhat opaque. Early in the disease there is often increased activity 824 DISEASES OF THE SKIN. of the sweat and sebaceous glands, but later there is lessening of secretion. In anesthetic leprosy the nervous system is chiefly attacked; characteristic anesthetic and macular patches are present. In this variety also the hair, the nails, the muscles and the sub- cutaneous tissue may undergo atrophy or degeneration. The affected parts become crooked, thinned, emaciated and other- wise distorted. Trophic ulcers are apt to develop, either spontaneously or as the result of injuries. The muscles atrophy, the fingers become permanently flexed and the hand claw-like. The bones eventually become diseased, the phalanges drop off or disappear by disintegration or absorp- tion. The toes and the feet share in the same process. There may be a persistent perforating ulcer on the plantar surface of the foot. In certain cases the hands, the feet, in addition to the fingers and toes, are gradually lost. The ulnar nerve is uniformly or irregularly thickened and gives a cord-like impression on palpation. There is loss of sensation of the mucous membranes of the mouth, the soft palate, the uvula, and the back of the pharynx. Deglutition is at times difficult and the food is regurgitated through the nose. The tubercular and anesthetic varieties of leprosy are not infrequently found in the same individual. The cause of leprosy is infection with a specific bacillus, the Bacillus Icprcc, which was discovered by Hansen in 1874. The exact method of inoculation is unknown, whether through the mucous membranes of the nose and mouth, or some break in the integumentary covering. BLASTOMYCOSIS. The disease starts as a papule or papulopustule, which soon becomes covered by a crust and the lesion slowly enlarges peripherally in the form of an indolent, flat, wart-like, or crusted nodule. Well-developed patches are raised, the surface covered by irregular papillary elevations of a reddish color, separated by clefts or fissures of varying depth, giving it a verrucous or cauliflower-like appearance. The border of the patch slopes more or less abruptly from the elevated, roughened ACNE VULGARIS. 825 surface to the normal skin, and it has a sharp margin. It is smooth, of a dark red or purplish color, from one-eighth to three-eighths of an inch in width, and contains a large number of miliary abscesses. These abscesses vary in size, and may be so small that they can only be distinguished with a magnifying glass. Some of these are superficial, while others are deep-seated. Abscesses of the same type are found on other portions of the growth. The specific organisms are obtainable from the mucus or mucopus contained in these abscesses; the smaller the abscess the greater the opportunity there is for obtaining a pure culture. The papillomatous surface may be replaced in older lesions, in part at least, with a thick, elevated, scar-like formation, pinkish-white in color, irregular and often corded, or with a smooth shining surface. The disease runs a slow, progres- sive course, months frequently elapsing before a patch reaches a diameter of an inch or more. In approximately one-half of the cases there is more than one patch present. Central healing may occur, with a resulting cicatrix. The regions usually attacked are the face, the hands, the wrists, or the forearms, although no portion of the cutaneous surface is exempt. The various viscera have been attacked in a few cases and death may result. The cause of the afifection is the blastomyces, a pathogenic yeast fungus inoculated at a break in the skin surface. The organism is a rounded, oval or irregularly shaped body hav- ing a well-defined double contour, a homogeneous capsule, and a finely or coarsely granular protoplasm. ACNE VULGARIS. A disease of the sebaceous glands, characterized by the development of papules, pustules, blackheads, and at times, sebaceous cysts, running a chronic course, and usually associated with digestive disturbances and constipation. The face is attacked, in most instances, either alone or in association with the shoulders and back, and less frequently the chest or other portions of the cutaneous surface. Acne vulgaris usually develops between puberty and twenty-five years of age. It is frequently associated with 826 DISEASES OF THE SKIN. digestive disturbances, constipation, menstrual irregularities, chlorosis, general debility, lack of tone in the muscular fibers of the skin, and scrofulosis. Lack of cleanliness, dust and dirt, seem to predispose to an outbreak. Certain drugs, par- ticularly the bromin and iodin preparations, are prone to cause an attack. Laborers in tar and petroleum products frequently show a profuse eruption. The condition is usually much worse during the monthly menstrual period. A fresh outbreak not infrequently follows indiscretions in diet, such as highly seasoned foods, excessive tea or coffee drinking, and indulgences in alcoholic beverages. ACNE ROSACEA. A chronic disease of the face characterized by congestion, capillary dilatation, papules, pustules, and occasionally hyper- trophy of the tissues. The nose, the cheeks, and forehead, particularly the first, are the sites of attack. Exceptionally the nose becomes slightly or markedly enlarged, the gland mouths widely dilated, and a tumor-like lobulated appearance is produced (rhinophyma). The color in this variety of the disease is a bright red or purplish red. The affection develops usually after thirty years of age, and both sexes are attacked, women possibly more often. The predisposing factors are almost the same as in acne vulgaris. Tea, coffee and alcoholic beverages have a marked influence in causing a relapse or making the outbreak more severe. HYPERTRICHOSIS. The condition is characterized by an excessive or abnormal growth of hair. Acquired hypertrichosis is usually of a limited character, but rarely it may be somewhat generalized. Although hair may be more abundant on the bodies of some individuals than others, the cases that usually consult the dermatologist are the women with a few long hairs scattered over the face, or a large number of hairs on the upper lip, the chin, the cheeks, and the neck. A few long hairs may be observed around the nipples in females. ALOPECIA AREATA. 827 Certain factors such as race, dark complexion, uteroovarian disease, menstrual disorders, local irritation, have all been mentioned as causal, but in a very large proportion of the cases, nothing predisposing or etiological can be determined. ALOPECIA AREATA. The disease is characterized by a rapid and complete hair fall in patches. The bald areas are usually the size of a quarter to a half a dollar, and there may be but one, two, three, or many present. The affected patch is entirely de- nuded of hair, slightly depressed, smooth, the hair follicles are less prominent than normal, the surface is white, non- inflammatory and without scale formation. The hairs sur- rounding the patch are firmly fastened in the follicles and are pulled out with a considerable amount of traction unless the area is spreading. There may be instead of a rounded patch, a linear area extending along the hair line, at the back or side of the neck, or at the hair-line of the forehead. Cir- cumscribed patches are not only found on the scalp, but, in certain cases, in the bearded region, either alone or combined with the bald areas on the head. Small patches may run together and large areas are thus formed, or the one spot may enlarge until a considerable portion of the scalp is de- nuded of hair. Occasionally the hair loss is more or less generalized, not only on the scalp, but eyebrows, the eye- lashes, the beard, the mustache, and in the axillary and pubic regions as well. Exceptionally every hair, including all of the lanugo growth, is lost (alopecia universalis). The con- dition runs a chronic course, but frequently the patches after reaching a certain size tend to remain stationary. In favor- able cases the hair returns first as a downy growth, frequently of a pale or white color, and as it grows thicker and stronger, becomes pigmented of the natural color of the surrounding hairs. Changes in the nails occasionally may also be present. Alopecia areata is usually observed between the ages of ten and twenty-five years; rarely under five or in those older than forty. Comparatively few cases are observed and either sex may be attacked. Two theories have been advanced as to its causation: parasitic or a trophoneurosis. 828 DISEASES OF THE SKIN. In regard to the neurotic theory of causation, numerous instances of the affection have followed fright, shocks, acci- dents, great anxiety, mental worries, etc. Other factors which have been mentioned are peripheral irritation from defective teeth and other reflex causes, such as defective vision, nasopharyngeal disorders and changes in the nerves. LEUKOPLAKIA. A disease which attacks the mucous membranes of the tongue, the inner surface of the cheeks, the gums, the lips, the floor and the roof of the mouth, and rarely the vagina or genitals of either sex. The disease is characterized by one, several, or more rounded, irregularly shaped or diffused, often more or less thickened, whitish patches, with at times a tendency to fissure. The patch may start with an increased redness, or slight bluish tinge of the affected parts, or the papillae may be slightly raised, and there is a variable degree of sensitiveness to hot and acid foods. After some weeks or months the diagnostic whitish and opaline appearance is observed. The original whitish lesions may appear as parallel, short or long, straight or crooked lines, or as scattered or grouped pinhead to small pea-sized spots. These areas run together and form the larger plaques. The surface is smooth, roughened, or somewhat papillomatous, and there may be an encircling hyperemia. The lesions run a chronic course, and ulceration and malignant change may occur, or after reaching a certain development they may remain more or less stationary. Although syphilis has been given as the cause of the affection, in those cases seen in this country it is only one of the etiologic factors. The conditions which predispose to or aggravate leukoplakia are excessive smoking, alcoholic beverages, hot, highly seasoned, irritating, and acid foods, various gastrointestinal disturbances, and sharp or rough teeth. SYPHILIS. Syphilis, for convenience of study, may be divided into three stages and three incubation periods. The first incuba- SYPHILIS. 829 tion period is from the time of infection until the appearance and development of the initial lesion, usually three weeks, sometimes more or less. The primary stage is characterized by the fully developed indurated initial lesion and the typical glandular enlargement. In the secondary period of incuba- tion, which lasts, as a rule, about six weeks, various con- comitant signs of syphilis are developed, increasing in sever- ity as the secondary or eruptive stage is reached. The secondary stage is characterized by the appearance of the eruption and various other symptoms, to be described in detail. The third period of incubation is of indefinite dura- tion, lasting from a few months to a few or many years. The third stage is also eruptive in type but is more destructive than the secondary period, and localized rather than general- ized. The primary sore or chancre is soft in consistency in the early stage, practically no induration being noted before the tenth day. Slight induration can usually be palpated about the fourteenth day. The penis, or some portion of the female genitalia, is the usual site of attack. Densely indurated chancre, the true Hunterian sore, is not so usual as the ero- sive type, the chief location being the sulcus coronarius. An extragenital chancre usually appears as a small red papule with more or less scaliness, and tends to become crusted. The initial lesion on the lip usually occurs upon the vermilion, frequently extending to the skin surface. Exceptionally the glands may be palpable on the fifth day after the appearance of the sore, and as a rule, between the seventh and the tenth, but in certain cases much later. The lymphatic glands are painless, densely indurated, freely movable, separate from each other, and feel like almonds or little round tumors. The most marked enlargement is usually noted in the ganglia near the initial lesion, although general glandular enlarge- ment of the superficial lymphatic glands frequently occurs before the eruption appears. During the stage of secondary incubation various signs of the constitutional involvement of the patient develop, such as anemia, wandering pains over the tibiae, the sternum, and articulations, a cachectic appearance, severe persistent head- ache, some loss of weight, a dingy or unhealthy tint to the 830 DISEASES OF THE SKIN. skin, and general lassitude. The eruption may be ushered in by moderate or high fever at times being mistaken for typhoid, frequently however, none of these signs of constitu- tional involvement are present. The various symptoms are found, as a rule, in those who are physically unfit to resist the disease. The above symptoms, if present, usually appear a few days to a week or more before the eruption. The secondary eruption of syphilis has certain characteristics; it is more or less generalized and somewhat symmetrical, al- though certain types show predilection for various areas. It may be stated, in a general way, that the favorite areas are the upper part of the forehead, just at the margin of the hair, the angles of the mouth, the nasolabial folds, the palms, the soles, the region of the anus, and the genitalia. The eruption may be abundant or somewhat scanty, and varies considerably in duration. In relapses the eruption is much more scanty and usually less generally distributed and with more tendency to grouping. It should be well noted that in the beginning or recent eruption the color is frequently pink or even reddish which, however, after some days or weeks tends to become dark red and then the time-honored “ham color.” The lesions are usually oval or round, but at times are somewhat irregular in conformation. Infrequently in the white, but frequently in the negro, the lesions, particularly on the face, are circin- ate. The later the lesions the more tendency there is to grouping; the greater the depth and the less general is the distribution. In tertiary lesions there is a characteristic diagnostic tendency to segmental, circinate, and serpiginous arrangement. The scars of the late lesions take the diag- nostic shape of the former eruption. Usually in syphilis more than one type of eruption is present, thus at times assisting greatly in the diagnosis. The syphilodermata of the active or secondary stage usu- ally appear somewhat rapidly and attain full development in one or two weeks, after which it is not uncommon for a few new lesions to show themselves irregularly for a short time. In some cases there may be a scanty scattered out- break at first, followed in one or two weeks by numerous lesions, or the eruption may remain scanty. After a few SYPHILIS. 831 weeks the macular syphilide has pretty generally disap- peared. In other types, however, there is often a stationary period for a month or so, disappearance gradually taking place in a few months, occasionally leaving persistent lesions as those on the palms, or the soles. The papular eruption tends to relapse for some months. In the tertiary stage there is found very little tendency to spontaneous disappearance. Various signs or symptoms of the disease are associated with the active or secondary stage, being known as the con- comitant signs of syphilis. The chancre often persists or the scar is found; generally adenopathies are present, pharyngitis, mucous patches, or superficial ulcers on the inner surface of the lips, the mouth, the pharynx, etc. Iritis, cephalalgia, bone pains, sallow or dingy-looking skin, ca- chexia, and loss of flesh, may be present. Frequently but a few of these symptoms are present in a case. Concomitant symptoms are frequently wanting in the tertiary stage, although bone lesions and pain, alopecia, superficial glossitis, and leukoplakia, may be present. Alo- pecia, thinning of the scalp hair, “moth-eaten appearance/’ is more usual in the secondary than in the tertiary stage, but is infrequent at the most. In this condition there may be simply thinning pf the scalp hair, but at times incomplete bald areas may be seen; the hair frequently becomes dry, lusterless and lifeless in appearance. The nails also may be attacked; furrows, depressions, opacities, thickening of the nail itself, with brittleness of its edge, may be noted. The macular is usually the earliest and most common of the secondary syphilitic types. It is generally distributed, being most abundant, as a rule, on the sides of the trunk and the axillary folds, the umbilical region, the neck, and the flexure surface of the arms. The palms and the soles also may show numerous lesions, with a tendency to become papular. There are several varieties of the papular syphiloderm, which may be classed under the headings of the miliary papular, the flat papular, and the papulosquamous. The miliary papular is a fairly common variety, but -much less so than the flat papular. The flat papular syphiloderm varies 832 DISEASES OF THE SKIN. from pinhead to bean or larger in size. There is usually a predominance of either the large or small type in each case. Moist papules, or so-called mucous patches, are usually met with in the secondary stage. They are generally situated on opposing surfaces where there is a certain amount of natural heat and moisture and some friction. The usual location is around the anus and genitalia, particularly in women; the perineum, the genitocrural region, the corners of the mouth, and the nasolabial folds; the axillae and umbilical area are not unusual situations. At times lesions become hypertrophic, distinctly elevated, with an irregular surface; they are then known as condylomata. The pustular syphilodermata occur in several distinct types. They are much less frequent than the papular, and are usually noted in those individuals who are poorly nourished. The pustular eruption may be classed under two general head- ings : the acuminate pustular and the flat pustular. These two forms are divided into the large and the small. The palms, chiefly, and also the soles of the feet are fre- quently involved by dry, syphilitic eruptions, such as the macular, the maculopapular, the papular, and papulonodular, and the nodular. There may be a certain tendency to Assuring. The late lesions of syphilis may be classified under the heading of tertiary, and are generally divided under two sub- divisions, the nodular and the gummatous, with various modifications of each. An indeflnite incubation period of months or years frequently elapses between the early or secondary period and the late or tertiary. The late lesions are, as a rule, few in number, show a great tendency to group- ing, are destructive, and do not heal spontaneously. The group or the single lesion is arranged as a segment of a cir- cle, with a serpiginous or crescentic border, kidney-shaped. Previous scars, ulceration, or scarring in the lesion under observation, is frequently of assistance in diagnosing syphilis. The nodular form exceptionally occurs within the first year of the disease, but usually much later. It generally appears as a very late secondary, or years afterwards as a tertiary, outbreak. The syphilitic gumma is usually a late manifestation of the disease. The gumma is hard in the beginning but be- SYPHILIS. 833 comes soft and doughy, tending to break down and ulcerate. Usually the ulcer resulting is “punched out,” and shows a tendency to be kidney-shaped. The favorite sites for the gummatous lesions are the soft parts, particularly of the thigh and calf. No region, however, is exempt from attack. The cause of syphilis is the Treponema pallidum, which was discovered by Schaudinn and Hoffmann, in 1905. This or- ganism is an extremely delicate filament, coiled to form a grayish spiral, and has almost the same refractive index as the medium in which it is placed; hence the former difficulty in its recognition. The spiral arrangement is maintained not only during movement but also in the state of rest. The movements are very slow compared with the other spiro- chetes. According to the discoverers it varies in length from four to fourteen microns. The number of undulations or twists of which the organism is composed ranges from ten to twenty-six, with an average of twelve (Schaudinn). Diseases of the Blood BY JOSEPH SAILER, Ph.B., M.D. Professor of Clinical Medicine, University of Pennsylvania, School of Medicine. Diseases of the Blood. FOREWORD. The blood may be regarded as a liquid tissue, whose chief function is to serve as a system of transportation of various substances from and to the various organs and tissues of the body. It also serves as a repository and storehouse of certain materials, particularly foods, an excess of which is always kept in the body. The red blood cells apparently carry only oxygen and carbon dioxide, therefore the plasma, containing various substances in solution, is the chief trans- portation and storage agent. Aside from the ability to determine the percentage in the plasma of some of these substances, such as serum albumen, globulin, glucose, the various non-coagulable nitrogenous substances, cholesterol, the various inorganic substances, particularly sodium chloride and calcium, very little if anything of the pathology of the plasma is known and the available tests are usually more valuable for the purpose of estimating the disorders of other organs than those of the blood itself. On the other hand, because of various staining methods, the study of diseases of the blood has been chiefly advanced through the examina- tion of the cells by the microscope, which is used for inspec- tion and enumeration. One cubic millimeter of blood is universally adopted as the standard quantity for counting. The limits, which may be regarded as representing the maximum and minimum nor- mal figures for red blood cells, are between 4,000,000 and 6,000,000. These numbers may be found in persons other- wise normal, but the extremes are rare, and ordinarily any count below 4,500.000 or above 5,200,000, otherwise unex- plained, should indicate a careful clinical study of the case. Technical proficiency on the part of the counter is always presupposed. The red cell count is moderately increased after hard exer- cise, after great excitement, and when the atmospheric pres- 838 D IS EASES OF THE BLOOD. sure is reduced, therefore, after transfer to a high altitude. These changes are probably due to a response by the organ- ism to an increased need for oxygen by the tissues, and as soon as the emergency has ceased, the count returns to nor- mal. Acute cyanosis is also accompanied by high counts. It has also been shown that the injection of adrenalin in amounts sufficiently large to produce physiological effects, will cause an increase of the number of erythrocytes in the peripheral blood. In health and in normal conditions, the red blood count is quite constant. The number of white blood cells is more variable, less so in the adult than in the child, and less in the male than in the female. It may be assumed that the usual normal limits are from 6000 to 10,000, but numbers both above and below these limits are not unusual in otherwise normal persons. The proportion of the different cells varies widely. It may be determined by counting the percentage of each variety, or by calculating the absolute number of each type in a cubic millimeter. As this latter calculation is made from the total count and the percentages, it adds only a complica- tion and the additional possibility of error. It does, how- ever, often give a clearer idea of the changes that have occurred. The normal percentages are as follows: Per cent. Polymorphonuclears: Neutrophilic cells 50 to 80 Eosinophilic cells 1 ” 3 Basophilic cells 0 ” 1 Lymphocytes: 10 ” 25 Large mononuclears (including transitionals) : 5 ” 15 A fairly typical quantitative count, if there are 7000 leuco- cytes, might be as follows: Polymorphonuclears 4900 Lymphocytes 1400 Large mononuclears 700 Hemoglobin is estimated on an arbitrary scale of 100. In normal blood its percentage value should be twice the first two figures of the red blood count. Probably no clinical lalxmatory test is made as inaccurately as the hemoglobin test by the instruments usually employed. Tallqvist’s scale FOREWORD. 839 should be discarded. The method of Palmer with an efficient colorimeter, such as Duboscq’s, is adequate, but too difficult and complicated for the ordinary clinical laboratory. A transient increase in the number of white cells occurs during digestion, after violent exercise, in early infancy, after splenectomy, and after the injection into the body of various foreign substances, particularly foreign proteids. It may also occur just before death. Leucopenia precedes the leucocytosis, usually for a very brief period, after the injection of dead bacteria. Age has a definite influence upon some of the diseases of the blood; none upon others. All the diseases of the blood of known etiology may occur at any age. Of the diseases whose cause is not known, pernicious anemia, polycythemia, and purpura may occur at any age. The frequency of oc- currence of the different forms of leukemia is influenced by age. Chlorosis occurs only in youth and hemophilia presum- ably lasts throughout life. Of the various forms of splenic anemia, if the term may be used, Banti’s disease may occur at any age, von Jaksch’s occurs only in young children. Gaucher’s disease begins in childhood, and of the two forms of hemolytic icterus, the congenital or Chauffard-Minkow- ski type begins in infancy and the sporadic or Hayem-Widal type during adolescence. There is no form of blood disease peculiar to middle or old age. CLASSIFICATION OF THE DISEASES OF THE BLOOD. I. Those of known etiology. 1. Diminution of the red cells, or secondary anemia, as a result of a hemorrhage, poisons, cachexia, chronic in- fections, or parasites. 2. Diminution of the hemoglobin content of the red cells, after hemorrhage. 3. Increase of the white blood cells. Leucocytosis. (a) In infectious fevers and inflammation. (b) As a result of the injection of irritants, as tur- pentine. (c) After splenectomy. 4. Decrease of the white blood cells. Leucopenia. (a) In infectious fevers. 840 DISEASES OF THE BLOOD. (b) In certain endocrine disturbances. 5. The hemorrhagic diathesis. (a) In hypertension. Probably not a condition of the blood. (b) In passive congestion, as in the diseases of the mitral valve and cirrhosis of the liver. Again rather vascular than hemic. (c) The result of poisons, particularly snake venom, and the infections. 6. Hemolysis. This is exceedingly rare in the vessels of the living body. It occurs after the transfusion of blood from unappropriate donors, and as the result of serpent venom. 7. Gas poisoning, particularly with carbon monoxide, and cyanide poisoning. 8. The presence of living parasites in the blood. These are so various and numerous that it is not possible even to enumerate them all, but they may be grouped as follows: (a) Bacteria. Probably nearly all infectious forms may be found. (b) Spirochetes. (c) Plasmodia. (d) Filaria. 9. Increase of the red blood cells, as a result of transfer to a higher altitude. II. Those of unknown etiology. 1. Anemia. (a) Pernicious. Aplastic or heteroplastic. (h) The forms associated with splenic enlargement. (c) The form associated with lymph gland enlarge- ment. 2. Leukemia. 3. Chlorosis. 4. Polycythemia. 5. Purpura. 6. Hemophilia. Of the conditions under Group I only secondary anemia (1) and the hemorrhagic diathesis due to hypertension (5a) will be considered, as the others belong more properly under SECONDARY ANEMIA. 841 the discussion of their associated conditions. Of the condi- tions included under Group II, all are germane to this article with the exception of chlorosis (3), which is a disease of young women. There are two clinical forms recognized, the acute and chronic. Acute secondary anemia is produced by a massive hemor- rhage. The blood picture is characteristic. There is a re- duction of the number of red cells, in the very beginning not so pronounced, because the total volume of the blood is re- duced, but in a brief time, the blood volume is restored and the reduction, of the red cells is roughly proportionate to the amount of blood that has been lost. The effort on the part of the blood forming organs to restore the cells then results in the presence in the blood of a number of young cells, and there are found many cells slightly smaller than normal, but not microcytes, a much larger proportion of reticulated cells, a moderate number of cells showing polychromatophilia, and occasionally a few normoblasts. The amount of hemoglobin is reduced proportionately more than the number of red cells and the color index is less than unity. The blood platelets are increased. The white cells, particularly the polymorpho- nuclears are increased only temporarily, unless there is some other factor present that causes leucocytosis. The subse- quent changes in the blood picture depend upon the previous condition of the patient, the cause of the hemorrhage, the amount of blood lost, the repetition of the hemorrhage. In acute traumatic moderate hemorrhage, not repeated, oc- curring in a vigorous healthy individual of middle life, the restoration of the blood occurs very rapidly. In old age, in cachexia, and in lesser degrees of malnutrition and exhaus- tion, the restoration is either greatly delayed, or the anemia may persist and ultimately cause death. The causes of acute hemorrhage are many: 1. Traumatism. If external the diagnosis is easy, if in- ternal, the diagnosis may be difficult and only clinical study including the blood picture will determine the blood loss. An unusual case of this type was a man thrown to the SECONDARY ANEMIA. 842 DISEASES OF THE BLOOD. ground and trampled on by a panic stricken crowd. He was brought to the hospital in collapse, the blood count was low and free fluid was detected in the abdomen. At the sub- sequent autopsy blood was found in the peritoneal cavity due to a ruptured liver. In another case a coachman fainted on the box. He had received a blow on the side several days previously, but had thought little of it. The left pleural cavity contained fluid, which was apparently pure blood, and the x-ray later revealed a fractured rib. This was after aspiration. Presumably an intercostal artery had been torn at the seat of the fracture. The patient rapidly recovered. In all cases of sudden collapse, the blood should be studied; although the appearance of the patient often suggests the occurrence of internal hemorrhage. 2. Rupture of a diseased blood-vessel; usually an aneurism. The blood may be lost through the mouth, if the rupture occurs into the lung or upper part of the digestive tract; through the anus, if, as is rarely the case, the aneurism rup- tures into the intestines; or the blood may be retained in one of the cavities of the body. A negro was admitted to the hospital with a left pleura full of liquid. He was excessively pale, wherever pallor could be detected. The blood picture was that of secondary anemia, and therefore hemothorax was diagnosed. A curious feature was the pulsation of the thorax and a loud murmur heard over the left chest. At autopsy, a ruptured subclavian aneurism was found, opening into the pleural cavity. A case that died too soon for a careful clinical study had a huge pericardial sac filled with blood as the result of the rupture of an aneurism at the apex of the left ventricle. The epistaxis and hemoptysis that occur in hypertension are due to vascular rupture. 3. Massive hemorrhage of uncertain nature into the intes- tinal tract occurs in cirrhosis of the liver, and in cases of splenic enlargement, particularly Banti’s disease. 4. Massive hemorrhage from ulceration of the bronchial mucous membranes occurs in early tuberculosis; of the gas- tric mucous membrane in peptic ulcer; from the intestinal tract in duodenal and early tuberculous ulcers. The symptoms of acute anemia are: Pallor. The skin is white, waxy, and sometimes has a slight yellowish tint. The SECONDARY ANEMIA. 843 sclera are usually blue white, but sometimes have a slight yellowish tint. The pupils are dilated. The skin is usually moist, the extremities cold. The temperature of the body is subnormal. Depending upon the degree of hemorrhage, there is a sense of weakness, dizziness and often syncope. If the hemorrhage cannot be controlled, death ensues. The amount of blood lost may be guessed roughly by the amount seen, and the general appearance of the patient and the severity of the reaction. Blood counts are important and should be made as soon as it is possible to spare time from the urgency of checking the hemorrhage. A case of acute secondary anemia was as follows: A man 58 years of age, who had never been sick, whose life had been easy and habits, except for the indulgence of a very healthy appetite, very good, suddenly felt very faint. He lay down and shortly afterwards passed a considerable amount of tarry material and some bright blood from the bowel. He vomited twice, but the vomitus contained no visible blood. He was given shortly after this a dose of calomel, and had two more attacks of faintness. At this time his pallor was appreciable. When I saw him two days after the initial attack, the hemoglobin was 27 per cent.; red blood cells, 1,200,000; white blood cells, 11,000. The blood picture was polymorphonuclears, 69 per cent.; lymphocytes, 26 per cent.; large mononuclears, 5 per cent. Murmurs were heard everywhere over the heart. The pulse was distinctly receding. After measures had been em- ployed to check further bleeding, improvement in the blood picture was rapid, and the blood of none of several available donors was required. The source of the hemorrhage was supposed to be the small intestine, although no history of previous gastric disturbance could be obtained. In a similar case with partial obstruction, a diverticulitis was found. The treatment of massive hemorrhage divides itself into two parts: (1) Measures to prevent the recurrence of the hemorrhage. (2) Measures to restore the blood. Measures to check or prevent recurrence may be surgical as well as medical. All accessible bleeding vessels should be secured and all bleeding surfaces treated as may be required. As a rule bleeding from gastro-intestinal ulcers soon ceases, and 844 DISEASES OF THE BLOOD. if any considerable hemorrhage has occurred, they stand operations badly. I have always believed that a hemothorax should not be aspirated immediately unless it is known that no further hemorrhage can occur. The medical measures consist of the administration of substances supposed to increase the coagulability of the blood; and later, of various measures to increase the corpus- cular content of the blood. Four substances are usually accepted as of value for pro- moting coagulability, these are in the order of their useful- ness: 1. Thromboplastin, prepared from animal brains. It appears to be effective, it produces no anaphylaxis, no serum sickness, and may be repeated without danger. The ordinary dose is 10 c.c. injected subcutaneously with all aseptic pre- cautions, including painting the skin with tincture of iodin. It is not certain that a second dose increases its effectiveness. 2. Horse serum. As a matter of fact any other serum will do as well, but horse serum is usually more easily ob- tained. Some danger is involved, therefore the patient should receive a desensitizing dose of 1 c.c. subcutaneously, and one hour allowed to elapse. If then there is no reaction, 10 c.c. may be injected, either subcutaneously or intraven- ously. If the latter route is selected, the injection should be given at the rate of 1 c.c. per minute. From six to ten days later, the patient may have an attack of serum sickness, with fever, pains and urticaria, but it is never serious. The serum should not be repeated if there has been an interval of six days after the first injection. Horse serum seems to be quite as effective as thromboplastin. 3. Gelatin. This is of very doubtful value. It must be carefully prepared and sterilized. A 10 per cent, solution of gelatin should be made in normal salt solution, filtered through paper and sterilized by the fractional method to destroy all spores of tetanus, which constitute the chief dan- ger. The injection is often very painful. The preparation requires at least forty-eight hours, and should only be done by a competent bacteriologist. 4. Calcium salts. The lactate or chloride should always be given, usually one gram per day for four days. They can only aid any other method and are useless alone. SECONDARY ANEMIA. 845 Local styptics may be used. Cocaine and adrenalin may check a severe expistaxis. Severe hemorrhage from the mucous membranes may oc- cur in the course of some of the diseases of the blood, such as leukemia, pernicious anemia and purpura hemorrhagica, but in none of these do local measures have much effect. In the leukemic forms x-ray treatment usually checks the hem- orrhagic tendency. There is only one effective method of restoring the blood, and that is by transfusion. With proper precautions, healthy blood of a suitable type, preferably tested also by cross ag- glutination, and the operation performed by an expert, is a safe procedure and should be given if the hemorrhage has been severe, or if the blood count is below 2,000,000 or the hemoglobin below 30 per cent. Chronic secondary anemia occurs in cases in which there are repeated small hemorrhages or when there is some con- dition, assumed to be a form of poison, that destroys the blood. The causes are very numerous. Repeated bleeding may occur from almost any mucous membrane, it may be an exacerbation of a physiological process, as in menorrhagia, or the blood may be sucked from the intestinal mucosa by a parasitic worm. Anemia may occur when there is infesta- tion by parasites, particularly the Bothriocephalus latus, in chronic infections as malaria, streptococcic infections, in amy- loid disease, in starvation, and in defective food, as beri-beri. Sometimes no obvious cause is found, nevertheless the clinical course and the blood picture exclude pernicious anemia. The blood shows reduction in the hemoglobin and red cells, the color index is low, and changes are present in the white cells such as may be produced by the underlying cause. The patient is pale, listless, the nutrition is usually poor. The treatment consists in the removal of the cause if possible, if not, such palliative measures as iron, arsenic, bit- ters, fresh air, rest, over feeding, and change of climate may be employed. If no focus is evident, search must be made for some focus of infection, such as a sinusitis, an abscessed tooth, an infected tonsil, and the many other foci that have been so industriously described during recent years. 846 DISEASES OF THE BLOOD. HEMORRHAGIC DIATHESIS DUE TO HYPERTENSION. The hemorrhagic diathesis of hypertension is a disturb- ance of middle and old age and appears in various forms. The most common are epistaxis and hemopytsis; hematem- esis and melena are rare. Epistaxis for some reason, occurs most frequently at night, and does not seem to be the im- mediate result of active exercise. It is often profuse and difficult to control, but if not exhausting, is beneficial. Hemoptysis usually occurs in association with some infec- tion of the respiratory tract, especially a tracheitis or bron- chitis, a small amount of blood accompanying the sputum ex- pelled by coughing, but it may also occur as a single hemor- rhage, not often excessive, with little tendency to repetition. Tuberculosis is suspected in practically all cases, but as the blood-pressure is commonly low in pulmonary tuberculosis, no case of pulmonary hemorrhage with high pressure should be regarded as tuberculous unless other signs than hemorrhage are present. Hemorrhage from the gastro-intestinal tract is produced by so many causes, often obscure, that it is not easy always to determine which, if any, are due solely or in part to in- creased blood-pressure. Passive congestion must not be confused with hypertension. Hemorrhage from the genito-urinary tract is not uncom- mon, it is not accompanied by pain, and is often considerable. The urine is thoroughly mixed with the blood and may re- semble pure blood. Clots are rare. Hemorrhage into the skin is not frequent. It occurs in two forms: First, massive, bruise-like subcutaneous extra- vasations. Sometimes peculiar sensations, sharp pain, ting- ling or discomfort are felt at the subsequent site of the hem- orrhage two or three days before it appears. Then the skin becomes discolored, at first bluish black, then green and yel- low. It seems as if the hemorrhage may have occurred in the deeper tissues, probably sometimes the muscles, although I have never been able to confirm this. Second, petechial hemorrhages into the skin, these may occur in the legs, and occasionally in the skin of the forearm after the blood-pres- PROGRESSIVE PERNICIOUS ANEMIA. 847 sure has been taken. (The tourniquet test.) Their appear- ance is usually accompanied by a tingling sensation. The treatment of these hemorrhages is local and general. The local treatment can be used only on the nasal mucous membrane. It consists of the application of cocaine, adren- alin, or some of the styptics derived from tissues. Packing may also be required. The general treatment may be that of hemorrhage, and has already been described, or better the treatment of hyper- tension, that is rest, restricted diet, nitrites, sweat baths, and, when indicated, venesection. This usually prevents the recurrence of the hemorrhages. PROGRESSIVE PERNICIOUS ANEMIA. Progressive pernicious anemia is a term usually applied to a fairly well marked clinical condition, that is character- ized by a diminution of the red blood cells, of the hemo- globin, no secretion of the gastric juice, numbness and pro- gressive weakness of the legs, and that ultimately after a progressive or remittent course terminates in death. It was first recognized and described by Addison. This disease usually occurs in adults, particularly in males, but cases in females are by no means uncommon. It usually begins after thirty-five years of age. The onset is gradual, and cases are usually seen for the first time by a physician after they have reached a comparatively advanced stage. The cause is wholly unknown. Various chemical substances such as lipoids and fatty acids have been described as possible factors; infectious agencies (streptococcus and parasites, par- ticularly intestinal) may produce similar conditions; also tumors of the bone marrow (myelophthisic anemia). Dis- turbances of the endocrine system are sometimes present. I have reported one case of pernicious anemia in a man with various female characteristics. It is said that some cases of pernicious anemia show certain features in the anatomy of the bones, but this has not been established. The blood picture is characteristic. The red blood cell count is reduced; often the actual count is below one million, and in one of my cases a count of 520,000 was made, and in 848 • DISEASES OF THE BLOOD. another, several residents independently made counts of less than 500,000, but unfortunately did not record their figures. The red cells are of all shapes and sizes, poikvlocytes and macrocytes. They stain well with eosin and other red cell stains, but some of the cells show stippling, reticulation and poly- chromatophilia. Nucleated red cells are usually found, megalo-, normo- and microblasts, and may from time to time be very numerous, this is assumed to be an indication of a tremendous effort put forth by the bone marrow to overcome the blood deficit. The fragility of the red cells is reduced. Each cell contains an excess of hemoglobin and the color index is higher than unity. The white blood cells are usually reduced, the leucopenia being due to the absolute reduction of the polymorphonuclear forms; and in consequence there is a per- centual lymphocytosis; rarely, in the later stages myelo- cytes may appear. The platelets, as a rule, are only slightly diminished. The physical signs are fairly characteristic. The expression is dull, although the face may become animated, the sclera are bluish white, and the pupils rather wide. The skin has a characteristic lemon yellow tint, somewhat similar to the hemolytic anemias, and distinguished from a light icterus by the blue sclera; as a rule the nutrition is fair, but in the later stages, there may be wasting and some edema of the limbs. The pulse is quick, and often of the Corrigan type, that is, it is more easily felt if the arm is in the vertical position. The heart dulness may or may not be enlarged; but murmurs are heard in all parts, particularly at the base, they are usually loud, harsh, systolic in time, and in the neck there is a “bruit de diable”. The systolic murmur is usually heard in both axillae. The veins are small. The edge of the liver and the spleen may be palpable, but neither is constant. Sometimes, however, the spleen is considerably increased in size, and forms a palpable hard tumor in the left upper quad- rant. Dyspnea on exertion is common, fatigue occurs easily, but often in severe anemia the patients are able to work. One of my patients continued as chief clerk in a large office with a blood count of less than 1,000,000. and the day she entered the hospital it was 617,000. The earliest spinal symptoms are numbness in the feet particularly at night, then some tingling PROGRESSIVE PERNICIOUS ANEMIA. 849 and discomfort amounting at times to actual pain. Later there may be a feeling of uncertainty in walking, and some- times complete or almost complete disability. The sensory disturbances are the loss of vibratory conduc- tion. This should be tested with a tuning fork (A108.75) specially prepared so that a definite amplitude of vibration can be determined, and from this the duration of the vibra- tory sensation measured with a stop watch. Normally it is from 15 to 25 seconds over the internal and external malleoli and slightly longer over the lower ends of the ulna and the radius. Touch, pain and temperature sensation may be well preserved and are rarely seriously impaired; the sense of position is usually defective and may be almost completely lost. There is apparently astereognosis. The motor disturb- ances are ataxia, which is rarely marked, but sometimes es- pecially in old people, is very severe and makes locomotion difficult. As the most frequent lesion is a combined sclerosis, the reflexes are usually increased, but if the involvement of the posterior columns is more pronounced, they are dimin- ished or lost. The sphincters are not disturbed. The spinal cord symptoms do not improve during the remissions, and are usually progressive. The results of instrumental examination are of much im- portance. The sphygmographic tracing is similar to that of aortic regurgitation. The electrocardiogram is not charac- teristic, except that left preponderance may not be present as it is in aortic disease. The blood-pressure is higher in the leg than it is in the arm; and vibratory sensation in the bones of the legs is usually lost early in the course of the disease, and always diminished when the patient is first seen. The laboratory findings are also valuable. Total achylia gastrica is almost constant. The free hydrochloric acid is absent, the total acidity is low, and the fasting contents small in amount and nearly neutral, but none of the depres- sive symptoms of achylia gastrica are present. The pancre- atic secretions have been present and apparently of normal activity in every case that I have tested, and this without the stimulating action of free hydrochloric acid. Much stress has been laid upon the study of the bile pigments in the duodenal contents; but the results have little clinical value. 850 DISEASES OF THE BLOOD. The course of the disease is extremely variable. The anemia may be progressive, leading in a few months to death, or it may increase steadily although slowly, and the patient may live for years. Inexplicable remissions may occur, with an improved blood count, often as much as 4,000.000, im- proved strength, and relief of all symptoms, particularly the gastrointestinal, but it should be noted that if the signs of spinal disease are present, these do not share in the im- provement, and as these are more common and severe in pa- tients who have passed the first half century of life, they concern this article more definitely. From time to time there may be attacks of diarrhea that weaken the patient and cause great discomfort. Periods of fever are not uncom- mon. The temperature is usually irregular, moderately high, and is borne by the patients extraordinarily well, often for periods of months. In the later stages edema is common in the legs, and sometimes there is a general anasarca, not often severe; pleural and pericardial exudates are occasionally present, but ascites is extremely rare. In the last stages there is sometimes a mild delirium. Death occurs as the result of gradual weakness, sometimes apparently hastened by a severe diarrhea. The nutrition is usually fair, and sometimes the patient actually becomes obese during the remissions, but at the end there is much wasting. The treatment is palliative, but remissions may follow some of the measures employed, for which these measures may or may not be responsible. The general measures are those common to almost all forms of disease, rest, including tranquillity, adequate ven- tilation, protection from the cold, bodily comfort, an ade- quate diet with hypernutrition if there is a tendency to lose weight. These need not be particularly described. The special measures that may be employed are three: 1. The administration of iron and arsenic. The value of iron has been questioned. It has been supposed that it contributes to and stimulates the formation of hemoglobin, and in certain blood diseases, particularly chlorosis, it has been extolled as a specific; but there is no adequate proof that it actually does stimulate blood formation or inhibit PROGRESSIVE PERNICIOUS ANEMIA. 851 hemolysis. On the other hand there is sufficient evidence that it can be given to patients for long periods without apparent bad results and therefore it is still given. The dose should be moderate. If given by the mouth the tinc- ture of iron chloride is satisfactory, about 1.0 c.c. (ttixv), given preferably two hours after meals to escape its inhibi- tory effect upon the digestive ferments. If there is evidence of syphilis, the syrup of the iodide, 2.0 c.c. (oss), may be used; or Blaud’s mass, 0.2 Gm. (gr. iij), or reduced iron. 0.1 Gm. (gr. iss), be tried. For hypodermic use the citrate of iron, 0.06 to 0.08 Gm. (gr. 1 to 1%), may be given daily. Arsenic should always be administered, for it often has a distinct effect in improving the patient’s condition. By the mouth, Fowler’s solution in ascending doses, or the arsenic trioxid, 0.002 Gm. (gr. usually combined with iron, seems useful; for hypodermic administration the cacody- late of sodium, 0.06 Gm. (gr. j), combined with ferric citrate, 0.06 Gm. (gr. j), is convenient, repeated once daily. The usual signs of overdose should be sought, and upon their appearance the arsenic discontinued. Herpes zoster may occur during the administration of arsenic. Transfusion of blood from other human beings is the best measure hitherto discovered. The nature of the effect pro- duced is not clearly understood. The improvement is not due wholly to the administration of corpuscles, although the introduction of washed corpuscles is beneficial, but appar- ently not as useful as the whole blood, but the improvement continues often for a considerable time, and therefore the ultimate improvement of the blood must be due to other fac- tors than its mere temporary enrichment. There are two theoretical explanations; that the donor’s blood inhibits hemolysis or that it stimulates blood forma- tion. As there is no general increase of the younger cell forms in the blood after transfusion, it would seem that the inhibition of hemolysis is the more likely explanation. The empirical fact of improvement is the only real justification for transfusion. Transfusion requires knowledge and technical skill. The donor must be carefully selected. The blood of human be- ings is divided into 4 Types according to the character of 852 DISEASES OE THE BLOOD. the cross agglutination and hemolysis. Type I can be agglutinated by all other types, Type II by Types III and IV, Type III by Types II and IV and Type IV cannot be ag- glutinated. This is probably due to the varying presence in the blood of two hemolyzing substances according as both, one, or none occur. As Type IV does not agglutinate in the blood of any recipient, it can be used in all cases; the others must be carefully selected. In all cases the donors should be typed, cross agglutination tested, and the donor’s blood tested for syphilis, and all chronic and constitutional disease ex- cluded as thoroughly as possible. In one of my cases I suspected, without being able to confirm my suspicions, that the husband might have been a malarial carrier. The patient with severe pernicious anemia was transfused with her husband’s blood which answered all tests. The operation was apparently successful, but a few hours later she developed hyperpyrexia and died. Both came from a malarial district in the South, and the husband had had malarial fever, at least so diagnosed, several times. A successful transfusion pro- duces no reaction. If a reaction occurs, the earliest signs usually appear while the operation is in progress. The first sign is a flushing of the face, then restlessness, often with fear of impending death, dyspnea, increased frequency of the pulse, pain in the lumbar region of an intense character, a chill fol- lowed by a high fever, and sometimes collapse. If there is hemolysis, the urine contains hemoglobin. The patient may die, otherwise the recovery is rapid, although fever may per- sist for days. If any of these symptoms occur, transfusion should be stopped and adrenalin administered. Despite all precautions reactions may occur. In the case of a woman fifty years of age, who in the course of eighteen months had been transfused eight times from several donors, a severe reaction occurred during the fourth transfusion from one of these donors, after all the blood tests had been re- peated with great care. Hemoglobinuria was not present. The reaction is similar in some respects to the anaphylactic reaction that occurs with serum. Only arbitrary rules exist for transfusion. It is my rule to employ it if the red cell count falls below 1,000.000. The quantity to be taken is usually 500 c.c., to be repeated accord- PROGRESSIVE PERNICIOUS ANEMIA. 853 ing to the subsequent course of the case. Even in very des- perate cases, transfusion should be attempted. One of my cases, was unconscious, pulseless and with shallow and al- most imperceptible breathing, when the transfusion was com- menced, and revived while it was still in progress, and actu- ally lived several months longer. His first transfusion had been performed three years previously. The technic of the operation does not belong here. The citrate method is the safest. Splenectomy is less used than formerly. A complete his- tory of this operation is given by Krumbhaar in “The Spleen and its Diseases,” by Pearce, Krumbhaar and Frazier. The remarkable feature of this operation is the comparative safety with which it can be performed in patients suffering with severe anemia. It usually produces an immediate rise in the blood count which may endure for some time. In one of my cases, an irregular fever that had persisted for six months, and probably longer, for it was present when the patient entered the hospital, ceased immediately after splen- ectomy and did not recur. Six months after the operation the patient reported, apparently well, stated that he was work- ing and his blood count was normal. He did not report again, and could not be found. Unfortunately the spleen was not examined or cultured. My impression is that the operation should be done only when transfusion ceases to be effective, and possibly when there is persistent fever. It should probably never be done if the cardiac symptoms are pronounced. Aplastic anemia occurs in a few rare conditions that destroy the bone marrow. Among these are osteosclerosis; tumors invading the bone marrow, either primary or secondary, mye- lophthisic anemia, and certain poisons particularly benzol. Signs of deficient blood formation may occur in certain severe infections, such as streptococcic infections, pneumonia, and after intense radiation. Idiopathic aplastic anemia is a rapidly progressive fatal dis- ease of the blood occurring usually in asthenic individuals, occasionally with evidence of status lymphaticus. It is sup- posed, chiefly on account of its similarity to benzol poisoning, to be due to some form of poison or toxin, but as no such 854 DISEASES OF THE BLOOD. toxin has ever been found, such an assumption is unwar- ranted. It occurs usually in adults and often follows a period of lack of energy. The usual signs of anemia are present, pallor, without as a rule much if any discoloration of the skin, rapidly progress- ing weakness. Hemorrhages into the skin and from the mucous membranes are characteristic, but may vary greatly in amount. The most characteristic feature in the blood is the great reduction in the number of platelets. The red cells are re- duced, and this reduction is rapidly progressive. The color index is about normal or slightly below. There is leucopenia as a result of the reduction of the polymorphonuclear cells. The red cells, as one would expect, show few immature cells, therefore nucleated and reticulated cells are rare, and there is much less deformity of the cells than in the heteroplastic type. To the reduction of the platelets may be ascribed the hemorrhagic diathesis. Death occurs in the course of two or three months after the disease has been recognized. Treatment is of little avail, arsenic and iron seem useless, transfusion has only a tem- porary beneficial effect, and is distinctly less useful than in the heteroplastic forms. Splenectomy should be harmful on theoretic grounds and experience seems to confirm this. Pos- sibly the administration of calcium or other substances to promote coagulation may temporarily diminish the hemor- rhagic tendency. Transfusion also helps this. LEUKEMIA. Leukemia is a disease characterized by the appearance in the blood of immature leucocytes and a great increase, dur- ing the greater part of the disease, of the total number of white blood cells. Associated with these features are anemia, often profound; enlargement of the spleen, liver and lymph glands, but not equally in the different forms; and at times, hemorrhages from the mucous membranes, fever, attacks of diarrhea, and an increased metabolic rate. The only constant feature is the over production of white blood cells, and their introduction into the circulation, often LEUKEMIA. 855 in an immature form; not only this, dui masses of cells may be found in the various tissues. The number of leuco- cytes may be many hundred fold normal. The blood chem- istry is not generally altered. The non-protein nitrogen is not increased, the blood sugar remains normal, there is no definite change in the saline constituents. True leukemia is a disease of wide spread distribution in the animal kingdom, for it occurs not only in the human race but also in many species of animals; not only among mam- mals as dogs, swine, mice, but also among the birds, as chickens. It is altogether likely that, as the diseases of the lower animals are more carefully studied in zoological gar- dens, it will be found in many other species. Leukemia must be distinguished from the increase of the white cells that occurs in some of the inflammatory diseases, and after splenectomy, in which the excess of white blood cells is due to the increase of the number of polymorphonu- clear neutrophilic leucocytes; and from a few conditions in which certain other normal cells are present in excess, as in the eosinophilia of Trichiniasis. The nature of leukemia is unknown. The theories that seem to accord rather better with the characteristics of the dis- ease than the others, are: First, that it is due to some in- fection. In favor of this is the febrile course of many of the cases; the transmissibility of fowl leukemia, and the sup- posed association of leukemia with certain infections. As the latter involves the assumption of a peculiar reaction on the part of the patient, and as this involves an underlying predisposing cause, and particularly, as the majority of cases cannot be associated with a preceding infection, this theory may for the present be dismissed from consideration. Second, that leukemia is akin to tumor formation, that is, that the leucocytes proliferate as do the epithelial cells of car- cinoma, but as these cells live in a liquid stroma, the tumor continues to circulate in the blood stream. There is no bet- ter explanation for the proliferation of the leucocytes, but there is no proof that it is correct. An additional fact of no present significance, however, is the response of leukemia to x-ray treatment and to arsenic. 856 DISEASES OF THE BLOOD. Third, that leukemia is due to an abnormal stimulation of the functional activity of the bone marrow, by something, for example a toxin, but as nothing of this nature has ever been found, there is no reason to assume its existence. It must not be supposed that the presence of a few myelocytes in the blood constitutes the diagnosis of leukemia, for they are found occasionally in pernicious anemia, in carcinoma and in other conditions in which the bone marrow is in- volved. It is rather their continued presence, associated with a great excess of white cells and other changes in the body, that constitute the picture of the disease. I desire only to emphasize the fact, that a high leucocytosis, above 50,OCX), is not of itself sufficient to establish the diagnosis, for this may occur in various infections, and I have counted 100,000 white cells, 95 per cent, of which were of the polymorphonuclear type, in pneumonia, and higher counts in infections have been recorded. According to the predominant types of cells, the leukemias have been divided into myelogenous and lymphatic; accord- ing to the course into acute or chronic. The clinical course of these different forms is distinctive, and there is no evi- dence that they pass one into the other, hence they may be re- garded as different not only clinically but also morphologi- cally. Acute leukemia is a disease of early life, although it may occur at any age. Chronic leukemia is rare before twenty years of age. After this the myelogenous form predominates until sixty. Chronic lymphatic leukemia is not common until after forty-five. All forms are rare after sixty. Chronic myelogenous leukemia is the most common form of leukemia, except in early life. It occurs chiefly between the ages of 25 and 50, but has been observed in infants and in the aged. It is slightly more frequent in males than in females, the disproportion being less than in the other forms. The onset is gradual, usually the patient complains of las- situde, then observes enlargement of the abdomen, then suc- ceed gradually, pallor, dyspnea and palpitation, increasing weakness, periods of fever, occasional hemorrhages from the CHRONIC MYELOGENOUS LEUKEMIA. LEUKEMIA. 857 bowels and mucous membranes, diarrhea, edema including ascites, and almost inexorably death. During the course there may be remissions either spontaneous, which are rare, or induced by treatment. Sometimes one feature sometimes another attracts the at- tention of the patient, usually it is the lassitude, occasionally splenic :umor, in one of my cases the first symptom was a severe hemorrhage from the gums. The symptomatology develops rapidly, but the course is variable and irregular. Often some of the symptoms are absent. The lassitude in- creases, sometimes there is fever and sweating, diarrhea usually occurs in the more advanced cases, and may be paroxysmal, nutrition is impaired, and in the later stages a syndrome resembling that of toxic goiter may develop. Ord- way and Gorham call attention to the tolerance for cold, and explain it by the increased metabolic rate. The physical signs are pallor, a suggestion of exophthalmos, at least the eyes are bright and slightly staring, sometimes distinct pulsation in the vessels of the neck; vigorous pulsa- tion of the precordium, the enlarged abdomen, and towards the end edema of the extremities. The tonsils may be slightly enlarged. Neuroretinitis has been observed, and was discov- ered in one of my patients by Dr. de Schweinitz. The dis- turbance of vision was very slight. The spleen is nearly always greatly enlarged, and usually is the most striking feature. It may reach to the brim of the pelvis, and extend to the right of the median line. It moves with respiration, the surface is smooth, the substance firm, about as hard as sclerosed liver, the notch is usually distinct, and is not tender. In some cases the spleen does not enlarge, and of this I have seen one instance. In no other respect did the case differ from other cases, and the patient responded quite readily to treatment. The liver is slightly enlarged in the majority of cases, sometimes considerably; the lymph glands are rarely involved. The diagnostic features are the changes in the blood. There is usually a great increase in the leucocytes, and counts exceeding a million are not uncommon. The characteristic feature is the presence of myelocytes. A few actual counts will illustrate this better than a general description. 858 DISEASES OF THE BLOOD. Characteristic Blood Counts, Mild Type. Hemoglobin 89% Red blood cells 4,500,000 White blood cells 16,200 Polymorphonuclears 66% Lymphocytes 8% Large mononuclears and transitionals 11% Eosinophils 4% Basophils 5% Myelocytes, neutrophilic 6% Severe Type. Hemoglobin 75% Red blood cells 3,950,(XX) Nucleated red cells 2 Platelets 120,000 White blood cells 250,000 Polymorphonuclears 56% Lymphocytes 2% Large mononuclears and transitionals 10% Eosinophils 5% ■ Basophils 2% Myelocytes, neutrophilic 22% eosinophilic 2% basophilic 1% The chemical changes in the blood are uncertain. There is no increase in the non-coagulable nitrogen and there are some contradictory reports regarding the phosphorus excre- tion, otherwise the blood chemistry is slightly, if at all, changed. The basal metabolism is always increased, and the increase is often as great as it is in hyperthyroidism. Ordwav has collected the cases and finds that the increase averaged 44 per cent, in 5 cases of myelogenous leukemia. In one case I found 22 per cent, above normal. This decreases after successful treatment by the x-ray and in my case became normal. The white blood cells are said to have diminished phagocytic power, and they contain a proteolytic ferment. The blood-pressure is usually considerably higher in the leg than in the arm; as illustrated by the following two examples: LEUKEMIA. 859 Left leg Left arm Case I * f Systolic [ Diastolic 180 110 135 80 Case II ■< f Systolic 165 124 I Diastolic 110 70 The conduction of vibratory sensation through the bones is not affected, as it is always in a pernicious anemia. The gastric contents contain pepsin and free hydrochloric acid and the pancreatic ferments are present. CHRONIC LYMPHATIC LEUKEMIA. Chronic lymphatic leukemia is distinguished from the mye- logenous form in its clinical picture, particularly by two fea- tures, the frequency of changes in the tonsils and the ten- dency to hemorrhage . In some cases the enlargement of the tonsils is the earliest sign, and tonsillectomy may be per- formed with serious results, for a grave and even fatal hem- orrhage is likely to ensue. It is perhaps useless to urge that every case of enlarged tonsils, not manifestly infected, should be studied carefully for other signs of lymphatic leukemia before operation is undertaken, but it should always be done, if there is any possible doubt, especially if the differential count indicates a preponderance of lymphocytes. Hemorrhages occur from the mucous membranes, and are often profuse and difficult to control. Petechise and purpuric spots may appear in the skin. They are usually early mani- festations. In addition a number of skin lesions have been described, some of which may precede any of the other signs of leukemia. These are various but have all been grouped under the term leukemiacutis. Almost all forms of skin lesions have been observed, but the more general forms re- semble eczema. Sometimes there are tumors and nodules and rarely a form that resembles granuloma fungoides. All forms itch intolerably. Histologically they can sometimes be dif- ferentiated by the lymphocytic infiltration of the skin. The physical examination shows marked enlargement of the lymph glands. They are discrete, movable, not tender. Involvement shows a tendency to be symmetrical, although this may be due to the almost universal enlargement* Often 860 DISEASES OF THE BLOOD. the percussion note over the manubrium is dull. This may suggest enlargement of the thymus or of the glands of the superior mediastinum. The spleen is moderately enlarged. It can usually be palpated, but not always. It is distinctly harder than normal. The liver is slightly enlarged. The heart is enlarged, and over it can be heard a variety of mur- murs, due partly to the changes in the blood, more frequently to relative insufficiencies. The physical examination of the lungs is usually negative. Occasionally pleural transudate may occur. The blood picture is characterized by the presence of a great number of small cells resembling the ordinary lymphocytes of the blood, usually surrounded by a thin rim of proto- plasm, which does not contain granules by any of the ordinary stains. Frequently some of these cells may loose their pro- toplasm and often undergo further degenerative changes. There is a marked leucocytosis, often several hundred thous- and white cells to the cubic millimeter, and the changes in the reds are similar to those of progressive pernicious anemia. The prognosis is fatal. Remissions may occur, usually as the result of treatment. The disease progresses, hemor- rhages occur, slight fever appears, and the patient dies of cachexia. Characteristic Blood Count. Hemoglobin 50% Red blood cells 2,950,000 White blood cells 37,200 Polymorphonuclears 7% Lymphocytes 90% Large mononuclears and transitionals 2% Eosinophils 1% (From a male, 55 years of age, with severe nephritis, who showed 100 mgm. of blood-sugar per 100 c.c. of blood, and 450 mgm. of blood non- protein nitrogen.) ACUTE MYELOGENOUS LEUKEMIA. This is a condition in which leucocytosis develops, runs a very rapid course for a few weeks, and terminates in death. It may follow some minor infection. The characteristic fea- ture is hemorrhage from the mucous membranes, especially of the mouth, ulceration or gangrene of the mucous mem- LEUKEMIA. 861 branes of the mouth, and general hemorrhagic diathesis, or a condition resembling purpura hemorrhagica. Any of these forms may be febrile. In appearance there is the usual pal- lor of leukemia, there is enlargement of the glands of the neck and often of the other lymph glands. The spleen and liver are only moderately enlarged. There may be a hemorrhagic pleural exudate. The skin often contains smaller or larger hemorrhages as do also the mucous membranes. There are frequent hemorrhages of the gastrointestinal tract, and the patient may have severe and exhausting attacks of diarrhea. In the early stages it is said that leukopenia frequently oc- curs. In any event, in a very short time, the white cell count increases, the blood then contains large mononuclear cells, the protoplasm of which contains neutrophilic granules. It is generally believed now that a final differentiation between large lymphocytes and large mononuclears on the one hand, and myelocytes and myeloblasts can be made by means of the oxydase reaction, which is essentially the same reaction as that used for determining the presence of occult blood. Naegeli is the protagonist of the myelogenous nature of this form of acute leukemia. ACUTE LYMPHATIC LEUKEMIA. Acute lymphatic leukemia is a disease particularly of early life. It is only necessary to state that it resembles the acute myelogenous leukemia; that the blood picture shows particu- larly an excess of small lymphocytes, although large lympho- cytes with pale neuclei may be seen. Myelocytes of any type may be present. There is the same tendency to hemorrhagic diathesis, gangrenous process in the mouth, fever and death. TREATMENT OF LEUKEMIA. The treatment of all forms of leukemia is essentially the same, but the results of the treatment are not uniform in the dififerent types. There are three methods which, as a result of ample experience, have proven to be of value in leukemia; these are arsenic, radiotherapy and benzol. No other forms of treatment at the present time need be considered. 862 DISEASES OF THE BLOOD. Treatment by Arsenic. Until 1900 and even later, arsenic was the one remedy available for the treatment of leukemia. It may be given in various ways, but the important point is to introduce as much arsenic as possible into the patient without producing symptoms of poisoning. Almost any preparation of arsenic will do, but the most convenient, and the one which has been used most extensively, and concern- ing which, therefore, there is the most information is Fowler’s solution. A small dose is given at first, perhaps 5 minims three times a day, increasing at the rate of one minim per day until the patient has either pain in the epigastrium or slight swelling of the tissues around the eyes. The dose is then reduced one-half or one-third and continued indefin- itely until either the patient’s condition is satisfactory or death has occurred. To this iron may be added. Arsenic may also be given hypodermically in the form of cacodylate of sodium, one decigram (gr. ll/2) every day or every other day, or in the form of salvarsan intravenously, starting with a comparatively small dose of 2 to 4 decigrams (gr. iii to gr. vi) once a week; or a proportionate amount of neosalvarsan. Arsenic must not be used at the same time as radiother- apy is used, but it may be used during the intervals occurring between the other form of treatment. Radiotherapy. This was introduced by Beclere in 1904. The effects are so satisfactory, indeed so dramatic, that it has practically superseded all other forms of treatment, and these are now used only as adjuvants. I have the belief that there are certain essential things requisite successfully to employ radium or x-ray. First, that the treatment shall be given by one who is experienced and skillful in its use. Second, that no effort be made to produce sudden results by large doses, rather the treatment should be given con- servatively and carefully. Third, that the treatment should not be continued until a profound leukopenia has occurred. Fourth, that during the treatment the patient should be kept under the most favorable physical conditions, not ex- posed to variations in temperature, and not permitted to do LEUKEMIA. 863 anything that will cause fatigue, indeed, as a rule it is better that the patient remain quietly in bed, leaving it only to receive the treatment if necessary. This is particularly im- portant in the beginning. There are two methods each of which has its advocates— treatment of the bone marrow, and treatment of the spleen. The results seem to be approximately equal. Once the white blood count has been reduced to normal, the treatment should be discontinued. These are merely the statements of a clin- ician who does not use the treatment but has had oppor- tunities of observing its use by others. When the blood count increases again, the x-ray should be re-employed, and, in the interval, arsenic may be used. Radium may be used in place of x-ray. The effects are excellent, but apparently no better than are the effects of x-ray. Excepting in the large centers, radium is more difficult to obtain. Ordway, how- ever, believes that radium is the most effective treatment at our disposal at the present time. One important fact must be remembered, during either the x-ray or radium treatment, no irritant applications should be made to the skin. One of my patients, a man of sixty-five, whose leukemia had been held in check successfully for about five years, shortly after his return home from the last x-ray treatment, developed a trivial pain in the epigastrium. The nature of this pain was not investigated. His wife, in an effort to relieve him, ap- plied a mustard plaster to the skin. This caused an intense reaction with the development of erysipelas, general sepsis and death. The patient should therefore always be warned not to use iodine, mustard or any form of counter irritant, no matter what the indication may be, after x-ray treatment. The benzol treatment was suggested by Llewellys Barker. The administration of benzol is by the mouth in 5 decigram doses, usually given with equal parts of olive oil, in capsules, in increasing doses, starting with 2 capsules the first day, and increasing one capsule every day, until 8 or 10 are being given. The latter is the maximum dose. The treatment should be discontinued if the number of white corpuscles has been considerably reduced, or as soon as 20,000 has been reached. 864 DISEASES OF THE BLOOD. There are certain disagreeable results, particularly gastric disturbances, following the use of benzol and related com- pounds. There is danger of producing too severe a reaction; it does not appear to be as effective as the x-ray or radium, and gradually its use is becoming less common. Splenectomy has also been employed. According to the Mayo Clinic, this seems more effective if used after radia- tion of the spleen, but the results have not l>een sufficiently encouraging to justify the operation. It is said that leu- kemia sometimes improves after a severe septic infection from which the patient recovers. It is very difficult to ob- tain satisfactory case reports upon this subject. It is ex- tremely doubtful, because there are cases of leukemia which seem to be very susceptible to septic infection and die promptly when such an infection occurs. The response to treatment of the different types of leukemia is variable. Of all types the chronic myelogenous responds most rapidly, either to arsenic, x-ray, radiation or benzol. Probably no cures are obtained, but life may be prolonged for many years if the patient can be kept under observation, and the treatment employed whenever there is a tendency to relapse. The chronic lymphatic form does not do nearly so well. It is my impression that in this form the x-ray should be used with extreme care, very small doses being given at first and gradually increased as the patient seems to improve. In one of my cases, a severe form of the chronic lymphatic type, death occurred three days after the first ap- plication of radium, although only one half of the usual dose was applied. I feel that it would have been wiser if even a smaller dose had been given. The acute leukemias appear to be extremely refractory. Treatment has very little effect upon them, and they usually proceed to death with little if any delay as the result of medi- cal interference. Having seen a moderate number of cases, and having developed definite impressions upon the subject, 1 am inclined to believe that the most effective treatment, at present, is the administration of arsenic in some form, particularly subcutaneously. Other methods of treatment may also be employed. LEUKEMIA. 865 In how far personal impressions are valuable I do not know, as a rule they are not only worthless but sometimes, if attention is paid to them, they are misleading; neverthe- less I have acquired an impression, for which I lack the sup- port of any definite observation or experimental work; and this is that the cause of leukemia is an animal parasite, prob- ably related to the spirochete, and I harbor the hope that either in some selective poison, or in some anti-parasitic sub- stance, a cure will ultimately be found. POLYCYTHEMIA WITH SPLENOMEGALY. In 1892, Vaquez observed a child notable for an extreme and persistent cyanosis. He diagnosed stenosis of the pul- monary valve, but when the patient died the heart was found to be normal, and he then concluded that he had observed a previously unrecognized disease, probably of the blood. The case was remarkable for the fact that the number of red blood cells considerably exceeded 5,000,000. Subsequently, Osier called attention to Vaquez’ article, reported four cases of his own, and mentioned some other reports in the litera- ture, in which a very high red blood cell count had been made, some of which were in excess of 10,000,000 per cubic milli- meter. In the majority of these cases the spleen was found to be enlarged. It appeared therefore that a new symptom complex had been discovered by Vaquez, to which various names have since been given. Of these the most generally accepted is the descriptive term Polycythemia with spleno- megaly. Of late, however, Erythremia has also been used. The term Erythrocytosis is also employed to indicate an ex- cessive number of red blood cells in the blood. Polycythemia with splenomegalia is characterized by a peculiar cyanosis, evidence of deficient oxidation of the blood, and enlargement of the spleen. Its cause is unknown. Its onset is equally unknown, for it is never recognized until it has reached an obvious stage of development. Its course is chronic. Death usually occurs from some intercurrent con- dition, usually pulmonary. In one of my cases the terminal symptoms were intracranial, but no autopsy was permitted. It occurs at any age, but usually it is observed during mid- dle life. There does not appear to be any reason to suspect 866 DISEASES OF THE BLOOD. a geographical distribution, nor is there evidence that the disease is more severe at one season of the year than at another. The disease is not uncommon. Undoubtedly it was at firs,t fre- quently overlooked or incorrectly diagnosed. I observed with H. D. Geisler, a girl of ten who was sup- posed to have pulmonary stenosis, but whose heart at autopsy was found to be normal, undoubtedly a case of Vaquez’ dis- ease, with a red blood count that averaged about 8,000,000. This was before the publication of Osier’s paper. An interesting feature of the disease that suggests family tendency is the occurrence of fairly high red blood counts in other members of the patient’s family, usually not associated with any abnormal symptoms. The most characteristic feature of the disease is the cyan- osis. This is hardly a slatey blue but rather a light purple color, involving particularly the face and hands, being deeper at the ends of the fingers and tips of the ears. The extrem- ities are usually cold and often slightly moist. One of the features is the reddish or purplish discoloration of the con- junctivge, which is often the most striking feature. The patients complain of a variety of symptoms. Perhaps the most common is an indefinite discomfort which they can- not clearly describe. In addition there is dizziness, head- ache, tinnitus, nausea, and sometimes vomiting. There may be some disturbance of vision. Backache is not uncommon, and it has been observed that occasional paroxysms of pain in the back have been followed by hematuria, similar to the paroxysms of backache followed by hematuria that are ob- served in Banti’s disease. In addition I have observed in one case, agonizing pain involving the pelvic girdle, and ex- tending into the legs, not relieved by any remedies excepting very large doses of morphine. The physical examination shows the peculiar color already mentioned, the mucous membranes of the mouth being dark red or mahogany in color. The subcutaneous veins are often distinct, especially on the face. The respirations are often slightly above normal. The breath sounds as a rule are clear, no rales being heard at the bases. This is not always the case, for if the patient seems unusually weak and depressed, basal subcrepitant rales may occur. LEUKEMIA. 867 The heart is usually normal although there is no reason why a complicating peri or endocarditis should not be present. In one of my cases complete obliterative pericarditis was recognized during life and found at autopsy. The pulse is slightly increased in rate. Unless there is some complication, the blood-pressure remains normal. The lower edge of the liver can be palpated If the kidneys are palpable, it is an accidental complication and has nothing to do with the dis- ease. The spleen is large, indeed may be as large as in a severe case of leukemia. I observed one patient, a woman in her fifties, whose spleen extended to the crest of the ilium. As in leukemia, the spleen may be made to vary considerably in size as the result of treatment. As a rule, there is slight polyuria. Nocturia in older persons may be regarded rather as a complication than as a characteristic of the disease. Very often there are albumin and casts, and red blood cells in the urine. Apparently, however, the function of the kidneys is but little disturbed. The feces may also con- tain occult blood or red blood cells, and occasionally slight disturbances indicating transitory lesions in the central ner- vous system are noted. The characteristic changes are in the blood. The number of red blood cells per cubic millimeter is increased. The bulk of the red blood cells per cubic millimeter is also in- creased. There is some reason to suppose that there is an actual increase in the total quantity of blood in the body. The red blood count may vary from 7 to 12,000,000. There is some doubt whether the counts higher than these that have been recorded can possibly be correct, as the bulk of the corpuscles would then exceed one cubic millimeter. The hemoglobin ranges from 100 to 150 per cent., and higher figures have also been recorded. The white blood cells are usually increased, and the per- centual increase is greatest in the polymorphonuclear cells. There is no other consistent variation in the white cell pic- ture. The red cells are normal in size and shape. Nucleated cells are very rarely found. There is no excess of reticulated cells. It is said that the blood has increased viscosity, but the methods that we have of testing the viscosity are un- 868 DISEASES OF THE BLOOD. certain and not available for general clinical use. The fra- gility of the cells is normal. It is said that the basal metabolism is slightly increased. Only one pathological finding is of significance—the bone marrow is of the fetal type, otherwise there is simply vas- cular congestion of all of the organs. Nothing has heretofore been found that explains the nature of the disease. The diagnosis is easily made, if suspected. The prognosis is hopeless for cure. Remissions may occur spontaneously, but particularly as the result of treatment. The course is chronic. For long periods it may not even be progressive. The disease rarely kills. The treatment is un- satisfactory. In one case under my care for several years, the application of radium to the spleen was invariably fol- lowed by a reduction to normal of the number of red blood cells, and the shrinking of the spleen from the crest of the ilium to a position above the lower costal margin. This patient exhibited to an extreme degree the irritability which is a common manifestation of the disease. In other cases the x-ray is said to have done good. No form of radio activity can be regarded as a specific. It must be remembered, however, that this treatment must be ad- ministered by an expert, and continued for a long period of time. The mere casual exposure to x-rays is fore-doomed to failure. Of the other remedies that have been used, iodides have been given, and seem to me to have done good, at least patients have not grown notably worse during their administration. Benzol has also been recommended, but ap- parently has not been employed extensively. Venesection undoubtedly gives temporary relief, but it is only temporary. These patients are usually sluggish, are inclined to sleep, and probably do well if they lead quiet lives, and are shielded from exposure and exertion. Splenectomy has been tried, but apparently is injurious. PURPURA HEMORRHAGICA. Purpura hemorrhagica is a disease characterized by hemor- rhages from the mucous membranes and into the mucous membranes and the skin. The etiology is unknown. It oc- PURPURA HEMORRHAGICA. 869 curs suddenly and may continue for some time, and is often remittent. It is certainly due to some defect in the mega- caryocytes wnich causes them to cease producing the blood platelets. This is functional, for under the influence of a suitable stimulus, the formation of platelets is renewed and the disease is arrested. The cause of the inactivity of the megacaryocytes is un- known. Various conditions, such as infections, may precede an attack, or no obvious change. It has some features in common with aplastic anemia and lymphatic leukemia, but this fact adds nothing to our knowledge. It is not associated with any so-called diathesis or peculiarity of anatomical structure. Petechial eruptions in the skin occur in the course of certain severe infections, such as infectious endocarditis, typhus fever and smallpox, and occasionally in others, such as black measles. The symptoms and signs vary according to the severity and type of the case. The symptoms may be absent or noth- ing more than a tingling in the skin or a sense of tension in the mucous membranes, or they may be severe, with pain in the joints and soreness in the mouth. Sometimes fever is present. The characteristic sign is the hemorrhage. This may be variable. In the mildest form the skin may show only a few small spots that do not disappear upon pressure. These spots at first are bright red, then become darker and change to yellow before they fade entirely away. In the more severe cases the spots may coalesce, and oc- casionally blebs filled with black fluid blood may appear. The mucous membranes are more severely affected. Oozing occurs from the gingival surfaces, from the mucous membranes of the cheeks, and of the palate. Particularly on the palate large submucous extravarations may occur. The loss of blood from the mucous membranes may be so great that a severe secondary anemia may occur. Whether the usual form of purpura hemorrhagica is dis- tinct from the other forms, with visceral and arthritic symp- toms need not be discussed here. At any rate the apparently characteristic lesion, the disappearance of the platelets from the blood, is not always present in these. 870 DISEASES OF THE BLOOD. The course is variable, it may be brief, persistent, or intermit- tent; there is no satisfactory explanation of these varieties nor is there any sharp line of demarcation between them. The prognosis is favorable provided the proper treatment can be used. The treatment can best be described from a typical case. The patient was a man thirty-five years of age, he was seen after he had been sick five days with oozing from the gums, a purpuric eruption upon the skin and sharp brief pains in the abdomen. A systolic murmur was heard over the heart, there was slight tenderness over the abdomen. The spleen was pal- pable beneath the costal margin. The red blood cell count was 4,650,000, white blood cell count was 15,000, the poly- morphonuclear cells were eighty-six per cent. There were no platelets. The urine was bloody. The coagulation time was normal, three minutes, the bleeding prolonged, the clot did not retreat. This patient was given 10 c.c. of a coagulant hypodermatically, and calcium by the mouth. He stopped bleeding in forty-eight hours. Ten platelets by large power field were found in the blood. Eight days later the bleeding recommenced, no platelets were found in the blood, he was transfused from his wife, 300 c.c. being used, and the bleed- ing stopped. Three days later 640,000 platelets were found per cubic millimeter of blood, and he recovered permanently. In these cases transfusion is a specific; it is more successful in purpura hemorrhagica than in any other disease. Diseases of the Eye BY T. B. HOLLOWAY, M.D. Associate in Ophthalmology, University of Pennsylvania. Diseases of the Eye. FOREWORD. In the present section it was regarded as advisable to dis- regard certain rare or unusual conditions pertaining to various ocular structures that would be, in a sense, pertinent to this volume. Instead, attention has been given to those conditions which are frequently encountered and to which more atten- tion, with propriety, might be given by the average practi- tioner. Excluding the congenital anomalies, direct contamination of the conjunctival sac, the effects of radiant energy, refrac- tive errors, neoplasms and conditions resulting from trauma, practically all of the manifestations encountered in ophthal- mology are secondary to pathologic changes in adjacent or distant structures. It is true that as yet it cannot be definitely stated that the ordinary senile cataract should be so regarded, but we have passed the stage where this is to be regarded as a physiologic process. Even the refraction, through the cili- ary muscle and the various media, may be influenced by gen- eral or distant conditions, while a certain number of the new growths are metastatic. These facts are generally known, but all too frequently the attitude of the practitioner toward the eyes does not seem to substantiate a full realization of them. I may be pardoned, therefore, if I ask the reader to consider the relationship of the eye to the cerebrospinal system, of which, certain of its structures are in a sense a part, the fact that it may be af- fected by diseases of the respiratory tract, especially the up- per portion; diseases of the gastrointestinal and genitourinary tracts; the cardiovascular system, as well as diseases of the blood; the endocrins; disease of the skin; the exanthemata; certain general conditions such as tuberculosis and syphilis and the metabolic conditions, diabetes, gout and rheumatism; even the osseous and muscular structures and certain parasitic 874 DISEASES OF THE EYE. diseases are not exempt. Is there any other organ subject to such widespread influences that lends itself so readily to in- spection and palpation and at the same time permits of a minute and thorough examination of its interior, where, by direct inspection, certain of the nervous, vascular, and other elements are seen under a magnification of about fourteen diameters? The fact that the ocular findings, in many in- stances, cannot be so classified as to make them referable to this or that particular structure, in no sense mitigates against the value of such examinations; the same thing pertains to other organs and often to a greater degree. Two important facts may be emphasized: First, that in medical, surgical, and neurological conditions, the ocular find- ings are to be regarded in the light of data that must be con- sidered in conjunction with the other clinical and laboratory findings. Second, in a certain sense it may be said that, in most instances an individual with a diseased eye is just as much a sick patient as is the individual with a diseased heart or kidney, and it is the patient and not the diseased organ alone that should be treated. PRESBYOPIA. The most constant of all the ocular changes of middle life are those dependent upon the gradual failure of the accommo- dation, which, in the majority of cases, is evident from the age of forty to forty-five years. By accommodation we mean the adaptation of the refraction of the eye for different dis- tances, that is, between infinity and its so-called near point. While different theories have been advocated to explain this function the one most generally accepted is that offered by Helmholtz. Briefly stated, the ciliary muscle contracts and in doing so relaxes the suspensory ligament or zonula of the lens. Thus released from its tension, the pliable and elastic lens becomes more convex anteriorly and posteriorly and while the anterior surface advances, pushing with it the cen- tral part of the iris, the posterior pole of the lens remains fixed. From early childhood on through life the near point, or the closest point at which fine print can be read, has a tendency PRESBYOPIA. 875 to recede from the eye until some time in middle life when it passes beyond that particular distance from the eye where it would be serviceable for near work. For the average individ- ual and for ordinary purposes we may regard this distance as about 28 cm. or 11 inches. The patient is then presbyopic and a special glass becomes necessary for near work. This lessening in the accommodative power is dependent upon changes that have slowly and progressively developed in the lens substance, a hardening or sclerosis, which is most marked in the central portion. Thus, with the lessening of the elasticity of the lens its inherent power of increasing its own convexity diminishes and as a result, the near point of the eye gradually recedes more and more. I also believe that there is some lessening in the power of the ciliary muscle. With this in mind, it is evident that when we give an addi- tional glass for reading or near work we merely compensate extraocularly for a loss of function; that is, we place in front of the eye a convex glass; in youth the elasticity of the lens itself permitted it to become sufficiently convex. From what has been said it may be inferred that one of the first signs of presbyopia is the greater distance from the eye that a printed page must be held to be seen clearly. While such procedure increases the definition, it also makes the type appear smaller. Not infrequently women will complain of the difficulty of seeing the eye of a needle. For well known opti- cal reasons, such eyes see better when the pupils are contracted and as a consequence reading at night becomes difficult unless the light is so placed that it falls directly on the eyes and thus causes a contraction of the pupils. This is frequently resorted to and subjects the individual to the additional inconvenience and hazards of faulty illumination. While pain and other signs of accommodative strain are not as a rule complained of, under certain conditions they may be present. The individual with head slightly thrown back, arms extended, making frequent, short, to and fro shifts in the posi- tion of the page, “tromboning”, as it is sometimes called; or, the woman holding her needle with extended arm, chin ele- vated and at times, face averted, making repeated and futile 876 DISEASES OF THE EYE. thrusts at the eye of her needle with a thread, afford pictures too familiar to be dwelt upon. This failure of the accommodation may be readily determined by first finding the near point and for this purpose a simple test is always at hand. If the usual reading test card is not avail- able, fine print, of about this size, anddid notriTr fTilu"'; "" ‘T* Tn or slightly larger, may be selected from any text at hand. One eye is covered while the test type is slowly carried towards the eye until the print is indistinct, but can still be read. The distance from the print to the cornea is then measured and recorded. Instead of fine print, a fine black line, a sixth of an inch in length, may be made on a white card by a light stroke of a pen. This is made to approach the eye under ex- amination until the line becomes indistinct or there is a ten- dency to doubling. The distance from the eye is then meas- ured as above described. From what has been said it may be judged that the same individual might be presbyopic at a much earlier age if it is necessary to do near work at nine inches, than would be the case if the near work could be done at fourteen or even eighteen inches. The following table shows the distances of the near-point from the normal eye at different ages: 35 years 18 cm. 7 inches 40 ” 22 ” 8H 45 ” 29 ” 11J4 ” 50 ” 40 ” 15 V4 55 ” 55 ” 2\l/2 ” 60 ” 100 ” 39i4 In other words, every individual with normal .eyes who at- tains old age must wear glasses for near work in the later years of life if he desires to see properly, and this irrespective of any cherished scientific or other beliefs that he or she may foster. So far, only what might be regarded as physiologic changes in the normal eye have been referred to. The refraction of the eye, whether hyperopic or myopic, also has a determining influence on the onset of presbyopia. Thus the focus of the lens system or dioptric apparatus of the farsighted or short eye is behind the retina and an individual with such a hyper- PRESBYOPIA. 877 opic eye may, and invariably does, correct his hyperopia, by accommodating, unless it be of an excessive amount. This constant use of part of his accommodation to maintain good distant vision leaves just that much less power available for his close work and as a consequence his near point is further from the eye than is that of the individual of the same age with a normal or emmetropic eye. In other words, presbyopia develops earlier in the hyperopic eye. On the other hand, in myopia the accommodation cannot be utilized to improve the distant vision because the focus of the dioptric apparatus of the near-sighted eye is in front of the retina and as a conse- quence all eyes of this type have defective distant vision. However, it has this compensation, that with its short focus, an object at some point inside of infinity can form a clear image on the retina without utilizing the accommodation, which leaves all of this function intact for distances nearer the eye. Thus, a myope of moderate degree, say three diop- ters, with his eye at rest, would have a clear image formed on his retina when the object was placed at 33 cm. or 13 inches in front of the eye. To accomplish the same result an emme- tropic or normal eye would be compelled to accommodate three diopters, and it would necessitate six diopters of accommoda- tion in the case of a hyperopic eye of three diopters. It is thus seen that with three diopters of myopia an individual has all of his accommodative power available for use within 33 cm. or 13 inches of his eye and consequently can see objects, such as fine print, closer to the eye than can an emmetropic or hy- peropic individual of the same age. Mention must also be made of those instances where certain anomalies of accommodation exist; these Duane has classified as excessive accommodation; insufficiency of accommodation, inequality of accommodation and ill sustained accommoda- tion, terms that are sufficiently explanatory; finally inertia of accommodation, where there exists some difficulty of chang- ing from one state or stage of refraction to another. Need- less to say the first two of these would have an. important bearing on presbyopia. The insufficiency cases dependent up- on weakness of the ciliary muscle may be the result of an ocular condition such as glaucoma, or certain general condi- tions such as neurasthenia, nasal disorders, increased blood- 878 DISEASES OF THE EYE. pressure, disturbances of the endocrins and various toxemias. In many of these cases definite asthenopic symptoms are present. The treatment of this condition need not be discussed in a volume of this character, but a word may be said about myopic individuals and presbyopia. Through a misunder- standing many believe that because they are myopic, glasses for near work will not be necessary in the later years of life. This is true in certain instances where the myopia is of moder- ate degree, but it does not hold true in certain other instances where the amount of myopia is small or possibly where it is excessive. RETINAL VASCULAR CHANGES ASSOCIATED WITH HYPERPIESIA, ARTERIOSCLEROSIS AND NEPHRITIS. These cases showing retinal vascular changes with or with- out ophthalmoscopic alteration in the optic nerve and retina, form not only a definite percentage of the cases coming under the observation of the ophthalmic clinician, but they also con- stitute a most interesting group. As certain vascular symp- toms may suggest to such patients that their eyes are at fault or because early signs of retinal vascular changes are prone to develop about the time an individual comes under observa- tion for presbyopia, many of these cases are first seen by the oculist. Like many other eye conditions that from an ocular standpoint may be regarded as primary, they are really sec- ondary, and for their proper and successful handling and treat- ment, should have the cooperation of the internist. On the other hand, I believe it is just as truly appreciated by the internist that no case of vascular or cardio-vasculo-renal dis- ease has been properly studied unless an ocular examination has been made. Combined efforts should not cease after a diagnosis has been determined, but should continue through- out the course of the observations. This is the only way proper correlation can be maintained to advantage. It is well recognized that sclerosis of the retinal vessels is apt to be associated with a similar condition of the cerebral vessels and that these changes as revealed by the ophthalmo- RETINAL VASCULAR CHANGES. 879 scope may be decidedly out of proportion to evidences of ar- terial changes elsewhere. On the other hand, retinal changes may be but slight, and definite symptoms of a systemic scle- rosis exist; or, as Hertel has pointed out, the retinal vessels at times show arteriosclerotic changes microscopically when none can be discerned ophthalmoscopically. While in recent years attempts have been made to type the fundus manifestations according to various vascular or vas- culo-renal conditions, owing to the many still obscure and dis- puted questions pertaining to the organs involved, the fact that certain of the intraocular changes are common to all types, if we possibly exclude certain cases of acute nephritis, the border lines as we change from one condition to another are rather broad. It is with this in mind, that I have men- tioned the importance of repeated ocular examination so that the changes, whether progressive or not, may be watched and early evidences of new manifestations studied. It is the onset, extent, or sudden augmentation of certain lesions and the grouping of the various signs, more than the mere existence of these signs that, taken in conjunction with the clinical find- ings of the internist and the laboratory reports, go to build up the true clinical picture. Every experienced ophthalmic clinician is constantly encountering instances where shortly following the detection of these intraocular vascular signs, central vascular disturbances develop; or, where certain manifestations have been present, the explosion of fresh or new signs has indicated a rise of pressure or possibly a renal insufficiency. A clearer conception of the underlying complex vasculo- renal problem will ultimately admit of adequate classification of these intraocular signs, until then they remain in a sense as suggestive. The path between suggestion prompted by ac- curate and careful clinical observation and laboratory cor- roboration, is frequently a long and tortuous one, but this in no sense robs either of its value; as is shown by the present day status of medicine. Etiology. As to the etiology of hypertension, arteriosclero- sis without and with associated renal conditions and nephritis, the reader is respectfully referred to the sections by Dr. 880 DISEASES OF THE EYE. Piersol (pages 393 to 417) and that of Dr. Pepper (pages 605 to 609). Symptoms. While Hirschberg, Raehlmann, and in this country Friedenwald, made early observations on the retinal changes seen in arteriosclerosis, Gunn’s excellent contribu- tion in 1898, in which he described the lesions present in cases of increased tension in arterial disease with and without al- buminuria, was doubtless the factor that stimulated a more widespread study of this subject. It was followed in this country by a number of excellent contributions, notably by de Schweinitz. In arteriosclerosis with increased tension certain signs were regarded as suggestive, to which were added others believed to be pathognomonic. The suggestive signs were the light color of the arteries with an increase of the light streak, as- sociated with some tortuosity and irregularity in calibre; changes in the course and calibre of the veins. Later the pathognomonic signs appeared in the form of further changes in the arteries where there was a loss in the translucency and a beaded appearance might develop; lesions in the vessel walls gave rise to white stripes along the vessels, constituting the so-called periarteritis. The veins likewise showed further irregularity in calibre and in places revealed a flattening, definite indentation, or constriction where pressed upon by an overlying rigid artery. Evidences of obstruction might also be present in the affected vein, distal to the point of compression, as manifested by a localized dilatation. As with the arteries, white lateral stripes might develop along the veins, a periphlebitis. Linear or flame-shaped hemorrhages developed in the retina and more or less edema might be pres- ent about the disc or along the course of the vessels. De Schweinitz further emphasized that three signs may be noted early, namely, a cork-screw appearance of certain ar- terial twigs, the crinkled retinal vessel of Alleman, apt to be noted about the macular region or arising from some medium sized vessels of normal appearance; the flattened or indented vein and finally a congested appearance of the nerve head. He differentiated the last sign from the appearance of the disc in the hyperopic eye and in the early stage of neuritis. RETINAL VASCULAR CHANGES. 881 During the past fifteen years our increasing knowledge of vasculo-renal disease and more thorough study of these vas- cular fundus changes have made it possible to attempt further classification of these signs, but in well advanced vasculo- renal cases any or all of the above mentioned changes may be seen. Thus Moore, recording his observations in 1916, may be said to have instigated another wave of interest, and this has been followed by numerous other contributions. HYPERPIESIA. This condition may be indicated, according to Benedict, by an increased tortuosity of the artery which becomes copper colored through loss of translucency in its walls. The light streak is narrowed and intensified and venous in- dentation by the overlying artery occurs. As the condition persists and as the result of thickening of the intima and middle coat, the artery contracts and the curves and bends are straightened out. Further indentation of the veins oc- curs with possible localized dilatation distal to the point of compression. The veins become two to three times the diameter of the arteries. A few white dots may be scattered about the posterior pole and some edema may be present. Adams emphasizes the disappearance of the venous reflex stripe for a short distance on either side of the point of arter- ial crossing, while Bardsley believes that early the vessels are uniformly full with a broadened and increased intensity of the light streak. In an individual case seen for the first time, the changes in the course of the arteries above described would be of but little service, owing to the variations of the physiologic limits. ARTERIOSCLEROSIS WITH HIGH TENSION. In these cases the copper colored arteries show a narrowed and intensified light streak and at times the cork-screw terminals may be seen. There are present the manifestations above referred to, depending upon a crossing of the arteries and veins. At times one may note a contraction of a vein be- tween two near points of arterial crossing. Moore emphasizes the frequently seen instances of the dis- placed line of the vein near the point of crossing in the severer 882 DISEASES OF THE EYE. types. Instead of maintaining its oblique course as it passes under the artery, it is deviated and may parallel it for a short distance before and after crossing or may cross at right angles. As pointed out by de Schweinitz, the nervehead may present a more or less characteristic congested appearance. While in my experience it is not always evident when other signs may be quite well marked, I have seen it exist when it seemed to be out of proportion to the other signs. I have noted it to best advantage in those well marked cases in asso- ciation with nephritis. Irregularity in the calibre of the ar- teries is frequently seen in a varying degree and in the case with well developed signs the so-called “silver-wire” arteries may be present. Perivasculitis may be noted along certain vessels, in fact, an artery may be entirely replaced by a white cord which extends far into the periphery of the eyeground. Over the central portions of the fundus may be noted small hemor- rhages, usually of the linear or flatne-shaped type. Unless nephritis be present widespread edema is absent, although dis- crete areas have been observed. Aside from the solitary di- lated and tortuous vascular twigs, one at times sees in the advanced cases, usually about the macular region, masses of these tiny convoluted vessels, marked enough to give one the impression of a glomerulus of the kidney. I have ob- served in several instances that these vascular convolutions were apparently the point of origin of extensive hemorrhages. More rarely evidences of proliferative tissue will be seen, but in my experience this is usually more frequent in the asso- ciated nephritis cases. Moore believed the term arteriosclerotic retinitis should be applied to those cases in which there develops in addition to the vascular changes, small, discrete, irregularly circular whitish exudates, essentially chronic in character and apt to be grouped about the posterior pole. They may be associated with central larger lesions of dirty-white appearance, but hemorrhages and edema are not present about them. He also comments upon the occurrence of localized white plaques or pipe-stem casing of the arteries that have been described by Hulke. RETINAL VASCULAR CHANGES. 883 RENAL DISEASE. In those cases where a chronic nephritis exists the disc may present various manifestations. We may find hut slight in- jection or a brick-red disc, at times a partial or complete blurring of the margin with delicate striations and more or less adjacent edema of the retina, constituting the so-called neuroretinitis. Less frequently one encounters a definite choking, which it would be impossible to differentiate from that seen in brain tumor. More or less edema is frequently present, in fact Slocum in his interesting study from the service of Dr. W. R. Parker, found it present in 93 per cent, of his cases. Discrete yellow white or soft edged white spots are not infrequently seen about the disc or macular region and when they cover larger areas are sometimes designated as “snow banks”. Of the macular changes that occur the most conspicuous is the stellate figure which for years has been recognized as one of the distinguishing fea- tures. When well developed it constitutes a striking picture but it is questionable whether it is seen as frequently as the knowledge of its possibility would seem to indicate. In Slocum’s series it was present in 6.8 per cent, of the cases. Concerning this lesion, it must be remembered that it is not pathognomonic. It is not infrequently seen in brain-tumor cases, has been observed in syphilis independent of nephritis, and personally I have seen two instances of double perfora- tion of the globe by a foreign body, the posterior wound being at the border of the macular region, where typical macu- lar stellate figures developed. When incomplete, in both nephritis and brain tumor, the radiations that exist 'almost invariably extend from the macula towards the disc. Needless to say the vascular signs already described are present in varying degrees and in long continued cases are apt to be excessive. In Slocum’s series, hemorrhages were present in the “interstitial cases” in 73 per cent, and 50 per cent, in those of “chronic nephritis.” These may be of the linear, flame-shaped, or larger solitary type but at times the rosette is encountered. I have seen such a hemorrhage give rise to a central scotoma. Pepper has recently emphasized the importance of hypertension as a causal factor in the purely 884 DISEASES OF THE EYE. vascular as well as the nephritis cases. Needless to say in certain types of retinitis the vascular signs seem to predom- inate, in others, the exudative. Acute nephritis, as seen in pregnancy, infections or certain intoxications is not particularly pertinent, unless engrafted upon pre-existing vascular disease. Under these circum- stances we might expect the development of fresh exudative lesions and probably fresh hemorrhagic extravasations. The extent to which certain of the signs may be dependent upon high blood-pressure, arteriosclerotic changes in the ves- sel walls or faulty renal elimination, has been freely discussed and variously interpreted, but with our present knowledge, if we eliminate probability, the fact remains, that we do not know. Certain complications may develop in these vasculo-renal cases in the form of retinal detachment, thrombosis of the retinal vein or artery, embolus of the retinal artery, hemor- rhage into the vitreous, and finally glaucoma. While it is true that statistics show that the majority of patients with renal retinitis die within two years, a small number live three or four times that period. One of my own cases of vasculo-renal disease, survived at least five years after she was first seen, and at that time there existed the most widespread and extensive involvement. Closely allied in its appearance to the renal type is the retinitis of diabetes. Some clinicians regard it as rare, in my experience uncommon would be a more appropriate term. It is seldom seen before the age of forty and is more apt to develop in those cases with a low or moderate glycosuria. Hirschberg classified the manifestations into exudative and hemorrhagic types and alluded to certain other mixed forms. In the first type small discrete white spots, rather sharply circumscribed and opaque, are scattered about the disc and macular region. A few small hemorrhages are also present. Numerous hemorrhagic extravasations constitute the con- spicuous and predominating lesions in the hemorrhagic form. In other types there may be present more widespread whitish DIABETIC RETINITIS. RETINAL VASCULAR CHANGES. 885 or ivory white exudations and these may be associated with haziness or blurring of the disc margins. Vitreous opacities as well as hemorrhage into the vitreous may occur, and in the latter instance glaucoma may develop. Excluding the ex- istence of ocular or retro-bulbar complications, the vision is affected in accordance with the extent of macular involvement. Hirschberg and subsequent writers have noted the fre- quency with which the manifestations are apt to be associ- ated with sclerosis of the retinal vessels. In 1920 Garrod stated that while the retinitis of diabetes can be distinguished from that of renal disease, high blood-pressure and arterial changes are probable factors in both and the metabolic factor may be supposed to determine the difference in the fundus changes. In 1921 Wagener and Wilder placed on record their findings in 44 cases with retinal disturbance observed among 300 patients with diabetes. Those showing fundus manifesta- tions were invariably the patients with milder types of the disease and with associated vascular changes. While I believe most clinicians have correctly diagnosed diabetes from the fundus picture, on the other hand the fact remains that there are types where a differentiation between a diabetic and renal retinitis is impossible. Lipemia retinalis, characterized by a dilatation of the retinal vessels with changes in their color varying from a salmon pink to a grayish-white, need not be dwelt upon. Comparatively few cases are on record but it is possible that a number have been overlooked or missed, especially when the manifestations have been of but short duration. In the majority of'instances the patients have been under thirty years of age. It was first described by Heyl in 1880 and has been fully described in recent papers by Hardy and McGuire. Blood-Pressure in the Central Retinal Artery. As far as I am aware Henderson in 1914, during his interesting work con- cerning the relation of the intraocular tension to the intra- ocular venous level, was the first to devise an instrument to measure the arterial diastolic pressure within the eye. He found the pressure to be 15 to 25 mm. Hg above the intra- ocular pressure. Since then Bailliart has devised a new in- strument and has been making further observations on normal eyes and in certain pathologic conditions. As the result of 886 DISEASES OF THE EYE. these investigations he has placed the normal systolic pres- sure of the central artery of the retina at 70 to 80 mm. Hg and the diastolic at 30. While these studies are still more or less in the experimental stages they give promise of throw- ing new light upon certain intraocular conditions. CATARACT. Of the many types of cataract, the one most frequently seen, the so-called senile, is the one that pertains particularly to this volume. For clinical purposes it is frequently desig- nated by various descriptive terms depending upon the site of the opacity, the degree of opacification and the color. In the first instance the terms sub-capsular, cortical, nuclear or capsulo-lenticular seem sufficiently explicit and the same may be said about the terms incipient, immature, mature or ripe, and hypermature. The degree of sclerosis of the lens has an influence upon the color. The white cataract is most fre- quently seen in younger individuals. In the senile form the gray type is frequently observed and at times it assumes a mother-of-pearl appearance. In other instances the nucleus gives it an amber tint, although darker tints, even to the so- called black cataract, are also observed. Inasmuch as the nucleus is well formed in the senile type it is designated a hard cataract in contradistinction to the soft variety seen under the approximate age of thirty-five and the fluid or Morgagnian cataract, which may develop when the lens becomes hypermature. Etiology and Pathogenesis. The lens is a transparent elas- tic mass composed of an innumerable number of fibers which develop from the epithelium lining the anterior capsule. Towards middle life a nucleus develops as the result of a sclerosis of the more centrally placed fibers. Thus, from this time on the lens shows centrally, in the form of the nucleus, what may be regarded as a physiologic retrograde process, while a new growth of fibers from the capsular epithelium continues to form about it until late in life. The transparency must persist and growth continue if it is to carry on its func- tion properly. CATARACT. 887 While the nutrition of the lens doubtless depends upon the intraocular fluid and in turn the blood, we are practically in ignorance as to the exact essentials necessary for proper nu- trition as well as the metabolism of the cells. In fact our knowledge is by no means as complete as it should be con- cerning the composition, of the intraocular fluid in which the lens is practically suspended. Roemer demonstrated that physiologic fluctuations of the osmotic pressure of the serum were constantly transmitted to the aqueous and he believed the lens to be adapted to its surrounding medium in the same way as the blood-cell to the blood serum. Burdon-Cooper whose recent contributions to the subject have been so con- spicuous, studied the surface tension of the aqueous in senile cataract and found that it approximated more to that of water than in the normal eye, and as a consequence he believes there is a more rapid interchange between the lens and aqueous in the presence of cataractous changes than in the normal meta- bolism. Most authorities now concede that the anterior surface of the lens is the portion most concerned with nutrition and Roemer and Burdon-Cooper practically agree that the nutri- tion is maintained by three factors; an osmosis of the intra- ocular fluid, a slow diffusion between and slow inhibition by the individual cells and finally a specific affinity of its pro- toplasm. The older hypotheses dealt mostly with conditions pertain- ing to the lens while certain diseases with which cataract was frequently associated were discussed as probable factors. In more recent years with the further advances in biochemic studies and further research concerning the physical proper- ties of light, other hypotheses have been evolved. Becker in 1876 stated that an irregular sclerosis .of the lens nucleus brought about changes in the adjacent layers of the lens; later Deutschmann accepted the same theory believing that the water given off during the process of sclerosis caused swelling of the lens fibers. Magnus thought that the sclerosis brought about a stasis in certain portions of the lens as the result of interference with the nutritive currents. Schoen regarded as a factor, the tugging of the zonular fibers on the capsule of the lens during accommodation, believing 888 DISEASES OF THE EYE. that it first produced changes in the capsular epithelium and later in the lens itself. Hess, who has given so much time to the study of the lens, questioned each of these hypotheses. For years many clinicians have believed that hyperopia and uncorrected astigmatic errors especially of the oblique or against the rule type, predisposed to the development of catar- act. In support of this Burdon-Cooper recently has made em- phatic corroborative statements. It is his belief that an im- portant factor is the “irregular torsional accommodation ef- fort which produces an irregularity in lens shape and altera- tion in the axis” as this occurs in hyperopic astigmatism. As the result of this uncorrected strain on the suspensory ligament and the lens capsule, cataractous changes may de- velop. He strongly urges the correction of refractive errors as a prophylactic measure. This irregular torsional accom- modation brings up the old question of astigmatic accommo- dation first introduced by Dobrowolsky and while the theory has many supporters, others have never accepted it. The occurrence of cataract with certain general diseases has long been recognized and the association of lenticular changes with arteriosclerosis has been referred to frequently. Thus v.Michel thought that sclerotic changes in the carotid and its distribution might be responsible for the difference in time of the onset of the changes in the two eyes. Certain other observers felt that there existed some relation through changes in the vessels supplying the so-called secretory appar- atus, but no direct relation has been traced and Gunn believed that none existed. How much certain of the uncorrected tox- emias that seem to predispose to arteriosclerosis may act as inciting factors is of course conjectural, but it is not beyond reason to imagine that they may be contributory. For years the association of nephritis and cataract has been recognized but despite considerable investigation no direct connection has been assumed by many observers and Groen- ouw does not regard cataract as more frequent among neph- ritis cases. On the other hand, Burdon-Cooper after refer- ring to the findings of Frenkel that the insufficiency of the kidney in cataract cases is not accompanied by the usual clin- ical symptoms, but still admits of the accumulation of cyto- toxins, states, that his own experience with these cases point CATARACT. 889 to a definite renal inefficiency, as is manifested by a larger increase in tyrosin in the lens and the resemblance in the variations of the molecular concentration and surface tension of the aqueous and similar constants of the urine. While certain of the infectious diseases might not be per- tinent to the senile type, mention might be made of the as- sociation of cataract with hook-worm diseases as cited by the elder Calhoun and his son, J. Phinizy Calhoun. Welton and Whaley have also referred to its presence in twelve and six- teen per cent, of the cases of pellagra that came under their observation. Peters, from his researches, believed there must be a higher molecular concentration in the lens than in the anterior cham- ber and that this is regulated by the epithelium of the lens. Any increase in the molecular concentration in the aqueous would be detrimental to the lens by interference with the osmotic exchange and in turn with its normal nutrition. To these views Roemer and Burdon-Cooper do not subscribe. Roemer’s theory, which is one of the most interesting of modern hypotheses, is that the subcapsular, the most common of the senile type, is a true metabolic disease of the lens. It was not thought that lack of nutrition alone explained it. He believed that senile involution anti-bodies originated in the blood which possessed a specific affinity for some constituent of the lens protoplasm. If these were not excluded by the secretory apparatus of the eye then the lens might be impaired by the fixation of these abnormal products of metabolism with corresponding receptors of the protoplasm, just as a blood- cell may suffer through fixation of a specific cytotoxin. Thus, he attributed the cataractous changes to a cytotoxin effect upon the epithelium and lens fibers. He believed that when nuclear cataract is associated with the subcapsular type, two different processes are concerned. As the result of Burdon-Cooper’s admirable and painstak- ing work on the lens, he believes that the cataractous changes are brought about as the result of hydrolysis, which he de- fines as “a simple decomposition resulting from the assimila- tion by the proteid molecule of the lens of the constituents of a molecule of water .... with the production of new substances.” He states this theory would explain his finding 890 DISEASES OF THE EYE. of tyrosin in the aqueous after needling the lens and its presence in the aqueous and lens in senile cataract; the much increased amount of tyrosin in the lens and aqueous in both albuminuria and glycosuria. Further, it is the only theory which accounts for black cataract and pigmentation of the lens and the diminution in the weight of cataractous lenses. It would also explain the frequency of cortical opacities and the observation of Dor that the lental albumin is much less and sometimes disappears, because it is hydrolysed and carried away by the aqueous. In recent years the endocrins have not escaped suspicion, Vossius and Schiotz referring to them as causal factors. Triebenstein and Fisher have discussed the possible influence of the parathyroids on senile cataract and comment on the frequent occurrence of latent signs of tetany in these catar- actous patients. On the other hand, Hescheler found but two per cent, of his cases so affected. Gjessing suggests that pregnancy and lactation may have a slight contributing influ- ence through abeyance of the ovarian function. The influence of heredity, so thoroughly studied by Nettle- ship, in the production of lenticular changes is unquestionable as many observations have shown, and as I have seen in a number of instances in the congenital type at the Overbrook School for the Blind and elsewhere. Heredity influences the onset of cataract in later years but in just what way remains unknown. The influence of light rays on the production of cataract has attracted considerable attention in recent years. Hand- mann, from his study of a large series of incipient cataracts, found that the process began in the lower nasal quadrant and while he believed that through gravity this would tend to support his view that nutritional influences were responsible, he also pointed out that this portion of the lens was subjected to the greater effects of light. To the latter suggestion Hess and others have taken exception. The same year Schanz and Stockhausen after experiments with human lens substance exposed to prismatic light, thought the incipient changes noted in old age might be dependent upon the absorption of ultraviolet rays over a long period of time. Later Schanz stated that the portions of the lens protected by the iris were CATARACT. 891 affected by the rays being reflected from one surface of the lens to another, and that in addition to chemical influences, absorption, reflection and diffusion were also factors. Burge, from his studies with the quartz-mercury vapor lamp, believes that in senile and diabetic cataract two factors are active; (a) a modification of the lens protein and (b) its coagulation by the short wave radiations. As to the dangers of ultraviolet rays from artificial light, Verhoeff, Bell and Walker have pointed out that a glass globe is sufficient to eliminate their danger. Inasmuch as certain types of cataract that may be regarded as industrial are prone to develop about middle age, these may be briefly commented on; I refer to those seen in bottle-mak- ers, blacksmiths, tinplate millmen, chain workers, etc. Light, heat, the ultraviolet and the infra-red rays have all been re- garded as factors either alone or in combination and despite considerable research, especially in England and Germany, the question is still an open one. It would seem that in recent years less emphasis has been placed upon the ultraviolet rays and more upon the infra-red and that heat is one of the possi- ble factors concerned. While diabetes as a cause of cataract has been well estab- lished, it is now generally conceded that it is only in young individuals that we can properly designate a cataract as de- finitely diabetic. In the later years it may be impossible to differentiate it from the ordinary senile type, so that cataract in association with diabetes is a preferable way to refer to it. The presence of sugar in the aqueous has been shown to be too small in amount, even in the presence of seven to eight per cent, of sugar in the urine, to act as a definite factor. Others have attributed it to the changes produced by diabetes in the retinal pigment layer of the iris which have been de- scribed by various observers. These changes may be indicated at the time of operation by seeing the anterior chamber flooded with an inky fluid at the time an iridectomy is done. This occurred with a patient I now have under observation and has been frequently noted by others. Some observers (Strieker, Botlazzie and Scalinci) have regarded it as due to an acidity of the aqueous, which is contrary to the findings of Burdon- Cooper, who believes it to be dependent upon hydrolysis of 892 DISEASES OF THE EYE. the lens and states that in diabetes cholesterin is present in excess of the tyrosin. Roemer believed the lens was injured by specific metabolic products, in other words, he regarded his cytotoxic theory as applicable to diabetic as well as senile cataract. Langdon has recently suggested that in certain cases of senile cataract a low sugar tolerance might be a causal factor. Symptoms. Senile cataract is generally bilateral and fre- quently one lens is affected more than the other. However, it is possible for one lens to become mature before changes de- velop in the other eye. The patient may complain of slight photophobia and lacrimation and there may be some vague discomfort but not infrequently these symptoms are absent. At times spots are noted in the field of vision and these may be descril>ed as appearing like flies or spiders and may be sufficiently distinct to be drawn. When directly looked at they do not disappear or shoot to one side of the field as do the spots due to muscse volitantes. Frequently one of the first symptoms is the gradual failure of vision. The cataractous changes may produce an irregular lenticular astigmatism and as the result a polyopia, monocular diplopia and some distortion of objects regarded may develop. In the early stages no changes can be noted in the pupillary area with the unaided eye, but as the opacification of the lens advances the pupillary area assumes a gray appearance or a yellowish or amber tint if the nucleus be much involved. The pupillary area does not give evidences of the presence of a black cataract to the unaided eye. With increasing opacifica- tion some swelling of the lens may occur with a resulting de- crease in the depth of the anterior chamber. This is sometimes designated as the stage of intumescence and may be associated with a rise of the intraocular tension and definite glaucomatous symptoms. In the absence of such signs and symptoms all cases of cataract should be examined with a dilated pupil. For this purpose cocaine, euphthalmin or eucatropin may be used, after which a miotic should be instilled. With the ophthalmo- scope and a -f- 7 D. or -(- 16 D. lens any opacity capable of intercepting the light rays will appear as a dark area sur- rounded by the red glare of the fundus reflex. Thus the in- cipient cortical cataract may show as black striae, sectors, CATARACT. 893 dots, or bar-like opacities, usually in the periphery and ex- tending toward the center of the lens. In the early stages the lower periphery is the portion most frequently affected. In nuclear cataract the red fundus reflex is clouded centrally, the extent and intensity of which depends upon the degree of involvement. In either instance as the process advances throughout the lens, the red fundus reflex becomes less evi- dent until finally it is obliterated by the extent of the opaci- fication. Every practitioner should have in his office a condensing lens and some type of loupe. The Berger loupe is convenient and cheap. These instruments are invaluable for foreign bodies, dermatologic as well as external ocular examinations. The examination by oblique illumination is invaluable in cases of cataract. The cornea, anterior chamber and iris can be well studied, and the opacities in the lens noted and their position determined. Just as the ophthalmoscope is the only method for definitely determining a Vossius ring-shaped opacity in the lens that frequently follows ocular trauma, just so a coerulean punctate cataract can be diagnosed with certainty only by oblique illumination. To employ this method a light is placed a foot or two to the side of the patient’s head, a beam of light is then focused on the eye by means of the lens which is held between the thumb and index finger, the little finger resting upon the cheek. The eye is then observed through the loupe which has been ad- justed to the head by an elastic or metal band. The other hand is free for manipulation of the upper lid should this be neces- sary. By this method the opacities in the lens appear gray in the otherwise black pupillary area. An immature cataract with some uninvolved cortex can be detected when the light is directed on the eye by the existence of a dark shadow which is adjacent to that portion of the pupillary margin which is nearest the light. This is caused by the shadow of the iris cast on, the deeper seated opacity. The observer standing in front of the eye sees as a dark crescentic area that portion of the shadow extending beyond the pupillary margin. When the cataract is mature, this shadow cannot be formed. Those opacities in the deeper portions of the lens can best be studied if the light be directed into the pupillary area more perpen- 894 DISEASES OF THE EYE. dicitlarly, that is, by having the light more directly in front of the patient. With the light so placed, membranous or large cloud-like opacities of one type or another can be detected even in the anterior portion of the vitreous, providing the media anterior to the vitreous be clear. While it is true that any opacity in the lens may be regarded as a cataract, it should be remembered that in many instances very delicate opacities may exist for years in the periphery of the lens and give rise to but little if any visual disturbance. Frequently the progress of these lenticular changes is most ir- regular, they may remain stationary for considerable periods of time and then take on a more or less rapid growth, only to lapse again in their progress. In the absence of symptoms and defective vision and in the presence of faint peripheral changes in the lens it seems to me just as unwise to alarm a patient by telling him he has a cataract as it is unwise not to tell him when he has evident symptoms and a definite reduction in visual acuity unimproved by glasses. It should be more thor- oughly understood, that of all the real serious intraocular conditions that may develop in the later years of life, provid- ing it is uncomplicated, cataract is one of the most favorable, despite its possible inconvenience, for it is capable of removal with the vast majority of chances in favor of a good result. When cataract is suspected or definitely known to exist, the patient should be seen by an ophthalmic surgeon as early as possible for it is important that he be familiar with the condition of the intraocular structures and extensive opacifi- cation of the lens prevents a study of the fundus. His pro- gnosis, method of operation and treatment during the interval would be influenced by the conditions found, for a cataract in the later years of life may be but symptomatic of other serious intraocular changes. To wait until the vision is practically lost and the opacity well advanced is often a detriment to both patient and surgeon. When so-called “second sight” develops late in life in a farsighted individual, it is not indicative of strong eyes as is so commonly thought by the laity, but of some pathologic condition affecting the ocular structures. The same state- ment may apply to myopic eyes, but not necessarily so. The GLAUCOMA. 895 condition most frequently encountered is a swelling of the lens due to cataractous changes. At times diabetes is capable of producing certain alterations in the media without visible evidences of cataract, that give rise to marked changes in the refraction, usually an increase in the amount of hyperopia. Wescott, Lundsgaard, Knapp, Zentmayer, Roberts and others have recorded such incidences. Whether the changes concern the lens or vitreous or possibly both is not definitely known, but it is probable that a lessen- ing of the refractive power of the lens is at least a factor. An acromegalic patient without intraocular changes, seen by me in conjunction with Dr. Stengel, developed glycosuria. About a month later he complained of poor vision with his glasses; examination showed that he had lost practically all of his myopia, 2 D. Four months later his refraction had returned to its original condition. Industrial types of cataract. The cataract occurring in bot- tle makers (Legge, Robinson) tin-plate millmen (Healy), chain-makers (Roberts), and puddlers (Cridland) is apt to develop about middle life. In the earlier stages the posterior cortical layers of the lens are most frequently involved. While the opacity is frequently seen as an irregularly disc shaped posterior central opacity, Healy in the tin-plate cases also frequently noted a wedge-shaped opacity with the base down or down and in, and in its growth it usually involved the pos- terior cortex. In the several cases I have seen in puddlers, the opacity has been of the posterior central irregular rosette type with a few delicate peripheral strise. Naturally as these cases advance and the anterior cortex becomes involved, any- thing that might be regarded as characteristic is lost. GLAUCOMA. Glaucoma is a disease of the eye which may manifest itself in several different types. Increased intraocular tension is the most important sign. If, as the result of the rise of tension and irrespective of its cause, the globe is much injected from overfilling of the external vessels, we speak of acute conges- tive glaucoma. When there is but slight overfilling of the vessels, either as a primary condition or persisting after the 896 DISEASES OF THE EYE. subsidence of more acute signs, it is regarded as the subacute congestive type. We also speak of a chronic, simple, or non- congestive type when certain signs and symptoms are pres- ent without external injection of the globe. Any of these varieties may develop into one of the other types during the course of the disease. When the condition develops without contributing factors, the result of previous ocular disease, it is regarded as primary. When a condition like a bound down iris promotes its onset it is designated as secondary. A juven- ile type developing in childhood also occurs, while a congen- ital type constituting the so-called buphthalmos or hydro- phthalmos is likewise recognized. Pathogenesis, Pathology and Causes. The aqueous humor consists of about 95 per cent, water with certain extractives, the sodium chloride being rather high, and a small amount of albumin. Its formation is attributed to the ciliary body, but there still remains some question as to the particular structures concerned in its production, as well as the method of its production, that is, whether by filtration or a true secre- tion. Recently Magitot has entirely excluded the ciliary body and regards it as a secretion of special neurologic cells. The aqueous passes from the ciliary body between the pos- terior surface of the iris and the lens, then through the pupil into the anterior chamber. Here it passes towards the angle of the chamber where it filters through the pectinate ligament into the Canal of Schlemm. Part also escapes through the pitted and spongy anterior surface of the iris. The intra- ocular pressure, maintained by the intraocular fluids, may be regarded as equivalent to about 25 mm. Hg, but just how this maintenance is accomplished and what factors chiefly are con- cerned in its disturbance still remains a problem which has not been definitely solved. The retention theory concerning the production of glau- coma depends upon the assumption that there has been some obstruction to the outflow of the intraocular fluids, either in the posterior portion of the globe or anteriorly, especially at the angle of the anterior chamber. Thus, Knies and Weber have pointed out that in glaucoma there occurs an adhesion of the base of the iris to the posterior surface of the cornea which covers in or shuts off the filtration angle. In certain GLAUCOMA. 897 instances this may be brought about by congestion and swell- ing of the ciliary body, in others by an increased size of the lens. It is a condition that develops sooner or later in prac- tically all cases of primary glaucoma. Others, such as Laqueur and Birnbacker and Czermak have emphasized the importance of obstruction of the filtration channels about the venae vorticosae. Interruption of the posterior channels in con- nection with the optic nerve has also been considered. Hen- derson’s studies have led him to believe that a sclerosis of the pectinate or cribriform ligament acts as a predisposing and causal factor. It will be recalled that this so-called ligament is merely a network of interlacing fibers, the continuation of the inner corneal fibers; they form the anterior boundary of the angle of the anterior chamber. Priestly Smith, who has contributed so much to this sub- ject, long ago emphasized the importance of the increased size of the lens due to its continued growth until late in life. As the result of this, the space between its margin and the ad- jacent structure—the so-called circumlental space—becomes much smaller. He has also pointed out that the changes in the lens from the same cause would tend to push the base of the iris forward against the posterior surface of the cornea. Some years ago Fischer expressed the belief that this disease was caused by an edema brought about by an acidosis affect- ing the tissue colloids. Alterations in the character of the aqueous as the result of changes in the ciliary body and the intraocular vessels have also been adequately considered. As aptly stated by de Schweinitz, no one theory can explain all cases of glaucoma, sometimes one factor and sometimes an- other is active in its production. Nettleship and Lawford have referred to a hereditary tendency that may be present and state that when this exists the disease may develop at an earlier age in succeeding generations. Age has a definite relation and after forty there is a de- cided increase in its frequency; about eighty-five per cent, of the cases develop after this period. It is more frequently seen in women. It is more common among the Jews, and Elliot includes the natives of India with the Egyptians as also predisposed to it. Lack of proportion between the size of the lens and the globe is also a factor and Priestly Smith also 898 DISEASES OF THE EYE. emphasized the importance of the small cornea in its relation to this condition. In those with acquired or inherited pre- disposition the instillation of mydriatics may set up an at- tack. Injuries and certain conditions such as influenza, neu- ralgia of the fifth nerve, herpes zoster and cardiac disease may act as exciting causes. Snellen was of the opinion that the overuse of ametropic eyes was also a factor. Finally, there are few surgeons who have not seen instances where sudden shocks, great anxiety or overwhelming emotions of one type or another have been the provocative cause of a glaucomatous attack. ACUTE CONGESTIVE GLAUCOMA. Usually this type of glaucoma is preceded by certain pro- dromal signs which may or may not have been severe enough to attract the serious attention of the patient. They are manifested by short periods of hazy vision, varying in its in- tensity and persisting from one to several hours; there may be some accompanying ocuilar or periorbital discomfort. When looking at distant lights it may be noted that these appear to be surrounded by a ring of prismatic colors, in which those corresponding to the short wave lengths, the violet or blue, are within, while red, representing the long waves, is without. Upon examination the pupil of the af- fected side may be found to be a trifle larger than its fellow and if condensed light be thrown upon the eye a faint haze of the cornea may be detected. A slight rise of the intra- ocular tension will be found by the use of the tonometer. Certain or all of these signs may recur at more or less fre- quent intervals for several months or more before the actual outburst of an acute attack. During this interval, owing to changes in the cornea or in the accommodation, the patients may desire changes in their glasses, especially for near work. All too frequently physicians are not consulted during one of these prodromal periods and the patient is first seen after the outburst of a frank acute attack, which may be unilateral or bilateral. This is apt to occur sometime during the night and is ushered in by severe pain in the head and about the eye, at times so intense that nausea and vomiting may occur. A rapidly increasing failure of vision is now noted. At the GLAUCOMA. 899 height of a severe attack examination would show more or less swelling of the lids, the conjunctival and episcleral ves- sels much injected and this may be associated with some chemosis. The cornea is distinctly hazy, and more or less anesthetic; the anterior chamber shallow; the pupil dilated, frequently oval and reacts to light but slightly, if at all. The iris may appear discolored. When tested by the finger tips, the intraocular tension will be found to be markedly increased. The tenderness of the globe and the swelling of the lids, if this be present, may make it difficult for untrained fingers to elicit this rise of tension despite the fact that it is quite marked. Owing to the haziness of the media no satisfactory study can be made of the fundus, but if this were possible no cupping of the disc would be found during the first attack. Even a rough test will reveal a contraction in the visual field, the nasal portion being more involved. Depending upon the severity of the outburst, these signs and symptoms gradually subside although to the trained examiner some evidences of the past attack usually can be detected by the distention of the episcleral vessels; the slightly dilated pupil, which is often oval and less responsive to light; some impairment in the field of vision and persistence of the tension, to a greater or less degree. In certain cases the return of vision is astonish- ingly satisfactory but as a rule some impairment persists. The eye may remain in this condition for a variable period, but is liable to slight or severe exacerbations at any time. Eack attack still further lessens the functional integrity of the globe. It is during this period that the characteristic fundus changes develop, such as the cupping or excavation of the head of the optic nerve, which is frequently surrounded by a narrow zone of choroidal atrophy; with this there may be pulsation of the retinal arteries. Should the acute attack develop in the course of a chronic or non-congestive type of glaucoma, these fundus manifestations may be present dur- ing the first acute outbreak although the clouded media would prevent their observation with the ophthalmoscope. Sooner or later, if the progress of the disease continues, the stage of absolute glaucoma sets in, during which period degenerative changes in all the ocular structures develop. There is some injection of the globe, chiefly of the episcleral 900 DISEASES OF THE EYE. vessels; the cornea is distinctly hazy and may exhibit various degenerative manifestations. The anterior chamber is shal- low, the pupil dilated and fixed, the iris atrophic and apt to be plastered against the cornea at its periphery. The lens is cat- aractous and the tension is raised to the maximum. During this stage, the patient is apt to have attacks of pain, either de- pendent upon the primary process or upon degenerative cor- neal changes. As the condition persists evidences of staphy- lomata may appear owing to thinning of the sclera. Even- tually, if the patient does not seek relief by having the eye enucleated, atrophy of the globe sets in as the result of marked destructive changes produced in the intraocular structures. SUBACUTE CONGESTIVE GLAUCOMA. This type of the disease may result from either of the other two types as stated above. In turn it may be accompanied by acute exacerbations. The symptoms are essentially the same as those enumerated above but of less intensity. If not checked it shows the same progressive tendencies. CHRONIC NON-CONGESTIVE GLAUCOMA. (Simple Glaucoma.) This is invariably a bilateral manifestation although one eye may be affected before the other. As its name implies it is not associated with any external congestive signs such as accompanies the other forms, although slight overfilling and tortuosity of the episcleral vessels at times can be noted. As the border line between this and the subacute congestive type is not always sharply defined, a few observers have regarded this type as an optic atrophy with excavation. The onset is gradual and so insidious that it may be present for months without attracting the patient’s attention. Even in the presence of definite intraocular changes such eyes may show a clear cornea, anterior chamber of average depth and no iris or pupillary changes that could be regarded as charac- teristic. Finger tension may be normal and even the tono- metric findings may be within normal limits at the time of coming under observation. On the other hand careful exam- ination may detect a suspicious lack of corneal transparency, GLAUCOMA. 901 and a rise of tension does occur although it may be periodic, and this applies to different times of the same day just as it may apply to different days. As to the subjective symptoms, there is no pain and the patient may have standard vision. At times a history of temporarily disturbed vision may be obtained. If the con- dition has persisted for some time, the central vision may still remain unusually good, although at times associated with a certain amount of haziness, but there will be found definite changes in the peripheral vision. These changes usually af- fect the nasal field in the sense of a partial or complete loss, or more rarely, there may be a concentric contraction. With this small blind areas, or scotomata, are frequently present about the central part of the field, such as have been described by Bjerrum and Seidel; these are continuous with the physio- logic blind spot. Ronne’s sign or “step” may be found in certain instances. Sooner or later the central vision becomes impaired, but at no time can it be safely used as an index to the progress of the disease. This fact should be thoroughly understood. The definite diagnosis of this type is dependent upon the use of the ophthalmoscope. Here, in the absence of conges- tive signs, all the media are clear and from the onset the fundus structures can be readily seen, providing there are no associated anomalies to prevent. In a well established case there will be no difficulty in seeing the deep complete cup that extends to the margin of the nerve head, which in turn may be surrounded by the so-called halo. This cupping is associated with a sharp bending of the retinal vessels where they dip into or pass over the margin of the excavation. In certain instances pulsation of the retinal arteries can be seen. Diagnosis. Owing to the progressively destructive char- acter of this disease and the rapidity of its progress in certain acute cases, an early diagnosis is of the utmost importance. Glaucoma is not infrequently mistaken for certain other con- ditions where severe periorbital pain may occur, such as tri- geminal neuralgia and ophthalmic migraine. The confusing of acute glaucoma and acute iritis leads to the most serious con- sequences and not infrequently to the ultimate loss of the eye. It is the differential diagnosis with which every general 902 DISEASES OF THE EYE. practitioner should be familiar. Here the history of prodromal symptoms should be of service and the shallow chamber, dil- ated pupil and plus tension of glaucoma stands in contrast to the anterior chamber of normal depth, the contracted pupil and tendency to the formation of posterior synechiae as seen in iritis. Almost as serious is the mistaking of a chronic glaucoma for cataract. Here a glance with the ophthalmo- scope would prevent the gradually failing vision and greenish reflex from the lens being attributed to advancing cataractous changes. When in doubt as to the existence of glaucoma, the practitioner would do well to seek at once the best advice available. In certain cases the differentiation between optic atrophy and chronic glaucoma requires careful and painstak- ing investigation. The history, careful perimetric examina- tions, the use of the tonometer, and the study of the light sense are of value. Almost invariably an operation is, sooner or later, the best treatment for glaucoma; as a consequence the patient should be seen by an ophthalmic surgeon as early as possible. Treatment. If the condition is recognized in the prodromal period the use of pilocarpin hydrochlorate or eserin sulphate should be resorted to immediately and continued indefinitely. Three conditions must be considered at once when con- fronted by an acute attack: First, the advisability of an im- mediate consultation with an ophthalmic surgeon, for acute glaucoma is to ophthalmology what acute appendicitis is to medicine. Second, the opening up of the anterior filtration channels of the eye. Third, the relief of pain. As to the first, the patient should be seen as soon as possible by an ophthal- mic surgeon and the responsibility for the time and choice of operation should be placed in his hands. For the second, eserin, grains 2 to 4 to the ounce, should be used every hour until the pupil is well contracted. This opens up the filtration area in the angle of the anterior chamber and gives a greater expanse of spongy iris tissue; each contributes to better filtra- tion of the aqueous. With the pupils contracted the fre- quency of the instillations may be reduced, for considerable brow pain is apt to follow the frequent instillations of these stronger solutions. A drop two or three times a day as an initial routine is inadequate. For the third condition, the GLAUCOMA. 903 pain, the frequent use of hot fomentations will be of service, but the use of morphine is justifiable, for the pain is usually intense and in severity comparable to a renal or hepatic colic. Later, sodium salicylate in 15 to 20 grain doses three to four times a day will usually prove efficient. The condition is essentially a surgical one and the physician in general practice should not assume *the responsibility for delay, if this can be avoided. In the chronic, non-congestive type, certain cases do well for varying periods of time under the use of miotics. For this purpose weak solutions of pilocarpin or eserin should be used, but in sufficient strength to maintain miosis. With de Schweinitz, I believe pilocarpin is preferable at first, for it can be maintained over a longer period of time without producing conjunctival irritation. Eserin gr. %0 to gr. %, or pilocarpin gr. to the ounce, may be a sufficient initial strength. This should be instilled three to four times a day, the last drop to be used before the patient goes to bed. Small quantities should be prescribed as fresh solutions are desirable. Needless to say, many factors are to be considered when reliance is to be placed on miotics and in certain cases im- mediate operation is desirable. For this reason it may be said that all types of glaucoma should come under the earli- est possible surgical surveillance and what is of almost equal importance, should remain so. While many underlying fac- tors in this disease are still unknown, individuals affected should be regarded as sick patients rather than patients with sick eyes, and should be treated as such. The discussion of operative treatment is not particularly pertinent, but I prefer iridectomy in acute glaucoma; while in the chronic type iridectomy and the Elliot trephining opera- tion have been most frequently employed. In certain glau- comatous conditions cyclodialysis has been of service. Aside from the Elliot operation certain other filtering procedures have given satisfactory results, such as the operations of Fer- gus, Herbert, Lagrange and Holth. Harrower and others have obtained good results from iridotasis. INDEX Alcoholism, 579 acute alcoholic hallucinosis, 582 alcoholic pseudoparanoia, 582 alcoholic pseudoparesis, 582 delirium tremens, 581 Korsakow’s psychosis, 581 Arthritis, 611 acute infectious, 614 in erysipelas, 617 in influenza, 617 in measles, 618 in pneumonia, 615 in puerperal sepsis, 618 in pyemia, 617 in scarlet fever, 615 in smallpox, 617 in typhoid fever, 616 in typhus fever, 617 chronic infectious polyarthritis, 634 diagnosis, 652 from acute rheumatic fever, 652 etiology, 635 age, 635 bacteria, 638 diplococcus, Poynton and Paine, 640 streptococcus pyogenes, 642 climate, 636 focal infection, 643 heredity, 636 hygiene, 637 nutrition, 637 occupation, 636 sex, 636 pathology, 646 symptomatology, 648 treatment, 654 general management, 656 Arthritis, chronic infectious poly- arthritis, treatment, acute, 660 diet, 659 focal infection removal, 658 physiotherapy, 662 protein shock, 663 medical, 664 prophylaxis, 655 deformans, 650 classification, 613 gonorrheal, 665 bacteriology, 666 diagnosis, 669 pathology, 666 symptoms, 667 treatment, 670 rheumatic fever, acute, 618 complications, 626 diagnosis, 627 etiology, 619 incidence, 619 morbid anatomy, 622 prognosis, 627 symptoms, 625 treatment, 628 active, 629 diet, 633 medication, 630 prophylaxis, 628 syphilitic, 674 classification, 675 diagnosis, 676 introduction, 674 pathology, 676 symptomatology, 676 treatment, 679 tuberculous, 679 diagnosis, 682 introduction, 679 pathology, 680 906 INDEX Arthritis, tuberculous, symptoms, 681 treatment, 683 villous, 652 Blood, diseases of, 837 anemia, aplastic, 853 causes, 853 symptoms, 854 secondary, 841 acute, secondary, 841 blood picture, 841 etiology, 841 signs, 843 symptoms, 842 treatment, 843 chronic secondary, 845 classification, 839 hemorrhagic diathesis due to hypertension, 846 symptoms, 846 treatment, 847 leukemia, 854 general consideration of, 854 lymphatic, acute, 861 chronic, 859 blood picture, 860 clinical features, 859 myelogenous, acute, 860 myelogenous, chronic, 856 basal metabolism. 858 blood picture, 858 blood-pressure change, 859 clinical features, 857 treatment, 861 acute, 864 arsenic, 862 benzol, 863 radium, 862 splenectomy, 864 X-ray, 862 normal red blood-cell count, 837 factors influencing, 839 normal white blood-cell count, 838 factors influencing, 839 Blood, pernicious anemia, progres- sive, 847 blood picture, 847 blood-pressure change, 849 course, 850 laboratory findings, 849 physical signs, 848 treatment, 850 blood transfusion, 851 medicinal, 850 splenectomy, 853 vibratory sensation in bones, 849 purpura hemorrhagica, 868 symptoms, 869 treatment, 870 polycythemia with splenome- galy, 865 blood picture, 867 pathology, 868 signs, 866 symptoms, 866 treatment, 868 Cerebral disorders, 541 aphasia, 550 motor, 551 pathology, 550 prognosis, 551 sensory, 551 auditory, 551 visual, 551 apoplexy, 547 cerebral hemorrhage, 548 embolism, 548 signs, 549 thrombosis, 548 treatment, 550 chorea, hereditary, 578 confusion, 557 delirium, 555 hypochondria, 559 encephalitis, epidemic, 54 acute psychotic, 546 cataleptic, 546 lethargic, 545 meningitic, 546 myelitic, 546 INDEX. 907 Cerebral encephalitis, epidemic paralysis agitans, 546 polioencephalitic, 545 polyneuritic, 546 symptoms, 543 of established disease, 543 prodromal, 543 treatment, 547 manic depressive psychosis, 561 acute mania, 562 depressive period, 563 hypermania, 562 involutional melancholia, 564 treatment, 565 paranoia, 565 age, 566 course, 566 expansive, 569 prodromal, 566 persecutory, 567 pseudo-demented, 568 diagnosis, 570 erotic, 570 paranoid states, 571 periodic, 569 treatment, 570 pregnancy psychoses, 573 insanity, 574 during labor, 575 during lactation, 575 during pregnancy, 574 postpartum, 575 treatment, 576 stupor, 558 toxic psychoses, 576 carbonbisulphide poison, 577 carbonmonoxide poisoning, 577 pellagra, 576 tumor, 522 diagnosis, 555 prognosis, 555 sites of, 553-555 Cerebral tumor, symptoms, 552 treatment, 555 Drug addictions, 583 caffeinism, 587 effects of, 588 cocainism, 585 chronic, 587 symptoms, 586 morphinism, 583 incidence, 583 symptoms, 584 treatment, 584 nicotinism, 589 smokers’ heart, 589 snuff, 590 Endocrinopathies, 595 climacteric, 608 eunuchoidism, 607 ovarian, 607 hyperovarianism, 607 hypoovarianism, 607 parathyroid, 601 pineal, 605 pituitary, 604 acromegaly, 604 hypopituitarism, 605 suprarenal, 602 hyperfunction, 603 hypofunction, 603 treatment, 603 sympatheticotonia, 595 testicular, 606 thyroid, 596 hyperthyroidism, 598 symptoms, 600 treatment, 601 hypothyroidism, 596 vagatonia, 595 Eye, diseases of, 873 cataract, 886 diagnosis, 893 etiology, 886 Becker’s theory, 887 Burdon-Cooper’s theory, 889 908 INDEX Eye, cataract, etiology, diabetes, 891 endocrines, 890 hyperopia, 888 light rays, 890 nephritis, 888 Peters’ theory, 889 Roemer’s theory, 889 industrial, 895 second sight, 894 symptoms, 892 glaucoma, 895 acute congestive, 898 course, 899 symptoms, 898 prodromal, 898 treatment, 902 chronic non-congestive, 900 diagnosis, 901 onset, 900 symptoms, 901 treatment, 903 etiology, 896 pathogenesis, 897 pathology, 897 treatment, 902 foreword, 873 presbyopia, 874 accommodation, classifica- tion, 877 failure, 876 early signs, 875 near point, 876 treatment, 878 retinal vascular changes, 879 arteriosclerosis with hyper- tension, 881 arteriosclerotic retinitis, 882 perivasculitis, 882 blood-pressure, central ret- inal artery, 885 diabetic retinitis, 884 classifications, 884 lipemia retinalis, 885 hyperpiesia, 881 renal disease, 883 retinal appearance, 883 Gall-bladder disease, 248 cholecystitis, acute, 248 cholecystitis, acute, catar- rhal, 250 diagnosis, 251 pathology, 250 prognosis, 251 symptoms, 251 treatment, 251 cholecystitis acute phleg- monous, 253 diagnosis, 254 gangrene, 254 pathology, 253 prognosis, 253 treatment, 254 prophylactic, 254 chronic, 255 diagnosis, 256 pathology, 255 symptoms, 255 treatment, 256 suppurative, 252 cholelithiasis, 256 diagnosis, 2 etiology, 257 pathology, 259 symptoms, 261 colic, 262 diagnosis, 262 treatment, 263 tumors, 265 carcinoma, 265 diagnosis, 266 treatment, 266 Gastric disturbances, 3 achylia gastrica, 30, 91 etiology, 30, 91 symptoms, 31, 92 treatment, 31, 92 varieties, 30 anorexia in, 90 symptoms, 90 treatment, 91 arteriosclerosis of stomach, 96 diagnosis of, 100 etiology, 97 INDEX. 909 Gall-bladder, gastric disturbances, arteriosclerosis of stomach path- ology, 97 symptoms, 97 abdominal angina, 98 dyspepsia, 97 ulcer, 97 treatment, 100 types of, 96 atony, gastric, 88 symptoms, 89 treatment, 90 types of, 89 bulimia, 81 symptoms, 81 treatment, 82 cancer, 40 complications, 46 diagnosis of, 50 Abderhalden test, 52 blood sugar tolerance, 52 secretory change, 50 Wolf-Junghans test, 50 X-ray, 51 etiology, 42 cardiovascular changes, 44 digestive disorders, 43 heredity, 42 infectious disease, 44 trauma, 43 incidence of, 41 pathology of, 44 adenocarcinoma, 45 colloid carcinoma, 45 medullary carcinoma, 45 scirrhous carcinoma, 45 symptoms, 46 anorexia, 47 ascites, 49 dilatation, 49 dysphagia, 48 edema of extremities, 49 hematemesis, 48 loss of flesh, 47 melena, 48 pain, 47 palpable tumor, 49 Gall-bladder, cancer, symptoms, vomiting, 49 treatment, 54 cardiospasm, 72 diagnosis, 73 symptoms, 73 treatment, 73 dilatation, gastric, 55 acute, 58 etiology, 56 forms of, 55 symptoms, 56 treatment, 57 eructatus nervosa, 77 etiology, 4 arteriosclerosis, 7 degenerative changes, 6 dietary indiscretions, 12 diseases of other organs, 11 endocrine disorders, 13 chromaffin system, 17 interrenal gland, 17 parathyroids, 16 pituitary, 16 pyloric glands, 17 thyroid, 16 focal infections, 4 infectious disease, 6 nervous disorders, 13 autonomic imbalance, 13 vagatonia, 13 syphilis, 9 endarteritis, 10 gastritis chronic, 10 gummata, 9 gastralgia nervosa 79 symptoms, 79 treatment, 80 types of, 79 gastritis, acute, 23 etiology, 24 pathology, 24 symptoms, 24 treatment, 25 atrophic (see Achylia), chronic, 27 etiology, 27 pathology, 27 910 INDEX Gall-bladder, gastritis, chronic, prognosis, 29 symptoms, 28 membranous, 27 phlegmonous, 26 etiology, 26 pathology, 26 symptomatology, 26 treatment, 26 toxic, 25 etiology, 25 pathology, 25 symptomatology, 25 treatment, 25 gastroptosis, 58 diagnosis of, 60 etiology, 59 symptomatology, 59 treatment, 60 •gastrosuccorrhea, 85 continua chronica, 82 continua periodica, 85 digestive, 88 symptoms, 86 treatment, 87 hyperesthesia gastrica, 80 symptoms, 80 treatment, 80 hyperchlorhydria, 82 etiology, 83 symptoms, 83 treatment, 84 hypochlorhydria, 94 diagnosis, 94 treatment, 94 merycism, 78 motility in, 19 nervous dyspepsia, 94 diagnosis, 95 symptoms, 95 treatment, 95 nervous gastric affections, 69 classification, 72 vagatonia, 72 sympathetonia, 72 diagnosis, 70 prognosis, 71 symptoms, 69 Gall-bladder, pneumatosis, 75 treatment, 76 pylorospasm, 74 symptoms, 74 treatment, 75 secondary gastric affections, 63 in acute febrile diseases, 64 in gall-bladder disease, 64 in heart disease, 66 in intestinal disease, 64 in liver disease, 64 in metabolic diseases, 68 in pancreatic disease, 65 in nervous disorders, 68 in pulmonary disease, 67 in renal disease, 65 secretory, 19 tests for, 52 Abderhalden, 52 blood sugar tolerance, 52 occult blood, 54 Wolf-Junghans reaction, 53 ulcer, 32 complications, 37 diagnosis, 35 etiology, 33 pathology, 33 symptoms, 34 treatment, 37 medicinal, 38 surgical, 39 vomiting, nervous, 76 characteristics, 76 prognosis, 76 treatment, 77 Genitourinary diseases, male, 289 balanitis, 289 symptoms, 289 treatment, 290 balanoposthitis, 289 bladder disease, 311 atony, 312 calculus, 332 diagnosis, 333 symptoms, 332 treatment, 333 INDEX 911 Genitourinary diseases, male, blad der capacity, 311 diverticulum, 313 diverticulitis, 313 hypertrophy, 312 inflammation, 315 diagnosis, 316 etiology, 315 symptoms, 316 treatment, 316 chancroid, 358 etiology, 359 prognosis, 359 treatment, 359 epididymitis, 301 diagnosis, 302 etiology, 301 pathology, 301 treatment, 302 palliative, 302 prophylactic, 302 operative, 303 herpes progenitalis, 290 hydrocele, 350 acute, 350 chronic, 350 treatment, 351 kidney disease, 319 calculus, 325 diagnosis, 327 formation, 325 prognosis, 328 symptoms, 326 treatment, 328 operative, 329 hydronephrosis, 324 pyelitis, 319 chronic, 321 diagnosis, 322 symptoms, 322 treatment, 322 diagnosis, 320 etiology, 319 in pregnancy, 320 symptoms, 319 treatment, 320 pyelonephritis, 323 symptoms, 324 Genitourinary diseases, male, kid- ney diseases of, pyelonephritis, treatment 324 pyonephrosis, 322 pathology, 323 treatment, 323 tuberculosis, 344 malformations, 348 diverticula, 349 epispadias, 350 exstrophy, 349 hypospadias, 350 undescended testicle, 349 movable kidney, 348 penitis, 290 prostatic disease, 304 prostatitis, 305 acute, 305 abscess, 306 prognosis, 306 symptoms, 306 treatment, 306 chronic, 307 diagnosis, 308 etiology, 307 prognosis, 311 symptoms, 307 general, 308 genital, 308 urinary, 308 treatment, 309 tuberculous, 347 treatment, 347 seminal vesiculitis, 303 syphilis, 352 autopsy findings, 352 chancre, 355 incidence of, 352 morbidity, 353 pathology, 354 treatment, 356 ureteral disease, 317 anatomy of ureter, 317 calculus, 329 diagnosis, 330 treatment, 331 ureteritis, 318 stricture, 318 912 INDEX Genitourinary diseases, male, ure teral diseases, ureteritis, prog nosis, 318 treatment, 318 urethral disease, 291 acute non-specific, 291 acute specific, 291 treatment, 292 diet, 293 general, 293 local, 293 arthritis, gonorrheal, 296 stricture, 296 acquired, 296 classification, 297 diagnosis, 298 symptoms, 299 treatment, 299 urinary fever, 301 varicocele, 351 tuberculosis, 345 tumors, 335 bladder, 337 carcinoma, 339 papillomata, 338 diagnosis, 338 prognosis, 338 treatment, 338 operative, 340 kidney, 335 benign, 335 malignant, 335 hypernephroma, 336 symptoms, 336 penis, 343 condylomata, 343 epithelioma, 343 treatment, 343 prostate, 340 testicle, 341 diagnosis, 341 teratoma, 341 treatment, 341 Gout, 689 diagnosis, 720 etiology, 697 exciting causes, 702 Llewellyn’s postulates, 695 Gout, etiology of, predisposing causes, 697 age, 699 alcohol, 698 excessive food ingestion, 698 heredity, 697 lack of exercise, 698 lead, 700 occupation, 701 sex, 699 traumatism, 701 geographical distribution, 695 historical facts, 689 incidence, 696 pathology, 705 blood, 705 Garrod’s thread test, 705 uric acid, 706 cardiovascular lesions, 712 aortitis, 713 eye complications, 714 cataract, 714 iritis, 714 kidney complications, 711 nervous manifestations,- 715 respiratory system, 713 emphysema, 713 larynx, 713 tophi, 707 composition, 708 immature, 709 mature, 709 site, 710 urinary disorders, 715 prognosis, 722 symptoms, 716 acute, 716 chronic, 717 irregular, 719 retrocedent, 719 treatment, 723 acute, 725 diet, 728 medicinal, 726 chronic, 730 diet, 730 medicinal, 731 INDEX 913 Gout, treatment, chronic, local, 731 prophylaxis, 723 tophic, 732 Gynecological diseases, 363 child-birth injuries, 375 cervical laceration, 376 perineal laceration, 377 symptoms, 377 treatment, 378 operative, 378 esthiomene, 370 treatment, 371 extrauterine gestation, 395 anatomical classification, 395 differential diagnosis, 399 etiology, 3% prognosis, 403 symptoms, 396 terminations, 403 treatment, 400 inflammatory infections, 386 endometritis, 387 acute, 387 treatment, 388 chronic, 389 symptoms, 389 treatment, 389 Fallopian tubes, inflamma- tion of, 390 acute, 391 symptoms, 391 treatment, 391 chronic, 392 treatment, 393 etiology, 390 ovaritis, 393 acute, 394 symptoms, 394 treatment, 394 chronic, 395 malignant disease, 404 carcinoma, ovaries, 421 symptoms, 422 types, 421 carcinoma, uterus, 406 cervical, 406 Gynecological diseases, malignant disease, carcinoma, uterus, cer- vical, etiology, 406 histology, 410 local signs, 409 pathology, 407 symptoms, 408 treatment, 411 inoperable, 414 uterine artery liga- tion, 415 operable, 412 Fallopian tubes, 425 symptoms, 421 fundus, 416 pathology, 416 prognosis, 418 symptoms, 417 treatment, 418 chorioepithelioma, 418 etiology, 418 histology, 419 pathology, 419 prognosis, 420 symptoms, 420 sarcoma, 422 Fallopian tubes, 420 ovaries, 425 symptofns, 425 treatment, 425 uterus, 424 diagnosis, 424 symptoms, 424 vaginal, 423 menopause, 363 causes, 364 symptoms, 364 treatment, 365 pruritis vulvse, 369 diagnosis, 369 treatment, 369 tuberculosis vulvae, 371 tumours of vulva, 372 carcinoma, 374 cysts, 374 elephantiasis, 372 fibroma, 373 sarcoma, 373 914 INDEX Gynecological diseases, uterine fibroids, 426 classification, 426 complications, 432 diagnosis, 431 degeneration, 432 signs, 430 symptoms, 428 treatment, 434 operative, 436-442 polyps, 436 radium, 435 X-ray, 435 submucous growths, 437 uterine displacement, 381 posterior, 381 etiology, 381 symptoms, 384 treatment, 382 general, 382 prolapsis uteri, 383 classification, 383 local signs, 384 symptoms, 384 treatment, 384 local, 385 operative, 385 uterine hemorrhage, 366 Hepatitis, chronic, interstitial, 183 biliary, 196 etiology, 196 pathology, 197 prognosis, 198 symptoms, 197 treatment, 199 portal, 184 diagnosis, 191 etiology, 184 pathology, 185 prognosis, 192 physical signs, 188 symptoms, 186 hematemesis, 187 jaundice, 187 toxic, 187 treatment, 193 Hepatitis, portal, treatment, diet, 193 medicinal, 194 operative, 196 Intestinal diseases, 105 constipation, 105 diagnosis, 110 etiology, 106 defecation position, 107 diet, 107 functional intestinal dis- turbance, 108 habits, 106 rectal conditions, 110 atony, 110 valvular hypertrophy, 110 senility, 109 spastic colitis, 108 stomach conditions, 109 treatment, 110 diet, 111 agar-agar, 113 bran, 112 yeast, 113 dilatation, 115 electricity, 114 enemata, 115 . exercise, 114 massage, 114 medication, 115 suppositories, 115 surgery, 116 diarrhea, 118 ulcerative processes, infec- tive, 125 bacillary dysentery, 131 etiology, 132 pathology, 134 symptoms, 134 treatment, 136 cholera Asiatica, 139 diagnosis, 140 etiology, 139 symptoms, 140 treatment, 141 INDEX. 915 Intestinal diarrhea, cholera Asia- tica, influenza, gastrointestinal, 141 symptoms, 141 treatment, 141 sprue, 129 diagnosis, 130 etiology, 129 symptoms, 129 treatment, 131 syphilitic ulcers, 128 symptoms, 128 treatment, 129 tuberculous enteritis, 125 diagnosis, 126 symptoms, 126 treatment, 127 ulcerative processes, in- flammatory, catarrhal, 120 decubital ulcers, 122 follicular ulcers, 121 polypoid colitis, 121 simple ulcerative colitis, 121 stercoral ulcers, 122 symptoms, 122 treatment, 122 ulcerative processes, ne- crotic, 178 amyloid ulcers, 119 duodenal ulcer from body burns, 119 embolic ulcers, 119 symptoms, 120 treatment, 120 toxemia, chronic, excessive intestinal, 142 bacterial metabolism and foods, 149 classification, 147 etiology, 143 pathology, 144 symptoms, 150 adhesions, 159 anemia, 151 anorexia, 151 appendicitis chronic, 158 Intestinal toxemia, chronic, symp- toms, arthritis, 156 atony, 157 colitis, chronic, 158 eye changes, 154 fatigue, 150 gall-bladder disease, 159 hyperacidity, 156 hyperesthesia, gastrica, 151 ileal stasis, 157 insomnia, 152 megacecum, 158 mental disorders, 154 myocarditis, 155 nervous phenomena, 153 ptosis, 153 pyloritis, 157 treatment, 160 antisepsis, intestinal, 161 diet, 167 diet lists, 169 general rules, 170 high protein, 174 exercise, 164 hydrotherapy, 163 irrigations, 165 colonic, 165, 166 intestinal, 165 medicinal, 162 surgical, 182 vaccines, 172 autogenous:, colonic, 174 reasons for, 176 results of, 178 types of, 179 . bacterial antagonism methods, 181 vaccine immunity methods, 180 water drinking, 166 Liver, diseases of, 205 abscess, 218 amebic, 220 diagnosis, 222 etiology, 218 916 INDEX Liver, jaundice, Weil’s disease, treatment, 241 perihepatitis, acute, 213 pathology, 214 symptoms, 214 treatment, 214 chronic hyperplastic, 215 diagnosis, 216 pathology, 215 symptoms, 215 treatment, 216 syphilis, 227 acquired, 227 congenital, 227 symptoms, 228 treatment, 228 tuberculosis, 229 pathology, 229 symptoms, 229 types, 229 treatment, 230 tumors, 230 carcinoma, 230 diagnosis, 234 primary, 231 pathology, 231 symptoms, 231 secondary, 230 pathology, 231 treatment, 234 hypernephroma, 235 melano sarcoma, 235 sarcoma, 235 yellow atrophy, acute, 227 pathology, 223 symptoms, 224 treatment, 226 Nervous system, diseases of, 453 cervical rib in, 505 drowsiness, excessive, 478 dreams, 479 epilepsy, 467 complications, 469 symptoms, 468 treatment, 470 fibrositis, 470 etiology, 471 Liver, abscess, pathology, 219 primary, 218 secondary, 218 symptoms, 220 treatment, 222 tropical, 220 cholangitis, acute catarrhal, 241 pathology, 242 symptoms, 242 treatment, 243 acute suppurative, 246 pathology, 246 symptoms, 247 treatment, 247 chronic catarrhal, 244 pathology, 244 symptoms, 244 treatment, 245 cirrhosis—see Hepatitis inter- stitial congestion, 208 active, 209 symptoms, 210 treatment, 210 passive, 211 pathology, 211 symptoms, 212 treatment, 212 degenerative conditions, 217 amyloid, 217 fatty, 217 ecchinococcus cyst, 235 pathology, 235 symptoms, 237 jaundice, 205 epidemic infectious, 238 hemolytic, 207 acquired, 207 hereditary, 208 obstructive, 205 toxic, 207 Weil’s disease, 238 diagnosis, 241 etiology, 238 pathology, 238 prognosis, 241 symptoms, 240 INDEX, 917 Nervous system, diseases of, mul- tiple neuritis, treatment, 504 sciatica, 500 causes, 500 symptoms, 500 treatment, 501 paralysis agitans, 482 diagnosis, 483 etiology, 482 symptoms, 482 treatment, 483 paralysis, 494 external popliteal, 499 facial, 494 etiology, 494 symptoms, 496 treatment, 497 internal popliteal, 499 musculospiral, 497 median, 498 sciatic, 499 ulnar, 498 peripheral nerve disease, 488 brachial, 491 cervico, occipital neuralgia, 491 coccygodynia, 493 crural, 493 intercostal, 492 testicular, 492 traumatic, 494 psychasthenia, 460 symptoms, 460 treatment, 461 rabies, 485 etiology, 485 symptoms, 485 treatment, 485 somnolentia, 480 somnambulism, 480 sunstroke, 486 heat cramps, 488 heat prostration, 487 hyperpyrexia, 487 hypopyrexia, 487 syphilis, 529 cerebral, 539 cerebral meningitis, 538 Nervous system, diseases of, fibro- sitis, signs, 471 treatment, 472 headache, 472 induration, 473 migraine, 474 syphilitic, 474 herpes zoster, 504 pathology, 504 treatment, 505 hysteria, 461 convulsions., 464 differential diagnosis, 466 etiology, 462 symptoms, 463 treatment, 467 insomnia, 477 multiple cerebrospinal scler- osis, 480 diagnosis, 482 etiology, 480 symptoms, 481 muscular dystrophy, 505 arthritic muscular atrophy, 506 myasthenia gravis, 507 symptoms, 507 treatment, 508 progressive bulbar paraly- sis, 508 muscular atrophy, 505 neuritic muscular atro- phy, 506 narcolepsy, 480 neurasthenia, 455 diagnosis, 458 forms of, 456 sexual, 457 symptoms, 456 treatment, 459 neuritis, 500 multiple neuritis, 502 alcoholic, 502 arsenical, 503 diphtheria, 503 etiology, 502 lead, 503 pregnancy, 504 918 INDEX Nervous system, diseases of, syph- ilis, paresis, 535 diagnosis, 532 symptoms, 536 treatment, 540 spinal fluid in, 530 spinal meningitis, 539 tabes dorsalis, 531 diagnosis, 533 symptoms, 532 treatment, 534 tetanus, 484 trance, 480 vertigo, 476 aural, 476 visual, 477 Obesity, 735 circulatory disorders in. 780 diabetes mellitus and, 742 extreme obesity, instances of, 747 fat formation, 737 alcohol in, 739 climate in, 739 endocrine influence. 740 racial tendencies, 740 seasonal influence, 739 life expectancy in, 744 mortality surface chart, 746 tables of, 745 metabolism in, 752 thyroid influence, 753 mortality in, 744 standard weight in, 744 treatment, 751 class treatment of over- weight, 772 calisthenics, 772 daily diet, 773 low caloric diet, 776 weekly diet, 777 dietetic, 766 caloric table, 769 food requirements, 766 exercise, 785 hydrotherapy, 786 dangers of, 786 Obesity, treatment, 788 regime, 788 spas, 789 weight chart, 791 mechanical and electrical de- vices, 782 Bergonie method, 782 Morse wave, 783 Titus method, 782 popular reduction cures, 759 Fletcher method, 762 Salsbury method, 760 prophylactic, 751 reduction for surgery, 771 water, 764 retention, 764 thyroid effect, 764 Pancreas, diseases of, 266 pancreatic hemorrhage, 271 pancreatitis, acute, 266 hemorrhagic, 266 pathology, 267 symptoms, 268 suppurative, 269 differential diagnosis, 270 pathology, 270 symptoms, 270 treatment, 271 chronic interstitial, 271 pathology, 273 symptoms, 273 treatment, 274 azotorrhea, 276 dietary, 276 medicinal, 278 steatorrhea, 275 dietary, 275 pancreatic calculi, 284 pathology, 284 'symptoms, 285 treatment, 285 pancreatic cysts, 281 pathology, 281 congenital, 282 hydatid, 282 proliferation, 282 pseudocysts, 282 INDEX. 919 Pancreas, pancreatic cysts, path- ology, retention, 282 symptoms, 283 treatment, 284 tumors, 279 adenomata, 280 carcinoma, 279 pathology, 279 symptoms, 279 treatment, 281 Psychopathic personalities, 590 character abnormalities, 591 treatment, 592 Sexual anomalies, 592 bestiality, 594 exhibitionism, 594 fetichism, 593 masochism, 594 sadism, 594 Skin, diseases of, 797 acne rosacea, 826 acne vulgaris, 825 alopecia areata, 827 argyria, 818 blastomycosis, 824 dermatitis dysmenorrheica, 811 factitia, 813 medicamentosa, 812 diphtheria of the skin, 809 eczema, 804 erysipelas, 821 erythema induratum, 822 erythema multiforme, 798 herpes iris, 799 erythema nodosum, 799 erythema, toxic, 797 furuncle, 820 herpes simplex, 806 herpes zoster, 807 hypertrichosis, 826 hyperidrosis, 810 keratodermia blennorrhagica, 821 leprosy, 823 nervous system in, 824 nodular, 823 leukemia cutis, 819 Skin, diseases of, leukoplakia, 828 pemphigus, 808 acute, 809 psoriasis, 803 pruritis, 819 purpura, 814 hemorrhagica, 815 rheumatica, 814 Raynaud’s disease, 812, 525 scleroderma, 816 syphilis, 828 chancre, 829 eruption, 830 papular, 831 pustular, 832 gumma, 832 secondary stage, 830 tuberculosis verrucosa cutis, 821 urticaria, 800 causes, 802 symptoms, 801 vitiligo, 818 xanthoma diabeticorum, 819 Spinal cord, diseases of, 509 amyotrophic lateral sclerosis, 516 caisson disease, 513 combined sclerosis, 517 fractures and dislocation, spinal, 523 symptoms, 524 treatment, 525 hematomyelia, 512 hypertrophic cervical pachy- meningitis, 521 Landry’s paralysis, 512 differential diagnosis, 513 treatment, 513 lateral sclerosis, 516 meningitis, spinal, 519 chronic, 521 circumscribed serous, 520 onset, 519 symptoms, 520 treatment, 520 syringomyelia, 514 920 INDEX. Spinal cord, diseases of, meningi- tis, spinal, pathology, 514 symptoms, 515 syringobulbia, 515 tumors, 522 diagnosis, 523 symptoms, 522 treatment, 523 Sunstroke, 486 heat cramps, 488 heat stroke, 487 Sunstroke, thermic fever, 486 treatment, 488 Trophic diseases, 526 scleroderma, 527 spondylose rhizomelique, 528 Vasomotor diseases, 526 angioneurotic edema, 526 erythromelalgia, 527 intermittent claudication, 526 Raynaud’s disease, 525, 812